EPI/Lifestyle 2015 Scientific Sessions Abstracts

Transcription

EPI/Lifestyle 2015 Scientific Sessions Abstracts
01
The Role of Renin-Angiotensin-Aldosterone
System Genes in the Progression of Chronic
Kidney Disease: Findings from the Chronic
Renal Insufficiency Cohort (CRIC) Study
Tanika N. Kelly, Tulane Univ, New Orleans, LA;
Dominic Raj, George Washington Univ,
Washington, DC, DC; Mahboob Rahman, Case
Western Reserve Univ, Cleveland, OH; Matthias
Kretzler, Univ of Michigan, Ann Arbor, MI;
Radhakrishna R. Kallem, Univ of Pennsylvania,
Philadelphia, PA; Ana C. Ricardo, Univ of Illinois
at Chicago, Chicago, IL; Sylvia E. Rosas, Harvard
Medical Sch, Boston, MA; Kaixiang Tao, Daiwei
Xie, Univ of Pennsylvania, Philadelphia, PA; L.
Lee Hamm, Tulane Univ Sch of Med, New
Orleans, LA; Jiang He, Tulane Univ, New
Orleans, LA
Background
We conducted single-marker, gene-based and
pathway-based analyses to examine the
association between renin-angiotensinaldosterone system (RAAS) variants and chronic
kidney disease (CKD) progression among
Chronic Renal Insufficiency Cohort (CRIC) study
participants.
Methods
A total of 1,523 white and 1,490 black subjects
were genotyped for 490 SNPs in 12 RAAS genes
as part of the ITMAT-Broad-CARe array. CKD
progression phenotypes included decline in
estimated glomerular filtration rate (eGFR) over
time and the occurrence of a renal disease
event, defined as incident end stage renal
disease or halving of eGFR from baseline.
Mixed-effects models were used to examine
SNP associations with eGFR decline, while Cox
proportional hazards models tested SNP
associations with renal events. Gene and
pathway-based analyses were conducted using
the truncated product method. All analyses
were stratified by race, and a Bonferroni
correction was applied to adjust for multiple
testing.
Results
Among white and black participants, eGFR
declined an average of 1.2 and 2.3
ml/min/1.73m2 per year, respectively, while
renal events occurred in a respective 11.5% and
24.9% of participants. We identified strong gene
and pathway-based associations with CKD
progression. The AGT and RENBP genes were
consistently associated with risk of renal events
in separate analyses of white and black
participants (all P<1.00×10-6). Driven by the
significant gene-based findings, the entire RAAS
pathway was also associated with renal events
in both groups (both P<1.00×10-6). No singlemarker associations with CKD progression were
observed.
Conclusions
The current study provides strong evidence for
a role of the RAAS in CKD progression.
T.N. Kelly: None. D. Raj: None. M. Rahman:
None. M. Kretzler: None. R.R. Kallem:
None. A.C. Ricardo: None. S.E. Rosas: None. K.
Tao: None. D. Xie: None. L. Hamm: None. J. He:
None.
02
Lifetime Risk of Lower Extremity Peripheral
Artery Disease in the US
Kunihiro Matsushita, Yingying Sang, Shoshana
Ballew, Eric K Chow, Morgan Grams, Elizabeth
Selvin, Johns Hopkins Univ, Baltimore, MD; Alan
T Hirsch, Univ of Minnesota, Minneapolis, MN;
Josef Coresh, Johns Hopkins Univ, Baltimore,
MD
Background: Prevalence provides information
about the burden of disease in the population
but does not capture individuals’ risk over time.
In contrast, lifetime risk is a useful measure of
long-term disease incidence in an individual and
is underscored for coronary disease and stroke
in the AHA/ACC 2013 guidelines. However,
there are no available estimates of lifetime risk
of lower extremity peripheral artery disease
(PAD), despite its impact on prognosis, leg
amputation, and physical function.
Methods: With an established method for
lifetime risk estimation used in other fields (e.g.,
kidney disease), we estimated national average
probability of developing PAD, defined as an
ankle-brachial index (ABI) <0.9, at each single
year of age from birth to 80 years for
black/white women and men based on the
prevalence of PAD and relative mortality risk
related to PAD from the National Health and
Nutrition Examination Surveys and overall
mortality rate from US National Vital Statistics.
Then, Markov chain Monte Carlo simulations in
a simulated cohort of 100,000 individuals were
implemented to estimate lifetime risk of PAD.
Results: In an 80-year horizon, lifetime risk of
PAD was similar between sexes but 1.5-fold
higher in blacks compared to whites (35.6% for
black women, 30.6% for black men, 22.5% for
white women, and 19.4% for white men)
(Figure). From another perspective, 10% of
blacks and whites develop PAD by the age of 60
years and 70 years, respectively. The remaining
lifetime risk at ages of 65 (for those free of PAD
until this age) through 80 years was 29.6% in
black women, 28.0% in black men, 17.9% in
white women, and 16.5% in white men.
Conclusion: In the US, 1 in 3 blacks and 1 in 5
whites will experience lower extremity PAD
during their life course. This is the first national
estimate of lifetime risk for PAD and should
help inform risk-centered screening and
prevention strategies. Our results suggest that
race is a critical factor in PAD risk, a factor not
taken into account for ABI screening in the
current clinical guidelines.
K. Matsushita: None. Y. Sang: None. S. Ballew:
None. E.K. Chow: None. M. Grams: None. E.
Selvin: None. A.T. Hirsch: None. J. Coresh:
None.
This research has received full or partial funding
support from the American Heart Association,
National Center
03
Outpatient Care Preceding Incident Heart
Failure (HF) and Implications for Long-Term
Outcomes. The Atherosclerosis Risk in
Communities (ARIC) Study
Anna Kucharska-Newton, Lloyd Chambless,
Ricky Camplain, Carmen Cuthbertson, Patricia
Chang, Univ of North Carolina, Chapel Hill, NC;
Sunil Agarwal, Icahn Sch of Med at Mt Sinai,
New York, NY; Lisa Wruck, Univ of North
Carolina, Chapel Hill, NC; Norrina Allen,
Northwestern Univ, Chicago, IL; Eyal Shahar,
Univ of Arizona, Tucson, AZ; Alain Bertoni,
Wake Forest Univ, Winston-Salem, NC; Gerardo
Heiss, Univ of North Carolina, Chapel Hill, NC
Hypothesis: We hypothesized that outpatient
management of patients at risk for a HF
hospitalization is associated with lower
mortality following an incident HF
hospitalization.
Methods: Patterns of outpatient visits prior to
incident HF hospitalization were assessed
among CMS Medicare beneficiaries with
continuous fee-for-service eligibility residing
during 2003-2006 in four geographic areas of
CVD surveillance conducted by the ARIC Study.
Incident HF hospitalization was defined as
hospitalization with ICD9 code 428.x with no HF
hospitalizations in preceding 2 years.
Outpatient visits to primary care physicians,
general internists, or cardiologists were
identified from Carrier files. A comorbidity score
was calculated from ICD9 codes at the time of
incident HF hospitalization. Cox proportional
hazard models adjusted for age, comorbidity
score, gender, and race were used to estimate
mortality.
Results: Mean age among beneficiaries with
observed incident HF hospitalization (n=2006;
90.4% white, 45.1% male) was 79.8 years (SD
7.4). Mean comorbidity score was 3.6 (SD 1.9).
Mean number of outpatient physician visits
occurring in two years preceding the incident
HF hospitalization, was 9.6 (SD 9.0); 19.6%
beneficiaries had no observed prior outpatient
physician visits. Risk of death within one year of
incident HF hospitalization was greater among
those with no preceding outpatient physician
visits as compared to those with at least one
physician visit (adjusted HR=1.81 (95% CI 1.50,
2.18); Figure). Adjustment for the presence of
an outpatient visit within 2 weeks following the
HF hospitalization attenuated the risk of death
(HR=1.56 (1.29, 1.89)).
Conclusion: Lack of outpatient care in two years
prior to a HF-related hospitalization is
associated with increased mortality within one
year following hospitalization. Further inquiry is
warranted to assess whether the association
reflects diversity in causes/manifestations of
HF, ambulatory care received in ED settings, or
benefits associated with outpatient care.
A. Kucharska-Newton: None. L. Chambless:
None. R. Camplain: None. C. Cuthbertson:
None. P. Chang: None. S. Agarwal: None. L.
Wruck: None. N. Allen: None. E. Shahar:
None. A. Bertoni: None. G. Heiss: None.
04
Incident Heart Failure and Longitudinal
Cognitive Trajectories in the Cardiovascular
Health Study
Christa Schank, Natalie J Blades, Brigham Young
Univ, Provo, UT; Sarwat I Chaudhry, Yale Sch of
Med, New Haven, CT; John A Dodson, New York
Univ Medical Ctr, New York, NY; W T Longstreth
Jr, Susan R Heckbert, Bruce M Psaty, Alice M
Arnold, Univ of Washington, Seattle, WA;
Sascha Dublin, Group Health Res Inst, Seattle,
WA; Colleen M Sitlani, Univ of Washington,
Seattle, WA; Julius M Gardin, Hackensack Univ
Medical Ctr, Hackensack, NJ; Stephen M
Thielke, Univ of Washington, Seattle, WA;
Michael Nanna, Yale Sch of Med, New Haven,
CT; Rebecca F Gottesman, Johns Hopkins Univ
Sch of Med, Baltimore, MD; Anne B Newman,
Univ of Pittsburgh, Pittsburgh, PA; Evan L
Thacker, Brigham Young Univ, Provo, UT
OBJECTIVE: To determine whether older adults
who develop incident heart failure (HF)
experience faster cognitive decline than those
without HF.
METHODS: We analyzed longitudinal cognitive
test data from the Cardiovascular Health Study,
a community-based study of adults aged 65
years and older. Participants in this analysis did
not have HF or history of stroke at baseline and
were censored when they experienced incident
clinical stroke. Incident HF was identified by
self-report of physician-diagnosed HF and
confirmed by adjudicated review of inpatient
and outpatient medical records and medication
use. Outcomes were mean score and rate of
decline in mean score on the 100-point
Modified Mini-Mental State Examination
(3MSE), administered annually up to nine times
from 1990 to 1998. A linear mixed effects
model was used to model the relationship of
cognitive decline with HF and age, adjusted for
demographics, health behaviors, and comorbid
conditions including hypertension and diabetes.
RESULTS: Analyses included 5,211 participants
with mean age 74 years at baseline, of whom
545 (10.5%) developed incident HF over a
median follow-up of 7.8 years. Mean 3MSE
score was lower at the time of HF diagnosis
compared with no HF, and declined faster after
incident HF compared with no HF. For example,
at age 80, covariate-adjusted predicted mean
3MSE score was 88.6 points (95% CI: 88.3, 89.0)
in participants without HF, but 87.6 points (95%
CI: 87.3, 87.9) in those with newly diagnosed
HF. Predicted five-year decline in mean 3MSE
score from age 80 to age 85 was 5.9 points (95%
CI: 5.7, 6.0) in participants without HF, but 10.0
points (95% CI: 8.6, 11.3) in those diagnosed
with incident HF at age 80. Faster decline in
3MSE score after HF diagnosis was seen at all
ages studied. The figure shows predicted mean
3MSE score trajectories without HF (solid line)
and after HF diagnosed at ages 70, 75, 80, and
85 (dashed lines), with 95% CI shaded.
CONCLUSIONS: Older adults diagnosed with
incident HF experience faster average cognitive
decline than those without HF.
C. Schank: None. N.J. Blades: None. S.I.
Chaudhry: None. J.A. Dodson: None. W.T.
Longstreth: None. S.R. Heckbert: None. B.M.
Psaty: None. A.M. Arnold: None. S. Dublin:
None. C.M. Sitlani: None. J.M. Gardin:
None. S.M. Thielke: None. M. Nanna:
None. R.F. Gottesman: None. A.B. Newman:
None. E.L. Thacker: None.
05
Assessing Population Impact of Statin
Treatment for Primary Prevention of
Atherosclerotic Cardiovascular Diseases in US
Quanhe Yang, Yuna Zhong, Catheen Gillespie,
Robert Merritt, Barbara Bowman, Mary George,
Ctrs for Diseases Control and Prevention (CDC),
Atlanta, GA; Dana Flanders, Emory Univ,
Atlanta, GA
Introduction: American College of
Cardiology/American Heart Association
(ACC/AHA) new cholesterol treatment
guidelines recommend consideration of statin
treatment for a larger proportion of population
for the primary prevention of atherosclerotic
cardiovascular disease (ASCVD). It is important
to assess the population impact of statin
treatment under these new guidelines.
Hypothesis: We assessed the hypothesis that
increased statin use for the primary prevention
of ASCVD might be accompanied by adverse
effects among population.
Methods: We used 2010 US Census, Multiple
Cause Mortality, Third National Health and
Nutrition Examination Survey Linked Mortality
File (NHANES III 1988-2006, n=7095) and
NHANES 2005-2010 (n=3178) participants 40-75
years of age to estimate prevalence of statin
use, annual ASCVD deaths prevented and
excess adverse effects by age, sex, and
race/ethnicity if everyone followed updated
guidelines.
Results: Among 33.0 million adults aged 40-75
years meeting new guidelines for primary
prevention of ASCVD (12.4 million with diabetes
and 20.6 without diabetes but with a predicted
10-year ASCVD risk ≥7.5% and 70 ≤ low-density
lipoprotein (LDL) ≤189 mg/dL), 26.9% (8.8
million) were on statins, indicating an additional
24.2 million potentially eligible for statin
treatment (7.7 million with diabetes and 16.5
million without). Among the 7.7 million with
diabetes, assuming 100% statin use, expected
annual ASCVD deaths prevented were 2,514
(95% CI 592-4,142) and number-needed-totreat (NNT) was 3,063 (1,860-13,017). The
additional cases of myopathy based on
estimates from randomized clinical trials (RCT)
was 482 (0-2239) and number-needed-to-harm
(NNH) was 15,992 (3,440-∞), and was 11,801
(9,251-14,916) and NNH 653 (516-833) based
on estimates from population-based studies.
Among 16.5 million without diabetes, ASCVD
deaths prevented were 5,425 (1,276-8,935)
with NNT 3,039 (1,845-12,914). The additional
diabetes cases were 16,406 (4,922-26,250) with
NNH 1,005 (628-3,349). Additional cases of
myopathy was 1,030 (0-4,791) with NNH 15,996
3,441-∞) based on RCT estimates, and 24,302
(19,363-30,292) with NNH 678 (544-851) for
population-based studies. ASCVD deaths
prevented increased with age and >70% of
ASCVD deaths prevented would occur among
adults aged ≥60 years.
Conclusions: Under ACC/AHA new guidelines
for primary prevention of ASCVD by statin,
assuming all those eligible took a statin, up to
12.6% of annual ASCVD deaths could be
prevented, but could be accompanied by
additional cases of diabetes and myopathy.
Q. Yang: None. Y. Zhong: None. C. Gillespie:
None. R. Merritt: None. B. Bowman: None. M.
George: None. D. Flanders: None.
06
Higher Fitness is Associated with Lower Heath
Care Costs: The Veterans Exercise Testing
Study
Jonathan Myers, VA Palo Alto Health Care
System/Stanford Univ, Palo Alto, CA; Rachelle
Doom, VA Palo Alto Health Care System, Palo
Alto, CA; Robert King, VA Palo Alto Health Care
Systrem, Palo Alto, CA; Holly Fonda, Joshua
Abella, VA Palo Alto Health Care System, Palo
Alto, CA; Victor Froelicher, VA Palo Alto Health
Care System/Stanford Univ, Palo Alto, CA; Peter
Kokkinos, Veterans Affairs Medical Ctr,
Washington, DC, Washington DC, DC; Khin
Chan, VA Palo Alto Health Care System, Palo
Alto, CA
Introduction: The association between poor
physical fitness and adverse health outcomes is
well-established, but few data are available
regarding the association between fitness and
health care costs.
higher fitness is associated with lower overall
health care costs.
Methods: We studied 9,945 patients (mean
58±11 years) who underwent maximal exercise
testing for clinical reasons at two VA hospitals
as part of the Veterans Exercise Testing Study
(VETS). Fitness was expressed as the percentage
of age-predicted peak METs achieved and
categorized in quartiles. Total and annualized
health care costs, derived from the VA Allocated
Resource Center, were assessed between 2006
and 2013. Health care costs between quartiles
of fitness were compared using ANOVA;
multiple regression was used to determine
clinical and exercise test predictors of health
care costs. Follow-up for all-cause mortality
(mean 8.5±5 years) was performed through
March 2013.
Results: A gradient for reduced health care
costs was observed with higher fitness.
Expressed as annualized costs per patient (in
USD x 103), subjects in the least-fit quartile had
approximately 55% higher overall costs as those
in the fittest quartile (Figure). Non-survivors
were significantly less fit (6.5±5.1 vs. 9.1±3.5
METs, p<0.001) and exhibited roughly 3 times
the health care costs of those who survived. In a
multivariate model including historical, clinical
and exercise test responses, fitness was a
significant predictor of health care costs
(p<0.001).
Conclusions: Low fitness is associated with a
significant burden on the health care system.
Improving fitness should be encouraged for its
potential to lower health care costs.
J. Myers: None. R. Doom: None. R. King:
None. H. Fonda: None. J. Abella: None. V.
Froelicher: None. P. Kokkinos: None. K. Chan:
None.
07
Longitudinal Patterns of Change in Systolic
Blood Pressure (SBP) and Incidence of
Cardiovascular Disease. The Atherosclerosis
Risk in Communities (ARIC) Study
Natalia Petruski-Ivleva, Anthony Viera, David
Couper, Univ of North Carolina, Chapel Hill, NC;
Daichi Schimbo, Columbia Univ, New York, NY;
Paul Muntner, Univ of Alabama, Birmingham,
AL; Christy Avery, Univ of North Carolina,
Chapel Hill, NC; Andrea Schneider, Johns
Hopkins Univ, Baltimore, MD; Anna KucharskaNewton, Univ of North Carolina, Chapel Hill, NC
Background
Increasing SBP throughout the life course is
associated with an increased risk of
cardiovascular disease (CVD); however, patterns
of SBP increase may differ among individuals.
We sought to examine the association of
longitudinal change in SBP with CVD outcomes
among middle-aged adults.
Methods
We used latent class growth models (STATA,
traj) to identify patterns of longitudinal change
in SBP among 11,565 ARIC cohort participants
with non-missing SBP measurements at 4
clinical examinations (1987-1998) Model
adequacy was assessed using BIC criteria,
average posterior probabilities of group
assignment, and odds of correct classification.
The association of SBP pattern with incidence of
CVD and mortality was examined in follow-up
from the fourth clinical examination (1998)
through Dec 31, 2011, using Poisson regression
models adjusted for age and use of
hypertension medication.
Results
We identified six distinct patterns of SBP
change, of which three showed a sustained
increase within the normal range (<140 mm
Hg), with the remaining ones showing an
increase in SBP from normal to elevated, a
decrease from elevated SBP to normal, and
elevated stable SBP (Figure). Distinct
longitudinal SBP patterns were associated with
different rates of incident heart failure (HF),
coronary heart disease (CHD), stroke, and
death. During median 14.0 years of follow-up,
lowest rates for all events were observed
among study participants with lowest SBP who
remained <140 mm Hg at all examinations. A
gradient of event rates was observed across SBP
patterns, with an increase observed even
among study participants whose SBP remained
within the normal range. The pattern
characterized by a change from elevated to
normal SBP was not associated with a decrease
in rate of CHD.
Conclusions
Increase in SBP during midlife is associated with
long-term risk of CVD, regardless of baseline
SBP. Having an elevated SBP in mid-life
increases the risk of CVD events and mortality.
Our observations highlight the value of
hypertension prevention efforts.
N. Petruski-Ivleva: None. A. Viera: None. D.
Couper: None. D. Schimbo: None. P. Muntner:
None. C. Avery: None. A. Schneider: None. A.
Kucharska-Newton: None.
08
Heterogeneity in Transitioning from Ideal
Blood Pressure Over the Life Course in the US
Shakia T Hardy, Katelyn M. Holliday, Sujatro
Chakladar, Joseph C. Engeda, Gerardo Heiss,
Danyu Lin, Christina M. Shay, Donglin Zeng,
Christy L. Avery, UNC-Chapel Hill, Chapel Hill,
NC
Introduction: Blood pressure (BP) levels in early
life have been shown to predict development of
hypertension and cardiovascular disease in later
life. Many studies have assessed differences in
trajectories of elevated BP from childhood to
adulthood, but few have examined gender and
racial disparities in the age-specific transition
from ideal BP over the life course.
Methods: Following AHA’s Ideal Cardiovascular
Health (CVH) criteria for BP, we used the
prevalence of ideal (age ≥20, <120/80 mm Hg,
untreated; age 16-19, <90th percentile),
intermediate (age ≥20, 120 to 139/80 to 89 mm
Hg or treated to goal levels; age 16-19, 90th-95th
percentile or SBP ≥120 or DBP ≥80 mm Hg) and
poor (age ≥20, ≥140/90 mm Hg; age 16-19,
>95th percentile) resting BP levels among EA,
and AA NHANES participants (2007-2012,
n=11,663) to estimate the race, age, and sexspecific probabilities and patterns of
transitioning between levels using novel
Markov-type transition models. These net
transition models were specifically designed to
estimate net transition probabilities from crosssectional data.
Results: At the youngest age studied (16 years),
marked differences were observed in the
prevalence of ideal BP by gender, with
prevalence among women (87%) being
considerably higher than among men (64%). At
age 16, the proportion of AAs with ideal BP
declined by 1.2% (95% CI: 0.9-1.4%) one year
later, approximately twice the decline observed
in EAs (0.6%, 95% CI: 0.5-0.8%). After age 16,
the population with ideal BP continued to
decrease, although more rapidly for AAs than
EAs and for women compared to men. For
example, between ages 16 and 30, the
population with ideal BP decreased
approximately 2.0% (95% CI: 1.6-2.4%) and
1.0% (95% CI: 0.9-1.5%) per year for AA and EA
women, respectively; between 30 and 40 years
of age, the annual decline in ideal BP increased
to approximately 3.9% (95% CI: 3.2-4.5%) and
2.1% (95% CI: 1.7-2.4%) per year for AA and EA
women, respectively. By age 50, decreases in
the population with ideal BP began to slow and
become more stable for men but continued to
decrease for both AA and EA women.
Conclusions: Our results suggest that BP-related
disparities emerge during adolescence, by
which the decline of ideal BP at age 16 places
AAs and men at risk for early, and sustained loss
of optimal BP. A focus on early life for
primordial prevention to prevent the transition
away from ideal BP seems particularly pertinent
for AAs and men.
S.T. Hardy: None. K.M. Holliday: None. S.
Chakladar: None. J.C. Engeda: None. G. Heiss:
None. D. Lin: None. C.M. Shay: None. D. Zeng:
None. C.L. Avery: None.
09
HDL That Contains Apolipoprotein C-III is Not
Inversely Associated with Risk of Coronary
Events: The Multi-Ethnic Study of
Atherosclerosis
Majken K Jensen, Sarah A Aroner, Jeremy D
Furtado, Harvard Sch of Public Health, Boston,
MA; Kenneth J Mukamal, Beth Israel Deaconess
Medical Ctr, Boston, MA; Wendy S Post, John
Hopkins Sch of Med, Baltimore, MD; Joseph F
Polak, Tufts Medical Ctr, Boston, MA; Frank M
Sacks, Harvard Sch of Public Health, Boston,
MA; Robyn McClelland, Univ of Washington,
Seattle, WA
Background: Apolipoprotein A-I (apoA-I), the
major protein component of high density
lipoprotein (HDL), is inversely associated with
risk of coronary heart disease (CHD). However,
the cardioprotective benefits of HDL levels
remain controversial. HDL is comprised of a
heterogeneous group of lipoproteins, and
subtypes of HDL could have different
cardioprotective potential. Apolipoprotein C-III
(apoC-III) is a small pro-inflammatory protein
that resides on the surface of some
lipoproteins. In case-control studies of mostly
white participants, the presence or absence of
apoC-III defines lipoprotein subtypes that show
differential associations with CHD risk.
Methods and Results: We used a novel in-house
combo ELISA to measure the concentration of
total apoC-III, apoA-I with and without apoC-III
in 5668 white, black, Hispanic and Chinese
members of the Multi-Ethnic Study of
Atherosclerosis without known cardiovascular
disease from the baseline visit in 2000-2002. A
total of 386 incident CHD events occurred by
2012. In Cox regression models adjusted for
lifestyle and clinical risk factors, apoA-I without
apoC-III was inversely associated with risk of
CHD (HR per 1 SD increase on the ln-scale =
0.85; 95% CI, 0.75-0.97) whereas apoA-I with
apoC-III was not associated with CHD (HR=1.07;
95% CI, 0.94-1.22) (p for heterogeneity=
0.05)(Figure). ApoC-III was found on
approximately 7% of apoA-I across all
ethnicities. Total plasma apoC-III was positively
associated with CHD, but this was not robust to
multivariable adjustment. There was no
evidence of effect-modification by
race/ethnicity.
Conclusions: While total apoC-III levels are not
independently associated with CHD, the
presence of apoC-III on HDL appears to modify
the inverse association with CHD. HDL with
apoC-III may mark a dysfunctional subtype of
HDL. Such novel measures could be relevant as
therapeutic targets and for evaluation of future
CHD risk.
M.K. Jensen: C. Other Research Support;
Modest; Roche Pharmaceutical. S.A. Aroner:
None. J.D. Furtado: C. Other Research Support;
Modest; Roche Pharmaceutical. K.J. Mukamal:
None. W.S. Post: None. J.F. Polak: None. F.M.
Sacks: C. Other Research Support; Significant;
Roche Pharmaceutical. R. McClelland: None.
10
Lipid Biomarkers Predict the Effect of Hormone
Therapy on Coronary Heart Disease Risk: A
Secondary Analysis of the Heart and
Estrogen/Progestin Replacement Study
Patti Curl, UCSF, San Francisco, CA
Introduction: Two large randomized trials
(HERS and WHI) showed that among
postmenopausal women, combined estrogen
and progestin hormone therapy (HT) use does
not on average reduce the incidence of
coronary heart disease (CHD). Previous analyses
have suggested baseline Lp(a) and LDL
cholesterol modify the effect of HT on CHD risk.
Hypothesis: Stratifying women based on a
combination of their baseline Lp(a) and LDL
levels may identify women whose CHD risk is
likely to increase or decrease from the use of
HT.
Methods: We performed subgroup analyses by
baseline LDL and Lp(a) levels of the effect of HT
on CHD in HERS. Prior to the development of
risk categories, we randomly split the HERS
study population (n=2763) into equal-sized
derivation and validation cohorts. In the
derivation cohort, we assessed how 10-point
differences in baseline LDL and Lp(a)
concentrations influenced the effect of HT on
CHD risk. Based on these observations, we
created criteria for categorizing patients into
four risk categories then tested the categories
in the validation cohort.
Results: In the validation cohort, for patients
meeting benefit criteria, average risk criteria,
and increased risk criteria, the hazard ratios
(HR) for HT on CHD events were 0.55, 0.76, and
1.83 respectively. A subset of the increased risk
group meeting the contraindication criteria
showed a HR for HT on CHD of 5.3 and a
number needed to treat to cause one CHD
event of four.
Conclusions: There appears to be a population
with substantially increased risk of CHD from
HT. There also appears to be a population who
benefits from HT as secondary prevention for
CHD. There may be clinical utility in testing lipid
levels before initiating HT for symptomatic
treatment of menopausal symptoms or testing
Lp(a) in women with a previous CHD event and
offering HT to those who meet the benefit
criteria. Investigating whether the decreased
risk seen in women who meet the benefit
criteria proves to be similar in women without
previous CHD could yield valuable information
with important public health impact.
P. Curl: None.
11
mActive: A Blinded, Randomized mHealth Trial
Supporting Digital Tracking and Smart Texting
for Promotion of Physical Activity
Seth S Martin, David I Feldman, Roger S
Blumenthal, Steven R Jones, Wendy S Post,
Chiadi E Ndumele, Elizabeth V Ratchford, Josef
Coresh, Michael J Blaha, Johns Hopkins Univ,
Baltimore, MD
Introduction: The recent advent of
smartphone-linked wearable pedometers offers
a novel opportunity to promote physical activity
using mobile health (mHealth) technology.
Hypothesis: We hypothesized that digital
activity tracking and smart (automated, realtime, personalized) texting would increase
physical activity.
Methods: mActive (NCT01917812) was a 5week, blinded, sequentially-randomized,
parallel group trial that enrolled patients at an
academic preventive cardiovascular center in
Baltimore, MD, USA from January 17th to May
20th, 2014. Eligible patients were 18-69 year old
smartphone users who reported low leisuretime physical activity by a standardized survey.
After establishing baseline activity during a 1week blinded run-in, we randomized 2:1 to
unblinded or blinded tracking in phase I (2
weeks), then randomized unblinded
participants 1:1 to receive or not receive smart
texts in phase II (2 weeks). Smart texts provided
automated, personalized, real-time coaching 3
times/day towards a daily goal of 10,000 steps.
The primary outcome was change in daily step
count.
Results: Forty-eight patients (22 women, 26
men) enrolled with a mean (SD) age of 58 (8)
years, body mass index of 31 (6), and baseline
daily step count of 9670 (4350). The phase I
change in activity was non-significantly higher in
unblinded participants versus blinded controls
by 1024 steps/day (95% CI -580-2628, p=0.21).
In phase II, smart text receiving participants
increased their daily steps over those not
receiving texts by 2534 (1318-3750, p<0.001)
and over blinded controls by 3376 (1951-4801,
p<0.001). The unblinded-texts group had the
highest proportion attaining the 10,000
steps/day goal (p=0.02) (Figure).
Conclusions: In present-day adult smartphone
users receiving preventive cardiovascular care
in the United States, a technologicallyintegrated mHealth strategy combining digital
tracking with automated, personalized, realtime text message coaching resulted in a large
short-term increase in physical activity.
S.S. Martin: None. D.I. Feldman: None. R.S.
Blumenthal: None. S.R. Jones: None. W.S. Post:
None. C.E. Ndumele: None. E.V. Ratchford:
None. J. Coresh: None. M.J. Blaha: None.
12
Afterschool Soccer Fitness and Nutrition
Program Improves BMI Percentile, Waist
Circumference, and Fitness Levels in
Participants Compared to Nonparticipants
Danielle Hollar, Healthy Networks Design &
Res, Shepherdstown, WV; Weidan Zhou, Elite
Res, LLC, Carrollton, TX; Zach Riggle, U.S. Soccer
Fndn, Washington, DC
Introduction: While childhood obesity has
begun to plateau, some subgroups continue to
experience increases - particularly children
living below the federal poverty level, African
American and Hispanic children. Many lack
access to afterschool recreation and/or reliable
health information, including information about
good nutrition.
Hypothesis: We hypothesized that more
children in the intervention would: 1) improve
their body mass index (BMI) percentile category
(for age and gender in accordance with Centers
for Disease Control and Prevention); 2) have
healthier waist circumference (WC) measures;
3) have higher levels of fitness (run more PACER
laps).
Methods: The U.S. Soccer Foundation
developed the Soccer for Success (SfS) program
to combat childhood obesity, promote healthy
eating and exercise habits, and foster youth
development among children in economically
disadvantaged communities. The intervention
operated 90 minutes per day, three days a
week, for 24 weeks over the course of the
school year. Nutritious snacks were provided.
Employing a one-year, quasi-experimental
design, data were collected at baseline and
follow-up (early Fall 2013 and late Spring 2014)
in 16 randomly-assigned intervention and 14
control sites located in five cities: Buffalo, NY (4
intervention, 4 control); Denver, CO (4
intervention, 2 control); Detroit, MI (4
intervention, 4 control); Los Angeles, CA (1
intervention, 1 control); and Seattle, WA (3
intervention, 3 control). Data included height,
weight, waist circumference, number PACER
laps run, demographic data (via administrative
records).
Results: The SfS sample included 1,234 lowincome children grades K-5 (712
intervention/522 control). The majority of
children were Hispanic (55.8%; 31.5% Black,
4.6% multi-ethnic; 4.4% White); 61.9% males.
There was no difference between groups
regarding demographic characteristics nor BMI
percentile at baseline.
More children in the intervention group, as
compared to controls, experienced
improvements in BMI percentile, WC, and laps
completed. The mean BMI percentile among
intervention children decreased 2.73 more than
control children (Repeated measures ANOVA, p
= .001). Similarly, the mean WC among
intervention children decreased (0.22 cm),
whereas the WC of controls increased (0.21 cm;
Repeated measures ANOVA, p = .001). Finally,
the number of laps completed during the PACER
tests children in the SfS group increased
dramatically (4.0 laps), while the number of laps
of children in the control group decreased
slightly (0.1 laps; Repeated measures ANOVA, p
< .001).
Conclusions: In conclusion, the success of SfS
calls for expansion of efficacious, coordinated
afterschool efforts, such as the SfS program and
perhaps other youth sports as well, that include
physical activity/exercise, nutrition education,
and healthy snacks to combat the public health
issue of childhood obesity.
D. Hollar: None. W. Zhou: None. Z. Riggle:
None.
13
Relations of Midlife Exercise Blood Pressure,
Heart Rate and Fitness to Late Life Brain
Structure and Function
Nicole L Spartano, Jayandra J. Himali, Alexa S.
Beiser, Boston Univ, Boston, MA; Charles
DeCarli, UC Davis, Davis, CA; Ramachandran S.
Vasan, Sudha Seshadri, Boston Univ, Boston,
MA
Background: Exaggerated blood pressure (BP)
and vascular stiffness have been associated
with lower cognitive performance and brain
atrophy in older age. The brain is a high-flow,
low impedance organ that is susceptible to
fluctuation in BP. Poor cardiovascular (CV)
fitness is also emerging as a factor associated
with cognitive decline in older age. The BP and
heart rate (HR) response to exercise are
impacted by CV fitness; and exercise BP is also
highly determined by vascular stiffness. The
objective of this investigation was to examine
whether poor fitness and exaggerated BP and
HR response to exercise in midlife are
associated with worse brain morphology in later
life.
Methods: A subset of Framingham Offspring
Study participants (n=1340, 54.5% F) free from
dementia and CV disease underwent an
exercise treadmill test (the modified Bruce
protocol) in midlife [mean age of 41±9 y] and
continued until exhaustion or until 85% HR
maximum (age- and sex- predicted) was
reached. Exercise test duration was used to
estimate VO2max. BP and HR were measured
during stage 2. MRI scans of the brain and
neurocognitive tests (Trail Making Tests [Trails]
B-A) were administered in later life [mean age
of 59±9 y].
Results: A greater exercise systolic (S)BP and HR
response at midlife was associated with smaller
total cerebral brain volume (TCBV) in later life
(β=-0.09 ±0.04, p=0.042; β=-0.10 ±0.05,
p=0.033) after adjustment models including
resting SBP and HR; an effect equal to
approximately 0.5 y brain aging for every 11.1
mm Hg increase in SBP or 10 beats per min
increase in HR. Higher estimated VO2max at
midlife was associated with larger TCBV in later
life (β=0.03 ±0.01, p=0.014). Additionally,
greater exercise HR response at midlife was
associated with smaller frontal lobe volume in
later life (β=-0.012 ±0.05, p=0.002). Exercise
diastolic (D)BP at midlife was associated with
poorer performance on Trails B-A in later life
(β=-0.009 ±0.004, p=0.017) and the
achievement of target HR during exercise was
associated with better performance on Trails BA in later life (β=0.03 ±0.01, p=0.044). Resting
SBP at midlife was associated with greater
white matter hyperintensity volume in later life
(β=0.05 ±0.02, p=0.031); and resting SBP and
DBP at midlife were also associated with smaller
frontal lobe volume in later life (β=-0.17 ±0.07,
p=0.011; β=-0.21 ±0.10, p=0.030).
Conclusion: Our investigation provides new
evidence that lower midlife fitness and worse
exercise BP and HR responses are associated
with smaller brain volumes and poorer
cognitive performance nearly two decades
later. Promotion of midlife physical fitness may
be an important step towards ensuring healthy
brain aging in the population.
N.L. Spartano: None. J.J. Himali: None. A.S.
Beiser: None. C. DeCarli: None. R.S. Vasan:
None. S. Seshadri: None.
14
Poor Physical Activity is Associated with
Subclinical Myocardial Injury in Obese Adults
Roberta Florido, Chiadi E. Ndumele, Yuanjie
Pang, Kunihiro Matsushita, Jennifer A. Schrack,
Mariana Lazo, Johns Hopkins Univ, Baltimore,
MD; Vijay Nambi, Michael E DeBakey Veterans
Affairs Hosp; Baylor Coll of Med, Houston, TX;
Roger S. Blumenthal, Johns Hopkins Univ,
Baltimore, MD; Aaron R. Folsom, Univ of
Minnesota, Minneapolis, MN; Josef Coresh,
Johns Hopkins Univ, Baltimore, MD; Christie M.
Ballantyne, Baylor Coll of Med, Houston, TX;
Elizabeth Selvin, Johns Hopkins Univ, Baltimore,
MD
Background: Obesity is associated with
myocardial injury and subsequent heart failure
(HF). Higher physical activity (PA) is associated
with reduced risk of HF among individuals with
obesity, but the mechanisms for this protective
association remain poorly understood.
Hypothesis: We hypothesized that low levels of
PA would be independently associated with a
higher prevalence of subclinical myocardial
injury among obese individuals, as assessed by a
high-sensitivity assay for cardiac troponin T (hscTnT).
Methods: We evaluated 9,845 ARIC participants
without cardiovascular disease at Visit 4 (199699) and with body-mass index (BMI) >18.5
kg/m2. PA was assessed at Visit 3 (1993-95)
using a modified Baecke questionnaire. The
sports indices were converted into minutes per
week of moderate or vigorous exercise, and
categorized as per AHA guidelines as:
recommended (≥150 min/wk of moderate +
vigorous intensity or ≥75 min/wk of vigorous
intensity); intermediate (1-149 min/wk of
moderate + vigorous intensity or 1-74 min/wk
of vigorous intensity); or poor (0 min/wk of
moderate or vigorous exercise). BMI was also
assessed at Visit 3. The primary outcome was
elevated hs-cTnT (>14 ng/L) measured at Visit 4.
We constructed multivariable logistic regression
models to assess the association of PA and
obesity with elevated hs-cTnT.
Results: After multivariable regression, relative
to recommended PA, poor PA was associated
with elevated hs-cTnT (OR 1.33, 95% CI: 1.091.61). In analyses stratified by obesity status,
lower PA levels were associated with subclinical
myocardial injury among non-obese and obese
participants (p for trend <0.02 in both groups).
Among obese participants, those with
recommended PA levels had the lowest
likelihood of myocardial injury (Table).
Conclusion: Low PA was associated with
prevalent subclinical chronic myocardial injury
as manifested by elevated hs-cTnT. This may
help explain the possible protection conferred
by PA against the development of HF in obese
individuals.
R. Florido: None. C.E. Ndumele: None. Y. Pang:
None. K. Matsushita: None. J.A. Schrack:
None. M. Lazo: None. V. Nambi: H. Other;
Modest; Has filed a provisional patent (patent
#61721475) entitled “Biomarkers to Improve
Prediction of Heart Failure Risk”. R.S.
Blumenthal: None. A.R. Folsom: None. J.
Coresh: None. C.M. Ballantyne: H. Other;
Modest; Has filed a provisional patent (patent
#61721475) entitled “Biomarkers to Improve
Prediction of Heart Failure Risk”. E. Selvin:
None.
15
Trends in Consumption of Key Foods and
Nutrients Linked to Cardiometabolic Risk
Among Us Adults, 1999 to 2012
Colin D Rehm, Dariush Mozaffarian, Tufts Univ,
Boston, MA
Introduction: Most prior studies of US diet
trends have evaluated macronutrients (e.g.,
total fat), rather than the foods and other
nutrients most strongly linked to
cardiometabolic risk. Assessment of these
trends, including heterogeneity by age, sex,
race, and education, is crucial to identify
challenges and opportunities to improve the
diet of Americans.
Objective: To characterize trends in US dietary
intakes of foods and nutrients related to
cardiometabolic health.
Methods: We evaluated repeated crosssectional diet assessments among 33,929 US
adults age 20+y from 6 consecutive cycles of
NHANES (1999-2012). Based on an in-person
24-hour dietary recall, we evaluated energyadjusted intakes for vegetables, fruits, whole
grains, processed meat, poultry, nuts/seeds,
100% fruit juice, and sugar-sweetened
beverages (SSBs); and sodium, potassium, fiber,
seafood omega-3’s, and total polyunsaturated
fat, among others. Analyses were further
stratified by age, sex, race, and education.
Results: Among all adults, significant increases
were seen in yogurt, nuts/seeds, whole grains,
dark-green vegetables, fruit, and poultry;
processed meat also increased (Figure).
Decreases were observed in potatoes,
unprocessed red meats, milk, fruit juice, and
SSBs. Energy-adjusted intakes of sodium, fiber,
and polyunsaturated fat increased; potassium
and seafood omega-3’s did not change (not
shown). Trends were generally consistent
within population subgroups, with some
exceptions. The increase in nuts/seeds was
strongest among the well-educated, the
decrease in SSBs was strongest in adults 20-34y
and the increase in yogurt consumption was
limited to women.
Conclusion: Overall US dietary habits are
improving, consistent with continuing declines
in population blood pressure and cholesterol;
although processed meat and sodium intake are
increasing. Disparities in dietary intakes by race
and education did not markedly change,
suggesting that additional efforts be explored to
reduce disparities.
C.D. Rehm: None. D. Mozaffarian: E.
Honoraria; Modest; Quaker Oats, Pollock
Institute, Bunge. G. Consultant/Advisory Board;
Modest; Foodminds, Nutrition Impact, Amarin,
Astra Zeneca, Winston and Strawn LLP, Life
Sciences Research Organization, Unilever North
American Scientific Advisory Board. H. Other;
Modest; Royalties from UpToDate, for an online
chapter on fish oil.
16
A Pro-Vegetarian Food Pattern and
Cardiovascular Mortality in the Epic Study
Camille Lassale, Imperial Coll London, London,
United Kingdom; Joline Beulens, Yvonne Van
der Schouw, Univ Medical Ctr Utrecht, Utrecht,
Netherlands; Nina Roswall, Inst of Cancer
Epidemiology, Copenhagen, Denmark; Elizabete
Weiderpass, Univ of Tromsø, Breivika, Norway;
Dora Romaguera, Elio Riboli, Ioanna Tzoulaki,
Imperial Coll London, London, United Kingdom
Background
Plant-based dietary pattern consumption,
especially the Mediterranean Diet, have
consistently shown inverse risk associations
with mortality due to cardiovascular disease
(CVD). In agreement, adherence to a vegetarian
diet has been associated with reduced CVD risk
compared to non-vegetarian; however, the
proportion of vegetarians in the population is
low. The Pro-vegetarian food pattern (PVEG)
has recently been proposed as an intermediate
dietary pattern towards vegetarianism which
consists in favouring only plant-based foods
while concomitantly reducing animal-derived
foods.
Hypothesis
We aimed to investigate the associations
between the a priori defined PVEG score and
CVD mortality across 10 different European
countries.
Methods
Included in the analysis were 451,256
participants (130,370 men and 320,886 women)
between 35 and 70 years from the European
Prospective Investigation into Cancer and
Nutrition (EPIC) cohort study. At recruitment,
between 1992 and 2000, dietary,
anthropometric and lifestyle data was collected.
CVD mortality was defined as death from
circulatory cause (I00–I99 according to the ICD
10th revision). An a priori PVEG dietary score
was constructed comprising 12 components.
The consumption of 7 plant-based food groups
(vegetables, fruit, legumes, cereals, potatoes,
nuts, olive oil) were categorized into quintiles,
positively rated, and 5 animal-based food
groups (meats/meat products, animal fats,
eggs, fish and other seafood and dairy products)
were inversely rated for a total score ranging
from 12 to 60. Five categories of the total score
were created: very low (<30), low (30-34),
moderate (35-39), high (40-44), and very high
(>45) adherence to a PVEG diet. Associations
with the PVEG dietary score and CVD mortality
were estimated using Cox regression analysis
using age as the primary time metrics providing
Hazard Ratios (HR) and 95% Confidence
Intervals (95%CI). The fully adjusted models
included total energy intake, body mass index,
physical activity, educational level and stratified
by centre, sex and age at baseline. Restricted
cubic splines were used to assess the shape of
the association in continuous.
Results
Over follow-up (median: 12.8 years), 5083 CVD
deaths occurred. Compared to very low
adherence to a PVEG diet (reference category),
the fully-adjusted HRs (95%CI) were: 0.92 (0.851.01) in the low, 0.88 (0.80-0.74) in the
moderate, 0.81 (0.74-0.90) in the high and 0.80
(0.70-0.93) in the very high
adherence categories. The suggested floor
effect for a score >=40 was also seen by
restricted cubic spline.
Conclusion
Adherence to the plant-based PVEG food
pattern was associated with overall decreased
risks of CVD mortality up to 20% risk reduction,
although no further risk reduction was obtained
from a very strong compared to a strong
adherence.
C. Lassale: None. J. Beulens: None. Y. Van der
Schouw: None. N. Roswall: None. E.
Weiderpass: None. D. Romaguera: None. E.
Riboli: None. I. Tzoulaki: None.
17
One Avocado Per Day Lowers Plasma OxidizedLDL and Increases Plasma Antioxidants in
Overweight and Obese Adults
Li Wang, Ling Tao, Todd H. Stanley, Jennifer A.
Fleming, Joshua D. Lambert, Penny M. KrisEtherton, Pennsylvania State Univ, University
Park, PA
Background: Avocados are a nutrient dense
source of monounsaturated fatty acids (MUFA)
and also are high in antioxidants. A previous
study has shown that avocados have additional
LDL-C lowering effects beyond their MUFA
content, especially on small, dense LDL
particles, which are susceptible to oxidation in
vivo. However, there is little information about
the effects of avocados on oxidative stress.
Methods and Result: A randomized, cross-over,
controlled feeding trial was conducted with 45
healthy, but overweight or obese participants
with a baseline LDL-C in the 25-90th percentile.
Three cholesterol-lowering diets (6-7% SFA)
were fed (for 5 weeks each): a lower-fat diet
(LF: 24% fat); two moderate fat diets (34% fat)
that provided similar foods and were matched
for macronutrients and fatty acids: the avocado
diet (AV) included one fresh Hass avocado (136
g) per day whereas the moderate fat diet (MF)
used high oleic acid oils mainly to match the
fatty acid content of one avocado. Compared to
the baseline, only the AV diet decreased oxLDL
(-7.0 U/L, -8.8%, p=0.0004) whereas the LF (-1.6
U/L p=0.1) and the MF diets (-3.2 U/L, p=0.2)
did not affect oxLDL significantly. Moreover,
plasma oxLDL after consumption of the AV diet
was significantly lower (p=0.05 and 0.03) than
the MF and LF diets. HPLC analysis showed that
only the AV diet increased plasma lutein by
68.7% from baseline (p<0.0001), and the
increase in lutein by the AV diet was
significantly greater than the increase by the
MF (21.1%, p=0.7) and LF (37.6%, p=0.1) diets.
Both MF and AV diets significantly increased
plasma α-carotene (72.8% and 68.4%, p<0.01
for both) and β-carotene (15.4% and 12%,
p<0.05 for both) from baseline. The LF diet did
not change plasma antioxidant vitamins
significantly, except for a decrease in γtocopherol (-7.8%, p=0.03). All three diets did
not change plasma F2-isoprotane significantly
from baseline. The change in oxLDL was
significantly correlated with the change in small
LDL-P (r=0.32, p=0.0002) and small, dense LDL-C
(r=0.47, p<0.0001) by not large LDL-P (r=0.15,
p=0.09) or large, buoyant LDL-C (r=-0.03, p=0.8).
Conclusion: Including one avocado per day in a
heart-healthy diet lowers plasma oxidized LDL
and lutein concentration; the benefits extend
beyond their fatty acid content. The change in
oxidized LDL by diet was correlated with a
change in small LDL but not large LDL particles.
L. Wang: None. L. Tao: None. T.H. Stanley:
None. J.A. Fleming: None. J.D. Lambert:
None. P.M. Kris-Etherton: None.
18
Changes in Diet Quality Scores and Risk of
Cardiovascular Disease Among Us Men and
Women
Mercedes Sotos-Prieto, Shilpa N Bhupathiraju,
Josiemer Mattei, Teresa T Fung, Yanping Li,
Harvard Sch of Public Health, Boston, MA; An
Pan, Saw Swee Hock Sch of Public Health, Natl
Univ of Singapore, Singapore, MA; Walter C
Willett, Eric B Rimm, Frank B Hu, Harvard Sch of
Public Health, Boston, MA
Background: While adherence to several diet
quality scores, including the Alternative Healthy
Eating Index (AHEI), Alternative Mediterranean
diet score (AMED), and Dietary Approach to
Stop Hypertension (DASH), has been associated
with lower risk of cardiovascular disease (CVD),
little is known about how changes in these
scores over time influence subsequent CVD risk.
Objective: To evaluate the association between
4-y changes in three diet quality scores (AHEI,
AMED and DASH) and subsequent risk of CVD
among women and men in the Nurses’ Health
Study I and Health Professionals Follow-up
Study.
Methods: We followed up 50,195 women in the
Nurses’ Health Study (1986-2010) and 29,547
men in the Health Professionals Follow-up
Study (1986-2010). AHEI, AMED and DASH were
defined using data obtained from validated
food frequency questionnaires updated every 4y. Time-dependent and baseline Cox
proportional hazards regression models were
used to calculate hazard ratios (HR) with
adjustment for age, family history of CVD, race,
baseline diet quality, changes in smoking status,
and initial and changes in other lifestyle factors
(physical activity, alcohol intake, total energy
intake). Outcome was defined as the number of
confirmed incident cases of CVD (total coronary
heart disease and stroke). Results across
cohorts were pooled by an inverse varianceweighted, random-effect meta-analysis.
Results: During 1,397,871 person-years of
follow-up, we documented 11,542 incident CVD
cases. Compared with individuals whose diet
quality remained relatively stable (no change) in
each 4-y period, those with the greatest
improvements (11-22%) in diet quality had a 78% lower risk of CVD in the subsequent 4-y
period [pooled HR (95% CI): AHEI: 0.92(0.87,
0.99); AMED: 0.93 (0.85, 1.02); DASH: 0.93,
(0.87, 0.99); all P-trend<0.05]. A 20 % increase
in diet scores was associated with 3-9% lower
risk of CVD (AHEI: 0.91 (0.86, 0.97); AMED: 0.97
(0.94, 0.99); DASH: 0.94 (0.90, 0.98). Increasing
the diet scores (12-22%) from baseline to the
first 4-y follow-up was associated with a lower
risk of CVD during the next 20 years of followup [7% (1%, 12%) for AHEI and 9% (3%, 14%) for
AMED]. On the other hand, a decrease in DASH
score (16%) was associated with 8% (2%, 15%)
higher risk of CVD over 20 years.
Conclusions: Improving adherence to diet
quality scores over time is associated with
significantly lower risk of CVD, both in the shortterm and long-term. Our results provide novel
evidence that modest improvement in diet
quality over time confers benefits for CVD
prevention.
M. Sotos-Prieto: None. S.N. Bhupathiraju:
None. J. Mattei: None. T.T. Fung: None. Y. Li:
None. A. Pan: None. W.C. Willett: None. E.B.
Rimm: None. F.B. Hu: None.
19
Dietary Lipophilic Load and Dietary Lipophilic
Index with Risk of Coronary Heart Disease in
Middle-Aged Women: Beyond Conventional
Fat Classifications
Eric L Ding, Katerina M De Vito, Hongyu Wu, Qi
Sun, Harvard Sch of Public Health, Boston, MA;
An Pan, Natl Univ of Singapore, Singapore,
Singapore; Hannia Campos, Eilis J O'Reilly,
Harvard Sch of Public Health, Boston, MA;
JoAnn E Manson, Brigham and Women's Hosp
and Harvard Medical Sch, Boston, MA
INTRODUCTION: Studies indicate dietary types
of fats are associated with risk of coronary heart
disease (CHD). Traditional broad classifications
may incompletely capture the diversity of fatty
acids on CHD. The novel lipid index Dietary
Lipophilic Load (DLL) reflects a unique
combination of fatty acid fluidity,
intermolecular attraction, plus relative fat
quantity, while Dietary Lipophilic Index (DLI) is a
measure of average fat fluidity, regardless of fat
quantity. Thus, we evaluated the association,
DLL and DLI, with risk of incident CHD.
METHODS: Participants included 30,932 women
in the Women’s Health Study (WHS), who were
free of major chronic diseases at baseline. DLL
was calculated by weighted summation of the
multiplicative product of each fatty acid’s
intakes (g/day) and its melting points (Celcius);
DLI was calculated by dividing DLL by total fat
intake (g/day). Hazard ratios (HRs) were
adjusted for established risk factors, with
updated dietary data, and potential mediators.
We also investigated hypothesized interactions
with C-Reactive Protein (CRP).
RESULTS: There were 1137 cases of incident
CHD in 525,828 person-years over 19 years
follow-up. At baseline in over 27,000 women
with blood samples, DLL and DLI were not
correlated with serum cholesterol, triglyceride,
HbA1c, ICAM-1, or CRP biomarkers (r<0.02 for
all). In overall multivariate analysis, DLL was
associated with higher risk of CHD (extreme
quintile HR=1.40, 95%CI: 1.11-1.76, P
trend=0.0002), while DLI was not (HR=0.83,
95%CI: 0.67-1.03, P trend=0.75). DLL results
were independent beyond adjustment for
dietary trans, saturated, monounsaturated, and
polyunsaturated fats, nor their aggregate
adjustment or the P:S ratio. DLL effects
persisted even adjusting for CRP (HR=1.29, Ptrend=1 mg/dL for DLL (extreme quintile
HR=1.38, 1.02-1.88), than among individuals
with low CRP <1 mg/dl for DLL (HR=1.08, 0.681.72), with P-interaction<0.0001. Furthermore,
CRP also modified DLI, where effects again
diverged among higher CRP (HR=0.98, 0.731.31) versus low CRP (HR=0.45, 0.27-0.74), with
P-interaction<0.0001. Moreover, adjustment of
triglycerides, HbA1c, ICAM-1, LDL or HDL
cholesterol also did not materially affect overall
results.
CONCLUSION: Results indicate that DLL is
associated with increased risk of incident CHD,
independent of traditional risk factors,
conventional dietary fat classifications, and
major CHD biomarkers. Effects of DLL and DLI
appear to be modified by levels of CRP. DLL
appears to be an important novel dietary fat
index that captures additional CHD risk
information beyond biomarkers and traditional
dietary fat categories. Further studies are
warranted.
E.L. Ding: None. K.M. De Vito: None. H. Wu:
None. Q. Sun: None. A. Pan: None. H. Campos:
None. E.J. O'Reilly: None. J.E. Manson: None.
National Center
20
Carbohydrate Quality, Measured Using
Multiple Carbohydrate Quality Metrics, is
Negatively Associated with Risk of Type 2
Diabetes in US Women
Hala AlEssa, Shilpa Bhupathiraju, Vasanti Malik,
Nicole Wedick, Univ of Massachusetts Medical
Sch, Worcester, MA; Hannia Campos, Bernard
Rosner, Walter Willett, Frank B Hu, Harvard Sch
of Public Health, Boston, MA
Background: Carbohydrate quality may be an
important determinant of type 2 diabetes
(T2D), however, the relationships between
various carbohydrate quality metrics and T2D
risk have not been systematically investigated.
Objective: To prospectively examine the
association between carbohydrate, starch,
fiber, and different combinations of these
nutrients in relation to the risk of T2D in US
women.
Methods: We prospectively collected
information on diet and lifestyle behaviors
among 70,041 women from the Nurses Health
Study every 2-4 years, after baseline in 1984.
These participants were free of diagnosed
cardiovascular disease, cancer, or diabetes at
baseline. We used Cox proportional hazards
regression models to assess the association
between dietary factors of interest and
incidence of T2D.
Results: With 24 years of follow-up we
ascertained 6,934 incident cases of T2D during
1,484, 213 person years of follow-up. After
adjusting for age, lifestyle and dietary variables,
total carbohydrate intake was not associated
with T2D (RR=0.98, 95% CI: 0.89 - 1.08, p for
trend=0.84), while starch was positively
associated with T2D (RR=1.23, 95%CI: 1.12 1.35), p for trend <0.0001), comparing the
highest to lowest quintile. Total fiber (RR= 0.80,
95%CI: 0.72 - 0.89, p for trend < 0.0001), cereal
fiber (RR= 0.71, 95%CI: 0.65 - 0.78, p for trend <
0.0001) and fruit fiber (RR= 0.80, 95%CI: 0.73 0.88, p for trend < 0.0001) were all inversely
associated with T2D, comparing extreme
quintiles. . There was a borderline significant
positive association between the ratio of
carbohydrate to total fiber intake and risk of
T2D (RR= 1.09, 95%CI: 1.00 - 1.20, p for trend =
0.039), and stronger positive associations
between the ratios of carbohydrate to cereal
fiber (RR= 1.28, 95%CI: 1.17 - 1.39, p for trend <
0.0001), starch to total fiber (RR= 1.12, 95%CI:
1.02 - 1.23, p for trend = 0.030) and starch to
cereal fiber (RR= 1.39, 95%CI: 1.27 - 1.53, p for
trend < 0.0001) with T2D, comparing extreme
quintiles..
Conclusion: Diets with high starch, low fiber and
high starch to cereal fiber ratio were associated
with increased risk of T2D. Using the starch to
cereal fiber ratio of the overall diet is a
potentially useful way of assessing
carbohydrate quality in relation to T2D.
H. AlEssa: None. S. Bhupathiraju: None. V.
Malik: None. N. Wedick: None. H. Campos:
None. B. Rosner: None. W. Willett: None. F.B.
Hu: None.
21
The Effects of Carbohydrate Amount and Type
on Kidney Function in Healthy Adults: Results
From the Omnicarb Trial
Stephen P Juraschek, Johns Hopkins Univ,
Baltimore, MD; Alex R Chang, Geisinger Health
System, Harrisburg, PA; Lawrence J Appel, Johns
Hopkins Univ, Baltimore, MD; Cheryl A
Anderson, Univ of California, San Diego, San
Diego, CA; Deidra C Crews, Jeanne Charleston,
Edgar R Miller, Johns Hopkins Univ, Baltimore,
MD
Background: While there is considerable
interest in the effect of glycemic index (GI) and
amount of carbohydrate (%carb) on health, few
studies have examined the effects of GI and
%carb on kidney function, an important risk
factor for cardiovascular disease. We
determined the effects of reducing GI and
%carb on kidney function.
Methods: We conducted a four-period,
randomized, crossover feeding study in
overweight/obese adults without diabetes or
kidney disease (N=163). Participants were fed
each of four diets for 5 weeks, separated by 2week washout periods. Weight was held
constant. The four diets were: high GI (GI >65)
with high %carb (58% kcal from carbohydrates)
(reference diet), low GI (GI <45) with low %carb
(40% kcal from carbohydrates), low GI with high
%carb; and high GI with low %carb. Plasma was
collected at baseline and at the end of each
feeding period. Primary outcomes were β2microglobulin, cystatin C, and estimated
glomerular filtration rate based on cystatin C
(eGFRcys). Instead of serum creatinine (a
biomarker that rises with protein intake), we
used β2-microglobulin and cystatin C, which are
not appreciably affected by protein intake.
Results: Mean (SD) age was 53 (11) years; 52%
were women and 40% were non-Hispanic
African American. At baseline, mean (SD) β2microglobulin, cystatin C, and eGFRcys were 1.9
(0.4), 0.8 (0.1), and 104 (16), respectively.
Compared to the reference diet, reducing either
GI or %carb was associated with significant
reductions in β2-microglobulin (P-values ≤ 0.05)
and cystatin C (P-values < 0.001) as well as
significant increases in eGFRcys (P-values <
0.001). The low GI and low %carb diet was
associated with even greater reductions in both
cystatin C (P < 0.001) and β2M (P < 0.001), and
an increase in eGFRcys of 4.5 mL/min/1.73m2
(95% CI: 3.5, 5.4; P < 0.001) (Figure).
Conclusions: Reducing dietary GI and %carb
increased glomerular filtration. Future studies
on glycemic index and kidney function should
examine the long-term effects of this increase
in GFR on cardiovascular events.
S.P. Juraschek: None. A.R. Chang: None. L.J.
Appel: None. C.A.M. Anderson: None. D.C.
Crews: None. J. Charleston: None. E.R. Miller:
None.
22
Visit-to-Visit Variability in Blood Pressure is
Related to Late-Life Cognitive Decline
Bo Qin, Univ of North Carolina at Chapel Hill Sch
of Public Health, Chapel Hill, NC; Anthony J.
Viera, Univ of North Carolina at Chapel Hill Sch
of Med, Chapel Hill, NC; Linda S. Adair, Univ of
North Carolina at Chapel Hill Sch of Public
Health, Chapel Hill, NC; Brenda L. Plassman,
Duke Univ Medical Ctr, Durham, NC; Lloyd J.
Edwards, Barry M. Popkin, Michelle A. Mendez,
Univ of North Carolina at Chapel Hill Sch of
Public Health, Chapel Hill, NC
Introduction:
Recent studies suggest higher visit-to-visit
variability of blood pressure (BP) is associated
with worse cognitive function, but evidence
based on longitudinal cognitive testing has not
been reported.
Hypothesis:
We assessed the hypothesis that higher visit-tovisit variability in BP, but not mean BP, would
be associated with faster decline in cognitive
function among community-dwelling older
adults.
Methods:
This prospective cohort study comprised 1213
adults who had two or more waves of BP
measurements as part of the China Health and
Nutrition Survey from 1991, up to their first
cognitive tests, and completed a cognitive
screening test at two or more waves in 1997,
2000 or 2004. Mean (SD) age at first cognitive
test was 64 (6) y. Outcomes were repeated
measures of global cognitive scores (baseline
mean ± SD: 19 ± 6 points), standardized
composite cognitive and verbal memory scores
(standardized units [SU]). Visit-to visit BP
variability was expressed as the standard
deviation [SD] or as the variation independent
of mean (SD/mean^x, with x derived from curve
fitting) in BP measures obtained at a mean
interval of 3.6 years. Multivariable-adjusted
linear mixed-effects models were used to
determine the association of changes in
cognitive scores with visit-to visit BP variability.
Results:
Higher visit-to-visit variability in systolic BP, but
not mean systolic BP, was associated with a
faster decline of cognitive function (adjusted
mean difference [95% CI] for high vs. low tertile
of SD in variability (Figure): global score -0.23
points/y [-0.41 to -0.04], composite scores 0.029 SU/y [-0.056 to -0.002] and verbal
memory -0.044 SU/y [-0.075 to -0.012]). Higher
visit-to-visit variability in diastolic BP was
associated with a faster decline of global
cognitive function only among adults 55-64
years, independent of mean diastolic BP.
Conclusion:
Higher long-term BP visit-to-visit variability
predicted a faster rate of cognitive decline
among older adults.
B. Qin: None. A.J. Viera: None. L.S. Adair:
None. B.L. Plassman: None. L.J. Edwards:
None. B.M. Popkin: None. M.A. Mendez: None.
23
Divergent Temporal Trends in the Incidence of
Heart Failure with Preserved and Reduced
Ejection Fraction
Connie W. Tsao, Beth Israel Deaconess Medical
Ctr, Boston, MA; Asya Lyass, Martin G. Larson,
Ramachandran S. Vasan, Boston Univ, Boston,
MA
Background
The past two decades have witnessed divergent
trends in the prevalence of major
cardiovascular disease risk factors and advances
in medical therapy for coronary disease. Over
this time period (1990-2009), we hypothesized
that the incidence of heart failure with
preserved ejection fraction (HFPEF) may have
decreased with improved blood pressure
control, whereas the incidence of heart failure
with reduced ejection fraction (HFREF) may
have increased due to improved treatment of
coronary disease with myocardial salvage.
Methods
We studied Framingham Heart Study Original
and Offspring Cohort participants at least 40
years of age and free of HF (n=6648, 56%
women, 21285 five-year epochs, 769 HF, 97829
person-years). We estimated age- and sexadjusted rates of HF, HFPEF, and HFREF
(cumulative incidence at 5 years) for 5-year
time windows between 1990 and 2009 and for
10-year intervals, 1990-1999 and 2000-2009.
We used proportional hazards models to
estimate cumulative incidence and test time
trends in hazards ratios, for the overall sample
and for each sex separately.
Results
HF incidence varied modestly across the time
windows but differences were not statistically
significant overall, in men, or in women
(TABLE). Across the two decades, there was a
40% increase in the incidence of HFPEF
(p=0.003), but a 20% decrease in the incidence
of HFREF (p<0.0001). The incidence of HFPEF
between decades did not change significantly in
men but increased 56% in women (p=0.014).
Between decades, the incidence of HFREF
declined by 13% in men and by 29% in women
(p=0.01 and 0.003, respectively).
Conclusions
Whereas the overall incidence of HF has not
changed significantly in the past two decades,
the incidence of HFPEF has risen and that of
HFREF has declined reciprocally, opposite to
what we hypothesized. Future investigation into
the potential factors underlying these intriguing
trends is warranted.
C.W. Tsao: None. A. Lyass: None. M.G. Larson:
None. R.S. Vasan: None.
National Center
24
From JNC 1 to JNC 8: Population Impact and
Cost-Effectiveness of U.S. Hypertension
Guidelines
Nathalie Moise, Keane Tzong, Lee Goldman,
Columbia Univ Medical Ctr, New York, NY;
Pamela Coxson, Kirsten Bibbins-Domingo, Univ
of California at San Francisco, San Francisco, CA;
Andrew Moran, Columbia Univ Medical Ctr,
New York, NY
The 2014 “JNC 8” hypertension guideline
decreased the population eligible for treatment
and altered blood pressure (BP) targets. We
aimed to assess the public health impact and
cost-effectiveness of implementing JNC 8
recommendations in the context of prior JNC
guidelines.
Methods: Using the Cardiovascular Disease
(CVD) Policy Model, we simulated CVD events
and non-CVD deaths prevented, qualityadjusted life years (QALYs) gained, drug and
monitoring costs incurred, and CVD treatment
costs averted, if each JNC guideline were fully
implemented in a population of untreated U.S.
adults aged 35-74 years between 2014-2024.
Incremental cost effectiveness ratios (ICER)
were calculated as change in costs divided by
change in QALYs. An ICER of <50,000 was
considered cost effective. JNC guidelines were
simplified into four periods based on treatment
targets: JNC 1-3 (DBP <90 mmHg), JNC 4 (DBP <
90mmHg or isolated SBP <160mmHg), JNC 5-7
[<130/80 mmHg for diabetes and/or chronic
kidney disease (CKD); BP <140/90 mmHg for all
others] and JNC 8 (BP<140/90 mmHg for
diabetes and/or CKD or <60 years old; BP
<150/90mmHg for ≥60 years without diabetes
or CKD).
Results: All JNC guidelines would be overall cost
saving compared with no treatment (Table).
Though JNC8 scaled back CVD prevention
compared with its immediate predecessors, it
would be the most cost saving guideline.
Expanding from JNC 8 back to JNC 7 would be
cost effective ($33,000 per QALY gained).
Discussion: We found that, if fully implemented
today, all JNC guidelines would be cost saving
compared to no treatment but that JNC 8 would
be the most cost saving guideline to date.
Under our assumptions, adding lower risk
individuals eligible for treatment according to
JNC 5-7 would still be a cost effective policy if
JNC 8 could first be fully implemented. Further
analyses will highlight evidence gaps by
exploring uncertainty around the benefits of
treating pre-hypertension in high risk patients
and the balance of risks and benefits associated
with treating older adults to a goal of 140/90
mmHg.
N. Moise: None. K. Tzong: None. L. Goldman:
None. P. Coxson: None. K. Bibbins-Domingo:
None. A. Moran: None.
25
Adolescent Diet Quality and Primordial
Prevention of Cardiovascular Disease in the
Nurses’ Health Study II
Christina C Dahm, Dept of Public Health, Aarhus
Univ, Aarhus C, Denmark; Andrea K Chomistek,
Sch of Public Health, Indiana Univ, Bloomington,
IN; Marianne U Jakobsen, Dept of Public Health,
Aarhus Univ, Aarhus C, Denmark; Kenneth J
Mukamal, Beth Israel Deaconess Medical Ctr,
Boston, MA; Heather Eliassen, Harvard Medical
Sch, Harvard Sch of Public Health, Boston, MA;
Kim Overvad, Dept of Public Health, Aarhus
Univ, Aarhus C, Denmark; Walter C Willett, Dept
of Nutrition, Harvard Sch of Public Health,
Boston, MA; Eric B Rimm, Harvard Medical Sch,
Stephanie E Chiuve, Harvard Sch of Public
Health, Brigham And Women's Hosp, Boston,
MA
Background: Current clinical practice focuses on
primary prevention of CVD through
modification of clinical risk factors, such as high
cholesterol, hypertension and diabetes. The
absence of established risk factors at mid-life is
associated with a low long-term risk of CVD.
Previously, a healthy lifestyle in young
adulthood was associated with a low CVD risk
profile at mid-life. Whether a high quality diet in
adolescence can prevent development of CVD
risk factors in adulthood is unknown.
Methods: As part of the Nurses’ Health Study II,
which included women aged 25-42 at
recruitment in 1989, women completed a
validated high school food frequency
questionnaire, reflecting intake in grades 9-12,
in 1998. Diet quality was defined by a modified
Alternative Healthy Eating Index (AHEI-hs),
where high scores reflect a diet high in fruits,
vegetables, whole grains and unsaturated fats
and low in red/processed meat, sugar
sweetened beverages and trans fat. Physiciandiagnosed clinical risk factors (hypertension,
high cholesterol, diabetes) were assessed every
2 years. We assessed the relation between the
AHEI-hs and time-to-first-development of any
risk factor in 28,284 women who were free of
diagnosed clinical risk factors in 1998 (mean age
43). We also explored the AHEI-hs in relation to
risk of CVD (CHD or ischemic stroke) in 43,721
women who were free from CVD, but not
necessarily risk factors, in 1998 (mean age 44).
Cox proportional hazards models were adjusted
for potential confounders in high school (BMI,
energy, smoking, physical activity) and
adulthood (smoking, physical activity, oral
contraceptives, postmenopausal hormones,
aspirin use, energy, alcohol, family history of
disease).
Results: From 1998 through 2011, 11,328 risk
factors and 520 CVD events were documented.
After adjustment for high school and adult
confounders, higher AHEI-hs scores were
associated with a lower rate of diagnosed risk
factors (HR comparing quartile 4 to 1: 0.84, 95%
CI 0.80,0.89, p trend <0.001). Further
adjustment for adult diet quality did not alter
results appreciably. A higher AHEI-hs was also
associated with lower risk of CVD (HR
comparing quartile 4 to 1: 0.77, 95% CI 0.60,
0.99, p trend = 0.03), but not after adjustment
for adult confounders and adult diet quality (HR
0.98, 95% CI 0.75, 1.27, p trend = 0.85).
Compared to women in the lowest tertiles of
AHEI scores in high school and adulthood,
women in the highest tertiles at both time
points had a lower risk of developing a CVD risk
factor (HR 0.78, 95% CI 0.73, 0.84) and of CVD
(HR: 0.70, 95% CI 0.50, 0.97).
Conclusions: A high quality diet during
adolescence was associated with lower risk of
developing clinical CVD risk factors in
adulthood, and maintenance of good dietary
habits throughout early adulthood was most
strongly associated with lower risk of CVD. For
ideal cardiovascular health, healthy diet habits
should begin in early life and continue through
adulthood.
C.C. Dahm: None. A.K. Chomistek: None. M.U.
Jakobsen: None. K.J. Mukamal: None. H.
Eliassen: None. K. Overvad: None. W.C. Willett:
None. E.B. Rimm: None. S.E. Chiuve: None.
26
DASH-Style Eating Pattern in Early Adolescence
Reduces Cardiometabolic Risk Clustering
Lynn L Moore, M. Loring Bradlee, Martha R
Singer, Boston Univ Sch of Med, Boston, MA;
Stephen R Daniels, Univ of Colorado Sch of Med
and The Children’s Hosp, Denver, CO
Cardiometabolic risk (CMR) factor clustering has
its roots
in childhood and the presence of multiple
cardiovascular risk factors in
younger populations has been linked with early
vascular dysfunction. A
DASH-style eating pattern has been shown to
reduce blood pressure and other selected
cardiometabolic outcomes, primarily in adults,
but its role in the development
of CMR clustering during adolescence has not
been studied. Data from the
National Heart, Lung, and Blood Institute’s
Growth and Health Study (NGHS) will
be used to evaluate the relation between earlyto-mid adolescent dietary intake
and CMR clustering at the end of adolescence.
The NGHS began in 1987-1988 with
the enrollment of 2,379 adolescent girls (with
approximately equal numbers of
blacks and whites), ages 9-10 years. Diet was
assessed using 3-day diet records
during eight of 10 years of follow up. A total of
1,369 girls had complete data
on diet, all potential confounding variables, and
follow-up over 10 years for all
CMR factors of interest. Risk factor clustering
scores were created by summing individual
CMR outcomes defined as follows: waist
circumference ≥88 cm, systolic and/or
diastolic blood pressure ≥90th percentile for
age, sex and height, LDL ≥110
mg/dL, HDL <50 mg/dL, serum TG ≥110mg/dl,
and HOMA-IR ≥4. Multiple logistic
regression analyses were used to estimate the
impact of a DASH-style pattern on
the relative risk (odds ratio) of CMR clustering
at the end of adolescence, defined
as having ≥ 2 or ≥ 3 of the above risk factors at
18-20 years of age. The
proportion of white and black girls with CMR
clustering was very similar.
However, the types of risk factors differed by
race with blacks being nearly
twice as likely to have an increased waist size,
elevated BP, or insulin
resistance and white girls being much more
likely to have abnormal lipid levels,
particularly elevated triglyceride levels. By the
end of adolescence, only
30.1% of girls had no abnormal CMR factors and
34.9% had a single risk factor;
16.6% of girls had two risk factors and 18.4%
had between 3-6 prevalent risk
factors. Higher intakes of fruit and non-starchy
vegetables, dairy, and grains
were independently associated with less CMR
clustering. After adjusting for
age, race, socio-economic status, height,
physical activity, and television
watching, girls with a DASH-style eating pattern
during early-to-mid
adolescence were nearly 50% less likely to have
three or more CMR factors
(O.R.=0.52; 95% CI: 0.30, 0.89) by late
adolescence (at 18-20 years of age). These
results suggest a DASH-style eating pattern
during adolescence, characterized
by higher intakes of fruit, non-starchy
vegetables, and dairy, may lower risk
for the development of subsequent
cardiometabolic disorders.
L.L. Moore: None. M. Bradlee: None. M.R.
Singer: None. S.R. Daniels: None.
27
Poor Adherence to US Dietary Guidelines for
Children and Adolescents in the National
Health and Nutrition Examination Survey
(NHANES) 2005-2010 Population
Alexis C Frazier-Wood, Baylor Coll of Med,
Houston, TX; Emilyn C Banfield, Univ of Texas
Health Sch of Public Health, Houston, TX; Yan
Liu, Baylor Coll of Med, Houston, TX; Jennifer S
Davis, Shine Chang, MD Anderson Cancer Ctr,
Houston, TX
Poor diet quality in childhood often tracks into
adulthood and is associated with cardiovascular
disease risk factors such as obesity and insulin
resistance. Despite the importance of good diet
quality in childhood, how the dietary habits of
American children change across childhood is
unknown. The USDA releases the Dietary
Guidelines for Americans (DGA) every five
years, which advise on the nutritional intake of
12 food components with the goal of “achieving
and maintaining a healthy weight, promoting
health, and preventing disease”. This study
sought assess whether intake of each
component of the DGA was different between 3
age groups: 4-8, 9-13 and 14-18 years of age.
We employed a cross-sectional design using
data from NHANES 2005-10, and included 8,390
children ages 4-18, after excluding those with
insufficient data on dietary recall (n=852) or
who were pregnant / lactating at the time of
interview (n=38). We analyzed whether each of
12 HEI-10 components and the total (sum)
score were different between the age groups,
using the population ratio approach which
corrects for dietary intake under reporting.
Total scores ranged from 44-52 out of 100.
After an FDR correction for multiple testing, the
youngest children had the highest overall diet
quality (Q=.002-.02) due to the significantly
higher consumption of total fruit, whole fruit,
dairy, and whole grains (Q=.002-.04; Figure 1).
Children in the youngest age group also
consumed the least sodium, refined grains, and
empty calories (Q=.002-.01; Figure 1). Overall,
children are failing to meet the minimum total
HEI-10 score of 80 thought to associate with
health. Our results suggest that US children are
at increased risk for preventable diseases, and
the risk increases as children age. By analyzing
which food groups show declines between age
groups, we provide data which will inform the
development of dietary interventions targeting
specific food components at given ages. If we
can use these data to improve the diet quality
of children we offer the hope of reducing
disease risk.
A.C. Frazier-Wood: B. Research Grant;
Significant; USDA. E.C. Banfield: B. Research
Grant; Modest; NIH. Y. Liu: None. J.S. Davis:
None. S. Chang: None.
South Central Affiliate (Arkansas, New Mexico,
Oklahoma & Texas)
28
KickinNutrition.TV: A Digital Nutrition
Education Curriculum for Middle-School
Students Increases Self-Efficacy for Healthy
Habits.
Nicolette S. Maggiolo, Raymond T. Yan, Boston
Univ, Boston, MA; Christine M. Zakhour, Kaylie
A. Patrick, Boston Univ Sch of Public Health,
Boston, MA; Tianjiao Cui, Paula A Quatromoni,
Boston Univ, Boston, MA
Child health promotion and obesity prevention
efforts demand effective skills-based nutrition
education. KickinNutrition.TV (KNTV) offers an
innovation in school-based nutrition education
where evidence-based curricula, teacher
training, classroom time, and school resources
are lacking. KNTV was designed using digital
technology to empower students to get in the
kitchen and cook by providing information and
skills to increase consumption of fresh, whole
foods. We assessed the hypothesis that
exposure to KickinNutrition.TV would impact
nutrition-related behaviors to a greater extent
than exposure to traditional (non-digital)
nutrition lessons. This quasi-experiment
involved 1,105 students in 10 schools in three
public school districts in Massachusetts (2
urban, 1 suburban). Schools were assigned in a
2:1 ratio within districts to receive either the
digital KNTV curriculum or a comparison
curriculum. Classroom teachers in each school
were trained to deliver a set of 6 weekly
nutrition lessons to students in 6th grade.
Assessments included pre- and post-curriculum
surveys of nutrition knowledge, personal
behaviors, readiness to change and selfefficacy. Baseline surveys were completed by
1,052 (95%) students and 778 (82%) provided
follow up surveys. The study sample was 51%
female, 48% white, 26% Latino and 16.5%
African American. At baseline, average nutrition
knowledge scores were 69.8% ± 20% and were
not different for students in KNTV or
comparison classrooms. At baseline, about half
of students (49%) reportedly ate vegetables on
a daily basis and only 42% consumed milk or
yogurt daily. Only 46% of students reported
that they knew how to identify a whole grain
food, with a similarly low percentage (47%)
reportedly eating whole grain foods daily. One
in three children reported being involved in
helping to cook dinner for their family. At
program conclusion, compared to students
receiving traditional lessons, measurably larger
shifts in self-efficacy were observed among
students exposed to KNTV for being able to
identify whole grain foods (p=.08) and for
helping to cook dinner (p=.01). Larger shifts in
readiness to change were observed among
KNTV students for daily consumption of
vegetables (p=.06) and breakfast (p=.03). About
40% of students increased their nutrition
knowledge score but gains were not different
by classroom type. Participation in KNTV was
associated with greater likelihood of having
eaten breakfast daily in the past week (p=.01)
and for achieving My Plate guidelines for food
variety at breakfast (p=.001) and lunch (p=.01).
These data provide evidence of nutritional
vulnerability among a diverse sample of middleschool students and demonstrate the positive
impact of a novel nutrition education program.
KickinNutrition.TV offers a digital solution to
overcome several obstacles to nutrition
education in schools.
N.S. Maggiolo: None. R.T. Yan: None. C.M.
Zakhour: None. K.A. Patrick: None. T. Cui:
None. P.A. Quatromoni: None.
29
Loss of Ideal Total Cholesterol Early in Life: The
National Health and Nutrition Examination
Survey (NHANES)
Joseph C Engeda, Katelyn M Holliday, Shakia T
Hardy, Sujatro Chakladar, Gerardo Heiss, Danyu
Lin, Donglin Zeng, Christina M Shay, Christy L
Avery, Univ of North Carolina, Chapel Hill,
Chapel Hill, NC
Introduction: Ideal total blood cholesterol (TC)
levels are associated with lower cardiovascular
disease (CVD) morbidity and mortality. In the
U.S. TC increases up to middle age, but declines
at older ages. Few studies have characterized
the transition from ideal to intermediate and
poor TC levels in different life epochs and in
minorities.
Methods: Cross-sectional 2007-2012 NHANES
data (N = 11,140) were used to estimate the
age-, race-, and sex- specific prevalence of ideal
(≥20 years: <200 mg/dL untreated, 16-19 years:
<170 mg/dL), intermediate (≥20 years: 200-239
mg/dL or treated to goal, 16-19 years: 170-199
mg/dL), and poor (≥20 years: ≥240 mg/dL, 1619 years: ≥200 mg/dL) TC, defined per American
Heart Association criteria. We then used these
data and novel Markov-type models to estimate
net transition probabilities between ideal,
intermediate and poor TC.
Results: Between the ages of 16 and 18, the
prevalence of ideal TC among European
American (EA) and African American (AA) men
was approximately 68%, notably higher than
the prevalence in EA women (63%) and AA
women (61%). Variation in the loss of ideal TC
was also observed by race and sex. Between 16-
50 years of age, the proportion of AA men, EA
men and EA women with ideal levels of TC
declined approximately 2.0% (95% CI: 1.8%,
2.2%) per year. In AA women by contrast, the
age-specific decline in ideal TC was not uniform
between 16-50 years of age. The proportion of
AA women with ideal levels of TC declined 0.7%
(95% CI: 0.2%, 1.2%) per year from 16-20 years
of age but increased to 2.8% (95% CI: 2.4%,
3.3%) per year by age 50. Among populations
with intermediate TC levels, estimated 1-year
net transitions to poor TC peaked at age 16, the
earliest age under investigation, for EA men, EA
women, and AA men but remained stable for
AA women through 70 years of age, where a
net 0.6% (95% CI: 0.1%, 1.3%) of the population
with intermediate TC levels transitioned to poor
TC levels one year later. In all demographic
groups and life epochs, greater proportions of
the population transitioned from intermediate
to poor TC than from poor to intermediate TC.
Conclusions: Loss of ideal TC begins early in life
and shows divergent patters by gender and
race. Difficulties re-attaining ideal TC once
classified as intermediate or poor support
interventions that promote ideal TC levels in
younger ages, especially among AA women.
J.C. Engeda: None. K.M. Holliday: None. S.T.
Hardy: None. S. Chakladar: None. G. Heiss:
None. D. Lin: None. D. Zeng: None. C.M. Shay:
None. C.L. Avery: None.
30
High Intra-Individual Variation in Urinary
Sodium Excretion in Teenage Girls on a Fixed
Sodium Intake
Berdine Martin, George McCabe, Linda
McCabe, Purdue Univ, West Lafayette, IN;
Lawrence J Appel, Johns Hopkins Univ Sch of
Med, Baltimore, MD; Connie Weaver, Purdue
Univ, West Lafayette, IN
Introduction: According to traditional
understanding of sodium homeostasis, nearly
100% of daily sodium (Na) intake is excreted in
urine, with intra-individual variability attributed
to variability in dietary Na intake and nonadherence with urine collection procedures.
However, a recent report from a Russian space
flight simulation documented unexpectedly
high day-to-day variability in urine Na excretion
on a fixed intake.
Objective: To analyze daily urinary Na excretion
from a balance study that was conducted in
black and white girls on both low and high
levels of dietary Na.
Methods: Sodium balance was assessed in 22
black and 13 white adolescent girls, (11-15 y,
BMI 15-29 kg/m2) in a randomized, crossover
design with controlled diets containing either
low (57 mmol/d) or high (167 mmol/d) Na, each
for three weeks. Participants collected all urine
in acid washed containers. Urine was pooled as
24-h samples and analyzed for sodium by
atomic absorption spectrophotometry and
creatinine by automated colorimetric method.
Coefficients of variation (CV) for urinary Na
were calculated for each teen. A mixed model
was used to describe the effects of dietary Na
and race.
Results: The figures below give an example of
the Na variability of one black teen on both the
high (left) and low (right) Na diets. The
horizontal line represents the Na intake. The CV
analysis indicated higher variation about the
mean on low (vs high) Na (40% vs 32%, p=0.02)
and in black (vs white) girls (42% vs 30%,
p<0.001). There was no diet x race interaction.
Excretion of 50 mmol/d or less was
documented on 6.6% of the days during the
high Na dietary period.
Conclusions: The high intra-individual variability
in urinary Na excretion on a fixed diet highlights
the potential for substantial error in (a) using a
single 24 hour urine collection to estimate usual
Na intake and (b) relating Na excretion from a
single 24 hour collection with outcomes.
B. Martin: None. G. McCabe: None. L. McCabe:
None. L.J. Appel: None. C. Weaver: None.
31
Impact of Acculturation on Cardiac Structure
and Function Among Latinos in the Hispanic
Community Health Study/Study of Latinos
(HCHS/SOL): The ECHO-SOL Ancillary Study
Lenny Lopez, Massachusetts General Hosp,
Boston, MA; Katrina Sweet, Wake Forest Sch of
Med, Winston-Salem, NC; Fátima Rodríguez,
Stanford Univ, Palo Alto, CA; Jorge R Kizer,
Albert Einstein Coll of Med, Bronx, NY; Frank J
Penedo, Northwestern Univ, Chicago, IL; Linda C
Gallo, San Diego State Univ, San Diego, CA;
Matthew A Allison, Univ of California San Diego,
San Diego, CA; William Arguelles, Univ of
Miami, Miami, FL; Franklyn Gonzalez II, Univ of
North Carolina, Chapel Hill, NC; Robert Kaplan,
Albert Einstein Coll of Med, Bronx, NY; Carlos
Rodríguez, Wake Forest Sch of Med, WinstonSalem, NC
Background
Abnormalities of cardiac structure and function
are part of the spectrum of heart failure risk
and progression. Acculturation is the process
whereby an individual adopts the beliefs and
practices of a host culture. Increasing
acculturation has been associated with
increased psychosocial stress and the adoption
of deleterious health behaviors. The extent to
which acculturation contributes to
cardiovascular disease among Latinos is not well
defined, and its association with cardiac
structure and function in particular has not
been studied among Latinos.
Hypothesis
We hypothesized that higher acculturation is
associated with worse left ventricular structure
and function.
Methods
The HCHS/SOL cohort included 16,415 Latino
adults age 18-74 years from Cuban, Dominican,
Mexican, Puerto Rican, Central American, and
South American backgrounds. A random
subsample of 1350 also underwent detailed
echocardiographic assessment for the following
primary outcome measures: left atrial volume
index (LAVI), left ventricular mass index (LVMI)
and LV ejection fraction (LVEF), LV end diastolic
volume (LVEDV) and diastolic dysfunction
(Grade 0 vs. Grade 1-3). Acculturation was
measured by length of residence in the US
categorized as (< 5 years, 5-10 years, >10 years).
Chi-square and ANOVA were used to assess
differences across acculturation level and
dependent variables. Separate linear and
logistic regression analyses were used with
sequential modeling for age and sex followed
by models including diabetes, hypertension,
body mass index, tobacco use, and estimated
glomerular filtration rate.
Results
The mean age of the Echocardiographic Cohort
was 56 years (S.D. ±0.5). Length of residence
among first generation immigrants (n=1239)
was as follows: 9.7% ≤ 5 years; 14.8% 5-10
years; and 75.5% ≥10 years. Fully adjusted
models demonstrated abnormal cardiac
structure was significantly higher with
increasing years of US residence: increasing
LAVI (1.6 ml/m2 higher ≥10 years vs. ≤ 5 years),
increasing LVEDV (5.6 ml higher ≥10 years vs. ≤
5 years), and LVMI (4.9g/m2 higher ≥10 years vs.
≤ 5 years) (p<0.01 each). Increasing length of
residence in the US was also associated with
higher prevalence of diastolic dysfunction in
models adjusted for age and gender (54.2% ≤ 5
years vs. 63.7% ≥10 years; p=0.04), though this
became marginally non-significant in our fully
adjustment models (p=0.07). There were no
significant differences in systolic cardiac
function as measured by LVEF.
Conclusions
Among a diverse Latino population, higher
acculturation defined as greater length of
residence in the US, a proxy measure for
acculturation, was associated with larger LA
volume, larger LV cavity, higher LV mass and a
tendency to higher prevalence of diastolic
dysfunction independent of traditional risk
factors. Acculturation may be a significant
process that impacts cardiac structure and
function among Latinos.
L. Lopez: None. K. Sweet: None. F. Rodríguez:
None. J.R. Kizer: None. F.J. Penedo: None. L.C.
Gallo: None. M.A. Allison: None. W. Arguelles:
None. F. Gonzalez: None. R. Kaplan: None. C.
Rodríguez: None.
32
Global Burden and Control of Hypertension in
2010: Analysis of Population-Based Studies
from 89 Countries
Katherine T Mills, Joshua D Bundy, Tanika N
Kelly, Jennifer E Reed, Tulane Univ, New
Orleans, LA; Patricia M Kearney, Univ Coll Cork,
Cork, Ireland; Kristi Reynolds, Kaiser
Permanente Southern California, Pasadena, CA;
Jing Chen, Jiang He, Tulane Univ, New Orleans,
LA
Background: Hypertension is an important
global health challenge due to its high
prevalence and resulting cardiovascular disease
and chronic kidney disease. Hypertension is the
leading preventable risk factor for premature
death and disability worldwide.
Objective: We estimated the prevalence,
awareness, treatment and control of
hypertension worldwide in 2010 and compared
the global burden of hypertension in 2000 and
2010.
Methods: We searched MEDLINE for published
reports from January 1, 2001 to June 30, 2014
and supplemented with manual searches of
references from retrieved articles. We included
population-based studies and applied sex-agespecific prevalence of hypertension from each
country to population data to assess the
number of hypertensive adults in each region
and globally. Proportions of awareness,
treatment and control from each country were
applied to hypertensive populations to obtain
regional and global estimates.
Results: An estimated 29.8% (95% confidence
interval 29.6-30.0%) of the world’s adult
population in 2010 had hypertension (30.7%
[30.4-31.0%] in men and 28.8% [28.6-29.0%] in
women). The estimated total number of
hypertensive adults in 2010 was 1.33 billion
(1.32-1.34 billion); 346 million (336-356 million)
in high-income and 985 million (977-994
million) in low- and middle-income countries.
From 2000 to 2010, the age-standardized
prevalence of hypertension increased by 2.5%
worldwide. The hypertension prevalence
decreased 3.5% in high-income countries,
whereas the prevalence increased 4.5% in lowand middle-income countries. In addition, from
2000 to 2010 the number of hypertensive
adults increased by 354 million (334 million in
low- and middle-income countries compared to
19 million in high-income countries).
Proportions of hypertension awareness,
treatment and control worldwide in 2010 were
43.5% (43.1-44.0%), 33.8% (33.3-34.2%), and
12.3% (12.1-12.6%), respectively. The
proportion of hypertension control was 27.7%
(27.0-28.3%) in high-income and 6.9% (6.7-7.1)
in low- and middle-income countries.
Conclusions: Prevention and treatment of
hypertension should be a global health priority
due to its high prevalence and low control rate
globally, especially in low- and middle-income
countries.
K.T. Mills: None. J.D. Bundy: None. T.N. Kelly:
None. J.E. Reed: None. P.M. Kearney: None. K.
Reynolds: None. J. Chen: None. J. He: None.
33
Early Loss of Normal Body Weight in
Multiethnic US Populations: The Hispanic
(HCHS/SOL), Strong Heart Family Study (SHFS),
and the National Health and Nutrition
Examination Survey (NHANES)
Christy L Avery, Katelyn M Holliday, Sujatro
Chakladar, Dan Yu Lin, Univ of North Carolina at
Chapel Hill, Chapel Hill, NC; Ashley E Moncrieft,
Univ of Miami, Miami, FL; Robert J Ostfeld,
Yeshiva Univ, New York, NY; Jared P Reis, Natl
Heart, Lung and Blood Inst, Bethesda, MD;
Pamela J Schreiner, Univ of Minnesota,
Minneapolis, MN; Christina M Shay, Univ of
North Carolina at Chapel Hill, Chapel Hill, NC;
Jeremiah Stamler, Northwestern Univ, Chicago,
IL; Gregory A Talavera, San Diego State Univ,
San Diego, CA; Fawn Yeh, Univ of Oklahoma,
Norman, OK; Marston Youngblood, Univ of
Ying Zhang, Univ of Oklahoma, Norman, OK;
Martha L Daviglus, Univ of Illinois at Chicago,
Chicago, IL; Gerardo Heiss, Donglin Zeng, Univ
of North Carolina at Chapel Hill, Chapel Hill, NC
Approximately 69% of American adults are
obese or overweight, with the greatest burdens
shouldered by Hispanic/Latinos (HL), African
Americans (AA), and American Indians (AI).
Emerging evidence suggests that minority
populations also transition away from normal
weight at earlier ages than European Americans
(EA), yet few studies have evaluated weight
transition patterns across the life course in
contemporary multi-ethnic populations. We
therefore leveraged cross-sectional data from
the HCHS/SOL (n=16,332, 2008-2011), NHANES
(n=11,901, 2007-2012), and the SHFS (n=3,364,
2001-2003) and novel Markov models that
accommodated complex sampling and family
structure to estimate age-, sex-, and
race/ethnic-specific net transition probabilities
of moving between normal weight (body mass
index (BMI)<25 kg/m2), overweight (BMI 2529.99 kg/m2) and obesity (BMI≥30 kg/m2)
among AA, AI, EA, and HL participants ≥18 years
of age. At age 18, the prevalence of normal
weight ranged 49-73%, with the highest
prevalence observed in EA females and the
lowest in AI females. Age 18 also marked a time
of accelerated net transitions away from normal
weight. For example, between 18-30 years, the
population of normal weight AI males
decreased approximately 6.9% (95% CI: 5.7%,
8.1%) per year. AI females [6.0% (95% CI: 5.0%,
6.9%)], HL males [5.6% (95% CI: 5.0%, 6.1%)],
and AA females [5.2% (95% CI: 4.4%, 6.0%)] also
experienced large annual reductions in the
proportion of the population classified as
normal weight during this time. Among
overweight populations, estimated 1-year net
transitions to obesity peaked at age 18, the
earliest age under investigation, for all
race/ethnic- and sex-specific groups, and were
highest for AI females, where a net 10.6% (95%
CI: 7.0%, 14%) of the overweight population
transitioned to obesity one year later. For all
populations, greater proportions of the
population transitioned from overweight to
obese than from obese to overweight until late
middle age (range: 43-58 years), when
transitions began to favor very modest
decreases in the proportion of the population
classified as obese, possibly reflecting selective
survival. Our results suggest that by age 18,
substantial proportions of AAs, AIs, and HLs,
have already transitioned away from normal
weight. Difficulties reattaining normal body
weight throughout the life course support the
design and implementation of evidence-based
obesity prevention and control efforts targeted
to children and adolescents, with emphasis on
AA, AI, and HL populations.
C.L. Avery: None. K.M. Holliday: None. S.
Chakladar: None. D.Y. Lin: None. A.E.
Moncrieft: None. R.J. Ostfeld: None. J.P. Reis:
None. P.J. Schreiner: None. C.M. Shay: None. J.
Stamler: None. G.A. Talavera: None. F. Yeh:
None. M. Youngblood: None. Y. Zhang:
None. M.L. Daviglus: None. G. Heiss: None. D.
Zeng: None.
34
Traffic-Light Labels and Financial Incentives
Reduce Purchase of Sugar-Sweetened
Beverages by Low-Income, Latino Families: A
Randomized Controlled Trial
Anne Thorndike, Douglas E. Levy,
Massachusetts General Hosp, Boston, MA;
Lorena Macias-Navarro, Rebecca L. Franckle,
Eric B. Rimm, Harvard Sch of Public Health,
Boston, MA
Background: Strategies to reduce consumption
of sugar-sweetened beverages (SSBs) are
needed for obesity prevention, particularly
among low-income and minority populations
that have both high rates of SSB consumption
and of obesity-related diseases.
Methods: We conducted a randomized,
controlled trial of 216 frequent customers of a
Latino supermarket to determine if providing
both in-store traffic light labels on all beverages
as well as financial incentives for not purchasing
unhealthy (red-labeled) beverages would
reduce their purchase. Subjects were recruited
in the store and were eligible if they: had > 1
child in the household; purchased > $100 of
groceries at the study store/month; and spoke
Spanish or English. Regardless of intervention
arm, all subjects received a store “loyalty card”
that provided a 5% discount on all groceries and
identified their purchases in cash register data.
After a 2-month period to track subjects’
baseline beverage purchases, traffic-light labels
(red=unhealthy=SSB; yellow=less healthy;
green=healthy) were posted on all beverage
shelves for a 5 month intervention period. The
intervention group (N=108) received monthly
letters that provided targeted education about
healthy beverages and offered a financial
incentive ($25 grocery coupon) if they
purchased no red-labeled beverages in the
following month; the control group (N=108)
received monthly letters with general nutrition
guidelines. Subject demographics were
collected at the time of enrollment. We
compared the trend in the proportion of
subjects who purchased red beverages during
the 5-month intervention period between the
two groups, adjusting for pre-intervention
(baseline) beverage purchases.
Results: Subjects were 98% female, 97% Latino,
and 58% on government food assistance.
During the 2-month baseline period (before
traffic light labels were posted), 43% of the
intervention and 34% of the control group
purchased ≥ 1 red-labeled beverage/month.
During the study period, 151 subjects (70%)
used the loyalty card to pay for purchases at
least once during the study period. In the
intention-to-treat analysis (N=216) for the 5month intervention period, the proportion of
subjects in the intervention group that
purchased red beverages decreased 3% more
per month than the control group (p=0.05). In a
secondary analysis of only subjects who used
the loyalty card to pay for purchases, the
proportion of those in the intervention group
that purchased red beverages decreased 9%
more per month than the control group
(p=0.002).
Conclusion: Our results suggest that targeted
beverage education and in-store traffic-light
labels combined with financial incentives
reduced grocery store purchases of sugarsweetened beverages by low-income, Latino
families compared to traffic-light labels alone.
A. Thorndike: B. Research Grant; Modest;
Harvard Catalyst/The Harvard Clinical and
Translational Science Center. D.E. Levy: None. L.
Macias-Navarro: None. R.L. Franckle: None.
E.B. Rimm: B. Research Grant; Modest; Harvard
Catalyst/The Harvard Clinical and Translational
Science Center.
35
Unprocessed and Processed Meat
Consumption and Blood Pressure: The
INTERMAP Study
Linda M. Oude Griep, Imperial Coll London,
London, United Kingdom; Paraskevi Seferidi,
Wageningen Univ, Wageningen, Netherlands;
Jeremiah Stamler, Northwestern Univ, Chicago,
IL; Queenie Chan, Imperial Coll London, London,
United Kingdom; Linda Van Horn, Northwestern
Univ, Chicago, IL; Lyn M. Steffen, Univ of
Minnesota, Minneapolis, MN; Katsuyuki Miura,
Hirotsugu Ueshima, Shiga Univ of Medical
Science, Otsu, Japan; Nagako Okuda, Natl Inst of
Health and Nutrition, Tokyo, Japan; Liancheng
Zhao, Fu Wai Hosp and Cardiovascular Inst,
Beijing, China; Sabita S. Soedamah-Muthu,
Wageningen Univ, Wageningen, Netherlands;
Martha L. Daviglus, Univ of Illinois, Chicago, IL;
Paul Elliott, Imperial Coll London, London,
United Kingdom
Background
Evidence from prospective cohort studies
indicates that consumption of processed meats
is associated with higher incidence of CHD.
Processed meats are high in saturated fatty
acids, cholesterol, and preservatives including
sodium that may unfavorably influence blood
pressure (BP), but evidence is limited. We
therefore investigated associations with BP of
unprocessed and processed meat consumption,
including types of processed meats.
Methods
We used cross-sectional data from the
INTERMAP Study on 4,680 men and women
aged 40-59 years from Japan, China, UK, and
US. During four visits, eight BPs and four 24-hr
dietary recalls were collected. Processed meats
included preserved meats; fresh processed
meats (ready-made, salted, and/or spiced, no
curing), bacon, ham (cured and cooked), cold
cuts and sausages, and canned meat products.
Country-specific linear regression coefficients
were estimated and pooled, weighted by
inverse of their variance. Adjustments were
made for demographic (age, gender, sample),
lifestyle (total energy, alcohol, smoking,
education, supplement use, adherence to
special diet, low-fat dairy, fruit, vegetables,
fiber-rich grain products, fish and shellfish), and
clinical confounders (history of cardiovascular
diseases or diabetes, family history of
hypertension, use of anti-hypertensive,
cardiovascular, or diabetes medication, BMI).
The influence of adjustment for urinary sodium,
total cholesterol, and total saturated fatty acids
was additionally investigated.
Results
Average daily unprocessed/processed meat
consumption (g/1000 kcal) was 41/10 in Asian
participants and 82/47 in Western participants.
In Western participants, processed meats
comprised fresh processed meat (36%), cold
cuts and sausages (34%), ham (16%), and bacon
(7%).
Meat consumption was not associated with BP
in Asian participants. After adjustment for
demographic and lifestyle factors, significant
associations with systolic BP were observed per
each 50 g/1000 kcal higher intake of
unprocessed (+1.19 mm Hg, P=0.02) and
processed (+2.00 mm Hg, P=0.01) meat
consumption in Western participants. However,
these associations attenuated and did not
remain significant after adjustment for BMI. We
further examined types of processed meat in
Western participants. Consumption of cold cuts
and sausages higher by 12,5 g/1000 kcal was
associated with a systolic BP difference of +0.72
mm Hg (P=0.02). Consumption of ham higher by
12,5 g/1000 kcal was associated with a systolic
BP difference of -0.92 mm Hg (P=0.03). These
associations prevailed after adjustment for
urinary sodium excretion, intakes of saturated
fatty acids, and total cholesterol.
Conclusion
Unprocessed and processed meat consumption
was not associated with BP, however, some
types of processed meat may influence BP in
opposite directions.
L.M. Oude Griep: None. P. Seferidi: None. J.
Stamler: None. Q. Chan: None. L. Van Horn:
None. L.M. Steffen: None. K. Miura: None. H.
Ueshima: None. N. Okuda: None. L. Zhao:
None. S.S. Soedamah-Muthu: None. M.L.
Daviglus: None. P. Elliott: None.
36
Sedentary Behavior and Cardiometabolic Risk
Factors Among US Hispanic/Latino Adults: The
Hispanic Community Health Study/Study of
Latinos (HCHS/SOL)
Qibin Qi, Garrett Strizich, Albert Einstein Coll of
Med, Bronx, NY; Gina Merchant, Christina
Buelna, Sheila F. Castañeda, Linda C. Gallo, San
Diego State Univ, San Diego, CA; Jianwen Cai,
Univeristy of North Carolina, Chapel Hill, NC;
Marc D. Gellman, Univ of Miami, Miami, FL;
Carmen Isasi, Albert Einstein Coll of Med, Bronx,
NY; Ashley E. Moncrieft, Univ of Miami, Miami,
FL; Lisa A. Sanchez-Johnsen, Univ of Illinois at
Chicago, Chicago, IL; Neil Schneiderman, Univ of
Miami, Miami, FL; Robert Kaplan, Albert
Einstein Coll of Med, Bronx, NY
Background
Sedentary behavior is recognized as a distinct
construct that is qualitatively different from lack
of physical activity and it has been suggested to
be associated with increased risk of
cardiometabolic diseases. Data on relationship
between objectively measured sedentary
behavior and cardiometabolic biomarkers are
sparse, especially among US Hispanics/Latinos.
Methods
Sedentary behavior and physical activity were
measured using Acticala accelerometers for a 7day period in 12,443 participants from the
Latinos, a population-based study of
Hispanics/Latinos aged 18-74 years recruited
from randomly selected households in 4 US
cities conducted between 2008 and 2011.
Participants with at least 10-hour/day of
accelerometer wear on at least three days were
included in the current analysis. Sedentary
behavior was defined as average accelerometer
counts per minute <100. Sedentary time was
standardized to 16-hour/day of wear time.
Results
The mean sedentary time was 11.9 hours/day
(74% of accelerometer wear time). After
adjustment for age, gender and other
demographic, socioeconomic and lifestyle
variables, diastolic blood pressure, LDLcholesterol, triglycerides, 2-hour glucose,
fasting insulin and HOMA-IR increased, while
HDL-cholesterol decreased across the quartiles
of sedentary time (all P for trend <0.015). Most
associations were attenuated but remained
significant after further adjustment for BMI and
physical activity. Even among individuals
meeting physical activity recommendations,
sedentary time remained associated with higher
levels of diastolic blood pressure, 2-hour
glucose, fasting insulin and HOMA-IR (Figure).
Conclusions
Sedentary time is high in US Hispanic/Latino
adults and it is associated with an adverse
cardiometabolic biomarker profile, independent
of physical activity. Our results emphasize the
importance of reducing sedentary behavior
beyond increasing physical activity in the
prevention of cardiometabolic diseases.
Q. Qi: None. G. Strizich: None. G. Merchant:
None. C. Buelna: None. S.F. Castañeda:
None. L.C. Gallo: None. J. Cai: None. M.D.
Gellman: None. C. Isasi: None. A.E. Moncrieft:
None. L.A.P. Sanchez-Johnsen: None. N.
Schneiderman: None. R. Kaplan: None.
43
Association of Plasminogen Activator Inhibitor1 with Prevalent and Incident Obesity is
Independent of Inflammatory Markers: The
Multi-Ethnic Study of Atherosclerosis (MESA)
Sadiya S. Khan, Donald M. Lloyd-Jones, Cheelin
Chan, Kiang Liu, Northwestern Univ Feinberg
Sch of Med, Chicago, IL; Mary Cushman, Univ of
Vermont Coll of Med, Colchester, VT; Bryan
Kestenbaum, Univ of Washington, Seattle, WA;
Joachim Ix, Univ of California, San Diego, San
Diego, CA; Ian De Boer, Univ of Washington,
Seattle, WA
Background: In experimental animal models,
deficiency of plasminogen activator inhibitor-1
(PAI-1) protects against development of
obesity. In addition, elevated circulating levels
of PAI-1 are associated in cross-sectional studies
with prevalent obesity in humans. However, no
studies have investigated the prospective
association between PAI-1 and incident obesity.
Methods: Plasma PAI-1 levels were measured in
a random sample of men and women at
baseline (2000-2002) in the Multi-Ethnic Study
of Atherosclerosis. Obesity was defined as body
mass index (BMI) > 30kg/m2. Incident obesity
was identified at four follow-up exams (20022011) among those who were not obese at
baseline. Logistic regression was used to
examine the odds ratios (OR) and 95%
confidence intervals (CI) of prevalent obesity at
baseline. Cox proportional hazards regression
was used to estimate hazard ratios (HR) for time
to incident obesity. The covariates used for
adjustment included baseline demographics
(age, race, sex, center), lifestyle risk factors
(physical activity, dietary energy intake,
smoking status, alcohol consumption,
education), and inflammatory markers (CRP and
IL-6).
Results: In 839 participants mean age was 59
years old; 59% and 47% of the cohort were
female and white, respectively. At baseline,
each standard deviation (SD) increase in
log(PAI-1) level was associated with an odds
ratio (OR) for adjusted prevalent obesity of 2.70
(95% CI: 2.21 - 3.30, p<0.001. This association
remained significant after further adjustment
for IL-6 and CRP with OR 2.39 (95% CI: 1.942.94, p<0.001). Over a median follow-up of 8.5
years, 16% of participants developed obesity.
The multivariable adjusted hazard ratio for
incident obesity was 1.36 (95% CI 1.09-1.69,
p<0.001) per 1 SD increase in log(PAI-1). (Table).
Conclusions: Elevated PAI-1 levels are
associated with prevalent and incident obesity.
These findings are consistent with results from
murine studies and provide evidence suggesting
a potential role of PAI-1 in the pathogenesis of
obesity.
S.S. Khan: None. D.M. Lloyd-Jones: None. C.
Chan: None. K. Liu: None. M. Cushman:
None. B. Kestenbaum: None. J. Ix: None. I. De
Boer: None.
44
Cardiometabolic Responses to Weight Change
are Different between Obese and Normal
Weight Adults Who are Metabolically Healthy:
The Atherosclerosis Risk in Communities Study
Zhaohui Cui, Kimberly P Truesdale, Patrick T
Bradshaw, Jianwen Cai, June Stevens, Gillings
Sch of Global Public Health, Univ of North
Carolina at Chapel Hill, Chapel Hill, NC
Introduction: The 2013 AHA/ACC/TOS Guideline
for the Management of Overweight and Obesity
in Adults recommended weight loss for obese
adults in order to reduce their cardiovascular
disease (CVD) risk. However, not all obese
adults develop CVD and approximately 17% of
obese Americans in the 1999-2004 NHANES
were metabolically healthy. The absence of
abnormal CVD risk factors in this subgroup of
obese adults indicates that some individuals are
resistant to excess adiposity and positive energy
balance, and raises the question of whether all
obese adults should be recommended for
weight loss treatment. We know of no study
that has examined whether metabolically
healthy obese (MHO) adults respond to weight
changes the same way as metabolically healthy
normal weight adults (MHNW). Also, no study
has compared the effects of weight loss, weight
maintenance and weight gain on CVD risk
factors in MHO adults.
Hypothesis: We hypothesized that the effects
of weight change would be different in MHNW
and MHO adults, with MHO adults having less
stable risk factors, and that weight loss has a
protective effect on CVD risk factors in the MHO
compared to weight maintenance and weight
gain.
Methods: Data were from 2,710 MHO and
MHNW participants in the Atherosclerosis Risk
in Communities (ARIC) study. Four examinations
yielded 4,541 observations over sequential 3year intervals. Metabolically healthy was
defined as absence of all components of
metabolic syndrome, excluding waist
circumference, at the beginning of a 3-year
interval. Mixed effect models were applied to
individually compare changes in five CVD risk
factors (systolic blood pressure, diastolic blood
pressure, triglycerides, high-density lipoprotein
cholesterol and glucose) in MHO and MHNW
adults within 3 weight change categories (<3%
weight loss, weight maintenance (±3%) and >3%
weight gain).
Results: Weight loss was associated with small
or no changes in the five CVD risk factors in
both MHO and MHNW adults. Weight
maintenance was associated with larger
increases in MHO compared to MHNW adults in
triglycerides (mean ± standard error: 10.0±1.7
vs. 6.5±1.0 mg/dL) and glucose (1.7±0.4 vs.
0.9±0.2 mg/dL). Weight gain was associated
with larger increases in systolic (8.6±0.6 vs.
6.2±0.4 mmHg) and diastolic (3.9±0.4 vs.
2.5±0.3 mmHg) blood pressure, triglycerides
(22.0±1.8 vs. 16.0±1.1 mg/dL) and glucose
(4.9±0.4 vs. 1.9±0.3 mg/dL) among the MHO
compared to the MHNW. MHO weight losers
experienced more favorable changes in the five
CVD risk factors compared to MHO weight
maintainers (p<0.04) or gainers (p<0.0001).
Conclusions: We showed that compared to
MHNW, MHO adults experienced similar
changes in CVD risk factors with weight loss and
larger increases with weight maintenance and
gain. Our study supports the 2013 Guideline
that primary health care providers should
recommend weight loss treatment for MHO
patients.
Z. Cui: None. K.P. Truesdale: None. P.T.
Bradshaw: None. J. Cai: None. J. Stevens: None.
45
Prior Weight History Provides Prognostic
Information Beyond Current Weight Regarding
HF Risk
Chiadi E. Ndumele, Laura Cobb, Mariana Lazo,
Johns Hopkins Univ, Baltimore, MD; Natalie
Bello, Columbia Univ, New York, NY; Amil Shah,
Brigham and Women's Hosp, Boston, MA; Vijay
Nambi, Michael E DeBakey Veterans Affairs
Hosp, Houston, TX; Roger S. Blumenthal, Gary
Gerstenblith, Johns Hopkins Univ, Baltimore,
MD; Scott D. Solomon, Brigham and Women's
Hosp, Boston, MA; Christie M. Ballantyne,
Baylor Coll of Med, Houston, TX; Elizabeth
Selvin, Josef Coresh, Johns Hopkins Univ,
Baltimore, MD
Background: While obesity is an established risk
factor for heart failure (HF), there are limited
prospective analyses examining the relationship
of weight history or trajectories of weight
change with incident HF.
Hypothesis: We hypothesized that prior
overweight and obesity, and increasing weight
over time, would be associated with an
increased risk of incident HF.
Methods: We performed a prospective analysis
of 9,710 ARIC Visit 4 (1996-98) participants with
available body-mass index (BMI) measurements
at Visit 1 (1987-89) and Visit 4, excluding those
with CVD at Visit 4 or BMI < 18.5. BMI (kg/m2)
at Visits 1 and 4 was categorized as normal
weight (18.5-24.9), overweight (25-29.9) or
obese (≥30). We additionally categorized BMI
based on self-reported weight at age 25
(reported at Visit 1; N=9,122). The primary
outcome was incident HF occurring after Visit 4.
Cox regression with cross tabulations of BMI
categories at Visit 4 and at each of the earlier
time points (Visit 1 or age 25, in separate
models) was performed to assess the
association of different weight history patterns
with incident HF.
Results: Over the 9 years from Visit 1 to 4, 72%
remained in a stable BMI category, 23%
increased to a higher BMI category and 5%
decreased. Less weight stability was seen from
age 25 to Visit 4 (33% stable, 65% increased, 2%
decreased). Higher HF risk was seen with
increases in BMI category from Visit 1 to 4 (HR
1.26 [1.07-1.49]) and from age 25 to Visit 4 (HR
1.44 [1.24-1.67]) relative to stable weight, with
non-significant risk if BMI category decreased.
In analyses assessing combinations of BMI
categories at Visit 4 and at an earlier time point
(Table), higher BMI category at an earlier time
point was associated with greater risk within
each Visit 4 BMI category. Individuals who
remained obese at both time points had the
highest risk of incident HF.
Conclusion: Prior elevated weight and
increasing weight over time are associated with
an increased risk of HF. Weight history may be
more informative than single anthropometric
measurements for assessing HF risk.
C.E. Ndumele: None. L. Cobb: None. M. Lazo:
None. N. Bello: None. A. Shah: None. V. Nambi:
None. R.S. Blumenthal: None. G. Gerstenblith:
None. S.D. Solomon: None. C.M. Ballantyne:
None. E. Selvin: None. J. Coresh: None.
46
A Randomized Trial of Moderate and Intensive
Exercise on Fatty Liver and Cardiometabolic
Risk Factors in Obese Adults
Huijie Zhang, Xuejun Li, The First Hosp of
Xiamen, Xiamen Univ, Xiamen, China; ZhiMin
Ma, the Second Affiliated Hosp of Soochow
Univ, Suzhou, China; LingLing Pan, Shanghai Inst
of Endocrinology and Metabolism, Shanghai,
China; Zheng Chen, zhufeng Huang, ChengKun
Han, Shi Chen, XiongJie Zhuang, Mingzhu Lin,
ZhiBin Li, The First Hosp of Xiamen, Xiamen
Univ, Xiamen, China; Jiang He, Tulane Univ Sch
of Public Health and Tropical Med, New
Orleans, LA; ShuYu Yang, The First Hosp of
Xiamen, Xiamen Univ, Xiamen, China; Xiaoying
Li, Shanghai Inst of Endocrinology and
Metabolism, Shanghai, China
Corresponding authors: Shu-yu Yang, Xiamen
Diabetes Institute, Department of
Endocrinology and Metabolism, The First
Hospital of Xiamen, Xiamen University, 55
Zhenhai Road, Xiamen 361003, China (
[email protected]). Jiang He, MD, PhD,
Department of Epidemiology, Tulane University
School of Public Health and Tropical Medicine,
1440 Canal St, Ste 2000, New Orleans, LA 70112
([email protected]). Xiao-Ying Li, MD, PhD,
Department of Endocrinology and Metabolism,
Rui-Jin Hospital, Shanghai Jiao-Tong University
School of Medicine, 197 Rui-Jin 2nd Road,
Shanghai 200025 ([email protected]).
Introduction: Nonalcoholic fatty liver disease
(NAFLD) and its cardiovascular complications
are common public health problems.
Hypothesis: Although the benefit of exercise on
NAFLD and cardiometabolic risk factors is
documented, the effects of intensive and
moderate exercise on these outcomes have not
been thoroughly investigated..
Methods: We conducted a randomized
controlled trial among 220 individuals aged 4065 years with a waist circumference of ≥90 cm
in men and ≥85 cm in women. NAFLD was
defined by proton magnetic resonance
spectroscopy (1H-MRS). Participants were
randomly assigned to the intensive exercise
group (vigorous exercise at 65-80% maximum
oxygen consumption by running on a treadmill
30 min/day and 5 days/week for 6 months,
followed by moderate exercise by brisk walking
150 min/week for another 6 months), the
moderate exercise group (brisk walking 150
min/week for the entire 12 months), or the
usual care control (lifestyle counseling for 12
months). The primary outcome was the change
of intra-hepatic triglyceride content as
determined by 1H-MRS. Secondary outcomes
were metabolic risk factors.
Results: At 12 months, the mean change of
intra-hepatic triglyceride content from baseline
was -6.10% in the intensive exercise, -5.91% in
the moderate exercise, and -2.73% in the
control groups (P<0.0001). Compared to the
control group,the intensive and moderate
exercise groups had significant net reductions
of intra-hepatic triglyceride content at 6 months
(-4.56%, 95% CL-6.71 to -2.42, p<0.001 for
intensive and -3.86%, 95% CL-6.01 to -1.71,
p<0.001 for moderate) and 12 months (-3.37%,
95% CL-5.52 to -1.22, p<0.001 for intensive, and
-3.19%, 95% CL-5.34 to -1.04, p<0.001 for
moderate). The net changes of intra-hepatic
triglyceride content were not significantly
different between the two exercise groups.
Both intensive and moderate exercise reduced
waist circumference, body weight, and blood
pressure; additionally, intensive exercise
reduced body fat mass, visceral fat, and body
fat percent.
Conclusions: Moderate intensity and vigorous
intensity exercise were equally effective in
improving NAFLD and blood pressure while
vigorous exercise produced greater reductions
of body fat.
H. Zhang: None. X. Li: None. Z. Ma: None. L.
Pan: None. Z. Chen: None. Z. Huang: None. C.
Han: None. S. Chen: None. X. Zhuang: None. M.
Lin: None. Z. Li: None. J. He: None. S. Yang:
None. X. Li: None.
47
Subclinical Atherosclerosis and 20-Year
Cognitive Decline: The Atherosclerosis Risk in
Communities (ARIC) Neurocognitive Study
Shelly-Ann M Love, Priya Palta, Corey A
Kalbaugh, Univ of North Carolina at Chapel Hill,
Chapel Hill, NC; A.Richey Sharrett, Johns
Hopkins Univ, Baltimore, MD; Alden L Gross,
Johns Hopkins Univeristy, Baltimore, MD;
Alvaro Alonso, Univ of Minnesota, Minneapolis,
MN; Lisa M Wruck, Michelle L Snyder, Univ of
Thomas H Mosley, Univ of Mississippi Medical
Ctr, Jackson, MS; Gerardo Heiss, Univ of North
Carolina at Chapel Hill, Chapel Hill, NC
Introduction: Cardiovascular risk factors are
reportedly predictive of cognitive decline and
dementia but the association between the
extent and severity of subclinical
atherosclerosis with cognitive decline remains
understudied.
Hypothesis: The systemic burden of
atherosclerosis measured non-invasively is
associated with the rate of decline in domainspecific (memory, executive function and
language) and global cognition from mid-life to
late life.
Methods: Members of the ARIC cohort
(N=12313; 58% women, 24% African American
(AA), 76% white) aged 46-70 years at their
1990-1992 examination were followed through
2011-2013. Participants with prevalent stroke,
myocardial infarction or coronary heart disease
were excluded. Atherosclerosis at baseline
(n=5217) was assessed by carotid artery bmode ultrasound (presence and number of
plaques, bilaterally) and by ankle-brachial index
<0.9 measured with an oscillometric device.
Tests of memory (Delayed Word Recall Test),
executive function (Digit Symbol Substitution
Test), and language (Word Fluency Test) were
administered in 1990-92, 1996-98 and 2011-13.
Test-specific z scores were calculated at each
exam based on the means and standard
deviations at baseline. A global cognition z score
was estimated by averaging the 3 test-specific z
scores and standardizing to baseline. Racestratified linear random effects regression was
used to estimate the association between
subclinical atherosclerosis and 20-year declines
in domain-specific cognition and global
cognition. We adjusted for age, sex and level of
education. Inverse probability weighting (IPW)
was used to limit bias due to attrition.
Results: In AA, the presence of carotid plaque
and/or ABI <0.90 (n=490) was associated with a
lower memory z score (Beta=-0.10, 95%
confidence interval, CI: -0.18, -0.02), a lower
language z score (Beta=-0.07, 95% CI: -0.14,0.002) and a lower global cognition z score at
baseline (Beta=-0.09, 95% CI: -0.16, -0.02), but
not with rates of change in any cognitive score.
Among whites at baseline, individuals with
subclinical atherosclerosis (n=4099) exhibited
lower executive function (Beta=-0.05, 95% CI: 0.08, -0.02) and global cognition (Beta=-0.04,
95% CI: -0.07, -0.01). White participants with
subclinical atherosclerosis had a greater 20-year
rate of decline in global cognition (Beta=-0.06,
95% CI: -0.10, -0.00) compared to those without
subclinical atherosclerosis.
Conclusions: Baseline memory, language, and
global cognition in AA and executive function
and global cognition in whites were lower
among those with non-invasively ascertained
atherosclerosis compared to those without,
independent of covariates in the model. Among
whites, subclinical clinical measures of
atherosclerosis in mid-life may be indicative of
modest, but measurable declines in cognition
after additional adjustment for potential bias
due to attrition.
S.M. Love: None. P. Palta: None. C.A.
Kalbaugh: None. A. Sharrett: None. A.L. Gross:
None. A. Alonso: None. L.M. Wruck: None. M.L.
Snyder: None. T.H. Mosley: None. G. Heiss:
None.
48
Long-Term Patterns in the Development of
Multiple Cardiovascular Diseases: The
Framingham Heart Study
Norrina B Allen, Hongyan Ning, John Wilkins,
Northwestern Univ, Chicago, IL; Daniel Levy,
NHLBI, Framingham, MA; Donald Lloyd-Jones,
Northwestern Univ, Chicago, IL
Background: Having a first CVD event increases
the risk for subsequent events; however, the
long-term patterns in the development and
sequence of multiple CVDs, including stroke,
myocardial infarction (MI) and chronic heart
failure (CHF) are unknown. The aim of this study
was to identify distinct long-term patterns in
the order and timing of MI, stroke and CHF
occurrence.
Methods: We used publicly available data from
the Framingham Heart Study (FHS). The
occurrence of fatal/non-fatal MI, stroke and
CHF were examined separately using discrete
mixture modeling implemented in SAS (Proc
Traj) to identify trajectory groups for the risk of
each CVD event starting at age 30. We included
both first and subsequent events. Clusters of
disease specific trajectory groups were
examined. Baseline demographics and risk
factors were compared across clusters.
Results: Among 5,079 participants (ppts) in FHS,
we identified 8 unique patterns in the
development of CVDs (see figure). The majority,
72.5%, of Framingham ppts experienced
average age- related increases in the yearly risk
for all three endpoints of MI, stroke and heart
failure (Average Risk group) other groups
experienced early or higher risks for specific
CVDs including the High CHF Risk group (6% of
ppts), Early CHF group (2%), High Stroke Risk
group (9%), High CHF and Stroke Risk group
(1%), High MI Risk group (4%), High MI and CHF
Risk group (1%), Early CHF and MI Risk group
(1%). Groups in which stroke and/or HF risk was
elevated had higher prevalence of smoking and
greater baseline BP levels; those groups at
elevated risk of MI had higher total cholesterol
levels and higher BMI.
Conclusions: We identified distinct patterns in
development and ordering of MI, stroke and
CHF associated with diverse risk factor profiles.
By understanding the life-course and likely
sequence of CVD events related to distinct risk
factor profiles, clinicians may be able to
consider personalized prevention strategies
with the highest likelihood of preventing first
CVD events and reducing the overall burden of
CVD.
N.B. Allen: None. H. Ning: None. J. Wilkins:
None. D. Levy: None. D. Lloyd-Jones: None.
49
Changes in Circulating Natriuretic Peptide and
Adiponectin Levels and All-cause Mortality in
Older People: The Cardiovascular Health Study
Jorge R Kizer, Albert Einstein Coll of Med,
Bronx, NY; Petra Buzkova, Alice M Arnold, Univ
of Washington, Seattle, WA; Christopher
deFilippi, Univ of Maryland Sch of Med,
Baltimore, MD; Elsa S Strotmeyer, Univ of
Pittsburgh, Pittsburgh, PA; Jason L Sanders,
Robert C Kaplan, Albert Einstein Coll of Med,
Bronx, NY; Mary Cushman, Univ of Vermont,
Colchester, VT; Stephen B Kritchevsky, Wake
Forest Sch of Med, Winston-Salem, NC; Calvin H
Hirsch, UC Davis Health System, Sacramento,
CA; Anne B Newman, Univ of Pittsburgh,
Pittsburgh, PA
Background: Despite its insulin-sensitizing and
atheroprotective properties, higher plasma
adiponectin (APN) has been linked to increased
mortality in older adults. The basis for this
adverse association is not well delineated, but
natriuretic peptides (NPs) have been invoked as
a potential explanation because they are known
to stimulate APN secretion. One prospective
study showed that adjustment for baseline NP
levels attenuated APN’s relationship with
mortality, but another demonstrated
persistence despite such adjustment. The
relationship between serial changes in NP and
APN levels, however, and their association with
fatal events, has not been previously examined.
Methods: We used linear regression to estimate
the association of change (Δ) in N-terminal proB-type natriuretic peptide (NT-proBNP) with
concurrent ΔAPN, and Cox regression to
estimate the relative risk of death for ΔNTproBNP and ΔAPN in a population-based study
of older adults (Cardiovascular Health Study).
NT-proBNP and APN were measured in stored
plasma from the 1996 exam to complement
previous measures of both analytes obtained at
the 1992 exam. There were n=2669 participants
with all measures; APN values were well
harmonized across the 2 exams, but because
NT-proBNP values >1000 pg/ml were not, we
excluded such values (n=238) from the primary
analysis. Both annualized change and average
level across both years were considered in
order to distinguish true change from improved
precision from repeated measurement.
Results: Age 77±4 yrs, 62% women; ΔNTproBNP 15±37 pg/mL/yr; ΔAPN 0.3±1.2
mg/L/yr. After full adjustment (age, sex, race,
smoking, alcohol, Δweight, Δglucose, albumin,
medications, prevalent CVD, health status,
eGFR, and CRP), ΔNT-proBNP, but not mean NTproBNP, was positively associated with ΔAPN
(0.1 mg/L/yr [0.06, 0.16] APN increase per SD
increment in ΔNT-proBNP). During follow-up
through 2010, 1792 participants died. In fully
adjusted models, both mean APN and ΔAPN
were significantly associated with mortality (HR
per SD increment 1.06 [1.00, 1.12] and 1.1
[1.05, 1.16], respectively), whereas mean NTproBNP (1.25 [1.18, 1.33]), but not ΔNT-proBNP,
was significantly related to this outcome. When
both measures of APN & NT-proBNP were
included in a fully adjusted model, mean APN
ceased to be significant, but associations of
ΔAPN and mean NT-proBNP with mortality
were not materially changed. Sensitivity
analysis including NT-proBNP >1000 pg/mL with
winsorization at the upper 99th %ile of NTproBNP showed similar findings.
Conclusion: These findings provide new insights
into APN’s association with mortality in older
adults, showing that (i) longitudinal change in
NT-proBNP is associated with change in APN;
and (ii) it is this longitudinal change in APN,
independent of concurrent change or average
level of NT-proBNP, but not the adipokine’s
mean level, that is associated with increased
mortality.
J.R. Kizer: None. P. Buzkova: None. A.M.
Arnold: None. C. deFilippi: None. E.S.
Strotmeyer: None. J.L. Sanders: None. R.C.
Kaplan: None. M. Cushman: None. S.B.
Kritchevsky: None. C.H. Hirsch: None. A.B.
Newman: None.
50
Hypertension, Antihypertensive Treatment,
Sodium Intake and Cognitive Decline
Bernhard Haring, Univ of Wuerzburg,
Wuerzburg, Germany; Chunyuan Wu, Fred
Hutchinson Cancer Res Ctr, Seattle, WA; Laura
H. Coker, Wake Forest Sch of Med, WinstonSalem, NC; Arjun Seth, Albert Einstein Coll of
Med, Bronx, NY; Linda Snetselaar, Univ of Iowa
Coll of Public Health, Iowa, IA; JoAnn E Manson,
Harvard Univ, Boston, MA; Jacques Rossouw,
Natl Heart, Lung, and Blood Inst, Bethesda, MD;
Sylvia Wassertheil-Smoller, Albert Einstein Coll
of Med, Bronx, NY
Objective
Our objective was to investigate the
relationships of hypertension, antihypertensive
treatment and sodium intake on cognitive
decline in older postmenopausal women.
Methods
Prospective follow-up of 6,426 cognitively intact
women aged 65 to 79 years old enrolled in the
Women’s Health Initiative Memory Study
(WHIMS) with a median follow-up of 9.1 years.
Dietary sodium intake was determined by food
frequency questionnaires. Cognitive functioning
was assessed annually by 3MS scores,
neurocognitive and neuropsychiatric
evaluations. Cognitive decline was identified by
the incidence of mild cognitive impairment
(MCI) or probable dementia (PD). Cox
proportional hazards analyses were used to
calculate hazard ratios (HRs) for the risk of
cognitive decline.
Results
Hypertension was associated with an increased
risk for cognitive decline (HR 1.23; 95% CI 1.06,
1.43; p=0.006) in elderly women.
Antihypertensive treatment was related to an
increased risk for cognitive decline with women
having blood pressure elevations
≥140/90mmHg being at highest risk (HR 1.38;
95% CI 1.12, 1.60; p=0.01) compared to
normotensive women without antihypertensive
medication. High sodium intake (>1500mg/d)
did not significantly alter the risk for cognitive
decline in hypertensive women or women with
antihypertensive treatment (p for interaction = 0.98
or 0.93).
Conclusions
In elderly postmenopausal women,
hypertension or antihypertensive therapy was
associated with an increased risk for developing
cognitive decline. High sodium intake did not
modify the risk for cognitive decline in
hypertensive women or women receiving
entihypertensive medication.
B. Haring: None. C. Wu: None. L.H. Coker:
None. A. Seth: None. L. Snetselaar: None. J.E.
Manson: None. J. Rossouw: None. S.
Wassertheil-Smoller: None.
51
Heart Rate Variability and its Association with
Cognitive Decline Over 20 years: The
Atherosclerosis Risk in Communities Neurocognitive Study
Faye L Lopez, Lin Y. Chen, Univ of Minnesota,
Minneapolis, MN; Elsayed Z. Soliman, Wake
Forest Univ Sch of Med, Winston-Salem, NC;
Jennifer A Deal, Rebecca F. Gottesman, Johns
Hopkins Bloomberg Sch of Public Health,
Baltimore, MD; Gerardo Heiss, Univ of North
Carolina, Chapel Hill, NC; Thomas H Mosley,
Univ of Mississippi, Jackson, MS; Alvaro Alonso,
Univ of Minnesota, Minneapolis, MN
Background– Heart rate variability (HRV)
reflects activity of the sympathetic and
parasympathetic nervous systems. Low HRV is
associated with an increased risk of heart
disease and mortality, and risk factors for lower
HRV are also linked to cognitive impairment.
We assessed whether HRV measures are
associated with cognitive decline in the
Atherosclerosis Risk in Communities (ARIC)
study.
Methods – We studied 10,623 individuals (23%
African-American, 57% female, mean age 54).
HRV measures were obtained from 2-minute
electrocardiogram rhythm strips in 1987-89 and
include the standard deviation of all normal RR
intervals (SDNN), root mean square of
successive differences (rMSSD), low frequency
(LF) and high frequency (HF) spectral power,
and the LF/HF ratio. Cognitive function was
measured in 1990-92, 1996-98 and 2011-2013
using 3 neuropsychological tests: Delayed Word
Recall (DWR), Digit Symbol Substitution (DSS),
and Word Fluency (WF). Scores were
standardized and their average was used as a
test of global cognitive function. HRV measures
were log-transformed and we used linear
regression models fit with generalized
estimating equations to evaluate associations
with cognitive performance over time, which
was modeled as a linear spline with a knot at
year 6 of follow-up.
Results – At baseline, lower levels of HRV were
significantly associated with reduced scores in
all cognitive tests. Lower baseline levels of HRV
measures of sympathetic activity (LF and LF/HF
ratio) were associated with faster decline in
tests evaluating executive function and
language (DSST and WF) (table). We did not
observe associations between parasympathetic
nervous system measures (rMSSD and HF) and
cognitive decline.
Conclusion – In this large population-based
study, markers of cardiac sympathetic
dysfunction measured in mid-life were
associated with a faster decline in executive
function, which is more frequently affected in
cognitive impairment of vascular origin.
Additional research should explore the
mechanism for this association.
F.L. Lopez: None. L.Y. Chen: None. E.Z.
Soliman: None. J.A. Deal: None. R.F.
Gottesman: None. G. Heiss: None. T.H. Mosley:
None. A. Alonso: None.
National Center
52
Purpose in Life and its Relationship to AllCause Mortality and Cardiovascular Events: A
Meta-Analysis
Randy Cohen, Chirag Bavishi, Alan Rozanski, Mt.
Sinai St. Luke's-Roosevelt, New York, NY
Background: Purpose in life is a component of
psychological well-being and has been
associated in some studies with reduced
mortality. To assess the net impact of purpose
in life on cardiovascular events, we performed a
meta-analysis of all relevant studies.
Methods: A systemic search was undertaken to
identify all studies investigating the relationship
between purpose in life, all-cause mortality and
cardiovascular events. Unadjusted and adjusted
effect estimates were pooled using random
effects model.
Results: 10 prospective studies (n =137,142,
mean follow-up 8.5 years) were included in the
analysis. A significant association was observed
between having a higher purpose in life and
reduced all-cause mortality [adjusted pooled
relative risk (RR): 0.77 (CI: 0.69-0.86), p<0.001]
and cardiovascular events [adjusted RR: 0.81
(CI: 0.73-0.90), p<0.001]. Subgroup analyses
yielded similar results.
Conclusions: Possessing a high sense of purpose
in life is associated with a reduced risk for allcause mortality and cardiovascular events.
Future research should focus on strategies to
assist individuals identified as having a low
sense of purpose in life.
R. Cohen: None. C. Bavishi: None. A. Rozanski:
None.
53
Transcriptomics and Methylomics of
Atherosclerosis in Circulating Monocytes - the
Multi-Ethnic Study of Atherosclerosis
Yongmei Liu, Jingzhong Ding, Lindsay M
Reynolds, Jackson R. Taylor, Kurt Lohman, Wake
Forest Univ Sch of Med, Winston-Salem, NC;
David Siscovick, New York Acad of Med, New
York, NY; Stephen S Rich, Univ of Virginia,
Charlottesville, VA; Bruce M Psaty, Joel D.
Kaufman, Univ of Washington, Seattle, WA;
Gregory Burke, Wake Forest Univ Sch of Med,
Winston-Salem, NC; Steven Shea, Columbia
Univ, New York, NY; David R. Jacobs Jr., Univ of
Minnesota, Minneapolis, MN; James H. Stein,
Univ of Wisconsin, Madison, WI; Ina Hoeschele,
Virginia Tech, Blacksburg, VA; Russell P Tracy,
Univ of Vermont, Colchester, VT; Wendy Post,
Johns Hopkins Univ, Baltimore, MD; David M
Herrington, Wake Forest Univ Sch of Med,
Winston-Salem, NC
Little is known regarding the transcriptional and
epigenetic basis for atherogenesis and
cardiovascular disease (CVD) risk. Here we
integrate transcriptomic (Illumina HumanHT-12
v4) and methylomic (Illumina 450K array) data
from purified monocytes with concurrent CVD
risk factors and measures of atherosclerosis carotid plaque (CP) identified using ultrasound
and coronary artery calcium (CAC), from 1,208
randomly selected participants (554 whites, 260
blacks, 394 Hispanics) of the Multi-Ethnic Study
of Atherosclerosis (MESA). Association analysis
was performed using linear and logistic
regression, adjusting for demographics,
technical covariates, and other known CVD risk
factors. A false discovery rate (FDR) <0.05 was
used to control for multiple comparisons.
RESULTS: We identified expression of two
genes, ARID5B (a transcription factor) and
PDLIM7, positively associated with both CP and
CAC, and 17 additional genes associated with
only CAC. We also identified 29 and seven
differentially methylated CpGs associated with
CP and CAC, respectively, including a CpG at
ILVBL associated with both CP and CAC. Eleven
of these atherosclerosis CpGs were also
associated with cis-gene expression, including
an ARID5B expression-associated methylation
site (cg25953130, ARID5B intron) which
overlapped a predicted strong enhancer, a
transcription factor binding site (for EP300), and
a DNase I hotspot (ENCODE and BLUEPRINT
monocyte data). The inverse association
between methylation of this ARID5B CpG and
atherosclerosis (CP:p=4.3x10-7, FDR=0.01; CAC:
p= 2.4x10-5, FDR=0.32) appeared to be
mediated through ARID5B expression (CP:
p=2.1x10-4, CAC: p=2.1 x10-3, using Structural
Equation modeling with bootstrapping).
Furthermore, many other known risk factors for
CVD (age, ethnicity, body mass index, diabetes,
HDL, and interleukin-6 levels) were also
associated with ARID5B expression at genomewide levels of significance. The ARID5B
associations with atherosclerosis at gene
expression and methylation levels together
explain an additional 2.3% variability in CP
above and beyond known CVD risk factors, and
were consistent across age (< or ≥65 years), sex,
race/ethnicity, CVD status, or statin use
subgroups, as well as the independent sites of
data collection. ARID5B expression was also
positively associated with prevalent CVD
(p=0.006).
CONCLUSIONS: The concurrent multi-omic
profiling of atherogenic-related cells coupled
with state-of-the-art measurements of
atherosclerosis in a large, well-phenotyped,
multi-ethnic cohort provide novel insights into
the biomarkers and the potential molecular
mechanisms of atherosclerosis. In particular,
our data on ARID5B, taken together with
previously reported experimental evidence for
its role in promoting lipid accumulation and
smooth muscle cell differentiation, strongly
suggests an atherogenic role for this gene.
Y. Liu: None. J. Ding: None. L.M. Reynolds:
None. J.R. Taylor: None. K. Lohman: None. D.
Siscovick: None. S.S. Rich: None. B.M. Psaty:
None. J.D. Kaufman: None. G. Burke: None. S.
Shea: None. D.R. Jacobs: None. J.H. Stein:
None. I. Hoeschele: None. R.P. Tracy: None. W.
Post: None. D.M. Herrington: None.
54
Genome-Wide Association Analysis of GeneSodium Interactions on Blood Pressure
Phenotypes: The GenSalt Study
Changwei Li, Tulane Univ Sch of Public Health
and Tropical Med, New Orleans, LA; Jiang He,
Dept of Epidemiology, Tulane Univ Sch of Public
Health and Tropical Med; Dept of Med, Tulane
Univ Sch of Med, New Orleans, LA; James
Hixson, Dept of Epidemiology, Human Genetics
and Environmental Sciences, Univ of Texas Sch
of Public Health, Houston, TX; Dongfeng Gu,
State Key Lab of Cardiovascular Disease, Fuwai
Hosp, Natl Ctr of Cardiovascular Diseases,
Chinese Acad of Medical Sciences and Peking
Union Medical Coll, Beijing, China; Dabeeru
Rao, Div of Biostatistics, Washington Univ Sch of
Med, St. Louis, MO; Lawrence Shimmin, Dept of
Epidemiology, Human Genetics and
Environmental Sciences, Univ of Texas Sch of
Public Health, Houston, TX; Jianfeng Huang,
Union Medical Coll, Beijing, China; Charles Gu,
Div of Biostatistics, Washington Univ Sch of
Med, St. Louis, MO; Jichun Chen, Jianxin Li,
Union Medical Coll, Beijing, China; Cashell
Jaquish, [email protected], Bethesda, MD;
Tanika N. Kelly, Dept of Epidemiology, Tulane
Univ Sch of Public Health, New Orleans, LA
Background: Elevated blood pressure (BP) is a
major public health challenge. Although the
heritability of BP has been long established,
current findings can explain only a small
proportion of the BP variability attributed to
genetic factors. Recent studies indicate that
gene-environmental interactions may help to
identify novel BP loci. Hence, the current study
aimed to identify genetic variants influencing BP
regulation by conducting genome-wide genesodium interaction analyses among 1,906
participants of the Genetic Epidemiology
Network of Salt-Sensitivity (GenSalt) study.
Methods: GenSalt recruited 1,906 Chinese
participants from 633 families. At baseline, one
24-hour and two 8-hour urine specimens were
collected to measure urinary sodium excretion.
Nine BP measurements were taken using a
random zero sphygmomanometer. A total of
868,158 autosomal single nucleotide
polymorphisms (SNPs) were genotyped using
Affymetrix Genomewide Human SNP array 6.0
(Affymetrix, Inc, Santa Clara, CA). Mixed effects
models were used to test genome-wide SNPsodium interactions on BP, adjusting for age,
gender, and body mass index. Promising
findings (interaction term P <1.00×10-6) from
GenSalt were further evaluated for replication
among Chinese participants of the Multi-Ethnic
Study of Atherosclerosis (MESA) with available
data from the database of genotypes and
phenotypes (dbGaP). SNP effects in GenSalt and
MESA were meta-analyzed using inversevariance weighted fixed effect models.
Results: The meta-analyses identified 3 novel
loci that significantly interacted with sodium to
influence BP phenotypes. SNP-sodium
interactions on systolic BP were identified for
NEK2 variant rs10494938 at 1q32.3 (GenSalt
P=2.19×10-6, MESA P=4.35×10-4, and Metaanalysis P= 3.93×10-8). In addition, CASP4
variant rs1944900 at 11q22.3 interacted with
sodium to influence both systolic BP (GenSalt
P=1.24×10-9, MESA P=4.22×10-2, and Meta-
analysis P= 1.14×10-10) and mean arterial
pressure (GenSalt P=1.68×10-9, MESA
P=4.27×10-2, and Meta-analysis P= 1.91×10-10).
Furthermore, C9orf3 variant rs17679141 at
9q22.32 interacted with sodium to influence
diastolic BP (GenSalt P=2.85×10-8, MESA
P=4.55×10-2, and
Meta-analysis P=4.61×10-9). The 3 variants all
physically mapped to the intronic regions of
their corresponding genes.
Conclusion: The current study identified 3 novel
loci which may interact with dietary sodium
intake to influence BP phenotypes.
C. Li: None. J. He: None. J. Hixson: None. D. Gu:
None. D. Rao: None. L. Shimmin: None. J.
Huang: None. C. Gu: None. J. Chen: None. J. Li:
None. C. Jaquish: None. T.N. Kelly: None.
55
Novel Genetic Risk Variants for Kidney
Function: A Large-Scale Exome Array Analysis
of 111,666 European Ancestry Individuals
Man Li, Johns Hopkins Univ Bloomberg Sch of
Public Health, Baltimore, MD; the CKDGen
Consortium
Introduction: Chronic kidney disease (CKD) is a
worldwide public health problem. Although
genome-wide association studies (GWAS) have
identified 29 loci for estimated glomerular
filtration rate (eGFR, a measure of kidney
function), they account for only a small
proportion of the variation in eGFR. Exonic
genetic variants with minor allele frequency
(MAF) < 5% had not been represented well in
existing GWAS.
Hypothesis: Multiple low frequency (MAF 1-5%)
and rare (MAF<1%) exonic variants are
associated with eGFR.
Methods: We meta-analyzed the association
result from 24 studies between eGFR as
estimated from serum creatinine with the
MDRD equation and up to 134,329 genetic
variants genotyped on the Illumina
HumanExome Beadchip (“Exome Array”) in up
to 111,666 European ancestry participants. We
conducted inverse-variance weighted fixedeffect meta-analysis for single variants. To test
for within-gene enrichment of rare exonic
variants, we performed gene-based collapsing
tests (T1 and sequence kernel association test
[SKAT]) incorporating variants annotated as
nonsynonymous or splice site with MAF < 1%.
Results: Among 29 known kidney function loci,
28 of them achieved exome array wide
significance (p < 3.7x10-7, Bonferroni
correction). We identified 8 novel loci
associated with eGFR that achieved exome
array wide significance. The most significant
association was found in the PPM1J gene
(MAF=13%, p=1.17E-14), which encodes the
serine/threonine protein phosphatase. The
lowest frequency variant that achieved exome
array wide significance is at EDEM3 (MAF=2%,
p=5.25E-08), which is involved in endoplasmic
reticulum-associated degradation. We also
identified a novel gene-based association with
eGFR (pskat=5.4x10-8).
Conclusions: Using the exome array, we have
not identified single rare exonic variants
associated with eGFR. With the identification of
common and low-frequency variants and one
gene with enrichment of rare coding variants
associated with eGFR, our findings provide
further insight into the genetic architecture of
kidney function and offer the potential to
provide new insights into the pathogenesis of
CKD.
M. Li: None.
56
Fine-Mapping of Metabochip Lipid Regions in
Global Populations Identifies Signals Unique to
Hispanic Descent Populations and Refines
Previously Identified Lipid Loci
Niha Zubair, Fred Hutchinson Cancer Res Ctr,
Seattle, WA; Mariaelisa Graff, Danyu Lin, Univ
of North Carolina at Chapel Hill, Chapel Hill, NC;
Ani Manichaikul, Univ of Virginia,
Charlottesville, VA; Ida Chen, Harbor-UCLA
Medical Ctr, Torrance, CA; Eli Stahl, Kevin Lu,
Icahn Sch of Med at Mount Sinai, New York, NY;
Iona Cheng, Cancer Prevention Inst of
California, Fremont, CA; Christopher Haiman,
Keck Sch of Med of USC, Los Angeles, CA; Dana
Crawford, Case Western Reserve Univ,
Cleveland, OH; Logan Dumitrescu, Vanderbilt
Medical Ctr, Nashville, TN; Petra Buzkova, Univ
of Washington, Seattle, WA; Steven Buyske,
Rutgers Univ, Piscataway, NJ; Myriam Fornage,
The Univ of Texas Health Science Ctr at
Houston, Houston, TX; Kari North, Univ of North
Carolina at Chapel Hill, Chapel Hill, NC; Charles
Kooperberg, Fred Hutchinson Cancer Res Ctr,
Seattle, WA; Cara Carty, Ctr for Translational
Science, Children's Natl Medical Ctr/George
Washington Univ, Washington D.C., DC
INTRODUCTION:
Genome wide association studies (GWAS) have
identified over 150 loci associated with lipids
traits. The majority of these GWAS were
performed in European Americans (EA); no
large-scale studies exist for Hispanic descent
populations. Additionally, in many cases, the
genetic architecture of these trait-influencing
loci remains largely unknown. To address these
gaps in knowledge, we performed one of the
most ethnically diverse fine-mapping genetic
studies on HDL-C, LDL-C, and triglycerides (TG)
to-date.
HYPOTHESIS:
Here we aimed to identify variants with the
strongest association at each locus, detect
population-specific signals, and refine
previously identified EA GWAS loci.
METHODS:
We used Metabochip data from African
American (AA, ~21,000), Hispanic American (HA,
~20,000), Asian (AS, ~2,000), and Native
American (NA, ~550) participants from the
Population Architecture using Genomics and
Epidemiology (PAGE) Study. We applied
multiple linear regression models and assumed
an additive mode of inheritance to test for
association between genotypes and HDL-C, LDLC, or log-transformed TG levels; lipid levels were
corrected for lipid-lowering medication use.
Model covariates included age, sex, and
principal components of ancestry. We first
conducted a meta-analysis within each ethnic
group separately and then performed a
combined trans-ethnic fixed effects metaanalysis. Significance was defined as p < 1 x 10-6;
equivalent to 0.05/ the mean number of
variants at each Metabochip lipid locus.
RESULTS:
For HDL-C, 19 loci significantly associated in the
trans-ethnic meta-analysis; the top signals at 5
of these loci, APOB, LIPC, STARD3, LIPG, and
APOC1, have not been reported in EA. We
identified a signal unique to HA at APOA5. In
addition, we refined the set of candidate
functional variants at PPP1R3B, LPL, and PLTP.
For LDL-C, 16 loci significantly associated in the
of these loci, PCSK9, APOB, APOA5, CLIP2, and
APOC1, have not been reported in EA. We
identified a signal unique to HA at SLC22A1. In
addition, we refined the set of candidate
functional variants at TIMD4 and LDLR.
For TG, 15 loci significantly associated in the
of these loci, APOB, APOA5, and LIPC, have not
been reported in EA. In addition, we refined the
set of candidate functional variants at ANGPTL3,
MLXIPL, PPP1R3B, and LPL.
CONCLUSIONS:
By taking advantage of the genetic architecture
of ethnically diverse populations, we identified
novel lipid-influencing variants in HA and
refined the set of candidate functional variants
at GWAS lipid loci. Anticipated conditional
analyses will provide further insight into
secondary and ethnic-specific signals. Our
results can guide the creation of more informed
risk models, which can then be used for
targeted prevention efforts, especially for
underrepresented populations.
N. Zubair: None. M. Graff: None. D. Lin:
None. A. Manichaikul: None. I. Chen: None. E.
Stahl: None. K. Lu: None. I. Cheng: None. C.
Haiman: None. D. Crawford: None. L.
Dumitrescu: None. P. Buzkova: None. S.
Buyske: None. M. Fornage: None. K. North:
None. C. Kooperberg: None. C. Carty: None.
MP01
Physical Activity and Incident Cardiovascular
Disease in Women: Is the Relation Influenced
by Level of Global Cardiovascular Risk?
Andrea K Chomistek, Indiana UnivBloomington, Bloomington, IN; Nancy R Cook,
Brigham and Women's Hosp, Boston, MA; Eric
B. Rimm, Harvard Sch of Public Health, Boston,
MA; Paul M. Ridker, Julie E. Buring, I-Min Lee,
Brigham and Women's Hosp, Boston, MA
Background: The inverse association between
physical activity and CVD is well-established and
has been shown in persons with and without
single CVD risk factors. Nonetheless, it is
unknown if physical activity is equally beneficial
for prevention of CVD among women with
varying levels of global cardiovascular risk. Thus,
the purpose of this analysis was to determine
whether level of cardiovascular risk, as assessed
by the Reynolds Risk Score, modifies the
association between physical activity and CVD.
Methods and Results: We conducted a
prospective analysis among 27,636 women
initially healthy women in the Women’s Health
Study, followed from 1992 to 2012. Leisuretime physical activity was reported at study
entry and updated during follow-up.
Participants were divided into 10-year risk
groups of < 5%, 5% to < 10%, 10% to < 20%, and
≥ 20% based on the Reynolds Risk Score. The
primary outcome was total CVD which included
MI, stroke, CVD death, CABG, and PTCA. During
a median of 19.1 years of follow-up, we
documented 1874 new cases of CVD. After
adjustment for other risk factors, the HR of CVD
for active (≥ 500 kcal/wk of physical activity,
sufficient to meet guidelines) compared to
inactive individuals (< 500 kcal/wk) was 0.73
(95% CI: 0.67, 0.80). There was no evidence of
effect modification of this association by level
of cardiovascular risk (p, interaction = 0.72);
physical activity was inversely associated with
CVD risk within all 10-year risk groups. When
the joint association of physical activity and 10year cardiovascular risk was examined, women
with higher 10-year risk based on the Reynolds
score had higher HRs for CVD. However, even
among women with ≥ 20% 10-year risk, being
physically active was associated with lower risk
of CVD (Figure).
Conclusions: In this large prospective cohort of
women, global level of cardiovascular risk did
not modify the inverse association between
physical activity and CVD risk. Thus, women
with low as well as high cardiovascular risk can
benefit from regular exercise.
A.K. Chomistek: None. N.R. Cook: None. E.B.
Rimm: None. P.M. Ridker: B. Research Grant;
Significant; Research grant support from
AstraZeneca and Pfizer. F. Ownership Interest;
Significant; Coinventor on patents held by BWH
that relate to use of inflammatory biomarkers in
CVD and DM that have been licensed to
AstraZeneca and Seimens. J.E. Buring: None. I.
Lee: None.
MP02
Dose Response Relationship Between Physical
Activity and Risk of Heart Failure: A MetaAnalysis
Ambarish Pandey, Univ of Texas Southwestern
Medical Ctr, Dallas, TX; Sushil Garg, Univ of
Minnesota Sch of Med, Minneapolis, TX;
Monica Khunger, All India Inst of Medical
Sciences, New Delhi, India; Colby Ayers, Dharam
Kumbhani, Benjamin Levine, James Delemos,
Jarett Berry, Univ of Texas Southwestern
Medical Ctr, Dallas, TX
Background: Prior studies have shown
qualitative inverse associations between
physical activity (PA)/fitness and risk for heart
failure (HF). However, a comprehensive
assessment of the quantitative dose response
association between PA and HF risk has not
been reported.
Methods: Epidemiological studies that
evaluated associations between PA/fitness and
HF incidence were included. The categorical
dose response association was evaluated by
comparing the pooled HR for HF associated with
different levels of PA (vs. lowest PA level) across
studies. The continuous dose response was
assessed among studies that allowed
quantitative estimation of PA levels using
generalized least square regression models.
Results: After reviewing 2,314 abstracts, 14
prospective cohort studies were included (PA =
12; Fitness = 2); eight allowed quantitative
estimation of PA levels. On pooled analysis, we
observed 21,114 HF events among 393,486
participants (52% women) during a median
follow up period of 15.5 years. The highest
levels of PA were associated with significantly
reduced risk of HF [Pooled HR vs. lowest PA: 0.68
(0.62-0.73)]. Furthermore, higher levels of PA
were associated with lower risk of HF in
categorical as well as continuous dose response
analyses (Figure). Compared to participants
reporting no leisure time PA, those who
engaged in guideline recommended minimum
levels of PA (500 MET*min/week, 2008 US
Federal Guidelines) had only modest reductions
in HF risk [HR: 0.90(0.87 - 0.92)]. In contrast, a
substantial risk reduction was observed among
individuals engaging in advanced guidelines
recommended PA levels [1000 MET-min/week,
HR: 0.81(0.76 - 0.85)]. The magnitude of HF risk
reduction associated with highest levels of PA
was similar in men and women with no
significant interaction by sex. [Pinteraction: 0.64].
Conclusion: There is an inverse dose response
relationship between PA and HF risk. Higher
doses of PA in excess of the current guideline
recommended minimum PA levels might be
required to significantly reduce the risk of HF.
A. Pandey: None. S. Garg: None. M. Khunger:
None. C. Ayers: None. D. Kumbhani: None. B.
Levine: None. J. Delemos: None. J. Berry: None.
MP03
All-Cause Mortality and Cardiorespiratory
Fitness Among Patients with a Family History
of CHD - The FIT Project
Jaideep Patel, VCU Medical Ctr, Richmond, VA;
Mahmoud Al Rifai, Johns Hopkins Ciccarone Ctr
for the Prevention of Heart Disease, Baltimore,
MD; Rupert K Hung, Johns Hopkins Sch of Med,
Baltimore, MD; Khurram Nasir, Ctr for
Prevention and Wellness Res, Baptist Health
Medical Group, Miami Beach, FL; Steve J
Keteyian, Clinton A Brawner, Mouaz H AlMallah, Div of Cardiovascular Med, Henry Ford
Hosp, Detroit, MI; Michael J Blaha, Johns
Hopkins Ciccarone Ctr for the Prevention of
Heart Disease, Baltimore, MD
BACKGROUND: The extent to which
cardiorespiratory fitness (CRF) provides
meaningful risk stratification among those with
a family history (FH) of coronary heart disease
(CHD) is yet to be defined. We compare allcause mortality in individuals with a FH of CHD
to those without.
METHODS: We retrospectively studied 68,947
patients without history of CHD (n=7,980) or
heart failure (n=1,564) who underwent
physician-referred treadmill stress testing
between 1991 and 2009. FH of CHD was defined
as a self-reported compatible history of CHD in
a first-degree relative. CRF was based on peak
estimated metabolic equivalents (METS) and
categorized into 4 groups: <6, 6 to 10, 10 to 12,
and ≥12 METS. Multivariable-adjusted Cox
proportional hazards models were used to
study the association between increasing METS
categories and risk of mortality using the lowest
METS category as the reference. Adjusted
mortality rates were calculated using direct
standardization. Multiplicative interaction
testing was performed for FH and METS
categories.
RESULTS: Overall, 50% (n=34,532) of patients
(mean age 53.5±12 years, 49% males) reported
a FH of CHD. Compared to those without a FH,
those with a FH were more likely to abuse
tobacco (43% vs 40%) and have hyperlipidemia
(47% vs 42%), but less likely to be diabetic (18%
vs 22%). FH was significantly associated with
mortality after adjusting for traditional risk
factors, however an association was not
observed with the addition of METS
[HR(95%CI)]: 0.92(0.88-0.97) and 0.96(0.911.01), respectively. Adjusted mortality rates
were lower with increasing METS categories
(43%,19%,10% and 7% in those without a FH vs
34%,15%,8% and 5%, respectively, in those with
a FH). In fully adjusted models, increasing METS
categories were associated with a lower risk of
mortality (figure), without effect modification
by FH of CHD (P=0.37).
CONCLUSION: CRF limited an independent
mortality association with FH. Higher levels of
CRF were associated with similar reductions in
mortality risk in those with and without a FH of
CHD.
J. Patel: None. M. Al Rifai: None. R.K. Hung:
None. K. Nasir: None. S.J. Keteyian: None. C.A.
Brawner: None. M.H. Al-Mallah: None. M.J.
Blaha: None.
MP04
25 year Physical Activity Trajectories and
Development of Subclinical Coronary Artery
Disease as Measured by Coronary Artery
Calcium: the CARDIA Study
Jamal S Rana, Kaiser Permanente Northern
California, Oakland, CA; Rosenda Murillo,
Northwestern Univ, Chicago, IL; Charles P.
Quesenberry Jr, Michael E. Sorel, Barbara
Sternfeld, Kaiser Permanente Northern
California, Oakland, CA; Kelley P Gabriel, Univ of
Texas, Houston, TX; Mercedes R Carnethon,
Kiang Liu, Northwestern Univ, Chicago, IL; Jared
P Reis, Natl Heart, Lung and Blood Inst,
Bethesda, MD; Norrina B Allen, Donald LloydJones, Northwestern Univ, Chicago, IL; J. Jeffrey
Carr, Vanderbilt Univ, Nashville, TN; Stephen
Sidney, Kaiser Permanente Northern California,
Oakland, CA
Background: Physical activity (PA) has been
shown to be protective against the
development of clinical cardiovascular disease.
There is paucity of data regarding the
association of long term PA patterns and
development of subclinical atherosclerosis, as
measured by coronary artery calcium (CAC).
Studies so far are limited by evaluation of PA
only at baseline. The goal of this study was to
identify 25 year patterns of PA from young to
middle age and its association with
development of CAC.
Methods: CARDIA is a prospective longitudinal
study of black and white men and women, ages
18-30 years at baseline in 1985-86, with up to 7
follow-up exams over 25 years of follow-up. PA
was determined at each exam by a
questionnaire that assessed typical PA during
the past 12 months for 13 types of activities.
Men and women who had at least 3 measures
of PA during the 25 years of follow up and CAC
assessment at the Year 25 exam were included
(N= 3178). CARDIA Physical Activity Score > 300
units is approximately equivalent to >150
min/week of moderate or vigorous physical
activity and was considered as meeting PA
guidelines (MPAG). Latent class modeling was
used to identify unique trajectories of PA. Odds
ratios for CAC were estimated from a
multivariable logistic model controlling for age,
sex, ethnicity, hypertension, diabetes, BMI,
smoking status and education.
Results: Our analyses showed 5 unique PA
trajectories (figure). 1. Maintaining-not MPAG
(46.5%); 2. maintaining-MPAG (35.6%); 3
increasing-MPAG (8.5%); 4. decreasing-MPAG
(6.5%), and 5. maintaining- > 3 fold MPAG
(2.4%). Compared with the maintaining-not
MPAG, the multivariable adjusted odds ratio for
presence of CAC (non-zero CAC score) was 1.02
(95% CI, 0.84-1.24) for maintaining-MPAG, 1.07
(95% CI, 0.78-1.44) for increasing-MPAG ,
1.01(95% CI, 0.72- 1.41) for decreasing-MPAG ,
and 1.37 (95% CI, 0.82-2.27) for maintaining- >
3 fold MPAG.
Conclusion: Long-term trajectories for levels of
PA through young adulthood are not associated
with development of subclinical atherosclerosis
by middle age.
J.S. Rana: None. R. Murillo: None. C.P.
Quesenberry: None. M.E. Sorel: None. B.
Sternfeld: None. K.P. Gabriel: None. M.R.
Carnethon: None. K. Liu: None. J.P. Reis:
None. N.B. Allen: None. D. Lloyd-Jones:
None. J. Carr: None. S. Sidney: None.
MP05
Leisure-Time Running and Incident Type 2
Diabetes
Duck-chul Lee, Iowa State Univ, Ames, IA; Carl J.
Lavie, John Ochsner Heart and Vascular Inst,
New Orleans, LA; Timothy S. Church,
Pennington Biomedical Res Ctr, Baton Rouge,
LA; Xuemei Sui, Steven N. Blair, Univ of South
Carolina, Columbia, SC
Introduction: There is still little evidence on the
dose-response relation between leisure-time
running and incident type 2 diabetes (T2D).
Hypothesis: We examined the hypothesis that
running reduces the risk of developing T2D.
Methods: Participants were 19,347 adults aged
18 to 100 years (mean age, 44) who received an
extensive preventive medical examination
during 1974-2006 in the Aerobics Center
Longitudinal Study. Participants were free of
cardiovascular disease, cancer, and T2D at
baseline. Running and other physical activities
were assessed on the medical history
questionnaire by self-reported leisure-time
activities during the past 3 months. We defined
T2D as fasting glucose ≥126 mg/dl, insulin use,
or physician-diagnosis during follow-up medical
examinations. Cox regression was used to
quantify the association between running and
T2D after adjusting for baseline age, sex,
examination year, body mass index, smoking
status, heavy alcohol drinking, abnormal
electrocardiogram, hypertension,
hypercholesterolemia, and levels of other
physical activities.
Results: During an average follow-up of 6.5
years, 1,015 adults developed T2D.
Approximately 30% of adults participated in
leisure-time running. Runners had a 29% lower
risk of developing T2D compared with nonrunners. The hazard ratios (95% confidence
intervals) of T2D were 0.97 (0.74-1.27), 0.66
(0.49-0.89), 0.62 (0.45-0.85), 0.78 (0.58-1.03),
and 0.57 (0.42-0.79) across quintiles (Q) of
running time (minutes/week); 0.99 (0.76-1.30),
0.60 (0.44-0.82), 0.72 (0.55-0.94), 0.65 (0.470.90), and 0.63 (0.47-0.86) across Q of running
distance (miles/week); 1.08 (0.83-1.40), 0.67
(0.50-0.90), 0.70 (0.53-0.93), 0.61 (0.45-0.83),
and 0.53 (0.36-0.76) across Q of running
frequency (times/week); 0.95 (0.73-1.24), 0.70
(0.52-0.94), 0.62 (0.45-0.84), 0.73 (0.55-0.97),
and 0.58 (0.42-0.80) across Q of total amount of
running (MET-minutes/week); and 0.95 (0.711.28), 0.76 (0.59-0.99), 0.59 (0.42-0.83), 0.66
(0.51-0.85), and 0.62 (0.43-0.90) across Q of
running speed (mph), respectively, compared
with no running after adjusting for confounders
including levels of other physical activities.
Conclusions: Participating in leisure-time
running is associated with markedly lower risk
of developing T2D in adults. Except for those in
the very lowest Q for running doses, even
relatively low running doses (starting with Q 2)
were associated with marked reductions in T2D
risk over time, supporting the prescription of
running to reduce T2D.
D. Lee: None. C. Lavie: None. T. Church:
None. X. Sui: None. S. Blair: None.
MP06
Sport Club Participation During Adolescence
and Sports-Related Physical Activity During
Adulthood in Relation to Mortality From
Cardiovascular Disease: The JACC Study
Krisztina Gero, Hiroyasu Iso, Akihiko Kitamura,
Osaka Univ Graduate Sch of Med, Osaka, Japan;
Kazumasa Yamagishi, Univ of Tsukuba Faculty of
Med, Ibaraki, Japan; Hiroshi Yatsuya, Fujita
Health Univ Sch of Med, Aichi, Japan; Akiko
Tamakoshi, Hokkaido Univ Graduate Sch of
Med, Sapporo, Japan
Background and Purpose:
Taking part in cultural or sport club activities
during Junior and Senior high school years is an
integral part of Japanese culture. This study
examines potential effects of sport club
participation during Junior and Senior High
School and sports-related physical activity
during adulthood on mortality from
cardiovascular disease (CVD).
Methods:
Between 1988 and 1990, as part of the Japan
Collaborative Cohort (JACC) Study, 29 526 men
and 41 044 women aged 40 to 79 years with no
history of coronary heart disease (CHD),
cerebrovascular disease, or cancer responded
to a questionnaire, which included questions
regarding the frequency of sports participation
at baseline and sport club participation during
Junior and Senior high school. A follow-up study
was conducted until the end of 2009, and 4230
cardiovascular deaths (870 CHD and 1859
stroke) were identified. Cox proportionalhazard regression model was used to estimate
hazard ratios first separately, and then
combined for sports participation during Junior
and Senior high school, and sports participation
during adulthood at baseline. The multivariate
model was adjusted for age, sex, BMI, history of
hypertension, history of diabetes, smoking
status, alcohol intake, hours of sleep, age of
completed education, job style, stress, fish
intake, and walking time.
Results:
Men and women participating in sports
activities at baseline for 5 hours or more per
week had a 19% lower risk of CVD mortality
compared to the reference category of 1 to 2
hours of sports-related physical activity per
week. When examined separately, participation
in sport clubs during Junior or Senior high
school years was not associated with mortality
from CVD. The multivariate-adjusted hazard
ratios (95% confidence interval) for CHD and
CVD were 0.79 (0.58-1.08) and 0.81 (0.71-0.94),
respectively, for sports participation at baseline
(≥5h/week versus 1-2h/week); and 0.97 (0.831.13) and 0.99 (0.93-1.06), respectively, for
sport club participation during Junior or Senior
high school years (participants versus non
participants). When combined, compared to
men and women who did sports for less than
5h/week at baseline and did not participate in
sport clubs in Junior or Senior high school, the
multivariate-adjusted hazard ratio of CHD for
those who did sports for ≥5 h/week and
participated in sport clubs was 0.70 (0.46-1.07),
and for those who did sports for ≥5h/week but
did not participate in sport clubs was 0.90 (0.631.27). The corresponding multivariate-adjusted
hazard ratios for total CVD were 0.79 (0.660.95) and 0.80 (0.68-0.94), respectively.
Conclusion:
Participating in sports activities during
adolescence might have an additional riskreducing effect for CHD mortality among those
who participate in sports activities during
adulthood.
K. Gero: None. H. Iso: None. A. Kitamura:
None. K. Yamagishi: None. H. Yatsuya: None. A.
Tamakoshi: None.
MP07
Rising Incidence and Prevalence of Atrial
Fibrillation from 2004 to 2013: A CommunityBased Study Using Electronic Medical Records
Brent Williams, Peter Berger, Geisinger Health
System, Danville, PA
Introduction: Atrial fibrillation (AF) is the most
common cardiac arrhythmia observed in clinical
practice and is associated with an elevated risk
of stroke and mortality. Evaluating communitylevel temporal trends in AF incidence and
prevalence serve to describe the evolving public
health and clinical burden of AF, however
recent studies describing AF trends in
community-based settings have been
inconsistent, with no recent data evaluating
trends among individuals under 65 years of age.
Accordingly, this study sought to describe
community-level trends in AF incidence and
prevalence from 2004 to 2013 using the
electronic medical records (EMR) of a single,
large health care system.
Methods: This study includes 329,634 patients
receiving primary care and other health care
services through the Geisinger Health System
(Geisinger) over at least a two-year period.
Geisinger consists of over 40 outpatient and
seven inpatient facilities spread throughout
central and northeastern Pennsylvania.
Geisinger’s extensive EMR data repository
contains information on demographics, vital
signs, social history, diagnoses, medical history,
problem lists, medications, procedures,
laboratory results, and billing information from
all Geisinger encounters since 2001. Incident
and prevalent AF were identified by ICD-9 codes
observed within any EMR domain. For incident
AF, cases had no AF ICD-9 code in the EMR for
at least two years prior to the diagnosis.
Incidence and prevalence rates were age- and
sex-adjusted to the 2010 US census and
reported per 1000 person-years (persons).
Stratified rates are reported across age groups
(<45, 45-54, ⋯ , >85) and sex.
Results: Age- and sex-adjusted AF incidence
rates remained relatively stable from 2004 to
2008, but increased sharply thereafter.
Incidence rates were 5.0, 5.2, and 8.4 cases per
1000 person-years in 2004, 2008, and 2013,
respectively. The overall annual increase was
5.5% per year (95% CI: 4.8, 6.3%). Incidence
rates increased significantly in all age and
gender groups, with the largest relative increase
observed among patients <45 years of age
(annual increase in males: 10.8%, females:
11.6%). Prevalence rates increased consistently
throughout the entire 10-year period from 23.5
to 39.2 AF cases per 1000 persons from 2004 to
2013 (6.0% annual increase; 95% CI: 5.7, 6.4%).
Conclusions: AF incidence and prevalence have
been increasing in the community over the last
10 years. Increases were observed in all age and
gender groups, with notable increases in the
very young. Prevailing trends may be
attributable to increased application of AF
diagnostics in an aging population and/or an
increased clinical recognition of AF due to the
recent availability of novel oral anticoagulants
for stroke prevention. A mature EMR system
functioning within a large health care system
can be a powerful tool for performing
epidemiologic studies and disease surveillance.
B. Williams: None. P. Berger: None.
MP08
Evaluating the Influence of Bloomberg Era
Policy on New York City Cardiovascular Disease
Mortality Rates
Paulina Ong, Gina Lovasi, Ryan Demmer,
Columbia Univ, New York, NY
Background: Since 2002, under the Bloomberg
administration, New York City (NYC) has
aggressively pursued and implemented a broad
set of public health policies to reduce chronic
disease. Limited research exists evaluating
secular trends in cardiovascular disease (CVD)
mortality against the backdrop of these policy
initiatives.
Hypothesis: We hypothesized that CVD
mortality trends declined more rapidly during
the years 2002-2011 compared with the
previous decade.
Methods: Using individual death certificates of
NYC residents during 1990-2011, all-cause
mortality rates were calculated in addition to
the following cause-specific mortality rates: any
CVD, atherosclerotic CVD (ACVD), coronary
artery disease (CAD), stroke, ischemic stroke.
Mortality rates were age and sex standardized
to the NYC year 2000 population. Joinpoint
regression identified years in which mortality
trends changed after excluding 116,285 deaths
(10% of all deaths) occurring in 9 NYC hospitals
(due to their participation in a cause of death
reporting quality improvement training in 2009,
sponsored by NYC Department of Health &
Mental Hygiene (DOHMH)).
Results: 1,149,217 deaths occurred to NYC
residents from 1990-2011, 566,181 among
women and 583,036 among men. The annual
percent change (APC) in all-cause mortality
rates for women and men were -2.6% and -7.1%
between 1994 and 1998, while rates were
approximately -2.5% for both sexes from 19982011. CVD accounted 49.5% and 37.5% of
deaths among women and men, respectively in
1990; in 2011 these proportions were 40.4%
and 35.3%. Age standardized CVD mortality
rates (per 100,000) for women and men were
391.0 and 357.8 in 1990 vs. 197.2 and 166.2 in
2011. Overall CVD mortality rates increased in
women and men by 1.7% and 0.05% from 19901993 and began to decline in 1993 with APCs of
-3.8% and -4.0% during 1993-2011. In contrast,
the decline in atherosclerotic CVD mortality
accelerated during 2002-2011 (APC=-4.7%) vs.
1990-2002 (APC=-2.4%) among men. Among
women, atherosclerotic CVD rates began to
decline more rapidly in 1993 (APC=-3.2%) and
again in 2006 (APC=-6.6%) vs. 1990-1993
(APC=1.9%). Similar trends were evident for
CAD mortality. Ischemic stroke mortality rates
declined steadily from 1990-2011 in both sexes
and there was no evidence of change in these
trends. Results were generally consistent when
all hospitals were included with the exception
of rates for overall CVD mortality, which began
to show more rapid decline in 2009 immediately following DOHMH cause-of-death
training efforts.
Conclusion: Overall, CVD mortality rates in NYC
did not accelerate during the 2002-2011 period
after accounting for changes in cause of death
reporting. However, atherosclerotic CVD rates
did appear to change in slope (shift to declining
more rapidly) during this period, with possible
differences in timing between men and women.
P. Ong: None. G. Lovasi: None. R. Demmer:
None.
MP09
Using Online Surveillance Tools for Heart
Disease and Stroke Prevention
Linda Schieb, Cathleen Gillespie, Sophia Greer,
Michele Casper, Robert Merritt, CDC, Atlanta,
GA
The Centers for Disease Control and
Prevention’s Division for Heart Disease and
Stroke Prevention has created two unique
online tools that enable researchers, public
health practitioners and clinicians to examine
and document heart disease and stroke
outcomes across geographic regions, time
periods, and sociodemographic groups using
high quality and regularly updated data. This
session will provide attendees an interactive
experience including specific examples of how
these tools can be used in their work.
Tool 1: The National Cardiovascular Disease
Surveillance Data Trends & Maps website
(http://nccd.cdc.gov/DHDSP_DTM) provides
easy access to datasets that document the
public health burden of cardiovascular diseases
and their risk factors at the national, regional,
and state levels. Users can choose to display
data by priority areas (e.g., AHA Cardiovascular
Health Metrics, Million Hearts®) or by data
source. In addition, trends in data over time can
be displayed. These data can inform planning,
implementation, and evaluation of prevention
measures and policies.
Tool 2: The Interactive Atlas of Heart Disease
and Stroke (http://nccd.cdc.gov/DHDSPAtlas) is
an online mapping tool that documents
geographic disparities in heart disease and
stroke and their risk factors at the local level.
With the Atlas, users can create county-level
maps of cardiovascular disease outcomes by
race/ethnicity, gender, and age group. In
addition, users can explore maps showing
county-level contextual factors associated with
cardiovascular disease, including poverty rates
and education levels. Congressional boundaries
and health care facility locations can be overlaid
on any of the maps to allow users to examine
the location of clinical services in relation to
areas of high disease burden. Summary reports
can be generated for targeted regions of
interest.
Using these two tools, this session will describe
how to document the burden of heart disease
and stroke in a specific area, how to compare
data and generate hypotheses related to risk
factors and heart disease, how to identify areas
with poor access to specialist care, and how to
share this information with partners and
collaborators. Attendees will learn how to easily
access maps, tables and graphic displays of
heart disease and stroke data and related risk
factors that can be used to enhance their work
toward the prevention and treatment of
cardiovascular disease in communities
throughout the United States.
L. Schieb: None. C. Gillespie: None. S. Greer:
None. M. Casper: None. R. Merritt: None.
MP10
Text Messaging to Reduce Inactivity Using
Real-Time Step Count Monitoring in Sedentary
Overweight Females
Pamela Ouyang, Kerry J Stewart, McKenzie E
Bedra, Sarah York, Johns Hopkins Univ,
Baltimore, MD; Carolina Valdiviezo, Medstar
Heart and Vascular Inst, Baltimore, MD; Joseph
Finkelstein, Johns Hopkins Univ, Baltimore, MD
Introduction. Prolonged periods of of inactivity
are associated with higher CV morbidity
independent of level of activity. Work and
lifestyle choices today are associated with long
periods of sitting, e.g. computer or screen
watching. Wearable activity monitors such as
pedometers have focused on increasing daily
activity but not on reducing inactivity.
Hypothesis. Sedentary women will decrease
inactivity if given a real time reminder of
inactivity .
Method: We developed a program to monitor
real-time activity levels generated by a
wearable activity monitor (Fitbit). Fitbit
communicated step counts to a smartphone
which sent this information to a database every
15 minutes. When 10 or fewer steps had been
recorded for a 60 min period of time, an
inactivity reminder text message was sent to
the participant to encourage them to move
about. 30 obese women with self-reported > 3
hours of inactivity per day, were enrolled,
provided with a Fitbit and smartphone, and
monitored for 8 weeks. Women were
randomized to two groups. Gp A received
inactivity reminders (IR) for the first 4 weeks
followed by 4 weeks without IR. Gp B received
no IR during the first 4 weeks and IR was given
during the second 4 weeks. We defined
inactivity as ≤ 20 steps in a 2 hr block. We
compared the percent of 2-hr blocks between
8:00 and 24:00 hr where women were inactive
during the 4 weeks with IR-on vs IR-off, for each
of the 2 groups. The mean number of steps per
day over each 4 week block was also compared.
Results:. Gps A and B were similar in age (51.8 +
12.2 y), BMI (37.1 + 6.9), self-reported
hypertension (27% ), diabetes (23 %), and
hyperlipidemia (23%). Fitbit data was available
from 27 women. Gp A (n=15) self-reported 5.2 +
2.5 hr sitting/day at work during IR-off vs 3.9 +
2.7 with IR-on (p<0.004). Gp B (n=12), who had
IR turned on in the second 4 week block, selfreported no change in hours sitting with or
without IR. Activity monitoring data showed
that Gp A were inactive for 32 + 23% of the 2-hr
periods during the 4 weeks with IR-off vs 21 +
14% with IR-on (p < 0.004). However, Gp B had
no difference in inactivity periods (28 + 12%
with IR-off vs 28 + 14 % with IR-on). There were
no differences in mean total daily steps walked
during either 4 week block with IR-on or IR-off
in either Gp.
Conclusion: The use of real-time text messaging
to inform women that they had been inactive
for more than 60 mins was associated with a
reduction in number of inactive periods
independent of the number of steps taken a
day. However, this effect was seen only when
the reminder was implemented soon after
enrollment. The behavior change did not persist
after the reminders stopped. This study
demonstrates that automated real time
reminders can reduce periods of inactivity
though the timing of the intervention affected
the results. Further work will explore the
behavioral factors that could improve the
effectiveness and sustainability of the
intervention.
P. Ouyang: B. Research Grant; Significant;
Society for Women's Health Research. K.J.
Stewart: None. M.E. Bedra: None. S. York:
None. C. Valdiviezo: None. J. Finkelstein: None.
MP11
Fitbit: An Accurate and Reliable Device for
Wireless Physical Activity Tracking
Keith M Diaz, David J Krupka, Melinda J Chang,
Yao Ma, Jeff Goldsmith, Joseph E Schwartz,
Karina W Davidson, Columbia Univ Medical Ctr,
New York, NY
Background: A smart accelerometer named the
Fitbit has recently been introduced in the
consumer market as a physical activity monitor
that can interface wirelessly with mobile
phones and a manufacturer-established website
to allow consumers to track their physical
activity in real-time. The purpose of this study
was to examine the validity and reliability of the
Fitbit for measuring energy expenditure during
treadmill walking and running relative to energy
expenditure assessed by indirect calorimetry.
Methods: A total of 23 healthy adults (10
males, mean age: 30.6 ± 7.9 years; mean BMI:
24.7 ± 3.0 kg/m2) completed a four-phase
treadmill exercise protocol (6 min/phase) under
laboratory conditions. The protocol consisted of
walking at slow (1.9 mph), moderate (3.0 mph),
and brisk (4.0 mph) paces; and jogging (5.2
mph). Participants were fitted with three hipbased Fitbit One devices (two on right, one on
left hip) and two wrist-based Fitbit Flex devices
(one on right and left wrist). Energy expenditure
was measured by gas exchange indirect
calorimetry. Results: The mean difference of
Fitbit-estimated energy expenditure from
measured energy expenditure ranged from -0.8
to 0.4 kcals and -0.2 to 2.6 kcals for the hip- and
wrist-based Fitbit devices, respectively (see
Table). The greatest differences were seen in
the wrist-based Fitbit during moderate and
brisk walking. Across all phases, the withinparticipant correlation of Fitbit-estimated
energy expenditure to measured energy
expenditure was 0.86 to 0.87 for all hip devices
(two on right, one on left hip) and 0.88 for both
wrist devices (left and right wrists). The interdevice correlation between Fitbit-estimated
energy expenditure of the right hip devices was
0.96, between right (front-most) and left hip
devices was 0.97, and between right and left
wrist devices was 0.95. Conclusions: These
results suggest that the Fitbit One and Fitbit
Flex physical activity monitors are valid and
reliable devices for measuring energy
expenditure during physical activity.
K.M. Diaz: None. D.J. Krupka: None. M.J.
Chang: None. Y. Ma: None. J. Goldsmith:
None. J.E. Schwartz: None. K.W. Davidson:
None.
MP12
Electronic Health Record-Based Assessment of
Cardiovascular Health
Randi E Foraker, Abigail B Shoben, Albert M Lai,
Philip R Payne, Marjorie Kelley, Marcelo A
Lopetegui, Michael Langan, The Ohio State
Univ, Columbus, OH; Hilary A Tindle, Vanderbilt
Univ Sch of Med, Nashville, TN; Rebecca D
Jackson, The Ohio State Univ, Columbus, OH
INTRODUCTION. An electronic health record
(EHR)-based visualization tool was developed to
facilitate patient-provider communication
around the American Heart Association’s (AHA)
Life’s Simple 7™ for cardiovascular health (CVH).
The tool automatically populates with patient
data from the EHR and utilizes a stoplight color
scheme to indicate “ideal” (green),
“intermediate” (yellow), and “poor” (red) CVH.
METHODS. CVH was defined for smoking, body
mass index, blood pressure, and cholesterol
according to AHA criteria. For this analysis,
diabetes was characterized as either yellow
(treated) or green (untreated), as most patients
were missing fasting glucose values. An overall
CVH score was calculated and ranged from 0
(worst) to 10 (best) by summing across
behaviors and factors as follows: poor, 0;
intermediate, 1; and ideal, 2. The CVH tool first
launched within the EHR of our outpatient
intervention clinic in October 2013. The change
in CVH of female patients ages 65 and older
seen in the clinic during the pre-intervention
period (May 1 - July 31, 2013) and the postintervention period (May 1 - July 31, 2014) was
described.
RESULTS. One hundred nine women (average
age 74 years; 35% black), seen pre- and postintervention, were enrolled in the study. The
mean CVH score was 6.0 and the mean
fractional score (actual score/maximum
possible) was 0.63 at both time points, and
neither differed significantly by race. Figure 1
shows the distribution of ideal, intermediate,
poor, and missing CVH values for each behavior
and factor in 2013 and 2014. From 2013 to
2014, the proportion of obese women
decreased from 47% to 43%, and the proportion
of normal-weight women increased from 15%
to 19%. Favorable changes were also seen for
diabetes.
CONCLUSIONS. This is the first study to develop
and implement an EHR-based CVH visualization
tool. Our study demonstrates that it is feasible
to implement patient-centered EHR-based tools
at the point-of-care in the primary care setting.
Future work is needed to assess how to best
harness the potential of such tools.
R.E. Foraker: B. Research Grant; Significant;
Salary support on funded project: Pfizer,
Inc. A.B. Shoben: B. Research Grant; Significant;
Inc. A.M. Lai: B. Research Grant; Significant;
Inc. P.R. Payne: B. Research Grant; Significant;
Salary support on funded project: Pfizer, Inc. M.
Kelley: B. Research Grant; Significant; Salary
support on funded project: Pfizer, Inc. M.A.
Lopetegui: B. Research Grant; Modest; Salary
support on funded project: Pfizer, Inc. M.
Langan: B. Research Grant; Significant; Salary
support on funded project: Pfizer, Inc.. H.A.
Tindle: None. R.D. Jackson: B. Research Grant;
Significant; Salary support on funded project:
Pfizer, Inc..
MP13
Types and Sources of Dietary Fatty Acids and
Markers of Diabetes Risk: The NEO Study
Anne J Wanders, Marjan Alssema, Unilever
R&D, Vlaardingen, Netherlands; Eelco J de
Koning, Saskia le Cessie, Leiden Univ Medical
Ctr, Leiden, Netherlands; Peter L Zock, Unilever
R&D, Vlaardingen, Netherlands; Jeanne H de
Vries, Wageningen Univ, Wageningen,
Netherlands; Frits R Rosendaal, Martin den
Heijer, Renée de Mutsert, Leiden Univ Medical
Ctr, Leiden, Netherlands; for the NEO study
group
Introduction: Insufficient and inconsistent
evidence is available on the association
between dietary fatty acids and the
development of type 2 diabetes. The objective
of this study was to examine associations of the
intake of total fat, saturated fat (SFA), monoand poly-unsaturated fat (MUFA, PUFA), trans
fat (TFA), and their food sources (dairy, meat,
plant) with markers of glucose metabolism and
diabetes risk.
Hypothesis: We hypothesized that different
types of fatty acids are differentially associated
with markers of diabetes risk.
Methods: We analysed baseline data of 5,675
non-diabetic men and women, aged 45 to 65
years, from the Netherlands Epidemiology of
Obesity (NEO) study. Habitual intake of fatty
acids was measured using a 125-item semiquantitative food frequency questionnaire.
Glucose and insulin concentrations were
measured before, and 30 and 150 minutes after
a standardized liquid mixed meal, and HOMAIR, HOMA-B and Disposition index were
calculated. Linear regression models were
adjusted for demographic, lifestyle, and dietary
factors. Regression coefficients were expressed
as percentage difference in outcome variable.
Results: Mean (sd) habitual intakes of total fat,
SFA, MUFA, PUFA and TFA were 34.4 (5.8), 12.4
(2.9), 12.2 (2.4), 6.9 (1.9) and 0.6 (0.2) percent
of energy (En%), respectively. As compared with
1 En% of carbohydrates, SFA was weakly
associated with fasting insulin (difference per 1
En%: -1.4%; 95%CI: -2.7, -0.1) and HOMA-B (1.5%; -2.8, -0.2). Total fat, MUFA, PUFA or TFA
were not associated with any marker of
diabetes risk. As compared with 1 En% of
carbohydrates, each of total fat (1.8%; 0.6, 3.1),
SFA (3.4%; 0.0, 6.9), MUFA (4.6%; 1.6, 7.7),
PUFA (16.2%; 5.1, 28.6), and TFA (per 0.1 En%:
9.1%; 1.9, 16.8) from meat sources was
adversely associated with fasting insulin,
whereas fatty acids from dairy and plant
sources were not. Similarly, fatty acids from
meat, and not from dairy and plant sources,
were adversely associated with HOMA-IR,
HOMA-B and Disposition Index.
Conclusion: This cross-sectional analysis
revealed that all types of fatty acid from meat
were adversely associated with markers of
diabetes risk, whereas fatty acids from dairy
and plants were not. This suggests that types
and food sources of fatty acids interact in their
association with markers of diabetes risk. Such
interaction may be the result of differential
effects of specific fatty acids (e.g. C14:0 or
C18:0); other compounds in the food matrices
(e.g. heme iron or sodium); or confounding by
diet or lifestyle factors. Results need to be
confirmed in prospective cohorts with different
dietary patterns.
A.J. Wanders: A. Employment; Significant;
Unilever R&D. M. Alssema: A. Employment;
Significant; Unilever R&D. E.J.P. de Koning:
None. S. le Cessie: None. P.L. Zock: A.
Employment; Significant; Unilever R&D. J.H. de
Vries: None. F.R. Rosendaal: None. M. den
Heijer: None. R. de Mutsert: B. Research Grant;
Modest; Unilever R&D.
MP14
A Prospective Study of the Association
Between Plant-Based Dietary Patterns and
Incident Type 2 Diabetes in Women
Ambika Satija, Shilpa N Bhupathiraju, Walter C
Willett, JoAnn E Manson, Qi Sun, Frank B Hu,
Harvard Sch of Public Health, Boston, MA
Studies of dietary determinants of type 2
diabetes (T2D) have found inverse associations
with several plant-foods, and positive
associations with some animal-foods, raising
the question of whether plant-based diets are
protective against T2D. However, as not all
plant-foods are equally beneficial, the
healthiest version of a plant-based diet needs to
be identified.
We assessed the hypothesis that plant-based
diets are associated with lower T2D risk. We
prospectively observed 74,248 women from the
Nurses’ Health Study (1984-2012) who were
free of diabetes, cardiovascular disease, and
cancer at baseline. We created a total plantbased diet index (PDI) and a healthy or
‘alternate’ plant-based diet index (aPDI) using
dietary data collected every 4 years with a food
frequency questionnaire. Individual foods were
aggregated into healthy plant-food groups
(whole grains, fruits, vegetables, nuts, legumes,
vegetable oils, and tea/coffee), unhealthy plantfood groups (fruit juices, refined grains,
potato/fries, margarine, sugar sweetened
beverages, and sweets) and animal-food groups
(animal fats, dairy, egg, fish, and processed &
fresh red meat & poultry). For PDI, positive
scores were given to all plant-foods, and
negative scores to the animal-foods. For aPDI,
positive scores were given to the healthy plantfoods, and reverse scores to the unhealthy
plant-foods and the animal-foods.
We documented 8119 incident T2D cases
during 1,761,104 person-years of follow-up. In
multivariable-adjusted analysis, both PDI and
aPDI were inversely associated with T2D (PDI
[HR for extreme deciles: 0.61, 95% CI: 0.55-0.68;
p trend<0.0001]; aPDI [HR for extreme deciles:
0.49, 95% CI: 0.44-0.55; p trend<0.0001]). The
association with PDI was attenuated when body
mass index was also included in the model (HR
for extreme deciles: 0.91, 95% CI: 0.82-1.02; p
trend: 0.009). The inverse association observed
with aPDI was only slightly attenuated after
additionally adjusting for body mass index [HR
for extreme deciles: 0.56, 95% CI: 0.50-0.63; p
trend<0.0001]. Similar associations were found
across all strata in analyses stratified by obesity,
physical activity, and family history of T2D. Our
data suggest that an overall plant-based diet
was associated with lower T2D risk but the
associations were stronger for a healthier
version of the plant-based diet.
A. Satija: None. S.N. Bhupathiraju: None. W.C.
Willett: None. J.E. Manson: None. Q. Sun:
None. F.B. Hu: None.
MP15
Innovative Self-Regulation Strategies Reduce
Weight Gain in Young Adults
Rena R Wing, Alpert Medical Sch of Brown Univ,
Providence, RI; Deborah Tate, Univ of North
Carolina - Chapel Hill, Chapel Hill, NC; Mark
Espeland, Wake Forest Sch of Med, WinstonSalem, NC; Cora E Lewis, Univ of Alabama at
Birmingham, Birmingham, AL; Amy Gorin, Univ
of Connecticut, Storrs, CT; Jessica LaRose,
Virginia Commonwealth Univ, Richmond, VA;
Judy Bahnson, Letitia Perdue, Wake Forest Sch
of Med, Winston-Salem, NC; Karen Erickson,
Univ of North Carolina - Chapel Hill, Chapel Hill,
NC; Erica Ferguson, Alpert Medical Sch of
Brown Univ, Providence, RI; Wei Lang, Wake
Forest Sch of Med, Winston-Salem, NC
Introduction: Young adults gain an average of 2
pounds per year, increasing their risk for obesity
and co-morbidities. To date, no approaches
have successfully reduced this weight gain. The
Study of Novel Approaches to Prevention of
Weight Gain (SNAP) is a randomized clinical trial
testing two innovative self-regulation
interventions.
Hypothesis: We hypothesized that both
interventions would reduce weight change over
an average follow-up of 3 years relative to a
control.
Methods: Participants age 18-35 with a BMI of
21-30 were recruited in Raleigh-Durham, NC
and Providence, RI. The 599 participants
included 27% from minority groups and 22%
males, mean age 28.4 (SD 4.4) yrs and BMI 25.4
(2.6). The interventions were based on a selfregulation model, involving frequent selfweighing and changes in eating and activity if
weight gain occurred. The SMALL changes
approach focused on making small (100 calorie)
changes in daily eating and exercise; LARGE
changes emphasized larger initial changes in
eating and exercise, to create a 5 to 10-pound
buffer against anticipated weight gain.
Interventions were delivered via 8 face-to-face
group sessions in the first 4 months, followed
by ongoing weight reporting and feedback and
optional Internet refreshers. CONTROL received
one face-to-face session. Assessments were at
baseline, 4 months, and then annually.
Results: Data collection ends 12/31/14; final
results will be presented. Retention at year 3 is
87%. Currently, mean (SE) weight changes
across 3 years differ significantly between the
groups (see Fig 1); for LARGE, mean weight loss
is -2.48 (0.22) kg, which differs significantly
from -0.75 (0.22) kg loss in SMALL, and both
differ from the +0.10 (0.22) kg gain in Control.
For secondary outcomes of weight gain from
baseline to 2 years and % gaining >1 lb at 2
years, both interventions significantly differed
from Control, but not from each other.
Conclusion: Self-regulation approaches using
LARGE or SMALL change strategies reduce
weight gain in young adults.
R.R. Wing: None. D. Tate: None. M. Espeland:
None. C.E. Lewis: None. A. Gorin: None. J.
LaRose: None. J. Bahnson: None. L. Perdue:
None. K. Erickson: None. E. Ferguson: None. W.
Lang: None.
MP16
Adherence to Healthy Lifestyle Factors is
Associated With a Lower Risk of Death Among
US Male Physicians With Type 2 Diabetes
Andrew B Petrone, J. Michael Gaziano, Luc
Djousse, Brigham and Women's Hosp, Boston,
MA
Background: Previous studies have suggested
that adherence to a healthy lifestyle is
associated with reduced risk of type 2 diabetes,
cardiovascular disease, and mortality. However,
it is unknown whether a combination of healthy
lifestyle after the diagnosis of diabetes is
associated with reduced risk of all-cause
mortality.
Objective: To test the hypothesis that healthy
modifiable lifestyle factors are associated with a
lower risk of all-cause mortality in people
diagnosed with type 2 diabetes.
Methods: A prospective cohort study of 1,160
male physicians from the Physicians’ Health
Study with prevalent type 2 diabetes. Smoking
habits, body mass index, exercise frequency,
and alcohol consumption were assessed via
questionnaire, and diet was assessed via a food
frequency questionnaire between 1999 and
2002. Death was ascertained by an endpoint
committee. Healthy lifestyle factors were
defined as: 1) never or past smoking, 2) body
mass index <25 kg/m2, 3) vigorous physical
activity 1+ days/week, alcohol consumption of
1-2 drinks/day, and 5) being in the top two
quintiles of the Alternative Healthy Eating Index
score. We used Cox regression to estimate
multivariable adjusted hazard ratios of death
according to each lifestyle factor, and total
number of healthy lifestyle factors met.
Results: During a median follow-up of 9.2 years,
there were 248 deaths. The mean age at
baseline was 68.9 ± 8.2 years. Healthy diet
score was associated with a 40% (95% CI: 2055%) lower risk of mortality. Multivariable
adjusted hazard ratios (95% CI) for mortality
were: 1.0 (ref), 0.58 (0.42-0.80), 0.58 (0.410.81), and 0.55 (0.35-0.87) for meeting 0 or 1, 2,
3, and 4+ healthy lifestyle factors, respectively.
Conclusions: Our data are consistent with an
inverse association between the number of
healthy lifestyle factors and risk of mortality in
US male physicians with type 2 diabetes.
A.B. Petrone: None. J. Gaziano: None. L.
Djousse: None.
MP17
Fruits and Vegetables Consumption and the
Incidence of Hypertension in Three Prospective
Cohort Studies
Lea Borgi, John Forman, Brigham and Women's
Hosp, Boston, MA
Introduction:
Intake of fruits and vegetables lower blood
pressures in short-term interventional studies.
However, data on the association of long-term
intake of fruits and vegetables with
hypertension risk are scarce.
Hypothesis:
We assessed the hypothesis that a higher longterm intake of fruits and vegetables is
associated with a lower incidence of
hypertension when compared with minimal
intake of fruits and vegetables.
Methods:
We prospectively examined the independent
association of fruit and vegetable intake with
incident hypertension in three large longitudinal
cohort studies of originally non-hypertensive
individuals: Nurses’ Health Study I (NHS1,
n=62,273, aged 38-63 years in 1984), Nurses’
Health Study II (NHS2, n=88,831, aged 27-44
years in 1991), and Health Professionals Followup Study (HPFS, n =37,414, aged 40-75 years in
1986). Information about diet (using a validated
food frequency questionnaire), other risk
factors and behaviors, and health status was
updated biennially. We used multivariable Cox
proportional hazards regression to calculate
hazard ratios (HR) and 95% confidence intervals
for fruit and vegetable consumption while
controlling for numerous other hypertension
risk factors. Random effects meta-analysis was
employed to derive pooled estimates of effect.
Results:
Compared with participants whose
consumption was <1 serving/month, the pooled
HRs among those whose intake was ≥1
serving/day were 0.80 (0.72-0.89) for total fruit,
0.91 (95% CI: 0.82-1.00) for green leafy
vegetables (combination of spinach, kale and
lettuce), 0.94 (0.88-1.00) for cruciferous
vegetables (broccoli, cauliflower, cabbage and
Brussel sprouts), and 0.97 (0.78-1.21) for other
vegetables.
Conclusions:
In conclusion, our results suggest that greater
long-term intake of fruits is prospectively and
independently associated with a reduced risk of
developing hypertension; green leafy and
cruciferous vegetables were modestly but
significantly inverse associated with reduced
long-term risk.
L. Borgi: B. Research Grant; Significant; AHA
Fellowship grant-14POST20380070. J. Forman:
None.
Founders Affiliate (Connecticut, Maine,
Massachusetts, New Hampshire, New Jersey,
New York, Rhode Island, Vermont)
MP18
DNA Methylation Variants, B Vitamins Intake,
and Long-Term Weight Change: Gene-Diet
Interactions in Two Us Cohorts
Tao Huang, Yan Zheng, Harvard Sch of Public
Health, Boston, MA; Qi Qibin, Albert Einstein
Coll of Med, Bronx, NY; Min Xu, Shanghai Jiao
Tong Univ Sch of Med, Shanghai, China; Sylvia
H. Ley, Yanping Li, Harvard Sch of Public Health,
Boston, MA; Jae H. Kang, Channing Div of
Network Med, Dept of Med, Brigham and
Women’s Hosp and Harvard Medical Sch,
Boston, MA; Janey Wiggs, Dept of
Ophthalmology, Harvard Medical Sch,
Massachusetts Eye and Ear Infirmary, Boston,
MA; Louis R. Pasquale, Channing Div of Network
Med, Dept of Med, Brigham and Women’s Hosp
and Harvard Medical Sch, Boston, MA; Andrew
T. Chan, Div of Gastroenterology,
Massachusetts General Hosp, Boston, MA; Eric
B. Rimm, David J. Hunter, Harvard Sch of Public
Health, Boston, MA; JoAnn E. Manson,
Channing Div of Network Med, Dept of Med,
Brigham and Women’s Hosp and Harvard
Medical Sch, Boston, MA; Walter C. Willett,
Frank B. Hu, Lu Qi, Harvard Sch of Public Health,
Boston, MA
Background: The first epigenome-wide
association study of body-mass index (BMI)
identified DNA methylation at a HIF3A locus
associated with BMI. However, the DNA
methylation-associated genetic variants
themselves were not associated with BMI. We
aimed to test the hypothesis that DNA
methylation variants might be associated with
BMI according to intake of B vitamins,
established metabolic cofactors of methylation.
Methods: We analyzed the interaction between
DNA methylation-associated HIF3A variants
(rs3826795 and rs8102595) and intake of B
vitamins in relation to BMI and its 10-year
change in 8109 women from the Nurses’ Health
Study (NHS) and 6761 men from the Health
Professionals Follow-up Study (HPFS). Intake of
B vitamins was assessed by validated semiquantitative food frequency questionnaires.
Results for the two cohorts were pooled by
means of inverse-variance-weighted, fixedeffects meta-analyses.
Results: In meta-analyses of the NHS and HPFS,
DNA methylation variants were not associated
with adiposity measures. However, we found
significant interactions between the DNA
methylation-associated HIF3A SNP rs3826795
and habitual intake of B vitamins in relation to
10-year changes in BMI. The association
between rs3826795 and BMI changes
consistently increased across the tertiles of
total vitamin B2 and vitamin B12 intake in the
NHS and HPFS. In combined analyses of cohorts,
the differences in the continuous BMI changes
per increment of minor allele (A allele) were 0•10 (SE 0•06), -0•01 (SE 0•06), and 0•12 (SE
0•07) kg/m2 within subgroups defined by
increasing tertiles of total vitamin B2 intake (all
P for interaction <0•01); and were -0•10 (SE
0•06), -0•01 (SE 0•06), and 0•10 (SE 0•07)
kg/m2 within subgroups defined by increasing
tertiles of total vitamin B12 intake (all P for
interaction <0•01). A significant interaction in
the pooled data was also observed for total
folate (P for interaction=0•02), but not for
vitamin B6 (P for interaction=0•18). In addition,
B vitamins from supplements showed stronger
interactions with the methylation variant than
those from food sources in relation to changes
in BMI.
Conclusions: In the combined data from these
two cohorts, a DNA methylation variant in
HIF3A was associated with BMI changes
through interactions with intakes of vitamin B2,
vitamin B12, and folate. These findings, which
should be replicated, suggest a potential causal
relation between DNA methylation and
adiposity.
T. Huang: None. Y. Zheng: None. Q. Qibin:
None. M. Xu: None. S. Ley: None. Y. Li: None. J.
Kang: None. J. Wiggs: None. L. Pasquale:
None. A. Chan: None. E. Rimm: None. D.
Hunter: None. J. Manson: None. W. Willett:
None. F. Hu: None. L. Qi: None.
MP19
Higher Parity is Associated With Components
of the Metabolic Syndrome Among U.S.
Hispanic/Latina Women: Results From the
HCHS/SOL Study
Catherine J. Vladutiu, Anna Maria Siega-Riz,
Alison M. Stuebe, Daniela Sotres-Alvarez, Andy
Ni, Univ of North Carolina at Chapel Hill, Chapel
Hill, NC; JoNell E. Potter, Univ of Miami Miller
Sch of Med, Miami, FL; Karen M. Tabb, Univ of
Illinois Urbana-Champaign, Urbana, IL; Linda C.
Gallo, San Diego State Univ, San Diego, CA;
Martha Daviglus, Univ of Illinois Coll of Med,
Chicago, IL; Mercedes Carnethon, Northwestern
Univ, Chicago, IL; Sylvia Smoller, Albert Einstein
Coll of Med, New York, NY; Gerardo Heiss, Univ
Background: Physiologic adaptations occurring
across successive pregnancies may increase the
risk of adverse cardiovascular health outcomes
in later life. Previous studies have found an
association between higher parity and the
metabolic syndrome (MetS). However, no
studies have examined this association in a
Hispanic/Latina population. Hispanic women
have a higher prevalence of the MetS and
higher birth rates than non-Hispanic women.
higher parity is associated with the prevalence
of components of the MetS in a cohort of
Hispanic/Latina women.
Methods: There were 9,482 Hispanic/Latina
women of diverse backgrounds, aged 18-74
years, who participated in the Hispanic
(HCHS/SOL) from 2008-2011. Components of
the MetS were defined according to the
AHA/NHLBI criteria and included abdominal
obesity (waist circumference ≥88cm), elevated
triglycerides (≥150 mg/dL), low HDL cholesterol
(<50mg/dL), high blood pressure (systolic
≥130mmHg or diastolic ≥85mmHg or on
medication), and elevated fasting glucose
(≥100mg/dL or on medication). Logistic
regression models were used to estimate odds
ratios for the association between parity and
components of the MetS, adjusting for
sociodemographic, behavioral, and
reproductive characteristics, and accounting for
the complex survey design and sampling
weights.
Results: At HCHS/SOL baseline, women
reported none (19.2%), one (18.9%), two
(25.3%), three (19.7%), four (9.3%), and five or
more (7.6%) prior live births. Compared to
women with only one live birth, women with
four live births had the highest odds of
abdominal obesity (OR=2.5, 95% CI 1.8, 3.3) and
those with five or more live births had the
highest odds of low HDL cholesterol (OR=1.5,
95% CI 1.2, 1.9), elevated glucose (OR=1.8, 95%
CI 1.3, 2.3), elevated triglycerides (OR=1.4, 95%
CI 1.01, 1.8), and high blood pressure (OR=1.5,
95% CI 1.1, 2.0), after adjusting for age,
Hispanic background, education, marital status,
income, nativity, smoking, physical activity,
menopause status, oral contraceptive use,
hormone replacement therapy, and field
center. Further adjustment for body mass index
attenuated these associations for all MetS
components, including abdominal obesity
(OR=1.5, 95% CI 1.1, 2.2), low HDL cholesterol
(OR=1.3, 95% CI 1.03, 1.7), and elevated glucose
(OR=1.6, 95% CI 1.2, 2.1), but the associations
for triglycerides and blood pressure were no
longer statistically significant.
Conclusion: Higher parity is associated with the
prevalence of selected components of the MetS
among U.S. Hispanic/Latina women. High parity
among Latinas with a high prevalence of
abdominal obesity suggests a context of high
risk for metabolic dysregulation. A better
characterization of the links between
pregnancy, adiposity, and body fat distribution
is needed.
C.J. Vladutiu: None. A. Siega-Riz: None. A.M.
Stuebe: None. D. Sotres-Alvarez: None. A. Ni:
None. J.E. Potter: None. K.M. Tabb: None. L.C.
Gallo: None. M. Daviglus: None. M. Carnethon:
None. S. Smoller: None. G. Heiss: None.
MP20
Hypertensive Disorders In Pregnancy and the
Risk of Incident Cardiovascular Disease
Sonia M Grandi, Karine Vallée-Pouliot, McGill
Univ, Montreal, QC, Canada; Maria Eberg, Lady
Davis Inst for Medical Res of the Jewish General
Hosp, Montreal, QC, Canada; Robert W Platt,
McGill Univ, Montreal, QC, Canada; Roxane
Arel, St. Mary’s Hosp Ctr, Montreal, QC, Canada;
Kristian B Filion, Lady Davis Inst for Medical Res
of the Jewish General Hosp, Montreal, QC,
Canada
Background: Despite the different
pathophysiological mechanisms of gestational
hypertension and preeclampsia, hypertensive
disorders (HTD) in pregnancy are hypothesized
to increase the risk of incident cardiovascular
disease (CVD). However, previous studies
investigating the association between HTD in
pregnancy and incident CVD have not
accounted for time-varying confounding.
Methods: A retrospective cohort of 156,967
women with a first recorded pregnancy
between the ages of 15-45 years and no prior
history of chronic hypertension or CVD.
Exposure was defined as a composite of: 1) a
diagnosis of HTD in pregnancy or new
hypertension; 2) high systolic or diastolic blood
pressure readings; or 3) a prescription for antihypertensive agents between 20 weeks
gestation and 6 weeks postpartum. Our primary
outcome was incident CVD, defined as a
composite endpoint of coronary artery disease
and related procedures, cerebrovascular
disease, and peripheral vascular disease. Our
secondary outcome was chronic hypertension.
Marginal structural Cox models were used to
account for important time-varying
confounders. In secondary analyses, exposure
was sub-classified as 1) pre-eclampia or
eclampsia; and 2) other HTD of pregnancy. In
sensitivity analyses, an approach analogous to
an intention-to-treat analysis was used.
Results: The mean age at cohort entry was 29
years (SD 6). HTDs in pregnancy were
associated with an approximately 3 times
higher rate of CVD and 7 times higher rate of
hypertension (Table). Similar results were
obtained when using an intention-to-treat
approach. The increased rate of incident CVD
was greater with other HTDs in pregnancy than
with preeclampsia/eclampsia, while both
groups had a similarly increased rate of
hypertension.
Conclusions: Women who are exposed to HTD
in pregnancy are at increased risk of developing
future CVD. These results suggest that a more
aggressive approach to management for CVD
risk factors should be taken in women with a
history of HTD in pregnancy.
S.M. Grandi: None. K. Vallée-Pouliot: None. M.
Eberg: None. R.W. Platt: None. R. Arel:
None. K.B. Filion: None.
MP21
Achieving Cardiovascular Health in Young
Adulthood - Do Adolescent Factors Matter?
Holly C Gooding, Carly Milliren, Harvard
Medical Sch, Boston, MA; Christina M. Shay,
Univ of North Carolina, Chapel Hill, NC; Tracy K
Richmond, Alison E Field, Matthew W Gillman,
Harvard Medical Sch, Boston, MA
Introduction: Adults who reach middle age with
optimal levels of three physiologic factors –
blood pressure, cholesterol, and blood glucose
– have lower rates of CVD mortality compared
to those with one or more of these risk factors
in the non-optimal range. The American Heart
Association has identified four healthy lifestyle
components – BMI, smoking, diet, and physical
activity – important for preserving optimal
cardiovascular health as people age. However,
which lifestyle components in adolescence are
most strongly associated with physiologic
markers of cardiovascular health in adulthood is
unclear. The purpose of this study was to
quantify associations between lifestyle
components measured in adolescence and
optimal physiologic cardiovascular health in
young adulthood.
Methods: Analyses included 9,697 young
adults, age 24-32 years in 2007-2008, who
participated in Wave IV of the National
Longitudinal Study of Adolescent Health. We
defined optimal physiologic cardiovascular
heath as untreated blood pressure <120/80
mmHg, untreated fasting blood glucose <100
mg/dL and hemoglobin A1C < 5.7%, untreated
total cholesterol in the bottom 7 (women) or 6
(men) deciles for the study population, and
absence of diabetes or CVD as measured at
Wave IV. We used logistic regression models to
estimate the odds of having optimal physiologic
cardiovascular health in young adulthood
according to BMI category, smoking status, and
physical activity patterns measured during
Waves I and II when participants were ages 1120 years. Dietary data were not available.
Models were adjusted for age, sex, race,
educational attainment, and income in young
adulthood.
Results: Few young adults (16%, 1,592 of 9,697)
had optimal physiologic cardiovascular health.
Young adults who had been normal-weighted in
adolescence were more likely to have optimal
physiologic cardiovascular health (18.4%, 1,382
of 7,206) compared to those who had been
overweight (9.4%, 142 of 1,429) or obese (6.9%,
68 of 1,062). In models adjusted for young adult
sociodemographic factors, participants who had
been overweight or obese as adolescents were
less than half as likely as those who had been
normal-weighted to have optimal physiologic
cardiovascular health in young adulthood
(overweight odds ratio (OR) 0.43, 95%
confidence interval (CI) 0.35-0.61; obese OR
0.40, 95% CI 0.28-0.57). Adolescent tobacco
smoking and physical activity were not
associated with young adult cardiovascular
health.
Conclusions: Maintaining a healthy weight in
adolescence may be the most important
lifestyle factor for reaching young adulthood
with optimal physiologic cardiovascular health.
Overweight and obese adolescents should be
encouraged to achieve a healthy weight
through adherence to diet and physical activity
goals.
H.C. Gooding: None. C. Milliren: None. C.M.
Shay: None. T.K. Richmond: None. A.E. Field:
None. M.W. Gillman: None.
MP22
Cardiovascular Health in Young Adulthood and
Middle Age is Associated with Cumulative
Burden of Morbidity in Older Age
Norrina B Allen, Lihui Zhao, Lei Liu, Kiang Liu,
Northwestern Univ, Chicago, IL; Tina Shih, Univ
of Chicago, Chicago, IL; Thanh Huyen Vu,
Northwestern Univ, Chicago, IL; Jim Fries,
Stanford Univ, Palo Alto, CA; Martha Daviglus,
Univ of Illinois at Chicago, Chicago, IL; Daniel
Garside, Donald Lloyd-Jones, Northwestern
Univ, Chicago, IL
Introduction: Previous studies on the benefits of
favorable cardiovascular (CV) health have
examined single measures of morbidity. The
aims of this study were to determine the
association of CV health in young adulthood and
middle-age on the trajectory of morbidity and
cumulative morbidity burden in older age.
Methods: The CHA study is a longitudinal cohort
of 39,522 men and women aged 18-59 years at
baseline in 1967-1973 from 84 worksites in the
Chicago area. Baseline risk factor levels
including blood pressure, cholesterol, diabetes,
BMI and smoking were identified by trained
staff. Individuals were classified into one of four
mutually exclusive categories: optimal levels of
all factors, 0 factors high but 1+ borderline, 1
major, and ≥2 major risk factors. Linked
CMS/NDI data from 1984-2010 were used to
determine morbidity in older age. We included
CHA participants who were age 65+ between
1984 and 2010 and enrolled in Medicare FFS.
All-cause morbidity was defined using the
Gagne score. CV morbidity was quantified using
a CVD comorbidity score (the sum of 4 CVDs
including CHD (includes MI), PVD,
cerebrovascular disease and CHF).
Results: This study included 30,386 participants
(43% female, 90% White, mean age 44 at
baseline). 5% had optimal levels of all factors,
19% had 1+ risk factors at borderline levels,
40% had 1 major risk factor and 36% had 2+
major risk factors. Individuals with 2+ major risk
factors had higher all-cause and CV morbidity
scores at age 66 and continued to accrue
morbid conditions throughout older age (see
figure). Even after adjustment for demographics
and education, an increasing burden of risk
factors was associated with a greater
cumulative burden of comorbidities (p=0.01).
Conclusion: Individuals with optimal levels of all
major CV risk factors in young adulthood and
middle-age experience lower levels of all-cause
and CVD morbidity and less cumulative
morbidity later in life. Primordial prevention of
CV risk factors early in life is likely to reduce the
future burden of morbidity and mortality in
older age.
N.B. Allen: None. L. Zhao: None. L. Liu:
None. K. Liu: None. T. Shih: None. T. Vu:
None. J. Fries: None. M. Daviglus: None. D.
Garside: None. D. Lloyd-Jones: None.
MP23
Association of Trajectories of Adulthood
Weight Gain with Cardiovascular Disease Risk
Factors in Participants 50-74 Years in the
Latinos (HCHS/SOL)
Lindsay Fernández-Rhodes, Anne Justice, Univ
of North Carolina at Chapel Hill, Chapel Hill, NC;
Sheila F Castañeda, Christina Buelna, San Diego
State Univ, San Diego, CA; Carmen R Isasi, Qibin
Qi, Anita Agarwal, Albert Einstein Coll of Med,
Bronx, NY; Maria Llabre, Ashley Moncrieft, Univ
of Miami, Miami, FL; Martha L. Daviglus, Univ of
Illinois at Chicago, Chicago, IL; Penny GordonLarsen, Daniela Sotres-Alvarez, Kari E. North,
Univ of North Carolina at Chapel Hill, Chapel
Hill, NC
The CVD health of US Hispanic/Latino
individuals—the second largest ethnic group in
the US—is a top public health priority. Although
Hispanic/Latino individuals have higher rates of
obesity than non-Hispanic Whites, the pattern
of adulthood weight gain in this diverse group
and its relationship with CVD risk factors are
unknown.
We examined trajectories of weight gain and
the associations of these trajectory classes with
dyslipidemia, diabetes, physical inactivity, poor
diet quality and hypertension among HCHS/SOL
participants baseline ages 50-74 years.
HCHS/SOL is a population-based cohort study of
self-identified Hispanic/Latino adults from four
urban US communities.
At baseline HCHS/SOL participants were asked
to recall/report their body weight at 21, 45, 65
years old, last year and currently (kg or lb, 20082011). We used a finite mixture model (selected
for ≤10 classes, ≥3% of sample per class and
favored by change in the Bayesian Information
Criterion) to assign individuals with two or more
self-reported weights to their most likely
trajectory class. We then described the
distribution of class membership across
categories of CVD risk factors (Wald Chi-square
test). All analyses accounted for the complex
sampling design of HCHS/SOL and were
adjusted for baseline age, height, and gender.
There were 6,779 individuals who reported
weights at 2-5 time points (25,687
observations). In the final four-group quadratic
trajectory mixture model the two most
common classes comprised individuals who on
average maintained a normal weight in
adulthood (18.5-24.9kg/m2) but became
overweight (≥25kg/m2) in their 50s (class 1: 38%
of sample), or who gained enough weight in
early adulthood to become overweight by their
30s and obese (≥30kg/m2) by their 50s (class 2:
43%). The other two classes were characterized
by more severe weight gain across adulthood,
but these classes were less common (class 3:
16%; class 4: 3%). Individuals grouped in class 3
on average had a normal weight in their 20s,
gained weight steadily, and became obese by
their 40s. Class 4 represented the most dynamic
trajectory, wherein individuals began
overweight in their 20s and gained >40kg by
their late 50s when they began to lose weight.
At baseline dyslipidemia, untreated diabetes
(p<0.007), and physical inactivity (p=0.8) were
most common in class 3. Class 4 was
characterized at baseline by the poorest diet
quality and highest prevalence of hypertension
and treated diabetes (p<0.001).
In summary our results indicate that although
weight gain was ubiquitous, more than a third
of participants aged 50-74 years belonged to a
trajectory class that did not develop obesity
during adulthood. Trajectories of extreme
weight gain were associated with a higher
burden of CVD risk factors. Future studies
should investigate modifiable factors that
influence trajectories and could serve as targets
for public health interventions in CVD.
L. Fernández-Rhodes: None. A. Justice:
None. S.F. Castañeda: None. C. Buelna:
None. C.R. Isasi: None. Q. Qi: None. A. Agarwal:
None. M. Llabre: None. A. Moncrieft:
None. M.L. Daviglus: None. P. Gordon-Larsen:
None. D. Sotres-Alvarez: None. K.E. North:
None.
Mid-Atlantic Affiliate (Maryland, North Carolina,
South Carolina, Virginia & Washington, DC)
MP24
Comparison of Predictive Ability of Dietary and
Lifestyle Scores For 10-Year Risk of
Cardiovascular Mortality in a Pan-European
Cohort Study
Camille Lassale, Imperial Coll London, London,
United Kingdom; Yvonne Van der Schouw,
Joline Beulens, Univ Medical Ctr Utrecht,
Utrecht, Netherlands; Guy Fagherazzi, Inst
Gustave Roussy, Villejuif, France; Nina Roswall,
Inst of Cancer Epidemiology, Copenhagen,
Denmark; Brian Buijsse, German Inst of Human
Nutrition, Potsdam-Rehbrucke, Germany;
Antonia Trichopoulou, Univ of Athens Medical
Sch, Athens, Greece; Elizabete Weiderpass, Univ
of Tromsø, Breivika, Norway; Heinz Freisling,
Intl Agency for Res on Cancer, Lyon, France;
Dora Romaguera, Petra Wark, Elio Riboli,
Ioanna Tzoulaki, Imperial Coll London, London,
United Kingdom
Introduction
Diet quality indexes and lifestyle indexes (which
also include other lifestyle characteristics such
as smoking and obesity) have recently received
increased attention in disease prevention.
Hypothesis
We aimed to investigate the comparative
predictive performance of a comprehensive list
of dietary and lifestyle indexes in relation to
cardiovascular (CVD) mortality.
Methods
We applied these indexes to men and women
from 10 European countries participating in the
European Prospective Investigation into Cancer
and Nutrition (EPIC) study and examined their
association with 10-year CVD mortality risk. We
computed 10 dietary indexes and 2 diet and
lifestyle indexes and calculated quartiles. Cox
proportional hazard models stratified by age
and study centre, adjusted for age, BMI, energy
intake, smoking status, physical activity and
educational level were fit to estimate Hazard
Ratios (HR) and 95% CI. Harrell’s C-statistic, a
discrimination measure of predictive
performance, was calculated for each model.
Results:
After 10 years of follow up, 3761 CVD deaths
were observed among 451 256 participants. All
dietary indexes, except one, were significantly
associated with CVD mortality with HR ranging
from 0.75 to 0.84 for the fully adjusted model
when comparing top vs bottom quartile (Table
1). Stronger effect size was observed for the
diet and lifestyle indexes, particularly the
Healthy Lifestyle Index (HLI). Discrimination of
the full models was high and did not vary
between scores. We found no heterogeneity in
HRs across countries for most scores, except a
modest heterogeneity for Mediterranean diet
scores (I2=48%) and HLI (75%); however,
heterogeneity across countries of the Cstatistics was high for all scores (I2 = 87%).
Conclusion
Our results show that diet quality as a whole, or
a cluster of lifestyle behaviours including diet,
are consistently associated with a reduction of
10-year CVD mortality risk and that models
comprising only age, sex and lifestyle risk
factors could serve as predictors of CVD
mortality.
C. Lassale: None. Y. Van der Schouw: None. J.
Beulens: None. G. Fagherazzi: None. N.
Roswall: None. B. Buijsse: None. A.
Trichopoulou: None. E. Weiderpass: None. H.
Freisling: None. D. Romaguera: None. P. Wark:
None. E. Riboli: None. I. Tzoulaki: None.
MP25
Dietary Fat Intake, Mc4r Genotype and 2-Year
Changes in Body Composition: The Pounds Lost
Trial
Tao Huang, Harvard Sch of Public Health,
boston, MA; Yiru Shen, Tufts, boston, MA; Yan
Zheng, Harvard Sch of Public Health, boston,
MA; Steven Smith, George Bray, Pennington
Biomedical Res Ctr of the Louisiana State Univ
System, bostonBaton Rouge, LA; Frank Sacks, Lu
Qi, Harvard Sch of Public Health, boston, MA
Abstract
Background: Melanocortin receptor 4 (MC4R) is
a key protein regulating dietary intake and
adiposity in humans. MC4R gene variants have
been associated with fat intake, fat mass,
weight change, and risk of obesity.
Observational studies have suggested that
dietary fat may modify these effects; however,
this has yet to be verified in long-term
randomized clinical trials.
Objective: To examine the interaction between
an “obesity-predisposing” MC4R variant and fat
intake on long-term changes in body
composition in the context of a randomized
controlled trial.
Design and Methods: We genotyped MC4R
rs17782313 and assessed body composition in
373 overweight adults in the 2-year Preventing
Overweight Using Novel Dietary Strategies
(Pounds Lost) trial.
Results: We found significant interactions
between the MC4R rs17782313 and dietary fat
intake on changes in lean mass and total mass
at 6 months (p for interaction=0.019 and 0.012,
respectively) after adjusting for age, sex,
ethnicity, baseline BMI, 6 months weight loss,
and baseline perspective outcomes. The C allele
was significantly associated with a greater
increase in lean mass and total mass in the lowfat diet group (P=0.008 and 0.005, respectively),
but not associated with these measures in the
high-fat diet group at 6 months (P>0.05,
respectively) (Figure 1). We didn’t observe
significant genotype-diet interaction on changes
in body compositions at 24 months, probably
due to regain of body weight after 6 months.
Conclusions: Our data suggest that individuals
with the MC4R rs17782313 C allele might
experience greater increases in lean mass and
total mass when consuming a lower fat weightloss diet.
Keywords: MC4R genotype, body composition,
gene-diet interaction, weight-loss trial
T. Huang: None. Y. Shen: None. Y. Zheng:
None. S. Smith: None. G. Bray: None. F. Sacks:
None. L. Qi: None.
MP26
Adherence to Low Carbohydrate and Low Fat
Diets in Relation to Weight Loss and
Cardiovascular Risk Factor Reduction
TIAN HU, Patrick Stuchlik, Tulane Univ, New
Orleans, LA; Lu Yao, Univ of Minnesota,
Minneapolis, MN; Kristi Reynolds, Kaiser
Permanente Southern California, Pasadena, CA;
Paul Whelton, Jiang He, Lydia Bazzano, Tulane
Univ, New Orleans, LA
A low carbohydrate (carb) diet can reduce body
weight and some cardiovascular disease (CVD)
risk factors as compared to a low fat diet, but
differential adherence may play a role. We
compared indicators of dietary adherence
between two dietary interventions and
examined their relationship with dietary
efficacy using data from 148 obese adults
(Mean age, 47 y; Mean body mass index, 35.4
kg/m2; 11.5% men; 51% Black) who
participated in a randomized controlled trial
comparing the effect of a low carb diet (net
carb<40 g/day) with a low fat diet (<30% energy
from fat, <10% from saturated fat) on changes
in weight and CVD risk factors. Indicators of
dietary adherence included attendance at
dietary counseling sessions which provided the
same behavioral curriculum for weight loss to
each group, deviation from the macronutrient
goal of the diet, and the cumulative percentage
of urinary ketones detected at each of the 26
behavioral sessions. A composite adherence
score was created based on these three
indicators. Outcomes included changes in body
weight, body composition and CVD risk factors
at 12 months. There was no significant
difference in the attendance at dietary
counseling sessions between the groups (56.7%
low carb group vs. 52.3% low fat group). In the
low carb group, 45% of individuals met the
carbohydrate goal while 55% were above, with
a mean of 198% deviation representing a carb
intake of approximately 119 grams. In the low
fat group, 56% and 28% of individuals met total
and saturated fat goals, and those who were
above had mean deviations of 23% and 46%,
representing intakes of about 37% and 10% of
energy from total and saturated fat,
respectively. At 12 months, the low carb group
had a higher cumulative percentage of ketones
detected in urine, compared to the low fat
group (25% vs. 8%, P<0.001). There was no
significant difference in composite scores for
adherence between the groups [Mean (SD): 64
(19) low carb vs. 61 (20) low fat]. In the low carb
group, attendance at more dietary sessions, less
deviation from carb goals and presence of
urinary ketones were consistently associated
with reductions in body weight and fat mass
and increase in lean mass. Similarly, a higher
composite score reflecting adherence the low
carb diet was associated with more weight loss
(β= -0.12, P=0.01), loss of fat mass (β = -0.06,
p=0.008) and preservation of lean mass (β=0.07,
p=0.003). Indicators of adherence to a low carb
diet were not associated with blood pressure,
lipids, glucose or C-reactive protein. No
associations between indicators of adherence
and dietary efficacy were identified in the low
fat group. Further adjusting for body mass
index, percent fat mass or lean mass at baseline
did not change the results. In conclusion,
despite similar adherence between the low carb
and low fat diets, adherence to the low carb
diet resulted in greater weight loss and better
improvement in body composition at 12
months.
T. Hu: None. P. Stuchlik: None. L. Yao: None. K.
Reynolds: None. P. Whelton: None. J. He:
None. L. Bazzano: None.
MP27
Cellphone Intervention for You (CITY): A
Randomized, Controlled Trial of Behavioral
Weight Loss Intervention by Cellphone or
Personal Coaching for Young Adults
Laura P Svetkey, Duke Univ Medical Ctr,
Durham, NC; Stephen S Intille, Northeastern
Univ, Boston, MA; Bryan C Batch, Leonor
Corsino, Crystal C Tyson, Gary G Bennett,
Hayden B Bosworth, Corrine Voils, Steven
Grambow, Duke Univ Medical Ctr, Durham, NC;
Catherine Loria, S Sonia Arteaga, Natl Heart
Lung and Blood Inst, Bethesda, MD; Pao-Hwa
Lin, Duke Univ Medical Ctr, Durham, NC
Background: Obesity affects young adults,
leading to future morbidity and mortality. Early
behavioral intervention may promote long-term
weight control. Mobile technology-based
(mHealth) interventions may be particularly
effective in young adults. We compared both an
mHealth behavioral weight loss intervention
and a personal coaching weight loss
intervention to no intervention (and to each
other) in overweight/obese young adults.
Methods: We randomized 365 generally healthy
adults age 18-35 years with BMI > 25 kg/m2
(overweight or obese) to 24-months of
intervention delivered primarily via
investigator-designed cell phone (CP) or
intervention delivered primarily via in-person (6
weekly) and by phone (23 monthly) coaching
(PC), compared to usual care control group
(Control). Primary outcome was weight change
from baseline to 24 months. This study was
conducted as part of the Early Adult Reduction
of weight through LifestYle (EARLY) cooperative
trials.
Results: Randomized participants (N=365) had
mean BMI 35 kg/m2, mean age 29yrs, were 70%
women, 36% African American, 6% Latino. Final
weight was obtained in 86%; missing weight
was multiply imputed. At 24 months, weight
loss was not different in either PC or CP vs
Control (see Figure). Weight loss in PC was
significantly greater than Control at 6 months.
From baseline to 24 months, clinically
significant weight loss (> 3% per national
guidelines) occurred in 40% of PC, 34% of CP,
and 30% of Control.
Conclusions: mHealth alone may not be
sufficient for weight loss in young adults but
mHealth-enhanced contact with an
interventionist has a modest short-term effect.
Future interventions should maximize the
complementarity of mHealth and personal
contact to achieve larger and more sustained
effect.
L.P. Svetkey: B. Research Grant; Significant;
NHLBI funding for this study. S.S. Intille:
None. B.C. Batch: None. L. Corsino: None. C.C.
Tyson: None. G.G. Bennett: None. H.B.
Bosworth: None. C. Voils: None. S. Grambow:
None. C. Loria: None. S.S. Arteaga: None. P. Lin:
None.
MP28
The Longitudinal Effects of Parenting Style on
Childhood Obesity Risk: Evidence from a
Representative Birth Cohort in Quebec
Lisa Kakinami, Tracie A Barnett, Concordia Univ,
Montreal, QC, Canada; Lise Gauvin, Louise
Séguin, Univ of Montreal, Montreal, QC,
Canada; Gilles Paradis, McGill Univ, Montreal,
QC, Canada
Background: Parenting style has been shown to
be associated with children’s body mass index
(BMI) in cross-sectional studies, but its
influence on later weight status is less clear.
Objective: To assess the longitudinal association
between parenting style measured at age 4
years and risk of childhood overweight/obesity
from age 5 to 12 years in the Quebec
Longitudinal Study of Child Development
(QLSCD) birth-cohort.
Methods: Participants were from the 1998-2010
QLSCD study (n=2,120), a representative sample
of single-ton births born in Quebec in 1998.
Parenting style when the child was four years of
age was measured using 11 questions related to
the parent’s interactions with the child. Factor
analysis identified four parenting behaviours
(reasons with child, permissive with child,
responsive with child, and uses a firm approach
for punishing the child) which were grouped
into four parenting styles with cluster analysis.
The four styles were consistent with Baumrind’s
theory of authoritative (demanding and
responsive), authoritarian (demanding but not
responsive), permissive (responsive but not
demanding), and negligent (not demanding and
not responsive) parenting control prototypes.
BMI at age 5, 6, 7, 8, 10 and 12 years was
calculated based on measured height and
weight and overweight/obesity was
operationalised according to the Centers for
Disease Control and Prevention age- and sexspecific growth curves. Missing data were
handled with multiple imputation and
parameter estimates and standard errors from
50 imputed data sets were combined to
produce single estimates. The risk of being
overweight or obese was analyzed with
generalized estimating equations with an
unstructured error covariance and controlled
for age, sex, highest parental educational
achievement, single- vs. two-parent
households, immigrant vs. Canadian-born
mothers, and whether or not the household
was below the low-income cut-off. All
covariates (with the exception of maternal
immigration status) were modeled as timedependent. Parenting style was timeindependent, but there was no evidence of a
within-subject effect.
Results: Approximately one-third of the parents
had an authoritative style (29%, 613 of 2120),
22% were permissive (463 of 2120), 27% were
negligent (578 of 2120), and 22% (466 of 2120)
were authoritarian. Compared to children from
authoritative households, children from
authoritarian, permissive, and negligent parents
were 40% (95% Confidence Interval [CI]: 1.1,
1.7, p=0.002), 31%, (CI: 1.0, 1.6, p=0.02) and
17% (CI: 0.9, 1.4, p=0.15) more likely to be
overweight or obese, respectively.
Conclusion: Parenting style from early
childhood is associated with risk of
overweight/obesity as the children enter early
adolescence. Additional research investigating
the processes through which parenting styles
translate into higher risks of childhood
overweight/obesity is needed.
L. Kakinami: None. T.A. Barnett: None. L.
Gauvin: None. L. Séguin: None. G. Paradis:
None.
MP29
Identifying Risk Profiles for Childhood Obesity
Using Recursive Partitioning: Complex
Associations with Individual, Familial, and
Neighborhood Environment Factors
Tracie A Barnett, Andraea Van Hulst, SainteJustine Hosp Res Ctr, Montreal, QC, Canada;
Marie-Hélène Roy-Gagnon, Univ of Ottawa,
Ottawa, ON, Canada; Lise Gauvin, Ctr de
recherche du CHUM, Montreal, QC, Canada;
Melanie Henderson, Sainte-Justine Hosp Res
Ctr, Montreal, QC, Canada; QUALITY
investigators
Objective: To identify unique combinations of
individual, familial and neighborhood factors in
relation to obesity in children using recursive
partitioning, and to examine whether specific
profiles of these factors predict obesity at
follow-up.
Methods: Data include 512 participants from
the first two waves of QUALITY, an ongoing
study on the natural history of obesity in 630
Quebec youth aged 8-10 years at baseline with
a parental history of obesity. Children were
considered obese if their BMI was ≥95th CDC
age- and sex-specific percentile. Residential
neighborhoods were characterized using in
person neighborhood audits conducted by
trained observers and data from a Geographic
Information System for 500 m network buffers
around participants’ residential address. Eleven
variables were submitted to the recursive
partitioning process, based on evidence for
associations with childhood obesity: 2 individual
variables (sugar-sweetened beverage intake,
meeting PA guidelines), 4 familial variables
(number of BMI defined obese parents, number
of parents with abdominal obesity, parental
education, household income), and 5
neighborhood environment characteristics
(disadvantage, prestige, and presence of ≥1
park, fast food restaurant, and convenience
store). A classification tree was identified
following a series of binary splits. Multivariable
linear regression models were subsequently
used to examine associations between the
categorical variable that represents the
recursive partitioning subgroups and BMI
percentile while controlling for age, sex,
puberty, and parental education. The lowest
risk subgroup was the reference category; the
remaining subgroups were identified using 6
indicator variables. In addition, associations
between subgroup membership and BMI
percentile at follow-up were examined while
adjusting for BMI percentile at baseline.
Results: Recursive partitioning yielded 7
subgroups with prevalence of obesity equal to
8%, 14%, 26%, 28%, 41%, 61%, and 63%,
respectively. The 2 highest risk subgroups
comprised children not meeting PA guidelines,
with ≥1 obese (BMI) parent, with 2 abdominally
obese parents, living in a disadvantaged
neighborhood with no parks and, among those
with the same characteristics, with access to
park(s) but also living in close proximity to at
least one convenience store. After adjustment
for baseline obesity, the likelihood of obesity
was more than 12-fold for both subgroups
compared to children with no obese parents.
Although group membership was strongly
associated with BMI at baseline, it did not
systematically predict change in BMI.
Conclusion: Obesogenic environments are
characterized by multiple individual, familial,
and neighborhood factors that jointly relate to
child obesity in complex ways. Alternate
subgroup definitions may better predict change
in obesity.
T.A. Barnett: None. A. Van Hulst: None. M.
Roy-Gagnon: None. L. Gauvin: None. M.
Henderson: None.
MP30
More Young Children in an Obesity Prevention
Intervention in MS and LA Head Start Centers
Improve/Maintain BMI Percentile and Waist
Circumference Compared to Nonparticipants
Danielle Hollar, Healthy Networks Design and
Res, Shepherdstown, WV; Caitlin Heitz, The
OrganWise Guys, Inc., Duluth, GA; Weidan
Zhou, Elite Res, LLC, Carrollton, TX
Introduction: Although reports show obesity
plateauing among some young children, it
remains a significant health problem in the
Deep South. Head Start Centers can be leaders
in prevention because children spend the
majority of the day there, so interventions
addressing food, education, and physical
activity have potential since dosage is high.
Hypothesis: We hypothesized that more
children in the intervention would: 1) remain in
the normal body mass index (BMI) percentile
category (for age and gender in accordance
with Centers for Disease Control and
Prevention) and/or improve their status; and 2)
have healthier waist circumference (WC)
measures at the end of each year.
Methods: The Thriving Communities, Thriving
Children (TC2) intervention includes menu
changes, nutrition and health education, and
daily exercise. Our randomized design includes
6 MS Head Start Centers (3 Intervention (I)/3
Control (C)) and 6 LA Head Starts (3 I/3 C).
Height, weight, and waist circumference are
measured two times a year (fall and spring), for
three years. Demographic data provided via
administrative records. All children eat
breakfast, lunch, and snacks at Centers.
Results: The year-one sample presented here
includes 681 low-income children ages 2-5 (396
intervention/285 control). The majority of
children are African American (92.1%; 6.1%
Hispanic, 1.2% White); 50.9% males. There was
no difference between groups regarding
demographic characteristics nor baseline BMI
percentile.
More children in the intervention group, as
compared to controls, experienced health
improvements as measured by BMI percentile
and WC. The mean BMI percentile among
intervention children decreased 0.7 (from
55.573 to 54.904), whereas the mean among
control children increased 5.2 (from 49.735 to
54.904). Repeated measures ANOVA showed
that this difference was significant, p < .001.
Similarly, the mean WC among intervention
children increased less than among control
children. Specifically, WC among intervention
children increased 0.8 cm (from 53.628 to
54.422), whereas the mean among control
children increased 2.0 cm (from 53.617 to
55.612). Repeated measures ANOVA showed
that this difference was significant, p = .018
Conclusions: In this sample of children from the
most obese geographic area of the US, an
obesity intervention shows significant health
effect. Thus, continuing, and expansion of this
model addressing foods served, integration of
nutrition and health education into Head Start
lessons, and encouragement of daily exercise,
has much promise to improve obesity status of
young children.
D. Hollar: None. C. Heitz: A. Employment;
Significant; The OrganWise Guys, Inc.. W. Zhou:
None.
MP37
Macroeconomic Growth is Associated with
Increases in Cardiovascular Mortality in
Countries with Lower Social Protection
Spending
Usama Bilal, Johns Hopkins Bloomberg Sch of
Public Health, Baltimore, MD; Manuel Franco,
Univ of Alcala, Alcala de Henares, Spain;
Thomas A. Glass, Johns Hopkins Bloomberg Sch
of Public Health, Baltimore, MD
Background: Macroeconomic growth has been
shown to be associated with increases in
cardiovascular (CVD) mortality. However, it is
unclear whether concurrent social protection
policies may mitigate the observed associations.
Objective: To study if social protection
expenditure modifies the association between
macroeconomic growth and cardiovascular
mortality.
Methods: We included 21 OECD countries from
1980 to 2010 with available data in the
Comparative Welfare States Data Set and the
WHO Mortality Database. Gross Domestic
Product (GDP) was used as a proxy for
economic growth. Age-adjusted cardiovascular
mortality rates were calculated. Countries were
divided into tertiles of average Social Protection
expenditure. We used fixed-effect models to
study the association of GDP growth with CVD
mortality stratified by tertile of social protection
expenditure. We included four lagged GDP
terms to account for the cyclical nature of GDP.
A second fixed-effects model was fitted with
time-varying linear and quadratic social
protection expenditure and its interaction with
GDP.
Results: Overall, a 1% increase in GDP was
associated with an increase in CVD mortality of
0.5% (95% CI: 0.21-0.83%, p=0.001). In
countries with high and medium social
protection expenditure, GDP increases were not
associated with changes in CVD mortality
(p=0.80 and p=0.52 respectively). In countries
with the lowest social protection expenditure, a
1% GDP increase was associated with a
significant increase in CVD mortality of 0.7%
(95% CI: 0.04-1.32% p=0.03). These results were
consistent in analysis using time-varying social
protection expenditure (Figure).
Conclusion: Our results highlight the need for
social protection policies to accompany
economic growth to mitigate its potential
deleterious effects on cardiovascular diseases.
Further research should study specific policies
that mitigate the harmful effects of
macroeconomic growth.
U. Bilal: None. M. Franco: None. T.A. Glass:
None.
MP38
Local Population Income, Geographic Space
and Interactions Predict Increased Presence of
Physical Activity Facilities in New York City
Metropolitan Area Census Tracts, 1990-2010
David M Wutchiett, Columbia Univ, New York,
NY; Tanya K Kaufman, MDRC, New York, NY;
Daniel M Sheehan, Kathryn M Neckerman,
Andrew G Rundle, Stephen J Mooney, Jeff
Goldsmith, Gina S Lovasi, Columbia Univ, New
York, NY
Introduction:
Physical activity is associated with improved
health and is supported, in part, by the
presence of facilities that provide space and
equipment to pursue a variety of physical
activities. We assessed the hypothesis that
socio-geographic characteristics predict
increased local availability of commercial
physical activity facilities over time. Longitudinal
examination of physical activity facility
distribution can inform our response to current
disparities in access to public and private
physical activity venues.
Methods:
We used data from the National Establishment
Time-Series (NETS), a longitudinal database of
U.S. businesses, focusing on 4528 census tracts
(23 counties) in the New York City metropolitan
area and on decennial intervals for which
population data were also available through the
Census or American Community Survey (1990,
2000, 2010). Commercial physical activity
facilities (e.g., gyms, tennis courts, martial arts
studios) were defined based on Standard
Industrial Classification (SIC) codes and name
searches. Facility counts were aggregated to
2010 census tract boundaries and linked to local
population characteristics. Comparisons across
decennial intervals were used to define
increasing count of physical activity facilities
and shifting population demographics.
Associations were evaluated using lasso logistic
regression to estimate relationships with
predictor variables and their interactions with
model shrinkage and variable subset selection
through 10-fold cross-validation for
minimization of test set model deviance.
Results:
Census tracts with at least one physical activity
facility increased over time (1990=1172,
2000=2295, 2010=2365). Greater tract-level
median income, larger land area, and higher
previous total physical activity facilities at start
of decade were positively associated with
greater odds for local increase in physical
activity facilities (OR=1.27 per SD median
income; OR=1.30 per SD land area; OR=1.14 per
SD lagged facility count). Inclusion of two-way
interaction terms increased R2 estimates from
0.30 to 0.33, suggesting explanation of an
additional 3% of the variation in facility count
increase. Subset selection through lasso to
minimize cross-validation error resulted in
retention of 11 of 21 possible two-way
predictor interactions. The association between
10-year increase in median income with
increased physical activity facility count was
stronger in geographically larger census tracts
(interaction OR=1.05); similarly, a stronger
relationship was found for 10-year population
count increase with physical facility count
increase in larger census tracts (interaction
OR=1.05).
Conclusion:
Local population, geographic, and business
environment characteristics are associated with
change in physical activity facilities. Inclusion of
interaction terms improved prediction.
D.M. Wutchiett: None. T.K. Kaufman:
None. D.M. Sheehan: None. K.M. Neckerman:
None. A.G. Rundle: None. S.J. Mooney: None. J.
Goldsmith: None. G.S. Lovasi: None.
MP39
Metabolically Healthy Obesity and the Risk of
Incident Ischemic Heart Disease and Stroke The Kangbuk Samsung Health Study
Seungho Ryu, Yoosoo Chang, Kangbuk Samsung
Hosp, Seoul, Korea, Republic of; Juhee Cho,
Sungkyunkwan Univ, Seoul, Korea, Republic of;
Yiyi Zhang, Johns Hopkins Univ Bloomberg Sch
of Public Health, Baltimore, MD; Sanjay Rampal,
Univ of Malaya, Kuala Lumpur, Malaysia; Di
Zhao, Johns Hopkins Univ Bloomberg Sch of
Public Health, Baltimore, MD; Yuni Choi, Jiin
Ahn, Kangbuk Samsung Hosp, Seoul, Korea,
Republic of; Miguel Cainzos-Achirica, Johns
Hopkins Univ Bloomberg Sch of Public Health,
Baltimore, MD; Roberto Pastor-Barriuso, Insto
de Salud Carlos III, Madrid, Spain; Joao A Lima,
Johns Hopkins Univ Sch of Med, Baltimore, MD;
Hocheol Shin, Kangbuk Samsung Hosp, Seoul,
Korea, Republic of; Eliseo Guallar, Johns
Baltimore, MD
Abstract
Objective: The risk of cardiovascular disease
(CVD) among obese individuals without obesityrelated metabolic abnormalities, usually
referred to as metabolically healthy obesity
(MHO), is controversial. Furthermore, the
association between MHO and the risk of stroke
has not been evaluated in prospective studies.
Hypothesis: We evaluated the hypothesis that
MHO is associated with an increased risk of
incident coronary heart disease (CHD) and
stroke compared to metabolically healthy
normal weight subjects.
Methods: We performed a cohort study in
98,414 metabolically healthy adults without
CVD at baseline who underwent a health
checkup exam during 2008 - 2011 and were
followed-up through December 31, 2012
(average follow-up of 3.0 years). Being
metabolic healthy was defined as not having
any of the components of the metabolic
syndrome and having a homeostasis model
assessment of insulin resistance (HOMA-IR) <
2.5. Incident hospitalizations for CHD events
and strokes were ascertained through data
linkage with the Korean Health Insurance
Review and Assessment Service (HIRA)
database.
Results: During follow-up, 284 participants
developed CHD and 223 subjects developed
stroke. After adjusting for age, sex, center, year
of screening exam, smoking, alcohol intake,
physical activity, family history of CVD, and
education, the hazard ratios (95 % confidence
intervals) for CHD and stroke comparing MHO
to normal weight participants were 1.67 (1.25 2.25) and 1.46 (1.02 - 2.10), respectively. These
associations did not differ by clinically relevant
subgroups, although the association between
MHO and the risk of incident stroke was
stronger in younger participants (P for
interaction 0.02).
Conclusions: Participants with MHO had a
higher incidence of CHD and of stroke
compared to metabolically healthy normal
weight participants, supporting that MHO is not
a harmless condition. The findings of this study
suggest that prevention strategies are needed
in all obese individuals, including those without
obesity-related metabolic abnormalities, to
reduce the risk of CVD.
Key Words: ischemic heart disease; stroke;
metabolically healthy obesity; obesity;
cardiovascular disease.
S. Ryu: None. Y. Chang: None. J. Cho: None. Y.
Zhang: None. S. Rampal: None. D. Zhao:
None. Y. Choi: None. J. Ahn: None. M. CainzosAchirica: None. R. Pastor-Barriuso: None. J.A.
Lima: None. H. Shin: None. E. Guallar: None.
MP40
Global Burden of Chronic Kidney Disease in
2010: A Pooling Analysis of Population-Based
Data Worldwide
Katherine T Mills, Tulane Univ, New Orleans,
LA; Yu Xu, Rui-Jin Hosp, Shanghai Jiao-Tong
Univ, Shanghai, China; Weidong Zhang,
Zhengzhou Univ, Zhengzhou, China; Joshua D
Bundy, Chung-Shiuan Chen, Tanika N Kelly, Jing
Chen, Jiang He, Tulane Univ, New Orleans, LA
Introduction: Chronic kidney disease (CKD) is a
major risk factor for end-stage renal disease,
cardiovascular disease and premature death.
Accurate estimates of the prevalence and global
burden of CKD are essential for assigning
sufficient priority and resources to its
prevention and treatment. We aimed to
estimate the global prevalence and absolute
burden of CKD in 2010 by pooling data from
population-based studies in different world
regions.
Methods: We searched published literature
from January 1, 1990, to June 30, 2014 using
MEDLINE, supplemented by manually searching
bibliographies of retrieved articles. We included
studies that reported sex- and age-specific
prevalence of CKD in representative population
samples. CKD stages 1-5 was defined as the
presence of albuminuria/proteinuria or an
estimated-glomerular filtration rate <60
ml/min/1.73m2. All data were extracted
independently and in duplicate by at least two
investigators using a standardized protocol and
data-collection form. Sex- and age-specific
prevalence estimates were applied to the 2010
population to estimate the number of people
with CKD in each country, world region, and
globally.
Results: The age-standardized global prevalence
of CKD stages 1-5 among adults aged ≥20 years
in 2010 was 10.3% in men (95% confidence
interval 10.1 to 10.5%) and 12.1% in women
(11.8 to 12.4%): 8.6% in men (8.4 to 8.9%) and
9.6% in women (9.4 to 9.8%) in high-income
countries, and 10.6% in men (10.3 to 10.9%)
and 12.9% in women (12.5 to 13.3%) in lowand middle-income countries. The estimated
total number of adults with any stage of CKD in
2010 was 224.0 million (218.7 to 229.3 million)
in men and 278.3 million (272.1 to 284.6
million) in women: 48.3 million (47.1 to 49.5
million) in men and 61.8 million (60.6 to 63.1
million) in women in high-income countries,
and 175.7 million (170.6 to 180.9 million) in
men and 216.5 million (210.4 to 222.6 million)
in women in low- and middle-income countries.
Conclusions: CKD is an important global-health
challenge, especially in low- and middle-income
countries. National and international efforts on
the prevention, detection, and treatment of
CKD are needed to reduce its morbidities and
mortalities worldwide.
K.T. Mills: None. Y. Xu: None. W. Zhang:
None. J.D. Bundy: None. C. Chen: None. T.N.
Kelly: None. J. Chen: None. J. He: None.
MP41
Implications of the Use of the New ACC/AHA
Guidelines for Cardiovascular Disease
Prevention in a Brazilian Cohort - The Elsa
Brasil Study
Marcio S. Bittencourt, Isabela Bensenor, Univ
Hosp - Univ of Sao Paulo, São Paulo, Brazil; Dora
Chor, Paulo Vasconcelos, Oswaldo Cruz Fndn,
Rio de Janeiro, Brazil; Paulo Lotufo, Univ Hosp Univ of Sao Paulo, São Paulo, Brazil
Introduction: The 2013 American College of
Cardiology / American Heart Association
(ACC/AHA) guidelines developed a new
prediction model for cardiovascular disease
(CVD) and suggested the use of a lower
threshold of 7.5% 10 year hard CVD risk for
primary prevention. The implications of the use
of this model in other cohort and admixed races
has not yet been tested. The current study
sought to evaluate the potential impact of its
use in a large Brazilian cohort.
Methods: We have included 15105 participants
of the (Brazilian Longitudinal Study of Adult
Health) ELSA-Brasil study, a multicenter
prospective study that enrolled civil servants
aged 35 to 74 years in 6 different urban areas in
brazil. We have calculated the both the
Framingham risk score (FRS) and the new risk
prediction model to the entire cohort, and
estimated the impact of changing current
recommendations based on the FRS and lipid
targets to the new recommendations based on
the absolute risk estimated by the new model.
Results: The mean age was 52±9.1 years, with
8218 (54%) women. The race distribution
included 52% white, 16% black, 28% mixed
(brown), and 4% of other. While 19.2% (95% CI:
18.4 to 19.6) of the cohort would require statins
for primary prevention accordion to prior
recommendations, the new guidelines would
recommend treatment for approximately 40.2%
(95%CI: 39.4 to 41.0) of the cohort. A
substantial increase in the population in whom
statins are recommended occurred for males,
from 23.3% (95%CI: 22.6 to 24.0%) to 55.7%
(95%CI: 54.9 to 56.5), as well as females, from
16.6 (95%CI: 16.0 to 17.2) to 27.1 (95%CI: 26.4
to 27.8), and across all races and age levels
(figure).
Conclusion: The new ACC/AHA guidelines for
primary prevention would approximately
double the proportion of Brazilian adults in
whom statins are indicated, mostly among older
individuals. The epidemiological and economical
impact of this changes are not yet known.
M.S. Bittencourt: None. I. Bensenor: None. D.
Chor: None. P. Vasconcelos: None. P. Lotufo:
None.
MP42
The Potential Impact of Food Taxation and
Subsidies on Cardiometabolic Mortality in The
US
Jose L Penalvo, Ashkan Ashkin, Frederik
Cudhea, Colin D Rehm, Gitanjali Maya Singh,
Dariush Mozaffarian, Friedman Sch of Nutrition
Science and Policy, Boston, MA
Peñalvo JL, Asfhin A, Rehm CD, Cudhea F, Singh
G, Mozaffarian D
Tufts Friedman School of Nutrition Science and
Policy, Boston MA-02111
Background: Food-specific taxes and subsidies
have been proposed as a strategy for the
prevention of cardiometabolic diseases (CMD).
However, the potential impact of such policies
on CMD-mortality in the US, and heterogeneity
by age, sex, and race have not been quantified.
Aim: To estimate the number of CMD-deaths
prevented by the introduction of fiscal
interventions on food items related with CMD.
Methods: We conducted a Comparative Risk
Assessment analysis to estimate the impact of a
10% subsidy for fruits, vegetables, whole grains,
and nuts and a 10% tax on processed and
unprocessed red meat on deaths due to CMD in
the US. Dietary intakes in 2010 by age, sex, and
race, were determined from NHANES based on
two 24-h recalls. Age-specific, diet-disease
relative risks, were derived from meta-analyses
(2013 Global Burden of Diseases study). Age,
sex, and race-stratified deaths due to CVD from
2010 were obtained from the US-NCHS. Efficacy
of taxes and subsidies on dietary change were
obtained from new meta-analysis of
prospective studies. Monte Carlo simulations
incorporated uncertainty in dietary intakes,
diet-disease risks, underlying death rates, and
efficacy of interventions.
Results: Based on prospective studies, subsidies
produce larger changes (14% increase per 10%
price change) than taxes (3% decrease per 10%
price change) (p-interaction=0.012). Subsidizing
the price of food items such as nuts could
derive in averting almost 12000 deaths (Figure
A). Combining both taxes and subsides would
have the greatest impact. Due to the marked
heterogeneity found on the estimations across
population strata, information about age, sex,
and race should be considered when proposing
fiscal interventions (Figures B and C).
Conclusions: This information will be useful to
quantify the effect and support evidence-based
decisions on fiscal policies to reduce the burden
of cardiometabolic disease in the US.
J.L. Penalvo: B. Research Grant; Significant;
Bunge Fellowship. A. Ashkin: None. F. Cudhea:
None. C.D. Rehm: None. G.M. Singh: None. D.
Mozaffarian: None.
MP43
Baseline High-Sensitivity Cardiac Troponin-T is
Independently Associated With Incident
Hypertension
Bill Mcevoy, Yuan Chen, Johns Hopkins Hosp,
Baltimore, MD; Vijay Nambi, Michael E DeBakey
Veterans Affairs Hosp, Houston, TX; Christie
Ballantyne, Baylor Coll of Med and Houston
Methodist DeBakey Heart and Vascular Ctr,
Houston, TX; Richey Sharrett, Lawrence Appel,
Johns Hopkins Sch of Public Health, Baltimore,
MD; Wendy Post, Roger Blumenthal, Johns
Hopkins Hosp, Baltimore, MD; Kunihiro
Matsushita, Elizabeth Selvin, Johns Hopkins Sch
of Public Health, Baltimore, MD
Introduction: Elevated blood pressure (BP) is
often preceded by cardiac structural
abnormalities, potentially allowing early
detection before the onset of overt
hypertension.
Hypothesis: We hypothesized that highsensitivity cardiac troponin-T (hs-cTNT), a
marker of subclinical myocardial damage, can
identify persons at risk for hypertension.
Methods: We studied 6,516 ARIC Study
participants, free of prevalent hypertension and
cardiovascular disease at baseline (1990-1992).
Using Cox models, we examined the association
of baseline hs-cTNT categories with incident
diagnosed hypertension (defined by medication
use or annual self-report over a median of 12
years) and with incident visit-based
hypertension (defined by medication use, selfreport, or BP measurement [>140/90 mmHg]
over 6 years).
Results: Relative to hs-cTNT <5ng/L, adjusted
hazard-ratios for incident diagnosed
hypertension were 1.16 (95% CI 1.08, 1.25) for
those with hs-cTNT 5-8ng/L, 1.29 (1.14, 1.47)
for hs-cTNT 9-13ng/L, and 1.31 (1.07, 1.61) for
hs-cTNT ≥14ng/L (p-value for trend <0.001).
Findings were stronger for incident visit-based
hypertension. We noted higher relative hazard
in normotensive persons (relative to those with
prehypertension). Associations were not
appreciably changed after adjustment for
baseline NT-proBNP. In addition, baseline hscTNT was associated with a combined outcome
of incident hypertension or incident LVH over 6
years follow-up (adjusted hazard-ratio of 1.58
[1.16-2.15], comparing hs-cTNT ≥14ng/L vs
<5ng/L).
Conclusion: In conclusion, baseline hs-cTNT is
associated with incident hypertension and risk
of LVH. Further research is needed to determine
whether hs-cTNT can identify persons who may
benefit from ambulatory BP monitoring,
hypertension prevention lifestyle strategies, or
early BP intervention.
B. Mcevoy: C. Other Research Support;
Modest; Reagents for the high-sensitivity
cardiac troponin-T and C-reactive protein assays
were donated by Roche Diagnostics.. Y. Chen:
None. V. Nambi: F. Ownership Interest;
Modest; Drs. Ballantyne and Nambi are coinvestigators on a provisional patent filed by
Roche for use of biomarkers in heart failure
prediction. C. Ballantyne: B. Research Grant;
Modest; Dr Ballantyne has received grant
support from Roche Diagnostics (and the
National Institutes of Health).. F. Ownership
Interest; Modest; Drs. Ballantyne and Nambi
are co-investigators on a provisional patent filed
by Roche for use of biomarkers in heart failure
prediction.. R. Sharrett: None. L. Appel:
None. W. Post: None. R. Blumenthal: None. K.
Matsushita: E. Honoraria; Modest; Dr.
Matsushita has received an honorarium from
Mitsubishi Tanabe Pharma, Kyowa Hakko Kirin,
and Merck Sharp & Dohme.. E. Selvin: None.
MP44
Leukocyte Telomere Length and Risks of
Incident Coronary Heart Disease and Mortality
in a Racially Diverse Population
Cara L. Carty, Children's Natl Medical Ctr/
George Washington Univ, Washington, DC;
Jingmin Liu, Charles Kooperberg, Megan Skinner
Herndon, Fred Hutchinson Cancer Res Ctr,
Seattle, WA; Andrea LaCroix, Univ of California,
San Diego, CA; Abraham Aviv, Rutgers Univ,
Newark, NJ; Alexander P. Reiner, Univ of
Washington, Seattle, WA
Background: Telomeres are nucleotide repeat
regions at the ends of chromosomes that
maintain chromosomal structural integrity and
genomic stability. Telomeres from circulating
leukocytes can be readily measured; mean
leukocyte telomere length (LTL) tends to
decrease with age, vary by race/ ethnicity and is
a putative marker of cellular aging. In studies of
mainly white populations, shorter LTL has been
associated with cardio-metabolic risk factors
and increased risks of mortality and coronary
heart disease (CHD), yet it is not clear whether
these findings extend to other race/ethnicity
groups. We sought to assess the relationship of
LTL with risks of incident CHD and total
mortality in a racially diverse population of
post-menopausal women.
Methods: Using a nested case-cohort design,
African American (AA) and white women with
incident CHD or mortality during a maximal
follow-up of 19.4 years were randomly selected
from the Women’s Health Initiative. LTL from
baseline blood samples was assayed by
Southern blotting. Race-stratified and risk
factor-adjusted Cox proportional hazards
models, weighted to account for the sampling
scheme, were used to estimate the hazard of
CHD or mortality.
Results: A total of 1,525 women (858 whites
and 667 AA) were included in the analyses. In
whites, there were 367 incident CHD (292
mortality) events, while AA experienced 269
incident CHD (265 mortality) events. Crosssectional LTL associations (p<0.05) with age,
current smoking, and US recruitment region
were observed in AA, whereas in whites, LTL
was associated with age, current smoking and
HDL cholesterol. Whites with longer LTL at
baseline were less likely to have incident CHD,
HR=0.58 (95%CI: 0.40-0.84), p=0.004, yet no
significant association was observed in AA,
HR=1.07 (95%CI: 0.71-1.61), p=0.74. This LTLCHD association varied significantly by
race/ethnicity, p=0.028. Similar trends were
observed for total mortality, with longer LTL
associated with reduced hazard in whites,
HR=0.70 (95%CI: 0.46-1.06), but a slightly
increased hazard in AA, HR=1.10 (95%CI: 0.801.53), though neither association was
significant. In exploratory analyses of causespecific mortality, increased LTL was associated
with an increased, but non-significant hazard of
cancer mortality in both AA and whites, p=0.17
and 0.28 respectively.
Conclusion: We describe LTL associations with
incident mortality, CHD and cardiovascular risk
factors in post-menopausal women; these
findings appear to vary by race/ethnicity. As a
marker of chronic inflammation and cellular
stress, LTL is robustly associated with CHD in
whites, even after adjustment for cardiometabolic risk factors including C-reactive
protein, yet it does not appear to be associated
with CHD in AA. Future studies exploring these
race-specific differences may be warranted.
C.L. Carty: None. J. Liu: None. C. Kooperberg:
None. M. Skinner Herndon: None. A. LaCroix:
None. A. Aviv: None. A.P. Reiner: None.
MP45
Liver Fat Content Does Not Account for the
Strong Association of Fetuin-A with Diabetes
Risk in Women: The Multi-Ethnic Study of
Atherosclerosis
Sarah A. Aroner, Harvard Sch of Public Health,
Boston, MA; Kenneth J. Mukamal, Harvard Sch
of Public Health and Beth Israel Deaconess
Medical Ctr, Boston, MA; David E. St-Jules, New
York Univ, New York, NY; Matthew J. Budoff,
Los Angeles Biomedical Res Inst at Harbor-UCLA
Medical Ctr, Los Angeles, CA; Ronit Katz, Kidney
Res Group, Univ of Washington, Seattle, WA;
Michael H. Criqui, Matthew A. Allison, Univ of
California, San Diego, CA; Ian H. de Boer, Univ of
Washington, Seattle, WA; David S. Siscovick,
The New York Acad of Med, New York, NY;
Joachim H. Ix, Univ of California and Veterans
Affairs San Diego Healthcare System, San Diego,
CA; Majken K. Jensen, Harvard Sch of Public
Health, Boston, MA
Introduction: Fetuin-A, a hepatic secretory
protein, has been associated with risk of
diabetes. However, liver fat content may be an
important confounder or effect modifier not
fully accounted for in previous studies. Further,
it remains unclear whether associations differ
between women and men.
Aim: In an ethnically diverse cohort of women
and men, we assessed the association of fetuinA with risk of diabetes and investigated the role
of liver fat in this association.
Methods: We conducted a case-cohort study
nested in the Multi-Ethnic Study of
Atherosclerosis among 1,957 subcohort
members and 455 cases (265 of whom
belonged to the subcohort) with follow-up from
2000-2012. Fetuin-A was measured from
baseline plasma samples by enzyme-linked
immunosorbent assay, and liver fat was
assessed via computed tomography.
Associations were estimated using
multivariable-adjusted Cox models, with
weighting to account for the case-cohort
design.
Results: The association of fetuin-A with risk of
diabetes differed between women and men (pinteraction = 0.001). Each standard deviation
(SD) higher fetuin-A concentration (0.10 g/L)
was associated with a hazard ratio (HR) of 1.51
(95% CI: 1.32-1.74, p <0.0001) among women
and an HR of 1.12 (95% CI: 0.94-1.32, p = 0.20)
among men. With additional adjustment for
liver fat, associations were slightly attenuated in
both women (HR per SD fetuin-A = 1.37, 95% CI:
1.19-1.59, p<0.0001) and men (HR = 1.06, 95%
CI: 0.90-1.24, p = 0.40). Additional adjustment
for other clinical variables had minimal impact
on multivariable-adjusted estimates (Figure).
Associations did not differ by degree of liver fat
content (p-heterogeneity >0.25 for both women
and men).
Conclusions: Fetuin-A was associated with
diabetes risk, particularly in women, even after
adjustment for liver fat.
S.A. Aroner: None. K.J. Mukamal: None. D.E.
St-Jules: None. M.J. Budoff: None. R. Katz:
None. M.H. Criqui: None. M.A. Allison:
None. I.H. de Boer: None. D.S. Siscovick:
None. J.H. Ix: None. M.K. Jensen: None.
MP46
Growth Factors Are Associated With Imaging
Markers of Brain Aging in Young Adults
Claudia L Satizabal, Alexa Beiser, Jayandra J
Himali, Rhoda Au, Philip A Wolf, Boston Univ,
Boston, MA; Charles DeCarli, Univ of California
at Davis, Sacramento, CA; Ramachandran
Vasan, Sudha Seshadri, Boston Univ, Boston,
MA
Metabolic and vascular dysregulation are
related to stroke, cognitive decline and
dementia. Growth factor biomarkers of these
processes, such as Insulin-like Growth Factor 1
(IGF1) and Vascular Endothelial Growth Factor
(VEGF) have been associated with risk of
neurodegeneration and stroke in middle-aged
and older Framingham participants.
Additionally, hepatocyte growth factor (HGF)
and angiopoietin 2 are novel biomarkers of
interest as they have been related to
cardiovascular events.
As abnormal brain changes probably start years
before clinical symptoms, we hypothesize that
circulating growth factors are related to MRI
endophenotypes of brain aging.
We included 1,877 individuals aged 46±8 years
from the Framingham Study. Blood samples
were collected during 2008-2011, and used to
measure IGF1, VEGF, HGF, angiopoietin 2 and
its receptor tyrosine kinase (TIE2). Participants
underwent brain MRI examination (2009-2013)
from which brain volumes and white matter
hyperintensities were estimated. We related
growth factor levels to brain MRI markers
adjusting for age, sex, time between blood draw
and MRI, and cardiovascular risk factors.
Lower IGF1, as well as higher HGF and
angiopoietin 2 levels were associated with
higher ventricular volumes indicative of brain
shrinkage. Higher TIE2 levels were associated
with lower total brain and gray matter volumes,
while higher angiopoietin 2 levels were
associated with lower white matter volumes.
Lower IGF1 levels were also associated with
reduced hippocampal volumes. Finally, higher
TIE2 levels were associated with larger white
matter hyperintensities.
Our results suggest that growth factors are
associated with neurodegenerative and
cerebrovascular markers of brain aging in
healthy young adults. Whereas IGF1 seems
protective, higher levels of HGF, angiopoietin 2
and TIE2 were associated with greater
subclinical brain injury. These associations
expand our understanding of the earliest stages
of brain aging. We will extend our findings by
analyzing cognitive outcomes.
C.L. Satizabal: None. A. Beiser: None. J.J.
Himali: None. R. Au: None. P.A. Wolf: None. C.
DeCarli: None. R. Vasan: None. S. Seshadri:
None.
MP47
The Association of Socioeconomic Status with
Subclinical Myocardial Damage
Anna E Fretz, Johns Hopkins Bloomberg Sch of
Public Health, Baltimore, MD; Andrea L
Schneider, Johns Hopkins Univ Sch of Med,
Baltimore, MD; John McEvoy, Johns Hopkins
Ciccarone Ctr for the Prevention of Heart
Disease, Baltimore, MD; Ron Hoogeveen,
Christie M Ballantyne, Baylor Coll of Med,
Houston, TX; Joseph Coresh, Elizabeth Selvin,
Johns Hopkins Bloomberg Sch of Public Health,
Baltimore, MD
Background: The association between
socioeconomic status (SES) and clinical
cardiovascular events is well established.
However, little is known about the relationship
between SES and subclinical myocardial
damage, as assessed by a novel highly sensitive
assay for cardiac troponin T (hs-cTnT).
Methods: We conducted a cross-sectional
analysis of 11,411 participants from the ARIC
Study with no history of cardiovascular disease
who had hs-cTnT measured at visit 2 (19901992). SES was defined using either annual
household income, categorized as: low
(<$16,000), mid-level ($16,000 - $34,999), high
(≥ $35,000), or lifetime educational attainment,
categorized as: low (<12th grade), mid-level
(12th grade/some college) and high (college
degree or higher). hs-cTnT was categorized as
non-elevated (<14 ng/L) and elevated (≥
14ng/L). Poisson regression was used to
generate prevalence ratios for elevated hscTnT, separately by level of income and
education after adjusting for demographic,
clinical, and behavioral factors.
Results: Persons with low income or low
education were more likely to have subclinical
myocardial damage as assessed by elevated hscTnT (≥14ng/L). Adjusted prevalence ratios for
elevated troponin comparing low to high levels
of income and education were 1.74 (95% CI:
1.32, 2.29) and 1.54 (95% CI: 1.21, 1.97),
respectively (Table, Model 1). These results
were slightly attenuated, but remained
statistically significant after adjusting for
cardiovascular risk factors and health behaviors
(Models 2 and 3). Race-stratified results
demonstrate a somewhat stronger and only
significant association of low education with
subclinical myocardial damage in blacks
compared to whites (PR 1.83 vs 1.05, pinteraction =0.08). There was no race
interaction with income (p-interaction =0.33).
Conclusions: Low SES was associated with
elevated hs-cTnT, independent of
cardiovascular risk factors, especially in blacks.
Further research is needed to explore how low
SES contributes to subclinical myocardial
damage.
A.E. Fretz: None. A.L.C. Schneider: None. J.
McEvoy: None. R. Hoogeveen: B. Research
Grant; Significant; Received grant support from
Roche Diagnostics and co-investigator on a
provisional patient filed by Roche for use of
biomarkers in heart failure prediction.. C. Other
Research Support; Significant; Reagents for the
high sensitivity cardiac troponin T assays were
donated by Roche Diagnostics. C.M. Ballantyne:
B. Research Grant; Significant; Received grant
support from Roche Diagnostics and coinvestigator on a provisional patient filed by
Roche for use of biomarkers in heart failure
prediction.. C. Other Research Support;
Significant; Reagents for the high sensitivity
cardiac troponin T assays were donated by
Roche Diagnostics.. J. Coresh: None. E. Selvin:
None.
MP48
Genetic Variation, Human Metabolome and
Incident Heart Failure among African-
Americans in the Atherosclerosis Risk in
Bing Yu, Alanna C Morrison, Univ of Texas
Health Science Ctr at Houston, Houston, TX;
Thomas H Mosley, The Memory Impairment
and Neurodegenerative Dementia Res Ctr, Univ
of Mississippi, Jackson, MS; Amil M Shah, Scott
D Solomon, Dept of Cardiovascular Med,
Brigham and Women's Hosp, Boston, MA;
Calum Macrae, Dept of Cardiovascular Med,
Brigham and Women's Hosp; Dept of Med,
Harvard Medical Sch, Boston, MA; Patricia P
Chang, Dept of Med, Univ of North Carolina,
Chapel Hill, NC; Richard A Gibbs, Human
Genome Sequencing Ctr, Baylor Coll of Med,
Houston, TX; Eric Boerwinkle, Univ of Texas
Health Science Ctr at Houston; Human Genome
Sequencing Ctr, Baylor Coll of Med, Houston, TX
Introduction: Heart failure (HF) results from the
interaction of multiple genes and
environmental factors. The human metabolome
reflects multiple cellular and physiologic
processes and forms a bridge between the
genome and HF.
the human metabolome is associated with and
may mediate the first hospitalization for HF.
Methods: We examined the association
between the human serum metabolome,
measured by GC-MS and LC-MS, and incident
hospitalized HF with median 22 years of followup among 1850 African-Americans in the
Study (HF events = 355). We next tested the
relationship of identified metabolites with LV
ejection fraction, mass and wall thickness
measured by echocardiography. We genotyped
a candidate metabolomics-influencing variant,
rs77271279, in the entire ARIC cohort (10,263
European-Americans and 3,543 African-
Americans) to evaluate its effect on incident HF.
Results: Six out of 308 analyzed named
metabolites were significantly associated with
incident HF in African-Americans (p < 1.6⊆10-4
using Bonferroni correction taking into account
the correlation among variables) after adjusting
for traditional risk factors, including eGFR.
Depending on the particular metabolite, per SD
change was associated with 17-25% risk
difference in incident HF, with an average effect
at 21%. Five out of six metabolites were
mutually independent, and the predictive ability
for incident HF was improved over the
traditional risk factors by adding the five
metabolites (AUC = 0.761 vs. 0.748, p = 0.037).
Three metabolites were nominally associated
with LV ejection fraction or wall thickness (p <
0.05). Hexadecanedioate, a medium chain fatty
acid, was the most significant metabolite for HF
(HR = 1.22, p = 3.0⊆10-7) and was also
associated with echocardiographicallydetermined reduced LV wall thickness. A lossof-function variant in a hepatic organic ion
transporter, SLCO1B1, (rs77271279) leads to
high hexadecanedioate levels. By genotyping
rs77271279 in the entire ARIC, we estimate that
one copy of the T allele was associated with
29% increased risk for hospitalized HF (HR =
1.29, p = 0.048).
Conclusion: In conclusion, we identified six
metabolites that influence incident hospitalized
HF among African-Americans, and
demonstrated that SLCO1B1 is a candidate
causal gene for HF. If replicated, our results may
provide new insights into biological mechanism
for HF process.
B. Yu: None. A.C. Morrison: None. T.H. Mosley:
None. A.M. Shah: None. S.D. Solomon:
None. C. Macrae: None. P.P. Chang: None. R.A.
Gibbs: None. E. Boerwinkle: None.
MP49
Three Months of Novel Triple Combination
Pharmacotherapy Reduces Body Weight and
Blood Pressure but Not Aortic Stiffness in
Obese Adults: a Randomized, Placebo
Controlled, Double Blind Clinical Trial
Graziela Z Kalil, Univ of Iowa, Iowa City, IA;
William G. Haynes, Novartis Inst for Biomedical
Res, Inc, Cambridge, Massachusetts (current
position) formerly faculty Univ of Iowa, at the
time study was conducted, Iowa City, IA; M.
Bridget Zimmerman, Gary L. Pierce, Univ of
Iowa, Iowa City, IA
increased carotid-femoral pulse wave velocity
(CFPWV), an index of aortic stiffness and
independent predictor of cardiovascular disease
(CVD) risk. Lifestyle advice results in modest
reductions in weight, blood pressure (BP) and
aortic stiffness in obese adults, however, less is
known about the efficacy of triple combination
pharmacotherapy on weight loss and CVD risk.
We tested the hypothesis that triple
combination pharmacotherapy (metformin +
topiramate + orlistat) results in more weight
loss and improve BP and CFPWV in obese adults
than dual therapy (metformin + topiramate;
metformin + orlistat), mono-therapy
(metformin; topiramate) or placebo.
Methods: In a double-blind, randomized,
placebo controlled single-center trial, 117 obese
adults (age 55.6 1.2 yrs, body mass index 37.3
0.7 kg/m2, 66% female) with at least one
additional CVD risk factor, were randomized to
one of 6 study groups: (triple therapy n=20;
metformin + topiramate n=20; metformin +
orlistat n= 18; metformin n=20; topiramate
n=19; placebo n=20) for 3 months. Subjects had
body weight, blood pressure and CFPWV
assessed before and after 3 months, and
received written advice on healthy diet and
physical activity at baseline.
Results: Age, body mass index and gender
distribution were similar at baseline among the
groups, and 88 subjects completed the study.
After 3 months, subjects on triple combination
therapy had larger reductions (P<0.001) in
weight (-12.1%, 95% CI -13.81 to -10.28, n=12)
compared with placebo (-5.3%, 95% CI -7.2 to 3.5, n=16). In contrast, the reduction in weight
in subjects on metformin + topiramate (-9.3%,
95% CI -11.1 to -7.5, n=15), metformin + orlistat
(-8.4%, 95% CI -10.2 to -6.6, n=15), metformin (6.6%,95% CI -8.4 to -4.7, n=15 ) or topiramate (8.6%, 95% CI -10.5 to -6.8, n=15) did not differ
from placebo (all P>0.05). Mean BP decreased
to a greater extent in the triple combination
group compared with placebo (-14.6 3.2 vs. -1.1
3.5 mmHg, P<0.001), but did not decrease (all
P>0.05) more than placebo in the metformin +
topiramate (-8.7 2.8 mmHg), metformin +
orlistat (-4.9 2.7 mmHg), metformin (-3.0 2.7
mmHg) or topiramate (-8.2 2.9 mmHg) groups.
Furthermore, the reduction in CFPWV after
triple combination therapy (-0.96 0.36 vs. -0.37
0.39 m/sec, P=0.28) and the dual and mono
therapy groups (all P>0.05) was not significantly
different than after placebo.
Conclusion: Three months of triple combination
pharmacotherapy plus lifestyle advice results in
significantly larger reductions in body weight
and BP but not aortic stiffness compared with
placebo and lifestyle advice. It may require
more than three months of triple combination
pharmacotherapy-induced weight loss to
demonstrate a significant improvement in
aortic stiffness.
G.Z. Kalil: None. W.G. Haynes: None. M.
Zimmerman: None. G.L. Pierce: None.
MP50
Fat Distribution and Metabolic Health: Central
and Lower Body Adipose Tissue Depots are
Differentially Associated with Insulin
Sensitivity in Parous and Nulliparous Caucasian
and African American Women
Katherine H Ingram, Kennesaw State Univ,
Kennesaw, GA; Gary R Hunter, Barbara A
Gower, Univ of Alabama at Birmingham,
Birmingham, AL
Parity and race individually affect the
accumulation of visceral adipose tissue, but
their combined influence on the relationship
between fat distribution and insulin sensitivity
is unknown. The purpose of this study is to test
the influence of parity and race in the
relationship between insulin sensitivity and the
preference of central versus lower-body fat
accumulation in overweight women.
METHODS: In non-Hispanic white (white; n=
109, 56 parous) and African American (AA; n=
119, 58 parous) pre-menopausal women
matched for age and BMI (age 34 ± 6.2; BMI =
27.5 ± 4.7), intra-abdominal adipose tissue
(IAAT) via CT, regional and total body fat by
DXA, insulin sensitivity (SI) calculated from
minimal model, and cardiorespiratory fitness
(VO2max) were assessed.
RESULTS: Nulliparous women (NP) were
younger (31.3 ± 6.5 vs 36.4 ± 5.1), had less IAAT
(69.6 ± 31.4 vs 85.4 ± 30.3), and a higher VO2max
(29.5 ± 4.0 vs 27.7 ± 3.6), but showed no
difference in SI or leg fat compared to parous
women. Stratified by race, white women were
more insulin sensitive (3.5 ± 1.8 vs 2.5 ± 1.9 [x
10-4 min-1/(μIU/ml)]), had a higher VO2max
(29.2±4.0 vs 27.6±3.6), and more IAAT
(92.7±30.4 vs 65.1 ± 25.9) than AA women, but
less leg fat (26.6 ± 3.7 vs 28.2 ± 3.1).
IAAT is negatively related to SI in NP (r= -.40, p<
.001), but not in parous (r= -.15, p= .16), when
controlled for age and body fat. This
relationship is particularly strong in white NP (r=
-.58, p< .001), but not in AA NP (r = -.24, p =
.13), white parous (r= -.24, p= .09), or AA parous
(r= -.18, p= .24). These relationships remain
robust whether analyses are controlled for total
body fat mass, leg fat, and/or VO2max. Leg fat is
positively related to SI in both NP (r= .45, p<
.001) and parous (r= .25, p< .05). Stratified by
race, this relationship remains strong in all
groups (r> .4, p< .01), except parous AA women
(r= .17, p= .26).
Multiple linear regression indicates that IAAT,
age, leg fat, race, and VO2max are independent
predictors of SI in NP. In parous women, only
race achieved significance. IAAT, age, leg fat,
and VO2max are predictors of SI in white NP, but
not in white parous. Leg fat is the sole predictor
of SI in AA NP, while none of the variables are
significant in AA parous.
CONCLUSION: These data demonstrate that the
relationship between fat distribution and insulin
sensitivity in overweight women varies as a
result of race and reproductive history. In NP,
the more insulin sensitive the individual is, the
more fat accumulates in the legs and the less it
accumulates in the abdomen. Race clearly
influences these relationships. The
SI/abdominal fat relationship is more
pronounced in white women, while SI/leg fat
predominates in AA. SI loses its strong
association with abdominal obesity in white
parous women and its association with leg fat in
AA parous women. This dissociation suggests
that both hepatic metabolism and fat
distribution are altered by high hormones
during pregnancy in both racial groups.
K.H. Ingram: None. G.R. Hunter: None. B.A.
Gower: None.
MP51
Evaluating the Effectiveness of a Web-Based
Intervention to Prevent Unhealthy Weight
Gain in College Students
Leslie A Lytle, Univ of North Carolina, Chapel
Hill, Chapel Hill, NC; Melissa Laska, Univ of
Minnesota, MInneapolis, MN; Marilyn Nanney,
Univ of Minnesota, Minneapolis, MN; Jennifer
Linde, Univ of Minnesota, MInneapolis, MN;
Stacey Moe, Univ of Minnesota, Minneapolis,
MN
CHOICES was a randomized control trial
evaluating a one-credit college course and a
social-network website to reduce unhealthy
weight gain in young adults. The primary
outcome was relative change in BMI and weight
status between conditions at the end of the 24month intervention. The study sample was 441
young adults attending 3 2-year colleges in the
Twin Cities of Minnesota. At baseline the mean
age of the sample was 22.8 and the sample was
approximately 68% female, 73% white, and 71%
lower income (income less than $12,000). At
baseline 47% of the sample was overweight or
obese with a mean BMI of 25.4. Students were
randomized after baseline data were collected
into one of two conditions. Students in the
intervention condition took a one credit class
focusing on weight gain prevention behaviors
and were invited to participate in a social
networking website designed to help individuals
track and learn about weight related health
behaviors and network with each other for
support. The retention rate of participants at
the final data collection period (24 months) was
83.4%. Adjusting for age, gender, race and
education, there were no statistically significant
differences in BMI between study conditions at
24 months (26.13: intervention and 26.09:
control). However, the proportion of students
that were overweight and obese was
significantly smaller in the intervention
condition (47%) as compared to the control
condition (55%) at the 24-month
period. Analyses also examined the extent to
which participants maintained, gained and lost
weight over the course of the trial. More that
half (54%) of the sample gained weight (more
than 3% of baseline weight) during the 24
months of the trial. There were no treatment
differences between categories of weight
stability. CHOICES is one of the first web-based
weight gain prevention intervention trials to be
conducted in 2-year or technical colleges and
the results suggest that a primarily web-based
intervention may be useful in helping young
adults avoid transitioning from a healthy weight
to overweight or obese weight status.
L.A. Lytle: None. M. Laska: None. M. Nanney:
None. J. Linde: None. S. Moe: None.
MP52
Beyond Body Mass Index: A Population-Based
Comparison Demonstrates Advantages of
Abdominal Anthropometry for Identifying
Cardiometabolic Dysfunctions
Henry S Kahn, Kai McKeever Bullard, CDC,
Atlanta, GA
Background: A weight-based adiposity indicator
(body mass index; BMI, kg/m2) is often reported
for adults. Indicators based on sagittal
abdominal diameter (SAD) or waist
circumference have also identified
cardiometabolic risk.
Aim: Compare SAD/height ratio (SADHtR) or
waist/height ratio (WHtR) with BMI for
identifying risks in a representative sample of
non-elderly adults without diagnosed diabetes.
Outcome dysfunctions were Dysglycemia
(glycated hemoglobin ≥5.7%), HyperNonHDLc
(non-HDL-cholesterol ≥160 mg/dL or taking
cholesterol meds), Hypertension (SBP ≥140 or
DBP ≥90 or taking blood-pressure meds) and
HyperALT (alanine transaminase ≥75th %ile [sexspecific p75]).
Methods: Non-pregnant adults (ages 20-64 y;
N=3,071) in the 2011-2012 US National Health
and Nutrition Examination Survey provided
conventional anthropometry and supine SAD
(by sliding-beam caliper). Sample weighting
permitted estimation of population
characteristics, including odds ratios (ORs)
associated with each adiposity indicator (logistic
regression models adjusted for age, sex and
ancestry). For each dysfunction, we compared
the ORs for 3 indicators after rescaling them to
the indicator’s sex-specific, interquartile range.
Results: The population distributions (mean;
p25, p75) of indicators among men were:
SADHtR (0.129; 0.112, 0.144), WHtR (0.564;
0.505, 0.613), and BMI (28.2; 24.2, 31.0).
Among women they were: SADHtR (0.131;
0.112, 0.148), WHtR (0.580; 0.510, 0.636), and
BMI (28.3; 23.4, 31.7). Dysfunction prevalence
ranged from 21.9% (Dysglycemia in women) to
42.4% (HyperNonHDLc in men). To identify
HyperNonHDLc, Hypertension and HyperALT
(but not Dysglycemia), the ORs were highest for
SADHtR and lowest for BMI. When SADHtR
entered models simultaneously with BMI, the
ORs associated with BMI no longer contributed
to identification of HyperNonHDLc,
Hypertension, or HyperALT (Figure).
Conclusions: Among US adults, the SADHtR
provides low-cost estimation of cardiometabolic
risk independently of BMI.
H.S. Kahn: None. K.M. Bullard: None.
MP53
The Impact of the Obesity Epidemic on
Atherosclerotic Cardiovascular Disease Risk
Scores: The CARDIA Study
Duke Appiah, Pamela J. Schreiner, Univ of
Minnesota, Minneapolis, MN; Raegan W.
Durant, Univ of Alabama at Birmingham,
Birmingham, AL; Sharina D. Person, Catarina I.
Kiefe, Univ of Massachusetts, Worcester, MA;
Cora E. Lewis, Univ of Alabama at Birmingham,
Birmingham, AL; Catherine Loria, NIH/NHLBI,
Bethesda, MD; Stephen Sidney, Kaiser
Permanente Northern California, Oakland, CA;
O. Dale Williams, Florida Intl Univ, Miami, FL
INTRODUCTION: Cardiovascular disease (CVD)
mortality has decreased over recent decades, in
part, due to changes in the prevalence of risk
factors. However, few studies have explored
the impact of the obesity epidemic on CVD risk
prediction in young adults.
HYPOTHESIS: We assessed the hypothesis that
BMI trends are positively associated with
changes in 10-year AHA/ACC atherosclerotic
cardiovascular disease (ASCVD) risk scores from
young adulthood to middle age beyond the
effect of other CVD risk factors included in the
scores (age, sex, race, lipids, blood pressure,
hypertension medication, diabetes, smoking).
METHODS: Data were obtained from 2437 black
and white men and women aged 18-30 years at
baseline (1985-1986) enrolled in the Coronary
Artery Risk Development in Young Adults
(CARDIA) study with follow-up exams at year 0,
5, 10, 15, 20 and 25 (ages 43-55 years).
Repeated-measures regression was used to
model the association between ASCVD risk
scores and time-varying BMI measures.
RESULTS: The average 10-year ASCVD risk
increased from 0.6% at baseline (mean age:
25.3) to 3.9% at year 25 (mean age: 50.3) with
the change higher for men (blacks: 1.0 to 8.2%,
whites: 0.3 to 4.6%) than women (blacks: 0.5 to
3.6%, whites: 1.2 to 1.4%). The overall
prevalence of obesity at baseline and year 25
was 10% and 42% respectively. BMI trends were
positively associated with 10-year change in
ASCVD risk scores (0.12% per 1 kg/m2 increase,
p<0.001). BMI adjustment minimally reduced
risk scores trends with the greatest change
between unadjusted and adjusted risk scores
observed among black women (0.1 to 3.0%)
(Figures A and B).
CONCLUSION: In young adults, BMI trends are
associated positively with 10-year changes in
ASCVD risk independent of other risk factors.
This adds to the evidence that weight control in
early adulthood is an important predictor of
lower future CVD risk.
D. Appiah: None. P.J. Schreiner: None. R.W.
Durant: None. S.D. Person: None. C.I. Kiefe:
None. C.E. Lewis: None. C. Loria: None. S.
Sidney: None. O. Williams: None.
MP54
Dietary Protein Lowers Obesity Risk in MiddleAged Framingham Offspring Study Adults
Justin Rene Buendia, Syed Ridda Hasnain, M.
Loring Bradlee, Martha R. Singer, Boston Univ
Sch of Med, Boston, MA; Ralph B. D'Agostino,
Boston Univ, Boston, MA; Lynn L Moore, Boston
Univ Sch of Med, Boston, MA
Aging triggers increases in fat mass and changes
in body composition. Since dietary protein may
impact the balance of lean/fat mass, it has been
suggested that current Dietary Guidelines for
protein may be inadequate for older adults.
Using data from the Framingham Offspring
Study, we examined the role of dietary protein
on body mass index (BMI), waist size, and risks
of obesity and excess central adiposity in
middle-aged adults. Dietary data were derived
from 3-day records collected in exams 3 and 5
in 1490 subjects, ages 30-54 years who were
free of diabetes, CVD and cancer. Protein
intakes (total, animal, and plant) were
expressed as weight-adjusted residuals to
minimize potential confounding by body size.
BMI and waist circumference were measured at
each exam. Analysis of covariance (ANCOVA)
was used to estimate mean follow-up BMI and
waist size while controlling for the following
potential confounders: age, sex, education,
height, activity, smoking, total energy intake, %
energy from fat, and baseline weight. Multiple
logistic regression models were used to
determine the effect of protein intake on
obesity and central adiposity risks, while
adjusting for the above potential confounders.
Adjusted protein intakes were classified into
tertiles, with mean intakes of 0.9, 1.2, and 1.5
grams/kg of body weight across these tertiles.
BMI declined with increasing total, animal, and
plant protein intakes for both men and women
(p<0.05 for all). Overall, those in the highest
tertile of total protein intake, had a BMI that
was 2.4 kg/m2 lower than those in the lowest
tertile (p<0.0001). Results for men and women
separately were very similar. The highest (vs.
lowest) tertile of animal and plant protein
intakes were associated with 1.3 kg/m2 and 2.6
kg/m2 lower BMI, respectively (p<0.0001, for
both). Waist size also declined (Men: 39.9, 38.2,
37.7 inches; Women: 32.8, 31.8, 30.6 inches; ptrend<0.0001) with increasing tertile of total
protein intake. Among non-obese subjects at
baseline, incident obesity risk was 35% lower
(95% CI: 0.43-1.00) in the highest (vs. lowest)
tertile of total protein intake. Both animal and
plant proteins lowered obesity and central
adiposity risks although the results were
somewhat stronger for plant than for animal
protein. Finally, the effects of dietary protein
intake as part of a healthier diet pattern (e.g., in
combination with higher fruits and vegetables,
fiber, and whole grain intakes) were explored.
In these analyses, the beneficial effects of
protein on obesity risk did not differ in those
with higher (O.R.: 0.76; 95% CI: 0.61, 0.95) vs.
lower (O.R. 0.78; 95% CI: 0.63, 0.97) intakes of
fruits and vegetables. The same was true for
fiber and whole grain intakes. In Framingham,
higher dietary protein intakes lowered the longterm risk of obesity in middle-aged adults.
J. Buendia: None. S. Hasnain: None. M.
Bradlee: None. M.R. Singer: None. R.B.
D'Agostino: None. L.L. Moore: None.
MP55
Electrocardiographic versus Echocardiographic
Left Ventricular Hypertrophy in Prediction of
Congestive Heart Failure in the Elderly
Mohamed Faher Almahmoud, Elsayed Soliman,
Waqas Qureshi, Wesley T O'Neal, Wake Forest
Univ, Winston-Salem, NC
Background: Left ventricular hypertrophy (LVH)
is an established risk factor for congestive heart
failure (HF) and is a component of the
Framingham HF Risk Score (FHFRS). Whether
LVH detected by electrocardiogram (ECG-LVH)
is equally predictive of HF as LVH detected by
echocardiography (Echo-LVH) is unclear.
Methods: This analysis included 4,543
participants (85% white; 41% male) aged 65
years or older from the Cardiovascular Health
Study (CHS) who were free of HF and major
intraventricular conduction defects at baseline.
Adjudicated incident HF was identified during a
median follow-up of 12 years. ECG-LVH was
defined by the sex-specific Cornell voltage
criteria. Echo-LVH was defined from the
observed left ventricular (LV) mass compared
with the sex-specific predicted LV mass values.
Cox proportional hazard regression was used to
compute hazard ratios (HR) and 95% confidence
intervals (95%CI) for the association between
ECG-LVH and Echo-LVH with incident HF,
separately. Models were adjusted for age, sex,
race, education, income, smoking status,
systolic blood pressure, diabetes, body mass
index, total cholesterol, HDL-cholesterol,
aspirin, statins, antihypertensive medications,
log (hs-CRP), and history of coronary heart
disease. Harrell’s concordance indices were
calculated for the FHFRS with inclusion of ECGLVH and Echo-LVH, separately.
Results: At baseline, 168 participants had ECGLVH and 78 had Echo-LVH. A total of 30% (1,380
out of 4,543) incident HF events occurred
during follow up. In separate multivariable
adjusted models, both ECG-LVH and Echo-LVH
were predictive of incident HF (ECG-LVH:
HR=1.4, 95%CI=1.1, 1.8; Echo-LVH: HR=1.7,
95%CI=1.2, 2.5). The ability of the FHFRS to
predict HF was similar when ECG-LVH (C-index:
0.772, 95%CI=0.726, 0.815) and Echo-LVH (Cindex: 0.771, 95%CI=0.726, 0.814) were
included into the model separately.
Conclusion: Both LVH-ECG and Echo-LVH are
predictive of incident HF and can be used
interchangeably in heart failure risk prediction
models.
M. Almahmoud: None. E. Soliman: None. W.
Qureshi: None. W. O'Neal: None.
MP56
Misclassification of Incident Heart Failure
Hospitalizations in Administrative Claims Data:
The Atherosclerosis Risk in Communities (ARIC)
Study.
Ricky Camplain, Anna Kucharska-Newton, Lloyd
E Chambless, Univ of North Carolina at Chapel
Hill, Chapel Hill, NC; Jacqueline D Wright, Natl
Heart Lung and Blood Inst, NIH, Bethesda, MD;
Kenneth R Butler, Univ of Mississippi Medical
Ctr, Jackson, MS; Carmen Cuthbertson, Gerardo
Heiss, Univ of North Carolina at Chapel Hill,
Chapel Hill, NC
Background
Estimation of disease incidence from
administrative data requires an adequate lookback (prevalence) period to exclude pre-existing
conditions from the incidence risk set. We
characterized optimal lengths of the prevalence
period to minimize misclassification of incident
heart failure (HF) hospitalization, a proxy for
incident HF.
Methods
Data for participants of the ARIC Study (a
prospective longitudinal cohort of 15,792
individuals sampled from 4 US communities)
were linked with CMS Medicare claims from the
years 2000-2012. We included only participants
with >36 months of continuous CMS Medicare
fee for service (FFS) enrollment. Each
participant’s time-in-observation was divided
into two phases. The first 36 months were the
prevalence period. Observation time after an
index date 36 months following the date of
enrollment was the incidence period.
HF hospitalizations were identified from CMS
MedPAR records using ICD-9 code 428.xx in any
position. Patients were classified as having a HF
hospitalization in (a) both the prevalence and
incidence periods, (b) in the prevalence period
only, (c) in the incidence period only, or (d)
neither. Incident HF was defined as the first HF
hospitalization in the incidence period not
preceded by a HF hospitalization in the
prevalence period. The proportion of events
misclassified as incident HF hospitalization was
estimated from incremental reductions of the
prevalence period to start 36, 30, 24, 18, 12, or
6 months before the index date. The impact of
misclassification was estimated as differences in
incidence per 1,000 patients at risk.
Results
Of 11,054 ARIC participants enrolled in
Medicare FFS, 9,568 met the study inclusion
criteria. A total of 1,129 incident HF
hospitalizations were identified based on the 36
month prevalence period, considered as the
referent (incidence rate 118 HF hospitalizations
per 1,000 patients at risk). Shortening the
prevalence period to 24 months increased the
HF incidence rate to 123 per 1,000,
overestimating the number of incident HF
hospitalizations by 4.2% while retaining over
90% of the sample. A 12 month prevalence
period yielded an overestimation of the number
of incident HF hospitalizations by 11%
(incidence rate 129 per 1,000 patients at risk)
while retaining 95% of the sample.
Conclusions
Selection of too short of a prevalence period to
define incident hospitalized HF from CMS
Medicare claims data can introduce substantial
misclassification. Consideration of several
prevalence periods indicates that a 24 month
prevalence period reduces the potential for bias
in the estimation of incident hospitalized HF
while retaining most observations.
R. Camplain: None. A. Kucharska-Newton:
None. L.E. Chambless: None. J.D. Wright:
None. K.R. Butler: None. C. Cuthbertson:
None. G. Heiss: None.
MP57
The Association Between Anthropometrics and
Different Measures of Cardiac Structure and
Function - The Echo-SOL Study
Matthew A Allison, Univ of California San
Diego, La Jolla, CA; Jianwen Cai, Univ of North
Carolina, Chapel Hill, NC; Ankit Desai, Univ of
Chicago, Chicago, IL; Barry Hurwitz, Univ of
Miami, Miami, FL; Ai Ni, Univ of North Carolina,
Chapel Hill, NC; Neil Schneiderman, Univ of
Miami, Miami, FL; Sanjiv Shah, Univ of Chicago,
Chicago, IL; Daniel Spevack, Einstein Coll of
Med, Bronx, NY; Greg Talavera, San Diego State
Univ, San Diego, CA; Carlos Rodriguez, Wake
Forest Univ, Winston-Salem, NC
Background: The purpose of this study was to
determine the magnitudes and significances of
the associations between adiposity and
echocardiographically determined measures of
left ventricular (LV) structure and function in a
diverse cohort of Hispanic/Latino adults.
Methods: Subjects were 1,350 adult men and
women participants of the Hispanic
Communities Health Study - Study of Latinos
(HCHS-SOL) who enrolled in an ancillary study
to determine cardiac structure and function by
echocardiography. In addition to
echocardiography, subjects were evaluated by
extensive survey information, relevant physical
measurements (to include bioelectrical
impedance) and fasting blood assays.
Results: The mean age was 56.1 years and 57%
were female. Twenty-six percent were Mexican
American, 25% Cuban American, 18%
Dominican American, 17% Puerto Rican
American, 8% Central American and 7% South
American. Overall, the mean ejection fraction
was 60.5%, while the mean stroke volume was
70 ml, end diastolic volume 83 ml, fractional
shortening 31% and cardiac output 4.5 L/min.
Results of multivariable linear regression
adjusted for age, gender, hypertension,
diabetes, dyslipidemia, cigarette smoking,
family history of coronary heart disease, Creactive protein and chronic kidney disease
revealed that each 1-unit increment in body
mass index (BMI) and fat mass (FM) by
impedance was associated with 0.64 and 0.25
(p < 0.01 for both) higher LV mass index (to
height), while a 0.1 unit increment in the waist
to hip ratio (WHR) was associated with 3.2
higher LV mass index. Concomitantly, each 1unit increment in BMI and FM was associated
with 7 and 3% (p < 0.01 for each) higher odds of
LV hypertrophy, while a 0.1 unit increment in
WHR was associated with 78% higher odds for
LV hypertrophy (p < 0.01). On the other hand,
none of these variables were significantly
associated with ejection fraction. There were no
significant interactions between the
anthropometric variables and the different
Hispanic groups for LV mass index or
hypertrophy.
Conclusions: Among Hispanics/Latinos from
different cultural backgrounds, and by three
measures of body composition (BMI, FM and
WHR), higher levels of adiposity are significantly
associated with higher LV mass indexed for
height and the odds for hypertrophy, while not
being associated with better or worse ejection
fraction.
M.A. Allison: None. J. Cai: None. A. Desai:
None. B. Hurwitz: None. A. Ni: None. N.
Schneiderman: None. S. Shah: None. D.
Spevack: None. G. Talavera: None. C.
Rodriguez: None.
MP58
Vitamin D Consumption is Not Associated with
Incident Heart Failure in the Physicians' Health
Study
Jeremy Robbins, Andrew Petrone, J. Michael
Gaziano, Luc Djousse, Brigham and Women's
Hosp, Boston, MA
Background: Previous research investigating the
relationship between vitamin D
supplementation and incident heart failure (HF)
has yielded equivocal results. Limited research
exists on the association of dietary vitamin D
consumption and the risk of incident heart
failure.
Objective: We sought to test the hypothesis
that vitamin D consumption is associated with a
lower incidence of heart failure.
Methods and Results: Using a validated food
frequency questionnaire, we estimated dietary
vitamin D consumption for 19,635 participants
of the Physician’s Health Study who were free
of HF at baseline. The mean age at baseline was
66.4 ± 9.2 years. Over a mean followup of 9.3
years, 858 cases of incident HF were captured
using an annual follow-up questionnaire with
validation in a subsample. From the
multivariable Cox regression model, hazard
ratios (95% CI) of incident HF were 1.0
(reference), 1.49 (1.17 to 1.89), 1.37 (1.07 to
1.75), 1.34 (1.02 to 1.75), and 1.28 (0.94 to
1.75) from lowest to highest quintile of calorieadjusted vitamin D, respectively, after adjusting
for age, BMI, smoking, alcohol, exercise,
multivitamin use, fruits and vegetables,
chocolate, and breakfast cereal consumption,
atrial fibrillation, and valvular heart disease (p
for linear trend = 0.71).
Conclusions: In this prospective study of male
health professionals, dietary vitamin D
consumption is associated with a higher risk of
HF.
J. Robbins: None. A. Petrone: None. J. Gaziano:
None. L. Djousse: None.
MP59
Mediating the Medical, Economic and Social
Impact of HF: There is an APP for That
Linda Houston-Feenstra, Mercy Kagoda, Wayne
Dysinger, Loma Linda Univ Medical Ctr, Loma
Linda, CA; Samir Chatterjee, Nagla Alnosayan,
Ala Alluhaidan, Claremont Colls, Claremont, CA;
Sharon Fabbri, Denise Peterson, Loma Linda
Univ Medical Ctr, Loma Linda, CA
The continued rise in cost of Heart failure (HF)
management, begs the question, why can
advances in science and medicine not stem this
rising cost? Why do patients fail to adhere to
prescribed medications and lifestyle
recommendations? Lack of effective training for
patient/families challenge successful transition
to home due to conflicts generated by pressure
within the patient’s home environment
reinforced by societal attitudes about food. This
pilot was designed as a multidisciplinary
project, including information systems
professionals, clinicians, and patients working
together to develop/evaluate a customized
mobile phone application (app). Using, home
based monitoring of daily weights, blood
pressure, heart rate, blood glucose, and a dash
board of cumulative data accessed daily by
clinicians. A built in algorithm identifies
patients’ risk for re-admission based on changes
in their vital signs or self-reported symptoms
defined by clinical staff as representing best
practices pathways decision points. 7 patients
with a clinical diagnosis of HF who had
documentation of at least one HF related
admission in the past 14 months were recruited
to trial the App. Patients have been followed for
120 days with an endpoint of 365 days. Data
points for outcomes are: HF related
hospitalizations; emergency department and
urgent care visits, weight, blood pressure, and
Minnesota living with heart failure quality of
life. Preliminary data analysis shows mean
compliance rate for daily measurements =
68.5%. Utilization has prevented one HF
readmission, changed one admission from an
acute ICU readmission into a short stay guided
HF admission, accomplished by early
identification of symptoms that unmanaged
would have resulted in a more serious and
lengthy admission. This integrated innovative
system has demonstrated improved
accountability and outcomes in the enrolled
participants. Patient input at 120 days resulted
in system revisions. Data collection will restart
and continue to the 365 day end point.
L. Houston-Feenstra: None. M. Kagoda:
None. W. Dysinger: None. S. Chatterjee:
None. N. Alnosayan: None. A. Alluhaidan:
None. S. Fabbri: None. D. Peterson: None.
MP60
Associations of Socio-Economic and Access to
Care Factors With Inpatient and Outpatient
Heart Failure. The Aric Study
Carmen Cuthbertson, Anna Kucharska-Newton,
Mehul Patel, Ricky Camplain, Univ of North
Carolina, Chapel Hill, NC; Randi Foraker, Ohio
State Univ, Columbus, OH; Lisa Wruck, Univ of
North Carolina, Chapel Hill, NC; Aaron Folsom,
Univ of Minnesota, Minneapolis, MN; Nicole
Puccinelli-Ortega, Wake Forest Univ, WinstonSalem, NC; Kunihiro Matsushita, Johns Hopkins
Univ, Baltimore, MD; Gerardo Heiss, Univ of
North Carolina, Chapel Hill, NC
BACKGROUND: Little is known about the
burden of heart failure (HF) managed in
outpatient settings and of the characteristics
that influence the degree to which HF is
diagnosed in outpatient venues predating a
hospitalization. We hypothesized that access to
care and socio-economic contextual factors
relate to patient ascertainment of incident HF in
outpatient vs inpatient settings.
METHODS: We created an open cohort of
consecutive fee-for-service CMS Medicare
beneficiaries (2003 - 2006) residing in the four
epidemiologic surveillance areas of the
Study. Using a 24 month look-back period we
classified incident inpatient HF (IP HF) diagnoses
as the first observed HF hospitalization (ICD-9
code 428.xx in any position). Incident
outpatient HF (OP HF) diagnoses were defined
as two outpatient HF encounters within 365
days, with a 12 month look-back period. Three
contextual factors were characterized at the
level of zip code tabulation area: number of
primary care physicians per 1,000 population
(grouped by tertiles), the proportion of the
population living in a medically underserved
area (MUA) (any vs. none), and the proportion
of the population living in poverty (high defined
as 10% or more). Associations of contextual
factors with incident IP HF or OP HF diagnoses
were estimated as incidence rate ratios (IRR,
95% CI) using Poisson generalized linear
models. We estimated separate models for
each contextual factor while controlling for the
other contextual factors, age, sex, race, and
ARIC community.
RESULTS: The study population included
106,585 consecutive fee-for-service
beneficiaries (40% male, median age 75 years,
11.5% non-white). We observed 3,348 incident
IP HF diagnoses and 1,050 OP HF diagnoses over
310,689 person-years of follow-up (ageadjusted rates per 1,000 person-years: IP HF
15.8 (95% CI 15.0, 16.6); OP HF rate 4.7 (4.4,
5.2). The adjusted rates of IP HF diagnosis were
similar across strata of physician density, while
rates of OP HF diagnoses were higher in low
physician density areas compared to high
physician density areas (IRR 1.23, (1.17, 1.29).
Rates of IP HF and OP HF diagnoses were higher
in high poverty areas compared to low poverty
areas (IP HF IRR 1.23 (1.10, 1.38); OP HF IRR
1.26 (1.03, 1.55)). In areas with any MUA
population, IP HF rates were higher as
compared to areas with no MUA (IRR 1.10
(1.01, 1.21)) but no difference was found for OP
HF rates.
CONCLUSION: Contextual factors pertaining to
low access to care and low socio-economic
status were associated with differences in the
rate of inpatient versus outpatient HF diagnoses
among CMS Medicare beneficiaries in four ARIC
Study communities. Further research is needed
to understand the effect of observed
differences in the clinical location of HF
diagnosis on outcomes.
C. Cuthbertson: None. A. Kucharska-Newton:
None. M. Patel: None. R. Camplain: None. R.
Foraker: None. L. Wruck: None. A. Folsom:
None. N. Puccinelli-Ortega: None. K.
Matsushita: None. G. Heiss: None.
MP61
Comparing the Influence of Individual vs.
Community Socioeconomic Factors on
Courtney Pilkerton, Sarah Singh, WVU Sch of
Public Health, Morgantown, WV; Adam
Christian, WVU Sch of Med, Morgantown, WV;
Thomas K Bias, Stephanie J Frisbee, WVU Sch of
Public Health, Morgantown, WV
BACKGROUND: Despite advances in treatment
and decreases in risk factors, cardiovascular
disease remains the cause of 1/3 deaths. Both
prevalence and cost of cardiovascular disease
are expected to increase over the coming
decades. In supporting health efforts to reduce
cardiovascular disease burden, the AHA
developed a comprehensive cardiovascular
health index (CVHI) incorporating behavioral
and biological factors. A thorough
understanding of health determinants requires
inclusion of factors at multiple levels of
proximity to individuals and communities. The
objective of this study was to identify the
demographic characteristics of individuals and
areas in which they live that promote
cardiovascular health. METHODS: Data from
2011 BRFSS were used to calculate CVHI.
Participants were ineligible if missing
information necessary to calculate CVHI (n =
156,973), if pregnant or pregnancy status was
unknown (n = 3,693), or if missing county code
(n = 37,163). Poisson model was used to
determine change in the expected number of
ideal factors an individual had due to various
individual and county demographic
characteristics. County demographic variables
were abstracted from the Area Health Resource
File. RESULTS: The effect of a 10 year increase in
an individual’s age decreased the expected
number of ideal CVHI factors by 6.31% (6.14,
6.47). Females had a 12.09% (11.48, 12.70)
increase in expected number of ideal CVHI
factors over males. Non-Hispanic blacks had a
7.42% (6.39, 8.44) decrease in expected number
of ideal CVHI factors compared to other
race/ethnicities. An individual’s education and
income level had a dose response association
with CVHI. Compared to having less than a high
school education, those with a high school
education had a 5.15% increase in the expected
number of ideal CVHI factors and an 11.64%
increase for those with a 4 year degree. As an
individual’s income category increased there
was a 7.89%, 10.79%, and 16.34% increase
respectively in the expected number of ideal
CVHI factors. For county demographics
increases in the expected number of ideal
factors was seen with increases in Hispanic
population (0.93% per 10% increase) and
increasing socioeconomic index (0.14% per 10
unit increase). A 10% increase in the population
with no health insurance decreased the
expected number of factors 1.49% (0.75, 2.22).
There was a significant interaction (p <0.01)
between an individual’s income level and the
socioeconomic status of the county lived in,
with those in lower income categories
benefiting more from living in higher
socioeconomic areas than those with higher
incomes. In conclusion, both individual and
county demographic characteristics were
associated with changes in an individual’s CVHI.
CONCLUSION: This information can assist public
health and government agencies in developing
priorities and evaluating the potential
effectiveness of policies and programs.
C. Pilkerton: None. S. Singh: None. A.
Christian: None. T.K. Bias: None. S.J. Frisbee:
None.
MP62
Age and Gender Differences in Cardiovascular
Health in a Rural Cohort of Children and Adults
Stephanie J Frisbee, Sheldon Steiner, Courtney
Pilkerton, Sarah Singh, WVU Sch of Public
Health, Morgantown, WV; Adam Christian,
WVU Sch of Med, Morgantown, WV; Thomas K
Bias, WVU Sch of Public Health, Morgantown,
WV
BACKGROUND: Cardiovascular disease is the
leading cause of death in the U.S. and, despite
advances in treatment modalities, the
increasing prevalence of risk factors,
particularly lifestyle-based risk factors, has led
to a concern for future increased societal
burden of cardiovascular disease. This has also
highlighted the need for an emphasis on
population approaches to the promotion and
support of cardiovascular health. To this end,
the American Heart Association recently
developed a comprehensive cardiovascular
health index (CVHI) incorporating behavioral
and biological factors. OBJECTIVE: The objective
of the current study was to assess CVHI in a
large cohort of children and adults and assess
how CVHI changes with increasing age and
between genders. METHODS: We used data
from the C8 Health Project to perform a
secondary data analysis consisting of a final
sample of 51,652 adults (≥20 years old) and
9624 children (<19 years of age) after exclusions
and incomplete data. The CVHI as developed by
the AHA was adapted to fit the data and
questions available in this cohort. Most notably,
dietary quality was excluded and so the final
score has a denominator of 6 (vs. 7 as originally
published by the AHA). RESULTS: Overall, 40.6%
of children and 9.8% of adults had ideal
cardiovascular health. In this cohort, both
children and adults were least likely to have
ideal exercise (<15% for both), and most likely
to have ideal tobacco use, blood pressure, and
blood glucose. Significant gender-based
differences were observed: for all component
scores except exercise, girls/women were more
likely to be classified as ideal compared to
boys/men. For overall classification, girls and
boys were similar (40.5% ideal vs. 40.8% ideal)
but women had better overall CVHI compared
to men (11.8% ideal vs. 7.2% ideal). In
evaluating CVHI by 10-year age groupings, a
steady age-related decay in CVHI was observed:
42.2% of 10-19 year olds had ideal
cardiovascular health compared to 20.3% of 20year olds, 13.0% of 30-year olds, and down to
2.7% in 80+ year olds. Significant gender- and
SES-related differences in this age-related decay
were observed, with women showing steeper
declines in CVHI after age 50 and lower SES
showing both a lower baseline and a steeper
decline in CVHI (p<0.05 for both).
CONCLUSIONS: Results from this study suggest
that population cardiovascular health is low
even in adolescents, and declines sharply even
in early adulthood. Results may identify
priorities for population-wide and / or policybased interventions to improve cardiovascular
health.
S.J. Frisbee: None. S. Steiner: None. C.
Pilkerton: None. S. Singh: None. A. Christian:
None. T.K. Bias: None.
MP63
Cardiovascular Health and Cumulative Burden
of Disease in a Rural Adult Population
Stephanie J Frisbee, Sheldon Steiner, Courtney
Pilkerton, Sarah Singh, WVU Sch of Public
Health, Morgantown, WV; Adam Christian,
WVU Sch of Med, Morgantown, WV; Thomas K
Bias, WVU Sch of Public Health, Morgantown,
WV
BACKGROUND: Cardiovascular disease, the
leading cause of death in the U.S, is associated
with significant socioeconomic and geographic
disparities. These disparities may create
challenges with individual- or population-based
strategies aimed at improving cardiovascular
health, particularly if poor cardiovascular health
is only one health challenge facing a
community. OBJECTIVE: The objective of the
current study was to assess the extent to which
cardiovascular health, or the absence there of,
was accompanied by one or several other
health challenges, and the socioeconomic
factors associated with disparities in these
associations, in a cohort of rural adults.
METHODS: We used the comprehensive
cardiovascular health index (CVHI) developed by
the American Heart Association, which
incorporates behavioral and biological factors.
We used data from the C8 Health Project to
perform a secondary data analysis consisting of
a final sample of 51,652 adults (≥20 years old)
after exclusions and incomplete data. The CVHI
as developed by the AHA was adapted to fit the
data and questions available in this cohort.
Most notably, dietary quality was excluded and
so the final score has a denominator of 6 (vs. 7
as originally published by the AHA). As part of
their participation in this project, enrollees
completed an extensive health survey that
included self-reported medical conditions,
several of which were verified with medical
records review. RESULTS: Overall, only 9.6% of
adults had ideal cardiovascular health (67.4%
had intermediate CVHI and 23.1% had poor
CVHI). Poor CVHI was associated with increased
risk for host of other health problems including:
Alzheimer’s, asthma, chronic bronchitis, COPD,
emphysema, fibromyalgia, liver disease,
arthritis, Parkinson’s, thyroid disease, stroke,
kidney disease, and cancer (p<0.05 for all).
Multiple age- and gender based disparities were
observed. For example, women with poor CVHI
were more than twice as likely as men with
poor CVHI to also have asthma, chronic
bronchitis, immune disease, arthritis, and
thyroid disease (p<0.05). Men and women with
poor CVHI had similar probability of developing
liver disease, stroke and cancer. Older age
groups, regardless of gender, were associated
with decreasing CVHI. The probability of having
multiple diagnoses increased with decreasing
CVHI (p<0.05); these differences were not equal
across gender and other socioeconomic
variables, thus representing sources of health
disparities. CONCLUSIONS: Results from this
study suggest that CVHI is strongly associated
with multiple other health conditions and that
these indices of poor health are clustering in
lower socioeconomic strata. This clustering and
concentration of poor health will likely
represent significant challenges for public
health advocates developing population-based
strategies to improve health.
S.J. Frisbee: None. S. Steiner: None. C.
Pilkerton: None. S. Singh: None. A. Christian:
None. T.K. Bias: None.
MP64
Heart to Heart Connections Benefit Behavior
Change
Jo-Ann Eastwood, UCLA Sch of Nursing, Los
Angeles, CA; Nabil Alshurafa, UCLA Computer
Science, Los Angeles, CA; Joy Toyama, UCLA Sch
of Nursing, Los Angeles, CA; Debra K Moser,
Univ of Kentucky, Lexington, KY
Cardiovascular disease is the number 1 killer of
women. Substantial racial disparities compound
the problem for Black women (BW) who are
particularly vulnerable with higher rates of CVD
mortality and morbidity compared to other
women. BW exhibit risk factors (RFs) at younger
ages and have a higher prevalence and greater
clustering of multiple CVD RFs. The
consequences of untreated CVD RFs for black
women are more severe, with increased
disability, decreased QOL, and higher mortality
rates. The purpose of this community - based
pilot was to test the feasibility of a program
combining self-care education with wireless
individualized feedback via a unique
smartphone designed to appeal specifically to
young YBW.
Methods: Using church-based recruitment, 62
young BW (aged 25-45) were randomized to
treatment (TX)(n=39) and control groups (n=23)
by church site. The TX group participated in 4
interactive self-care classes on CVD RF
reduction. Each participant set individualized
goals. RF profiles (waist circumference (WC),
BP, lipid panel by Cholestech [Alere]), medical
history and the Medical Outcomes Study
Adherence Scale were assessed prior to classes
and 3 months later. Participants were given
smartphones with embedded accelerometers
and WANDA-CVD, an application that delivered
prompts and messages specifically for this pilot.
Participants obtained and transmitted BP
measurements wirelessly. To identify the
effects of the intervention over time (baseline-3
months), a longitudinal mixed model was used
that included treatment by time interaction for
outcomes.
Results: Significant differences in time x
treatment interactions favoring the TX group
occurred in TC, LDL and adherence. (see
graphs).
Conclusion: These interim pilot data validate
the feasibility of implementing a risk reduction
program of combined education/wireless
monitoring and feedback in YBW. Further
testing in a large randomized trial is warranted
to determine long-term effects on behavior
change and cardiac RFs in this high risk
population.
J. Eastwood: B. Research Grant; Modest; AHA
Clinical Research. N. Alshurafa: None. J.
Toyama: None. D.K. Moser: None.
Western States Affiliate (California, Nevada &
Utah)
MP65
High Mobile Device Usage Associated With
Sedentary Behaviors and Less Physical Activity
in 6th Grade Students
Lauren Gordon, Rachel Sylvester, Robert
Rogers, Wen-Ching Wei, Alexandra Pew,
Qingmei Jiang, Eva Kline-Rogers, Caren
Goldberg, Jean DuRussel-Weston, Kim A. Eagle,
Elizabeth A. Jackson, Univ of Michigan, Ann
Arbor, MI
Background: Sedentary screen time (including
TV, computer and video games) has been
correlated with childhood obesity and other
health risks. The American Academy of
Pediatrics (AAP) recommends that children limit
their daily screen time to two hours in order to
reduce the associated risk. Mobile device use
has become increasingly popular amongst
children and adolescents. However, mobile
screen time (cell phone and tablet use) and its
effect on physical activity in adolescents has yet
to be thoroughly researched.
Methods: Self-reported survey data were
collected from 2,566 6th grade students
enrolled in Project Healthy Schools during the
2013-2014 school year. Based on AAP
guidelines, we split our sample into low mobile
device users (≤2 hours/day) and high mobile
device users (>2 hours/day). We compared
physical activity, sports team participation and
screen time habits between groups.
Results: 20.73% (n=532) of the 6th graders
surveyed reported being high mobile device
users. 60.5% (n=322) of these were female;
39.5% (n=210) were male. In addition to >2
hours/day on a mobile device, these students
spent significantly more time watching TV (2.30
v 1.70, p<0.001), on the computer (1.39 v 0.88,
p<0.001), and playing video games (1.47 v 1.01,
p<0.001) than low mobile device users. Low
mobile device users participated in significantly
more strengthening exercises (2.80 v 2.62,
p=0.046) and outside of school sports teams
(1.20 v 1.09, p=0.03) than high mobile device
users.
Conclusions: A large percentage of middle
school students (20.73%) reported spending
more time on a mobile device than
recommended by the AAP. High mobile device
usage appears to be associated with less
physical activity and more sedentary behaviors.
This illustrates the need to educate children and
encourage the reduction of time spent on a
mobile device.
L. Gordon: None. R. Sylvester: None. R. Rogers:
None. W. Wei: None. A. Pew: None. Q. Jiang:
None. E. Kline-Rogers: None. C. Goldberg:
None. J. DuRussel-Weston: None. K.A. Eagle:
None. E.A. Jackson: None.
MP66
AREST Lifestyle: Adherence Effects of a
Comprehensive Reminder System on Exercise
Adherence in Post-Myocardial Infarction
Patients
Avinash Pandey, Cambridge Cardiac Care Ctr
and Ctr for Healthcare Delivery Sciences,
Brigham and Women’s Hosp, Harvard Medical
Sch, Cambridge, ON, Canada; Niteesh K
Choudhry, Ctr for Healthcare Delivery Sciences,
Sch, Boston, MA
Background: The risk of recurrent cardiac
events can be reduced by 30-50% through
regular, structured exercise; however, there
remains a high rate of inactivity in post
myocardial infarction (MI) patients. Forgetting
to exercise may be a contributor to inactivity.
This study assessed the hypothesis that text
message reminders may be an effective
strategy to reduce forgetfulness and inactivity.
Methods: In this one year, single center study,
we recruited 50 cardiac rehabilitation patients
within 2 weeks of their MI. Participants were
randomized to usual care or to receive text
message reminders 4 times daily which stated
"Please remember to exercise 45 minutes
today". The outcomes measured were the
frequency and total duration of exercise
(assessed by log books) and physical
endurance/ aerobic fitness (assessed by
exercise stress testing at months 1, 3 and 12).
Results: Intervention and control patients had
similar baseline characteristics with an average
age of 64. In the control group, monthly
duration of exercise fell from an average of 683
minutes over 17 days at month 1 to 416
minutes over 11 days at month 12. Patients
randomized to text message reminders
exercised 772 minutes over 18 days at month 1
and 794 minutes over 18 days in month 12
(p<0.01 for duration of exercise, control versus
intervention, month 12). Baseline aerobic
fitness and cardiac endurance was similar
between control and intervention groups.
However, there was a significant improvement
in aerobic fitness and cardiac endurance at
month 12 with text reminders (7.4 versus 6.1
METS achieved month 12, p<0.01). In all subgroups analyzed this intervention significantly
improved exercise adherence and fitness.
Conclusions: In summary, this system improved
frequency and duration of exercise, and
objective measures of cardiac endurance and
aerobic fitness. While this study was not
designed to assess clinical outcomes, this text
message reminder system represents a simple
and scalable method for improving adherence
to exercise regimens among post-MI patients.
A. Pandey: None. N.K. Choudhry: None.
MP67
Objectively Measured Sleep Characteristics
and Prevalence of Coronary Artery
Calcification: The Multi-Ethnic Study of
Atherosclerosis Sleep Study
Pamela L Lutsey, Univ of Minnesota,
Minneapolis, MN; Robyn L McClelland, Univ of
Washington, Seattle, WA; Daniel Duprez, Univ
of Minnesota, Minneapolis, MN; Steven Shea,
Columbia Univ, New York, NY; Eyal Shahar, Univ
of Arizona, Tucson, AZ; Mako Nagayoshi,
Nagasaki Univ, Nagasaki, Japan; Matthew
Budoff, Univ of California – Los Angeles,
Torrance, CA; Joel D Kaufman, Univ of
Washington, Seattle, WA; Susan Redline,
Harvard Univ, Boston, MA
Background: It is unclear whether objectively
measured obstructive sleep apnea (OSA) and
other abnormal sleep phenotypes are
associated with coronary artery calcification
(CAC) prevalence independent of obesity, a
classic confounder. We tested that hypothesis,
and also examined possible mediation by
cardiovascular risk factors.
Methods: A total of 1,465 Multi-Ethnic Study of
Atherosclerosis participants [mean age 68
years] had both coronary CT and in-home
polysomnography and actigraphy. OSA
categories were defined by apnea-hypopnea
index (AHI). Other sleep phenotypes included
measures of sleep stages, fragmentation and
duration. Prevalence ratios for CAC >0 and >400
(high burden) were calculated.
Results: Participants with severe OSA (AHI ≥30;
14.6%) were more likely to have prevalent CAC,
relative to those with no evidence of OSA, after
adjustment for demographics and smoking
status [1.16 (95% CI: 1.06-1.26)], body mass
index [1.11 (1.02-1.21)], and traditional
cardiovascular risk factors [1.10 (1.01-1.19)].
Other markers of hypoxia tended to be
associated with higher prevalence of CAC >0,
while markers of sleep architecture,
fragmentation and duration were not. For CAC
>400 a higher prevalence was observed with
both a higher arousal index and less slow-wave
sleep. Overall, associations were somewhat
stronger among younger participants, but there
was no evidence of interaction by sex or
race/ethnicity.
Conclusions: Subclinical coronary artery disease,
measured by CAC >0, was more prevalent
among participants with OSA, independent of
obesity and traditional cardiovascular risk
factors, relative to participants with no OSA.
These findings support recent evidence
suggesting that OSA is associated with risk of
incident coronary artery disease.
P.L. Lutsey: None. R.L. McClelland: None. D.
Duprez: None. S. Shea: None. E. Shahar:
None. M. Nagayoshi: None. M. Budoff:
None. J.D. Kaufman: None. S. Redline: None.
MP68
Risk of Sleep Apnea and Subclinical
Cardiovascular Disease in Young-to-Middle
Aged Adults: The Bogalusa Heart Study
TIAN HU, Tulane Univ, New Orleans, LA; Suzie
Bertisch, Beth Israel Deaconess Medical Ctr,
Boston, MA; Wei Chen, Emily Harville, Tulane
Univ, New Orleans, LA; Susan Redline, Brigham
and Women's Hosp, Boston, MA; Lydia Bazzano,
Tulane Univ, New Orleans, LA
Obstructive sleep apnea (OSA) may affect
cardiovascular risk. Prior studies examining this
issue have often been limited to patients in
clinical settings or older adults. Given the high
prevalence of obstructive sleep apnea in
middle-aged adults and the influence of
duration of OSA on cardiovascular risk,
examining subclinical cardiovascular in middle
aged-adults would further elucidate the direct
relationship between OSA and cardiovascular
disease. We examined the association between
risk of OSA and subclinical cardiovascular
disease indicators among 914 young-to-middle
aged adults who responded to the Berlin
Questionnaire assessment of OSA risk in 2010,
and had measures of carotid intima-media
thickness (IMT) and left ventricular (LV)
geometry. Carotid IMT was measured using
standard procedures and categorized into
quartiles. Indices of LV geometry were assessed
by M-mode echocardiography and classified
into normal, concentric remodeling, eccentric
hypertrophy, and concentric hypertrophy by
integrating gender and race specific relative
wall thickness and LV mass index. High-risk for
OSA was determined using Berlin Questionnaire
score as the primary outcome. Secondary
outcomes included habitual snoring and
excessive sleepiness. Of those included in the
analysis, mean (SD) age was 43.1 (4.5) yrs;
42.1% were male and 31.7% were Black. A total
of 235 (25.7%) participants had elevated Berlin
scores indicating high-risk for OSA. Mean (SD) of
carotid IMT was 0.66 (0.15) mm, and 87 (9.5%)
and 161 (17.6%) participants had eccentric and
concentric LV hypertrophy, respectively. In loglinear regression models adjusted for age, race,
sex, education, current smoking, regular alcohol
consumption, total cholesterol, high-density
lipoprotein cholesterol, and type-2 diabetes,
participants at high-risk of OSA were 1.35 (95%
CI: 1.07 - 1.71) times more likely to be in the
highest quartile of IMT (≥0.74 mm), were 1.68
(1.09 - 2.58) times as likely to have concentric
hypertrophy, and 1.64 (0.95 - 2.82) times as
likely to have eccentric hypertrophy, compared
to those at low-risk of OSA. Similar positive
associations were observed for habitual snoring
but not for excessive sleepiness. After further
adjusting for current obesity status in the
models, the association of OSA risk with IMT
remained consistent while the associations with
LV hypertrophy was attenuated. There was no
significant effect modification by race or sex. In
summary, being at high risk OSA was associated
with substantially higher risk of subclinical
cardiovascular disease in this biracial, semirural, community-based population of youngto-middle age adults.
T. Hu: None. S. Bertisch: None. W. Chen:
None. E. Harville: None. S. Redline: None. L.
Bazzano: None.
MP69
Relationships Between Sleep Apnea,
Cardiovascular Disease Risk Factors, and Aortic
Pulse Wave Velocity over 9 Years: The
Wisconsin Sleep Cohort
Rebecca Stern, Claudia E Korcarz, Paul E
Peppard, Jodi H Barnet, Erika W Hagen, Terry
Young, James H Stein, Univ of Wisconsin Sch of
Med and Public Health, Madison, WI
Background
Cardiovascular disease (CVD) risk factors
associated with obstructive sleep apnea (OSA)
contribute to endothelial dysfunction and
arterial stiffening. We hypothesized that OSA
severity would predict aortic pulse wave
velocity (PWV) after nearly a decade of aging in
the Wisconsin Sleep Cohort (WSC).
Methods
Subjects were 596 participants in the WSC that
underwent overnight polysomnography
between 2000 and 2008; subsequent
tonometry data was acquired a mean of 8.8
(standard deviation, 2.1) years later. OSA
severity was described by the apnea-hypopnea
index (AHI), mean and minimum nocturnal
blood oxygen saturation level (SaO2, %), and
time with SaO2<90%. AHI+1 was log
transformed. Participants using positive airway
pressure therapy (PAP) at the tonometry visit
were evaluated as a distinct categorical
variable. Non-invasive applanation tonometry
was used to derive aortic (carotid-to-femoral)
PWV. Multivariable linear and logistic
regression models that included CVD risk
factors, antihypertensive, and lipid medications
were fit to evaluate longitudinal associations
between baseline OSA markers and future PWV.
Results
At baseline, the 596 participants were mean
55.9 (7.3) years old (53% male, 97.5%
Caucasian). Their mean body-mass index (was
31.4 (6.9) kg/m2, 89 (14.9%) had diabetes
mellitus, and 252 (42.3%) were hypertensive.
Excluding the 40 CPAP users, the mean AHI was
5.8 (7.6) events/hour (range 0.0-53.6); 54
(9.1%) had AHI ≥15 events/hr. Mean SaO2 was
94.7% (2.1%) and minimum SaO2 was 82.8%
(9.5%). Time with SaO2<90% did not predict
PWV. In models adjusted for age and sex, lower
mean SaO2 (β=-0.16, SE 0.06, p=0.004), lower
minimum SaO2 (β=-0.04, SE 0.01, p=0.005) and
higher log10(AHI+1) (β=0.55, SE 0.20, p=0.005)
predicted higher PWV a mean of approximately
9 years after OSA assessment. However, none
of these associations were statistically
significant after waist circumference (p≤0.005
for all 3 outcomes) and height were added to
the models. For models with mean SaO2, waist
circumference independently predicted PWV,
but after addition of CVD risk factors, only age
(β=0.14, SE 0.01, p<0.001), systolic blood
pressure (β=0.02, SE 0.01, p<0.001), and
diabetes status (β=0.96, SE 0.28, p=0.002) were
independent predictors. Very similar results
were observed for models with minimum Sa02
and PWV. None of the OSA parameters
interacted with age or smoking status to predict
PWV. Presence of Metabolic Syndrome did not
predict PWV; it did not interact with OSA
parameters to predict PWV.
Conclusions
The longitudinal associations between OSA and
PWV are confounded by body size and
influenced by diabetes mellitus and blood
pressure. These results suggest that weight
management and blood pressure control may
help prevent arterial stiffening associated with
sleep apnea.
R. Stern: None. C.E. Korcarz: None. P.E.
Peppard: None. J.H. Barnet: None. E.W. Hagen:
None. T. Young: None. J.H. Stein: None.
MP70
Habitual Sleep Variability, Mediated by Energy
Intake, is Associated with Abdominal Obesity
in Adolescents
Fan He, Edward O Bixler, Jiangang Liao, Arthur
Berg, Yuka Imamura Kawasawa, Julio
Fernandez-Mendoza, Alexandros N Vgontzas,
Duanping Liao, Penn State Univ Coll of Med,
Hershey, PA
Introduction: Although self-reported sleep
duration has been associated with obesity,
study of the association between objectivelymeasured habitual sleep pattern and the more
metabolically relevant abdominal obesity, and
the mediation factors for such an association, is
limited.Hypothesis: We assessed the hypothesis
that objectively-measured variability, mediated
by excessive energy intake, is associated with
abdominal obesity in adolescents.
Methods: We used data from 421 adolescents
in the Penn State Child Cohort follow-up
examination. Actigraphy was used for 7
consecutive nights to calculate each
participant’s mean sleep duration as habitual
sleep duration (HSD) and the standard deviation
of the mean as habitual sleep variability (HSV).
Abdominal obesity was assessed by dual-energy
x-ray absorptiometry as Android/Gynoid Fat
Ratio and visceral fat area. Youth/Adolescents
Food Frequency Questionnaire was used to
obtain daily caloric, fat, carbohydrate, and
protein intakes one year prior to the study. The
R-based Mediation Effect Models were used to
assess the association between sleep pattern
and abdominal obesity, and quantitatively
estimate the mediation effects of caloric intake
and of other
factors not analyzed in this report.
Results: As shown in the table, after controlling
for major confounders and BMI percentile, HSV
was significantly and consistently associated
with both abdominal obesity measures. The
Mediation analysis consistently indicated a
significant mediation effect of caloric intake,
especially carbohydrate intake. For example,
20% of the association between HSV and
visceral fat could be attributed to carbohydrate
intake, while 80% by other factors not analyzed.
HSD was not associated with abdominal
obesity.
Conclusions: Higher HSV, not HSD, is associated
with abdominal obesity, which can be partially
explained by increased caloric intake, especially
from carbohydrate, in adolescents. More
studies are needed to identify other mediation
factors in the association.
F. He: None. E.O. Bixler: None. J. Liao: None. A.
Berg: None. Y. Imamura Kawasawa: None. J.
Fernandez-Mendoza: None. A.N. Vgontzas:
None. D. Liao: None.
MP71
Short Sleep Duration Modifies the Relationship
Between Hypertension and All-Cause Mortality
Julio Fernandez-Mendoza, Fan He, Alexandros
Vgontzas, Duanping Liao, Edward Bixler, Penn
State Coll of Med, Hershey, PA
Introduction: Short sleep duration has been
associated with increased risk of hypertension
and mortality. However, previous
epidemiological studies have been limited in
that they used self-reported sleep measures
and treated sleep duration as a sole,
independent predictor of cardiometabolic
morbidity or mortality. Therefore, the role of
sleep duration in predicting morbidity and
mortality is still not well-understood. Our
current research project examines the role of
objective sleep duration as an effect modifier
between traditional cardiometabolic risk factors
and mortality.
objectively-measured sleep duration is a key
effect modifier of the relationship between
hypertension and all-cause mortality.
Methods: We addressed this question in the
Penn State Adult Cohort, a random, general
population sample of 1,741 men and women
(48.7 ± 13.5 years) who were studied in the
sleep laboratory and were followed-up for 15.5
± 4.1 years. Hypertension was defined as
systolic blood pressure ≥ 90mmHg / diastolic
blood pressure ≥ 140mmHg or use of
antihypertensive medication. Polysomnographic
sleep duration was classified into three
categories: ≥ 6 hours (i.e., ≥ 50th percentile), 56 hours (i.e., 25-50th percentile), and ≤ 5 hours
(i.e., ≤ 25th percentile). We tested the
interaction between hypertension and objective
sleep duration on all-cause mortality using
multiple logistic regression, while controlling for
sex, age, race, obesity, diabetes, history of heart
disease and stroke, smoking, depression,
insomnia, and sleep apnea.
Results: The mortality rate was 19.6%. The
multivariable-adjusted odds ratio (OR) of allcause mortality associated with hypertension
was 2.54 (95% CI: 1.81-3.56). The multivariableadjusted ORs associating hypertension and allcause mortality were 1.75 (95% CI: 1.01-3.02),
2.36 (95% CI: 1.15-4.83), and 4.04 (95% CI: 2.227.38) for individuals with ≥ 6 hours, 5-6 hours,
and ≤ 5 hours of sleep, respectively (p-value for
interaction = .03).
Conclusion: We found that objective sleep
duration modifies the relationship between
hypertension and all-cause mortality in a doseresponse manner, with the largest magnitude of
association observed in those who slept ≤ 5
hours. Short sleep duration in hypertensive
individuals may be biologically driven,
behaviorally induced, or a marker of the
severity of the degree of autonomic
dysfunction. Further analyses will examine this
effect modification using cause-specific
mortality data and future studies should
examine whether improving/lengthening sleep
reduces the odds of mortality in individuals with
hypertension.
J. Fernandez-Mendoza: None. F. He: None. A.
Vgontzas: None. D. Liao: None. E. Bixler: None.
National Center
MP72
Habitual Sleep Variability is Associated with
Caloric and Food Intake
Fan He, Edward O Bixler, Jiangang Liao, Arthur
Berg, Yuka Imamura Kawasawa, Julio
Fernandez-Mendoza, Alexandros N Vgontzas,
Duanping Liao, Penn State Coll of Med, Hershey,
PA
Introduction: Excessive food intake is the
primary factor for obesity in adolescents
whereas subjectively reported sleep duration
has been suggested as a novel risk factor.
However, the association between
objectively measured habitual sleep pattern
and adolescent caloric and snack consumption
behaviors has not been assessed.
objectively-measured habitual sleep variability
is associated with caloric and snack intakes in
adolescents.
Methods: We used data from 421 adolescents
who participated in the population-based Penn
State Child Cohort follow-up examination.
Actigraphy was used for 7 consecutive nights to
calculate each participant’s mean sleep
duration as habitual sleep duration (HSD) and
the standard deviation of the mean as habitual
sleep variability (HSV). Participants’ caloric and
snack intakes for one year prior to the clinical
examination were assessed using
Youth/Adolescent Food Frequency
Questionnaire. Daily total caloric intake (kcal),
protein intake (g), total fat intake (g),
carbohydrates intake (g), and the number of
snacks consumed were obtained and analyzed.
Linear regression and proportional odds models
were used to assess the relationship between
habitual sleep pattern and total caloric, protein,
fat, and carbohydrate intakes, and number of
snacks consumed, respectively.
Results: The mean age of the study sample was
17 (SD=2.3) years. There are 52% male and 79%
white in the study sample. After adjusting for
age, gender, race, BMI percentile and HSD, 1hour increase in HSV is associated with 201 kcal
higher total caloric intake (β=201, SE=65,
p<0.01), 6 grams of total fat intake (β=6.4,
SE=2.50, p=0.01), and 32 grams of
carbohydrates intake (β=32, SE=8.79, p<0.01).
One-hour higher HSV was also associated with
higher odds of consuming more snacks,
especially after dinner. Specifically, one-hour
increase in HSV is associated with 60% higher
odds of consuming more snacks after-dinner
(OR=1.60, 95% CI: 1.07-2.38, p=0.02) during
school days. One-hour increase in HSV is
associated with 100% higher odds of consuming
more snacks after dinner during the weekend
(OR=2.04, 95% CI: 1.38-3.02, p<0.01). Higher
HSV was also associated with daytime snack
consumption during weekends/vacation days as
well. HSD was not related to caloric or snack
intakes.
Conclusion: In adolescents, higher habitual
sleep duration variability, but NOT habitual
sleep duration, is associated with higher caloric
and snack food consumption, especially calories
from fat and carbohydrate-dense food, such as
snacks.
F. He: None. E.O. Bixler: None. J. Liao: None. A.
Berg: None. Y. Imamura Kawasawa: None. J.
Fernandez-Mendoza: None. A.N. Vgontzas:
None. D. Liao: None.
MP73
Leisure Time Physical Activity and Cognitive
Decline in the Northern Manhattan Study
Joshua Z Willey, Columbia Univ, New York, NY;
Hannah Gardener, Univ of Miami, Miami, FL;
Sandino Cespedes, Columbia Univ, New York,
NY; Charles DeCarli, Univ of California Davis,
Davis, CA; Mitsuhiro Yoshita, Hokuriku Natl
Hosp, Nanto, Japan; Yaakov Stern, Columbia
Univ, New York, NY; Ralph L Sacco, Univ of
Miami, Miami, FL; Mitchell S Elkind, Columbia
Univ, New York, NY; Clinton B Wright, Univ of
Miami, Miami, FL
Background: Leisure time physical activity
(LTPA) has been associated with a lower risk of
dementia, but whether the effects are specific
to particular cognitive abilities or improvement
in functional status remains unclear. We
examined LTPA in relation to domain-specific
neurocognitive (NC) performance and change
over time in a diverse community sample.
Methods: Data on LTPA was collected during
enrollment (1993-2001) into the Northern
Manhattan Study (NOMAS), a prospective
cohort study of risk factors for stroke and
cognitive decline, using a validated in-person
questionnaire, and two waves of NC
assessments were done on a subcohort of
participants undergoing brain MRI an mean of
six and 12 years later (NC1: 2003-2008; NC2:
2008-2014). Baseline LTPA was defined in two
manners: (1) maximum intensity of all activities
performed categorized as moderate-heavy,
light, and none; (2) total summarized as a
continuous variable with the metabolic
equivalent (MET) score, a composite of total
reported intensity and time. Factor analysisderived construct-relevant cognitive domains,
including memory (MEM), executive function
(EXEC), processing speed (PS), and language
ability (LA), were computed by averaging ztransformed NC test scores. We used
multivariable linear regression to examine LTPA
in relation to baseline domain-specific NC
performance, and change in performance over
time, adjusting for socio-demographics,
vascular risk factors, and MRI markers of
cerebrovascular injury (white matter
hyperintensity volume and total cerebral
volume, both adjusted for total intracranial
volume, and silent brain infarcts).
Results: There were 1236 participants (mean
age=64 years, 61% women, 67% Latino, 18%
black, 15% white) with LTPA and NC data, and
879 with a second NC assessment. Moderateto-heavy activity was associated with higher
baseline LA (p <0.05) and PS (p <0.05), and with
a protective effect on change of MEM (p <0.05)
and PS (p <0.05); these effects were not
attenuated after adjustment for MRI variables.
Total MET-score was not associated with
baseline NC domain performance. However,
participants with greater MET-scores had
significantly less decline in processing speed
adjusting for age and education. Inclusion of
vascular risk factors and MRI markers each
attenuated these associations though they
remained statistically significant.
Conclusions: Leisure time physical activity is
independently protective against a decline in
processing speed and memory, and was partly
mediated by MRI markers. Leisure-time physical
activity may protect against dementia through
preventing cerebrovascular correlates of brain
injury.
J.Z. Willey: B. Research Grant; Modest; NINDS
K23 NS 073104. H. Gardener: None. S.
Cespedes: None. C. DeCarli: None. M. Yoshita:
None. Y. Stern: None. R.L. Sacco: None. M.S.V.
Elkind: None. C.B. Wright: None.
MP74
Use of Cd34+ Cells as a Cellular Biomarker in
Prediabetes Subjects, Post Aerobic Exercise
Sabyasachi Sen, George Washington Univ,
Washington, DC; Ashequl Islam, Baystate
Medical Ctr, Springfield, MA
Introduction: Pre-diabetes has been associated
with endothelial dysfunction that may affect
both endothelium and stem cells. We
hypothesized that aerobic exercise can improve
function and gene expression of hemopoetic
stem cells (CD34+ cells)in pre-diabetes. Though
life-style modification has been shown to
prevent progression from Pre-diabetes to overt
diabetes, the effect of exercise on endothelium
in pre-diabetes has not been tested. Also use of
CD34+ cells as biomarker is novel.
Methods: This is a crossover study of 16-week
duration, using exercise-naive pre-diabetes
patients, aged 40-70 yrs with a BMI of 25-39.9,
n=11. We studied their flow mediated dilatation
(FMD), CD34+ cell function, gene expression
and serum endothelial inflammatory markers
after 6 weeks each of aerobic exercise
(150min/week) and non-exercise phase, with 4
week wash-out period between the 2 phases.
We tested migration in response to chemotactic
factors VEGF-A(50ng/ml) and SDF1alpha(0,10
and 100 ng/ml). We also assessed Hill colony
formation. Adherence to exercise regimen was
monitored by regular phone calls and
downloadable accelerometers (actigraphs).
Results: There was no statistically significant
weight loss in post exercise phase. FMD studies
(by 3 observers) showed mean FMD of
5.7±0.6% which improved to 11.2±0.9% postexercise. Biochemistry showed significant
reduction in leptin, Triglyceride, Apo-B, ApoA1
levels and inflammatory markers, IL-6, TNF
alpha & hs-CRP. CD34+ cell gene expression
analysis showed increase in eNOS (2.5 fold)and
VEGF-A (2 fold)and reduction in Endothelin-1
(3-fold), IL-6 (2.4-fold reduction), TNF (3-fold )
following exercise. CD34+ migration improved
post exercise, particularly in response to
10ng/ml SDF-1. Hill Colony Counts doubled post
exercise.
Conclusion: We demonstrate that pre-diabetic
state is associated with poor vascular reactivity
and impaired CD34+ cell number, function and
gene expression. However, significant
improvement in FMD may indicate that Prediabetes state may also be the clinical window
of therapeutic opportunity when interventions
such as aerobic exercise can prevent
progression of endothelial dysfunction.
The study also demonstrates that CD34+ cell
can serve as a useful cellular bio-marker in prediabetes and possibly early diabetes patients.
S. Sen: None. A. Islam: None.
MP75
Characterization of Physical Activity Patterns
From Mid-Life to Older Adulthood: The
Study
Dmitry Kats, Priya Palta, Dept of Epidemiology,
Univ of North Carolina at Chapel Hill, Gillings
Sch of Global Public Health, Chapel Hill, NC;
Kelley P Gabriel, Div of Epidemiology, Human
Genetics, and Environmental Sciences, Univ of
Texas Health Science Ctr at Houston, Sch of
Public Health – Austin Regional Campus, Austin,
TX; Ricky Camplain, Gerardo Heiss, Kelly
Evenson, Dept of Epidemiology, Univ of North
Carolina at Chapel Hill, Gillings Sch of Global
Public Health, Chapel Hill, NC
Introduction: Lack of physical activity is
associated with cardiovascular disease and
mortality. Studies that characterize patterns of
change in physical activity from mid- to late-life
are limited.
Objectives: To examine variation in physical
activity patterns from mid-life to older
adulthood in a large, population-based cohort
by socio-demographic and cardiovascular
factors.
Methods: The study population included 5,627
(58% female, 21% African American, mean age
at visit 1: 52 years) ARIC participants who
completed a modified Baecke physical activity
questionnaire at visits 1 (1987-1989), 3 (19931995), and 5 (2011-2013). Using the reported
type, duration (hours/week), and frequency
(months/year) of up to four leisure activities
over the past year, estimates of average
min/wk spent on moderate to vigorous
intensity activities (MVPA) were computed. The
AHA “Life’s Simple 7” physical activity
recommendations for adults were applied: Poor
(0 min/wk MVPA), Intermediate (1-74 min/wk
vigorous or 1-149 min/wk of MVPA), and Ideal
(>75 min/wk vigorous or >150 min/wk MVPA)
to assess temporal changes across these
categories from visits 1 to 5, by sex, race,
education level, diabetes and hypertension by
visit 5.
Results: An increase in the prevalence of Ideal
physical activity was observed from mid- to
late-life, particularly in Caucasian males with
education beyond high school (Figure 1). The
prevalence of Poor physical activity was >25% at
both time periods in all groups, but highest
among African Americans. Increases in the
prevalence of Ideal physical activity from mid-
life were greater among adults who did not
develop diabetes or hypertension compared to
those who did.
Conclusion: These results suggest that
individuals who reach older adulthood without
severe comorbidity report higher levels of
MVPA late in life; although, a high proportion of
aging adults report not engaging in MVPA.
Factors predicting changes and stability in
MVPA levels through this important life
transition require further elucidation.
D. Kats: None. P. Palta: None. K.P. Gabriel:
None. R. Camplain: None. G. Heiss: None. K.
Evenson: None.
MP76
The Effect of Exercise Training Modality on 30Year Cardiovascular Mortality Risk in
Individuals with Type 2 Diabetes
Damon Swift, East Carolina Univ, Greenville,
NC; Neil M Johannsen, Louisiana State Univ,
Baton Rouge, LA; Carl J Lavie, John Ochsner
Heart and Vascular Inst, New Orleans, LA; Jarett
D Berry, Univ of Texas Southwestern Medical
Ctr, Dallas, TX; Conrad P Earnest, Univ of Texas
A&M, College Station, TX; Logan B Dunn, East
Carolina Univ, Greenville, NC; Steven N Blair,
Univ of South Carolina, Columbia, SC; Timothy S
Church, Pennington Biomedical Res Ctr, Baton
Rouge, LA
Introduction: Current calculators to estimate
risk of cardiovascular (CV) disease mortality do
not include cardiorespiratory fitness (CRF) or
physical activity (PA) measures. This is
problematic as CRF is an independent risk factor
for CV mortality. To address this issue,
Wickramasinghe et al. developed a calculator
which includes CRF along with other traditional
CV risk factors. The purpose of the present
study is to determine the effect of aerobic
(AER), resistance (RES) or combination (COMB)
exercise training on 30-year CV mortality risk in
individuals with type 2 diabetes (T2D).
Methods: The present study is an ancillary
analysis of the Health Benefits of Aerobic and
Resistance Training Study (HART-D). Adults with
type 2 diabetes (T2D) (n=196) were randomized
to 9 months of AER, RES, COMB exercise
training or a control group (CON). Thirty-year
CV mortality risk was evaluated by entering
each participant’s sex, age, blood pressure,
smoking status, T2D status, cholesterol, and
BMI into a risk calculator developed by
Wickramasinghe et al. at baseline and followup. CRF was quantified as the highest metabolic
equivalent level (estimated from the final speed
and grade using American College of Sports
Medicine equations) achieved during a maximal
treadmill test at baseline and follow-up.
Analysis of covariance was used to evaluate
change in CV risk with adjustments for age, sex
and baseline CV risk.
Results: Participants in the present analysis had
a mean (SD) 30-year CV risk of 30.4% (17.8). A
significant reduction in 30-year CV risk was
observed in the AERO (-2.9%, CI: -4.7 to -1.0)
and COMB groups (-2.8%, CI: -4.5 to -1.0), but
not in the RES group (0.0%, CI: -1.8 to 1.7)
compared to CON (2.1%, CI: -0.1 to 4.3). In the
AERO and COMB groups, change in CV risk was
associated with change in fat mass (r= -0.19,
p=0.04), but not change in lean mass or
hemoglobin A1c (all ps>0.05).
Conclusions: The present study suggests that 9
months of aerobic exercise training or
combination of resistance with aerobic exercise
training resulted in a ~3% reduction in absolute
30-year CV risk (~11% relative risk), and further
validates the importance of aerobic exercise in
the treatment of individuals with T2D.
D. Swift: None. N.M. Johannsen: None. C.J.
Lavie: None. J.D. Berry: None. C.P. Earnest:
None. L.B. Dunn: None. S.N. Blair: None. T.S.
Church: None.
MP77
Intramuscular Fat is Associated with Decreased
Physical Performance
Kate E Therkelsen, Alison Pedley, 1.Natl Heart,
Lung, and Blood Inst’s Framingham Heart Study,
Framingham, MA; Udo Hoffman, 3.Dept of Med
and Dept of Radiology, Massachusetts General
Hosp and Harvard Medical Sch, Boston, MA;
Caroline Fox, 4.NHLBI Div of Intra-mural
research and the Ctr for Population Studies,
Framingham, MA; Joanne Murabito, Natl Heart,
Lung, and Blood Inst’s Framingham Heart Study,
Framingham, MA
Introduction: Obesity is associated with a
substantial burden of physical disability.
Intramuscular fat may in part mediate some of
these associations.
Hypothesis: We hypothesized that muscle
attenuation, an estimation of intramuscular fat,
is associated with increased mobility disability,
as well as decreased grip strength and walking
speed, two physical performance measures
associated with functional decline.
Methods: The sample (n=1152, 56% women,
mean age 66 years) consisted of Framingham
Heart Study participants who underwent
computed tomography scanning and an
examination in 2005-2008. Muscle attenuation
was estimated from scans by placing regions of
interest on the paraspinous muscles bilaterally
and averaging the resulting Hounsfield units.
Visceral adipose tissue (VAT) and subcutaneous
adipose tissue (SAT) were measured using
standard protocols. Hand grip strength was
measured with a handheld dynamometer
bilaterally, walking speed was measured over a
4 m course, and mobility disability via selfreport of inability to walk half a mile or climb a
flight of stairs. Multivariable logistic and linear
regression models were used to investigate the
association between muscle attenuation and
mobility disability, grip strength, and walking
speed after accounting for standard covariates;
models additionally adjusted for body mass
index (BMI) and VAT volume separately.
Additional models were used to investigate the
association between VAT and SAT volumes and
mobility disability and physical performance
measures.
Results: Mean BMI was 28.3 kg/m2, average
walking speed was 1.23 m/s, and average grip
strength was 31.9 kg. Per 1 standard deviation
decrease in muscle attenuation (i.e. more
muscle fat), we observed a 1.29 (95% CI 1.09 –
1.53, p=0.0009) increased odds of walking
speed ≤ 1 m/s, a cutoff associated with
increased mortality. This persisted even after
adjustment for BMI and VAT volume separately
(p<0.02). In men only (sex interaction
p<0.0001), there was a 1.29 (95% CI 0.46 – 2.12,
p=0.0005) kg decrease in grip strength, which
persisted after adjustment for BMI and VAT
volume separately (p≤0.0004). No associations
were observed with mobility disability. For VAT
and SAT volumes, no associations with grip
strength (p≥0.19) were observed. Furthermore,
no associations with walking speed ≤ 1 m/s
were observed after adjustment for BMI
(p≥0.18).
Conclusion: Intramuscular fat is associated with
increased odds of walking speed ≤ 1m/s in both
sexes and decreased grip strength in men,
associations which persist after adjustment for
VAT volume and BMI. Similar associations for
VAT and SAT volumes were not observed. These
findings highlight the specificity of
intramuscular fat and important indices of
physical performance.
K.E. Therkelsen: None. A. Pedley: A.
Employment; Modest; Merck
pharmaceuticals. U. Hoffman: None. C. Fox:
None. J. Murabito: None.
MP78
Effect of Beta-Blocker Therapy, Maximal Heart
Rate and Exercise Capacity During Stress
Testing on Long-Term Survival
Rupert K Hung, Johns Hopkins Ciccarone Ctr for
the Prevention of Heart Disease, Baltimore, MD;
Mouaz Al-Mallah, King Abdul-Aziz Cardiac Ctr,
Riyadh, Saudi Arabia; Seamus P Whelton, Roger
S Blumenthal, Johns Hopkins Ciccarone Ctr for
the Prevention of Heart Disease, Baltimore, MD;
Clinton A Brawner, Steven J Keteyian, Henry
Ford Health System, Detroit, MI; Michael J
Blaha, Johns Hopkins Ciccarone Ctr for the
Prevention of Heart Disease, Baltimore, MD
Background: Whether beta-blocker therapy
(BBT) attenuates the prognostic value of
percentage-predicted maximal heart rate
(ppMHR) achieved during stress testing remains
unclear. The combined effect of ppMHR and
exercise capacity on long-term mortality is
unknown.
Methods: We analyzed 67,772 adults (54 ± 13
years old, 54% men (36,639 of 67,772), 29%
black (19,834 of 67,772)) from The FIT Project, a
retrospective cohort study of patients who
underwent physician-referred exercise stress
testing at a single healthcare system between
1991 and 2009. Patients were categorized by
baseline use of BBT. Maximal age-predicted
heart rate was defined as 220-age. We derived
adjusted mortality rates over the range of
ppMHR using margins of response logistic
regression models. Our primary model included
adjustment for demographic data, resting blood
pressures, medical history, pertinent
medications, and indication for stress testing.
Our secondary model included further
adjustment for exercise capacity.
Results: There were 10,594 deaths over 11 ± 5
years of follow-up. Patients on BBT tended to
have more comorbidities and other medication
use (P<.001). After accounting for differences
between BBT groups, BBT was associated with
an 8% lower ppMHR (83% in BBT vs. 91% in no
BBT) in both men and women. ppMHR was
inversely associated with all-cause mortality in
both analyses performed (P≤.001), though the
association was significantly attenuated by BBT
(P=.03) [Panel A]. Exercise capacity further
attenuated the prognostic value of ppMHR in all
patients, particularly in those on BBT, and
reduced the difference in risk between those on
BBT and not on BBT (P=.08) [Panel B].
Conclusion: BBT attenuated the association
between ppMHR achieved during stress testing
and long-term mortality. Exercise capacity
further attenuated the prognostic significance
of ppMHR, particularly in patients on BBT.
R.K. Hung: None. M. Al-Mallah: None. S.P.
Whelton: None. R.S. Blumenthal: None. C.A.
Brawner: None. S.J. Keteyian: None. M.J.
Blaha: None.
MP79
Pre-Admission History of Depression and
Mortality After Acute Myocardial Infarction
Elena Salmoirago-Blotcher, Brown Univ Sch of
Med, Providence, RI; Darleen Lessard, Univ of
Massachusetts Med. Sch, Worcester, MA; Joel
Gore, Univ of Massachusetts Medical Sch,
Worcester, MA; Robert Goldberg, Univ of
Massachusetts Med. Sch, Worcester, MA
Background. Whether a diagnosis of depression
after developing an acute myocardial infarction
(AMI) is linked to a worse prognosis remains a
matter of debate after several RCTs of
interventions to treat post-AMI depression have
yielded negative results. A possible explanation
is that depressive symptoms after AMI may be
part of the normal adjustment to an adverse life
event. A pre-admission history of depression
could better identify patients who may derive
the most benefit from depression treatment.
The objective of this study was to evaluate
whether a pre-admission history of depression
was associated with a worse post-discharge
prognosis among patients with AMI.
Methods. This was a secondary analysis
conducted among patients included (biennial
basis between 1999-2009) in the Worcester
Heart Attack Study, an ongoing epidemiologic
study examining long-term trends in the clinical
outcomes of AMI among residents of the
Worcester, MA metropolitan area. The
exposure was defined as a physician-recorded
diagnosis of depression preceding the index
hospitalization for AMI based on the review of
hospital medical records (MR). The outcome
was all-cause death rates in-hospital and 1-year
post discharge. Information regarding
demographics, medical history, in-hospital
treatment, and discharge status was abstracted
from the MR by trained study physicians and
nurses. Survival status after discharge was
obtained from the MR and from death
certificates. Univariate and multivariate logistic
regression models were used to assess
associations between depression and the
outcome.
Results. This analysis included 5,068 patients
(mean age 70 years, 44% women).
Approximately 16% of patients had a history of
depression pre-admission. No significant
differences were found between patients with
and without a history of depression with regard
to in-hospital mortality (11.5% vs. 9.9%;
unadjusted OR=1.18; 95% CI: 0.95, 1.48). At 1
year after discharge all-cause mortality was
significantly higher among patients with a preadmission history of depression (27.5% vs.
18.2%; unadjusted OR=1.71; 95% CI: 1.44, 2.02).
While the association between history of
depression and in-hospital mortality was largely
explained by confounding, the association with
1 year mortality remained significant even after
adjustment for demographics, coronary risk
factors, co-morbidities, clinical characteristics
and medications at discharge (OR=1.57; CI:
1.24, 1.98).
Conclusions. In this community-based cohort of
patients hospitalized with AMI at different
hospitals in central MA, a pre-admission history
of depression was an independent predictor of
all-cause mortality 1 year after MI.
Documentation of a history of depression in the
medical record could be a simple tool for
cardiologists and primary care physicians to
identify high-risk patients who may benefit
from depression treatment.
E. Salmoirago-Blotcher: None. D. Lessard:
None. J. Gore: None. R. Goldberg: None.
MP80
Psychosocial Factors and Risk of Incident Heart
Failure: The Multi-Ethnic Study of
Atherosclerosis (MESA)
Rachel P Ogilvie, Univ of Minnesota,
Minneapolis, MN; Susan Everson-Rose, Univ of
Minnesota Medical Sch, Minneapolis, MN;
Carlos Rodriguez, Wake Forest Sch of Med,
Winston-Salem, NC; W.T. Longstreth, Jr, Univ of
Washington, Seattle, WA; Michelle Albert,
Howard Univ Sch of Med, Washington, DC; Ana
Diez-Roux, Drexel Univ Sch of Med,
Philadelphia, PA; Pamela L Lutsey, Univ of
Minnesota, Minneapolis, MN
Background: Heart failure is a major source of
morbidity and mortality in the United States.
Psychosocial factors have frequently been
studied as risk factors for coronary heart
disease, but not for heart failure.
Methods: We examined the relationship
between psychological status and incident heart
failure among 6,782 individuals from the MultiEthnic Study of Atherosclerosis (MESA) who
were free of cardiovascular disease at baseline.
Anger, anxiety, chronic burden, depression, and
hostility were measured using validated scales
and were modeled categorically. Physician
reviewers adjudicated incident heart failure
events. Cox proportional hazards models were
used to generate hazard ratios (HR) and 95%
confidence intervals (CI) and adjusted for
relevant demographic, behavioral, and
physiological covariates. In exploratory
analyses, we evaluated interactions between
self-rated health and each psychosocial factor,
and then stratified by baseline self-rated health
(fair/poor and good/very good/excellent).
Results: During a mean follow up of 9.3 years,
242 participants developed incident heart
failure. Compared to participants in the lowest
level, hazard ratios for those categorized in the
highest level of anger [HR=1.14 (95%CI: 0.811.60)], anxiety [HR=0.74 (95%CI: 0.51-1.07),
chronic burden [HR=1.25 (95%CI: 0.90-1.72),
depression [HR=1.19 (95%CI: 0.76-1.85), and
hostility [HR=0.95 (95%CI: 0.62-1.42) revealed
no association with incident heart failure. In the
exploratory analysis, interactions between the
psychosocial factors and self-rated health were
only statistically significant for hostility, but
stratified models differed according to baseline
health status. Compared to the lowest level,
hazard ratios for those categorized in the
highest level of anxiety [HR=2.11 (95%CI: 1.004.47)], chronic burden [HR=2.25 (95%CI: 1.084.67)], and depression [HR=2.15 (95%CI: 0.984.68)] revealed a positive association with
incident heart failure among participants selfrated poor health at baseline, but there was no
association for those with good self-rated
health at baseline. For hostility, HRs for the
highest versus lowest categorization were
larger among those with good self-rated health
and for anger, associations were similar
regardless of self-rated health status.
Conclusions: Overall these five psychosocial
factors were not significantly associated with
incident heart failure. However, for participants
reporting poor health at baseline, anxiety,
chronic burden, and depression were
associated with an increased risk of heart
failure. Future research with greater statistical
power is necessary to confirm these findings
and seek explanations.
R.P. Ogilvie: None. S. Everson-Rose: None. C.
Rodriguez: None. W. Longstreth, Jr: None. M.
Albert: None. A. Diez-Roux: None. P.L. Lutsey:
None.
MP81
Community Characteristics Are Associated
With Blood Pressure Levels in a Racially
Integrated Community
Laura J Samuel, Roland J. Thorpe Jr, Thomas A.
LaVeist, Johns Hopkins Univ Bloomberg Sch of
Public Health, Baltimore, MD
Some community characteristics, such as
perceived problems, have been associated with
higher blood pressure levels, while access to
community resources and community social
cohesion have been associated with lower
blood pressure levels. However, potential
confounding by residential racial segregation
has previously been ignored, despite positive
correlations between segregation and
hypertension. This study tests the hypothesis
that results differ in a racially integrated
community.
Blood pressure was measured as the average of
three readings from 1326 black and white
adults residing in two racially integrated,
contiguous, low income, urban US Census
Tracts. Hypertension was defined as systolic
BP≥140 mmHg and/or diastolic BP≥90 mmHg or
use of antihypertensive medication(s).
Neighborhood problems were measured with
15 questions about lack of resources, safety and
crime. Participants were asked if people work
together to solve problems to measure social
cohesion and if the neighborhood has a leader.
The presence of any desirable community
resources on the participant’s block was also
observed. Regression models were racially
stratified because the effect of residential
integration likely differs by race.
Perceptions of community problems and social
cohesion and rates of community resources did
not differ by race. Models adjusted for all
community characteristics, age, sex, income,
marital status, residency length, and in blood
pressure models, antihypertensive medication
use. In whites, each standard deviation increase
in community problems was associated with
lower systolic (β =-2.312, p=0.011) and diastolic
(β =-1.484, p=0.014) blood pressure levels. Also,
whites living on blocks with community
resources had lower systolic (β=-4.079,
p=0.011) and diastolic (β=-2.251, p=0.034)
blood pressure levels and a lower likelihood of
hypertension (PR=0.83, 95% CI: 0.73, 0.93),
compared with whites lacking such resources. In
African Americans, community social cohesion
was associated with higher systolic (β =4.923,
p=0.008) and diastolic (β=3.397, p=0.008) blood
pressure levels. No associations were found for
reporting a community leader. Results were
unchanged after additional adjustment for
behavioral variables.
Despite a shared community environment,
perceptions of the community varied and some
were associated with blood pressure levels, but
not prevalent hypertension. Directions of
associations oppose those of prior studies. This
may be due to adverse features of this low
income setting, which may contribute to
hypertensive disparities. Closer proximity to
community resources was associated with
lower blood pressure levels and prevalent
hypertension in whites. In conclusion, in this
racially integrated and low income urban
community, some community characteristics
were associated with blood pressure levels,
though some results differ from prior studies.
L.J. Samuel: None. R.J. Thorpe: None. T.A.
LaVeist: None.
MP82
Associations of Positive Psychological Wellbeing on Changes in Allostatic Load: MultiEthnic Study of Atherosclerosis (MESA)
Rosalba Hernandez, Univ of Illinois at UrbanaChampaign, Urbana, IL; Kiarri Kershaw,
Northwestern Univ, Chicago, IL; Teresa Seeman,
Univ of California, Los Angeles, Los Angeles, CA;
Julia Boehm, Chapman Univ, Orange, CA;
Thanh-Huyen Vu, Hongyan Ning, Donald LloydJones, Northwestern Univ, Chicago, IL
Background: Cumulative multi-system
physiological dysregulation may represent an
important pathway linking psychological wellbeing to cardiovascular disease (CVD) risk but
this relationship is poorly understood. This
study examines the cross-sectional associations
of psychological well-being (positive affect and
dispositional optimism) with allostatic load (AL),
i.e., cumulative multi-system physiologic
burden.
Methods: We used data collected from
approximately 4,000 adults aged 45-84 who
participated in the Multi-Ethnic Study of
Atherosclerosis (MESA) with initial baseline
enrollment in 2000-2002. Positive affect was
calculated by summing four positively-worded
items included in the Center for Epidemiologic
Studies Depression Scale Revised. The Life
Orientation Test-Revised was used to assess
levels of dispositional optimism. A composite
score for AL was derived from the following
physiological components: wait-to-hip ratio,
triglycerides, LDL and HDL cholesterol, glucose,
systolic blood pressure, resting heart rate, and
pulse pressure. Multiple linear regression was
used to examine cross-sectional associations of
positive affect and AL at baseline (2000-2002)
and optimism and AL at the first follow-up visit
(2002-2004).
Results: In models adjusted for sociodemographic factors, psychological well-being
was not significantly related to AL for the total
sample. However, effect modification was
evident by sex and race/ethnicity when
examining the association of optimism and AL.
Optimism was inversely associated with AL for
Caucasian men, after adjustment for sociodemographic factors (Table 1), with a 1-unit
increase in optimism associated with a 0.07
reduction in AL (p = 0.03).
Conclusion: The current study offers
preliminary evidence for an inverse association
between dispositional optimism and AL among
Caucasian men. Prospective analyses to come.
R. Hernandez: None. K. Kershaw: None. T.
Seeman: None. J. Boehm: None. T. Vu:
None. H. Ning: None. D. Lloyd-Jones: None.
MP83
Post-traumatic Stress Disorder Symptoms and
Increased Risk of Cardiovascular Disease: What
Happens When Symptoms Remit?
Paola Gilsanz, Harvard Sch of Public Health,
Boston, MA; Jennifer A Sumner, Columbia Univ
Mailman Sch of Public Health, New York, NY;
Ashley Winning, Andrea L Roberts, Harvard Sch
of Public Health, Boston, MA; Jessica C AgnewBlais, Columbia Univ Mailman Sch of Public
Health, New York, NY; Eric B Rimm, Harvard Sch
of Public Health, Boston, MA; Karestan C
Koenen, Columbia Univ Mailman Sch of Public
Health, New York, NY; Laura D Kubzansky,
Harvard Sch of Public Health, Boston, MA
Introduction: Women with trauma and posttraumatic stress disorder (PTSD) are at greater
risk of cardiovascular diseases (CVD); whether
symptom remission is associated with less risk
remains unknown.
Hypothesis: Women who experience trauma
and developed persistent PTSD will have
increased risk of CVD, but those whose
symptoms remit will not have increased risk.
between time-updated trauma exposure, PTSD
symptoms, and PTSD symptom remission in
relation to incident CVD over a 20-year period
in 36,958 healthy women in the Nurses’ Health
Study II. We used proportional hazards models
to estimate hazards ratios (HRs) and 95%
confidence intervals (CIs) for CVD events
confirmed by additional information or medical
record review (n=402; 202 myocardial
infarctions and 200 strokes). Trauma exposure
was assessed using the Brief Trauma
Questionnaire. PTSD symptoms were assessed
using Breslau’s PTSD screen; report of 4 or more
(out of 7) symptoms was characterized as
clinically-relevant PTSD. All models adjusted for
age, family history of CVD, and childhood
factors. Additional models controlled for health
behaviors (smoking, physical activity, drinking,
and diet) and medical risk factors
(hypertension, Type 2 diabetes, and use of
hormone replacement therapy).
Results: Compared to women with no trauma,
trauma-exposed women with no PTSD
symptoms had elevated CVD risk (HR=2.31; 95%
CI 1.79-2.98) as did those with clinicallyrelevant PTSD (HR=1.84; 95% CI 1.36-2.50).
Women with remission of clinically relevant
levels of PTSD symptoms were at lower risk of
CVD (HR=1.39; 95% CI: 0.88-2.19). Associations
of clinically relevant PTSD symptoms (HR=1.59;
95% CI: 1.17, 2.16) and trauma exposure
without PTSD symptoms (HR=2.14; 95% CI:
1.65, 2.77) remain significant albeit somewhat
attenuated after adjustment for health
behaviors and medical conditions.
Conclusions: Trauma exposure and elevated
PTSD symptoms may increase the risk of CVD.
However, our findings suggest that
interventions targeted at alleviating PTSD
symptoms may attenuate the associated CVD
risk.
P. Gilsanz: None. J.A. Sumner: None. A.
Winning: None. A.L. Roberts: None. J.C.
Agnew-Blais: None. E.B. Rimm: None. K.C.
Koenen: None. L.D. Kubzansky: None.
MP84
Associations Between Cardiovascular Health
and Health-Related Quality of Life
Erika Odom, Jing Fang, Latetia Moore, Matthew
Zack, Fleetwood Loustalot, Ctrs for Disease
Control and Prevention, Atlanta, GA
Background
The American Heart Association’s 2020
Strategic Impact Goals define 7 cardiovascular
health metrics (CVHM) as targets for
promoting prevention of cardiovascular
disease risk factors. The association between
health-related quality of life (HRQoL) and
individual cardiovascular risk factors has been
examined; however, to date, no study has
examined the joint association between
HRQoL and each of the 7 CVHM in a national
survey.
Methods
Data were from the 2011 Behavioral Risk
Factor Surveillance System. Adults >18 years
rated their HRQoL, using 4 measures: 1)
general health status, 2) physically unhealthy
days per month, and 3) mentally unhealthy
days per month. Participants also reported
whether or not they met the CVHM -- normal
blood pressure, cholesterol, body mass index,
not having diabetes, not smoking, being
physically active, and having adequate fruit or
vegetable intake. Multiple logistic regression
was used to examine the association between
meeting ideal CVHM and the likelihood of
reporting poor HRQoL, adjusting for age,
education, race, and income (N = 323,583).
Results
Overall, 18.1% of adults reported their general
health status as fair or poor, 12.6% reported
≥14 physically unhealthy days, and 11.2%
reported ≥14 mentally unhealthy days in the
previous 30-day period. Only 10.8% of adults
met ≥6 CVHM; 71.5% met 3-5 CVHM; and
17.7% met 0-2 CVHM. On average, adults who
achieved 0-2 CVHM had 11.8 physically or
mentally unhealthy days; adults who achieved
3-5 CVHM had 5.8 physically or mentally
unhealthy days; adults who achieved 6-7
CVHM had 3.5 physically or mentally
unhealthy days. Meeting 3-5 or 6-7 CVHM was
associated with 70 and 90% lower odds of
having fair/poor health respectively (aOR=.30,
95%CI[.28-.31], aOR=.10, 95%CI[.08-.11]) ; 60
and 81% lower odds of having ≥14 physically
unhealthy days respectively (aOR=.40,
95%CI[.38-.42], aOR=.19, 95%CI[.17-.22]); 52
and 73% lower odds of having ≥14 mentally
unhealthy days respectively (aOR=.48,
95%CI[.45-.50], aOR=.27, 95%CI[.24-.30]).
Conclusion
Meeting a greater number of CVH
recommendations was associated with better
self-reported health and fewer mentally or
physically unhealthy days. The results of this
study contribute to the noted association
between health-related quality of life and
cardiovascular health. Broad community and
clinical activities promoting cardiovascular
health should address potential barriers to
participation in healthy lifestyles, such as poor
HRQoL. Although BRFSS is a cross-sectional
survey and causation cannot be inferred from
the results, our findings suggest that meeting
ideal recommendations of CVHM is a positive
goal for all Americans.
E. Odom: None. J. Fang: None. L. Moore:
None. M. Zack: None. F. Loustalot: None.
MP85
Mediterranean Diet and Incidence of Stroke in
the California Teachers Study
Ayesha Z Sherzai, Columbia Univ Medical Ctr,
New York, NY; Huiyan Ma, Population Sciences,
City of Hope, Duarte, CA; Pamela Horn-Ross,
Alison J Canchola, Cancer Prevention Inst of
California, Fremont, CA; Jenna Voutsinas,
Population Sciences, City of Hope, Duarte, CA;
Joshua Z Willey, Columbia Univ Medical Ctr,
New York, NY; Yian Gu, Columbia Univ, New
York, NY; Nikolaos Scarmeas, Columbia Univ
Medical Ctr, New York, NY; Dean Sherzai,
Cedars Sinai Medical Ctr, Los Angeles, CA; Leslie
Bernstein, Population Sciences, City of Hope,
Duarte, CA; Mitchell S Elkind, Columbia Univ
Medical Ctr, New York, NY; Sophia S Wang,
Population Sciences, City of Hope, Duarte, CA
Introduction:
A Mediterranean diet (MeDi) has been
associated with a reduced incidence of
cardiovascular and neurodegenerative diseases,
and overall mortality, in several prospective
studies. There is limited data, however,
regarding the relationship between MeDi and
stroke, and in particular, stroke subtypes. We
hypothesized that MeDi would be associated
with reduced total, ischemic, and hemorrhagic
stroke incidence.
Methods:
The California Teachers Study comprises
133,478 women who enrolled in 1995 and have
been continuously followed. Using linked
California state hospitalization data and
national death records from 1996-2011,
incident strokes were identified and validated.
Socio-demographic and medical risk factor data
were collected from the baseline questionnaire.
Diet was assessed using a food-frequency
questionnaire in 113,547 women. The
Mediterranean diet emphasizes plant-based
foods, mono-unsaturated fats, fish and
moderate alcohol intake. We used the MeDi
adherence score, a nine point scale, which has
been used and validated in prior studies. A
higher score on the 0-9 scale represents
increased adherence. Multivariable Cox
proportional-hazard models adjusted for sociodemographic factors including age, ethnicity,
socioeconomic status, moderate-to-strenuous
physical activity, total calorie intake, body mass
index, cigarette smoking, menopausal and
hormonal status and vascular risk factors were
used to assess the association (hazard ratios
and 95% confidence intervals, HR 95% CI)
between MeDi score and risk of stroke and
stroke subtypes.
Results:
A total of 104,268 participants were eligible for
the analysis (mean age 52 ± 13.9 years, 87.4%
white, 4.6% Hispanic, 3.2% Asian and 2.1%
black). The MeDi score distribution was: 0-2
(16.1%), 3 (18.2%), 4 (21.4%), 5 (20.1%), and 6-9
(24.3%). During follow-up, 3165 stroke events
occurred (2270 ischemic ; 895 hemorrhagic). In
the multivariable model, compared to those in
the lowest MeDi score quintile (score 0-2),
those in the fourth quintile (score 5: HR 0.86,
95% CI 0.75-0.98) and highest quintile (score 6 9: HR 0.83, 95% CI 0.73-0.95) were at lower risk
of stroke (p for trend 0.009). For ischemic
stroke, those in the third (HR 0.84, 95% CI 0.72-
0.97), fourth (0.85, 95% CI 0.73-0.98), and
highest quintile (HR 0.82, 95% CI 0.70-0.95)
were all at reduced risk (p for trend 0.02). There
was no association with hemorrhagic stroke.
Discussion:
Adherence to the Mediterranean diet is
associated with decreased risk of total and
ischemic stroke incidence among the
participants of the California Teachers Study.
A.Z. Sherzai: None. H. Ma: None. P. Horn-Ross:
None. A.J. Canchola: None. J. Voutsinas:
None. J.Z. Willey: None. Y. Gu: None. N.
Scarmeas: None. D. Sherzai: None. L. Bernstein:
None. M.S.V. Elkind: None. S.S. Wang: None.
MP86
Effects of Immediate Blood Pressure Reduction
on Death and Major Disability in Acute
Ischemic Stroke Patients by History of
Hypertension and Use of Antihypertensive
Medications
Tan Xu, Yonghong Zhang, Soochow Univ,
Suzhou, China; Yingxian Sun, China Medical
Univ, Liaoning, China; Chung-Shiuan Chen, Jing
Chen, Jiang He, Tulane Univ, New Orleans, LA;
for the CATIS investigators
Introduction: The effects of blood pressure (BP)
reduction on clinical outcomes among acute
stroke patient remain uncertain.
Hypothesis: We tested the effects of immediate
BP reduction on death and major disability at 14
days or hospital discharge and 3-month followup in acute ischemic stroke patients with and
without a previous history of hypertension or
use of antihypertensive medications.
Methods: The China Antihypertensive Trial in
Acute Ischemic Stroke (CATIS) randomly
assigned patients with ischemic stroke within 48
hours of onset and elevated systolic BP (SBP) to
receive antihypertensive treatment (N=2,038)
or to discontinue all antihypertensive
medications (N=2,033) during hospitalization.
Randomization was stratified by participating
hospitals and use of antihypertensive
medications. Study outcomes were assessed at
14 days or hospital discharge and 3-month posttreatment follow-up. The primary outcome was
death and major disability (modified Rankin
Scale score≥3), and secondary outcomes
included recurrent stroke and vascular events.
Results: Mean SBP was reduced 12.7% in the
treatment group and 7.2% in the control group
within 24 hours after randomization (P<0.001).
Mean SBP was 137.3 mmHg in the treatment
group and 146.5 in the control group at day 7
after randomization (P<0.001). At 14 days or
hospital discharge, the primary and secondary
outcomes were not significantly different
between the treatment and control groups by
subgroups. At the 3-month follow-up, recurrent
stroke was significantly reduced in the
antihypertensive treatment group among
patients with a history of hypertension (odds
ratio 0.43, 95% CI 0.24-0.75, P=0.003) and
among patients with a history of use of
antihypertensive medications (odds ratio 0.41,
95% CI 0.20-0.84, P=0.01). All-cause mortality
(odds ratio 2.84, 95% CI 1.11-7.27, P=0.03) was
increased among patients without a history of
hypertension.
Conclusion: Immediate BP reduction lowers
recurrent stroke among acute ischemic stroke
patients with a previous history of hypertension
or use of antihypertensive medications at 3
months. On the other hand, BP reduction
increases all-cause mortality among patients
without a history of hypertension.
T. Xu: None. Y. Zhang: None. Y. Sun: None. C.
Chen: None. J. Chen: None. J. He: None.
MP87
Association of Hemostasis Biomarkers with
Intracerebral Hemorrhage: the REasons for
Geographic and Racial Differences in Stroke
Study (REGARDS)
Neil Zakai, Univ of Vermont, Burlington, VT;
Suzanne Judd, Univ of Alabama at Birmingham,
Birmingham, AL; Nels Olson, Univ of Vermont,
Burlington, VT; Dawn Kleindorfer, Brett Kissela,
Univ of Cincinnati, Cincinnati, OH; George
Howard, Univ of Alabama at Birmingham,
Birmingham, AL; Mary Cushman, Univ of
Vermont, Burlington, VT
Introduction: Risk factors for intracerebral
hemorrhage (ICH) are poorly characterized.
Deficiencies of fibrinogen and factors VIII, IX,
and XI cause bleeding disorders but whether
these factors relate to ICH risk is unknown.
Methods: REGARDS recruited 30,239
individuals ≥45 years from the contiguous US
oversampling blacks (44%) and residents of the
southeast (56%) from 2003-07. ICH were
confirmed by medical record review.
Biomarkers were measured in a case cohort
study of ICH and a 1104 person cohort random
sample. The hazard ratio (HR) and 95%
confidence interval (CI) per standard deviation
(SD) lower biomarker were estimated using
Cox models adjusting for stroke risk factors
(Table). Individuals on warfarin were excluded.
Results: Over a median 5.8 years (Interquartile
range 4.1, 7.0) 66 ICH occurred. Compared with
participants without ICH, participants with ICH
were older (67 vs 65 years), more likely male
(62 vs 44%), had higher aspirin use (53 vs 44%),
higher systolic blood pressure (135 vs
127mmHg), and a greater prevalence of
cardiovascular disease (26 vs 16%), left
ventricular hypertrophy (61 vs 51%), and a
lower prevalence of atrial fibrillation (5 vs 7%);
all p <0.05. Only mean levels of factor IX (97%
vs 104%; p <0.05) were lower in participants
with vs those without ICH. Factor IX was
significantly associated with ICH per SD lower
increment (Table). Compared to the highest
tertile of factor IX (>112%), the lowest tertile
(<94%) was associated with a HR of 4.1 (95% CI
1.7, 9.8) and the middle tertile (94%-112%)
with a HR of 2.3 (95% CI 0.9, 5.8) for ICH.
Excluding individuals in lowest 2.5% (<66%) of
factor IX levels did not change the results.
Discussion: Factor IX was associated with risk
of ICH. As congenital factor IX deficiency is a
bleeding disorder (hemophilia B), the observed
gradation of risk, and the biologic plausibility,
our results suggest a likely causal role for
normal variation of factor IX levels and
population ICH risk.
N. Zakai: None. S. Judd: None. N. Olson:
None. D. Kleindorfer: None. B. Kissela: None. G.
Howard: None. M. Cushman: None.
MP88
Dehydroepiandrosterone (DHEAS) and Risk of
Stroke in Black and White Americans: The
Reasons for Geographic and Racial Differences
in Stroke Cohort (REGARDS)
Markus Degirmenci, Peter W Callas, Univ of
Vermont/Fletcher Allen Health Care, Burlington,
VT; Suzanne E Judd, Virginia Howard, Univ of
Alabama at Birmingham, Birmingham, AL;
Nancy S Jenny, Univ of Vermont/Fletcher Allen
Health Care, Burlington, VT; Brett Kissela, Univ
of Cincinnati, Cincinnati, OH; Catherine Kim,
Univ of Michigan, Ann Arbor, MI; Mary
Cushman, Univ of Vermont/Fletcher Allen
Health Care, Burlington, VT
Introduction: The association of DHEAS with
coronary risk has been extensively studied, but
little information is available on stroke risk.
DHEAS levels are lower with stroke risk factors
such as atrial fibrillation, arterial stiffness and
atherosclerosis, but only one paper evaluated
stroke risk and showed an inverse association of
DHEAS and stroke risk in female nurses.
lower DHEAS level is associated with increased
ischemic stroke risk.
Methods: REGARDS enrolled 30,239 US
participants aged 45 and older in 2003-07 (41%
black, 59% white, 55% living in the southeastern
stroke belt). Baseline serum DHEAS was
measured in 1,578 participants; 963 in a cohort
random sample and 544 with first-time ischemic
stroke during 5.4 years of follow up. Cox
proportional hazard models with weights to
account for the case cohort design were used to
calculate hazard ratios (HR) of stroke by
quartiles of DHEAS levels.
Results: DHEAS was significantly lower with
older age, white race, female sex, and history of
heart disease. DHEAS in the first compared to
the fourth quartile was associated with
increased risk of stroke (HR 1.7, CI: 1.2-2.4),
although this association was not present after
adjusting for age (or other stroke risk factors:
HR 1.0, CI: 0.7-1.6). These findings were similar
in men and women. Stratifying on age, as
shown in the table, in those <65 at baseline,
lower DHEAS was associated with increased
stroke after adjustment for sex, race, and
Framingham stroke risk factors (HR 3.1, CI: 1.37.6), but there was no association in those >65
years (HR 0.8, CI: 0.5-1.4).
Conclusion: There was no overall association of
lower DHEAS and stroke risk in this bi-racial
cohort of men and women from across the US,
although a possible difference by age was
observed. More research is needed to
determine association of DHEAS with stroke
risk.
M. Degirmenci: None. P.W. Callas: None. S.E.
Judd: None. V. Howard: None. N.S. Jenny:
None. B. Kissela: None. C. Kim: None. M.
Cushman: None.
MP89
Epidemiology of Ischemic Stroke Subtypes
within the Mashhad Stroke Incidence Study
(MSIS): A Population-Based Study of Stroke in
the Middle East
Hamidreza Saber, Boston Univ Sch of Public
Health, Brookline, MA; Ashkan Shoamanesh,
Harvard Univ Sch of Med, Boston, MA;
Mahmoud Reza Azarpazhooh, Boston Univ Sch
of Public Health, Brookline, MA
BACKGROUND: Incidence and case fatality rates
of ischemic stroke subtypes are unknown in the
Middle-East due to the lack of communitybased incidence stroke studies in this region.
AIM: To characterize ischemic stroke subtypes
in a Middle Eastern population.
Methods: MSIS is a community-based study,
that prospectively ascertained all cases of
stroke among the 450 229 inhabitants of
Mashhad, Iran between 2006-2007. Within this
population, we identified 560 cases of first-ever
ischemic stroke. Ischemic stroke subtypes were
classified according to the modified-TOAST
criteria. Incidence rates were age standardized
to the European population. The primary
outcome of interest was all cause mortality at 1year follow-up.
Results: The proportion of stroke subtypes were
distributed as follows: 53% large-artery disease
(LAD), 14% cardioembolic, 23% small vessel
disease (SVD), 6% undetermined and 5% other.
The incidence rates (per 100 000) were 157 for
LAD, 34 for cardioembolism, 66 for SVD, 16 for
undetermined and 7 for other types category. In
comparison to individuals with the other stroke
subtypes, those with LAD stroke were older and
had overrepresentation of diabetes (P<0.001),
hyperlipidemia (p=0.047) and prior TIA
(p=0.005), whereas those with SVD had
overrepresentation of hypertension (p<0.001).
Overall, there were 163 deaths (30%) during the
1-year of follow-up. The highest 1-year
mortality was observed in cases of
cardioembolism (59%) and the lowest in SVD
(8%). Ischemic stroke subtype was a significant
predictor of one-year mortality (Log-rank
P<0.0001).
Conclusions: We observed markedly higher
incidence rates of ischemic stroke within the
MSIS, particularly in the LAD subtype. Our
findings should be considered when planning
prevention and stroke-care services in this
region.
H. Saber: None. A. Shoamanesh: None. M.
Azarpazhooh: None.
MP90
Carotid Arterial Stiffness is Associated with An
Increased Risk of Incident Cerebral
Microbleeds in Older People: the Age,
Gene/Environment Susceptibility-Reykjavik
Study
Jie Ding, Natl Inst on Aging, Bethesda, MD;
Michiel L Bots, Julius Ctr for Health Sciences and
Primary Care, Univ Medical Ctr Utrecht,
Utrecht, Netherlands; Sigurdur Sigurdsson,
Icelandic Heart Association, Kopavogur, Iceland;
Melissa Garcia, Tamara B Harris, Natl Inst on
Aging, Bethesda, MD; Gudny Eiriksdottir,
Icelandic Heart Association, Kopavogur, Iceland;
Mark A van Buchem, Dept of Radiology, Leiden
Univ Medical Ctr, Leiden, Netherlands;
Vilmundur Gudnason, Icelandic Heart
Association, Kopavogur, Iceland; Lenore J
Launer, Natl Inst on Aging, Bethesda, MD
Introduction- Cerebral microbleeds (CMBs)
resulting from cerebral amyloid angiopathy are
predominantly located in lobar regions,
whereas those from hypertension are in deep
and infratentorial regions. Although age and
high blood pressure are major risk factors for
CMBs, the underlying mechanisms remain
unclear; arterial stiffness may be important.
Hypothesis- We hypothesized that carotid
arterial stiffness, would be associated with
incident CMBs. Given the spatial distributions of
the underlying arteriopathies in which
hypertensive arteriopathy typically affects the
small perforating end-arteries of the deep
structures, we further hypothesized that the
associations would be more robust for deep
CMBs attributed to hypertensive arteriopathy.
Methods- In the prospective, population-based
Age, Gene/Environment Susceptibility-Reykjavik
Study, 2,512 participants aged 66-97 years
underwent a baseline brain MRI examination
and carotid ultrasound in 2002-2006, and
returned for a repeat brain MRI in 2007-2011.
Common carotid arterial stiffness was assessed
using a standardized protocol and expressed as
carotid arterial strain (CAS), distensibility
coefficient (DC) and Young’s elastic modulus
(YEM). Log-binomial regression was applied to
relate carotid arterial stiffness parameters to
CMBs incidence.
Results- During a mean follow-up of 5.2 years,
463 people (18.4%) developed new CMBs, of
whom 292 had CMBs restricted to lobar regions
and 171 had CMBs in a deep or infratentorial
region. After adjusting for age, sex and brain
MRI interval, all arterial stiffness parameters
were each significantly associated with incident
CMBs (Risk ratio [RR] per SD decrease in CAS,
1.11 [95%CI, 1.02-1.21]; RR per SD decrease in
natural log-transformed DC, 1.14[1.05-1.23]; RR
per SD decrease in natural log-transformed
YEM, 1.13[1.04-1.22]) and deep CMBs (RR,
1.17[1.00-1.36]; 1.24[1.07-1.43]; 1.22[1.061.41] respectively) but not with lobar CMBs.
When further adjusted for baseline vascular risk
factors including blood pressure and use of
blood pressure lowering drugs, the presence of
carotid plaque, prevalent CMBs, subcortical
infarcts and white matter hyperintensities, the
associations persisted.
Conclusion- Our findings support the hypothesis
that localized increases in carotid arterial
stiffness may contribute to the development of
CMBs, especially those occuring in a deep
location.
J. Ding: None. M.L. Bots: None. S. Sigurdsson:
None. M. Garcia: None. T.B. Harris: None. G.
Eiriksdottir: None. M.A. van Buchem: None. V.
Gudnason: None. L.J. Launer: None.
MP91
Abdominal Obesity, Independent of General
Obesity, is Associated With Reduced Circadian
Pattern of Cardiac Autonomic Modulation in
Adolescents
Sol M Rodríguez-Colón, Arthur Berg, Yuka
Imamura Kawasawa, Anna Salzberg, Edward O
Bixler, Julio Fernandez-Mendoza, Alexandros N
Vgontzas, Duanping Liao, Penn State Univ Coll
of Med, Hershey, PA
Introduction: Reduced cardiac autonomic
modulation (CAM) has been associated with
metabolic syndrome and higher CVD risk in
adults. However, the association between
abdominal obesity and the circadian pattern of
CAM has not been examined in adolescents.
Hypothesis: We hypothesize that abdominal
obesity is adversely associated with the
circadian pattern of cardiac autonomic
modulation in
adolescents.
Methods: We used data from the Penn State
Child Cohort follow-up examination (N=421).
Cardiac autonomic modulation was assessed by
heart rate variability (HRV) analysis of 24-hour
RR intervals, including frequency and time
domain variables. We used 3-parameters from a
cosine periodic regression to quantify the 24hour HRV circadian pattern, namely, the mean
levels of HRV indices (M), the amplitude of the
oscillation (Â), and the timing of the highest
oscillation (θ). A dual-energy x-ray
absorptiometry was used to assess abdominal
obesity, as android/gynoid fat ratio, visceral
(VAT) and subcutaneous (SAT) fat areas. BMI
percentile was used to assess general obesity.
Random-effect meta-analysis regression was
used to associate the 3 HRV circadian
parameters with abdominal obesity measures,
adjusting for BMI percentile, age, sex, and race.
Results: The mean age was 17 years (SD=2.3).
The mean BMI percentile was 66 (SD=28). The
prevalence of obesity was 16%. After adjusting
for the above mentioned covariables,
abdominal obesity was significantly associated
with a lower M of HRV, and starting to affect
the Â and θ by shifting its circadian pattern
away from the normal individuals, as illustrated
in the figure below contrasting adolescents in
the highest quartile of VAT and those in the
lower 3 quartiles of VAT. A consistent pattern of
associations were observed across various
measures of HRV and various measures of
abdominal obesity.
Conclusion: Abdominal obesity, independent of
general obesity, has started to adversely affect
the circadian pattern of cardiac autonomic
modulation in otherwise healthy adolescents.
S.M. Rodríguez-Colón: None. A. Berg: None. Y.
Imamura Kawasawa: None. A. Salzberg:
None. E.O. Bixler: None. J. FernandezMendoza: None. A.N. Vgontzas: None. D. Liao:
None.
MP92
Changes in Ectopic Fat are Associated with
Changes in Adipokines in Healthy,
Overweight/Obese Young Adults
Thomas R Radomski, Univ of Pittsburgh Sch of
Med, Pittsburgh, PA; Lina Bai, Emma BarinasMitchell, Univ of Pittsburgh Graduate Sch of
Public Health, Pittsburgh, PA; Molly B Conroy,
Univ of Pittsburgh Sch of Med, Pittsburgh, PA
Background: Excess ectopic fat has been
associated with increased cardiometabolic risk,
which may partially stem from changes in
adipokines such as leptin and adiponectin. Prior
studies have demonstrated that increased
leptin and decreased adiponectin are associated
with an increase in body mass index (BMI), but
few have examined changes in adipokines
related to changes in ectopic fat. We
hypothesized that in healthy overweight and
obese young adults, a decrease in ectopic fat
will be associated with decreased levels of
leptin and increased levels of adiponectin.
Methods: We analyzed 244 subjects
participating in the Slow Adverse Vascular
Effects (SAVE) study, a randomized trial of a
behavioral weight loss intervention in 349
overweight and obese (BMI 25-40 kg/m2) men
and women ages 20-45 years. Subjects
underwent a CT scan of their abdomen and left
thigh to quantify their amount of visceral (VAT)
and intramuscular (IMAT) adipose tissue at
baseline and 12 months. Serum concentrations
of leptin and adiponectin were also measured
at baseline and 12 months. We generated
variables for the change in VAT, IMAT,
adiponectin and leptin by subtracting 12-month
from baseline values. To evaluate the
association between changes in serum
adipokine (dependent variable) levels with
changes in VAT and left thigh IMAT
(independent variables), we performed a series
of multiple linear regression analyses
controlling for: 1) age, sex, race and 2) previous
variables + change in BMI tertile.
Results: The mean age at baseline was 38 ± 6
years; 181 (74.5%) subjects were female; and
198 (81.5%) were white. Mean VAT at baseline
was 115.27 ± 53.58 cm2 with a mean decrease
of 17.54 ± 36.71 cm2 at 12 months. Mean left
thigh IMAT was 12.76 ± 4.87 cm2 at baseline
with a mean decrease of 5.05 ± 3.20 cm2 at 12
months. Serum adiponectin was 11.90 ± 6.15
μg/mL at baseline, with a mean increase of 0.14
± 3.79 μg/mL at 12 months. Serum leptin was
25.11 ± 13.38 μg/mL at baseline, with a mean
decrease of 4.26 ± 10.71μg/mL at 12 months.
After adjusting for age, sex, and race, a
decrease in VAT was significantly associated
with an increase in adiponectin (P=0.010) and
decrease in leptin (P<0.001); a decrease in IMAT
was significantly associated with an increase in
adiponectin (P=0.003), but was not significantly
associated with a decrease in leptin (P=0.297).
Except for the association between a decrease
in IMAT and decrease in leptin (P=0.048), these
relationships were no longer significant after
adjusting for change in BMI tertile.
Conclusion: A decrease in ectopic fat was
associated with an increase in adiponectin and
a decrease in leptin in young overweight/obese
adults after adjusting for age, sex, and race. This
underscores the metabolic activity of ectopic fat
and supports the role of adiponectin and leptin
as mediators of cardiometabolic risk.
T.R. Radomski: None. L. Bai: None. E. BarinasMitchell: None. M.B. Conroy: None.
MP93
Waist Circumference Has a Stronger
Association With Diabetes Than Body Mass
Index: Results From a Large Health
Examination of 355,310 Thai Men and Women
Parinya Chamnan, Sanpasitthiprasong Hosp,
Ubon Ratchathani, Thailand; Hansa
Choenchoopon, Suvit Rojanasaksothorn,
Provincial Public Health Office of Ubon
Ratchathani, Ubon Ratchathani, Thailand
Background: Although obesity is known to
increase the risk of diabetes, few studies have
investigated the relative association of diabetes
with body mass index (BMI) and waist
circumference (WC) in Asian populations.
Methods: Using data from the Health Check
Ubon Ratchathani (HCUR) project, a large
health examination of 355,510 Thai men and
women aged ≥30 years in Ubon Ratchathani,
Thailand, we investigated the association
between BMI, WC and prevalent diabetes.
Weight, height, WC and fasting blood glucose
were measured using standard procedures and
point-of-care glucometers. We defined diabetes
as fasting blood glucose ≥126 mg%, or selfreported diabetes.
Results: Among 355,510 participants, 21,838
(6.1%) had diabetes. BMI and WC were
continuously and consistently associated with
the risk of diabetes. There was a J-shape
relationship between BMI and diabetes risk,
while a threshold pattern for the association
between WC and diabetes was observed. Each 1
kg/m2 higher BMI was associated with a 11%
increased risk of diabetes, and each 5-cm higher
WC was associated with a 35% increased risk.
For every standard deviation or quintile
increase, WC was more strongly associated with
the risk of diabetes than BMI. After adjustment
for age, sex, smoking, exercise, alcohol drinking,
family history of diabetes, hypertension and
cholesterol, the odds ratios for diabetes across
WC quintile were 1.00 (reference), 1.03 (95%CI
0.98-1.08), 1.38 (1.30-1.47), 1.66 (1.58-1.74)
and 3.16 (3.03-3.30) respectively (p for trend
<0.001). The corresponding odds ratios for BMI
quintile were 1.00 (reference), 0.92 (0.87-0.96),
1.00 (0.96-1.06), 1.29 (1.23-1.36) and 1.98
(1.89-2.06) respectively (p for trend <0.001).
Conclusions: In this Thai population, we found a
continuous relationship between waist
circumference, BMI and diabetes across the
whole range of their values, with a stronger
association for waist circumference than BMI.
P. Chamnan: None. H. Choenchoopon:
None. S. Rojanasaksothorn: None.
MP94
Impact of a 12-Weeks Supervised Physical
Activity Program After Bariatric Surgery on
Body Composition and on Abdominal and MidThigh Body Fat Distribution Changes; a
Randomized Study
Audrey Auclair, Jany Harvey, Alexandre
Sanctuaire, Simon Marceau, Laurent Biertho,
Simon Biron, Frederic-Simon Hould, Stefane
Lebel, Odette Lescelleur, Paul Poirier, Inst
Univire de Cardiologie et de Pneumologie de
Quebec, Quebec, QC, Canada
Bariatric surgery is the most effective long-term
treatment for the management of severe
obesity. Weight loss induced by bariatric
surgery is characterize by a greater reduction of
fat mass but also by a reduction of muscle mass.
So far, there is a lack of data regarding the
effect of physical activity after bariatric surgery
on changes in weight and muscle mass. The
purpose of this study was to measure the
impact of supervised physical activity program,
between months 3 to 6 after bariatric surgery,
on body composition and on abdominal and
mid-thigh body fat distribution. Patients were
randomized either in a supervised physical
activity program group (exercise group) or
either usual care without personalized physical
activity follow-up group (control group). For all
patients, anthropometric measurements (waist
circumference and bioimpedance analysis) and
computed tomography scan (CT scan) at the
abdomen and mid-thigh levels were performed
before, at 3 and 6 months after bariatric surgery
(sleeve gastrectomy or biliopancreatic diversion
with duodenal switch). Patients in the exercise
group, were encouraged, between 3 to 6
months, to perform at least 3 times per week,
60 minutes of supervised physical activity
including aerobic and resistance training. Up to
now, 52 patients are performing this study for
which so far, 22 patients (13 patients in exercise
group and 9 patients in control group) have
completed 6 months follow-up. At baseline,
both groups were similar for the proportion of
women (54 % vs. 56 %; exercise vs. control
group respectively), age (47±12 years vs. 43±15
years), waist circumference (137.5 ±11.1 cm vs.
136.5±8.9 cm), body mass index (45.7±6.6
kg/m2 vs. 43.0±3.8 kg/m2) and for all
parameters related to CT scan. At 3 months,
post-operative changes were similar between
groups except for waist circumference and
abdominal subcutaneous adipose tissue which
showed a trend (p=0.10) toward a greater
reduction in exercise group. During the exercise
period, between 3 to 6 months, the reduction
was similar between groups for waist
circumference (-7.6±5.3 % vs. -8.0±5.1%),
weight (-8.9±5.6% vs. -9.2±4.6%) and body fat (14.1±7.1% vs. -12.7±6.4%). However, there was
a trend toward a lower reduction regarding fatfree mass (-0.3±4.2% vs. -2.3±2.0%; p=0.12),
mid-thigh total muscle (1.1±4.8% vs. -1.6±3.7%;
p=0.19) and mid-thigh fat-infiltrated muscle (5.6±10.3% vs. -12.9±11.3%; p=0.16) for the
exercise group compares to the control group.
In conclusion, so far, our complete data in 22
patients suggested a trend toward a favorable
impact of exercise regarding a lower decrement
in fat-free mass, mid-thigh total muscle and
mid-thigh fat-infiltrated muscle in severely
obese patients who underwent either sleeve
gastrectomy or biliopancreatic diversion with
duodenal switch surgery. More patients are
being studied to further delineate the effect of
supervised physical activity program.
A. Auclair: None. J. Harvey: None. A.
Sanctuaire: None. S. Marceau: None. L.
Biertho: None. S. Biron: None. F. Hould:
None. S. Lebel: None. O. Lescelleur: None. P.
Poirier: None.
MP95
Prevalence of General and Abdominal Obesity
in Adults with Chronic Kidney Disease: Results
from NHANES 2007-2012
Alex R Chang, Geisinger Clinic, Danville, PA;
Lawrence J Appel, Morgan E Grams, Johns
Hopkins Univ, Baltimore, MD
increased risk for chronic kidney disease (CKD),
and may be a modifiable risk factor for its
progression. Prevalence of general and
abdominal obesity has not been well-described
in a nationally-representative sample of adults
with CKD.
Methods: We used data from the National
Health and Nutrition Examination Survey
(NHANES) 2007-2012 to estimate prevalence of
obesity [body mass index (BMI) ≥30 kg/m2],
severe obesity (BMI ≥35 kg/m2), and elevated
waist circumference (World Health Organization
guidelines: women ≥ 88 cm; men ≥ 102 cm) in
adults ≥ 20 years for individuals with CKD
[estimated glomerular filtration rate (eGFR) <
60 ml/min/1.73m2 or albumin/creatinine ratio
(ACR) ≥ 30mg/g] overall, and in categories of
eGFR and ACR. Correlations between BMI and
waist circumference were examined and
compared between persons with and without
CKD. Continuous relationships between eGFR,
log-transformed ACR and obesity were
examined using logistic regression, adjusted for
age, race, and sex.
Results:
Prevalence of obesity, severe obesity, and
elevated waist circumference was 43.2%,
20.7%, and 67.4% in adults with CKD compared
to 33.5%, 13.7%, and 52.6% in adults without
CKD (p<0.001 for all comparisons). Overall, the
prevalence of obesity and elevated waist
circumference tended to increase with more
severe category of eGFR and ACR (Figure). BMI
and waist circumference were strongly
correlated for both adults with CKD (r=0.89) and
without CKD (r=0.9). However, 44.2% of nonobese persons with CKD had elevated waist
circumference compared to 30.9% of non-obese
persons without CKD (p<0.001). In continuous
analyses, obesity was associated with higher
ACR, particularly among persons with higher
eGFR (p for interaction = 0.1); obesity and eGFR
were not independently associated.
Conclusion: Obesity, particularly in a central
distribution, is common among individuals with
CKD. Clinical trials are needed to determine
whether reducing weight can prevent or slow
progression of CKD.
A.R. Chang: None. L.J. Appel: None. M.E.
Grams: None.
MP96
Directly Quantified Visceral Adipose Tissue
Predicts Vascular Inflammation Beyond
Traditional Anthropometric Measures
Tiffany M Powell-Wiley, NIH, Bethesda, MD;
Parasurnam Krishnamoorthy, Englewood Hosp,
Englewood, NJ; Balaji Natarajan, Martin
Playford, Julia Doveikis, Qimin Ng, Jack Yao,
Nehal Mehta, NIH, Bethesda, MD
Background: Visceral adipose tissue (VAT) has
been linked to increased cardiovascular (CV)
risk. Data are limited comparing volume-based
VAT by computed tomography (CT) to standard
anthropometric measures (body mass index
[BMI], waist-to-hip ratio [WHR]) in predicting
vascular inflammation (VI) measured by (18FFDG) PET-CT. Therefore, we sought to compare
the ability of BMI, WHR, and VAT to predict VI in
a cohort study of inflammation and CV risk. We
hypothesized that direct quantification of VAT
will provide incremental value beyond standard
anthropometric measures in association with
VI.
Methods and Results:We evaluated the
relationship between adiposity measures (VAT,
BMI, WHR) and (18F-FDG) PET-CT measured
arterial inflammation [target-to-background
ratio (TBR)] from the thoracic aorta in a
longitudinal study of CV risk predictors in
chronic inflammation (NCT: NCT01778569).
Patients underwent (18F-FDG) PET-CT during a
baseline visit in 2012-2014 (N=56). Volume of
VAT from the diaphragm to the inferior border
of the urinary bladder was measured by CT
using a validated method (VAT=sum of slices 50150). Likelihood ratio testing was applied in
nested Tobit regression models to assess the
incremental value of adding VAT to models with
BMI and WHR in predicting VI. Those with
greater VAT had higher BMI and Framingham
risk score (p<0.05 across VAT tertiles). VAT was
associated with TBR (beta coefficient = 2.7, 95%
CI=0.7-4.7) independent of age, sex, race,
physical activity and CV risk factors
(hypertension, hyperlipidemia, family history).
VAT added incremental value to traditional CV
risk factors, BMI, and WHR in predicting TBR. In
contrast, BMI and WHR did not predict TBR
beyond CV risk factors (Table).
Conclusions: Volume-based CT measures of
visceral adiposity are more accurate predictors
of vascular inflammation as compared to BMI
and WHR, independent of traditional CV risk
markers. Thus, volume-based VAT may serve as
a novel anthropometric measure in identifying
vascular inflammation and CV risk.
T.M. Powell-Wiley: None. P. Krishnamoorthy:
None. B. Natarajan: None. M. Playford:
None. J. Doveikis: None. Q. Ng: None. J. Yao:
None. N. Mehta: None.
ControlExtraData.FullOrPartialFundingFromAH
A:
No
ControlExtraData.AHAFundingComponent:
P001
State-Level Trends in Cardiovascular Health,
2003-2011
Courtney Pilkerton, Sarah Singh, WVU Sch of
BACKGROUND: Cardiovascular disease is the
leading cause of death in the United States, so
improving cardiovascular health (CVH) is a key
population health goal. As part of public health
efforts to achieve this, the American Heart
Association recently developed a
comprehensive CVH index that incorporates
smoking, body mass index, physical activity,
diet, cholesterol, blood pressure, and blood
glucose. OBJECTIVE: The objective of the
current study was to investigate the change in
CVH in each of the U.S. states using Behavioral
Risk Factor Surveillance System (BRFSS) data
between 2003 and 2011. A secondary objective
was to assess the impact of 2011
methodological changes to BRFSS on CVH.
METHODS: Data from the Behavioral Risk Factor
Surveillance System were used to determine
calculate CVH for each state for 2003, 2005,
2007, 2009, and 2011. Federal Information
Processing Standards codes were used to obtain
age-standardized mean CVH for each state. The
main outcomes were age-standardized mean
CVH score and prevalence of each component.
Time trends for each state were determined
using by including a time variable corresponding
to the BRFSS study year in a Poisson model for
total CVH and logistic models for individual CVH
components. Differences in total CVH and
prevalence of components between 2003 and
2009 as well as between 2009 and 2011 were
calculated and Pearson chi square tests were
used to determine significant differences.
RESULTS: Overall the age-standardized mean
CVH index was 3.73 for 2003, 3.71 for 2005,
3.68 for 2007, 3.65 for 2009, and 3.45 for 2011.
In 2011, CVHI ranged from a high of 3.70 in
Colorado to a low of 3.15 in West Virginia and
Mississippi. The majority of states in the U.S.
had both a decline in mean CVH and an increase
in the prevalence of poor CVHI between 2003
and 2009. Overall, the prevalence of ideal
smoking behavior increased from 79.2% to
83.5% and the prevalence of ideal diet
increased from 12.1% to 13.4%. The prevalence
of ideal for all other components decreased;
blood pressure by 4.2 percentage points,
cholesterol by 5.9, blood glucose by 1.4, and
physical activity by 12.2. Comparing the
magnitude of absolute differences in CVHI
between 2003 and 2009 with 2009 and 2011,
many of the one year changes (09 to 11) were
greater than the six year changes (03 to 09).
CVH has decreased in a linear fashion between
2003 and 2009 likely due to decreases during
this time in ideal blood pressure, cholesterol,
and BMI. CONCLUSIONS: This data can be used
to inform state specific risk factor targets that
would be most effective in improving overall
CVH. The large differences seen due to 2011
BRFSS methodological changes raise concerns
for states that rely on this data to evaluate
programs and target resources.
C. Pilkerton: None. S. Singh: None. A.
None.
P002
Long Term Exposure to Outdoor Air Pollution
and Cardiovascular Health
Sarah Singh, Courtney Pilkerton, WVU Sch of
BACKGROUND: Although the link between air
pollution and cardiovascular disease has been
controversial in recent decades, it remains a top
global health concern. Most studies have
assessed only the relationship between
pollutant concentrations and morbidity or
mortality in populous cities. In this study, we
investigated the association of long term
exposure to major air pollutants with current
cardiovascular health. This outcome was a
measure of health rather than disease, as
measured by the Cardiovascular Health Index
(CVHI) developed by the American Heart
Association. METHODS: We analyzed 2011 data
from 3007 counties across the US using
Behavioral Risk Factor Surveillance System and
Area Health Resources File. Air Quality Index
(AQI) for five major pollutants from 2001-2011;
Ozone, Sulfur dioxide and Carbon monoxide
and Fine particulate matter (aerodynamic
diameter of 10 and ≤2.5 µm) were obtained
from the EPA Air Quality System database.
Categories were based on the 11-year average
pollutant AQI level and using Jenks optimization
method; persistently good, variant and
persistently bad. Associations between
categories and the mean CVHI were evaluated
using Poisson regression models adjusting for
age, sex, race/ethnicity and socioeconomic
status at the individual and population level.
RESULTS: PM2.5 was most frequently measured
(938 counties) and carbon monoxide least
frequently (224 counties). Correlations between
pollutants were moderate and significant
(p<0.0001), ranging from r=0.30 between CO
and Oz to r=0.52 between SD and PM2.5. Four
pollutants had 11-year average AQI levels
significantly associated with increased mean
CVHI score of individuals. Living in a county
categorized as ‘persistently good’ or ‘variant’
AQI levels for ozone is significantly associated
with an estimated 3% increase in CVHI (95% CI
0.1% - 5.0%) as compared to living in a county
of ‘persistently bad’ AQI levels. In addition,
living in a county of only ‘persistently good’ AQI
levels for PM2.5 is significantly associated with
an estimated 5% increase in CVHI (95% CI 3% 9%) as compared to living in a county of
‘persistently bad’ AQI levels. Inverse
relationships existed for both PM10 and carbon
monoxide. CONCLUSIONS: It is difficult to tease
apart the independent effects of individual air
pollutants on health as humans are exposed to
a mixture of gases. However we have shown
that at the individual level, there is an
association between long term exposure to air
pollution and its effects on current
cardiovascular health. Further research is
needed to determine whether these effects
exist at varying levels of subject characteristics.
S. Singh: None. C. Pilkerton: None. A.
None.
P003
Distribution of Ideal Cardiovascular Health
Metrics in US and Non-US populations: A
Meta-Analysis of Proportions
Adnan Younus, Ehimen Aneni, Oluseye
Ogunmoroti, Omar Jamal, Shozab Ali, Baptist
Health South Florida, South Miami, FL; Sameer
Shaharyar, Aventura Hosp, South Miami, FL;
Muhammad Aziz, Rehan Malik, Rameez Ahmad,
Chukwuemeka Osondu, Lara Roberson, Janisse
Post, Theodore Feldman, Wasim Maziak, Arthur
S Agatston, Emir Veledar, Khurram Nasir,
Baptist Health South Florida, South Miami, FL
Introduction: With the development of new
health metrics to define ideal cardiovascular
health (CVH), several studies have examined the
distribution of the American Heart Association
(AHA) 2020 ideal CVH metrics both within and
outside the United States (US). In this metaanalysis of proportions, we synthesized
available data on ideal CVH metrics distribution
in US cohorts and compared them with non-US
populations.
Methods: A MEDLINE database search was
conducted using relevant free text terms such
as “life’s simple 7”, “AHA 2020”, “American
Heart Association 2020” and “ideal
cardiovascular health” between January 2000
and October 2014. Studies were included in the
meta-analysis if the proportions achieving ideal
for 0, 1, 2, 3, 4, 5 or ≥6 ideal CVH metrics were
known or could be estimated. A meta-analysis
of proportions was conducted for US and nonUS studies using a random effect model (REM).
REM models were chosen because of the
significant heterogeneity among studies.
Results: Overall the pooled data consisted of 10
US cohorts with a total population of 94,761
participants and 6 non-US cohorts with a total
of 130,242 participants. The table shows the
pooled prevalence of ideal CVH factors in this
population. Overall the pooled estimates of US
cohorts showed 15% had 0-1 ideal CVH metrics
(inter-study range: 7-22%), while 3% (interstudy range: 1-10%) had 6-7 ideal CVH metrics.
This is comparable to 12% (inter-study range 117%) and 2% (inter-study range: 1-12%) for 0-1
and 6-7 ideal CVH metrics in the non-US studies.
Conclusion: The proportion of persons achieving
6 or more ideal CVH metrics in both US and
non-US cohorts is very low and the distribution
of CVH metrics is similar in both US and non-US
populations. Considering the strong association
with worse outcomes, a coordinated global
effort at improving CVH should be considered a
priority.
A. Younus: None. E. Aneni: None. O.
Ogunmoroti: None. O. Jamal: None. S. Ali:
None. S. Shaharyar: None. M. Aziz: None. R.
Malik: None. R. Ahmad: None. C. Osondu:
None. L. Roberson: None. J. Post: None. T.
Feldman: None. W. Maziak: None. A.S.
Agatston: None. E. Veledar: None. K. Nasir:
None.
P004
Three Year Trends of Ideal Cardiovascular
Health Metrics Among Employees of a Large
Health Care Organization: The Baptist Health
South Florida Employee Study
Oluseye Ogunmoroti, Adnan Younus, Maribeth
Rouseff, Ehimen Aneni, Sankalp Das, Don Parris,
Leah Holzwarth, Henry Guzman, Thinh Tran,
Omar Jamal, Shozab Ali, Muhammad Aziz,
Rehan Malik, Rameez Ahmad, Chukwuemeka
Osondu, Janisse Post, Arthur Agatston,
Theodore Feldman, Michael Ozner, Emir
Veledar, Khurram Nasir, Baptist Health South
Florida, Miami, FL
BACKGROUND: More than 1 in 3 U.S. adults has
cardiovascular disease (CVD). The U.S.
workforce makes up over 50% of the entire
population, making the workplace the ideal
setting for addressing the burden of CVD. This
study used the American Heart Association’s
(AHA) cardiovascular (CV) health metrics to
assess the risk of CVD over 3 years among
employees of Baptist Health South Florida
(BHSF), a large nonprofit health care
organization.
METHODS: Ideal CV health is defined by the
AHA as meeting ideal status in 7 health metrics:
diet, body mass index (BMI), physical activity,
blood pressure, total cholesterol, blood glucose
and smoking. The health metrics were
calculated using data collected annually from
voluntary wellness fairs and health risk
assessments. Each metric was categorized as
ideal, intermediate or poor according to AHA
criteria.
RESULTS: Data were collected for a total of
6147 employees in 2011, 11112 in 2012 and
9996 in 2013. For each year, approximately 75%
were women and mean age (SD) was 43 (12).
Less than 1% of employees achieved ideal CV
health in a given year during the study period.
While less than 50% had ≥5 ideal health metrics
across the years, an 11% increase was observed
between 2011 and 2013. Among individual
metrics, diet and body mass index had the
lowest proportion of participants who reached
ideal status during the 3 years.
CONCLUSIONS: Although less than half of
participants met the ideal status for ≥5 metrics,
a trend towards improvement was noticed and
could be attributed to worksite wellness
programs. Diet and BMI are areas that need
more attention. Worksite wellness programs
should address these two metrics among
employees to improve cardiovascular health.
O. Ogunmoroti: None. A. Younus: None. M.
Rouseff: None. E. Aneni: None. S. Das: None. D.
Parris: None. L. Holzwarth: None. H. Guzman:
None. T. Tran: None. O. Jamal: None. S. Ali:
None. M. Aziz: None. R. Malik: None. R.
Ahmad: None. C. Osondu: None. J. Post:
None. A. Agatston: None. T. Feldman: None. M.
Ozner: None. E. Veledar: None. K. Nasir: None.
P005
Association Between County Elementary and
Secondary Educational Policy With
Adam Christian, WVU Sch of Med,
Morgantown, WV; Courtney Pilkerton, Sarah
Singh, Thomas K Bias, Stephanie J Frisbee, WVU
Sch of Public Health, Morgantown, WV
BACKGROUND: Recent research recognizing the
socioeconomic influence of educational
attainment on population health, including
cardiovascular health (CVH), suggests that
modifying educational policy to improve
educational outcomes could be an effective
approach to improving health outcomes.
Although the positive association of educational
level with health status is well documented, the
effect of education policy on health outcomes is
not as thoroughly studied. Identifying
relationships amongst educational policy and
CVH could provide a target for public policy
initiatives designed to positively impact
population health. OBJECTIVE: The objective
was to examine the potential effect of varying
county educational policy on county and
individual CVH outcomes.
METHODS: Variables of county educational
policy were expenditures per pupil, percent of
total revenue from each state and local sources,
and pupil teacher ratios. School district data
from 1997-2005 sourced from the National
Center for Education Statistics were adjusted
for inflation using the U.S. Dept. of Labor
Consumer Price Index as well as regional cost
differences using the NCES Comparable Wage
Index by school district, and grouped by county.
County and individual CVH for 2011 was scored
using the AHA’s CVH metric and data from the
Behavioral Risk Factor Surveillance System.
Linear regression models were used to compare
the county means for each education policy
variable with both county and individual CVH
scores.
RESULTS: Mean percent revenue from local
sources and mean pupil teacher ratio were both
shown to be positively associated with county
level CVH (p=0.007 and p=0.023). Individual
CVH was inversely associated with mean
expenditures per pupil (p=0.023), and positively
associated with mean percent revenue from
local (p<0.01), mean percent revenue from
state (p<0.01), and mean pupil teacher ratio
(p<0.001). There was an interactive effect
between mean expenditure per pupil and
county urbanicity on county CVH (p<0.05),
which differed in rural counties compared to
the most urban. There was also an interactive
effect between mean percent revenue from
local and county urbanicity on county CVH
(p<0.001). Although no significant effect was
observed for mean expenditures per pupil on
county CVH, mean expenditures per pupil was
inversely related to county CVH in the most
urban counties (b=-3.58e-06), and positively
related to county CVH in most rural counties
(b=4.62e-06). Evidence of relationships
between county educational policies and
resources with CVH suggests the need for
continued research more thoroughly examining
variables of education policy as indicators for
CVH. CONCLUSION: Further clarification of
these relationships will help determine if
educational policy adjustments driven by health
improvement initiatives would be a useful
addition to current strategies aimed at
improving population health.
A. Christian: None. C. Pilkerton: None. S.
Singh: None. T.K. Bias: None. S.J. Frisbee: None.
P006
Ideal Cardiovascular Health is Associated With
Self-Rated Health Status. The PolishNorwegian Study (PONS)
Marta Manczuk, The Maria Sklodowska-Curie
Memorial Cancer Ctr and Inst of Oncology,
Warsaw, Poland; Georgeta Vaidean, Icahn Sch
of Med at Mount Sinai, New York, NY; Rajesh
Vedanthan, Icahn Sch of Med at Mount Sinai,
Warsaw, NY; Paolo Boffetta, Icahn Sch of Med
at Mount Sinai, New York, NY; Witold A
Zatonski, The Maria Sklodowska-Curie Memorial
Cancer Ctr and Inst of Oncology, Warsaw,
Poland
ABSTRACT
Introduction: The current status of ideal
cardiovascular (CV) health in Eastern and
Central Europe is not well characterized. In
addition, the association of self-rated health
with ideal CV health has not been fully
explored.
Hypothesis: we investigated whether ideal CV
health is associated with self-reported health
status in a community-based study from
Poland.
Methods: We used cross-sectional, baseline
data of 10858 participants, age 45 to 64 years
free of CV diseases in an ongoing cohort study
(PONS). Data were collected through structured
questionnaires and fasting blood samples. Ideal
CV health was defined according to the
American Heart Association criteria (7 metrics
assessed at 3 levels: ideal, intermediate, and
poor). A single-item of self-rated health was
recorded on a scale from 1 to 10. The rating was
analyzed as a continuous, ordinal and
dichotomous variable (cut-off point of 3).
Results: Only 0.03% of the study population had
ideal values for all 7 metrics (ideal CV health)
(Table). The ideal metrics with highest and
lowest prevalence were current non-smoking
status (78.79%) and diet (0.52%). Higher
prevalence of ideal metrics was observed
among women, urban residents, and those
higher educated.
The mean ideal cardiovascular score for the
entire sample population was 2.94 (SD=1.15).
Adjusting for age, sex and education, those with
the lowest and highest self-rated health had
mean ideal CV scores of 2.73 (95% CI 2.62 to
2.83) and 3.14 (95% CI 3.07 to 3.21)
respectively. Participants with the lowest self-
rated health were less likely to have an ideal
cardiovascular score above 3 (OR 0.34, 95 % CI
0.13 to 0.86) compared to those with the
highest health rating.
Conclusion: In this community-based study,
ideal CV health was present in very few
participants. Our results suggest that there is an
association between self-rated health status
and ideal CV score. If self-rated health
association with health outcomes is confirmed,
it may serve as a proxy for identifying risk
groups and tailoring public health interventions.
M. Manczuk: None. G. Vaidean: None. R.
Vedanthan: None. P. Boffetta: None. W.A.
Zatonski: None.
P007
Maternal Heavy Smoking during Pregnancy in
Association with Higher Risk of Gestational
Diabetes in the Offspring
Wei Bao, NICHD, Natl Insts of Health, Rockville,
MD; Karin B. Michels, Harvard Sch of Public
Health, Boston, MA; Deirdre K. Tobias, Brigham
and Women’s Hosp and Harvard Medical Sch,
Boston, MA; Shanshan Li, NICHD, Natl Insts of
Health, Rockville, MD; Jorge E. Chavarro,
Audrey J. Gaskins, Harvard Sch of Public Health,
Boston, MA; Sjurdur F. Olsen, Statens Serum
Inst, Copenhagen, Denmark; Allan A. Vaag,
Rigshospitalet, Copenhagen, Denmark; Frank B.
Hu, Harvard Sch of Public Health, Boston, MA;
Cuilin Zhang, NICHD, Natl Insts of Health,
Rockville, MD
Introduction: Maternal smoking during
pregnancy is an established risk factor for
adverse perinatal outcomes. However, data on
the intergenerational impact of maternal
smoking during pregnancy on offspring’s longterm risk of adulthood disease are limited.
maternal smoking during pregnancy may be
associated with risk of gestational diabetes
mellitus (GDM) in the offspring.
Methods: The analytical population was
composed of 10138 parous women in the
Nurses' Health Study II cohort whose mothers
participated in the Nurses’ Mothers’ Cohort
Study; 819 of the nurses developed GDM. Data
on maternal and paternal smoking during
pregnancy and associated covariates were
recalled by the nurses’ mothers. GDM diagnosis
was self-reported by nurse participants and was
validated by medical record review in a previous
study. We used logistic regression models to
estimate the odds ratios (ORs) and 95%
confidence intervals (CIs).
Results: We observed a significant association
between maternal heavy smoking during
pregnancy and risk of GDM in the offspring. The
multivariable-adjusted ORs (95% CIs) of GDM
among women whose mothers did not smoke
during pregnancy, continued smoking 1-14, 1524, and ≥ 25 cigarettes/day were 1.00
(reference), 1.13 (0.91-1.42), 1.17 (0.88-1.55),
and 1.74 (1.03-2.95) (P for trend = 0.04),
respectively. Further adjustment for the nurses’
birth weight, adult life variables and body mass
index during various periods of life only slightly
changed the association. No significant
association was observed between paternal
smoking during the pregnancy period and the
risk of GDM. We further examined the joint
effect of both maternal and paternal smoking
during pregnancy on the risk of GDM. The
nurses whose parents both smoked during
pregnancy ≥ 15 cigarettes/day had an OR (95%
CI) of 1.25 (0.94-1.66), compared with those
whose parents did not smoke during pregnancy
or smoked < 15 cigarettes/day. In an analysis on
the joint effect of maternal smoking during
pregnancy and the nurse’s smoking during
adulthood, we found that the nurses who ever
smoked during adulthood and their mothers
ever smoked during the pregnancy with them
had a significantly higher risk of GDM (OR 1.40,
95% CI 1.08-1.81), compared to the nurses
neither themselves nor the mothers smoked.
Conclusions: In conclusion, maternal heavy
smoking (≥ 25 cigarettes/day) during pregnancy
is significantly associated with higher risk of
gestational diabetes in the offspring. Further
studies are warranted to confirm our findings
and to elucidate the underlying mechanisms.
W. Bao: None. K.B. Michels: None. D.K. Tobias:
None. S. Li: None. J.E. Chavarro: None. A.J.
Gaskins: None. S.F. Olsen: None. A.A. Vaag:
None. F.B. Hu: None. C. Zhang: None.
P008
Weight Gain and Cardiovascular Risk
Reduction Associated With Tobacco
Abstinence in Smokers With Serious Mental
Illness
Anne N. Thorndike, Susanne S. Hoeppner,
Corinne Cather, Gladys N. Pachas,
Massachusetts General Hosp, Boston, MA; Eric
D. Achtyes, Michigan State Univ Coll of Human
Med, Grand Rapids, MI; A. Eden Evins,
Massachusetts General Hosp, Boston, MA
Background: In patients with serious mental
illness, high prevalence of smoking and obesityrelated risk factors contribute to high rates of
cardiovascular disease (CVD) and premature
mortality. The impact of smoking cessation on
weight gain, obesity-related risk factors, and
overall cardiovascular risk among this
population is unknown.
Methods: We conducted secondary analyses to
assess weight gain and change in CVD risk of 87
smokers with serious mental illness
(schizophrenia, schizoaffective disorder, and
bipolar disorder) who participated in a
randomized controlled trial to test the longterm effectiveness of varenicline on smoking
cessation. Initially, 203 smokers with serious
mental illness were enrolled into an open-label
12-week course of varenicline. Subjects who
attained abstinence at the end of the openlabel phase were eligible to participate in the
randomized phase, and 87 subjects were
randomized to continue either varenicline or
placebo for the following 40 weeks. Smoking
cessation at week 52 (end of treatment) was
defined as 21-day point prevalence abstinence.
We compared subjects who were abstinent at
week 52 (N=33) to subjects who had relapsed to
smoking (N=54) on changes in weight and
Framingham 10-year CVD risk score over the 52week trial; outcomes were modeled with
repeated measures analyses of variance.
Results: At baseline, subjects who achieved
week 52 abstinence were older (52 vs. 46 years,
p=0.01) and had higher fasting serum glucose
(98 vs. 89 mg/dL, p=0.008) than subjects who
relapsed, but they did not differ on sex, race,
smoking characteristics, blood pressure, lipids,
treatment for diabetes, or treatment with
antipsychotic medications. Baseline mean body
mass index did not differ between abstinent
and relapsed subjects (31.4 vs. 32.4, p=0.52),
but the baseline mean Framingham risk score
was higher for abstinent than relapsed subjects
(14.2% vs. 10.8%, p=0.02). Over the 52 week
study period, abstinent subjects gained more
weight than relapsed subjects (4.8 kg vs. 1.2 kg,
p=0.002 for time*abstinence interaction), but
the mean Framingham risk score decreased
substantially for abstinent subjects and not for
relapsed subjects (-7.6% vs. 0.0%, p=0.003 for
abstinence effect adjusting for sex, site,
varenicline or placebo, and antipsychotic
medications).
Conclusion: Despite the high prevalence of
obesity at baseline and substantial weight gain
associated with long-term abstinence, smoking
cessation resulted in a large reduction in the
Framingham estimated 10-year CVD risk among
patients with serious mental illness.
A.N. Thorndike: None. S.S. Hoeppner: None. C.
Cather: None. G.N. Pachas: None. E.D. Achtyes:
None. A.E. Evins: B. Research Grant; Significant;
National Institute on Drug Abuse R01
DA021245. C. Other Research Support; Modest;
Pfizer- unrestricted research grant, EnVivo
Pharmaceuticals- unrestricted research grant,
GSK- unrestricted research grant.
P009
Dietary Exposure to Polychlorinated Biphenyls
and Incidence of Myocardial Infarction in Men
- A Population-Based Prospective Cohort Study
Agneta Åkesson, Karolinska Instt, Stockholm,
Sweden; Charlotte Bergkvist, European Food
Safety Authority, Parma, Italy; Marika Bergkvist,
Karolinska Instt, Stockholm, Sweden; Anders
Glynn, The Swedish Food Agency, Uppsala,
Sweden; Bettina Julin, Alicja Wolk, Karolinska
Instt, Stockholm, Sweden
Introduction Fish consumption may promote
cardiovascular health. The role of major food
contaminants present in fish, such as
polychlorinated biphenyls (PCBs) is, however,
largely unexplored. Experimental studies
indicate that PCBs cause endothelial cell
dysfunction, hyperlipidemia and hypertension
and cross-sectional associations have been
observed between PCB-biomarkers and several
intermediate risk factors for cardiovascular
disease. PCBs accumulate and magnify in the
food chain and fatty fish is a dominating source
of exposure in populations with a relatively high
fish intake. We assessed the hypothesis that
dietary PCB exposure is associated with
increased risk of myocardial infarction (MI) and
that the exposure may mask a protective
association with marine omega-3 fish fatty acids
intake.
Methods Validated food frequency
questionnaire-based estimates of dietary PCB
exposure was obtained at baseline (1997) in
36,759 men from the population-based Cohort
of Swedish Men, free of cancer, cardiovascular
disease and diabetes. The estimated dietary
PCB exposure was based on the food
concentrations of PCB congener 153 at the time
of baseline. PCB-153 is the most abundant
congener in food and an excellent indicator for
total PCB in food and in blood. The long-term
dietary PCB exposure assessments showed
acceptable validity against six PCB congeners in
serum (correlation coefficients 0.30 to 0.58).
Cases of MI were ascertained via registerlinkage through 2010. Relative risks (RR) and
95% confidence intervals (CI) were adjusted for
known cardiovascular risk factors.
Results During 12 years of follow-up (433,243
person-years), we ascertained 3,005 incident
cases of MI. The major dietary sources of PCB
exposure was fish, dairy products and meat.
Compared with the lowest quintile of dietary
PCB exposure (median 113 ng/day), men in the
highest quintile (median 436 ng/day) had
multivariable-adjusted RR of 1.22 (95% CI, 1.051.41) for MI, without adjusting for the intake of
marine omega-3 fish fatty acids. In a separate
model, we observed no association between
the intake of marine omega-3 fish fatty acids
and MI (RR, 1.07; 95% CI, 0.93-1.24). In
mutually-adjusted models, dietary PCB
exposure was associated with RR 1.72 (95% CI
1.28-2.30), and the intake of marine omega-3
fish fatty acids with RR, 0.67 (95% CI, 0.50-0.90),
comparing highest quintiles with lowest.
Conclusions Exposure to an integrated measure
of total PCBs from food was associated with
increased risk of MI in men. The results may
provide important information regarding the
risk-benefit analysis of fish consumption. To
increase the net benefits of fish consumption,
PCB contamination should be reduced to a
minimum: Future studies are needed to clarify
the concentrations of PCBs that may offset the
beneficial effects of fish consumption.
A. Åkesson: None. C. Bergkvist: None. M.
Bergkvist: None. A. Glynn: None. B. Julin:
None. A. Wolk: None.
P010
Dose-Response Meta-Analysis of Arsenic
Exposure and Coronary Heart Disease Risk
Katherine A. Moon, Johns Hopkins Bloomberg
Sch of Public Health, Baltimore, MD; Shilpi
Oberoi, Aaron Barchowsky, Univ of Pittsburgh,
Pittsburgh, PA; Eliseo Guallar, Keeve E.
Nachman, Johns Hopkins Bloomberg Sch of
Public Health, Baltimore, MD; Yu Chen, New
York Univ Sch of Med, New York, NY; Katherine
A. James, Univ of Colorado, Denver, CO; Ana
Navas-Acien, Johns Hopkins Bloomberg Sch of
Public Health, Baltimore, MD
Introduction: Inorganic arsenic is an established
toxicant and carcinogen found in drinking water
and in some foods. Exposure to high levels of
arsenic in drinking water (>100 μg/L) has
consistently been associated with
cardiovascular disease risk. In recent years,
evidence of an association between
cardiovascular disease and drinking water
arsenic levels that are most relevant to the U.S.
general population (<100 μg/L) has been
building. Several high-quality prospective
cohort studies are now available. In 2013, the
National Academy of Science recommended
that the U.S. Environmental Protection Agency
include coronary heart disease as a critical
endpoint in its ongoing reevaluation of the
arsenic risk assessment. One critical aspect of
this assessment is the shape of the doseresponse relationship across low (<50 μg/L) and
moderate (50-150 μg/L) levels of arsenic.
Hypothesis: We examined the hypothesis that
the positive relationship between arsenic
exposure and coronary heart disease risk is
linear when modeling arsenic concentrations as
log2-transformed.
Methods: We conducted a systematic review to
identify all epidemiologic studies of arsenic and
coronary heart disease conducted in general,
non-occupationally exposed populations. We
excluded studies with fewer than three
exposure categories and studies without arsenic
measurements in urine or water. Urine and
water measurements were converted into
estimates of internal daily dose (μg/kg/day) as a
common exposure metric. Arsenic internal daily
dose was log2-transformed. We calculated
pooled relative risks using a two-stage randomeffects meta-analysis based on the mean
arsenic dose within each category and the
categorical relative risks. The shape of the doseresponse was examined using restricted
quadratic splines. Studies for incident (fatal and
non-fatal) and fatal coronary heart disease were
examined in separate models.
Results: We identified ten studies meeting our
inclusion criteria, including four prospective,
two cross-sectional, and four ecological studies.
Across the two prospective studies of coronary
heart disease mortality, the pooled relative risk
of fatal coronary heart disease was 1.23 (95%
CI: 1.10, 1.38) per doubling of arsenic dose
(μg/kg/day). Combining the three prospective
studies of incident coronary heart disease, the
pooled relative risk of incident coronary heart
disease was 1.12 (95% CI: 1.05, 1.17) per
doubling of arsenic dose (μg/kg/day). We found
no evidence of non-linearity.
Conclusions: In conclusion, this analysis
strengthens the evidence of a positive
association between arsenic exposure at lowmoderate levels and the risk of coronary heart
disease. Further, it provides timely evidence for
the current U.S. EPA risk assessment regarding
the shape of the dose-response relationship at
levels in drinking water relevant to the U.S.
general population.
K.A. Moon: None. S. Oberoi: None. A.
Barchowsky: None. E. Guallar: None. K.E.
Nachman: None. Y. Chen: None. K.A. James:
None. A. Navas-Acien: None.
P011
Inverse Relationship between Environmental
Contaminant Perfluorooctane Acid and
Coronary Heart Disease in Diabetes
Baqiyyah Conway, Karen Innes, West Virginia
Univestiy, Morgantown, WV
Background: The perfluoralkyl acid,
perfluorooctanoate is a persistent and
widespread environmental contaminant that
has been linked to proinflammatory as well as
anti-inflammatory changes in both humans and
experimental models. Perfluorooctanoate, also
called C8, has been positively related to several
risk factors for both coronary heart disease and
diabetes in the general population. However,
the relationship of C8 to coronary heart disease
in adults with diabetes remains unexplored.
This study examines the association of C8 with
coronary heart disease in individuals with
diabetes drawn from a large Appalachian
population.
Methods: Data on 3943 adults aged ≥20 years
with diabetes were obtained from the C8
Health Project, which collected blood samples,
self-reported demographics, medical diagnoses,
height, and weight in 2005-2006 as part of a
legal settlement following perfluorooctanoate
(C8) contamination of drinking water in West
Virginia and Ohio.
Results: The population was 52% female and
98% White. Mean age and diabetes duration
were 58.0 and 10.0 years, respectively. In a
logistic regression analysis adjusting for age
(OR=1.06, 95% CI=1.06-1.07), diabetes duration
(OR=1.01, 95% CI=1.01-1.02), and sex (OR=1.83,
95% CI=1.69-2.13 male vs. female), logtransformed C8 was inversely associated with
coronary heart disease (OR=0.88, 95% CI=0.830.94). Although the odds of coronary heart
disease was nearly twice as great in men, the
relationship of C8 with coronary heart disease
was similar in each sex (women OR=0.88, 95%
CI=0.81-0.96; men OR=0.89, 95% CI=0.82-0.96).
In multivariable analyses adjusting for age,
diabetes duration, sex, BMI, estimated
glomerular filtration rate, HDLc, LDLc, VLDLc,
use of lipid medication, log-CRP, insulin, WBC
count, and smoking, the inflammatory marker
CRP demonstrated a positive association with
coronary heart disease (OR=1.12, 95% CI=1.041.20), while log-C8 remained inversely
associated with coronary heart disease
(OR=0.91, 95% CI=085-0.96).
Conclusion: In this cross-sectional analysis of
nearly 4000 individuals with diabetes, although
the inflammatory marker CRP demonstrated
the expected relationship with coronary heart
disease, C8 demonstrated an inverse
relationship with this largely inflammatory
driven disease.
B. Conway: None. K. Innes: None.
P012
Hypertension and Alterations in Left
Ventricular Geometry in African Americans:
The Jackson Heart Study
Marwah Abdalla, Columbia Univ Medical Ctr,
New York, NY; John N Booth III, Univ of
Alabama, Birmingham, AL; Keith M Diaz,
Mario Sims, Univ of Mississippi Medical Ctr,
Jackson, MS; Paul Muntner, Univ of Alabama,
Birmingham, AL; Daichi Shimbo, Columbia Univ
Medical Ctr, New York, NY
Introduction: Compared with whites, African
Americans (AAs) have a higher risk for
hypertension-related cardiovascular disease
outcomes, which may be related to alterations
in left ventricular geometry. Scarce data exist
on how the left ventricle remodels in response
to hypertension among AAs.
Hypothesis: We hypothesized that among AAs,
hypertension will be associated with abnormal
echocardiographic–derived left ventricular
geometric patterns defined as concentric
remodeling (CR), concentric hypertrophy (CH),
and eccentric hypertrophy (EH).
Methods: We analyzed data from the Jackson
Heart Study, a community-based AA cohort who
completed a baseline exam that included clinic
blood pressure (CBP) and 2D echocardiography
(n=5,301). CR, CH, EH, and normal patterns
were defined according to left ventricular mass
index and relative wall thickness defined using
standard American Society of Echocardiography
recommendations. The analysis was restricted
to 4,572 participants with complete CBP,
information on antihypertensive medication,
and echocardiographic data.
Results: Mean ± SD age was 55.5 ± 12.7 years;
64% were female. Mean ± SD systolic and
diastolic CBP was 127 ± 18 and 79 ± 11 mmHg,
respectively; 2,785 (61%) of participants had
hypertension (CBP ≥140/90 mmHg and/or
taking antihypertensive medications). The
prevalence of CR, CH, and EH were 10.1%, 5.2%,
and 8.2%, respectively. In a multivariableadjusted model with a normal pattern as the
referent group, hypertension was associated
with a greater risk of CR, CH, and EH: odds ratio
1.85 (95% confidence interval (CI) 1.43-2.38),
4.16 (95% CI 2.53-6.86), and 1.67 (95% CI: 1.262.23) respectively. Among hypertensive
participants, older age was significantly
associated with CR, CH, and EH after
multivariable adjustment. Higher systolic CBP,
current smoking and a higher number of classes
of antihypertensive medications were
additionally significantly associated with CH and
EH. Male sex, and heavy and moderate alcohol
consumption versus none were also
significantly associated with CR.
Conclusions: In conclusion, abnormal left
ventricular geometry was present in almost 25%
of AAs. Hypertension was associated with each
abnormal geometric pattern, with
approximately a four-fold greater odds for CH.
Future studies should examine whether
abnormal left ventricular geometric patterns,
particularly CH, explains the increased risk of
cardiovascular disease outcomes associated
with hypertension in AAs.
M. Abdalla: None. J.N. Booth: None. K.M. Diaz:
None. M. Sims: None. P. Muntner: B. Research
Grant; Significant; Amgen. G.
Consultant/Advisory Board; Modest; Amgen. D.
Shimbo: None.
P013
Cost-Effectiveness of Treating Hypertension in
African Americans According to 2014
Guidelines
Eshan Vasudeva, Columbia Univ Coll of
Physicans & Surgeons, New York, NY; Nathalie
Moise, Keane Y Tzong, Columbia Univ Medical
Ctr, New York, NY; Joanne Penko, Univ of
California at San Francisco, San Francisco, CA;
Lee Goldman, Columbia Univ Coll of Physicans &
Surgeons, New York, NY; Pamela G Coxson,
Kirsten Bibbins-Domingo, Univ of California at
San Francisco, San Francisco, CA; Andrew E
Moran, Columbia Univ Medical Ctr, New York,
NY
Background
Among U.S. ethnic groups, African Americans
have the highest prevalence of hypertension
and higher rates of hypertension-related
morbidity and mortality. We estimated the
cost-effectiveness of improved hypertension
control in African Americans.
Methods
The populations studied were African
Americans and all U.S. adults aged 35-74 years.
Using the CVD Policy Model, we simulated CVD
events and non-CVD deaths, quality-adjusted
life years (QALYs), and hypertension and CVD
treatment costs, before and after implementing
2014 U.S. guidelines. African American and
overall U.S. CVD incidence, mortality, and risk
factor levels were obtained from cohort studies,
vital statistics, and the NHANES. Hypertension
treatment effects were derived from a metaanalysis of clinical trials. Stage 2 hypertension
was defined as BP ≥160/100 mmHg; stage 1 as
BP ≥140/90 and <160/100 mmHg. Incremental
cost-effectiveness ratios (ICERs) were calculated
as change in costs divided by change in QALYs.
An ICER <50,000 was cost effective, ≥$50,000
and <$150,000 intermediate value, and
>$150,000 low value.
Results
Treating hypertension in CVD patients and in
stage 2 hypertensives without CVD would be
cost-saving in all African Americans and in all
but the youngest women overall (Table).
Treating stage 1 hypertension would be costsaving in all African American men except for
ages 35-44 without diabetes or CKD, and costsaving in all women ≥45 years old. Treating the
youngest women with stage 1 hypertension was
of intermediate or low value in both African
Americans and the U.S. overall, but of more
value in African American women.
Discussion
In a computer simulation of hypertension
treatment according to 2014 guidelines, we
found that controlling hypertension would be
cost-saving in all African American adults age 45
or older. These results suggest that investment
in effective clinic and community-based
interventions aimed at controlling hypertension
in African Americans would yield high value to
health system payers and to society.
E. Vasudeva: B. Research Grant; Modest; NIH
T35 student fellowship. N. Moise: B. Research
Grant; Modest; HRSA training grant
(T32HP10260),. K.Y. Tzong: None. J. Penko:
None. L. Goldman: B. Research Grant; Modest;
NHLBI R01 (R01 HL107475). P.G. Coxson: None.
K. Bibbins-Domingo: B. Research Grant;
Significant; NINDS project grant
(U54NS081760). G. Consultant/Advisory Board;
Modest; member of the United States
Preventive Services Task Force (USPSTF) and
current co-Vice Chair. A.E. Moran: B. Research
Grant; Significant; NHLBI R01 (R01 HL107475),
AHA Founder's Clinical Research Program
(10CRP4140089).
P014
Impact of Antihypertensive Class on Central
Systolic Blood Pressure and Augmentation
Index: A Meta-Analysis
Tracey J McGaughey, Emily A Fletcher, USAF,
Fairfield, CA; Sachin A Shah, Univ of the Pacific,
Stockton, CA
INTRODUCTION: New evidence suggests central
systolic blood pressure (cSBP) is a superior
predictor of adverse cardiovascular outcomes
as compared to peripheral systolic blood
pressure (pSBP). Additionally, augmentation
index (AI) provides a surrogate assessment of
vascular stiffness. We performed a metaanalysis to assess the impact of
antihypertensive drug classes on cSBP and AI.
METHODS: Search terms related to blood
pressure and AI were used to identify relevant
articles in PubMed, Cochrane Library and
CINAHL limited to randomized trials in humans
and publications in English. Appropriate data on
cSBP, pSBP and AI were extracted along with
other study characteristics. Weighted mean
differences (WMD) between the pSBP and cSBP
with 95% confidence intervals (CI) were
calculated using the DerSimonian-Laird randomeffects methodology. For AI, the WMD from
baseline was determined. Further, the data was
sorted by antihypertensive class (angiotensin
converting enzyme inhibitors (ACE-Is),
angiotensin II receptor blockers (ARBs), beta-
blockers (BBs), calcium channel blockers (CCBs)
and diuretics) to determine their impact on
cSBP and AI. Subgroup analyses were
performed to assess robustness of results by
limiting to the fixed-effects model, a primary
diagnosis of hypertension, and excluding
studies with JADAD scores < 3. Publication bias
was assessed using the Egger’s statistic and
visual inspection of funnel plots. Statistical
heterogeneity was assessed using the I2
statistic.
RESULTS: Fifty-one and 58 studies incorporating
4381 and 3716 unique subjects were included
for cSBP and AI respectively. Overall,
antihypertensives reduced pSBP more than
cSBP (2.52mmHg, 95%CI 1.35 to 3.69; I2
=21.9%). ACE-Is, ARBs, CCBs and diuretics
reduced cSBP and pSBP in a similar manner (2.40mmHg, 95%CI -4.89 to 0.08; 1.12mmHg,
95%CI -2.25 to 4.49; 1.01mmHg, 95%CI -2.17 to
4.19; 0.65mmHg, 95%CI -2.47 to 3.77
respectively). BBs posed a significantly greater
reduction in pSBP as compared to cSBP
(5.19mmHg, 95%CI 3.21 to 7.18). The change in
AI from baseline was (-3.09, 95%CI -3.90 to 2.28; I2 =84.5%). A significant reduction in AI
was seen with ACE-Is, ARBs, CCB and diuretics (5.61, 95%CI -6.95 to -4.27; -5.28, 95%CI -8.61 to
-1.95; -5.36, 95%CI -6.95 to -3.77; -3.24, 95%CI 5.45 to -1.03 respectively). BBs reduced AI nonsignificantly (-0.32, 95% CI -1.48 to 0.84). While
the Egger’s statistic showed a lack of
publication bias (p>0.125), it cannot be ruled
out based on visual inspection of funnel plots.
CONCLUSIONS: BBs are not as beneficial in
reducing cSBP as opposed to ACE-Is, ARBs, CCBs
and diuretics. In contrast, ACE-Is, ARBs, CCBs
and diuretics significantly reduce AI, which is
not evident with BB therapy. The views
expressed in this material are those of the
author(s), and do not reflect the official policy
or position of the U.S. Government, the
Department of Defense, or the Department of
the Air Force.
T.J. McGaughey: None. E.A. Fletcher:
None. S.A. Shah: None.
P015
Cumulative Exposure to Prehypertensive Blood
Pressure and Incident Atrial Fibrillation: The
Multi-Ethnic Study of Atherosclerosis
Wesley T O'Neal, Elsayed Z. Soliman, Wake
Forest Sch of Med, Winston Salem, NC; Alvaro
Alonso, Univ of Minnesota, Minneapolis, MN;
Susan R. Heckbert, Univ of Washington, Seattle,
WA; David Herrington, Wake Forest Sch of Med,
Winston Salem, NC
Background: Hypertension is an established risk
factor for atrial fibrillation (AF). However,
whether cumulative exposure over time to
blood pressure in the prehypertensive range is
associated with AF remains unclear.
Methods: A total of 5,311 study participants
(mean age 62 ± 10 years; 47% male; 42.9% nonwhites) from the Multi-Ethnic Study of
Atherosclerosis (MESA) were included in this
analysis. Blood pressure measurements from
MESA visits 1, 2, and 3 (2000-2005) were used
to categorize participants as follows: optimal
(<120/80 mm Hg), prehypertension (120139/80-89 mm Hg), and hypertension (≥140/90
mm Hg or antihypertensive medication use).
The cumulative exposure to blood pressure
levels were based on 2 or more visits with blood
pressure values in the same category. Incident
AF was identified from Visit 3 (2004-2005) until
December 31, 2010. Cox proportional hazards
regression was used to compute hazard ratios
(HR) and 95% confidence intervals (CI) for the
association between blood pressure level and
AF.
Results: Over a median follow-up of 5.3 years, a
total of 182 (3.4%) participants developed AF. A
higher incidence of AF was observed among
participants with prehypertension (6.0 cases per
1000 person-years) and hypertension (10.5
cases per 1000 person-years) compared with
participants with optimal blood pressure (2.2
cases per 1000 person-years). In a multivariable
Cox regression analysis adjusted for potential
confounders and cardiovascular risk factors,
prehypertension and hypertension were
associated with an increased risk of AF
compared with participants who had optimal
blood pressure (optimal: HR=1.0, referent;
prehypertension: HR=1.8, 95%CI=1.004, 3.2;
hypertension: HR=2.6, 95%CI=1.6, 4.4).
Conclusion: Cumulative exposure to
prehypertension is associated with an increased
risk of AF. Further research is needed to
examine whether current blood pressure goals
reduce the risk of AF.
W.T. O'Neal: None. E.Z. Soliman: None. A.
Alonso: None. S.R. Heckbert: None. D.
Herrington: None.
P016
Preventing Heart Disease, Stroke, and Related
Chronic Diseases in the Mississippi Delta
Region: Clinical Community Health Worker
Initiative
Vincent Mendy, Tameka Walls, Amanda Cole,
Cassandra Dove, Augusta Bilbro, Mississippi
State Dept of Health, Greenwood, MS
Background
Community Health Workers (CHW) are
increasingly being used to address chronic
disease prevention, but knowledge of their use
in underserved rural settings is limited. CHW
can be instrumental in linking underserved
populations to clinical care and navigating the
health care system. We report on the influence
of our Clinical Community Health Worker
Initiative (CCHWI) intervention program on
clinical risk factors for heart disease and stroke
in the Mississippi Delta region.
Methods
Patients diagnosed with hypertension, diabetes
or high cholesterol, and ≥18 years and
consented to participate in the CCHWI were
referred to a CHW for follow-up. CHW conducts
an initial home visit, a follow-up phone call 7 to
10 days after the initial visit, a second home
visit after 30-45 days and a subsequent
recurring 90-day follow-up home visit. CHW
activities include appointment scheduling and
transportation arrangement, interpretation of
health information, demonstrating proper
procedures in monitoring blood pressure and
blood glucose and encouraging patients to keep
monitoring logs, assisting patients in
documenting questions or concerns regarding
medication and/or treat regimens for next
doctors visit, assisting patients in setting
nutrition target and goals, explaining the
benefits of changing lifestyle habits, performing
height, weight, and blood pressure
measurements, encouraging patient to enroll in
chronic disease self-management classes, and
arranging referral for counseling to tobacco
cessation treatment programs. Clinical data
from 432 participants contacted by CHWs
during home visits and phone calls from August
2012 to August 2014 were evaluated. We used
paired t tests to assess changes from baseline
for the following clinical measures: blood
pressure, hemoglobin A1c, total blood
cholesterol, high density lipoprotein
cholesterol, low density lipoprotein (LDL)
cholesterol, triglycerides, and body mass index.
Results
Mean age of participants was 57.6 (range 20-
89) years; 71.1% were female, and 91.9% were
black. The majority of the participants were
diagnosed with hypertension (82.4%) and
diabetes (72.0%) and more than half (57.2%)
with high cholesterol. One in five (21.1%)
participants had only one condition, 46.3% had
two conditions and a third (32.6%) had all three
conditions. We observed statistically significant
improvements (baseline vs most recent value)
for diastolic blood pressure (p=0.0045), total
cholesterol (p=0.0014), LDL cholesterol
(p=0.0117), and triglycerides (p=0.0255).
Conclusion
The use of CHW may help improve heart
disease and stroke clinical risk factors among
rural underserved populations.
V. Mendy: None. T. Walls: None. A. Cole:
None. C. Dove: None. A. Bilbro: None.
P017
Cardiorespiratory Fitness, Body Mass Index
and Blood Pressure-Aging Trajectories in
Women
Junxiu Liu, Univ of South Carolina, Columbia, SC
ABSTRACT
Junxiu Liu, MD; Haiming Zhou, MS; Xuemei Sui,
MD, MPH, PhD, Jihong Liu, Sc.D., Steven N.
Blair, PED
Department of Epidemiology and Biostatistics
(J.L., J.L.,S.N.B.); Department of Exercise Science
(X.S., S.N.B.); Department of Statistics(H.Z.).
University of South Carolina, Columbia, SC
(H.Z.).
Introduction: The blood pressure-aging increase
trajectory is well documented among
industrialized populations. Identifying the
modifiable lifestyle factors on BP-aging
trajectories is very important for preventing or
delaying aging BP increase, however data on
women is very limited.
Hypothesis: Our hypotheses are (1) Both body
mass index (BMI) and cardiorespiratory fitness
(CRF) are significant effect modifiers on the
systolic BP (SBP) trajectory among women; (2)
both BMI and CRF have significant impact on
the BP aging trajectories including diastolic BP
(DBP), mean arterial pressure (MAP) and pulse
pressure (PP); and (3) one unit of BMI has
bigger impact on the BP-aging trajectories than
one unit of CRF.
METHODS: We studied female participants free
of hypertension, cardiovascular diseases and
cancers from the Aerobics Center Longitudinal
Study, who completed an average of 3.3 followup examinations between 1971 and 2006. CRF
was objectively measured by a symptom-limited
maximal treadmill exercise test. BMI was
calculated as the measured weight in kilograms
divided by the square of the height in meters.
Multilevel modeling method was applied to
analyze the longitudinal data.
RESULTS: SBP and DBP were linearly increasing
with age, while MAP and PP were quadratically
related with age. After adjusting for potential
confounding factors, for every 10-year increase
in age, SBP increased by 4.91 mmHg (P<0.0001),
DBP by 2.30 mmHg (P<0.0001), PP and MAP
quadratically by 2.63 mmHg (P<0.0001) and
3.16 mmHg (P<0.0001), respectively. On
average, women with a BMI ≥30 would reach
abnormal SBP (>120 mmHg) or abnormal DBP
(>80 mm Hg) 10 years earlier than those with
BMI range 18.5-25, while high CRF had around 5
years later to reach an abnormal SBP or
abnormal DBP level. CRF had no effect on PPaging trajectory; however, women within lower
CRF would reach the same value of MAP two
years earlier than those in high CRF. Women
with a BMI≥30 had about 3 years or 6 years
earlier shift than those with BMI range 18.525for PP and MAP, respectively.
CONCLUSION: Our finding showed that both
CRF and BMI were significant effect modifiers
on SBP-aging trajectories. Compared to higher
BMI and lower CRF, people within normal range
of BMI and higher CRF have delayed all BP
trajectories. These findings indicate that
maintaining a lower BMI and a higher CRF are
important for delaying the aging-BP trajectory
in women.
KEY WORDS: blood pressure, cardiorespiratory
fitness, body mass index, longitudinal study
J. Liu: None.
P019
Association Between Hypertension and Kidney
Function Trajectory: The Atherosclerosis Risk
in Communities Study
Casey M Rebholz, Yuan Chen, Kunihiro
Matsushita, Josef Coresh, Morgan E. Grams,
Baltimore, MD
Introduction: Cardiovascular disease, including
hypertension, increases the risk of kidney
disease progression. The relationship between
hypertension and change in kidney function has
not been fully elucidated. We hypothesized that
hypertension is associated with faster kidney
function decline.
Methods: Hypertension status was assessed
among Atherosclerosis Risk in Communities
(ARIC) Study participants at baseline (1987-89)
and defined as systolic blood pressure ≥140,
diastolic blood pressure ≥90, or antihypertensive medication use in the last two
weeks. Chronic Kidney Disease Epidemiology
Collaboration (CKD-EPI) estimated glomerular
filtration rate (eGFR) was calculated using
creatinine measured at baseline and follow-up
study visits (1990-92; 1996-98; 2011-13) and an
eGFR value of 15 mL/min/1.73 m2 was imputed
for incident end-stage renal disease cases.
Results: After excluding those with missing
baseline measurements of blood pressure,
missing serum creatinine, and prevalent endstage renal disease, there were 15,622 study
participants. Baseline mean age was 55 years,
55% were female, 26% were black, and 35% had
hypertension. Mean annual eGFR decline was
1.98 mL/min/1.73 m2 per year among those
with hypertension and 1.54 mL/min/1.73 m2
per year among those without hypertension,
after adjusting for demographic characteristics
and co-morbidities (Figure, p<0.001).
Participants with hypertension at baseline were
more likely to develop chronic kidney disease
than those without hypertension. Over 25
years, for those with hypertension and those
without hypertension, respectively, the
probability of developing chronic kidney disease
stage 3A (eGFR <60 mL/min/1.73 m2) was 55.3%
and 44.5%, stage 3B (eGFR <45 mL/min/1.73
m2) was 24.3% and 19.1%, stage 4 (eGFR <30
mL/min/1.73 m2) was 9.2% and 7.7%, and stage
5 (eGFR <15 mL/min/1.73 m2) was 3.9% and
3.5%.
Conclusion: Hypertension status was associated
with faster kidney function decline. Absolute
risk increase was greater for earlier kidney
disease stages.
C.M. Rebholz: None. Y. Chen: None. K.
Matsushita: None. J. Coresh: None. M.E.
Grams: None.
P020
Multivitamin Use and Risk of Hypertension in
Prospective Cohort Study of Women
Susanne Rautiainen Jr., Karolinska Instt,
Stockholm, Sweden; Lu Wang, Brigham and
Women's Hosp, Boston, MA; I-Min Lee, J.
Michael Gaziano, Julie E Buring, Howard D
Sesso, Brigham and Women's Hosp and Harvard
Medical Sch, Boston, MA
Introduction: Despite the widespread use of
multivitamin supplements, little is known
regarding its effects on blood pressure (BP) and
the development of hypertension. We therefore
sought to prospectively investigate how
multivitamin use was associated with incident
hypertension among middle-aged and older
women.
Hypothesis: Multivitamin use is associated with
the risk of hypertension among middle-aged
and older women.
Methods: We studied 29,082 women from the
Women’s Health Study aged ≥45 years and free
of cardiovascular disease, cancer and
hypertension at baseline. At baseline, women
self-reported lifestyle, clinical and dietary
factors, including multivitamin and supplement
use. Cases of incident hypertension were
identified during an average of 11.5 years
follow-up through self-reports from annual
follow-up questionnaires. Incident hypertension
was defined as either a new diagnosis of
hypertension by a physician, initiation of
antihypertensive medication, systolic BP ≥140
mmHg, or diastolic BP ≥90 mmHg.
Results: During a mean follow-up of 11.5 years,
we identified 16,810 cases of incident
hypertension. We found that current
multivitamin use was not associated with the
risk of hypertension in age and multivariableadjusted models (Table 1). When we
investigated the duration of multivitamin use
reported at baseline, we observed no
association with the risk of hypertension. The
lack of effect was consistent across categories
of age, smoking, and fruit and vegetable intake.
Conclusions: The results from this prospective
study of middle-aged and older women suggest
that multivitamin use is not associated with the
risk of developing hypertension. Additional
observational studies and randomized trials are
needed to clarify whether multivitamin use
would affect BP levels and have a role in the
prevention of hypertension.
S. Rautiainen: None. L. Wang: None. I. Lee:
None. J. Gaziano: None. J.E. Buring: None. H.D.
Sesso: None.
P021
Parathyroid Hormone and the Risk of Incident
Hypertension: The Atherosclerosis Risk in
Communities Study (ARIC)
Lu Yao, Aaron Folsom, Weihong Tang, Univ of
Minnesota, Minneapolis, MN; Erin Michos,
Johns Hopkins Sch of Med, Baltimore, MD;
James Pankow, Univ of Minnesota,
Minneapolis, MN; Elizabeth Selvin, Johns
Baltimore, MD; Alvaro Alonso, Pamela Lutsey,
Univ of Minnesota, Minneapolis, MN
Background: Recent evidence suggests that
parathyroid hormone (PTH) has effects on
vascular smooth muscle cells, the reninangiotensin system and kidney function. Thus,
PTH levels may alter blood pressure. The
distribution of serum PTH also varies by race.
We examined the relation between PTH and
incident hypertension, and explored racespecific associations.
Methods: A total of 7,504 ARIC study
participants (1,264 Black, 6,240 White, median
age 56) without hypertension at baseline in
1990-1992 were followed through 1996-1998.
Incident hypertension was defined during the
follow-up exams by elevated measured blood
pressure (DBP≥ 90 mm Hg, or SBP≥140 mm Hg,
based on the average of 2 measurements)
and/or use of hypertension medications.
Complementary log-log regression was used to
evaluate the independent association of
baseline serum PTH with incident hypertension.
Results: The median level of PTH was 38.2
pg/mL overall, 37.4 pg/mL in whites, and 42.7
pg/mL in blacks. During a median follow-up of 6
years, 1,487 White and 509 Black participants
developed hypertension. In the full sample, PTH
was positively associated with incident
hypertension after adjustment for
demographics, though the association was quite
modest after accounting for behavioral risk
factors (Table). Although there was no
significant interaction by race (p for interaction
= 0.60), there was some evidence that the
association differed by race. Among Blacks, PTH
was positively associated with incident
hypertension, independent of demographics
and behavioral risk factors (P for linear trend
0.003). Among whites, PTH was not significantly
associated with hypertension risk. Results were
similar when a clinical cut-point for elevated
PTH was employed [HR, 95% CI for ≥ 65 vs. < 65
pg/mL: blacks = 1.24 (1.02-1.54); whites = 0.95
(0.78, 1.16)]
Conclusions: In this large, population-based
cohort, PTH levels were not associated with the
risk of hypertension. However, a potential
association between PTH and hypertension in
blacks may merit further study.
L. Yao: None. A. Folsom: None. W. Tang:
None. E. Michos: None. J. Pankow: None. E.
Selvin: None. A. Alonso: None. P. Lutsey: None.
P022
Uncontrolled Hypertension and Lifestyle
Factors among US Adults with Disabilities
Alissa Stevens, Elizabeth Courtney-Long, Dianna
Carroll, Div of Human Development and
Disability, Ctrs for Disease Control and
Prevention, Atlanta, GA; Cathleen Gillespie, Div
for Heart Disease and Stroke Prevention, Ctrs
for Disease Control and Prevention, Atlanta, GA;
Brian Armour, Div of Human Development and
Disability, Ctrs for Disease Control and
Prevention, Atlanta, GA
Introduction: While hypertension is a key
treatable risk
factor for cardiovascular disease, it is not
controlled in an estimated 36
million US adults. Previous research has shown
that nearly half of adults with
disabilities have hypertension and that adults
with disabilities are more
likely to have hypertension than those without
disabilities. However, no study
has documented the prevalence of uncontrolled
hypertension among the disability
population. Our objectives were 1) to
determine the prevalence of uncontrolled
hypertension among adults with
a disability, and 2) estimate the prevalence of
awareness, treatment with blood
pressure (BP)-lowering medication, and lifestyle
factors among adults with
disabilities who have uncontrolled
hypertension.
Methods: Using nationally-representative data
from the
2001-2010 National Health and Nutrition
Examination Survey for 10,805
participants aged ≥20 years with a disability
(self-reported limitation in
cognition, hearing, vision, or mobility), we
examined the prevalence of hypertension
(measured systolic BP ≥140, diastolic BP ≥90 or
self-reported use of BP-lowering
medication) and uncontrolled hypertension
(systolic BP ≥140 or diastolic BP ≥90).
Among those with uncontrolled hypertension,
we estimated the prevalence of
awareness (ever told by a doctor that had
hypertension), treatment (self-reported
use of BP-lowering medication), and lifestyle
factors (measured body mass index
and dietary sodium intake and self-reported
aerobic physical activity and cigarette
smoking).
Results: Nearly 38% of US adults have a
disability. Overall 46.0%
(nearly 37 million) of US adults with disabilities
have hypertension. Of
those, nearly 20 million (52.4%) had
uncontrolled hypertension. Over half of
those with uncontrolled hypertension were
aware and treated (52.9%), 13.6% were
aware but untreated, and 33.4% were unaware.
Among those with uncontrolled
hypertension 40.5% were obese, 52.1% were
physically inactive (had no bouts of
aerobic physical activity per week that lasted
≥10 minutes), 18.2% were current
smokers, and 62.0% had an average sodium
intake of ≥2,300 mg per day.
Conclusion: Over half of the 37 million adults
with
disabilities who have hypertension do not have
it controlled; and of those, one
third are unaware they have hypertension. This
study highlights the need to
regularly measure and monitor blood pressure
among adults with disabilities. It
also identifies adults with disabilities as an
important population to include
in public health efforts that support and
encourage healthy behaviors that
might improve BP control and lower risk for
A. Stevens: None. E. Courtney-Long: None. D.
Carroll: None. C. Gillespie: None. B. Armour:
None.
P023
Burden of Hypertension, Prehypertension and
Associated Lifestyle Risk Factors Among Tribals
in Tribal and Urban Areas in the Northern State
of Sub-Himalayan Region of India
Dhiraj Kapoor, R.P.Govt medical Coll,India,
Kangra, India
Introduction: Rapid urbanization has been
associated with high prevalence of
hypertension in indigenous populations .
Hypothesis : The study is based on the
hypothesis of the effect of lifestyle changes on
hypertension in nomadic tribes settled in urban
areas .
Objectives:
To determine the prevalence of hypertension
and evaluate associated risk factors in
traditional tribal individuals residing in tribal
areas and migrated tribals in urban areas .
Methodology : It was a population based cross
sectional study .The population studied were
the tribals , representing the traditional people
settled in mountainous terrain centuries ago
leading a nomadic life and migrating from upper
reaches of Himalayas to Himalayan foothills
during winters .Some of them settled in urban
areas .
Men and women above 20 years were
considered as eligible subjects . A probabilistic
proportionate sampling method was used.The
final sample of 8000 individuals consisting of
4000 subjects each of tribal and urban tribals
were evaluated which included demographical
profile , BMI , central obesity ,blood pressure ,
fasting blood sugar , oral glucose tolerance test
using 75 gm glucose and physical activity .
Results:
The urban tribals were engaged in white collar
and business jobs (33%) vs 11.1% in tribal
tribals(p=0.00) .Urban tribals had mild physical
activity in 19.3% vs 8.6 % in tribal
tribals(p=0.00) whereas tribal tribals had
significantly more heavy physical activity(23%)
vs 7.3% in urban tribals(p=0.00)
In urban tribals central obesity was seen in 59%
of cases vs 43.3% in tribal tribals(p=0.00).Urban
tribals had statistically more (29.3%) overweight
individuals as compared to 13.3% in tribal
tribals(p=0.00).Stage 1 hypertension and stage
2 hypertension was seen in 22.8% and 5.3%
resspectively in urban tribals which is
statistically higher than seen in tribal
tribals(10.2 % and 0.9%
respectively)(p=0.00)The age distribution of
prevalence of hypertension was high amongst
urban tribals of more than 65 years(54%)
followed by 51 to 56 years(48.3%) and 36 to 50
years of age(34.2%).Diabetes mellitus was
significantly higher in urban tribals(7.8%) vs
3.9% in tribal tribals(p=0.00).Prehypertension
and impaired fasting glucose was statistically
more often seen in tribal tribals(78.8% and
2.4%) vs 58.2% and 0.7% respectively in urban
tribals(p=0.00)
Conclusion:
In conclusion prevalence of hypertension ,
central obesity,diabetes mellitus and physical
inactivity was higher in urban tribals .On
contrary pre hypertension and impaired fasting
glucose was significantly higher in tribals in
tribal areas which necessitate a need for early
preventive intervention .
D. Kapoor: B. Research Grant; Significant; from
ICMR,Delhi.
P024
Blood Pressure Levels, Aggressiveness of
Antihypertensive Therapy, and Prevalence of
Left Ventricular Hypertrophy
Sindhu Lakkur, Univ of Alabama at Birmingham,
Birmingham, AL; Sayed Soliman, Wake Forest
Univ, Winston-Salem, NC; Suzanne Oparil,
Suzanne Judd, George Howard, Univ of Alabama
at Birmingham, Birmingham, AL
A major cause of left ventricular hypertrophy
(LVH) is an excessive hemodynamic load,
making LVH more common among people with
hypertension. Clinical trials of antihypertensive
medication have found that treatment reduces
left ventricular mass among those with
hypertension, but little is known about the
prevalence of LVH in the general population
that are taking, and not taking, antihypertensive
medication. We examined the cross-sectional
association between blood pressure control and
LVH among 28,106 participants in the Reasons
for Geographic and Racial Differences in Stroke
(REGARDS) study, to test the hypotheses that:
1) within strata of blood pressure control, LVH
will be more prevalent in those requiring more
intensive treatment, and 2) that within strata of
intensiveness of blood pressure treatment, that
LVH will be more prevalent at higher blood
pressure levels.
The REGARDS study enrolled black and white
participants, aged 45 and older, from 20032007. Systolic blood pressure was defined as
normal (<120 mmHg), prehypertension (120
mmHg - 139 mmHg), stage 1 (140 mmHg - 159
mmHg), and stage 2 hypertension (>160
mmHg). Classes of antihypertensive
medications at baseline were defined as 0, 1, 2,
or 3 or more. LVH by electrocardiogram was
detected in 2,803 participants. Multivariableadjusted odds ratios (ORs) for LVH and 95%
confidence intervals (CIs) were calculated using
logistic regression models.
The ORs (95% CIs) for each additional
medication class were 1.31 (1.20-1.43) for
normal blood pressure, 1.21 (1.14-1.27) for
prehypertension, 1.07 (0.98-1.16) for stage 1,
and 1.02 (0.88-1.17) for stage 2. The ORs (95%
CIs) for each additional increase in blood
pressure category were 1.57 (1.41-1.75) for no
medications, 1.47 (1.33-1.63) for 1, 1.30 (1.181.43) for 2, and 1.21 (1.10-1.34) for 3
medications.
We observed that successful blood pressure
control by medication is still associated with
elevated odds of LVH compared to untreated
normotensive participants, emphasizing the
importance of hypertension prevention.
S. Lakkur: None. S. Soliman: None. S. Oparil:
None. S. Judd: None. G. Howard: None.
P025
Arterial Stiffness is Unrelated to Number of
Antihypertensive Medication Classes used to
Normalize Blood Pressure with Control for
Cardiovascular Risk Factors
Rachael V Torres, Merrill F Elias, Kevin J
Sullivan, Univ of Maine, Orono, ME; Gregory A
Dore, Natl Insts of Health, Bethesda, MD;
Michael A Robbins, Univ of Maine, Orono, ME
Pulse wave velocity (PWV) has become the gold
standard indirect measure of arterial stiffness.
Previous research in our laboratory has
indicated that polypharmacy (treatment with
more than one antihypertensive medication
class) is related to elevated levels of PWV. The
present study examines this association using
number of antihypertensive medication classes
(1 to 4/5), a more precise measure of treatment
regimen than polypharmacy. We hypothesize
that any observed rise in PWV related to
polypharmacy reflects severity of hypertensionrelated comorbidity, rather than the adverse
influence of multiple medications.
Methods
Hypertensive participants (blood pressure [BP]
≥ 140/90 mmHg) (mean age = 67 years, 55%
(205 of 373) female) came from the 6th and 7th
waves of the community-based Maine-Syracuse
Longitudinal Study (2001-2009). After the 5th
wave, hypertensive participants in the present
study (n = 373 after exclusions of acute stroke,
dementia, and dialysis) were referred to their
physicians for treatment-as-usual to normalize
BP. By wave 6, 4-5 years after the referral, 52%
(194 of 373) of hypertensives were normalized,
and by wave 7, the percentage dropped to 44%
(164 of 373). We related number of
antihypertensive medication classes utilized for
each individual to PWV using cross-sectional
analyses at wave 7. Medication change
between waves 6 and 7 was then used to
predict wave 7 PWV.
Three sets of covariate controls were employed
for each analysis: 1. basic (age + sex + education
+ ethnicity + heart rate); 2. PWV-relevant (basic
+ mean arterial pressure + height + weight); 3.
cardiovascular disease (CVD) risk factor (basic +
PWV-relevant + CVD prevalence + diabetes
mellitus + HDL + waist circumference + number
of cigarettes per week).
Results
In cross-sectional analyses controlling for basic
and PWV-relevant covariates, there was a
significant linear increase in PWV across rising
number of antihypertensive medication classes.
This relationship was only seen in subjects for
whom BP was not controlled and was replicated
with adjustment for number of other
medications in the treatment regimen. Findings
were not replicated when longitudinal analyses
utilizing medication change were performed. It
is notable that the largest increase in CVD
prevalence was seen between persons taking 3
to 4/5 antihypertensive medication classes,
further indicating the importance of severity of
hypertension-related comorbidity when
predicting PWV.
Conclusions
The elevation of PWV levels in persons treated
with multiple antihypertensive medication
classes reflects the fact that PWV is higher in
persons most in need of polypharmacy, and is
not a consequence of combining classes of
medication to normalize BP. Higher PWV in
those on more classes of antihypertensive
medications is only seen in cross-sectional
analyses and when complications of
hypertension and other CVD risk factors are not
taken into account.
R.V. Torres: None. M.F. Elias: None. K.J.
Sullivan: None. G.A. Dore: None. M.A. Robbins:
None.
P026
Gender Difference of the Association of Serum
Polyunsaturated Fatty Acids With the
Evolution of Hemodynamics
Chisa Matsumoto, Hirofumi Tomiyaa, Akira
Yamashina, Tokyo Medical Univ, Tokyo, Japan
Background: While abnormal hemodynamics
and abnormal lipid profiles of polyunsaturated
fatty acids (PUFAs) are noted as risk for
cardiovascular disease, their association has not
been fully clarified.
Objective: We examined whether plasma PUFAs
(Arachidonic acid (AA), Eicosapentaenoic acid
(EPA), and Docosahexaenoic acid (DHA)) levels
are associated with change of hemodynamics in
healthy middle aged Japanese subjects.
Design: 1,527 healthy Japanese subjects (316
women) were prospectively followed up for
three years from 2008. Central blood pressure
(CBP), brachial pulse wave velocity (baPWV),
and radical augmentation index (rAI) were
measured as marker of hemodynamics. CBP and
rAI were measured by arterial applanation
tonometry, and baPWV was measured using
volume plethysmographic apparatus.
Multivariate linear regression adjusted for
established risk factors for raised blood
pressure were performed to evaluate the
association between each PUFAs and change of
hemodynamics (CSBP, ba PWV, raAI) during
3years. We conducted overall and stratified
analyses by gender.
Results: Mean age of women and that for men
was 40 ± 6 and 41 ± 6 years, respectively. In a
multivariable model controlling for established
risk factors for raised BP, all of PUFAs were not
significantly associated with any change of
hemodynamics overall. However, only among
women, plasma DHA but not EPA and AA was
significantly associated with change in CBP.
1standard deviation (SD) increase of plasma
DHA was associated with decreased CBP of 1.77
mmHg (P<0.05).
Conclusions: The association of serum PUFAs
with the evolution of central hemodynamics
may be different between genders. Especially,
low DHA levels may be a risk for the progression
of abnormal central hemodynamics in middle
aged healthy women.
C. Matsumoto: None. H. Tomiyaa: None. A.
Yamashina: None.
P027
Associations of Renin-Angiotensin-Aldosterone
System Genes with Blood Pressure changes
and Hypertension Incidence: The GenSalt
Study
William J He, Tulane Univ, New Orleans, LA;
Changwei Li, Tulane Univ SPHTM, New Orleans,
LA; Dabeeru C. Rao, Washington Univ Sch of
Med, St. Louis, MO; James E. Hixson, Univ of
Texas Sch of Public Health, Houston, TX;
Dongfeng Gu, Chinese Acad of Medical Sciences
and Peking Union Medical Coll, Beijing, China;
Treva K. Rice, Washington Univ Sch of Med, St.
Louis, MO; Jianfeng Huang, Chinese Acad of
Medical Sciences and Peking Union Medical
Coll, Beijing, China; Lawrence C. Shimmin, Univ
of Texas Sch of Public Health, Houston, TX; Jie
Cao, Chinese Acad of Medical Sciences and
Peking Union Medical Coll, Beijing, China;
Tanika N. Kelly, Tulane Univ SPHTM, New
Orleans, LA
Objective The renin-angiotensin-aldosterone
system (RAAS) plays an important role in blood
pressure regulation. The current study used
single-marker and gene-based analyses to
examine the association between RAAS genes
and longitudinal blood pressure (BP)
phenotypes in a Han Chinese population.
Methods A total of 1,768 participants from the
Genetic Epidemiology Network of Salt
Sensitivity follow-up study were included in the
current study. Twenty-seven BP measurements
were taken using random-zero
sphygmomanometers at baseline and 2 followup visits. Mixed-effect models were used to
assess the additive associations of 106 SNPs in
10 RAAS genes with longitudinal BP changes
and hypertension incidence. Gene-based
analyses were conducted using the truncated
product method. Attempts were made to
replicate significant findings among 775 Asian
participants of the Multi-ethnic Study of
Atherosclerosis (MESA) using available data
from the database of Genotypes and
Phenotypes. False discovery rate procedures
were used to adjust for multiple testing.
Results During an average of 7.2 years of
follow-up, average systolic and diastolic BP
increased, and 32.1% (512) of participants free
from hypertension at baseline developed
hypertension. NR3C2 SNPs rs7694064 and
rs6856803 were significantly associated with
longitudinal changes in systolic BP (P values of
6.9×10-5 and 8.2×10-4, respectively). Through
gene-based analysis, NR3C2 was found to be
significantly associated with longitudinal systolic
BP change (P value of 1.00×10-7), even after
removal of significant markers rs7694064 and
rs6856803 from the analysis. The gene-based
association between NR3C2 and longitudinal
systolic BP change was successfully replicated in
Asian MESA participants (P value of 1.00×10-4).
However, single-marker findings could not be
replicated in this relatively small sample.
Conclusions These findings indicate that NR3C2
may play an important role in BP progression
and development of hypertension.
W.J. He: None. C. Li: None. D.C. Rao: None. J.E.
Hixson: None. D. Gu: None. T.K. Rice: None. J.
Huang: None. L.C. Shimmin: None. J. Cao:
None. T.N. Kelly: None.
P028
Length of Residence in Urban Environment
based on MODIS Satellite Derived Urban Land
Cover is an Independent Predictor of Blood
Pressure
Kevin J Lane, Yale Univ Sch of Forestry &
Environmental Studies, New Haven, CT; Jahnavi
Sunderarajan, Vijaykumar Harivanzan, Sri
Ramachandra Univ, Porur, India; Kenneth K
Chui, Tufts Univ Sch of Med, Boston, MA;
Sadagopan Thanikachalam, Sri Ramachandra
Univ, Porur, India; Mohan Thanikachalam, Tufts
Univ Sch of Med, Boston, MA
Background: Prevalence of hypertension (HTN)
in urban populations in Southeast Asia is
increasing. We assessed the association
between time residing in urban area (using
MODIS satellite based land cover (LC) at two
different time points) and blood pressure (BP)
of residents in Chennai, a rapidly expanding
metropolitan city in India, and surrounding nonurban areas.
Methods: In the cross-sectional analysis, 8080
participants (mean age 42 years; 58% female)
spread over a 65 x 80 km area constituted the
study sample. BP measures included brachial
systolic (SBP) and diastolic (DBP), and central
systolic (cSBP) by applanation tonometry.
Residences were geolocated in ArcGIS and
joined with LC data for the years 2000 and 2010
to classify residences into urban before 2000
(n=1851), urban after 2000 (n=1444) and
nonurban (n=4766) [figure]. Generalized linear
and logistic regression models assessed the
effect of length of residence in urban areas on
BP and odds for HTN (SBP ≥140; or DBP ≥90 or
reported history), respectively. All models were
adjusted for age, gender, BMI, physical activity,
LDL, blood sugar, smoking, stress, and anxiety
status
Results: Residents in urban areas before 2000
had significantly (p<0.01) higher brachial BP
(SBP=130.6; DBP=79.6) and cSBP (117.2) and
higher prevalence of HTN (37%) than those in
urban areas after 2000 (SBP=121.6; DBP=76.9;
cSBP=114.3; HTN= 27%) and non-urban
(SBP=118.4; DBP=74.9; cSBP=114.1; HTN= 22%).
In adjusted linear regression models length of
residency in the urban areas was independently
associated with BP (SBP (β=0.24); DBP (β= 0.13);
cSBP (β=0.096); p<0.01). After multivariable
adjustments, compared to living in nonurban
LC, residents in urban areas before 2000 had
significantly higher odds for HTN [OR = 2.05
(1.79, 2.35)] than those residing after 2000 [OR
= 1.13 (0.97, 1.32)].
Conclusions: Residential length of time in an
urban area was an independent predictor of BP
and of HTN. Future research is needed to
determine what components of the urban
environment contribute to increased BP.
K.J. Lane: None. J. Sunderarajan: None. V.
Harivanzan: None. K.K. Chui: None. S.
Thanikachalam: None. M. Thanikachalam:
None.
P029
Sucralose Promotes Increase in Fat
Accumulation in Human Mesenchymal Stem
Cells
Sabyasachi Sen, Carol Rouphael, Sara Houston,
George Washington Univ, Washington, DC
Background: Artificial sweeteners are
extensively used nowadays as a non-caloric
sugar alternative. They are sweeter than sugar,
with a presumed high safety profile, hence
commonly promoted in weight loss and weight
maintenance programs as a sugar substitute.
However, recent studies showed that saccharin
and acesulfame potassium may actually
increase adipogenesis. Here we choose to study
the effect of Sucralose on Mesenchymal Stem
Cells (MSCs), which was never been tested
before. MSCs are multipotent cells which can
differentiate to adipocytes, myoblasts,
osteoblasts or chondroblasts. We were
interested to note if presence of sucralose
promotes adipocyte formation. Methods: We
cultured MSCs in Normal Glucose DMEM media
(5.5mM) or in Adipogenic Media (Lonza Inc.,
5.5mM) with or without 0.00mM, 0.45mM or
4.5mM of Sucralose for a total of 6 days. At the
end of day 6, cells were stained with Oil Red O
stain (lipolysis). Cells were lysed post staining
and absorbance of the assimilated dye was
measured using a plate reader at 520 nm. Nonstained cells from each media and Sucralose
concentration were also lysed as control and
RNA was collected for RT-PCR to measure
oxidation, inflammation and adipogenesis gene
expression estimation. Results: Before lysing
the cells for absorbance readings, cells were
observed under the microscope for phase
contrast image. As we increased the Sucralose
concentration, (10-fold) a higher number of fat
droplets was observed in MSCs cultured.
Moreover, absorbance measurements showed
that adipogenesis increased by 1.8 folds as we
increased the Sucralose concentration from
0.00mM to 0.45mM. It was also increased by
2.85 folds as we increased the concentrations
from 0.00mM to 4.5mM in cells cultured in both
Normal Glucose and Adipogenic Media. RT-PCR
results for oxidation genes ( Catalase,
Superoxide dismutase 1, 2 and 3) ,
inflammation (TNF, IL-6) and adipogenesis(
leptin, adiponectin, PPAR-g, FABP-4, c/EBP
alpha and c/EBP beta) are pending. In summary,
sucralose appears to promote fat accumulation
by Oil Red O stain quantification. RT-PCR studies
will confirm if adipogenic genes follow a similar
pattern of up-regulation. Conclusion: Our
studies indicate that sucralose may promote fat
accumulation and warrants further cellular and
animal model studies
S. Sen: None. C. Rouphael: None. S. Houston:
None.
P030
Traditional Cultural Beliefs and Length of
Residence in the United States are Associated
With Dietary Intakes Among South Asians
Sameera A Talegawkar, Johns Hopkins
Bloomberg Sch of Public Health, Baltimore, MD;
Namratha R Kandula, Div of General Internal
Med, Northwestern Univ, Chicago, IL; Meghana
D. Gadgil, Div of General Internal Med, Univ of
California, San Francisco, San Francisco, CA;
Dipika Desai, Population Health Res Inst,
Hamilton Health Sciences, Hamilton, ON,
Canada; Alka M. Kanaya, Div of General Internal
Med, Univ of California, San Francisco, San
Francisco, CA
Background: Studies of immigrants in the
United States (U.S.) have shown mixed
consequences of acculturation on diet and
health outcomes. Detailed investigations
examining diets of South Asians in the U.S. are
lacking.
Objective: To examine whether nutrient and
food intakes among South Asians differ by
traditional cultural beliefs and length of
residence in the U.S.
Methods: Cross-sectional analyses of data
collected from 890 South Asians [mean age
(SD): 55(9) y; 47% women] who were part of the
Mediators of Atherosclerosis in South Asians
Living in America (MASALA) Study. Dietary data
were collected using an interviewer
administered, validated, culturally appropriate
food frequency questionnaire. Acculturation
status was assessed by a South Asian traditional
cultural beliefs scale which was categorized by
tertiles as weak, moderate and strong beliefs,
and by length of U.S. residence also categorized
using tertiles. We computed daily adjusted
mean intakes of selected nutrients across the
traditional cultural beliefs and length of U.S.
residence tertiles using ANCOVA. Final models
were adjusted for age, sex, education, and daily
energy intake. Differences in the consumption
of foods and food groups (servings/week)
between the groups were examined using the
Kruskal-Wallis test.
Results: Length of residence [mean 27 (10.8) y]
in the U.S was directly associated with
traditional cultural beliefs (P<0.001). Higher
daily intakes of total fat, saturated fat, and
dietary cholesterol were associated with weak
traditional cultural beliefs and a longer length of
residence in the U.S. Higher daily intakes of
energy, carbohydrate, glycemic index and load,
and protein were associated with strong
traditional beliefs and a shorter length of
residence in the U.S (P for trend <0.05). Weak
traditional cultural beliefs and/or a longer
length of residence in the U.S. were associated
with higher weekly intakes of alcoholic
beverages, meat, poultry, seafood and eggs,
mixed dishes such as pizza and pasta, fats and
oils, and lower intakes of beans and lentils,
breads, grains and flour products, fried foods,
milk and dairy products, nuts, rice and rice
preparations and starchy vegetables (P for
differences across groups <0.05).
Conclusions: Cultural beliefs and length of
residence in the U.S. both influence dietary
intakes of South Asian immigrants. Unlike other
immigrants, more acculturation in South Asians
is associated with higher intakes of fat and
animal protein and lower intakes of refined
carbohydrates. These factors should therefore
be considered when investigating and planning
dietary interventions among South Indians to
mitigate chronic disease risk.
S.A. Talegawkar: None. N.R. Kandula:
None. M.D. Gadgil: None. D. Desai: None. A.M.
Kanaya: None.
P031
Significant Predicted Change in Usual Sodium
Intake for the U.S. Population From Meeting
Sodium Standards for Commercially-Packaged
and Restaurant Foods: National Health and
Nutrition Examination Survey, 2007-2010
Mary Cogswell, Sheena Patel, Keming Yuan,
Cathleen Gillespie, CDC, Atlanta, GA; WenYen
Juan, FDA, College Park, MD; Christine Johnson,
New York City Dept of Health and Mental
Hygiene, New York, NY; Michel Vigneault,
Health Canada, Ottawa, ON, Canada; Jenifer
Clapp, New York City Dept of Health and Mental
Hygiene, New York, NY; Paula Roach, Health
Canada, Ottawa, ON, Canada; Alanna
Moshfegh, Jaspreet Ahuja, Pamela Pehrsson,
USDA, Beltsville, MD; Robert Merrritt, CDC,
Atlanta, GA
Background: A 400 mg daily reduction in the
average sodium intake of the U.S. population is
projected to save up to 28,000 lives and $7
billion health care dollars annually. In 2010, the
Institute of Medicine recommended setting
standards for the sodium content of
commercially-packaged and restaurant foods to
reduce U.S.sodium intake given the majority of
sodium intake is from these foods. We assessed
this hypothesis.
Methods: We developed models using 20072010 data for 17,979 participants one year and
older participating in two 24-hour dietary
recalls, a part of the What We Eat in America
component of the National Health and Nutrition
Examination Survey. We projected the sodium
content in foods reported by survey
respondents based on percent changes in sales
weighted averages from baseline for specific
food categories using New York City’s National
Salt Reduction Initiative (NSRI) 2014 targets or
Health Canada’s 2016 sodium benchmarks. To
predict the changes in usual sodium intake from
foods for the U.S. population aged >1 year we
used analyses accounting for the complex
survey design with measurement error models
to adjust for within person day-to-day variation
in intake.
Results: Based on a conservative estimate of
the foods included in specific categories, if NSRI
targets had been met in 2007-10, we estimated
that the U.S. population aged >1 year could
have reduced
their average usual daily mean sodium intake of
3343 mg by 14%, or 484 mg (95% Confidence
Interval [CI], 471 mg, 498 mg). If Health
Canada’s benchmarks were met, the US
population could have reduced their average
usual daily sodium intake by 18% or 612 mg
(95% CI, 594 mg, 630 mg). Across age, sex, and
race-ethnic population subgroups, the average
predicted relative reductions in sodium intake
by group ranged from 13% -15% using NSRI
targets and 16%-19% using Health Canada’s
benchmarks. If sodium standards had been met,
we estimated the proportion of adults aged 19
years and older consuming >2300 mg
daily would have declined from 87% (95% CI,
84%, 89%) to 75% (95% CI, 72%, 77%) using
NSRI targets or to 70% (95% CI, 68%, 73%) using
Health Canada benchmarks. The proportion of
adults consuming >1500
mg daily would have declined from 99% to 96%97%.
Conclusion: Results suggest that if U.S.
commercially-packaged and restaurant foods
had met established sodium standards, a
significant reduction in sodium intake could
have occurred across age, sex, and race-ethnic
groups in the U.S. population.
M. Cogswell: None. S. Patel: None. K. Yuan:
None. C. Gillespie: None. W. Juan: None. C.
Johnson: None. M. Vigneault: None. J. Clapp:
None. P. Roach: None. A. Moshfegh: None. J.
Ahuja: None. P. Pehrsson: None. R. Merrritt:
None.
P032
Wine Consumption and Cognitive Function
Chelsey Kamson, Alexis K. Bui, Beatrice
Alexandra Golomb, Univ of California San Diego,
La Jolla, CA
Background: Regular modest wine consumption
may be linked favorably or adversely to
cognition.
Goal: To assess the cross-sectional relation
between wine consumption frequency (WineF)
& cognitive indices.
Method: Of 1018 adults age 20-85 without CVD
or DM, 945 completed a food frequency
questionnaire eliciting WineF. Frequency was of
interest, since frequency of a food with
antioxidant effects previously related favorably
to cognitive indices in younger adults. Cognitive
tests included grooved pegboard (time), Trails A
& B (time), digit symbol, Elithorn mazes, Stroop
color word. Memory and attention tests
included digit span and recurrent words; and
digit vigilance. (Table legend shows coding).
Regression (robust standard errors) assessed
how WineF predicted cognitive performance.
Since two prior dietary predictors showed agedependency in relation to cognition (selectively
evident in younger adults), assessment included
age-stratified analysis. Covariates adjusted were
known cognitive predictors (per this sample
and/or the literature): age, sex, education,
exercise, diet variables linked to cognition in
this sample, and metabolic variables (glucose,
LDL, systolic blood pressure), recognizing that
adjustment for the latter could attenuate
associations if these variables are mediating.
Results: More frequent WineF predicted
significantly better performance, in younger
adults and often in the full sample, for the tests
shown in the Table (fully adjusted model).
These tests involved timed performance and/or
constructs such as executive function. WineF
did not relate significantly to the tests above of
memory or attention (data not shown).
Limitations: Alcohol bears risks and findings are
observational. Heavy drinkers were poorly
represented and findings need not apply to
them.
Conclusion: More frequent WineF in a study
sample (with few heavy wine drinkers) was
favorably linked to performance on cognitive
tests related to timed performance and
executive function, particularly in younger
adults.
C. Kamson: None. A.K. Bui: None. B.A.
Golomb: None.
P033
Sugar Sweetened Beverage Intake,
Chromosome 9p21 Variants, and Risk of
Myocardial Infarction in Hispanics
Yan Zheng, Yanping Li, Tao Huang, Harvard Sch
of Public Health, Boston, MA; Han-Ling Cheng,
Boston Univeristy, Boston, MA; Hannia Campos,
Lu Qi, Harvard Sch of Public Health, Boston, MA
Introduction: Chromosome 9p21 variants are
among the most robust genetic markers for
coronary heart disease (CHD). Our previous
study showing that intake of sugar-sweetened
beverages (SSB) interacts with genetic factors to
affect risk of obesity, a major CHD risk factor,
suggests that SSB could modify the effect of
chromosome 9p21 variants on CHD. SSB are the
main source of added sugar in the diet among
Hispanics living in the United States and Latin
America. Thus, this study is aimed to test
whether SSB intake modifies the association
between chromosome 9p21 variants and CHD
risk in Hispanics.
Methods: The study population included 1,603
incident cases of non-fatal myocardial infarction
(MI) and 1,778 population-based controls living
in Costa Rica. Three independent singlenucleotide polymorphisms (SNPs) at
chromosome 9p21 locus were genotyped. SSB
intake was defined as the frequency of daily
servings of commercially available and homemade sweetened beverages, and fruit juice
assessed using a food-frequency questionnaire.
Odds ratios were estimated using unconditional
logistic regression models.
Results: A significant interaction (p=0.003) was
found between SSB intake and the rs4977574
variant. The per-risk-allele odds ratio for MI was
1.45 among the participants in the highest
tertile of SSB intake and 0.96 among the
participants in the lowest tertile (Figure Panel
A). Results for variants rs2383206 and
rs1333049 did not reach statistical significance
(P for interaction =0.07 and 0.15, respectively).
A genetic risk score derived from the sum of risk
alleles of the 3 SNPs, also showed a significant
interaction with SSB intake on MI risk (P for
interaction=0.03, Figure Panel B), although the
magnitude of this effect was attenuated.
Conclusions: Our data suggest that unhealthy
dietary habits such as higher intake of SSB could
exacerbate the effects of the 9p21 variants on
CHD.
Y. Zheng: None. Y. Li: None. T. Huang: None. H.
Cheng: None. H. Campos: None. L. Qi: None.
P034
Circulating Omega-3 Fatty Acids and Risk of
Acute Myocardial Infarction in Singapore
Chinese
Ye Sun, Natl Univ of Singapore, Singapore,
Singapore; Woon-Puay Koh, Duke-NUS
Graduate Medical Sch, Singapore, Singapore;
Jian-Min Yuan, Univ of Pittsburgh, Pittsburgh,
PA; Hyungwon Choi, Choon Nam Ong, Rob M
van Dam, Natl Univ of Singapore, Singapore,
Singapore
Introduction: Omega-3 fatty acids have been
associated with reduced risk of coronary heart
disease, but it remains unclear whether plantbased alpha-linolenic acid (ALA) provide similar
benefits as marine-originated eicosapentaenoic
acid (EPA) and docosahexaenoic acid (DHA), and
evidence from Asian populations is limited.
Objective: We aimed to examine the
association between plasma omega-3 fatty acid
biomarkers, including ALA, EPA and DHA, and
risk of acute myocardial infarction (AMI) in a
Chinese population in Singapore, and to explore
the potential biological mediators of their
effects.
Methods: We conducted a nested case control
study with 759 incident fatal and non-fatal AMI
cases and 796 matched controls selected from
the Singapore Chinese Health Study, who were
of ages 45-74 at the time of recruitment and
free of cardiovascular disease at the time of
blood collection. Plasma fatty acid biomarkers
were measured using gas chromatography
tandem mass spectrometry. Conditional logistic
regression was used to calculate the odds ratios
(ORs) with adjustment for other risk factors.
Results: In multivariable adjusted models, all
three omega-3 fatty acid biomarkers were
inversely associated with incident AMI. As
compared with the lowest quartile, the OR for
the highest quartile was 0.65 (95% CI: 0.45-0.94,
Ptrend=0.068) for ALA, 0.67 (95% CI: 0.45-0.98,
Ptrend =0.018) for EPA, and 0.59 (95% CI: 0.390.89, Ptrend =0.013) for DHA. The inverse
association for ALA tended to be more
pronounced for fatal AMI (OR 0.53; 95% CI:
0.29-0.96) than for nonfatal MI (OR 0.75; 95%
CI: 0.48-1.16), but this was not observed for EPA
or DHA.
Linear regression suggested that ALA was
associated with lower systolic blood pressure
(p<0.01) and LDL cholesterol (p<0.001), while
EPA was associated with higher HDL cholesterol
(p<0.01). The association of ALA with AMI
appeared partially mediated by lower systolic
blood pressure (27.2%) and lower LDL
cholesterol (31.2%), while the association for
EPA appeared partially mediated by higher HDL
cholesterol (8.5%).
Conclusions: Circulating EPA, DHA and ALA are
all associated with a lower risk of AMI, with the
association for ALA being more pronounced for
AMI death than for non-fatal MI. Associations
appeared partially mediated by changes in
blood pressure and blood lipids. These findings
suggest that higher intake of omega-3 fatty
acids from both marine and non-marine sources
may protect against risk of coronary heart
disease in Singapore Chinese population.
Y. Sun: None. W. Koh: None. J. Yuan: None. H.
Choi: None. C. Ong: None. R.M. van Dam:
None.
P035
Simple Cooking With Heart Culinary Literacy
Program: Skill Acquisition, Attitudinal Change,
Intention and Efficacy Lead to Improved
Dietary Consumption Patters
Liz McKnight, Dorothea K Vafiadis, American
Heart Association, Dallas, TX
Introduction:
Less than 1% of Americans consume a diet that
is consistent with the American Heart
Association (AHA) definition for ideal
cardiovascular health. In-home food
preparation is associated with healthier dietary
patterns and is more likely to align with current
AHA recommendations for healthy eating.
Hypothesis:
The AHA’s Simple Cooking with Heart (SCwH)
program aims to increase the healthfulness of
family meals by addressing common barriers to
cooking at home (lack of time, lack of skill, lack
of budget). By increasing self-efficacy,
individuals will demonstrate changes in
attitudes and intention to choose wisely when
shopping, as well as prepare and consume more
meals at home, resulting in improved diet
quality. Exposure to a “live” demonstration
program that engages participants will improve
cooking confidence and change attitudes in lowsocioeconomic populations, compared to an
online only, skills-building video exposure. The
theoretical framework for this intervention is
based upon the Health Belief Model.
Methods:
A 4-week, 2-cell controlled exposure study
design measured the discrete impact of SCwH
on low-income individuals exposed to a live
cooking demonstration experience compared to
individuals who received an online only
exposure. All individuals were assessed via
questionnaire post baseline for changes in
attitude/intention, skill acquisition, frequency
of meals prepared in home, dietary
consumption and relevance of materials and
information received; 337 participants
completed the 4 week study.
Results:
Participation in “live” cooking demonstrations
had a near immediate positive impact on
participants’ intentions to: increase number of
meals at home, reduce added salt and
sugar/sweeteners, eat more
fruits/vegetables/whole grains, and decrease
unhealthy items. Participants who receive a
“live” exposure have increased outcomes
compared to those who received an online-only
exposure. Demonstration participants,
compared to web-only participants, reported:
more often using new information in-home and
reported a significant increase in the frequency
of consuming healthy food items and a
decrease in unhealthy items. Online-only cell
respondents reported no significant difference
in the mean frequency an item (healthy or
unhealthy) was consumed. Both cells reported
learning new information/skills.
Conclusions: Culinary skill development,
changing perceptions about affordable meals
and addressing barriers to preparing and
consuming meals in-home can be an effective
way to improve dietary quality in lowsocioeconomic populations. Exposure to “live”
demonstration programs can increase
effectiveness and promote healthier cooking at
home; however, online-only intervention can
still have a positive impact.
L. McKnight: None. D.K. Vafiadis: None.
National Center
P036
Medical Advice is Associated with Taking
Action to Reduce Sodium Intake, Behavior Risk
Factor Surveillance System 2013
Sandra L. Jackson, Sallyann C King, Soyoun Park,
Jing Fang, Erika Odom, Mary E Cogswell, Ctrs for
Disease Control and Prevention, Chamblee, GA
Background: Excessive sodium intake is a key
modifiable risk factor for hypertension and
subsequent cardiovascular disease: 95% of US
adults consume >2300 mg daily (Institute of
Medicine tolerable upper intake level). Yet
knowledge is limited regarding U.S. adult
behaviors to reduce sodium intake. Our
objectives were to describe the prevalence and
determinants of taking action to reduce sodium
intake, and to test the hypothesis that receiving
medical advice is associated with taking action
to reduce sodium intake.
Methods: We used data from the 2013
Behavioral Risk Factor Surveillance System, a
state-based telephone survey representative of
non-institutionalized adults aged >18 years.
Twenty-six U.S. states, the District of Columbia,
and Puerto Rico participated in the new,
optional sodium module. The median
cooperation rate for these states and territories
was 66.9%; range 51.8 – 75.9%. We estimated
prevalence ratios (PR) adjusting for
sociodemographic and health characteristics. All
analyses accounted for selection probabilities
and the complex design. Analyses included
173,778 respondents with complete data.
Results: Fifty-three percent of adults reported
watching or reducing sodium intake (“taking
action”). The prevalence of taking action was
highest among adults reporting having received
doctor or other health professional advice to
reduce sodium intake (82%), followed by (73%75%) adults taking anti-hypertensive
medications, with diabetes, kidney disease, or a
history of cardiovascular disease, and lowest
(29%) among adults aged 18-24 years. Among
those taking action, 36% reported initiating the
behavior within the last 3 years. Overall, 23% of
adults reported receiving advice to reduce
sodium intake. Receiving advice was highest
(51% - 56%) among adults taking antihypertensive medications,
with diabetes, kidney disease, or a history of
cardiovascular disease, and lowest among
adults aged 18-24 years (7%) or without
hypertension (10%). Among adults who had
hypertension, yet were untreated, only 32%
received advice. Overall, receiving advice was
associated with action to reduce sodium intake
(adjusted PR 1.59, 95% CI 1.56-1.62). Although
there was some evidence of disparities across
race/ethnicity and body mass index categories,
after adjusting for other sociodemographic and
health characteristics, 74%-83% of adults who
received advice, reported taking action.
Conclusion: Our results suggest slightly over
half of U.S. adults are taking action to reduce
their sodium intake, and receiving advice is
strongly associated with taking action. Although
data are based on self-report, the substantial
proportion of respondents who do not report
receiving advice from health professionals
suggests a missed opportunity for reducing
sodium intake among U.S. adults, particularly
among high risk groups.
S.L. Jackson: None. S.C. King: None. S. Park:
None. J. Fang: None. E. Odom: None. M.E.
Cogswell: None.
P037
Effect of a Family Based Intervention on
Biomarkers of Diet Quality/Endogenous
Metabolism and BMI z-score
Nirupa R Matthan, Tufts Univ, Boston, MA;
Xiaonan Xue, Qi Gao, Judith Wylie-Rosett,
Albert Einstein Coll of Med, Bronx, NY; Alice H
Lichtenstein, Tufts Univ, Boston, MA
Developing strategies to prevent excess weight
gain during childhood is critical to support
efforts to stem the current juvenile obesity
epidemic and associated long-term adverse
cardiometabolic consequences. The objective
was to assess how participation in a familybased weight management intervention
affected biomarkers of diet quality/endogenous
metabolism and cardiometabolic outcomes in
children aged 7-12 years (n=309) with baseline
BMI z-score (BMIz) >85th percentile. Families
were randomized to a control group, receiving a
booklet targeting healthy eating
behaviors/increasing physical activity, and
quarterly visits to review lifestyle
recommendations or an experimental group,
receiving weekly sessions for 3 months
including targeted diet strategies (increasing
highly pigmented fruit/vegetable and fish
intake; substituting non-fat/low-fat for full-fat
dairy products; and reducing meat, fried food
and savory snack intakes) and physical activity
curriculum followed by 9 monthly sessions.
Biomarkers of nutrient intake and metabolism
(RBC fatty acid profiles, plasma carotenoids,
vitamins A, E, K and dihydrovitamin K) were
measured using GC or HPLC. Presented are
results of pooled group analysis between
change in age and sex standardized BMIz and
dietary/endogenous metabolism biomarkers.
Using multivariate logistic regression (odds
ratios [95% confidence intervals]), MUFA 16:1n7 (0.26 [0.07-0.98]), an indicator of de novo
lipogenesis, was negatively associated with,
while 18:1n-9trans (13.5 [1.5-128.1]), a
biomarker of partially-hydrogenated fat, and
lycopene (1.02 [1.01-1.05]), a biomarker for
tomato-based foods, were positively associated
with change in BMIz. Delta-6-desaturase (D6D;
20:3n-6/18:2n-6) and delta-5-desaturase (D5D;
20:4n-6/20:3n-6) activities, indicators of
endogenous fatty acid metabolism, were
negatively (0.32 [0.15-0.68]) and positively (1.10
[1.01-1.22]) associated with change in BMIz,
respectively. Results suggest that foods high in
partially-hydrogenated fat and tomato-based
products (e.g., pizza) have an adverse effect on
change in BMIz. Additionally, the changes in
D6D and D5D indices suggest that in vivo
metabolism is predictive of change in BMIz in
this cohort of high-risk children.
N.R. Matthan: None. X. Xue: None. Q. Gao:
None. J. Wylie-Rosett: None. A.H. Lichtenstein:
None.
P038
Dietary Capsaicin May Decrease Blood
Pressure Through Enhancing NO With eNOS
Activation in 2-Kidney, 1-Clip Hypertensive
Rats
Yukiko Segawa, Kobe Women's Univ, Suma,
Kobe, Japan; Hiroko Hashimoto, Osaka Seikei
junior Coll, Higashiyodogawa, Osaka, Japan;
Tomoko Osera, Nobutaka Kurihara, Kobe
Women's Univ, Suma, Kobe, Japan
Objective: Capsaicin, a component of chili
peppers, is reported to have beneficial effects
on cardiovascular system through the
vasodilative effects. We recently demonstrated
the alleviation of blood pressure (BP) elevation
by consuming a low concentration of capsaicin
diet in 2-kidney, 1-clip (2K1C) hypertensive rats.
Since the alleviation was diminished when 2K1C
rats took NG-nitro-L-arginine methyl ester, a NO
synthase (NOS) inhibitor, during the protocol,
we hypothesized that NO has a key role in the
effect of capsaicin in 2K1C rats. In this study, we
observed eNOS mRNA expression and protein
expressions of eNOS and phosphorylated eNOS
in 2K1C rats fed a diet containing capsaicin.
Methods: Six-week old male Sprague-Dawley
rats were treated with sham operation (SHAM)
or clipping the left renal artery (2K1C). One
week after the surgery, each group of rats were
further divided into 2 groups randomly, which
received either a control diet (CTL) or a diet
containing 0.006% capsaicin (CAP) for 6 weeks.
The systolic BP was measured by a tail-cuff
method once per week throughout the
protocol. At the end of the protocol, rats were
euthanized and the abdominal aortas were
collected for extracting mRNA and protein.
Then, the expression of eNOS mRNA and
protein in aorta was evaluated in each group of
rats by real time RT-PCR and Western blotting.
Results: As shown in Table, capsaicin diet
alleviated BP elevation in 2K1C rats. After the
dietary protocol, eNOS mRNA expression in
2K1C-CAP was significantly higher than in 2K1CCTL. Although there were no significant
differences in eNOS protein expression among
four groups, phosphorylated eNOS protein
expression in 2K1C-CAP was marginally
significantly higher than in 2K1C-CTL. The
expression was also significantly higher in 2K1C
rats than in SHAM.
Discussion: The present data suggested that
dietary capsaicin decreases BP through
enhancing NO with activation of eNOS in 2K1C
hypertensive rats. It may be a clue for
developing a dietary therapy for prevention of
hypertension.
Y. Segawa: None. H. Hashimoto: None. T.
Osera: None. N. Kurihara: B. Research Grant;
Modest; This work was supported by JSPS
KAKENHI Grant Number 24501014.
P039
Dietary Patterns are Associated with Cognitive
Function in US Adults
Keith Pearson, Virginia Wadley, Leslie McClure,
Suzanne Judd, Univ of Alabama at Birmingham,
Birmingham, AL
Introduction: As America ages, identifying
factors that contribute to the preservation of
cognitive function is of growing importance to
maintain quality of life in advanced years. Of
modifiable risk factors, diet quality has emerged
as a promising candidate to impact cognition.
Although the Mediterranean diet pattern has
been associated with cognitive benefits, few
other dietary patterns have been considered.
empirically-derived dietary patterns are
associated with cognitive function.
Methods: The REasons for Geographic And
Racial Differences in Stroke (REGARDS) study is
a national cohort study of 30,239 black and
white participants (age > 45). Previously, five
dietary patterns (Convenience, Plant-based,
Sweets/fats, Southern, and Alcohol/salads)
were derived with principal component analysis
using data assessed by the Block98 FFQ.
Baseline cognitive impairment (a score ≤4) was
assessed using the Six-Item Screener. Logistic
regression was used to evaluate the odds of
baseline cognitive impairment by quintile of
dietary pattern adherence.
Results: This analysis included 19,888
participants with complete diet/cognitive data
who were free of stroke. After demographic
and energy intake adjustments, participants
with the highest adherence to the Southern
pattern had 37% higher odds of being
cognitively impaired at baseline (Q5 vs Q1:
OR=1.37; 95% CI: 1.11, 1.69; p for trend: <0.01),
while those with the highest adherence to the
Alcohol/Salads pattern had 27% lower odds of
impairment at baseline (Q5 vs Q1: OR=0.73;
95% CI: 0.61, 0.87; p for trend: <0.01). Addition
of covariates resulted in loss of significance but
direction of association was similar (Table).
Conclusion: A dietary pattern including salads
and alcohol intake was associated with lower
odds, and a pattern including fried food and
processed meat with higher odds, of baseline
cognitive impairment. These associations
should be further investigated in relation to
preservation of cognitive function over time.
K. Pearson: None. V. Wadley: None. L.
McClure: None. S. Judd: None.
P040
Animal and Vegetable Protein Intake and
Coronary Artery Calcium - The Kangbuk
Samsung Health Study
Yuni Choi, Seungho Ryu, Yoosoo Chang, Ctr for
Cohort Studies, Total Healthcare Screening Ctr,
Kangbuk Samsung Hosp,Sungkyunkwan Univ
Sch of Med., Seoul, Korea, Republic of; Jung Eun
Lee, Dept of Food and Nutrition, Sookmyung
Women's Univ., Seoul, Korea, Republic of; Eunju
Sung, Juhee Cho, Ctr for Cohort Studies, Total
Healthcare Screening Ctr, Kangbuk Samsung
Hosp,Sungkyunkwan Univ Sch of Med., Seoul,
Korea, Republic of; Sanjay Rampal, Di Zhao,
Depts of Epidemiology and Med, and Welch Ctr
for Prevention, Epidemiology, and Clinical Res,
Baltimore, Maryland, USA., Baltimore, MD; Yiyi
Zhang, Depts of Epidemiology and Med, and
Welch Ctr for Prevention, Epidemiology, and
Clinical Res, Johns Hopkins Bloomberg Sch of
Public Health, Baltimore, MD; Jiin Ahn, Ctr for
Kangbuk Samsung Hosp,Sungkyunkwan Univ
Sch of Med., Seoul, Korea, Republic of; Miguel
Cainzos-Achirica, Depts of Epidemiology and
Med, and Welch Ctr for Prevention,
Epidemiology, and Clinical Res, Johns Hopkins
Bloomberg Sch of Public Health., Baltimore,
MD; Roberto Pastor-Barriuso, Natl Ctr for
Epidemiology, Insto de Salud Carlos III., Seoul,
Spain; Joao A. Lima, Div of Cardiology, Johns
Hopkins Univ Sch of Med., Baltimore, MD;
Hocheol Shin, Ctr for Cohort Studies, Total
Hosp,Sungkyunkwan Univ Sch of Med., Seoul,
Korea, Republic of; Eliseo Guallar, Depts of
Epidemiology and Med, and Welch Ctr for
Prevention, Epidemiology, and Clinical Res,
Johns Hopkins Bloomberg Sch of Public Health.,
Baltimore, MD
Introduction: Few studies have evaluated the
association between type and amount of
dietary protein intake and clinically evident
cardiovascular disease, with inconsistent
findings, and no study has investigated the
association between type and amount of
dietary protein intake and subclinical coronary
atherosclerosis.
Hypothesis: We examined the associations of
total, animal, and vegetable protein intakes
with coronary artery calcium (CAC) in a large
population of asymptomatic adults.
Methods: We performed a cross-sectional study
of 29,034 asymptomatic young and middleaged adults (mean age 41.6 years; males 80.3%)
who are free of clinically evident cancer or
cardiovascular disease. All participants
underwent a health screening examination
including cardiac computed tomography for
CAC scoring and completed a food frequency
questionnaire at the Kangbuk Samsung Hospital
Total Healthcare Centers in Seoul and Suwon,
South Korea from March, 2011 to April, 2013.
Protein intake and other nutrient intake were
adjusted for total energy intake using the
residual method. Multivariable-adjusted CAC
score ratios and 95% confidence intervals (CIs)
were estimated by robust Tobit regression
models for natural logarithm (CAC score + 1).
Results: The proportion of study participants
with detectable CAC (CAC score > 0) was 13.4 %.
After adjustment for total energy intake, other
nutrient intake, and potential confounding
factors, we found an increased prevalence of
CAC with higher animal protein intake, but not
with total and vegetable protein intakes. In
multivariable-adjusted models, CAC ratios (95%
CIs) comparing the highest with the lowest
quintiles were 1.82 (1.09-3.04; P for trend =
0.01) for animal protein intake, 1.25 (0.87-1.81;
P for trend = 0.13) for vegetable protein intake,
and 1.19 (0.74-1.93; P for trend = 0.59) for total
protein intake.
Conclusion: High animal protein intake, but not
total or vegetable protein, was associated with
an increased prevalence of subclinical coronary
atherosclerosis and with a greater degree of
coronary calcification.
Y. Choi: None. S. Ryu: None. Y. Chang: None. J.
Lee: None. E. Sung: None. J. Cho: None. S.
Rampal: None. D. Zhao: None. Y. Zhang:
None. J. Ahn: None. M. Cainzos-Achirica:
None. R. Pastor-Barriuso: None. J.A. Lima:
None. H. Shin: None. E. Guallar: None.
P041
Relations of Three Types of Low Carbohydrate
Diet to Cardiometabolic Risk Factors and CReactive Protein: The INTERLIPID Study
Yasuyuki Nakamura, Kyoto Womans Univ,
Kyoto, Japan; Hirotsugu Ueshima, Shiga Univ of
Medical Science, Otsu, Japan; Nagako Okuda,
Univ of Human Arts and Sciences, Saitama,
Japan; Katsuyuki Miura, Shiga Univ of Medical
Science, Otsu, Japan; Yoshikuni Kita, Tsuruga
City Univ of Nursing, Tsuruga, Japan; Naoko
Miyagawa, Shiga Univ of Medical Science, Otsu,
Japan; Katsushi Yoshita, Osaka City Univ, Osaka,
Japan; Hideaki Nakagawa, Kanazawa Medical
Univ, Kanazawa, Japan; Kiyomi Sakata, Iwate
Medical Univ, Morioka, Japan; Shigeyuki Saitoh,
Sapporo Medical Univ Sch of Med, Sapporo,
Japan; Tomonori Okamura, Keio Univ, Tokyo,
Japan; Akira Okayama, Res Ctr for Lifestylerelated Diseases, Tokyo, Japan; Sohel R
Choudhry, Natl Heart Fndn Hosp & Res Inst,
Dhaka, Bangladesh; Beatriz Rodriguez, Kamal H
Masaki, Univ of Hawaii, Honolulu, HI; Queenie
Chan, Sch of Public Health Imperial Coll London,
London, United Kingdom; Jeremiah Stamler,
Introduction Sizable numbers of people have
tried low carbohydrate diets (LCD) of varied
types; data are sparse on effects on
cardiometabolic risk factors with different types
of LCD.
Hypothesis We assessed the hypothesis that
relationships of LCD score to cardiometabolic
risk factors and an inflammatory marker, highsensitivity C-reactive protein (CRP), are different
among usual, animal-based, and plant-based
LCD.
Methods We assessed serum concentrations of
high-density lipoprotein cholesterol (HDLc),
low-density lipoprotein cholesterol (LDLc), high
sensitivity C-reactive protein (CRP), and nutrient
intakes by standardized methods in men and
women ages 40 to 59 years from four
population samples of Japanese in Japan (553
men and 544 women, combined). For people
consuming usual, animal-based, and plantbased LCDs, we calculated LCD scores, based on
relative level of fat, protein, and carbohydrate,
by modifying the methods of Halton, et al.
Instead of calculating scores based on animal or
vegetable fat, we used saturated fatty acids
(SFA) or monounsaturated fatty acids (MUFA)
+polyunsaturated fatty acids (PUFA). Multiple
linear regression analyses were used to
examine relations of LCD scores to log-CRP and
cardiometabolic risk factors.
Results In multivariate regression analyses with
adjustment for site, age, sex, BMI, smoking,
alcohol intake, physical activity, years of
education, and Keys dietary lipid score, all three
LCD scores were significantly directly related to
HDLc (all Ps<0.001), but not to LDLc. The plantbased LCD score was significantly inversely
related to log-CRP (coefficient=-0.011, P=0.017).
Conclusions All three LCD scores were
significantly directly related to HDLc, but not to
LDLc. The plant-based LCD score, associated
with higher PUFA and lower SFA and dietary
cholesterol in comparison with the other two
LCD scores, was significantly inversely related to
log-CRP.
Y. Nakamura: None. H. Ueshima: None. N.
Okuda: None. K. Miura: None. Y. Kita: None. N.
Miyagawa: None. K. Yoshita: None. H.
Nakagawa: None. K. Sakata: None. S. Saitoh:
None. T. Okamura: None. A. Okayama:
None. S.R. Choudhry: None. B. Rodriguez:
None. K.H. Masaki: None. Q. Chan: None. J.
Stamler: None.
P042
Association of Long-Term Coffee Consumption
with Total and Cause-Specific Mortality
Ming Ding, Harvard Sch of Public Health,
Brookline, MA; Ambika Satija, Harvard Sch of
Public Health, Boston, MA; Shilpa Bhupathiraju,
Qi Sun, Harvard Sch of Public Health, Brookline,
MA; Jiali Han, Indiana Univ, Indianapolis, IN;
Walter Willett, Harvard Sch of Public Health,
Brookline, MA; Rob van Dam, Natl Univ of
Singapore and Natl Univ Health System,
Singapore, Singapore; Frank Hu, Harvard Sch of
Public Health, Brookline, MA
BACKGROUND Coffee is one of the most
popular beverages worldwide; however, the
association between coffee consumption and
risk of mortality remains inconclusive.
METHOD We examined the associations of
consumption of total, caffeinated, and
decaffeinated coffee with risk of subsequent
total and cause-specific mortality among
121,704 women in the Nurses’ Health Study
(1984 - 2013), 116,683 women in the Nurses’
Health Study 2 (1991 - 2013), and 51,530 men in
the Health Professionals Follow-up Study (1986
- 2013). Participants with a history of cancer,
heart disease, or stroke at baseline were
excluded. Coffee consumption was assessed at
baseline using a semi-quantitative food
frequency questionnaire.
RESULTS During 5,048,976 person-years of
follow-up, 20,025 women and 13,391 men died.
Consumption of total, caffeinated, and
decaffeinated coffee were non-linearly
associated with total mortality (P for non-linear
trend < 0.001). The pooled hazard ratios (HRs)
for death among participants who drank coffee,
as compared with those who did not, were 0.96
(95% CI: 0.92 - 1.00) for coffee consumption less
than one cup/d, 0.89 (95% CI: 0.86 - 0.92) for
coffee consumption one to three cups/d, 0.91
(95% CI: 0.87 - 0.95) for coffee consumption
three to five cups/d, and 1.01 (95% CI: 0.96 1.06) for coffee consumption more than five
cups/d (p for non-linearity < 0.001; p for nonlinear trend < 0.001). When restricting to never
smokers, compared to non-drinkers, the
multivariate adjusted HRs of total mortality
across categories of total coffee consumption
were 0.93 (0.86-1.02) for 1 cup/d, 0.87 (0.820.96) for 1-3 cups/d, 0.85 (0.77-0.94) for 3-5
cups/d, and 0.83 (0.71-0.97) for >5 cups/d (p for
non-linearity = 0.15; p for linear trend <0.001).
A significant inverse association was observed
for both caffeinated coffee (p for trend < 0.001)
and decaffeinated coffee (p for trend = 0.03).
CONCLUSION These data indicate higher
consumption of total coffee, caffeinated coffee,
and decaffeinated coffee was associated with
lower risk of total mortality.
M. Ding: None. A. Satija: None. S.
Bhupathiraju: None. Q. Sun: None. J. Han:
None. W. Willett: None. R. van Dam: None. F.
Hu: None.
P043
Alcohol Consumption, Transferrin Saturation
and Risk of All-Cause Mortality in The National
Health and Nutrition Examination Surveys
Laurence O James, Vanderbilt Univ Medical Ctr,
Nashville, TN; James N Kiage, Coll of Med Univ
of Tennessee Health Science Ctr, Memphis, TN;
Loren Lipworth, Uchechukwu K Sampson,
Edmond K. Kabagambe, Vanderbilt Univ
Medical Ctr, Nashville, TN
Background- Moderate alcohol consumers have
a reduced risk for cardiovascular and all-cause
mortality. Alcohol intake improves iron
absorption and also has a profound effect on
iron metabolism and thus could in part explain
the observed inverse association between
moderate alcohol intake and mortality. We
sought to investigate whether moderate alcohol
confers mortality benefits in part through
improvement in iron status.
Methods- Publicly available data from two
consecutive National Health and Nutrition
Examination Survey (NHANES) cycles
(1999/2000 and 2001/2002) were obtained and
linked to public data on all-cause mortality.
Study participants were grouped as never, past,
moderate (≤2 drinks/day for men, ≤ 1 drink/day
for women) and heavy drinkers (>2 drinks/day
for men, >1 drink/day for women). To assess
the quality of alcohol data in NHANES, we
tested whether self-reported alcohol
consumption was associated with biomarkers of
alcohol intake (HDL-C and γ-glutamyl
transferase (GGT)). Cox-models, weighted using
four-year sampling weights, were fitted to
determine whether alcohol intake was
associated with all-cause mortality. Measures of
iron status, particularly serum ferritin,
transferrin saturation, hemoglobin and free
erythrocyte protoporphyrin were evaluated as
potential mediators of the association between
alcohol consumption and risk of all-cause
mortality.
Results- Among 7,532 men and women with
complete data, 17% were never drinkers, 20%
were past drinkers, 30% were moderate
drinkers and 33% were heavy drinkers. We
found an increase in HDL-C and GGT with
increased alcohol intake, suggesting that selfreported alcohol intake is reliable in this
population. In the weighted analysis, the hazard
ratio (95% CI) for all-cause mortality among
moderate alcohol users compared to never
users was 0.56 (0.37-0.85), in models adjusted
for age, race, smoking, statin use and history of
diabetes, among other variables. Adjustment
for transferrin saturation as a measure of iron
status attenuated the benefit from moderate
alcohol (HR = 0.69; 95% CI: 0.41-1.14),
suggesting that moderate alcohol consumption
may in part confer a benefit on mortality
through improvement in iron status. These
results warrant further evaluation in rigorous
formal mediation analyses.
Conclusions- Moderate alcohol consumption
was associated with higher transferrin
saturation and with reduced risk of mortality.
Adjusting for iron status attenuated the
association between moderate alcohol
consumption and all-cause mortality suggesting
that the effects of moderate alcohol on
mortality may in part be via improvement in
iron status.
L.O. James: None. J.N. Kiage: None. L.
Lipworth: None. U.K.A. Sampson: None. E.K.
Kabagambe: None.
P044
Alcohol Consumption, Statin Use and Risk of
All-Cause Mortality in the Reasons for
(REGARDS) Cohort
Edmond K Kabagambe, Vanderbilt Univ Medical
Ctr, Nashville, TN; James N Kiage, Univ of
Tenessee Health Science Ctr, Memphis, TN;
Suzanne E Judd, Univ of Alabama at
Birmingham, Birmingham, AL; James C
Slaughter, Loren Lipworth, Uchechukwu
Sampson, Vanderbilt Univ Medical Ctr,
Nashville, TN; Luc Djousse, Brigham and
Women's Hosp, Boston, MA; Eric B Rimm,
Harvard Sch of Public Health, Boston, MA; Mary
Cushman, Univ of Vermont, Colchester, VT;
Sergio Fazio, Oregon Health and Science Univ,
Portland, OR; Monika Safford, Virginia J
Howard, George Howard, Univ of Alabama at
Birmingham, Birmingham, AL; for the Alcohol
and Statin Epidemiology Consortium
Background- Moderate alcohol consumption is
associated with a lower risk of all-cause
mortality while heavy alcohol intake increases
this risk. Statins also reduce all-cause mortality.
In recent years, use of statins has increased,
resulting in frequent joint exposure to both
alcohol and statins, but whether moderate
alcohol consumption confers a mortality benefit
beyond that from statin therapy is not known.
Methods- We followed 23,555 black and white
men and women in the REGARDS cohort to
determine whether statin use modifies effects
of alcohol consumption on the risk of all-cause
mortality. Alcohol consumption, statin use, and
data on potential confounders were assessed at
baseline while occurrence of clinical events
including death was assessed by telephone
every 6 months. Participants were classified as
never, past, moderate (≤2 drinks/day for men, ≤
1 drink/day for women) and heavy drinkers (>2
drinks/day for men, >1 drink/day for women).
Statin use was defined as use of any statin
regardless of type or dose. Cox-regression
analyses were used to test whether alcohol
intake was associated with mortality and
whether there was an interaction with statin
use. Models included baseline age, sex, BMI,
race, region, smoking, income, education,
marital status, diabetes, stroke, hypertension,
coronary artery disease, regular use of antiinflammatory medications, alcohol use, statin
use and alcohol*statin use interaction term.
Results- Over a median follow-up of 6.1 years
there were 3,076 deaths. Most participants
(65%) consumed alcohol, but even among
heavy drinkers (n=1,105), only 341 participants
reported consuming >3 drinks/day. Statins were
used by 31%, 36%, 32% and 28% of never, past,
moderate and heavy drinkers, respectively. We
observed a significant interaction between
alcohol consumption and statin use with regard
to risk of all-cause mortality (P <0.0001 for main
effects and the interaction). In fully adjusted
models and using never drinkers as the referent
group, the hazard ratios and 95% confidence
intervals for all-cause mortality for past,
moderate and heavy drinkers were 1.12 (0.991.25), 0.73 (0.65-0.82) and 0.91 (0.73-1.13),
respectively, among non-statin users, while
they were 0.88 (0.76-1.03), 0.87 (0.75-1.01) and
0.49 (0.32-0.75) among statin users. In crosssectional analyses of baseline data, alcohol
intake was positively associated with HDL-C and
inversely associated with CRP and triglycerides,
with significant interactions between alcohol
consumption and statin use for all three
markers (P for interaction <0.01 for all).
Conclusions- Statin use is common among
heavy drinkers. Our data show that alcohol
consumption at levels observed in this study is
inversely associated with risk of all-cause
mortality, and its effects may be synergistic to
those of statins. Future studies with adequate
sample size of heavy drinkers are needed to
confirm these findings.
E.K. Kabagambe: None. J.N. Kiage: None. S.E.
Judd: None. J.C. Slaughter: None. L. Lipworth:
None. U. Sampson: None. L. Djousse:
None. E.B. Rimm: None. M. Cushman: None. S.
Fazio: B. Research Grant; Modest; Isis
Pharmaceuticals, Merck. G. Consultant/Advisory
Board; Modest; Merck, Kowa, Sanofi-Aventis,
Roche, Amarin, Lupin, BASF. M. Safford:
None. V.J. Howard: None. G. Howard: None.
P045
Western Dietary Patterns are Associated with
the Prevalence of Hypertension in South Korea
- The Kangbuk Samsung Health Study
Sanjay Rampal, Juhee Cho, Depts of
Johns Hopkins Univ Bloomberg Sch of Public
Health, Baltimore, MD; Yuni Choi, Ctr for Cohort
Studies, Total Healthcare Ctr, Kangbuk Samsung
Hosp, Sungkyunkwan Univ Sch of Med, Seoul,
Korea, Republic of; Yiyi Zhang, Di Zhao, Depts of
Health, Baltimore, MD; Roberto PastorBarriuso, Natl Ctr for Epidemiology, Carlos III
Inst of Health and Consortium for Biomedical
Res in Epidemiology and Public Health
(CIBERESP), Madrid, Spain; Yoosoo Chang, Ctr
for Cohort Studies, Total Healthcare Ctr,
Kangbuk Samsung Hosp, Sungkyunkwan Univ
Sch of Med, Seoul, Korea, Republic of; Joao A
Lima, Div of Cardiology, Johns Hopkins Univ Sch
of Med, Baltimore, MD; Hocheol Shin, Dept of
Family Med, Kangbuk Samsung Hosp and
Sungkyunkwan Univ Sch of Med, Seoul, Korea,
Republic of; Seungho Ryu, Ctr for Cohort
Studies, Total Healthcare Ctr, Kangbuk Samsung
Hosp, Sungkyunkwan Univ Sch of Med, Seoul,
Korea, Republic of; Eliseo Guallar, Depts of
Health, Baltimore, MD
Introduction
Diet is a complex exposure of unquestionable
relevance for cardiovascular disease (CVD) risk.
South Korea, a population with traditionally low
rates of CVD, has changed in recent decades
from a traditional diet to more Western and
modern dietary patterns. The impact of these
changes are uncertain.
Hypothesis
We aimed to evaluate the hypothesis that nontraditional dietary patterns were associated
with an increased prevalence of hypertension in
a large sample of young and middle-aged
Korean adults.
Methods
We conducted a cross sectional study of
220,979 adult men and women who underwent
a screening health examination between
January 2011 and December 2013 at the
Kangbuk Samsung Total Healthcare Center in
Seoul and Suwon, South Korea who did not
have any history of cardiovascular disease,
cancer, diabetes, hypertension, or dyslipidemia.
Diet was assessed using a validated 103-item
food frequency questionnaire and principal
component analysis was used to derive three
major dietary patterns: Western Korean,
characterized by higher intakes of noodles, red
meat, processed meat, raw or salted fish,
shellfish, poultry, soda, and alcohol; Traditional
Korean, characterized by higher intakes of
vegetables, mushrooms, preserved vegetables,
soya and other beans, fruits, fish, and seaweed;
and Modern Korean, characterized by higher
intakes of bread and cereals, milk and dairy
products, snacks, and pizza, and lower intakes
of alcohol, rice, and preserved vegetables.
Hypertension was defined as having a systolic
blood pressure ≥140 mmHg and/or a diastolic
blood pressure ≥ 90 mmHg. Systolic
hypertension was defined as having a systolic
blood pressure ≥140 mmHg.
Results
The prevalence of hypertension was 2.9%. In
fully adjusted multivariable models, the odds
ratios for hypertension comparing the 90th to
the 10th percentile of dietary scores were 1.58
(95%CI 1.42, 1.75), 1.11 (95%CI 1.01, 1.21), 0.73
(95%CI 0.66, 0.81) for Western, Traditional, and
Modern Korean dietary patterns, respectively.
The corresponding odds ratios for systolic
hypertension were 1.50 (95%CI 1.28, 1.76), 1.17
(95%CI 1.01, 1.36), and 0.68 (95%CI 0.58, 0.79),
respectively.
Conclusion
In this large cross-sectional study of young and
middle-aged Korean men and women, diet
transition to a more Western pattern,
characterized by higher intake of meats and
alcohol, was associated with a higher
prevalence of hypertension and may be
associated with increased CVD risk.
S. Rampal: None. J. Cho: None. Y. Choi:
None. Y. Zhang: None. D. Zhao: None. R.
Pastor-Barriuso: None. Y. Chang: None. J.A.
Lima: None. H. Shin: None. S. Ryu: None. E.
Guallar: None.
P046
Dietary Fat Intake and Mortality Among
Women and Men With Prior Myocardial
Infarction: Results From Two Prospective
Cohort Studies
Daniela Schmid, Univ of Regensburg,
Regensburg, Germany; Shanshan Li, Natl Insts of
Health, Bethesda Md, WA; Kenneth J. Mukamal,
Div of General Med and Primary Care, Beth
Israel Deaconess Medical Ctr, Brookline, MA;
Alan Flint, Depts of Nutrition and Epidemiology,
Walter C. Willett, Eric B. Rimm, Depts of
Nutrition and Epidemiology, Harvard Sch of
Public Health, Channing Div of Network Med,
Dept of Med, Boston, MA
Background: Information about dietary fatty
acid intake and mortality among myocardial
infarction (MI) patients is sparse. We therefore
prospectively explored the association of postMI dietary fat intake and changes from pre- to
post-MI with all-cause and cardiovascular
disease (CVD) mortality among MI survivors.
Methods: We included 2258 women from the
Nurses’ Health Study and 1840 men from the
Health Professionals Follow-up Study with
confirmed incident non-fatal MI between 1980
and 2008 (women) and between 1986 and 2008
(men) who were free of cancer, stroke, CVD at
baseline, survived a first MI during follow-up,
were free of stroke at the time of initial onset of
MI, and provided information on pre- and postMI dietary fat intake. Dietary fat intake at
baseline and every four years thereafter was
assessed using validated self-administered
questionnaires.
Results: During a median of 8.7 years of followup in women and 9 years of follow-up in men,
we documented 682 total deaths in women and
451 in men. In multivariate Cox proportional
hazard models, no associations were evident for
intakes of post-MI total fat, saturated fatty
acids, and poly-unsaturated fatty acids with allcause mortality (pooled hazard ratios (HR) and
95% confidence intervals (CI) comparing
extreme quintiles =1.04, 95% CI=0.78-1.38;
1.06, 95% CI=0.75-1.49; and 0.86, 95% CI=0.671.09, respectively). Greater intake of post-MI
trans-fatty acid intake was related to higher allcause mortality (pooled HR=1.34, 95% CI=1.001.80, p trend=0.05). An increase in saturated
fatty acid intake from pre- to post-MI was
significantly associated with higher CVD
mortality (pooled HR=1.77, 95% CI=1.14-2.75, p
trend=0.01).
Conclusion: Findings from these long-term
prospective cohorts suggest that post-MI
dietary fat is not strongly associated with
mortality. However, an increase in saturated
fatty acid intake from the pre- to post-MI period
was related to higher CVD mortality. These
findings merit further investigation.
D. Schmid: None. S. Li: None. K.J. Mukamal:
None. A. Flint: None. W.C. Willett: None. E.B.
Rimm: None.
P047
The Role of the Healthy Heart Score in the
Primordial Prevention of CVD Among Women
Mercedes Sotos-Prieto, Josiemer Mattei, Frank
B Hu, Andrea K Chomistek, Eric B Rimm, Walter
C Willett, A Heather Eliassen, Stephanie E
Chiuve, Harvard Sch of Public Health, Boston,
MA
Background: Currently, clinical practice focuses
on primary prevention of CVD by treating
individuals at high risk of CVD based on the
presence of clinical risk factors, rather than
preventing the development of clinical risk
factors through maintenance or adoption of a
healthy lifestyle. We recently derived and
validated the Healthy Heart Score, which
estimates the 20-year risk of CVD based on
modifiable lifestyle factors. The Healthy Heart
Score in mid-adulthood effectively predicted
CVD events; however whether this risk score
can play an important role in the prevention of
clinical CVD risk factor development, or
primordial prevention of CVD, is not known.
Methods: We conducted a prospective analysis
among 69,264 women, in the Nurses’ Health
Study II, aged 26-45 years at study baseline in
1991 and free of CVD, diabetes, hypertension
and hypercholesterolemia. Diet and lifestyle
factors were first assessed in 1991 and were
updated by questionnaires every 2-4 years. The
Healthy Heart Score was calculated at study
baseline as the 20-year risk of CVD, based on a
prediction model that includes age, smoking,
BMI, hours of moderate to vigorous exercise,
alcohol intake and a composite diet score (fruit
& vegetables, sugar-sweetened beverages,
red/processed meats, cereal fiber, nuts). Selfreported diabetes was validated by
supplementary questionnaires. Physiciandiagnosed hypertension and
hypercholesterolemia were self-reported from
biennial questionnaires. Cox proportional
hazards models were used to calculate hazard
ratio (HR) for developing clinical CVD risk
factors (diabetes, hypertension,
hypercholesterolemia), adjusting for parental
history of MI, aspirin use, menopausal status,
postmenopausal hormone use, parity, and oral
contraceptive use.
Results: Through 2011 (996,553 person-years of
follow-up), we documented 2,745 diabetes,
16,605 hypertension and 20,926
hypercholesterolemia cases. The median 20
year risk of CVD based on the Healthy Heart
Score was 0.8% at baseline (mean age 36).
Compared to women in the lowest quintile of
the Healthy Heart Score (median CVD risk: =
0.35%), women in the highest quintile (median
CVD risk: 2.5%) had a HR (95%CI) of 5.1 (4.2,
6.2) for diabetes; 2.1 (1.9, 2.2) for hypertension
and 1.4 (1.3, 1.5) for high cholesterol. The HR
(95%CI) for developing ≥1 risk factor across
quintiles was Q1: 1.0 (ref); Q2: 1.22 (1.16, 1.28);
Q3: 1.34 (1.27, 1.40); Q4:1.48 (1.41, 1.56); Q5:
1.51 (1.43, 1.58); P-trend<0.0001. Results were
attenuated when we updated the Healthy Heart
Score during follow-up.
Conclusion: The Healthy Heart Score in early
adulthood was strongly associated with the
development of CVD risk factors among middleaged women. Therefore, the Healthy Heart
Score may be a useful tool in the clinic or
community-based setting to evaluate the
primordial prevention of CVD and help maintain
ideal cardiovascular health among women.
M. Sotos-Prieto: None. J. Mattei: None. F.B.
Hu: None. A.K. Chomistek: None. E.B. Rimm:
None. W.C. Willett: None. A.H. Eliassen:
None. S.E. Chiuve: None.
P048
Sodium Intake is Associated with Weight
Status in Australian Schoolchildren Aged 4-12
Years
Carley A Grimes, Janet Baxter, Lynn Riddell,
Karen Campbell, Deakin Univ, Melbourne,
Australia; Feng He, Queen Mary Univ of London,
London, United Kingdom; Caryl Nowson, Deakin
Univ, Melbourne, Australia
Introduction: A high sodium intake stimulates
thirst and in turn may promote greater
consumption of high energy sugary beverages,
which are linked to obesity risk in children. In
this study we assessed the hypothesis that
sodium intake, as measured by 24-hr urinary
sodium excretion, would be positively
associated with weight status in primary schoolaged children.
Methods: Cross-sectional study completed
within a convenience sample of Victorian
primary schools (n=43). Sodium intake was
assessed via one 24-hr urine collection.
Fourteen percent of samples were deemed
invalid and excluded. BMI was calculated from
measured weight and height and converted to
BMI z-scores using the 2000 Centers for Disease
Control and Prevention reference growth
charts. Participants were grouped into weight
categories using the International Obesity Task
Force cut-points. Differences in sodium intake
and weight status were assessed using multilevel linear and logistic regression analysis with
adjustment for random effects (gender, age)
and fixed effect (school cluster).
Results: Of the 667 children with valid urine
samples 55% were male and the average age
was 9.3±(SD) 1.8 years. Ten percent were
classified as underweight, 73% healthy weight,
14% overweight and 3% obese. Average sodium
intake differed across weight categories,
underweight 82±29 mmol/day (salt equivalent
4.8±1.7 g/day); healthy weight 102±43
mmol/day (salt 6.0±2.5 g/day); overweight
125±55 mmol/day (salt 7.3±3.2 g/day); obese
148±97 mmol/day (salt 8.7±5.7 g/day)
(p=0.001). In the fully adjusted model sodium
intake (mmol/d) was significantly associated
with BMI z-score (b=0.006, P<0.001). A 17
mmol/day increase in sodium intake (salt 1
g/day) was associated with a 23% (OR: 1.23;
95% CI 1.16, 1.31) greater risk of being
overweight or obese, adjusted for age and
gender.
Conclusions: Higher sodium intake is associated
with overweight and obesity in Victorian
schoolchildren. This may be related to increased
energy intake, and this association should be
explored further.
C.A. Grimes: None. J. Baxter: None. L. Riddell:
None. K. Campbell: None. F. He: None. C.
Nowson: None.
P049
Principal Component Analysis of Dietary
Patterns and the Risk of Cardiovascular
Disease and Mortality in Older British Men
Janice Atkins, Univ Coll London, London, United
Kingdom; Peter Whincup, St George's Univ of
London, London, United Kingdom; Richard
Morris, Lucy Lennon, Olia Papacosta, Goya
Wannamethee, Univ Coll London, London,
United Kingdom
Background: Diet quality is a major risk factor
for morbidity and mortality, but few studies
have examined the relationship between
dietary patterns and the risk of cardiovascular
disease (CVD) and mortality in older adults. We
examined prospective associations between
dietary patterns defined using principal
component analysis and the risk of CVD and allcause mortality in older British men.
Methods: 3226 men aged 60-79 years from the
British Regional Heart Study, free from CVD at
baseline, were followed-up for 11 years.
Baseline food frequency questionnaire data
were used to generate dietary intake data on 34
food groups. Principal component analysis
identified dietary patterns which were then
categorised according to quartiles of adherence.
Cox proportional hazards regression examined
associations between dietary patterns and risk
of all-cause mortality, CVD mortality, CVD
events and coronary heart disease (CHD)
events, adjusting for confounders.
Results: Principal component analysis identified
three interpretable dietary patterns, which
explained 20.8% of the total variance. An
‘unhealthy’ dietary pattern explained the
greatest single proportion of the variance
(7.9%) and was characterised by consumption
of red meat, meat products, white bread, fried
potato and eggs. A ‘healthy’ dietary pattern was
characterised by consumption of poultry, fish,
fruit, vegetables, legumes, pasta, rice,
wholemeal bread, eggs and olive oil and
explained 7.1% of the variance. Finally, a
‘sweet’ dietary pattern was characterised by
consumption of biscuits, puddings, chocolate,
sweets, sweet spreads and breakfast cereal and
explained 5.8% of the variance. There were 899
deaths, 316 CVD deaths, 569 CVD events and
301 CHD events during follow-up. An
‘unhealthy’ dietary pattern was associated with
a graded increase in risk of all-cause mortality,
after adjustment for sociodemographic,
behavioural and cardiovascular risk factors
(highest vs. lowest quartile; HR: 1.44, 95% CI:
1.13-1.84, p-trend = 0.007). No significant
associations were seen between the risk of allcause mortality and the ‘healthy’ diet (highest
vs. lowest quartile; HR: 0.83, 95% CI: 0.66-1.04,
p-trend = 0.28) or the ‘sweet’ diet (highest vs.
lowest quartile; HR: 1.00, 95% CI: 0.77-1.29, ptrend = 0.71). None of the dietary patterns were
significantly associated with cardiovascular
outcomes (CVD mortality, CVD events or CHD
events).
Conclusions: Dietary patterns are an important
risk factor for all-cause mortality in the elderly.
Older adults should avoid a high consumption
of components of an ‘unhealthy’ dietary pattern
to reduce the risk of all-cause mortality.
J. Atkins: None. P. Whincup: None. R. Morris:
None. L. Lennon: None. O. Papacosta: None. G.
Wannamethee: None.
P050
Vitamin K Intake and Risk of Coronary Heart
Disease and Stroke in the Rotterdam Study
Anouk I Engelen, Top Inst Food and Nutrition
and Div of Human Nutrition, Wageningen Univ,
Wageningen, Netherlands; Johanna M
Geleijnse, Div of Human Nutrition, Wageningen
Univ, Wageningen, Netherlands; Cees Vermeer,
VitaK, Maastricht, Netherlands; Jacqueline C
Witteman, Albert Hofman, Oscar H Franco, Dept
of Epidemiology, Erasmus Medical Ctr,
Rotterdam, Netherlands; Edith J Feskens, Div of
Human Nutrition, Wageningen Univ,
Wageningen, Netherlands
Introduction: Vitamin K serves as a cofactor in
the carboxylation of vitamin K-dependent
proteins that play a role in blood coagulation
and the regulation of vascular calcification.
Therefore, vitamin K intake may decrease the
risk of cardiovascular diseases (CVD). We aimed
to investigate the associations of phylloquinone
(vitamin K1) and menaquinone (vitamin K2; MK4 through MK-10) intake with risk of coronary
heart disease (CHD) and stroke in a Dutch
population-based cohort study.
Methods: The analyses included 4,108
participants of the Rotterdam Study, aged 55
years and older, who were free of CVD and
diabetes at baseline. Nutrient intake was
estimated using a 170-item semi-quantitative
food frequency questionnaire. To estimate the
phylloquinone and menaquinone intake we
compiled a new vitamin K food composition
table using analytical and literature-based
values. The occurrence of CHD and stroke was
confirmed through medical records.
Associations of phylloquinone and
menaquinone intake with CHD and stroke
incidence were examined using multivariable
Cox proportional hazard models.
Results: Participants had a mean phylloquinone
intake of 191.7 mcg/day and a mean
menaquinone intake of 49.4 mcg/day. During
follow-up from 1990 to 2011, 460 CHD cases
and 546 stroke cases were confirmed. In
multivariable-adjusted analyses, we found no
associations of phylloquinone (HR: 0.94; 95%CI:
0.72-1.23) or menaquinone intake (0.97; 0.751.26) with CHD incidence when comparing the
highest to the lowest tertile of intake. Stroke
incidence was also not associated with
phylloquinone (1.22; 0.96-1.55) or
menaquinone intake (0.86; 0.68-1.10).
Moreover, we found no associations with CHD
or stroke incidence when analysing the intake
of short-chain (MK-4 through MK-6) and long-
chain menaquinones (MK-7 through MK-10)
separately.
Conclusion: In this study, phylloquinone and
menaquinone intake were not associated with
risk of CHD or stroke.
A.I.P. Engelen: B. Research Grant; Significant;
TI Food and Nutrition, a public private
partnership of science, industry and
government.. J.M. Geleijnse: None. C. Vermeer:
None. J.C.M. Witteman: None. A. Hofman:
None. O.H. Franco: None. E.J.M. Feskens:
None.
P051
Healthy Lifestyle Factors are Uncommon and
Associated with Reduced Risk of
Cardiovascular Disease and Mortality in
Candidates for Primary Prevention with Statin
Therapy
John N Booth III, Lisandro D. Colantonio, Mary
Cushman, George Howard, Monika Safford,
Maciej Banach, Kristi Reynolds, Paul Muntner,
Univ of Alabama at Birmingham, Birmingham,
AL
Introduction: Adults with a 10 year predicted
atherosclerotic cardiovascular disease (ASCVD)
risk ≥7.5% are candidates for statin therapy for
primary prevention. Lifestyle interventions may
benefit this high risk group. Hypothesis: We
estimated the use of healthy lifestyles and their
association with ASCVD and mortality risk in
adults with a 10 year predicted ASCVD risk
≥7.5%. Methods: The REasons for Geographic
and Racial Differences in Stroke cohort study
enrolled adults ≥45 years old from the 48
continental US states and District of Columbia in
January 2003 - October 2007 (n=30,239). The
final sample was restricted to adults 45 - 79
years old, without ASCVD or diabetes history,
low density lipoprotein cholesterol 70 - 189
mg/dL and a 10 year predicted ASCVD risk
≥7.5% (n=5,709). Ideal lifestyle factors, assessed
during an in-home physical exam and through
surveys, included non-obese waist
circumference (<88/<102 cm for women/men),
physical activity (PA) ≥4 times per week,
nonsmoking, low saturated fat intake (<7.0% of
daily calories) and highest Mediterranean diet
score quartile. Participants were contacted
every 6 months to detect incident ASCVD
events (nonfatal/fatal stroke, nonfatal
myocardial infarction or coronary heart disease
death) and all-cause mortality for adjudication.
Results: The prevalence of ideal lifestyles was
56.9% for non-obesity, 33.5% for PA, 80.7% for
nonsmoking, 7.1% for low saturated fat intake,
and 27.6% for highest Mediterranean diet score
quartile. Overall, 4.8%, 27.2%, 35.5%, 23.5%
and 9.0% had 0, 1, 2, 3, and ≥4 of the 5 ideal
lifestyles. There were 377 ASCVD events and
471 deaths (median follow up: 5.8 and 6.0
years, respectively). After multivariable
adjustment, there was a graded association for
lower ASCVD incidence and mortality with 1, 2,
3 and ≥4 versus 0 ideal lifestyles (Table 1).
Conclusion: Healthy lifestyles were underused
in adults with a 10 year predicted ASCVD risk
≥7.5%. Improving lifestyle factors may
significantly reduce ASCVD and delay mortality
in this high risk population.
J.N. Booth: None. L.D. Colantonio: None. M.
Cushman: None. G. Howard: None. M. Safford:
C. Other Research Support; Significant; Amgen
Inc. M. Banach: None. K. Reynolds: C. Other
Research Support; Significant; Amgen Inc. P.
Muntner: C. Other Research Support;
Significant; Amgen Inc.
P052
Coronary Heart Disease Mortality Declines in
the United States From 1980 through 2011:
Evidence for Stagnation in Young Adults,
Especially Women
Kobina A Wilmot, Emory Univ, Atlanta, GA;
Martin O’Flaherty, Simon Capewell, Univ of
Liverpool, Liverpool, United Kingdom; Earl S.
Ford, Ctrs for Disease Control and Prevention,
Atlanta, GA; Viola Vaccarino, Emory Univ,
Atlanta, GA
Background
Cardiovascular mortality rates have fallen
dramatically over the past four decades.
However, recent unfavorable trends in coronary
heart disease (CHD) risk factors among young
adults (obesity, diabetes, and tobacco use) raise
concerns about their subsequent impact on
CHD mortality. Furthermore, recent data from
the US and other countries suggest a worsening
of CHD incidence and mortality among young
women. We therefore examined recent trends
in CHD mortality rates in the US according to
age and sex.
Methods
We used mortality data between 1980 and
2011 from US adults ≥ 25 years. We calculated
age-specific CHD mortality rates and estimated
annual percentage change (EAPC) for US adults,
and compared three decades of data (19801989, 1990-1999, and 2000-2011). We also
used Joinpoint regression modeling to assess
changes in trends over time, based on inflection
points of the mortality distribution.
Results
Young men and women (aged<55 years)
showed a robust decline in CHD mortality from
1980 until 1989 (EAPC -5.5% in men and -4.6%
in women). However, the two subsequent
decades saw stagnation with minimal
improvement (Table). This was particularly true
for young women who had no improvements
between 1990 and 1999 (EAPC +0.1%), and only
-1% EAPC since 2000. In contrast, older adults
(65+years) showed steep annual declines since
2000, approximately doubled compared with
the previous period (women, -5.0% and men, 4.4%). Jointpoint analyses provided consistent
results.
Conclusions
The dramatic declines in cardiovascular
mortality since 1980 conceals major
heterogeneities. CHD death rates in older
groups are now falling steeply. However, young
men and women have enjoyed small decreases
in CHD mortality rates since 1990. The drivers of
these major differences in CHD mortality trends
by age and sex needs urgent study.
K.A. Wilmot: None. M. O’Flaherty: None. S.
Capewell: None. E.S. Ford: None. V. Vaccarino:
None.
P053
Modifiable Risk Factors for Prevention of
Cardiovascular Disease and Mortality in
Middle-Aged Women: Systematic Review and
Meta-Analysis
Veronica Colpani, ERASMUS MC, Rotterdam,
Netherlands; Cristina Baena, PUCPR, Curitiba,
Brazil; Loes Jaspers, Ziba Farajzadegan, Klodian
Dhana, Gilson Veloso, Myrte Tielemans,
Maryam Kavousi, ERASMUS MC, Rotterdam,
Netherlands; Rajiv Chowdhury, Univ of
Cambridge (UC), Cambridge, United Kingdom;
Oscar Franco, ERASMUS MC, Rotterdam,
Netherlands
INTRODUCTION: Modifiable risk factors can play
major role to prevent adverse outcomes but
their specific contribution in this phase of
women's life course remains unclear.
HYPOTHESIS: We assessed evidence on the
effects of different modifiable risk factors on
preventing CV events and mortality in middleaged women.
METHODS: Systematic searches of medical
databases (Pubmed, Embase, Medline, WoS,
Lilacs, Scielo, PsycInfo, Popline and Google
Scholar), reference lists of relevant studies and
correspondence with authors in the field were
conducted up to August 11th 2014. We selected
and extracted data from cohort studies, which
reported the association between leisure
physical activity (LPA) levels and coronary heart
disease (CHD),stroke, CV deaths and all-cause
mortality in women (>40 years old). For PA we
calculated study specific relative risks (RR)
comparing highest to lower exposure categories
in each study. Lower categories of LPA were
equivalent to ≤ 3 METS h/week, higher
categories of LPA were equivalent to ≥21 METS
h/week. For smoking we compared current to
never smokers. For alcohol intake, we
compared moderate intake (≤ 12 g/day) to nondrinkers. Pooled RR were meta-analysed using
random effect models. Heterogeneity was
analysed by I 2. Quality scores were based on
New-Castle Ottawa Scale and levels of
adjustment.
RESULTS: Of the 6582 references searched, 37
cohort studies were included in the systematic
review reporting effects of modifiable risk
factors in 3,637,512 participants and 24,561
CHD events, 18,347 stroke events, 22,833 CV
deaths and 166,504 all cause deaths. Metaanalysis of available information on LPA
revealed RR (CI 95%) of 0.71 (0.61;0.83) for CHD
events (I 2= 47 % p= 0.067), 0.77(0.67;0.88) for
stroke events (I 2= 0 % p= 0.68) ,0.70 (0.58;0.84)
for CV deaths (I 2= 59.3 % p= 0.086), 0.70
(0.65;0.76) for death from all causes (I 2= 13.4
%; p= 0.329). Meta-analysis of smoking habits
showed RR (95%)3.12 (2.15;4.52) for CHD
events (I 2= 98.4% p< 0.001), 2.09 (1.51;2.89)
for stroke (I 2= 96.3% p< 0.001), 2.76
(1.62;4.71) for CV deaths (I 2= 98.5 % p< 0.001),
2.22 (1.92;2.57) death from all causes (I 2= 97.3
%; p< 0.001). Meta-analysis of alcohol intake
showed RR (95%)0.75 (0.62;0.91) for CHD
events (I 2= 47.6% p=0.075), 0.61 (0.60;0.62) CV
deaths (I 2= 0 % p=0.510), 0.87 (0.79;0.96)
death from all causes (I 2= 76 %; p< 0.001).
Studies showed generally high quality.
CONCLUSION: Evidence from observational
studies indicates that these modifiable risk
factors play a major role in CV events and
deaths in middle-aged women. Prevention
strategies should focus on encouraging middle
aged women to practice moderate to vigorous
physical activity frequently, never smoking and
moderate drinking.
V. Colpani: None. C. Baena: None. L. Jaspers:
None. Z. Farajzadegan: None. K. Dhana:
None. G. Veloso: None. M. Tielemans:
None. M. Kavousi: None. R. Chowdhury:
None. O. Franco: None.
P054
Prevalence and Sociodemographic
Determinants of Cardiovascular Health in a
Sample of Adults From a Developing Country:
Results From the Chicamocha Cohort Study
Víctor M. Herrera, Univ Autónoma de
Bucaramanga, Floridablanca, Colombia;
Christina M. Shay, Univ of North Carolina at
Chapel Hill, Chapel Hill, NC; Yeny Z. Castellanos,
Juan C. Villar, Univ Autónoma de Bucaramanga,
Floridablanca, Colombia
Background. The novel AHA's concept of
cardiovascular health (CVH) extends the
traditional factor composition by incorporating
promotion of primordial prevention into a more
comprehensive framework. We aimed to
estimate the prevalence of CVH and to identify
potential sociodemographic determinants in a
sample of adults from Colombia. Methods. We
conducted a cross-sectional analysis on a
subsample of adults, free of transfusiontransmitted infectious and cardiovascular
diseases, who attended to a follow-up
evaluation of the CHICAMOCHA cohort study.
We determined the proportion of participants
with ideal healthy behaviors (never/former
smoking, ≥150 minutes/week of moderatevigorous physical activity, and consumption of
≥5 servings of fruits and vegetables per day)
and health factors, including body mass index
(<25 kg/m2), untreated blood pressure
(<120/80 mmHg), untreated fasting total
cholesterol (<200 mg/dl), and untreated fasting
glucose (<100 mg/dl, untreated). Educational
attainment and socioeconomic stratification
were assessed and dichotomized. We estimated
prevalence ratios (PRs) and 95% confidence
intervals (95%CI) for a high cardiovascular
health score (≥4/7 vs. <4/7 ideal items) using
multiple binomial regression. Results. We
evaluated 624 participants (mean age = 50.3
years; 64.6% male). Ideal diet was the least
prevalent CVH component (0.5%) and ideal
smoking status was the most frequent
component (90.4%). Prevalence of the number
of ideal cardiovascular health components was
2.3%, 48.2%, 46.3%, and 3.2% for 0-1, 2-3, 4-5,
and 6-7 items, respectively. Age and
educational attainment, but not sex or SES,
were associated with higher numbers of CVH
components. In a multivariate model including
age, sex, and education, older participants were
less likely to have a higher number of CVH
components and there was evidence of an ageby-education interaction (p=0.018). PRs for a
high cardiovascular health score were 0.60
(95%CI: 0.48, 0.75) and 0.40 (95%CI: 0.29, 0.55)
in participants with low educational attainment
aged 45-55 and ≥55 years old, as compared to
participants <45 years old, respectively. PRs for
the same contrasts but among participants with
high educational attainment were 0.84 (95%CI:
0.67, 1.05) and 0.70 (95%CI: 0.52, 0.93),
respectively. Conclusion. Colombians exhibit
fewer components of ideal CVH with increasing
age; however, educational attainment seems to
attenuate this age-related loss of CVH, an effect
that might be explained by higher levels of risk
factors awareness and treatment adherence.
V.M. Herrera: None. C.M. Shay: None. Y.Z.
Castellanos: None. J.C. Villar: None.
P055
Six-Month Changes in Ideal Health and
Cardiovascular Risk Scores Among Young
Adults Enrolled in a Weight Loss Intervention
Bethany Barone Gibbs, Wendy C. King, John M
Jakicic, Univ of Pittsburgh, Pittsburgh, PA
The Framingham 10-year (FRS-10) and lifetime
(FRS-LIFE) risk scores use clinical CVD risk
factors to predict coronary heart disease (CHD)
and CVD outcomes, respectively. In contrast,
the AHA’s Ideal Cardiovascular Health (IDEAL)
paradigm encourages a 7-component, healthy
phenotype that additionally includes healthy
diet, body mass index (BMI), and physical
activity behaviors that are also associated with
the avoidance of developing cardiovascular
disease (CVD).
Objective: To compare changes in IDEAL, FRS10, and FRS-LIFE over 6 months in young adults
enrolled in a behavioral weight loss intervention
Methods: FRS-10 and FRS-LIFE were calculated
using published equations at baseline and 6
months in young adults who were overweight
or obese at study entry but otherwise healthy.
IDEAL was calculated on a 14-point scale where,
for each component, 0, 1, or 2 points were
given for ‘poor’, ‘moderate’, or ‘ideal’
classification, respectively. Descriptive statistics
are reported as % or median [IQR]. McNemar’s
test, test of symmetry, and Wilcoxon signed
rank test were employed to evaluate pre- to
post-intervention changes. Spearman’s
correlations evaluate associations.
Results: In 335 young adults, age 31 [27, 34] yrs,
BMI 31 [28, 34] kg/m2, and 32% male, the
intervention achieved significant 6-month
decreases in BMI: -3.0 [-4.3, -1.5] kg/m2. Out of
a possible 14 points (higher is better), IDEAL
was 9 [8, 10] at baseline and 11 [10, 12] at 6
months, with 73% improving and 9% worsening
(net improvement 64%) (p<.0001). Though<1%
ever had IDEAL diet, a net improvement in diet
was observed in 19%, with specific
improvements in sugar-sweetened beverage
and sodium components (p<0.001). Significant
net improvements were also observed in IDEAL
classification for BMI (49%), physical activity
(39%), total cholesterol (14%), blood pressure
(14%) and glucose (11%) components (all
p<.0001). FRS-10 was negligible (<1%) for 88%
of the cohort at baseline and 94% at 6 months.
Across predicted FRS-10 scores, 7% improved
and 2% worsened (net improvement 5%) over
the 6 months (p<.0001). Improved FRS-10 and
IDEAL were correlated (Spearman’s rho = -0.49,
p<0.001). IDEAL had a stronger correlation with
change in weight compared to FRS-10
(Spearman’s rho = -0.49 vs. 0.30; both p<0.001).
FRS-LIFE indicated lifetime risk was high for 35%
of the cohort at baseline and 22% at 6 months
(p<.0001). FRS-LIFE as a 5-category scale
improved in 38% and worsened in 13% (net
improvement 26%) (p<.0001).
Conclusions: In a cohort of overweight or
obese, but otherwise healthy, young adults
enrolled in a weight loss intervention, IDEAL
was able to measure positive lifestyle changes
in a majority of participants while the FRS-10
and FRS-LIFE did not. These results suggest that
IDEAL may be particularly sensitive and
appropriate to detect positive cardiovascular
health changes in the growing population of
overweight and obese young adults.
B. Barone Gibbs: None. W.C. King: None. J.M.
Jakicic: None.
Great Rivers Affiliate (Delaware, Kentucky,
Ohio, Pennsylvania & West Virginia)
P056
Emerging Lifestyle Markers Predict Regression
of Carotid Intima-Media Thickness Scores
Steven C Masley, Univ of South Florida, St
Petersburg, FL; Richard Roetzheim, Univ of
South Florida, Tampa, FL; Lucas V Masley,
Timothy McNamara, Univ of South Florida, St
Petersburg, FL; Douglas D Schocken, Duke Univ
Medical Ctr, Durham, NC
Introduction: CVD remains the number one
cause of mortality in the western world. Carotid
intima-media thickness (IMT) is a safe & reliable
predictor of future CVD risk. This study assesses
which lifestyle factors best predict a change in
IMT over time.
Hypothesis: We assessed the null hypothesis
that all lifestyle changes are effective.
Methods: A prospective cross-sectional analysis
of 289 men & women undergoing health &
cardiovascular risk screening every 1-2 years at
an outpatient wellness center in Florida. This
study reflects the first visit at the clinic, & a
second visit that occurred on average 2.8 years
later. These subjects ranged in age from 23-65
(mean = 48.2). In addition to testing, subjects
received nutrition, fitness, & health coaching.
Measurements were made of fitness using
VO2max stress testing, diet intake using a 3-day
dietary intake survey. Laboratory &
anthropometric measures were obtained
fasting. Mean IMT scores used high resolution
B-mode ultrasonography of the common
carotid arteries. Each subject had ≥10 images
collected from the far wall of both distal 1 cm of
the common carotid arteries at end diastole.
The carotid intimal thickness was measured as a
continuous variable, using both multivariate &
bivariate linear regression, adjusting for age &
gender; as our site IMT precision was = 3%, we
selected a 4% change as significant.
Results: The average decrease in IMT score in
this cohort was -0.018 mm over 2.8 years, a
2.04% reduction. The bivariate analyses
showing a significant association with a ≥4%
reduction in IMT in 62 of 288 subjects; they
were a decrease in: Body mass index (BMI)
(p=0.047), body fat (p=0.025), total cholesterol
(TC) (p=0.031), LDL cholesterol (p=0.028),
TC/HDL (0.002), or an increase in dietary intake
of: magnesium (p=0.0001), fiber (p=0.017),
vitamin D (p=0.016), vitamin K (p=0.001),
potassium (p=0.001), & calcium (p=0.024). In a
multivariate analysis, starting a statin
medication (p=0.0007), a decrease in BMI
(p=0.042), baseline IMT, male gender, diastolic
BP decrease, & years of follow up were
predictive of 4% IMT decline. Prior use of a
statin medication was not significant.
Conclusions: In conclusion, this study shows
that a reduction in IMT score over 2.8 years is
associated with a decrease in: BMI, body fat, TC,
LDL, TC/HDL ratio, & diastolic BP; or, an
increase in intake of: magnesium, fiber,
vitamins K & D, potassium, & calcium; or,
starting a statin medication.
S.C. Masley: None. R. Roetzheim: None. L.V.
Masley: None. T. McNamara: None. D.D.
Schocken: None.
P057
Cardiovascular Diseases and Cancer Incidences
Associated With Cardiovascular Risk Profile:
Results from MATISS Italian Cohort
Smona C Ursu, Luigi Palmieri, Simona
Giampaoli, Istituto Superiore di Sanità, Rome,
Italy; Fabio Pannozzo, Population Carcer
Registry, Latina, Italy; Cinzia Lo Noce, Istituto
Superiore di Sanità, Rome, Italy; Annarita Vestri,
Sapienza Univ of Rome, Rome, Italy; Jeremiah
Stamler, Feinberg Sch of Med, Northwestern
Univ, Chicago, IL
Background: Individuals with low levels of
cardiovascular risk factors experience low
incidence of subsequent cardiovascular diseases
(CVD). The aims of this study were to assess
cancer incidence in people with favorable (low)
CVD risk profile and its association with
educational level (EL).
Methods: The MATISS longitudinal cohort
comprised 3609 men and 4146 women aged 2070 years, free of CVD and cancer at baseline
with validated non-fatal and fatal CVD and
cancer events during a median 17.7 years of
follow-up. People at baseline were classified as
‘low risk’ with total cholesterol <240 mg/dl and
blood pressure <140/90 mmHg and BMI <30.0
kg/m2 and no hypertension treatment and no
diabetes and no smoking habit and ‘high risk’
(total cholesterol >=240mg/dl or blood pressure
>=140/90 mmHg or BMI >=30.0 kg/m2 or
hypertension treatment, diabetes, smoking). EL
was classified as low (LEL=elementary school)
and middle-high (MHEL=middle/high
school/university).
Results: 724 cancer and 571 CVD events
occurred; 22.7% of participants were ‘low risk’;
77.3% were ‘high risk; 61.5% had LEL. Cancer
and CVD incidences increased with age; ageadjusted cancer and CVD incidence were higher
in men compared to women (cancer: 68.92
versus 48.95 x 10,000 person-years; CVD: 64.18
versus 29.5 x 10,000 person-years). Incidences
of cancer and CVD were higher in LEL (cancer:
83.22 versus 50.35 x 10,000 person-years in
men and 51.67 versus 33.59 x 10,000 personyears in women; CVD: 70.07 versus 64.84 x
10,000 person-years in men and 30.72 versus
17.89 x 10,000 person-years in women).
Persons with ‘low risk’ profile experienced less
cancers and CVD than persons with ‘high risk
(cancer: 37.66 versus 72.3 x 10,000 personyears in men and 39.57 versus 50.07 x 10,000
person-years in women; CVD: 18.49 versus
69.75 per 10,000 person-years in men and
20.34 versus 30.7 x 10,000 person-years in
women). In analysis by risk profile and EL
considered together for both genders rates of
both CVD and cancer were highest in those with
less education classified as high risk (cancer:
85.2 versus 56.13 x 10,000 person-years in men
and 50.97 versus 35.12 x 10,000 person-years in
women; CVD: 74.58 versus 69.06 per 10,000
person-years in men and 30.87 versus 22.69 x
10,000 person-years in women).
Conclusions: Increasing educational levels and
prevalence of low CVD risk profile in the general
population may be effective strategies for
population-wide CVD and cancer prevention.
S.C. Ursu: None. L. Palmieri: None. S.
Giampaoli: None. F. Pannozzo: None. C. Lo
Noce: None. A. Vestri: None. J. Stamler: None.
P058
Serum Fibroblast Growth Factor-23 Does Not
Have a Linear Relation to Cardiovascular
Mortality
Karl Krupp, Florida Intl Univ, Miami, FL; Emir
Veledar, Baptist Health South Florida, Miami,
FL; Purnima Madhivanan, Florida Intl Univ,
Miami, FL; Robert Cook, Univ of Florida,
Gainesville, FL; Khurram Nasir, Baptist Health
South Florida, Miami, FL
Introduction:
Fibroblast Growth Factor 23 (FGF23) is bonederived hormone regulating phosphate
homeostasis as part of a newly described bonekidney axis. Several studies have demonstrated
that elevated circulating FGF23 levels are
independently associated with cardiovascular
mortality.
Methods:
A systematic review was conducted according
to Meta-analysis of Observational Studies in
Epidemiology Group guidelines. Six databases
(PubMed-Central, Ovid-MEDLINE, EMBASE,
Web of Science, BIOSIS and Cochrane Database
of Systematic Reviews) were searched for
articles published between 2000 and 2014
examining the longitudinal association between
FGF23 and CVD mortality among populations
without prior CVD, Chronic Kidney Disease, or
Diabetes. The review yielded 1,961 articles, of
which 982 met the inclusion criteria. About 893
abstracts were excluded during the title and
abstract screen, and an additional 92 after full
text review. Only three articles met the review
criteria and were included in the meta-analysis.
Data from selected articles were abstracted and
independently assessed for quality by two
reviewers. Summary estimates and associated
95% confidence intervals were included in fixed
and random-effects models. The presence of
heterogeneity was evaluated using a Q-statistic
with a conservative p-value of 0.10. All analyses
were performed using R library meta.
Results:
Data for 15,379 participants were included in
the meta-analysis. The hazard ratio for quartiles
two and four when compared with quartile
one,the reference category, were 1.29 (1.061.58; p=0.01) and 1.31 (1.077-1.59; p=0.0068)
respectively. There was no significant difference
in CVD mortality between the third and first
quartile. There was also no evidence of
heterogeneity observed (I2 = 0%, p = 0.611).
Conclusions:
This study found a U-shaped association
between FGF23 and CVD mortality suggesting
that either low or high serum levels increase
risk for CVD mortality. Current strategies focus
on lowering high levels of circulating FGF23, but
little attention has been given to understanding
optimal levels necessary to prevent CVD
mortality. If this U-shaped relationship between
FGF23 and CVD mortality is real, the possible
links, causes, and mechanisms require
additional research.
K. Krupp: None. E. Veledar: None. P.
Madhivanan: None. R. Cook: None. K. Nasir:
None.
P059
Arterial Thickness and Stiffness are
Independent Predictors of Myocardial Strain
Connie E McCoy, Philip R Khoury, Stephanie N
Stewart, Lauren E Longhshore, Nicolas L
Madsen, Lawrence M Dolan, Thomas R Kimball,
Elaine M Urbina, Cincinnati Children's Hosp,
Cincinnati, OH
Vascular dysfunction is associated with cardiac
dysfunction, a precursor of CV events (MI,CHF)
in adults. We hypothesized that abnormalities
in vascular structure and function are
associated with cardiac systolic dysfunction as
measured by cardiac strain and strain rate in
young adults.
Carotid ultrasound and echocardiography were
performed on 338 subjects (22.2 + 3.7 years;
38% male (M); 63% non-white (NW); 33% lean,
36% obese and 31% T2DM). CIMT was traced
along the far wall of the distal CCA, bulb, and
proximal ICA. Stiffness measures included
carotid-femoral pulse wave velocity (PWVf),
brachial distensibility (BrachD) and Peterson’s
Elastic Modulus in the CCA (PEM). LV systolic
function was assessed by global longitudinal (4chamber) strain (GS) and strain rate in systole
(GSRs). Anthropometry, BP, HR, fasting lipids,
CRP, and glucose were collected. Correlations
were calculated between vascular measures
and cardiac strain. General linear models were
constructed to determine if vascular measures
were independent predictors of GS and GSRs.
Covariates included age, sex, race, BMI z-score,
MAP, group, TG, HDL, LDL, insulin, glucose, and
CRP.
GS and GSRs correlated with peripheral arterial
stiffness (lower BrachD, higher PEM, higher
PWVf) and structure (thicker CIMT), all p<.01
(Figure). After adjusting for other risk factors,
BrachD was an independent predictor of poorer
GSRs: GSRs=-1.1611 -.13*BrachD + .05 (if M) +
.06 (if NW) + .004*MAP - .0003*glucose +
.07*Insulin. CCA IMT independently predicted
both GS and GSRs: GS=-.26 + 4.6* CCA + .92 (if
M) + .58*BMIZ + .56*MAP- .03*HDL +
1.06*insulin; GSRs= -1.4 + .26*CCA+ .05 (if M) +
.03*BMIZ + .003*MAP - .0003*glucose +
.06*Insulin. All factors were significant at p<.05
in these models.
We conclude that adverse pre-clinical vascular
and cardiac findings are present in youth
simultaneously and may increase risk for future
CV events. Assessment of vascular structure and
function may add incremental benefit in
stratifying risk in young adults for future CV
events.
C.E. McCoy: None. P.R. Khoury: None. S.N.
Stewart: None. L.E. Longhshore: None. N.L.
Madsen: None. L.M. Dolan: B. Research Grant;
Modest; R01 HL105591-01. T.R. Kimball: B.
Research Grant; Modest; R01 HL105591-01.
E.M. Urbina: B. Research Grant; Significant; R0
1HL105591-01.
P060
Factors Affecting Cardiovascular Risk
Perception in Subjects Submitted to a Routine
Health Evaluation
Thais N Helou Sr., Raul D Santos, Antonio G
Laurinavicius, Fabio G Franco, Raquel D
Conceicao, Jose A Carvalho, Antonio E Pesaro,
Fernando M Silva, Mauricio Wajngarten,
Marcelo Katz, Hosp Israelita Albert Einstein, Sao
Paulo, Brazil
Introduction: Cardiovascular (CV) disease
remains the main cause of death worldwide and
preventive measures may decrease CV adverse
events. Individuals’ subjective perception of
own CV risk has been pointed as a key driver for
patients’ engagement on medical
recommendations. However, recent studies
indicate that subjects usually are hypo-
perceivers and may underestimate their own CV
risk. Fewer studies have evaluated the factors
associated with CV risk hypo-perception.
Therefore, the aim of this study was to test the
association between clinical characteristics and
individual’s perception of CV risk.
Hypothesis: traditional CV risk factors would be
associated with subjects’ perception of CV risk.
Methods: Patients (n = 5,863, 47.9 ± 6.2 years,
22.1% female) who underwent a routine health
evaluation, and for whom the lifetime risk score
(LRS) indicated an intermediate or high CV risk
were included in this analysis. All individuals
subjectively rated their CV risk for the next
years as low, intermediate or high, and this
perception was compared to the LRS.
Individuals were then classified as hypoperceivers, i.e. perceived risk lower than
estimated risk and normo-perceivers, i.e.
perceived risk coincident with the estimated
risk. Logistic regression analysis was performed
to test the association between clinical
characteristics (including CV risk factors) and
individuals’ perception of risk. P<0.05 was
considered statistically significant.
Results: Cardiovascular risk was intermediate in
45.7% and high in 54.3% of individuals as
provided by de LRS. When comparing the LRS
with subjects’ perception of risk, 4,918 (83.9%)
were hypo-perceivers and 945 (16.1%) were
normo-perceivers. By adjusted logistic
regression analysis, age (OR=1.02 [95%CI 1.011.04]; p=0.006), smoking (OR 2.04 [95%CI 1.432.91]; p<0.001), dyslipidemia (OR 1.21 [95%CI
1.01-1.46]; p=0.043), physical activity (OR 1.67
[95%CI 1.37-2.03]; p<0.001) and use of
medications (OR 3.50 [95%CI 2.55-4.81];
p<0.001) increased the chance of risk hypoperception, while a higher BMI (OR 0.36 [95%CI
0.28-0.47]; p<0.001), hypertension (OR 0.57
[95%CI 0.41-0.80]; p=0.001), depression (OR
0.46 [95%CI 0.37-0.57]; p<0.001) and stress (OR
0.40 [95%CI 0.33-0.49]; p<0.001) decreased the
chance of risk hypo-perception. Diabetes and
gender were not associated with individuals’
perception of risk.
Conclusions: Among asymptomatic individuals
submitted to a routine medical evaluation there
was a high prevalence of hypo-perception of CV
risk. Aging, smoking, dyslipidemia, physical
activity and the use of medications were
associated with a higher chance of risk hypoperception. Thus, subjects in these conditions
may benefit from a more careful risk
orientation on health check-ups.
T.N. Helou: None. R.D. Santos: D. Speakers
Bureau; Modest; Astra Zeneca, Biolab,
Boehringer-Ingelheim, Amgen, Sanofi, Novartis,
Eli Lilly, Bristol Myers Squibb, Pfizer,
Genzyme. A.G. Laurinavicius: None. F.G.M.
Franco: None. R.D.O. Conceicao: None. J.A.M.
Carvalho: None. A.E.P. Pesaro: None. F.M.F.
Silva: None. M. Wajngarten: None. M. Katz:
None.
P061
Dietary Intake of Saturated Fat by Food Source
and Incident Coronary Heart Disease: the
Zutphen Elderly Study
Janette de Goede, Sabita S. Soedamah-Muthu,
Eirini Trichia, Johanna M. Geleijnse, Daan
Kromhout, Wageningen Univ, Wageningen,
Netherlands
Introduction
Associations of saturated fatty acids (SFA)
with coronary heart disease (CHD) may depend
on their food source. We examined
the association of SFA intake from different
food sources, with 15-year
incidence of coronary heart disease (CHD) in
elderly men in the Netherlands.
Methods
Data were collected from 686 elderly men from
the Zutphen Elderly Study, aged 65-85 years
with no CHD or diabetes mellitus. At
baseline (1985), habitual diet was assessed with
a cross-check dietary history
method. Information on vital status and
incidence of CHD (fatal CHD and
nonfatal myocardial infarction) until July 1,
2000 was assessed through municipal
population registries and hospital or GP records.
Hazard ratios (HR) were
calculated with Cox proportional-hazards
models, adjusted for age, lifestyle (smoking,
BMI, physical activity, socioeconomic status,
and alcohol consumption) and
dietary factors including total energy,
carbohydrates, protein, monounsaturated
fatty acids, trans fatty acids and dietary fibre. In
addition, substitution
models were used to estimate the exchange of
2 en% SFA from different sources,
i.e. dairy, meat, and plant or butter SFA.
Results
During 15 years of follow-up, we observed 132
incident CHD events. Across tertiles (T), the
intake of SFA ranged from 14.2
(T1) to 21.7 (T3) energy percent (en%). Plant or
butter SFA contributed for 37
en% to total SFA intake, followed by dairy (27%)
and meat (17%). Total SFA
intake correlated most strongly with plant or
butter SFA (r=0.71). Spearman
correlation coefficients of total SFA with dairy
and meat were 0.34 and 0.09
respectively (all p<0.05). The intake of total SFA
was not significantly
associated with CHD (HR: 0.76; 95%CI: 0.411.39) for T3 vs T1. HRs for plant or
butter SFA, dairy SFA, and meat SFA were 0.96
(0.55-1.69), 0.82 (0.48-1.40),
and 1.64 (0.89-3.04) respectively, for the top
compared to the bottom tertile. A
2 en% higher intake of SFA from dairy or meat,
exchanged with plant or butter
SFA, resulted in a HR of 0.98 (95% CI: 0.79-1.20)
for dairy and 1.12
(0.75-1.66) for meat. The HR (95% CI) for an
exchange of 2 en% SFA from dairy
with SFA from meat was 1.15 (95% CI: 0.801.66).
Conclusion
In Dutch elderly men, total SFA or SFA from
specific food
sources were not significantly associated with
incident CHD. The association of
SFA from meat with CHD deserves further
attention.
J. de Goede: None. S.S. Soedamah-Muthu:
None. E. Trichia: None. J.M. Geleijnse: None. D.
Kromhout: None.
P062
Cardiovascular Health Awareness Among
School Children in the Rural District of
Midnapore, India: A School-Based Survey
Madhab Ray, Lahey Hosp and Medical Ctr,
Burlington, MA
Introduction: India is the second most populous
country in the world with two thirds of the
population in their youth. With economic
development and adoption of a western
lifestyle, a large number of people in India will
be affected by cardiovascular disease (CVD). As
atherosclerosis starts in the second decade of
life and many of the risk factors are better
controlled if addressed early, health awareness
among the school children assumes a central
role for primary prevention. Currently, there is
no established school health program for health
education about CVD in India. This survey was
conducted to assess the present level of health
awareness about CVD in the adolescent school
children with a goal to establish school-based
health education, early detection of different
risk factors and development of heart healthy
lifestyle.
Methods: A school-based survey was conducted
between 15th of June and 15th of July, 2014 as a
joint venture of Tufts University, USA and
Kolkata Medical College, India in the rural
district of Midnapore, India with approval from
the IRB of Tufts University and the local ethics
committee. This involved a pre-test with 20
questions each having 5 statements, a power
point presentation by a physician of the study
team, and a post-test using the same questions.
The data were analyzed by the cluster sampling
design method.
Results: Nine hundred and fifty nine students
(32 %) participated in the survey out of a target
population of 3003 from 11 schools with a
mean age 14.5 years, 58% male, 59% grade IX
and 41% grade X. Prevalence of known CAD
among the parents (as reported by the
students) was 3% and current history of
smoking (26%) was the predominant risk factor,
while other identified risk factors were less
common (hypertension 5%, diabetes mellitus
4%, and hyperlipidemia 3%). In the pretest
evaluation, the mean score was 41/100 (IQR 3348 and SD ± 10.5) with an improvement by 7%
in the post test results (IQR 36-59, SD ± 16.9).
This improvement was highly significant by
Wilcoxon signed rank test with continuity
correction (p <0.001). A
multivariable regression analysis showed family
history of hypertension (p = 0.01) and higher
parental education (p = 0.02) were the main
determinants for an improved score.
Conclusions: Cardiovascular health awareness
was modest among the adolescent school
children in the population under study. A
school-based educational program may help
improve awareness and reduce disease burden
in this community.
M. Ray: None.
P063
Defects in Well-Being Psychological Factors
Rather Than Ill-Being Factors Are Predictors of
Acute Coronary Syndrome: A Comprehensive
Lifestyle Analysis
Ick-Mo Chung, Ewha Womans Univ Sch of Med,
Seoul, Korea, Republic of; Jisun So, Seoul Natl
Univ, Seoul, Korea, Republic of; Jihyeon Seo,
Yonsei Univ, Seoul, Korea, Republic of; Hyejin
Chun, Byungmi Kim, Ewha Womans Univ Sch of
Med, Seoul, Korea, Republic of; Kyong-Mee
Chung, Yonsei Univ, Seoul, Korea, Republic of;
Sung Nim Han, Seoul Natl Univ, Seoul, Korea,
Republic of
Introduction: An increasing body of evidence
suggests that development
of coronary artery disease (CAD) is probably
affected by a variety of lifestyle factors.
However, most studies have not assessed
comprehensive lifestyle factors including wellbeing psychological factors simultaneously,
therefore relative contribution of each factors is
obscure. Hypothesis: A variety of lifestyle
factors including defect in well-being
psychological factors may contribute to
development of CAD through interacting
muturally. Methods and Results: A casecontrol, cross-sectional study analyzing
comprehensive lifestyle factors of patients with
acute coronary syndrome (ACS) and healthy
control was conducted. 92 patients with ACS
(73 male; 53.2 yr; 30 acute MI, 62 unstable
angina) and 69 healthy control (43 male; 48.7yr)
were recruited. For dietary analysis, food
frequency questionnaire (FFQ) and 2 days of 24
hour dietary recall were used. Anxiety,
depression, stress, job stress, and hostility were
analyzed to assess psychological ill-being
factors. Primary and secondary control
strategies, health-related quality of life
(HRQoL), and satisfaction degree in 7 life
domains such as marriage, leisure, standard of
living, job, family, sex life, and self were
analyzed to assess well-being factors. Univariate
analysis showed that ACS group vs. control
group had more current/ex-smoker and
exercised less (all, p<0.05). FFQ analysis showed
that ACS group vs. control consumed more
energy intake, fats, proteins, seafoods, and
sweets (all, p<0.05). Psychological analysis
showed that the ACS group had more
depressive score, less mean satisfaction score in
all 7 life domains, and less physical domain of
HRQoL especially in the fields of 1) general
health perceptrion and 2) bodily pain (all
p<0.05). The ACS group vs. control tended to
use more primary control strategy, although not
reaching statistical signifcance. Logistic
regression analysis, after adjustment of age and
gender, identified that mean satisfaction score
in 7 life domains (OR: 9.66), primary control
strategy (OR: 1.92), greater intake of sea foods
(OR 6.53) and sweets (OR: 7.40), exercise (OR:
0.26), and smoking (OR:7.53) were determined
as significant independent predictors of ACS (all,
p<0.05). Conclusions: Defects in well-being
psychological factors rather than ill-being
factors are closely associated with ACS. A
variety of lifestyle factors, especially, poor
satisfaction in 7 life domains, use of primary
control strategy, greater intake of sea foods and
sweets, smoking, and poor exercise are
independent predictors of ACS. Therefore
preventive intervention trial of ACS should
include modification of comprehensive lifestyle
factors including defects in well-being factors.
I. Chung: None. J. So: None. J. Seo: None. H.
Chun: None. B. Kim: None. K. Chung: None. S.
Han: None.
P064
Association of Cardiorespiratory Fitness and
Submaximal Blood Pressure Among Young
Healthy Men- A Reverse J-curve Pattern
Relationship
Vivek K Prasad, Clemens Drenowatz, Arnold Sch
of Public Health, Columbia, SC; Gregory A Hand,
Sch of Public Health, Morgantown, WV; Carl C
Lavie, Ochner Clinical Sch-UQ Sch of Med, New
Orleans, LA; Xuemei Sui, Madison Demello,
Steven N Blair, Arnold Sch of Public Health,
Columbia, SC
Objectives: Exaggerated blood pressure (BP)
response during exercise is an important
marker of cardiovascular events that are
associated with incident hypertension,
atherosclerosis, myocardial infarction, coronary
artery disease and stroke. Cardiorespiratory
fitness (CRF) is associated with a lower risk of
all-cause and cardiovascular disease (CVD)
mortality. The purpose of this study was to
examine the association between CRF and
submaximal BP at various stages of Graded
Exercise Test (GXT) in young healthy men.
Methods: GXT using a Modified Bruce protocol
on a treadmill was performed on 191
normotensive (resting BP < 140/90 mm Hg) men
aged 20-35years. BP was recorded at each stage
of the protocol. Quintiles of fitness were
established on the basis of peak Vo2 with the 1st
quintile being the lowest fit group and 5th
quintile being the highest fit group.
Results: The mean peak Vo2 in quintiles 1, 2, 3,
4 and 5 were 32.3, 39.1, 43.4, 48.1 and 55.5
respectively. A reverse J-curve pattern
relationship was evident between CRF and
submaximal systolic BP. Men in the 3rd quintile
displayed the lowest submaximal systolic BP
levels across all the stages of GXT. There was a
substantial decrease in submaximal BP from
quintile 1 to 3 followed by an increase in higher
quintiles, although still lower than quintile 1.
The J-shaped relationship remained significant
after controlling for potential confounders,
including age, race, body fat percentage, resting
systolic BP, smoking and alcohol intake
(Quadratic trend P value< 0.05).
Conclusion: These findings suggest that in
young healthy men, there is a reverse J-curve
pattern relationship between submaximal BP
and CRF. Improving the CRF from low to
average to high will progressively decrease
submaximal systolic BP and CVD risks. However,
the benefits from improvements in the CRF and
prevention of increased submaximal systolic BP
plateau at a point, beyond which there are no
additional benefits or loss of the benefits (in a
reverse J-curve pattern).
V.K. Prasad: None. C. Drenowatz: None. G.A.
Hand: None. C.C. Lavie: None. X. Sui: None. M.
Demello: None. S.N. Blair: None.
P065
Cross-Sectional and Prospective Associations
of the Cortisol/testosterone and Cortisol/ Sex
Hormone Binding Globulin Ratios With
Atherosclerosis in Women
Ju-Mi Lee, Laura A Colangelo, Northwestern
Univ, Chicago, IL; Joseph E Schwartz, Stony
Brook Sch of Med, New york, NY; Yuichiro Yano,
Northwestern Univ, Chicago, IL; David S.
Siscovick, The New York Acad of Med, New
york, NY; Teresa Seeman, David Geffen Sch of
Med at UCLA, LA, CA; Pamela J Schreiner, Univ
of Minnesota, Minneapolis, MN; Kiang J Liu,
Donald M Lloyd-Jones, Philip Philip,
Introduction: The ability to study chronic stress
in humans is complicated due to measurement
error of questionnaires and the inability of
short-term measures of stress hormones to
reflect the chronic state. Therefore
considerable controversy remains about
whether chronic stress influences
atherosclerosis or not. The
cortisol/testosterone (C/T) ratio was suggested
to be a better predictor of heart disease in men
than cortisol alone, as gonadotropin and
cortisol are derived from the same biochemical
precursor. This ratio has never been studied in a
U.S. epidemiologic study, especially in women.
Study question: Are C/T and C/sex hormone
binding globulin (SHBG) ratio associated with
subclinical atherosclerosis in women?
Methods: In the Coronary Artery Risk
Development in Young Adults (CARDIA) study,
367 women (age range 32 to 51, mean age 40
years old) who had both cortisol from year (Y)
15 and sex hormones from serum specimen Y16
measured are included. Intima-media thickness
(IMT) from Y20 was assessed cross-sectionally.
Coronary artery calcium (CAC) incidence from
Y15-25 was assessed prospectively where
available (n=299). Due to the instability and
diurnal characteristics of cortisol, area under
the curve (AUC) of six samples and slope of 1st
(or 3rd) and 6th (or 5th when 6th is not
available) sample of salivary cortisol collected
over one day were calculated. Ratios of AUC
and of slope of cortisol to total testosterone
(TT), free testosterone (FT), and sex hormone
binding globulin (SHBG) were computed:
AUC/TT, AUC/FT, AUC/SHBG, Slope/TT,
Slope/FT, and Slope/SHBG. The associations of
these variables categorized into tertiles with
CAC and IMT were assessed by logistic
regression analysis (CAC) and multiple linear
regression (IMT). Model I controlled for age and
race. Model II controlled for model I variables
plus BMI, systolic BP, menopause, oral
contraceptive usage, diabetes mellitus, alcohol
consumption, and cigarette smoking.
Results: The highest tertile of AUC/FT ratio was
associated with Y20 carotid bulb IMT max in
model I (β=0.07, p=0.031) and model II (β=0.09,
p=0.006). This ratio also had moderate OR with
incident CAC from Y15 to Y25 in model I (OR
2.22, 95% CI 0.89-5.51) and had significant
association in model II (OR 3.45, 95% CI 1.1810.06).
Conclusions: Findings suggest that AUC/FT ratio
is cross-sectionally and prospectively associated
with subclinical atherosclerosis in women.
J. Lee: None. L.A. Colangelo: None. J.E.
Schwartz: None. Y. Yano: None. D.S. Siscovick:
None. T. Seeman: None. P.J. Schreiner:
None. K.J. Liu: None. D.M. Lloyd-Jones:
None. P. Philip: None.
P066
Cortisol/Testosterone and Cortisol/ Sex
Hormone Binding Globulin Ratios With
Metabolic Syndrome in Women
Ju-Mi Lee, Laura Colangelo, Northwestern Univ,
Chicago, IL; Joseph E Schwartz, Stony Brook Sch
of Med, New york, NY; Yuichiro Yano,
Northwestern Univ, Chicago, IL; David S
Siscovick, The New York Acad of Med, New
york, NY; Teresa Seeman, David Geffen Sch of
Med at UCLA, LA, CA; Pamela J Schreiner, Univ
of Minnesota, Minneapolis, MN; Kiang J Liu,
Donald M Lloyd-Jones, Philip Greenland
Greenland, Northwestern Univ, Chicago, IL
Introduction: The ability to study chronic stress
in humans is complicated due to measurement
error of questionnaires and the inability of
short-term measures of stress hormones to
reflect the chronic state. Therefore
considerable controversy remains about
whether chronic stress influences
cardiovascular disease or not. The
cortisol/testosterone (C/T) ratio was suggested
to be a better predictor of heart disease in men
than cortisol alone, as gonadotropin and
cortisol are derived from the same biochemical
precursor. This ratio has never been studied
with metabolic syndrome (MetS) in a U.S.
epidemiologic study, especially in women.
Study question: Are C/T and C/sex hormone
binding globulin (SHBG) ratio associated with
MetS in women?
Methods: In the Coronary Artery Risk
Development in Young Adults (CARDIA) study,
367 women (age range 32 to 51, mean age 40
years old) who had both cortisol from year (Y)
15 and sex hormones from serum specimen Y16
measured are included. Metabolic syndrome
(MetS) from Y15, 20, 25 were assessed. Due to
the instability and diurnal characteristics of
cortisol, area under the curve (AUC) of six
samples and slope of 1st (or 3rd) and 6th (or
5th when 6th is not available) sample of salivary
cortisol collected over one day were calculated.
Ratios of AUC and of slope of cortisol to total
testosterone (TT), free testosterone (FT), and
sex hormone binding globulin (SHBG) were
computed: AUC/TT, AUC/FT, AUC/SHBG,
Slope/TT, Slope/FT, and Slope/SHBG. The
associations of these variables categorized into
tertiles with MetS were assessed crosssectionally by logistic regression analysis. Model
I controlled for age and race. Model II
controlled for model I variables plus
menopause, oral contraceptive usage, diabetes
mellitus, alcohol consumption, and cigarette
smoking.
Results: MetS was present in 53, 69, and 74
participants at Y15, Y20, and Y25, respectively.
The highest tertile of AUC/SHBG ratio was
associated with Y15, Y20, and Y25 MetS
prevalence in model I (OR 2.17, 3.77, 2.65, 95%
CI 1.02-4.61, 1.64-8.44, 1.75-9.20, respectively).
This association was slightly stronger in model II
(OR 3.72, 4.76, 3.26, 95% CI 1.49-9.30, 2.0011.34, 1.55-6.85, respectively). The highest
tertile of slope/FT ratio was associated with Y20
and Y25 MetS prevalence in model I (OR 2.10,
1.68, 95% CI 1.03-4.26, 0.86-3.31 respectively).
This association was slightly stronger in model II
(OR 2.32, 2.13, 95% CI 1.09-4.95, 1.03-4.41
respectively).
Conclusions: Findings suggest that some
indicators of chronic stress are cross-sectionally
associated with MetS in women.
J. Lee: None. L.A. Colangelo: None. J.E.
Schwartz: None. Y. Yano: None. D.S. Siscovick:
None. T. Seeman: None. P.J. Schreiner:
None. K.J. Liu: None. D.M. Lloyd-Jones:
None. P. Greenland: None.
P067
Longitudinal Association of Self-Reported
Sleep-Disordered Breathing and Peripheral
Arterial Disease: The Multi-Ethnic Study of
Atherosclerosis
Mako Nagayoshi, Dept of Community Med,
Nagasaki Univ, Nagasaki, Japan; Susan Redline,
Brigham and Women's Hosp and Beth Israel
Deaconess Medical Ctr, Harvard Medical Sch,
Boston, MA; Aaron R Folsom, Div of
Epidemiology and Community Health, Univ of
Minnesota, Minneapolis, MN; Eyal Shahar, Div
of Epidemiology and Biostatistics, Univ of
Arizona, Phoenix, AZ; Hiroyasu Iso, Div of
medicine, Osaka Univ, Suita, Japan; Christina L
Wassel, Dept of Epidemiology Graduate Sch of
Public Health, Univ of Pittsburgh, Pittsburgh,
PA; Matthew A Allison, Michael H Criqui, Dept
of Family and Preventive Med, Univ of
California, San Diego, CA; Pamela L Lutsey, Div
of Epidemiology and Community Health, Univ of
Background: Sleep-disordered breathing (SDB)
has been associated with cardiovascular disease
risk factors and event occurrence in previous
studies. However, the association between SDB
and peripheral arterial disease (PAD) is not well
characterized.
Hypothesis: SDB is associated with greater risk
of incident PAD.
Design: A total of 5,661 the Multi-Ethnic Study
of Atherosclerosis (MESA) participants (mean
age 61 years, 52% female) without prevalent
PAD at baseline (2000-2002) were followed for
incident PAD. A sleep questionnaire was
administered at exam 2 (2002-2004), and
participants were categorized as having
physician diagnosed apnea, habitual snoring, or
a normal sleep breathing pattern. Incident PAD
was defined by ABI <0.9 at exam 3 (2004-2006)
and/or exam 5 (2008-2010). Cox proportional
hazards models were used.
Results: Of our analytic sample, 3.5% reported
physician diagnosed sleep apnea, 22.7%
habitual snoring, and 73.8% had a normal sleep
breathing pattern (Table). Over a median
follow-up of 9.2 years, 230 incident PAD cases
occurred. Compared to participants without
SDB, although those with physician diagnosed
apnea were at greater risk of incident PAD after
adjustment for demographics and behavioral
risk factors [Hazard ratio (95% CI): 1.96 (1.083.54)], further adjustment for BMI attenuated
the association [1.79 (0.98-3.27)]. No
associations were observed for habitual
snoring. As all participants with physician
diagnosed apnea and incident PAD were obese,
we conducted analyses restricted to
participants who were obese (body mass index
≥30). The association between physician
diagnosed apnea and incident PAD was
seemingly stronger than for the full study
sample [HR=3.17 (1.59-6.30) for Model 3],
although the p-value was 0.14 for a SDB by BMI
interaction term.
Conclusion: These data suggest that incident
PAD is higher in individuals with sleep apnea,
with associations strongest amongst obese
individuals. Further studies using objectively
assessed sleep apnea severity and incident PAD
seem warranted.
M. Nagayoshi: None. S. Redline: None. A.R.
Folsom: None. E. Shahar: None. H. Iso:
None. C.L. Wassel: None. M.A. Allison:
None. M.H. Criqui: None. P.L. Lutsey: None.
P068
Obstructive Sleep Apnea is Associated with an
Increase Risk of Osteoporosis
Anawin Sanguankeo, Sikarin Upala, Bassett
Medical Ctr, Cooperstown, NY
Background: Obstructive sleep apnea (OSA) is
thought to be a systemic disease and has been
associated with many disorders such as
metabolic, endocrine, and especially
cardiovascular diseases. One of the
consequences of OSA is hypoxia, which can lead
to a reduction in growth of osteoblast and a
stimulation of osteoclast. Our meta-analysis
was conducted to determine the risk of
osteoporosis in patients with OSA compared to
controls.
Objectives: Eligible studies assessing the effects
of obstructive sleep apnea on osteoporosis risk
were comprehensively searched in
PubMed/MEDLINE, EMBASE, and CENTRAL from
their inception to September 2014. Two authors
independently assessed article quality and
extracted the data. Primary outcome were
number of participants, prevalence, or risk ratio
of osteoporosis in OSA and controls.
Results: From 40 full-text articles, 3 studies
involving 113,090 participants were included in
the meta-analysis that were based on the
random effects model. Compared with controls,
participants who were diagnosed with
obstructive sleep apnea had increased risk of
osteoporosis (pooled risks ratio, 1.85; 95% CI,
1.34, 2.56).
Conclusion:
Patients with OSA had a higher risk of
developing osteoporosis. Further study is
needed to evaluate the possible mechanisms
between these two conditions and to find
potential treatment for OSA that could prevent
osteoporosis.
A. Sanguankeo: None. S. Upala: None.
P069
Association Between Habitual Sleep Duration
and Cardiometabolic Disease, and the
Mediating Role of Foregoing Care: Data From
the 2013 Behavioral Risk Factor Surveillance
System
Michael A Grandner, Univ of Pennsylvania,
Philadelphia, PA; Megan Petrov, Arizona State
Univ, Phoenix, AZ; Subhajit Chakravorty, Siya
Bhatt, Indira Gurubhagavatula, Univ of
Pennsylvania, Philadelphia, PA
INTRODUCTION: Sleep duration is associated
with cardiometabolic disease risk, as well as
lower socioeconomic position. Shorter sleepers
may be at increased risk of adverse outcomes
due to the myriad pathophysiologic
consequences of decreased sleep, but also
partially because social/financial pressures that
may lead to less health care use, interact with
physiologic risks, and result in under-treatment
of conditions that may lead to chronic disease.
METHODS: The 2013 BRFSS was used
(N=483,495 adults). Sleep duration was
assessed by a survey item of 24h habitual sleep.
Responses were categorized as very short (<5h),
short (5-6h), normal (7-8h, ref), and long (≥9h).
Participants indicated if they did not receive
medical care due to cost within the past 12
months, as well as obesity (BMI≥30) and history
of diabetes, hypertension,
hypercholesterolemia, coronary heart disease,
myocardial infarction, or stroke. Covariates
included age, sex, race/ethnicity, education,
income, smoking, and BMI (except for obesity
analyses). Weighted logistic regression analyses
examined relationships with health outcomes.
The Baron and Kenny model was used for
mediation and Sobel tests for partial mediation.
RESULTS: See Table. Very short, short, and long
sleep were associated with all assessed health
outcomes. Foregoing healthcare due to cost
was more likely to occur among very short
(OR=2.68, 95%CI=2.47-2.90, p<0.001) and short
sleepers (OR=1.70, 95%CI=1.63-1.78, p<0.001),
but not long sleepers (p=0.89). In mediation
analyses, foregoing care explained 6-14% of the
relationship between very short and short sleep
duration and cardiometabolic disease history.
CONCLUSIONS: Habitual sleep duration is
associated with prevalent cardiometabolic
disease. Very short and short sleep duration are
associated with foregoing medical care, which
partially explains the relationship with
cardiometabolic disease. This suggests that a
non-physiologic pathway (reduced medical
care) may play a role in the relationship of sleep
to chronic disease.
M.A. Grandner: None. M. Petrov: None. S.
Chakravorty: None. S. Bhatt: None. I.
Gurubhagavatula: None.
P070
Comparison of Heritability Estimation Using
the Principal Components Calculated by
Maximizing Variance and Heritability for OSA
Traits
Jingjing Liang, Tao Feng, Case Western Reserve
Univ, Cleveland, OH; Brian Cade, Harvard
Medical Sch, Boston, MA; Xihong Lin, Harvard
Sch of Public Health, Boston, MA; Richa Saxena,
Kevin Gleason, Harvard Medical Sch, Boston,
MA; Xiaofeng Zhu, Case Western Reserve Univ,
Cleveland, OH; Susan Redline, Harvard Medical
Sch, Boston, MA
RATIONALE: Obstructive sleep apnea (OSA) is a
common disorder characterized by repetitive
pauses in breathing during sleep associated
with significant cardiovascular morbidity.
Accumulating study results suggest that there
are strong genetic contributions for this disease
as defined by the apnea hypopnea index (AHI),
the number of breathing pauses per hour of
sleep. Using this metric, it has been shown that
OSA significantly aggregates within families (12); heritability for the AHI is estimated to vary
from about 20 to 40% (2-3). However, the AHI is
only one index from several that describe OSA
severity, and may not be the most relevant
phenotype for genetic studies. It has not,
however, been clear how to systematically
assess heritability of multiple correlated and
uncorrelated OSA traits.
METHODS: To identify OSA related phenotypes
that are most heritable to inform discovery of
genetic risk variants for the disease, heritability
analysis of multiple OSA related phenotypes
were conducted using family data from
Cleveland Family Study which comprises 700
African Americans from 147 families and 669
European Americans from 139 families.
Principal-components analysis was performed
using two approaches for combining data for six
OSA traits that describe several dimensions of
physiological and clinical impairment: the AHI
and three other sleep study metrics (average
hypopnea duration, average oxygen saturation,
and percent time at oxygen saturation of < 90%)
and two OSA symptoms (habitual snoring and
excessive sleepiness). One method uses the
traditional principal-components (PC) approach
assuming all subjects are independent. The
other developed by Rabinowitz and Ott (4)
calculates principal components by maximizing
the heritability.
RESULTS: In European Americans, the maximum
heritability for the traditional multi-trait PC was
0.513 (SE=0.1010) while it was 0.512 (SE=0.100)
for the PC calculated maximizing heritability.
The maximum individual trait heritability was
for average oxygen saturation, which is 0.388
(SE=0.107). In African Americans, the maximum
heritability of traditional multi-trait 0.50
(SE=0.094) while it was 0.616 (SE=0.091) for the
PC calculated maximizing heritability. The
maximum individual trait heritability was for
average hypopnea duration, which is 0.570
(SE=0.096).
CONCLUSIONS: In general, both principal
components approaches (maximizing variance
and heritability) of six OSA related traits result
higher heritability estimates than individual
trait heritability estimates. The principal
components approach based on maximizing
heritability has the potential to improve trait
heritability and therefore can be useful in future
association analysis for searching genes
underlying obstructive sleep apnea.
J. Liang: None. T. Feng: None. B. Cade:
None. X. Lin: None. R. Saxena: None. K.
Gleason: None. X. Zhu: None. S. Redline: None.
P071
How to Get a Better Night’s Sleep: Be Active
and Reduce Sedentary Behaviour
Lisa Kakinami, Erin K O'Loughlin, Concordia
Univ, Montreal, QC, Canada; Jennifer Brunet,
Univ of Ottawa, Ottawa, ON, Canada; Erika N
Dugas, Ctr de Recherche du Ctr Hospier de
l'Univ de Montréal, Montreal, QC, Canada;
Catherine Sabiston, Univ of Toronto, Toronto,
ON, Canada; Jennifer L O'Loughlin, Univ of
Montreal, Montreal, QC, Canada
Background: Approximately 40% of the
population reports sleep problems such as poor
quality sleep and insufficient sleep duration.
Physical activity (PA) can help improve sleep,
but data on whether PA intensity or duration is
most strongly associated with sleep are lacking.
In addition, given that sedentary behaviour
(e.g., TV, computer use) is distinct from physical
inactivity, the association between sedentary
behaviour and sleep in young adults needs to
be characterized.
Objective: To describe the relationships
between sleep quality and sleep duration and
(1) frequency and duration of light, moderate,
and vigorous PA, and (2) different types of
sedentary behaviours (TV, computer, reading)
in young adults.
Methods: Self-report data for 658 participants
were from the 22nd wave of the Nicotine
Dependence in Teens (NDIT) cohort study
(mean age=24.0 years, 46% male [300 of 658]).
PA measures assessed frequency (number of
days) and minutes of light, moderate and
vigorous PA in the past week. Sedentary
measures assessed number of hours spent
reading, watching TV, and using the computer
per day. Sleep measures included (1) the
Pittsburgh Sleep Quality Index (PSQI) which
assessed seven dimensions of sleep (daytime
dysfunction, disturbances, duration, efficiency,
latency, quality, use of sleeping medications),
(2) general sleep quality, and (3) sleep duration
in the past month. General sleep quality and
sleep duration were two separate additional
measures distinct from similar PSQI items
(r=0.73 between general sleep quality and PSQI
score; r=0.69 between sleep duration and PSQI
score). Data were analyzed using multiple linear
regression. Due to evidence of non-normality
the PSQI score was log-transformed.
Results: Controlling for age, sex, and maternal
education, each additional day of light or
vigorous PA was associated with 3 minutes less
sleep per night (p<0.05). Each additional 10
minutes of moderate PA was associated with
greater general sleep quality (β=0.004, p=0.04).
TV was associated with a poorer PSQI score
(β=0.01, p<0.05) and each additional hour of
reading was associated with 2 minutes less
sleep per night (p=0.04). Computer use was
associated with a poorer PSQI score (β=0.02,
p=0.005) and poorer sleep quality (β=-0.02,
p=0.05). Results were similar when sedentary
and PA measures were included in the same
model. The inclusion of body mass index, selfrated mental and general health, and stress did
not affect the results and were omitted from
the final models.
Conclusion: PA and sedentary behaviours are
independently associated with sleep duration
and quality. Sedentary behaviours are
associated with poorer sleep duration and
quality. In contrast, PA frequency may decrease
sleep duration while PA duration may improve
sleep quality. Clinicians who treat sleep
problems in young adults may need to take PA
and sedentary behavior into account in
treatment plans.
L. Kakinami: None. E.K. O'Loughlin: None. J.
Brunet: None. E.N. Dugas: None. C. Sabiston:
None. J.L. O'Loughlin: None.
P072
Short Sleep Duration is Associated with
Elevated Homocysteine Levels
Megan E Petrov, Arizona State Univ, Phoenix,
AZ; Michael A Grandner, Univ of Pennsylvania,
Philadelphia, PA; Carol M Baldwin, Matthew P
Buman, Shawn D Youngstedt, Arizona State
Univ, Phoenix, AZ
Introduction: Short and long sleep durations are
associated with heightened risk for
cardiovascular disease and vascular risk factors.
Elevated homocysteine is also associated with
greater risk for cardiovascular disease;
however, studies have yet to investigate the
relationship between sleep duration and
homocysteine.
Hypothesis: We hypothesized that short and
long sleep duration would be associated with
clinical levels of homocysteine.
Methods: Adults (n=2,469; ≥20y) from the
2005-2006 National Health and Nutrition
Examination Survey (NHANES) were assessed
for habitual sleep duration (coded as <5, 5, 6, 7,
8, 9, and ≥10hrs) and fasting plasma
homocysteine levels (<10 [normative], 10 to
<15 [pre-clinical] and ≥15 [clinical] μmol/L).
Participants were excluded if pregnant,
lactating, missing data on the primary variables,
or if they had a history of cardiovascular
disease, cancer, diabetes, kidney disease, or
diagnosed sleep disorder. Population weighted,
multinomial logistic regression analyses
assessed the relationship between sleep
duration and homocysteine after adjustment
for age, sex, race/ethnicity, marital and
menopausal status, shift work, dietary folate,
alcohol intake, cotinine levels, reported physical
activity, hypertension, and reported frequency
of cessation of breathing at night.
Results: Pre-clinical and clinical levels of
homocysteine were present in 13.7% and 2.5%
of the sample, respectively. The mean sleep
duration was 6.9 ± 1.4 hours. In adjusted
analyses, sleep duration was significantly
related to homocysteine (p < 0.001). See Table.
Very short sleepers (<5hrs) were more likely to
have clinical levels of homocysteine (OR: 3.01,
95%CI: 1.38, 6.57) compared to 7-hr sleepers.
Conclusions: In a U.S. representative sample of
adults without cardiovascular disease or other
major conditions, short sleepers were at greater
odds for clinical levels of homocysteine Findings
suggest that homocysteine may be one
mechanism linking short sleep duration to
M.E. Petrov: None. M.A. Grandner: None. C.M.
Baldwin: None. M.P. Buman: None. S.D.
Youngstedt: None.
P073
Insufficient and Poor Sleep are Associated with
Barriers to Healthy Eating and Lower Physical
Activity: Baseline Characteristics of the
EMPOWER Study
Christopher E Kline, Patrick J. Strollo, Eileen R.
Chasens, Bonny Rockette-Wagner, Andrea
Kriska, Christopher C. Imes, Lora E. Burke, Univ
of Pittsburgh, Pittsburgh, PA
Background: Sleep is emerging as an important
factor that impacts dietary habits, physical
activity, and metabolism. However, minimal
attention is typically given to sleep in traditional
lifestyle interventions. The purpose of these
analyses was to examine baseline associations
between sleep and physical activity and
perceived barriers to healthy eating, which are
two common lifestyle intervention targets, in a
sample of apparently healthy adults enrolled in
a behavioral weight loss intervention study.
Methods: 150 overweight adults (51.1±10.2 y;
91% female; 79% Caucasian) participated in a
12-month lifestyle intervention that featured
adaptive ecological momentary assessment.
Sleep, physical activity, barriers to healthy
eating and body habitus/composition were
assessed prior to the intervention. Objective
sleep was estimated with 7 days of wrist-worn
actigraphy (Philips Actiwatch 2); sleep onset
latency (SOL; the amount of time it takes to fall
asleep after going to bed), sleep efficiency (SE;
the percentage of time in bed that is spent
asleep), and total sleep time (TST; total time
spent asleep) served as the primary actigraphic
sleep variables. Subjective sleep quality was
assessed with the Pittsburgh Sleep Quality
Index (PSQI). Physical activity was assessed with
7 days of waist-worn accelerometry (ActiGraph
GT3x). Perceived barriers to healthy eating were
assessed with the Barriers to Healthy Eating
questionnaire. Body mass index (BMI) served as
the measure of body habitus, and body fat was
assessed with bioelectrical impedance.
Results: Mean BMI and body fat for the sample
were 34.0±4.6 kg/m2 and 43.7±5.5%,
respectively. Mean TST was 6.6±0.8 h/night;
approximately 23% of the sample averaged less
than 6 hours of sleep. Mean SOL and SE for the
sample were 15.3±16.2 min and 85.7±6.1%,
respectively. Based on the PSQI, 52.0% of the
sample had poor sleep quality. Following
adjustment for age, sex, and race, longer SOL
was associated with fewer steps/day (β=-.19,
p=.02) and less time spent in moderate to
vigorous physical activity (MVPA; β=-.16, p=.03),
and lower SE was related to less MVPA (β=.15,
p=.04). Shorter TST was associated with greater
barriers to healthy eating (β=-.16, p=.05).
Longer SOL was associated with higher BMI
(β=.16, p=.05) and body fat % (β=.15, p=.03),
and lower SE was related to higher body fat %
(β=-.13, p=.06).
Conclusions: Short sleep duration and sleep
disturbance were highly prevalent in this
sample of overweight adults. Significant
associations were observed between sleep and
measures of body habitus/composition and
eating and physical activity habits. Efforts to
improve sleep during a behavioral intervention
for weight loss may reduce barriers to healthy
eating and improve physical activity habits as
well as weight loss outcomes.
C.E. Kline: None. P.J. Strollo: None. E.R.
Chasens: None. B. Rockette-Wagner: None. A.
Kriska: None. C.C. Imes: None. L.E. Burke:
None.
P074
Restless Legs Syndrome and Carotid IntimaMedia Thickness in Women
Karen Jacobo, Adriana Monge, Eduardo OrtizPanozo, Elsa Yunes, Insto Nacional de Salud
Publica, Cuernavaca, Morelos, Mexico; Andres
Catzin-Khulmann, Carlos Cantu-Brito, Insto
Nacional de Ciencias Médicas y Nutrición
Salvador Zubirán, Mexico City, Mexico; Ruy
Lopez-Ridaura, Martin Lajous, Insto Nacional de
Salud Publica, Cuernavaca, Morelos, Mexico
Introduction: Restless legs syndrome (RLS) is a
common chronic disorder characterized by an
irresistible need to move the lower limbs that is
usually worse in the evening and is associated
with sleep disturbances. RLS has been
associated with hypertension and has been
proposed as a marker for increased
cardiovascular risk.
Hypothesis: Individuals with RLS have an
increased common carotid intima-media
thickness (cIMT) relative to individuals without
RLS.
Methods: We evaluated cross-sectional relation
of RLS and cIMT in 1,147 disease-free Mexican
women of the Mexican Teachers’ Cohort. In
2011, participants responded to a follow-up
questionnaire that included standardized
questions addressing the four minimal
diagnostic criteria of the International Restless
Legs Study Group. Participants were asked: “Do
you have unpleasant leg sensations (like
crawling, loss of sensation or pain) combined
with restlessness and an urge to move your
legs?”, “Do these symptoms occur only at
rest?”, “Does moving improve these
symptoms?”, “Are these symptoms worse in the
evening or at night compared with the
morning?” Women who answered yes to all the
four questions were defined as having RLS.
Between 2012 and 2013, a subsample of
participants were invited for a clinical visit
where neurologists assessed cIMT with an
ultrasound. cIMT measurements were found to
be reproducible in a substudy in 52 participants
(intra-class correlation=0.89). We defined
subclinical atherosclerosis as a cIMT ≥0.8 mm or
the presence of plaque.
Results: Among women with a mean age of 48.2
(SD±4.3), the prevalence of RLS was 14.2%
(cases, 163). The age-adjusted mean difference
of cIMT comparing participants with RLS to
those without RLS was 0.009mm (95%CI -0.004
to 0.023). After further adjustment for diabetes,
hypercholesterolemia, migraine, oral
contraceptive use, menopause, smoking, body
mass index, physical activity and alcohol, the
mean difference of cIMT comparing participants
with and without RLS was not statistically
different (0.007mm; 95%CI -0.007 to 0.021).
The prevalence of subclinical atherosclerosis
was 27% (n=44) in those with RLS and 21.9%
(n=215) in those without RLS. The age-adjusted
OR comparing women with RLS to those
without RLS was 1.23 (95%CI 0.83-1.82). In the
multivariable model the OR remained nonsignificant (1.16, 95%CI 0.77-1.74).
Conclusions: In this cross-sectional study in
middle-aged women, RLS was not associated to
cIMT. Our results do not support the
observation that individuals with RLS are at an
increased risk for cardiovascular disease.
K. Jacobo: None. A. Monge: None. E. OrtizPanozo: None. E. Yunes: None. A. CatzinKhulmann: None. C. Cantu-Brito: None. R.
Lopez-Ridaura: B. Research Grant; Modest;
Non-restricted investigator-initiated grant from
AstraZeneca. M. Lajous: B. Research Grant;
Modest; Non-restricted investigator-initiated
grant from AstraZeneca.
P075
Prevalence and Characterization of Sleep
Disordered Breathing in Heart Failure Patients
Zunera Ghaznavi, Alberta Warner, Armand
Ryden, Dale Jun, Michelle Zeidler, West LA VA,
Los Angeles, CA
Introduction: There is increasing evidence that
sleep-disordered breathing (SDB) plays a
significant role in progression of heart failure
(HF) and increased risk of mortality, yet it
remains underdiagnosed among HF patients.
Retrospective studies suggest that the
prevalence of SDB among patients with HF is
approximately 50%, with more than 40% having
central sleep apnea (CSA) and about 27% having
obstructive sleep apnea (OSA). Few studies
have prospectively evaluated the prevalence of
SDB in a cohort of patients recently hospitalized
for heart failure.
Hypothesis: Prevalence of SDB among patients
with a recent HF hospitalization is greater than
50% and that greater than 40% will have CSA.
Methods: Patients hospitalized with a primary
diagnosis of HF were enrolled. Diagnosis was
verified using elevated B-type natruietic
peptide, Framingham criteria, and validated by
a cardiologist. Subjects completed standard
sleep questionnaires and underwent
ambulatory sleep tests. Overnight
polysomonography (PSG) was recommended
for validation and treatment titration if there
was evidence of CSA or inadequate ambulatory
sleep test. Recordings were considered
interpretable if they included ≥ 2hours of
recording. Standard AASM definitions were
used for diagnosis of SDB. CSA was defined as
an AHI > 5 with > 50% of the events being
central apnea.
Results: For 35 subjects, mean (±S.D.) age was
66.8 (10.5) years; BMI was 29.2 (5.6) with 67%
(24 of 35) BMI<30; neck circumference was 16.7
in. (1.6); abdominal circumference was 44.7 in.
(5.4); and 74% (26 of 35) had HF with reduced
ejection fraction (EF<50).
Only 13% (13 of 35) were classified as “high
risk” by the Berlin Questionnaire, and scored
mean (±S.D.) of 9.2 (5.3) on the Epsworth Sleep
Scale from 0-24, 14.9 (7.9) on the Insomnia
Severity Index on a 0-28 scale, and 10.1 (5.6) on
the Pittsburgh Sleep Quality Index (Global
Score) on a 0-21 scale. Higher scores from ESS,
ISI, and PSQI are suggestive of increased risk of
SDB.
Of the subjects with diagnostic sleep tests,
100% (27) had SDB, 67% (18) had CSA, 70% (19)
had OSA, and 41% (11) had both CSA/OSA.
Mean (±S.D.) Apnea-Hypopnea Index AHI was
28.8/hour (19.6) and oxygen desaturation index
was 34.7 (21.2).
Conclusion: Prevalence of sleep disordered
breath, CSA and OSA, was higher than expected
in the HF patient population. The current
screening questionnaires were not found to be
predictive of this population being at high risk.
The preliminary findings from this pilot study
suggest all HF patients should undergo testing
for presence of SDB.
Z. Ghaznavi: None. A. Warner: None. A. Ryden:
None. D. Jun: None. M. Zeidler: None.
P077
Sleep Disturbances and Risk of First
Cardiovascular Events. Results from the
MONICA Brianza and PAMELA Cohort Studies
in Northern Italy
Lorenza Bertù, Marco M Ferrario, Francesco
Gianfagna, Giovanni Veronesi, Univ
dell'Insubria, Varese, Italy; Guido Grassi, Clinica
Medica Univ degli Studi di Milano-Bicocca,
Monza, Italy; Giancarlo Cesana, Univ degli Studi
di Milano-Bicocca, Monza, Italy
Background and aim. Poor sleep quality has
been found associated with increasing risk of
cardiovascular diseases. We aim to estimate the
long-term risk of first cardiovascular (CVD)
event (coronary or ischemic stroke) in subjects
with sleep disturbances in North-Italian cohorts.
Methods. Four independent population-based
cohorts were enrolled between 1986 and 1994
from the Brianza population (Northern Italy). At
baseline LDL-, HDL-cholesterol, systolic blood
pressure, diabetes and cigarette smoking were
ascertained through standardized MONICA
procedures. The study sample comprises 3047
men and 3097 women, aged 25 to 75 years and
CVD-free at baseline, who were followed-up for
incidence of first coronary and ischemic stroke
events (fatal and non-fatal; MONICA validated).
Sleep disturbances were assessed with the
Jenkins Sleep Questionnaire, investigating sleep
disturbances (4 items) in the last month, and
then categorized in three classes: none-some
(reference), moderate, severe/extreme. Age
and CVD risk factors adjusted HRs for first CVD,
coronary or ischemic stroke event were
estimated in the overall sample, in men and
women, from separate Cox models.
Results. In a median 15 years of follow-up 437
first CVD events occurred (305 coronary and
ischemic stroke). When adjusting for LDL- and
HDL-cholesterol, systolic blood pressure,
diabetes and cigarette smoking, the risk of first
CVD events was higher in subjects with severe
sleep disorders compared with none-some
(HR=1.84; 95%CI:1.19-2.84). Genderstratification confirms the association both in
men and women, but only in men resulted
statistically significant (HR=2.34; 95%CI:1.344.08). The association was prominent for
ischemic strokes (HR=2.10; 95%CI:1.11-3.97)
and less clear for coronary events. These
associations resulted higher when the follow-up
was shortened to 10 years.
Conclusions. In this population of middle-aged
CVD-free subjects from Northern Italy, severe
sleep disturbances were associated with first
CVD events. The risk was higher in men and
when ischemic strokes were considered only.
L. Bertù: None. M.M. Ferrario: None. F.
Gianfagna: None. G. Veronesi: None. G. Grassi:
None. G. Cesana: None.
P078
Exploring Social Inequalities in Ischemic Stroke
Incidence in Europe. The MORGAM Project
Cohort Component
Marco M Ferrario, Giovanni Veronesi, Univ
dell'Insubria, Varese, Italy; Lloyd E Chambless,
Hill, NC; Kari Kuulasmaa, THL-Natl Inst for
Health and Welfare, Helsinki, Finland; Stefan
Soderberg, Cardiology and Heart Ctr, Umeå
Univ, Umeå, Sweden; Veikko Salomaa, THL-Natl
Inst for Health and Welfare, Helsinki, Finland;
Andrzej Pajak, Jagiellonian Univ Medical Coll,
Kracow, Poland; Philippe Amouyel, Pasteur Inst
of Lille, Lille, France; Dominique Arveiler, Univ
of Strasbourg, Strasbourg, France; Wojciech
Drygas, Natl Inst of Cardiology, Warsaw, Poland;
Jean Ferrieres, Toulouse Univ Sch of Med,
Toulouse, France; Nigel Hart, Queen’s Univ
Belfast, Belfast, United Kingdom; Torben
Jorgensen, Glostrup Univ Hosp, Glostrup,
Denmark; Sofia Malyutina, Siberian Branch of
Russian Acad of Medical Sciences, Novosibirsk,
Russian Federation; Annette Peters, German
Res Ctr for Environmental Health, Neuherberg,
Germany; Abdonas Tamosiunas, Lithuanian
Univ of Health Sciences, Kaunas, Lithuania;
Hugh Tunstall-Pedoe, Inst of Cardiovascular Res,
Univ of Dundee, Dundee, United Kingdom;
Giancarlo Cesana, Univ degli Studi di MilanoBicocca, Monza, Italy
Aims. To explore the magnitude of educationalclass inequalities in ischemic stroke incidence in
European populations, and to assess to what
extent they can be explained by major risk
factors.
Methods. The MORGAM study comprised 45
cohorts from Nordic Countries (Finland,
Denmark, Sweden), UK (Northern Ireland,
Scotland), Central EU (France, Germany,
Northern Italy) and East EU (Lithuania, Poland)
and Russia. Only cohorts with both fatal and
non-fatal ischemic strokes during follow-up
(median 12 years, IQR 10-19 years) were
included. Baseline data were collected adhering
to MONICA-like procedures. Stroke subtype was
attributed based on hospital records and death
codes. We derived 3 educational classes from
population-, sex- and birth year-specific tertiles
of years of schooling. We used Poisson
regression models to estimate the age-adjusted
difference in event rates between the bottom
and the top educational classes distribution
(Slope Index of Inequality, SII) and the
proportion of events to be redistributed to
achieve equality in event rates among
educational classes (Relative Concentration
Index, RCI). We estimated the pooled age- and
risk factors-adjusted hazard ratios for bottom to
top education (Relative Index of Inequality, RII)
from sex-specific Cox models with a dummy
variable for each population . We also tested
the hypothesis of homogeneity of inequalities
across populations by adding
population*education interaction terms. The
contribution of risk factors to RII was measured
by: (lnRII[RFadj]- lnRII[AGEadj]) ⁄ lnRII[AGEadj]
Results. The cohorts included 66,052 CVD-free
subjects aged 35-64 years (37,181 men) at
baseline. In men, the age-adjusted inequalities
in ischemic stroke rates (SIIs) were 125 events
per 100,000 person-years in the Nordic
Countries, 156 in the UK and 178 in Central EU;
the RCIs were 6%, 13% and 21%, respectively. In
women, an inverse gradient (higher rates
among more educated subjects) was present in
Northern Sweden; in the remaining
populations, the SII (RCI) ranged between 4
(1%) in Northern Italy and 278 (23%) events in
Germany. Age-adjusted pooled RIIs for bottom
to top education were 1.7 (95%CI: 1.4-2.1) in
men and 1.5 (1.2-1.9) in women, with some
variability across populations (homogeneity test
p-value=0.06 in men and 0.07 in women) and
gender groups. Together, total- and HDLcholesterol, systolic blood pressure, antihypertensive treatment, smoking and diabetes
explained 26% of hazard excess in men, and
40% in women. Main contributors were
smoking (13%) and systolic blood pressure (9%)
in men; and systolic blood pressure (13%), HDLcholesterol (12%) and smoking (11%) in women.
Conclusions. Less educated men and women
had a higher ischemic stroke incidence risk in
most European populations; in men, such
inequalities followed a clear North-South
geographic gradient. Traditional risk factors
accounted for a minor part of risk excess in
men.
M.M. Ferrario: None. G. Veronesi: None. L.E.
Chambless: None. K. Kuulasmaa: None. S.
Soderberg: None. V. Salomaa: None. A. Pajak:
None. P. Amouyel: None. D. Arveiler: None. W.
Drygas: None. J. Ferrieres: None. N. Hart:
None. T. Jorgensen: None. S. Malyutina:
None. A. Peters: None. A. Tamosiunas:
None. H. Tunstall-Pedoe: None. G. Cesana:
None.
P079
Disparities in Heart Failure in Older Age: Do
Individual or Neighbourhood Measures of
Deprivation Affect Incidence Over a 10-Year
Follow-up?
Sheena Ramsay, Univ Coll London, London,
United Kingdom; P H Whincup, St George's Univ
of London, London, United Kingdom; R W
Morris, A.O. Papacosta, L T Lennon, S G
Wannamethee, Univ Coll London, London,
United Kingdom
Background:
Few studies have examined the prospective
associations between socioeconomic measures
and incident heart failure, and in particular
effects of neighbourhood deprivation. The aim
of this study was to investigate the association
of socioeconomic measures (individual and
neighbourhood-level) with incident heart failure
in older adults and to examine possible
underlying pathways.
Methods:
A socially and geographically representative
cohort of men aged 60-79 years in 1998-2000
from 24 British towns was followed for 10 years
for incident heart failure (fatal and non-fatal
based on death certificates and doctordiagnosis). Individual-level socioeconomic
measures included longest-held occupational
social class, education, pension (state only or
state with private), and amenities (car and
house ownership, access to central heating) - a
cumulative score of adverse socioeconomic
measures from 0 to ≥4 was used. Index of
multiple deprivation (IMD) was the small arealevel socioeconomic measure (based on
income, employment, health, housing,
education, access to services and crime)
grouped into quintiles of increasing deprivation.
Prevalent myocardial infarctions and heart
failures were excluded.Results:
Among 3839 men, 232 incident cases of heart
failure occurred over 10 years. Heart failure risk
increased with increasing cumulative score of
adverse (individual-level) socioeconomic
measures (p for trend=0.0006). Compared to
men with a score of 0, the hazard ratio for men
with a score of ≥4 was 2.19 (95%CI 1.34-3.55)
which weakened to 1.99 (95%CI 1.16-3.45), but
remained significant after adjusting for
neighbourhood
deprivation (IMD), systolic blood pressure, body
mass index, smoking,
HDL-cholesterol, diabetes and lung function.
Adjustment for left ventricular hypertrophy,
atrial fibrillation, heart rate and renal function
made little difference. Further adjustment for Creactive protein, von Willebrand Factor and
plasma vitamin C slightly weakened the hazard
ratio to 1.78 (95%CI 1.01-3.13). Hazard ratio per
IMD quintile (neighbourhood deprivation) was
1.04 (95%CI 0.95-1.14).
Conclusions:
Disparities in heart failure in older populations
need to be addressed - the risk of heart failure
in older age was greater in the lowest
socioeconomic groups, which was only partly
explained by established and novel risk factors
for heart failure. This increased risk of heart
failure according to individual-level
socioeconomic measures was independent of
neighbourhood-level deprivation.
Neighbourhood level deprivation does not in
itself appear to influence risk of heart failure.
S. Ramsay: None. P.H. Whincup: None. R.W.
Morris: None. A. Papacosta: None. L.T. Lennon:
None. S.G. Wannamethee: None.
P080
The Combined Effect of Low Income and Low
Education on Coronary Heart Disease
Outcomes in the Reasons for Geographic and
Racial Differences in Stroke (REGARDS) Study
Marquita W Lewis, Yulia Khodneva, Monika M
Safford, Univeristiy of Alabama at Birmingham,
Birmigham, AL
Background: Low income (LoINC) and low
education (LoED) have both been associated
with higher coronary heart disease (CHD) risk,
but few studies have examined the combined
effects of both LoINC and LoED.
Hypothesis: The combination of LoINC and
LoED is more strongly associated with incident
CHD than either LoINC and LoED, or neither.
Methods: REGARDS recruited 30,239 black and
white participants aged >45 years residing in
the 48 contiguous US between 2003-2007.
Baseline data included telephone interviews
and in-home visits, and follow-up was
conducted every 6 months to detect potential
events with expert adjudication of endpoints
based on medical record review. Low income
(LoInc) was defined as annual household
income <$35,000, and low education (LoEd) was
defined as less than a high school education.
Income and education were combined into four
mutually exclusive exposure groups
(noLoInc+noLoEd, noLoInc+LoEd, LoInc+noLoEd
,LoInc+LoEd, ). CHD outcomes were definite or
probable myocardial infarction or acute CHD
death. We constructed Cox models estimating
the hazard ratios (HR) for CHD, sequentially
adjusting for sociodemographics, health
behaviors, physiologic parameters, access to
healthcare, and stress and depression. Because
of significant interaction by age (p<0.001),
analyses were stratified at age 65.
Results: We analyzed 24,461 participants
without baseline CHD, with numbers in each
income/education group as shown in the Table.
LoInc+LoEd was associated with the highest risk
of CHD among those aged <65 years, but not
among those >65 years of age. LoEd was
associated with higher CHD risk in those age
>65 years and LoInc was not, but LoInc was
associated with higher CHD risk in those age
<65 years, but LoEd was not.
Conclusion: LoInc+LoEd was associated with the
highest CHD risk at younger ages, but not at
higher ages. Income was more important than
education for CHD risk at younger ages, but
education was more important than income at
older ages.
M.W. Lewis: None. Y. Khodneva: None. M.M.
Safford: None.
P081
Neighborhood Social Environments and
Incident Obesity: the Multi-Ethnic Study of
Atherosclerosis (MESA)
Mahasin Mujahid, Univ of California, Berkeley,
Berkeley, CA; Amy Auchincloss, Drexel Univ,
Philadelphia, PA; Emon Elboudwarej, Univ of
California, Berkeley, Berkeley, CA; Mercedes
Carnethon, Northwestern Univ, Chicago, IL;
Tonatiuh Barrientos-Gutierrez, Natl Inst of
Public Health, Mexico City, Mexico; Tiffany
Powell-Wiley, Natl Heart, Lung, and Blood Inst,
Natl Insts of Health, Bethesda, MD; Ana Diez
Roux, Drexel Univ, Philadelphia, PA
Introduction: The public health burden of
obesity in the United States is well documented
and obesogenic environments, including the
neighborhoods in which individuals live, have
emerged as important determinants of obesity
risk. Studies examining the association between
neighborhood context and obesity have
primarily focused on the socioeconomic and
built/physical environment and have been
mostly cross-sectional.
Objective: To investigate associations between
neighborhood social environment and incident
obesity and to determine if these associations
are modified by gender.
Methods: Study participants were enrolled in
MESA from 2000-2002 and followed for an
average of 9.5 years. Obesity was defined as
body mass index of ≥30 kg/m2 using weight and
height measurement obtained at baseline and 4
follow-up examinations. Neighborhood social
environment was assessed using a survey of
area residents and MESA participants that
asked them to rate their neighborhood (1-mile
area surrounding the home) across dimensions
of safety, social cohesion, and aesthetic quality.
Cox proportional hazards models, with a robust
covariance matrix estimator to adjust for
clustering within neighborhoods, were used to
test study hypotheses.
Results: Among the 3965 participants free from
obesity at baseline and with complete data on
study covariates, the mean age was 62 (SD=10)
and 508 participants developed obesity over
the study follow-up. In multivariable models,
there were significant associations between
neighborhood social environment indicators
(Table 1) and incident obesity among men,
independent of individual and neighborhoodlevel confounders (age, gender, race/ethnicity,
education, income, neighborhood
socioeconomic factors, and neighborhood
physical environment). No associations were
present among women.
Conclusion: Neighborhood-level risk factors are
complex and future research is necessary to
better understand the increased risk of obesity
among men living in better neighborhood social
environments.
M. Mujahid: None. A. Auchincloss: None. E.
Elboudwarej: None. M. Carnethon: None. T.
Barrientos-Gutierrez: None. T. Powell-Wiley:
None. A. Diez Roux: None.
P082
Neighborhoods and Racial/Ethnic Differences
in Ideal Cardiovascular Health: The MultiEthnic Study of Atherosclerosis (MESA)
Mahasin Mujahid, Univ of Calif Berkeley,
Berkeley, CA; Latetia Moore, Ctr for Disease
Control and Prevention, Atlanta, GA; Lucia
Petito, Univ of California, Berkeley, Berkeley,
CA; Kiarri Kershaw, Northwestern Univ, Chicago,
IL; Karol Watson, Univ of California, Los Angeles,
Los Angeles, CA; Ana Diez Roux, Drexel Univ,
Philadelphia, PA
Introduction: Neighborhood environments have
been investigated in relation to individual
cardiovascular disease risk. However, few
studies have examined the contribution of
neighborhood environments to racial/ethnic
differences in cardiovascular health (CVH).
Hypothesis: We hypothesized that there would
be significant racial/ethnic differences in ideal
CVH and these differences would be reduced
after adjustment for neighborhood factors.
Methods: We used data from the MESA
baseline examination (2000-2002; mean
age=62, SD=10). Ideal cardiovascular health was
defined using guidelines from the American
Heart Association 2020 Strategic Impact Goals.
We examined seven CVH indicators (blood
pressure, fasting glucose, cholesterol, body
mass index, diet, physical activity, and smoking)
and three summary measures (health factors,
health behaviors, overall CVH). We compared
racial/ethnic differences in ideal CVH before
and after adjustment for neighborhood factors
(socioeconomic, physical activity, healthy food,
social environment) using logistic regression
and hybrid fixed effects models. Neighborhoodlevel data were obtained from various
administrative data sources including the
Neighborhood Community Survey and linked to
MESA study participants.
Results: Among the 5,263 participants in our
analytic sample, 215 (4.1%) had ideal CVH. This
proportion varied across racial/ethnic groups
(6.6% for whites, 2% for African Americans, and
2.1% for Hispanics). Significant racial/ethnic
differences were present for all indicators
(excluding physical activity and diet) and
summary measures of ideal CVH, independent
of confounders. Additional adjustments for
neighborhood factors produced modest
reductions in racial/ethnic differences.
Conclusion: Neighborhood factors may play a
role in shaping racial/ethnic health disparities in
CVH. Future research is necessary to better
understand the impact of neighborhood context
on CVH disparities over the life course.
M. Mujahid: None. L. Moore: None. L. Petito:
None. K. Kershaw: None. K. Watson: None. A.
Diez Roux: None.
P083
Friends Participating in Physical Activity with
Obese Youth is Associated with Lower
Perceived Barriers to Physical Activity and
More Time Spent in Physical Activity
Jessica G Woo, Alyxis Giordullo, Nancy A.
Crimmins, Lisa J Martin, Cincinnati Children's
Hosp Medical Ctr, Cincinnati, OH
Background: Physical activity is an important
component of pediatric comprehensive weight
management programs (CWMP), but little is
known about children and adolescents’ views of
parental/friend support for physical activity, or
perceived benefits or barriers to physical
activity. We hypothesized that high family or
friend support for physical activity would be
related to higher perceived benefits and lower
perceived barriers to physical activity.
Methods: Children and adolescents were
recruited at their initial CWMP clinic visit to
participate in the Biorepository of Environment,
Activity and Nutrition to Prevent Obesityrelated Disorders (BEANPOD) study.
Participants and parents provided written
informed consent/assent. Those over age 6
completed questionnaires rating their
agreement on a 5-point scale with 10 potential
benefits and 15 potential barriers to physical
activity (PA), and recoded into low, medium and
high categories. Participants also reported on
the perceived extent (low, medium, high) of
family/friend participation, offering and
encouragement with regard to PA, and the
amount of time spent in sports activities per
week.
Results: One hundred four children and
adolescents (74% female, median 12.5 yrs, 47%
white) answered questions about PA benefits
and barriers. Almost all benefits were perceived
as high by most children and adolescents, with
adolescents (> age 12) more likely than children
to endorse the benefits of reducing boredom
(p=0.04) and combatting disease (p=0.01). The
most commonly cited high barriers were “selfconsciousness” (29%), “lack of enjoyment”
(22%), “lack of self-discipline” (21%), “lack of
energy” (21%), and “poor health” (22%).
Adolescents were more likely to report higher
barriers due to lack of time (p=0.03), lack of
enjoyment (p=0.05), and fear of injury (p=0.03),
and less likely to report barriers due to lack of
knowledge (p=0.005) than children under 12.
Family encouragement was high (78%
reporting), but family and friend offering to or
doing physical activity with the participants was
less common (36-48% reporting). Friends doing
PA with the participant was associated with
many lower perceived barriers, including lack of
interest (p=0.01), energy (p=0.01), enjoyment
(p=0.005), equipment (p=0.003), skill
(p<0.0001), health (p=0.05) and knowledge
(p=0.03), adjusting for participant age, while
family participation and family/friend
encouragement/offers did not. Friends doing PA
with the participant also increased reported
time spent in PA (p=0.005).
Conclusions: Children and adolescents entering
a pediatric comprehensive weight management
program typically see the benefits of physical
activity, but also many barriers. While many
report family encouraging them to engage in
physical activity, only friends doing physical
activity with the participant was associated with
lower perceived barriers and more time spent
in PA.
J.G. Woo: None. A. Giordullo: None. N.A.
Crimmins: None. L.J. Martin: None.
P084
Neighborhood Characteristics and Changes in
Systolic Blood Pressure Over Time: The MultiEthnic Study of Atherosclerosis
Paulina Kaiser, Oregon State Univ, Corvallis, OR;
Lynda Lisabeth, Philippa Clarke, Sara Adar, Univ
of Michigan, Ann Arbor, MI; Mahasin Mujahid,
Univ of California, Berkeley, Berkeley, CA;
Robyn McClelland, Univ of Washington, Seattle,
WA; Mercedes Carnethon, Northwestern Univ,
Chicago, IL; Alain Bertoni, Wake Forest Univ,
Winston-Salem, NC; Steven Shea, Columbia
Univ, New York, NY; Ana V Diez Roux, Drexel
Univ, Philadelphia, PA
Introduction: Research on the association
between neighborhood environments and
systolic blood pressure (SBP) is limited,
predominantly cross-sectional, and has
produced mixed results. Investigating specific
aspects of neighborhood environments in
relation to changes in SBP may help to identify
the most important interventions for reducing
the population burden of hypertension.
Hypothesis: Better neighborhood food, physical
activity, and social environments will be
associated with lower baseline levels of SBP and
smaller increases in SBP over time.
Methods: The Multi-Ethnic Study of
Atherosclerosis recruited participants from six
sites in the U.S., aged 45-84 (mean 59) and free
of clinical cardiovascular disease at baseline.
Those with non-missing data for key variables
were included (N=5,997); the analytic sample
was 52.5% female, 39.1% White, 27.3%
Hispanic, 11.9% Black, and 21.7% Chinese, with
median follow-up time of 9.2 years (IQR 4.5)
and SBP measured at three or more exams for
91.3% of participants. SBP in subjects taking
anti-hypertensive medication were replaced
with multiply imputed estimates of
unmedicated SBP, imputed at each exam.
Summary measures of neighborhood food and
physical activity environments incorporated
survey-based scales (healthy food availability
and walking environment) and GIS-based
measures (density of favorable food stores and
recreational resources). The summary measure
of the social environment combined surveybased measures of social cohesion and safety.
Neighborhoods were defined by a one-mile
buffer around each participant’s home address.
Linear mixed models were used to model
associations of time-varying cumulative average
neighborhood environmental summary
measures with SBP over time, adjusting for
individual-level covariates (demographics,
individual- and neighborhood-level SES); models
with and without adjustment for baseline SBP
were used to evaluate associations of
neighborhood environments with SBP
trajectories.
Results: In models mutually adjusted for all
three neighborhood domains and covariates,
living in a better physical activity environment
was associated with lower SBP at baseline (1.34 mmHg [95% CI: -2.24, -0.45] per standard
deviation higher cumulative average physical
activity summary score), while living in a better
social environment was associated with higher
SBP at baseline (1.00 mmHg [0.39, 1.63] per
standard deviation higher); food environment
scores were not associated with baseline SBP.
After adjustment for baseline SBP, there was no
association between any neighborhood
environments and trajectories of SBP.
Conclusions: Better food and physical activity
environments were associated with lower
baseline SBP, while better social environments
were associated with higher baseline SBP.
Neighborhood environments appear to have
minimal direct effect on SBP trajectories.
P. Kaiser: None. L. Lisabeth: None. P. Clarke:
None. S. Adar: None. M. Mujahid: None. R.
McClelland: None. M. Carnethon: None. A.
Bertoni: None. S. Shea: None. A.V. Diez Roux:
None.
P085
Neighborhood Population Density is
Associated With Lower Levels of Potassium
Excretion in the Hispanic Community Health
Study/Study of Latinos (HCHS/SOL)
David B Hanna, Albert Einstein Coll of Med,
Bronx, NY; Franklyn Gonzalez II, Univ of North
Carolina at Chapel Hill, Chapel Hill, NC; Kiarri N
Kershaw, Northwestern Univ, Chicago, IL;
Andrew G Rundle, Columbia Univ, New York,
NY; Linda Van Horn, Northwestern Univ,
Chicago, IL; Judith Wylie-Rosett, Robert C
Kaplan, Yasmin Mossavar-Rahmani, Albert
Einstein Coll of Med, Bronx, NY; Gina S Lovasi,
Introduction: Sodium (Na) and potassium (K)
intake are associated with cardiovascular
disease risk. Whether neighborhood
characteristics influence Na and K intake is not
well-documented. We assessed the association
of neighborhood socioeconomic status and
population density with objectively measured
24-h urinary Na and K excretion levels as intake
markers.
Methods: The SOL Nutrition & Physical Activity
Assessment Study (SOLNAS) was an ancillary
study of the HCHS/SOL, a population-based
longitudinal study of Hispanics/Latinos in the
Bronx, Chicago, Miami, and San Diego. 24-h
urinary Na and K excretion levels were obtained
from 485 participants. We used Census data to
derive neighborhood characteristics for a
subgroup of eligible participants based on
residential census tract availability. Linear
mixed models determined associations of
neighborhood characteristics with Na and K
excretion, and Na:K ratio.
Results: We analyzed 335 individuals from 3
sites. Mean 24-h excretion of Na and K, and
Na:K ratio were 3593 mg (SD 1720), 2154 mg
(SD 918) and 1.8 (SD 0.8). Neighborhood
heterogeneity was observed for K excretion
(intraclass correlation coefficient 0.09) but not
Na excretion or Na:K ratio. In bivariate analyses,
lower levels of K excretion were associated with
lower neighborhood median household income
(mean excretion for quartile 1 [Q1] 2049 mg, Q4
2410 mg, ptrend=0.04) and higher neighborhood
population density (mean for Q1 2529 mg, Q4
1656 mg, ptrend<0.001). After adjusting for
individual-level confounders, the association of
K excretion with neighborhood income was no
longer present (p=0.37), but the association
with population density remained (p=0.04).
Additional adjustment for other neighborhood
factors attenuated the association with
population density (p=0.07).
Conclusion: Higher neighborhood population
density was associated with lower levels of 24-h
K but not Na excretion. Future research should
assess whether altering the food environment
can improve K intake in densely populated
neighborhoods.
D.B. Hanna: None. F. Gonzalez: None. K.N.
Kershaw: None. A.G. Rundle: None. L. Van
Horn: None. J. Wylie-Rosett: F. Ownership
Interest; Modest; Merck. G.
Consultant/Advisory Board; Modest; Alliance
for Potato Research. R.C. Kaplan: None. Y.
Mossavar-Rahmani: None. G.S. Lovasi: None.
P086
Sex-specific Differences in Psychosocial and
Other Determinants Predicting Hospital
Utilization in Older Adults
Marie Krousel-Wood, Ochsner Health System
and Tulane Univ, New Orleans, LA; Cara Joyce,
Tulane Univ Sch of Public Health and Tropical
Med, New Orleans, LA; Philip Oravetz, Janet
Niles, Ochsner Health System, New Orleans, LA;
Diane J Graziano, Argonne Natl Labs, New
Orleans, LA; Luke O Hansen, Bonnie Spring,
Northwestern Univ, Chicago, IL; Gina Graham,
General Electric Healthcare, Chicago, IL; Charles
Macal, Argonne Natl Labs, Chicago, IL
Background: Hospital utilization is common and
costly in the elderly, and rates differ by sex. Few
data are available regarding sex-specific
determinants of hospital utilization.
Methods: Using longitudinal data from the
Cohort Study of Medication Adherence in Older
Adults (CoSMO), all-cause hospitalizations were
captured over 3 years. Subjects were classified
as not hospitalized, hospitalized and not
readmitted, and hospitalized and readmitted
within 12 months. Comprehensive data on
psychosocial, clinical, healthcare and behavioral
risk factors were assessed at baseline using data
from validated surveys and healthcare
utilization databases. Sex-stratified generalized
logit models were used to identify baseline risk
factors predictive of hospital admission and
readmission.
Results: Of the 1981 subjects included in this
analysis, 48.8% were >75 years old, 58.9% were
female, 30.5% were black, 79.1% had high
school education or more, and 62.8% had
hypertension duration for 10 or more years.
Over 3 years, 508 (25.6%) were hospitalized but
not readmitted and 262 (13.2%) were
hospitalized and readmitted within 12 months;
women versus men were less likely to be
hospitalized (P<0.001). After multivariable
adjustment, the factors associated with hospital
readmission versus no hospitalization in men
were hypertension duration ≥10 years (Odds
ratio-OR 1.76 (95% confidence interval -CI 1.04,
2.97), Charlson comorbidity score ≥2 (OR 6.51
(95% CI 3.52, 12.06), 4 or more clinic visits/ year
(OR 2.19 (1.33, 3.61); low sexual functioning
(OR 1.71 (95% CI 1.03, 2.84), reducing salt to
control blood pressure (OR 2.12 (95% CI 1.12,
4.01), low social support (OR 0.26 (95% CI 0.26,
0.82), and being married (OR 0.32 (95% CI 0.17,
0.61). In women, the factors associated with
hospital readmission versus no hospitalization
were Charlson comorbidity score ≥2 (OR 4.41
(95% CI 2.78, 6.99) and low overall satisfaction
with healthcare (OR 4.85 (95% CI 1.93, 12.19).
Results were qualitatively similar for men and
women who were hospitalized but not
readmitted.
Conclusions: Sex-specific differences in
psychosocial and other determinants predicting
hospital use over 3 years were identified.
Further research is needed in larger samples to
explore the influence of change in key individual
factors on hospital utilization over time.
M. Krousel-Wood: None. C. Joyce: None. P.
Oravetz: None. J. Niles: None. D.J. Graziano:
None. L.O. Hansen: None. B. Spring: None. G.
Graham: None. C. Macal: None.
P087
Cardiometabolic Risk Factors and
Socioeconomic Status in Peruvian Adults: The
CRONICAS Cohort Study
Renato Quispe, Juan Carlos Bazo-Alvarez, Frank
Peralta-Alvarez, Giancarlo A. Valle, CRONICAS
Ctr of Excellence in Chronic Diseases, Lima,
Peru; William Checkley, Robert H. Gilman, Johns
Baltimore, MD; Liam Smeeth, London Sch of
Hygiene and Tropical Med, London, United
Kingdom; Antonio Bernabé-Ortiz, J. Jaime
Miranda, CRONICAS Ctr of Excellence in Chronic
Diseases, Lima, Peru
The association between cardiovascular
diseases (CVD) and social determinants remains
complex and varies between and within
countries. The distribution of CVD risk factors by
socioeconomic status (SES) determines the
health inequality arising across nations and
within countries, but it urges a better
understanding of how social determinants
affect health in LMIC. We sought to estimate
the association between SES indicators and
cardiometabolic risk factors in Peruvian
population.
Pooled data, from four distinct geographical
sites, from the age- and sex-stratified
population-based CRONICAS Cohort study was
analyzed. SES indicators were wealth index (in
tertiles), educational attainment (highest level
of education) and place of residence (urban or
rural). Outcomes were diabetes (fasting glucose
≥126mg/dL or current medication),
hypertension (SBP ≥140 or DBP ≥90mmHg, or
antihypertensive medication), obesity (BMI
≥30kg/m2), high total cholesterol (≥200mg/dL),
low HDL-c: (<40mg/dL men, <50mg/dL women),
and metabolic syndrome as per harmonized
ATP-III definition. Multiple logistic regressions,
adjusting for age, gender, place of residence,
wealth index and years of education as
appropriate, were used.
3619 individuals, (81% urban, 19% rural), mean
age 55.8±12.7 years, 49% men, were included in
the final analysis. Overall prevalence of
hypertension, diabetes, obesity, high total
cholesterol, low HDL-c and metabolic syndrome
were 27.5%, 8.7%, 26.9%, 40.6%, 66.0% and
34.8% in overall population. No clear pattern of
association was observed with SES indicators
except for residence in rural areas where
chances of having any given cardiometabolic
risk factor were much lower than urban areas
(Table 1).
Rural place of residence had a negative
association with all cardiometabolic risk factors
studied. These results highlight the need to
contextualize risk factors by socioeconomic
groups in countries in transition.
R. Quispe: None. J.C. Bazo-Alvarez: None. F.
Peralta-Alvarez: None. G.A. Valle: None. W.
Checkley: None. R.H. Gilman: None. L. Smeeth:
None. A. Bernabé-Ortiz: None. J.J. Miranda:
None.
P088
Perceptions of Alcohol as Heart Healthy: The
Health eHeart Study
Isaac R. Whitman, Mark J. Pletcher, Eric
Vittinghoff, Kourtney E. Imburgia, Carol
Maguire, Laura Betterncourt, Todd Parsnick,
Tuhin Sinha, Geoffrey H. Tison, Jeffrey E. Olgin,
Gregory M. Marcus, UCSF, San Francisco, CA
Background: Moderate consumption of alcohol
may provide protection against myocardial
infarction and mortality, but also likely
increases blood pressure and incidence of atrial
fibrillation. Despite the absence of rigorous
controlled trials on the actual cardiovascular
benefits of alcohol, the lay press frequently
portrays alcohol as “heart healthy” (HH). No
study to date has described individuals’
perceptions regarding the health effects of
alcohol, how they gained this perception, nor
how that perception may influence behavior.
Methods: We performed a cross-sectional
analysis of data obtained between March 8,
2013 to September 29, 2014 from consecutive
participants enrolled in the Health eHeart
Study, a prospective, internet-based cohort
study. The characteristics of participants that
reported alcohol as HH were determined.
Results: A total of 5,417 participants answered
questions regarding their perception of alcohol.
Thirty percent (n=1,707) viewed alcohol as HH,
39% (n=2,157) viewed it as bad for the heart,
and 31% (n=1,718) were unsure. Of those
reporting alcohol as HH, 78% cited lay press as a
source of their knowledge, 14% cited their
doctor, and 92% reported that red wine
exclusively was HH. In adjusted analyses, older
age, higher education, higher income, and
United States residence were associated with a
perception of alcohol as HH (Figure). Those with
a history of heart failure (HF) were significantly
less likely to cite alcohol as HH. Compared to
those who did not report alcohol as HH, those
who perceived alcohol as HH consumed more
alcohol (median 5 drinks per week, IQR 2-8 vs.
median 3 drinks, IQR 1-7, p=0.001; adjusted:
10% more alcohol per week, 95% CI 1-20%
more, p=0.02).
Conclusions: Among more than 5,000
consecutive Health eHeart participants,
approximately one third believe alcohol is HH
and one third believes it is not. Those who
believe alcohol is HH were of higher
socioeconomic status, more likely to be
American, less likely to have HF, and reported
drinking more alcohol.
I.R. Whitman: None. M.J. Pletcher: None. E.
Vittinghoff: None. K.E. Imburgia: None. C.
Maguire: None. L. Betterncourt: None. T.
Parsnick: None. T. Sinha: None. G.H. Tison:
None. J.E. Olgin: None. G.M. Marcus: None.
P089
Social Inequalities in Coronary Heart Disease
Across European Populations. The MORGAM
Project Cohort Component
Giovanni Veronesi, Marco M Ferrario, Univ
dell'Insubria, Varese, Italy; Lloyd E Chambless,
Hill, NC; Kari Kuulasmaa, THL-Natl Inst for
Health and Welfare, Helsinki, Finland; Stefan
Soderberg, Cardiology and Heart Ctr, Umeå
Univ, Umeå, Sweden; Veikko Salomaa, THL-Natl
Inst for Health and Welfare, Helsinki, Finland;
Andrzej Pajak, Jagiellonian Univ Medical Coll,
Kracow, Poland; Philippe Amouyel, Pasteur Inst
of Lille, Lille, France; Dominique Arveiler, Univ
of Strasbourg, Strasbourg, France; Wojciech
Drygas, Natl Inst of Cardiology, Warsaw, Poland;
Jean Ferrieres, Toulouse Univ Sch of Med,
Toulouse, France; Nigel Hart, Queen’s Univ
Belfast, Belfast, United Kingdom; Torben
Jorgensen, Glostrup Univ Hosp, Glostrup,
Denmark; Sofia Malyutina, Siberian Branch of
Russian Acad of Medical Sciences, Novosibirsk,
Russian Federation; Annette Peters, German
Res Ctr for Environmental Health, Neuherberg,
Germany; Abdonas Tamosiunas, Lithuanian
Univ of Health Sciences, Kaunas, Lithuania;
Hugh Tunstall-Pedoe, Inst of Cardiovascular Res,
Univ of Dundee, Dundee, United Kingdom;
Giancarlo Cesana, Univ degli Studi di MilanoBicocca, Monza, Italy
Aims. To compare the magnitude of
educational classes inequalities in CHD
morbidity in Europe, and to assess to what
extent they are explained by major risk factors.
Methods. The MORGAM study comprised 45
cohorts from Finland, Denmark, Sweden,
Northern Ireland, Scotland, France, Germany,
Northern Italy, Lithuania, Poland and Russia.
Baseline data collection and follow-up (median
12 years) of fatal and non-fatal CHD events
adhered to MONICA-like procedures. We
derived 3 educational classes from population-,
sex- and birth year-specific tertiles of years of
schooling.
We estimated the age-adjusted difference in
event rates, and the age- and risk factorsadjusted hazard ratio (HR), between the bottom
and the top of the educational classes
distribution from sex- and population-specific
Poisson and Cox regression models,
respectively. We provided pooled HR estimates
too, and tested the hypothesis of homogeneity
of inequalities adding population*education
interaction terms. We defined the contribution
of risk factors to HRs as (ln⁡HR[RFadj]ln⁡HR[AGEadj]) / ln⁡HR[AGEadj] .
Results. The cohorts included 89,307 CHD-free
subjects aged 35-64 at baseline (48,706 men).
The age-adjusted difference in CHD incidence
rates ranged in men from 116 CHD events per
100,000 person-years in Germany to 782 in
Scotland; in women from 17 (West Finland) to
391 (Scotland). In north Italian women the rate
difference corresponded to 130% of the
average event rate. Age-adjusted pooled HRs
were 1.6 in men and 2.0 in women, with some
variability across populations (homogeneity test
p-value=0.3 in men and 0.1 in women) and
genders (figure). Blood lipids, systolic BP,
smoking and diabetes explained 37% of risk
excess in each sex; main contributors were
smoking in men (20%) and HDL-cholesterol in
women (14%). Geographic gradients for CHD
mortality were similar.
Conclusions. Social inequalities in CHD are
present in most European populations, with no
clear North-South geographic gradient in
women. To target major risk factors may in part
reduce the gap.
Shunichi Yamashita, Masafumi Abe, Radiation
Medical Science Ctr for the Fukushima Health
Management Survey, Fukushima, Japan;
Fukushima Health Management Survey Group
G. Veronesi: None. M.M. Ferrario: None. L.E.
Chambless: None. K. Kuulasmaa: None. S.
Soderberg: None. V. Salomaa: None. A. Pajak:
None. P. Amouyel: None. D. Arveiler: None. W.
Drygas: None. J. Ferrieres: None. N. Hart:
None. T. Jorgensen: None. S. Malyutina:
None. A. Peters: None. A. Tamosiunas:
None. H. Tunstall-Pedoe: None. G. Cesana:
None.
Introduction: The Great East Japan Earthquake
on March 2011, which followed by a gigantic
tsunami and the radiation of Fukushima Daiichi
Nuclear Power Plant, was a big disaster in
Japan. The survivors lived in long-lasting anxiety
due to the worry about radiation and the
deterioration of daily-life
Hypothesis: We accessed the hypothesis that
worse socioeconomic status due to the
earthquake was associated with the
exacerbation of cardiovascular-related
symptoms among evacuees.
Methods: 73,433 subjects were included in
Fukushima Health Management survey, a largescale cohort study among evacuees after the
Great East Japan Earthquake in 2011. The
subjects were excluded if they did not report
their living conditions. Therefore, the data of
54,658 subjects (24,330 men and 30,328
women≧15 years) were used.
The exacerbation of headache, dizziness,
palpitation, shortness of breath was
determined based on the self-report
questionnaire. Socioeconomic factors included
living arrangement: evacuation shelter or
temporary housing, rental house or apartment,
relatives' home or own home; becoming
unemployed, decreased income and change of
work. Adjustment variables included age, sex,
depression, traumatic symptoms, hypertension,
diabetes mellitus and heart disease. The ORs
and 95% CIs were estimated by using multiple
logistic regression analyses.
Results: We identified 1,375 individuals
reported the exacerbation of headache, 881
reports of dizziness, 768 reports of palpitation
and 434 reports of shortness of breath. The
P090
Socioeconomic Factors After a Disaster Were
Associated with Cardiovascular-Related
Symptoms: Fukushima Health Management
Survey
Wen Zhang, Tetsuya Ohira, Epidemiology Dept,
Sch of Med,Fukushima Medical Univ,
Fukushima, Japan; Michiko Yuki, Mayumi
Harigane, Naoko Horikoshi, Radiation Medical
Science Ctr for the Fukushima Health
Management Survey, Fukushima, Japan; Yuriko
Suzuki, Dept of Adult Mental Health, Natl Inst of
Mental Health,Natl Ctr of Neurology and
Psychiatry Japan, Tokyo, Japan; Akira Ohtsuru,
Dept of Radiation Health Management, Sch of
Med, Fukushima Medical Univ, Fukushima,
Japan; Hirooki Yabe, Dept of Neuropsychiatry,
Sch of Med, Fukushima Medical Univ,
Fukushima, Japan; Masaharu Maeda, Dept of
Disaster Psychiatry, Sch of Med, Fukushima
Medical Univ, Fukushima, Japan; Masato Nagai,
Hironori Nakano, Hideto Takahashi, Radiation
Medical Science Ctr for the Fukushima Health
Management Survey, Fukushima, Japan; Seiji
Yasumura, Dept of Public Health, Sch of Med,
Fukushima Medical Univ, Fukushima, Japan;
multiple logistic regression analyses showed
that living in rental apartments was associated
with all the above symptoms. Comparing with
the participants living in relatives’ home or own
home, the odds ratios and 95% CIs among
the ones living in rental apartments was 1.51
(1.31-1.74) for headache, 1.43 (1.05-1.66) for
dizziness, 1.25 (1.04-1.49) for palpitation, 1.69
(1.32-2.15) for shortness of breath. Living in
evacuation shelter or temporary housing was
also associated with headache (1.42; 95%CI
1.17-1.72), dizziness (1.32; 95%CI 1.05-1.66)
and shortness of breath (1.53; 95%CI 1.13-2.07),
considering the participants living in relatives’
home or own home as references. Becoming
unemployed was another risk factor. Comparing
with the evacuees without losing jobs, the odds
ratios and 95% CIs among job-losers was 1.29
(1.13-1.48) for headache and 1.28 (1.09-1.51)
for dizziness. There was no association between
change of work or decreased income and the
exacerbation of cardiovascular-related
symptoms.
Conclusion: The present study suggest after the
earthquake, living in rental house, apartment,
evacuation shelter or temporary housing, rather
than relatives' home or own home were more
likely to have the exacerbation of
cardiovascular-related symptoms among
evacuees. Becoming unemployed was another
risk factor of the exacerbation of headache and
dizziness.
W. Zhang: None. T. Ohira: None. M. Yuki:
None. M. Harigane: None. N. Horikoshi:
None. Y. Suzuki: None. A. Ohtsuru: None. H.
Yabe: None. M. Maeda: None. M. Nagai:
None. H. Nakano: None. H. Takahashi: None. S.
Yasumura: None. S. Yamashita: None. M. Abe:
None.
P091
Atrial Fibrillation Prevalence and Clinical
Correlates Among Diverse Hispanic/Latinos:
The Hispanic Community Health Study / Study
of Latinos (HCHS-SOL)
Farah Dawood, Carlos Rodriguez, Wake Forest
Univ, Winston Salem, NC; Sylvia W Smoller,
Albert Einstein Coll of Med, Bronx, NY; Alvaro
Alonso, Univ of Minnesota Sch of Public Health,
Minneapolis, MN; Emelia J Benjamin, Boston
Univ, Framingham, MA; Susan Heckbert, Univ of
Washington, Seattle, WA; Elsayed Soliman,
Wake Forest Univ, Winston Salem, NC; Martha L
Daviglus, Univ of Illinois, Chicago, IL; Katrina
Swett, Wake Forest Univ, Winston Salem, NC;
Neil Schneiderman, Univ of Miami, Miami, FL
Introduction: Hispanics are the largest minority
ethnic group in the US. There is limited data on
the epidemiology of AF on Hispanic/Latino
populations. Previous studies examined
Hispanics/Latinos as an aggregate group or only
Mexicans. Methods and Results: Total of 16,415
adult men and women HCHS-SOL participants
were included in the analyses (60% women,
59% age > 45 years) representative of major US
Hispanic background groups: Cuban (CU),
Dominican (DR), Mexican (MX), Puerto Rican
(PR), Central American (CA), and South
American (SA). AF was defined by 12-lead ECG
and/or self-report of a physician diagnosis.
Ethnic-specific AF prevalence rates were
determined. Weighted sequential logistic
regression models were adjusted for
demographic factors (age, sex, education) and
clinical variables (diabetes, hypertension, body
mass index, tobacco use, and eGFR). Overall AF
prevalence was 0.97% (n=162) with highest
prevalence among DRs and PRs (1.8% and 2.5%
respectively) and the lowest among MXs
(0.30%). Diabetes, hypertension and
acculturation (language preference) (all p<0.01)
were significantly associated with higher AF
prevalence. Age-sex adjusted analysis by
Hispanic background with MX as the reference
showed DR, CU, and PR at three-fold to six-fold
higher risk than their MX counterparts. (Table)
In full multivariate models, the effect size for PR
and DR groups was somewhat attenuated but
for CUs and CAs the association became
marginally non-significant. Conclusions: In a
diverse population-based cohort of US
Hispanics/Latinos AF prevalence overall was less
than 1%. Increased acculturation was related to
higher AF prevalence. AF prevalence varies
significantly across Hispanic/Latino groups with
DR and PR particularly at risk independent of
clinical or demographic factors.
F. Dawood: None. C. Rodriguez: None. S.
Smoller: None. A. Alonso: None. E. Benjamin:
None. S. Heckbert: None. E. Soliman: None. M.
Daviglus: None. K. Swett: None. N.
Schneiderman: None.
P092
New Predictive Equation for 24-Hour Urine
Sodium Excretion from Spot Urine Samples
Among Older and Hypertensive Adults: The
MESA and CARDIA Urinary Sodium Study
Lihui Zhao, Norrina B. Allen, Northwestern
Univ, Chicago, IL; Catherine M. Loria, Natl Insts
of Health, Bethesda, MD; Linda Van Horn,
Northwestern Univ, Chicago, IL; Chia-Yih Wang,
Ctrs for Disease Control and Prevention,
Hyattsville, MD; Mary E. Cogswell, Ctrs for
Disease Control and Prevention, Atlanta, GA;
Jacqueline Wright, Natl Insts of Health,
Bethesda, MD; Alicia Carriquiry, Iowa State
Univ, Ames, IA; Kiang Liu, Northwestern Univ,
Chicago, IL
Background: Previous analyses indicated the
mean bias in existing predictive equations for
24-h urinary sodium (UNa) excretion using spot
urine specimens varied significantly among
different gender-race groups of adults aged 4579 years. Our goal is to develop a new equation
for 24-hour UNa which is unbiased across
gender-race groups of older adults.
Methods: 24-h urine samples were obtained
from 554 MESA and CARDIA participants aged
45-79 years. One third (n=189) provided a
second 24-h urine sample. Four timed voids
(morning, afternoon, evening, and overnight)
and the 24-h collection were analyzed for
sodium (Na) concentration. With each spot
specimen, we used the first day samples to
build gender-race specific equations for 24-h
UNa. Candidate predictors included age, agesquared, gender, race, height, weight, body
mass index (BMI), hypertensive status, diuretic
use, estimated Glomerular Filtration Rate
(eGFR), and timed-spot Na/creatinine
(Cr)/potassium (K)/chloride (Cl) concentrations
and excretions. Stepwise regression and the
lasso procedures were used to develop
parsimonious candidate equations for
predicting 24-h UNa. We chose the best fitted
model and then used the second day sample to
compare the mean biases in 24-h UNa of the
resulted equation with existing equations.
Results: Across the timing of specimens,
existing equations have significant mean bias
for one or more gender-race groups. The
proposed equation generally produced less or
equivalent bias than previous equations;
predictors included age, weight, BMI,
hypertensive status, diuretic use, eGFR, and
timed-spot urinary Na/Cr/K excretions. The
proposed equation performed best using the
overnight urine specimen, with unbiased
prediction of 24-h UNa overall (mean bias=21.3)
and across gender-race subgroups (mean bias
<300 mg/d) (Figure).
Conclusion: The proposed equation may result
in less biased estimates for the overall and
subgroup mean UNa excretion among older US
biracial adults, especially using an overnight
urine specimen.
L. Zhao: None. N.B. Allen: None. C.M. Loria:
None. L. Van Horn: None. C. Wang: None. M.E.
Cogswell: None. J. Wright: None. A. Carriquiry:
None. K. Liu: None.
P093
AREST CAD: Adherence Effects of a
Comprehensive Reminder System on
Medication Adherence in Stable Cardiac
Patients
Avinash Pandey, Cambridge Cardiac Care Ctr
and Ctr for Healthcare Delivery Sciences,
Sch, Cambridge, ON, Canada
Background: Non-adherence to evidence-based
cardiovascular therapies is extremely common.
By one year, only half of cardiac patients
continue to take their medications as
prescribed. Forgetfulness has been consistently
identified as a contributor to medication nonadherence. With the proliferation of cell
phones, text message could be a cost-effective
method to remind patients to take their
medications. This simple strategy has not been
rigorously evaluated.
Methods: We developed a novel automated
text message reminder system and assessed its
stability and capacity to improve adherence to
placebo in a pilot study of 20 healthy
volunteers. Subsequently, we recruited 30
stable cardiac patients from a single cardiac
center to test the hypothesis that such a system
could be effective at addressing medication
non-adherence. Eligible patients were
randomized to receive text message reminders
up to 4 times daily at times of their prescribed
medications for month 1 and cross over to usual
care (without reminders) in month 2.
Alternatively, individuals were randomized to
usual care (without reminders) in month 1 and
crossing over to reminders in month 2 of the
study. These messages simply stated, "Please
take your medication now" at the time of their
prescribed medications. Patients were
instructed to take their medications according
to their own prescribed regimen. Adherence
was assessed through logbooks. Subgroup
analyses of the elderly (age ≥ 65 years), patients
with depression, and those with less education
(grade 12 or less) were pre-specified.
Results: We randomized 30 cardiac patients
with an average age of 65 years; 60% were
male. Over the course of the 2 months, 100%
(30 of 30) of cardiac patients improved
adherence with text message reminders. There
was a relative risk reduction for non-adherence
of 64% with this intervention (from 1243 to 476
total missed doses, p<0.01). In all subgroups
analyzed, text message reminders significantly
improved medication adherence. Pre-specified
subgroups exhibited lower rates of medication
adherence with usual care compared to the
total study population (elderly patients,
patients with depression, and patients with less
than grade 12 education). However, these sub-
groups showed greater improvements with the
text message reminder intervention (16%
absolute improvement in these subgroups
versus 10% in the total study population).
Conclusions: In summary, this study
demonstrates the effectiveness of an
automated text message reminder system to
improve adherence to medications in cardiac
patients over a two month period. While the
impact of this intervention on clinical outcomes
was not assessed, it represents a potentially
simple and scalable method for improving
adherence to evidence-based therapies.
A. Pandey: None.
P094
Gender Difference of Left Ventricular
Geometry and Prolonged QRS Duration on
Electrocardiogram: MESA (Multi-Ethnic Study
of Atherosclerosis)
Yuko Inoue, Hiroshi Ashikaga, Yoshiaki Ohyama,
Gustavo Volpe, Bharath Ambale-Venkatesh,
João Lima, Johns Hopkins Hosp, Baltimore, MD
Backgrounds: Prolonged QRS duration (QRSd)
on electrocardiogram (ECG) is commonly found
in otherwise healthy individuals. However,
geometrical factors of the ventricles that
determine QRSd are poorly defined. T1 time by
cardiovascular magnetic resonance (CMR) is
good parameter to estimate extracellular
expansion (ECE). Our objective was to evaluate
the relationship between QRSd and CMR
measures of tissue composition in a large
community-based multiethnic population.
Methods: A total of 1,615 participants (52%
women; age range 44 to 84 years) of the MESA
cohort were evaluated with T1 mapping by
using 1.5-T CMR scanners. We excluded the
participants with focal scar on delayed
enhancement CMR and bundle branch block.
Midventricular short-axis T1 maps were
acquired before and at 12- and 25-min after
administration of gadolinium contrast using
Modified Look-Locker Inversion Recovery
sequence.
Results: Longer QRSd was associated with
greater LV end diastolic volume (LVEDV) index
(p <0.001), LV mass index (p <0.001), and stroke
volume index (p <0.01) in both women and
men. In addition, longer QRSd was associated
with lower ejection fraction (p<0.001),
circumferential shortening (p = 0.04), torsion (p
<0.001), and longer post-contrast T1 times at 12
min indicating less ECE (p = 0.001) in women
only. Longer T1 time remained significant after
adjusting for LVEDV, LV mass and QRS voltage.
Conclusions: In a large multiethnic population,
longer QRSd was associated with lower ECE and
LV dysfunction in women. However, these
relationships were sex dependent and were
absent in men.
Y. Inoue: None. H. Ashikaga: None. Y. Ohyama:
None. G. Volpe: None. B. Ambale-Venkatesh:
None. J. Lima: None.
P095
What R U Eating: A Pilot Study Using Text
Messaging to Track Adolescent Behavior
Habits in a High School Setting
Laura Dotson, Rachel Draper, William Beckner,
Samueli Inst, Alexandria, VA; Erica D Irvin,
HealthCorps, New York, NY; Shawn G Hayes,
HealthCorps, Sacramento, CA; Weimin Zhang,
Neetu Narang, John Ives, Samueli Inst,
Alexandria, VA
Introduction: The purpose of this study was to
examine the feasibility of using short messaging
services (SMS) technology with students
enrolled in HealthCorps’ school program.
Hypothesis: We hypothesized that students
would participate in SMS testing surveying for
at least 2 weeks without significant dropouts.
Methods: Participants were recruited from two
study site: 1) Humanities Prep/Baldwin
Academy in New York, New York and 2)
Woodrow Wilson High School in Washington,
District of Columbia by HealthCorp
Coordinators. Eligibility criteria included being
13-18 years old, enrolled in the HealthCorp
program, and owning a cell phone with text
messaging capabilities. After consenting,
students were given a short demographic and
health behavior questionnaire. Students were
then queried via text message each weekday for
45 days regarding their intake of fruits,
vegetables, and beverages as well as their daily
exercise. Descriptive statistics were used to
assess the data distribution. If a comparison
group was identified, differences in continuous
variables between the groups were tested using
t tests.
Results: The study sample included 57
adolescents from both school; 28 from
Humanities Prep/Baldwin Academy and 29 from
Woodrow Wilson. The majority of the
respondents were 15 years old or older and
they were equally divided by sex. According to
the national average of fruit and vegetable
intake for adolescents 12-18 years old by
gender (NHANES 2009-2010), study participants
had similar intakes. On average, students
exercised 28 minutes per day at each study site.
A subpopulation of those who responded to
50% or more of the survey queries was
analyzed. This subpopulation was statistically
more likely to exercise (p=0.0087), and more
likely to eat fruits and vegetables (p=0.0032 and
p=0.0201 respectively) if they ate dinner at
home. They were also more likely to eat
vegetables (p=0.0235) if they helped prepare
their dinner. Non-responders were more likely
to eat out compared to those who responded to
the survey (p=0.04).
Conclusion: Several feasibility studies using
mobile phones to assess dietary intake have
been conducted. However, the duration of
these studies were short and insufficient to
capture habitual data. This study provides an
innovative approach to capturing and
understanding adolescents and their behaviors
over a long duration (45 days). The
generalizability of these results is limited by the
small sample size of this pilot study. The use of
text messaging as a research tool in a high
school setting presents opportunities and
challenges. Further research is needed to
address the challenges associated with using
text messaging for research in a secondary
school-based environment.
L. Dotson: None. R. Draper: None. W. Beckner:
None. E.D. Irvin: None. S.G. Hayes: None. W.
Zhang: None. N. Narang: None. J. Ives: None.
P096
Effectiveness of a Comprehensive Care
Delivery System on Readmission Rates and
Self-Care in Older Adult Patients with Heart
Failure
Linda L Tavares, Bon Secours Heart and
Vascular Inst, Richmond, VA
Background: Telemedicine interventions to
prevent readmissions in patients with heart
failure (HF) have shown inconsistent results in
their effectiveness on HF-related and all-cause
rehospitalization. Team-based interventions
geared toward patient-centric care delivery in
concert with comprehensive care coordination
that enhances patient self-care may help to
prevent unplanned hospitalizations in patients
with HF.
Objective: To evaluate the outcomes of a
comprehensive care delivery system using a
team-based high-touch coaching and remote
patient monitoring intervention designed for
older adult patients with heart failure in a
community hospital setting.
Design: A descriptive cross-sectional
observational design was used to measure
readmission rates. A one-group pretest-posttest
design using the Self-care of Heart Failure Index
was used to measure self-care outcomes.
Correlation analysis was performed to
determine relationships between the coaching
and outcomes.
Patients: Participants were older adult patient
hospitalized with heart failure and followed for
30-days. Patients were excluded if they were
unwilling to participate, non- English speaking,
had end-stage renal disease, a terminal illness,
debilitating neuro-psychological disorder, or
lived greater than 30 miles away.
Results: The 30-patients were primarily
Caucasian, female with a mean age of 77.5
years. The majority of patients had medically
optimized NYHA class II or III HF with an
ejection fraction ≤ 40%. HF readmission rate
was zero, and 6% for all cause. Patient self-care
scores improved (p < .0001). Team based
coaching was correlated with improvement in
self-care maintenance scores (p =.009).
Conclusion: A comprehensive care delivery
system leveraging remote patient monitoring
and health coaching significantly reduced 30day readmission and enhanced patient self-care
management.
Implications: Patient centric team based care
models leveraging technology should continue
to be developed and implemented to transform
care delivery for older adults with HF.
Table 1. Change in Mean Self-Care of Heart
Failure Index Scores
p < .0001
p < .0001
p < .0001
L.L. Tavares: D. Speakers Bureau; Modest; Zoll.
G. Consultant/Advisory Board; Modest;
C3Nexus.
P097
Predictive Model of Bleeding Events in Atrial
Fibrillation Patients Using Dabigatran
Ian R Rapson, Lin Y Chen, Richard F Maclehose,
Pamela L Lutsey, Alvaro Alonso, Univ of
Objective: Develop a model to predict incident
bleeding events in atrial fibrillation (AF) patients
on dabigatran, using clinically available
variables.
Hypothesis: A predictive model of bleeding in
dabigatran users developed from claims data
will be clinically useful.
Methods: We studied AF patients initiating
dabigatran, a new oral anticoagulant, in the
MarketScan dataset, a large healthcare
utilization database, in the period 2010-2012.
Two thirds of the sample was randomly
selected and used to derive the predictive
model (training dataset), which was then
validated in the remaining third (testing
dataset). Predictors were selected from
diagnosis, procedural, and medication codes
potentially associated with bleeding using
health claims. The outcome of interest were
intracranial bleeding or gastrointestinal
hemorrhage, defined by validated algorithms. A
Cox model with backwards elimination of
variables (p<0.05 threshold) was used to select
variables for the predictive model.
Discrimination was determined with a Cstatistic for survival analysis and calibration with
a chi square test.
Results: The training data set included 26,283
individuals and 404 bleeding events. The testing
dataset included 13,224 individuals and 205
events. Median follow-up time was 436 days
(interquartile range 256-591 days). The final
model included the following variables: age,
hematologic disorders, heart failure, kidney
disease, prior vascular procedure, and prior use
of warfarin (table). The internal training cstatistic was 0.75 (0.72-0.77) with and adjusted
calibration chi-square p-value=0.0827. The
testing validation c-statistic was 0.77 (0.74-0.80)
with an adjusted calibration chi-square pvalue=0.0215.
Conclusion: A simple model using clinical
variables was able to identify AF patients at
higher risk of bleeding when using dabigatran.
This model could assist clinical decisions about
anticoagulant use. However, the model may
need recalibration before being used in an
external population.
I.R. Rapson: None. L.Y. Chen: None. R.F.
Maclehose: None. P.L. Lutsey: None. A. Alonso:
None.
P099
Atrial Flutter - Clinical Correlates and Adverse
Outcomes in the Framingham Heart Study
Faisal Rahman, Boston Univ Medical Ctr,
Boston, MA; Na Wang, Boston Univ Sch of
Public Health, Boston, MA; Xiaoyan Yin,
Framingham Heart Study, Framingham, MA;
Patrick T Ellinor, Steven A Lubitz, Massachusetts
General Hosp, Boston, MA; Paul A LeLorier,
Louisiana State Univ Sch of Med, New Orleans,
LA; David D McManus, Univ of Massachusetts
Medical Ctr, Worcester, MA; Emelia J Benjamin,
Jared W Magnani, Boston Univ Sch of Med,
Boston, MA
Introduction: There has been little study of
atrial flutter (AFl), distinct from atrial
fibrillation, in community-based, epidemiologic
cohorts. We determined the clinical correlates
of AFl and its associated outcomes in the
Framingham Heart Study.
Methods: We adjudicated electrocardiograms
from study exams, and ambulatory and hospital
records to identify typical AFl in participants
without prevalent atrial fibrillation or AFl. We
compared individuals with AFl to participants
with neither atrial fibrillation nor AFl. We
identified factors associated with a new
diagnosis of AFl. We examined the 10-year risks
of atrial fibrillation, myocardial infarction, heart
failure, stroke, and all-cause mortality in Cox
proportional hazards models with adjustment
for age, sex, body mass index, systolic and
diastolic blood pressures, hypertension
treatment, diabetes mellitus and prevalent
Results: During a follow-up of 33.0±12.2 years,
112 individuals developed AFl. In age- and sexadjusted analyses, smoking (odds ratio [OR]
2.02; 95% confidence interval [CI] 1.21-3.37;
P<0.01), moderate-to-heavy alcohol use (OR
2.48; 95% CI 1.10-5.55; P<0.05), increased PR
interval (OR 1.50; 95% CI 1.21-1.86; P<0.001),
myocardial infarction (OR 1.96; 95% CI 1.053.64; P<0.05), heart failure (OR 5.21; 95% CI
1.64-16.55; P<0.01), and stroke (OR 2.46; 95%
CI 1.19-5.07; P<0.05) were associated with
incident AFl. After multivariable adjustment, in
individuals with AFl the 10-year risk was
increased 14.1-fold for atrial fibrillation, 5.3-fold
for myocardial infarction, 3.7-fold for heart
failure, and 1.8-fold for mortality.
Conclusions: In our community-based cohort,
we identified factors associated with AFl onset
and found that AFl was associated with multiple
adverse outcomes. Future studies should
determine how treatment for AFl may modify
its prognosis.
F. Rahman: None. N. Wang: None. X. Yin:
None. P.T. Ellinor: None. S.A. Lubitz: None. P.A.
LeLorier: None. D.D. McManus: None. E.J.
Benjamin: None. J.W. Magnani: None.
P100
Kidney Health and Sudden Death Risk: The
Reasons for Geographic and Racial Differences
in Stroke (REGARDS) Cohort
Rajat Deo, Univ of Pennsylvania, Philadelphia,
PA; Elsayed Z Soliman, Wake Forest Univ Sch of
Med, Winston Salem, NC; Yulia Khodneva, Paul
M Muntner, Univ of Alabama, Birmingham, AL;
William McClellan, Emory Univ, Atlanta, GA;
Todd M Brown, Suzanne E Judd, James D
Rhodes, Orlando M Gutierrez, Univ of Alabama,
Birmingham, AL; Michael G Shlipak, Univ of
Christine M Albert, Brigham and Women's
Hosp, Boston, MA; Monika M Safford, Univ of
Alabama, Birmingham, AL
Objective: Chronic kidney disease (CKD) is a
known risk factor for sudden death (SD). Recent
improvements in the detection and
classification of kidney disease using creatinine
and cystatin C-based estimated glomerular
filtration rate (eGFR) and urine albumin-to-
creatinine ratio (UACR) have identified
individuals with mild forms of kidney
dysfunction who are at risk for adverse events.
A comprehensive assessment of SD incidence
across the spectrum of kidney health in a
racially diverse population has not been
performed.
Methods: The study was a prospective,
longitudinal analysis among 27,296 participants
≥ 45 years (54% women, 40% Black) from across
the continental US enrolled in the REGARDS
study. Serum cystatin C and creatinine and
urine albumin and creatinine were measured at
baseline. SD was defined as sudden
pulselessness from a presumed cardiac origin
that occurred out of hospital or in the
emergency room in a previously stable
individual without other clear precipitating
cause. Associations between estimated
glomerular filtration rate (eGFR), derived from
serum creatinine-cystatin C CKD-EPI, and urine
albumin to creatinine ratio (UACR) and SD were
estimated.
RESULTS: Over a mean follow-up of 5.8 ± 1.9
years, there were 335 SD. The annual incidence
of SD increased across eGFR and ACR categories
(from 1.2 to 5.2 per 1000-person years). Both
eGFR and ACR were independently and
additively associated with graded increases in
SD risk after adjustment for sociodemographics,
total cholesterol, HDL, statin use, blood
pressure, anti-hypertensive medication,
smoking, and heart failure (Table). Participants
with mild decreases in eGFR (60-90
ml/min/1.73m2) combined with mild elevations
in UACR (15-30 mg/g) were at significantly
increased SD risk, and UACR <30mg/g identified
individuals with normal eGFRs at higher SD risk.
Conclusion: Sensitive measures of eGFR and
ACR provide a gradient of SD risk across the
spectrum of kidney health.
R. Deo: None. E.Z. Soliman: None. Y.
Khodneva: None. P.M. Muntner: None. W.
McClellan: None. T.M. Brown: None. S.E. Judd:
None. J.D. Rhodes: None. O.M. Gutierrez:
None. M.G. Shlipak: None. C.M. Albert: None.
M.M. Safford: B. Research Grant; Modest;
Amgen, diaDexus.
P101
Associations of Adiposity and Atrial Fibrillation
in Older Adults: the Health ABC Study
Konstantinos N Aronis, Boston Medical Ctr,
Boston Universtiy Sch of Med, Boston, MA; Na
Wang, Data Coordinating Ctr, Boston Univ Sch
of Public Health, Boston, MA; Caroline Phillips,
Intramural Res Program, Natl Inst on Aging, Natl
Insts of Health, Univ of California, San Francisco,
CA; Emelia J Benjamin, Cardiology Section,
Whitaker Cardiovascular Inst, Evans Dept of
Med, Boston, Boston, MA; Gregory M Marcus,
Electrophysiology Section, Div of Cardiology,
Univ of California, San Francisco, CA; Anne B
Newman, Dept of Epidemiology, Graduate Sch
of Public Health, Univ of Pittsburgh, Pittsburgh,
PA; Nicolas Rodondi, Dept of General Internal
Med, Univ of Bern, Bern, Switzerland; Suzanne
Satterfield, Dept of Preventive Med, Univ of
Tennessee Health Science Ctr, Memphis, TN;
Tamara B Harris, Intramural Res Program, Natl
Inst on Aging, Natl Insts of Health, Univ of
California, San Francisco, CA; Jared W Magnani,
Cardiology Section, Whitaker Cardiovascular
Inst, Evans Dept of Med, Boston, Boston, MA
Introduction: Obesity is a well-recognized,
modifiable risk factor for atrial fibrillation (AF).
Limited studies have examined adiposity
measures other than body mass index (BMI)
and AF risk. We examined associations of
adiposity measures with incident AF in a biracial
cohort of older adults. Given the extensive
racial differences between obesity and AF, we
assessed for racial differences in relating
adiposity and AF.
Methods: The Dynamics of Health, Aging, and
Body Composition Study is a prospective cohort
of 3,075, community-dwelling, older adults.
Adiposity measures were determined using
anthropometry [BMI and abdominal
circumference (AC)], CT [subcutaneous and
visceral fat area (SAT, VAT)] and DXA (total and
percent fat mass). AF was identified from the
Center for Medicare and Medicaid Services. We
determined the associations between adiposity
measures and the 10-year risk of incident AF
using Cox proportional hazards models. We
examined for interactions between race and
adiposity measures with the outcome of AF.
Results: The cohort consisted of 2,717
participants (mean age 74±3 years, 51.7%
women, 41.4% black). The 10-year incidence of
AF was 16.6 (95% CI: 14.9-18.3) per 1000
person-years (371 events). In multivariableadjusted models, every 1-SD increase in BMI, AC
and total fat mass was associated with a 13-16%
increase in AF risk (HR: 1.14, 95%CI: 1.02-1.28,
HR:1.16, 95%CI: 1.04-1.28 and HR: 1.13, 95%CI:
1.002-1.27). Percent fat mass, SAT and VAT area
were not associated with incident AF. We did
not identify effect modification by race
between the adiposity measures and AF risk.
Figure 1 shows the multivariable-adjusted
splines relating BMI and risk of AF in whites and
blacks.
Conclusion: We determined that BMI, AC and
total fat mass, but not SAT or VAT are
associated with 10-year AF risk in a biracial
cohort of older adults. As obesity is one of the
few modifiable AF risk factors, future studies
are required to evaluate how weight change
can modify the incidence of AF.
K.N. Aronis: None. N. Wang: None. C. Phillips:
None. E.J. Benjamin: None. G.M. Marcus:
None. A.B. Newman: None. N. Rodondi:
None. S. Satterfield: None. T.B. Harris:
None. J.W. Magnani: None.
P102
Resting Heart Rate and Incident Atrial
Fibrillation in the Elderly
Mohamed Faher Almahmoud, Elsayed Soliman,
Wesley Oneal, Wake Forest Univ, Winston
Salem, NC
Background: Alterations in sympathetic tone
and/or sinus node dysfunction are common
with aging. We hypothesized that older persons
with low or high heart rates may represent a
population with subclinical conduction
abnormalities who are more likely to develop
atrial fibrillation (AF).
Methods: A total of 5,226 participants aged 65
years or more (85% white; 42% male) free of
baseline AF from the Cardiovascular Health
Study were used in this analysis. AF cases were
identified during the yearly study
electrocardiogram, a self-reported history of a
physician diagnosis, or by hospitalization data.
Cox regression was used to compute hazard
ratios (HR) and 95% confidence intervals
(95%CI) for the association between resting
heart rate and incident AF. The association by
clinically relevant categories (heart rate ≤60
bpm, 60 bpm < heart rate ≤90 bpm (reference),
heart rate >90 bpm) and as a continuous
variable per 5 bpm decrease were examined.
Results: The mean resting heart rate was 65+/11 bpm. Over a median follow-up of 12.7 years,
a total of 532 (10.2%) participants developed
AF. In a multivariable Cox regression analysis
adjusted for age, sex, race, education, income,
baseline cardiovascular disease, smoking status,
systolic blood pressure, diabetes, body mass
index, total cholesterol, HDL cholesterol, aspirin
use, statins use, antihypertensive and
antiarryhthmic medications use, and log(hsCRP), heart rates ≤60 bpm (HR=1.3, 95%CI=1.1,
1.5), but not >90 bpm (HR=1.1, 95%CI=0.52,
2.3), were associated with an increased risk of
AF. Using resting heart rate ≤50 bpm as a
cutpoint showed a greater increase in risk of AF
( HR=1.4,95%CI=1.02, 1.8), suggesting a dose
response relationship. In a similar model, each
5-bpm decrease in heart rate was associated
with a 6% increase in the risk of AF (HR=1.06,
95%CI=1.01, 1.1). A sensitivity analysis
excluding participants taking antiarrhythmic
and/or heart rate modifying agents did not alter
our results. The results were consistent in
subgroup analyses stratified by age, sex, race,
and baseline cardiovascular disease.
Conclusion: Low resting heart rates were
associated with an increased risk of AF in the
elderly population enrolled in the
Cardiovascular Health Study. Potentially,
marked sinus bradycardia in the elderly could
be an early marker for increased risk of AF
M. Almahmoud: None. E. Soliman: None. W.
Oneal: None.
P103
Kidney Function and Sudden Cardiac Death in
the Community: The Atherosclerosis Risk in
Takeki Suzuki, Sunil K Agarwal, Johns Hopkins
Univ, Baltimore, MD; Rajat Deo, Univ of
Pennsylvania, Philadelphia, PA; Nona
Sotoodehnia, Univ of Washington, Seattle, WA;
Morgan Grams, Elizabeth Selvin, Hugh Calkins,
Johns Hopkins Univ, Baltimore, MD; Wayne
Rosamond, Univ of North Carolina Sch of Public
Health, Chapel Hill, NC; Gordon Tomaselli, Josef
Coresh, Kunihiro Matsushita, Johns Hopkins
Univ, Baltimore, MD
Introduction: Individuals with chronic kidney
disease (CKD), particularly those requiring
dialysis, are at high risk of sudden cardiac death
(SCD). However, data for the full-spectrum of
kidney function and SCD risk in the community
are sparse. Furthermore, newly developed
equations for estimated glomerular filtration
rate (eGFR) and novel filtration markers might
add further insight to the role of kidney
function in SCD.
Methods: We investigated the associations of
baseline eGFRs using either serum creatinine,
cystatin C (CysC), or both (eGFRcr, eGFRcr-cys,
and eGFRcys), CysC itself, and β2-microglobulin
(B2M) with SCD through 2001 among 13,070
blacks and whites participants at the second
visit (1990-92) of the community-based ARIC
Study. Cox regression models were used to
quantify the associations of kidney function and
different markers of kidney filtration with SCD
after the adjustment for potential confounders.
The cohort was divided into 5 groups based on
clinical CKD Stages as well as quartiles.
Results: Over a median of 11 years of follow-up,
205 participants developed SCD (1.4 cases per
1000 person-years). Low eGFR was
independently associated with SCD risk: for
example, HR for eGFR 30-44 vs ≥90
ml/min/1.73m2 was 3.97 (95%CI 1.57-10.03)
with eGFRcr; HR 6.96 (3.56-13.61) with eGFRcrcys; and HR 5.47 (2.97-10.09) with eGFRcys. Of
note, when eGFRcr and eGFRcys were included
together in a single model, the association was
only significant for eGFRcys. When we
compared all kidney markers based on their
quartiles, B2M demonstrated the strongest
association with SCD (Table). Qualitatively
consistent results were observed across clinical
and demographic subgroups.
Conclusion: Kidney function was independently
and robustly associated with SCD in the
community, particularly when CysC or B2M
were taken into account as filtration markers.
These results may suggest the importance of
kidney function for SCD risk evaluation and the
value of novel filtration markers beyond eGFRcr
in association with SCD.
T. Suzuki: None. S.K. Agarwal: None. R. Deo:
None. N. Sotoodehnia: None. M. Grams:
None. E. Selvin: None. H. Calkins: None. W.
Rosamond: None. G. Tomaselli: None. J.
Coresh: None. K. Matsushita: None.
P104
Serum 25-hydroxyvitamin D Levels and
Incidence of Atrial Fibrillation: The
Atherosclerosis Risk in Communities Study
Jeffrey R. Misialek, Alvaro Alonso, Univ of
Minnesota, Minneapolis, MN; Erin D. Michos,
John Hopkins Univ, Baltimore, MD; Lin Y. Chen,
Univ of Minnesota, Minneapolis, MN; Elsayed Z.
Soliman, Wake Forest Sch of Med, WinstonSalem, NC; Elizabeth Selvin, John Hopkins Univ,
Baltimore, MD; Myron Gross, John H. Eckfeldt,
Pamela L. Lutsey, Univ of Minnesota,
Minneapolis, MN
Introduction: Low levels of serum 25hydroxyvitamin D [25(OH)D] have been
cardiovascular disease (CVD). However, few
studies have examined the association of
25(OH)D with atrial fibrillation (AF).
Hypotheses: Individuals with clinically deficient
serum 25(OH)D levels (<20 ng/mL) will have an
increased risk for AF, and the association will be
stronger among whites than blacks.
Methods: The Atherosclerosis Risk in
Communities (ARIC) study is a biracial,
community-based cohort in the United States. A
total of 12,300 ARIC participants (77% white,
57% women, mean age 57) with available
25(OH)D levels, and who were free of AF at
baseline (1990-92), were followed through
2011. Total serum 25(OH)D was measured in
stored samples at baseline using LCMS and
adjusted for month of blood draw to account
for seasonal differences in 25(OH)D levels.
Incident AF cases were identified from
electrocardiograms, hospital discharge codes,
and death certificates. Multivariable Cox
models were used to estimate hazard ratios and
95% confidence intervals for AF associated with
serum 25(OH)D levels by clinical cut-points.
Interactions by age, race, and sex were tested.
Results: During a median follow-up of 20 years,
there were 1,706 incident AF events. Those with
deficient 25(OH)D levels (<20 ng/mL) had a
higher AF risk compared to those with optimal
levels (>30 ng/mL) after adjustment for
demographics (Table, model 1). Additional
adjustment for cardiovascular risk factors and
history of CVD attenuated the associations
(Table, models 2 and 3). A significant interaction
with age (p=0.01), but not with race or sex (p
>0.40), was identified, with an inverse
association between serum 25(OH)D in younger
but not older individuals (Table).
Conclusions: After accounting for traditional
cardiovascular risk factors, low serum 25(OH)D
was not associated with risk of incident AF in
this community-based population. However, an
apparent association in younger individuals (4757) warrants further investigation.
J.R. Misialek: None. A. Alonso: None. E.D.
Michos: None. L.Y. Chen: None. E.Z. Soliman:
None. E. Selvin: None. M. Gross: None. J.H.
Eckfeldt: None. P.L. Lutsey: None.
P105
Small Magnitude of the Heart Movement Due
to Respiration is Associated With Sudden
Cardiac Death
Muammar M Kabir, Elyar Ghafoori, Oregon
Health & Science Univ, Portland, OR; Jonathan
W Waks, Beth Israel Deaconess Medical Ctr,
Boston, MA; Sunil K Agarwal, Johns Hopkins
Univ Sch of Public Health, Baltimore, MD; Dan E
Arking, Johns Hopkins Univ, Baltimore, MD;
Nona Sotoodehnia, Univ of Washington, Seattle,
WA; David S Siscovick, New York Acad of Med,
New York, NY; Wendy Post, Johns Hopkins Univ
SOM, Baltimore, MD; Charles Henrikson,
Oregon Health & Science Univ, Portland, OR;
Scott D Solomon, Brigham and Women’s Hosp,
Boston, MA; Elsayed Z Soliman, Wake Forest
Sch of Med, Winston Salem, NC; Josef Coresh,
Johns Hopkins Univ Sch of Public Health,
Baltimore, MD; Mark E Josephson, Beth Israel
Deaconess Medical Ctr, Boston, MA; Larisa G.
Tereshchenko, Oregon Health & Science Univ,
Portland, OR
Background-Respiration causes heart
movement in the chest and proportional
change in the heart’s electrical axis. The ECG
can be used to measure respiration-related
heart motion. The effect of respiration on the
ECG is usually considered an artifact. However,
it is unknown whether pattern of heart motion
due to respiration holds any prognostic value.
Method- After excluding those with atrial
fibrillation, or atrial or ventricular premature
contractions at baseline visit, 14613 ARIC cohort
participants (mean age 54.0±5.8 y; 6595 [45.1%]
men; 10744 [73.5%] white, 1311 [9.0%] with
prevalent cardiovascular disease (CVD)) were
included. The digital resting ECG was analyzed
using custom Matlab software. The absolute
magnitude of the displacement of the heart due
to respiration was calculated on X (left-right), Y
(up-down), and Z (anterior-posterior) axes.
Sudden cardiac death (SCD) and non-coronary
heart disease (CHD) death served as competing
outcomes in our analysis.
Results-In CVD-free participants (as compared
to prevalent CVD group) heart moved more on
X axis (137±46 vs. 128±47 µV; P<0.0001), and
less on Z axis (123±52 vs. 127±60 µV; P=0.05).
During a median follow-up of 14 years 278 SCDs
(96 in CVD group) and 1619 non-CHD (279 in
CVD group) deaths occurred. In competing risk
analysis that adjusted for age, gender, race,
history of myocardial infarction, CHD, heart
failure, systolic blood pressure, antihypertensive medications, diabetes, smoking,
total cholesterol, high density lipoprotein, level
of physical activity, use of beta-blockers, left
ventricular hypertrophy on ECG and QRS
duration, the absolute magnitude of
respiration-related heart movement on X axis
(SHR 0.74; 95%CI 0.59-0.93; P=0.009) and Z axis
(SHR 1.19; 95%CI 1.01-1.41; P=0.042) associated
with SCD (but not with non-CHD death) in CVD
group, but not in CVD-free participants.
Conclusion- Greater respiration-caused heart
motion on Z axis and smaller - on X axis likely
reflects cardiomegaly and is associated with
increased risk of SCD in patients with CVD.
M.M. Kabir: None. E. Ghafoori: None. J.W.
Waks: None. S.K. Agarwal: None. D.E. Arking:
None. N. Sotoodehnia: None. D.S. Siscovick:
None. W. Post: None. C. Henrikson: None. S.D.
Solomon: None. E.Z. Soliman: None. J. Coresh:
None. M.E. Josephson: None. L.G.
Tereshchenko: None.
P106
Physical Activity and Atrial Fibrillation in
NHANES III
Larisa G. Tereshchenko, Oregon Health &
Science Univ, Portland, OR; Amit Shah, Emory
Univ, Atlanta, GA; Elsayed Z Soliman, Wake
Forest Sch of Med, Winston Salem, NC
Background: The impact of physical activity (PA)
on the risk of atrial fibrillation (AF) is complex
and controversial. The goal of this study was to
examine the cross-sectional relationships
between PA and AF in the Third National Health
and Nutrition Examination Survey (NHANES III).
Methods: Self-reported type and level of PA
was evaluated in 19,620 NHANES III participants
(mean age 47.3±20.7y; 47% men; 42.0% nonHispanic white, 27.6% non-Hispanic black,
26.6% Hispanics). We defined prevalent AF via
ECG or by the presence of an irregular radial
pulse palpated during physical examination in
those excluded from ECG examination
(suspected AF was an exclusion criteria for
ECG). Logistic regression was adjusted for
demographics (age, sex, and race), history of
cardiovascular disease (heart attack, stroke and
heart failure), and cardiovascular risk factors
(diabetes, hypertension, hypercholesterolemia,
and smoking).
Results: Presumed AF was found in 1191
participant (6.07%). AF prevalence was higher in
participants who felt being less active (n=365,
8.2%) as compared to those who felt the same
(n=497, 5.5%) or more active (n=329, 5.4%)
than most men/women of the same age (Chi
square P<0.0001). Feeling of being more active
compared with most men/women of the same
age was associated with a lower rate of AF (OR
0.78; 95%CI 0.72-0.84; P<0.0001). However,
feeling of being more active compared with ten
years ago was not associated with AF (OR 1.01;
95%CI 0.91-1.12); P=0.888). Doing gardening or
yard work was associated with lower
prevalence of AF (OR 0.58; 95%CI 0.51-0.66;
P<0.0001), whereas running or jogging was
associated with higher AF prevalence (OR 1.27;
95% 1.05-1.53; P=0.013). Bicycling, swimming,
aerobics, dancing, calisthenics, and weight
lifting did not have a significant association with
AF. No interaction of PA with age, sex, or race
was observed.
Conclusion: Low-intensity leisure PA and high
perceived personal PA compared to age/sex
matched peers are associated with lower
prevalence of AF in a large sample of the adult
United States population. These results could
have potential implications on the types of
physical activity recommended for individuals at
risk of AF.
L.G. Tereshchenko: None. A. Shah: None. E.Z.
Soliman: None.
P107
The Association Between Cancer and Atrial
Fibrillation: The REasons for Geographic and
Racial Differences in Stroke (REGARDS) Study
Wesley T O'Neal, Wake Forest Sch of Med,
Winston Salem, NC; Susan G. Lakoski, Univ of
Vermont, Burlington, VT; Waqas Qureshi, Wake
Forest Sch of Med, Winston Salem, NC; Suzanne
E. Judd, George Howard, Virginia Howard, Univ
of Alabama at Birmingham, Birmingham, AL;
Mary Cushman, Univ of Vermont, Burlington,
VT; Elsayed Z. Soliman, Wake Forest Sch of
Med, Winston Salem, NC
Background: Atrial fibrillation (AF) is a common
finding in patients with life-threatening cancer
and those undergoing active cancer treatment.
However, data from persons with non-life
threatening cancer and not on active treatment
are lacking.
Methods: A total of 15,428 (mean age: 66 ± 8.9
years; 47% women; 45% blacks) participants
from the REasons for Geographic and Racial
Differences in Stroke (REGARDS) Study with
complete baseline data on prior cancer
diagnosis and AF were included in this analysis.
By design, life-threatening cancer and active
cancer treatment were exclusion criteria in
REGARDS. History of cancer was identified using
computer-assisted telephone interviews. AF
cases were identified from the study-scheduled
electrocardiogram and by self-reported history
of a previous physician diagnosis. Logistic
regression was used to examine the crosssectional association between prior cancer
diagnosis and AF.
Results: A total of 2,248 (14.6%) participants
reported a prior diagnosis of cancer, and 1,295
(8.4%) had AF. In a multivariable logistic
regression model adjusted for sociodemographics (age, sex, race, education,
income, and geographic region) and potential
confounders (systolic blood pressure, highdensity lipoprotein cholesterol, total
cholesterol, C-reactive protein, body mass
index, smoking, diabetes, antihypertensive
medications, lipid-lowering therapies, left
ventricular hypertrophy, and prior history of
cardiovascular disease), those with prior cancer
were more likely to have AF than those without
a prior cancer diagnosis (OR=1.19, 95%CI=1.02,
1.38). Similar results were obtained in
subgroups stratified by age, race, sex, prior
cardiovascular disease, and C-reactive protein
(stratified by median value).
Conclusion: In REGARDS, prior history of cancer
(not life threatening or requiring active
treatment) is associated with an increased risk
of AF. Our findings suggest that persons who
have survived cancer, and not only those with
severe forms of cancer, represent a high-risk
population for developing AF.
W.T. O'Neal: None. S.G. Lakoski: None. W.
Qureshi: None. S.E. Judd: None. G. Howard:
None. V. Howard: None. M. Cushman:
None. E.Z. Soliman: None.
P108
Comorbidity Burden in Atrial Fibrillation: A
Population-Based Case-Control Study
Alanna M. Chamberlain, Mayo Clinic,
Rochester, MN; Margaret C. Byrne, Mercyhurst
Univ, Erie, PA; Alvaro Alonso, Univ of
Minnesota, Minneapolis, MN; Bernard J. Gersh,
Sheila M. Manemann, Jill M. Killian, Susan A.
Weston, Veronique L. Roger, Mayo Clinic,
Rochester, MN
Background: Differences in the prevalence and
duration of co-morbid conditions in atrial
fibrillation (AF) patients compared to
population controls have not been well
documented.
Methods: The prevalence and duration of 17
chronic conditions defined by the US
Department of Health and Human Services, as
well as anxiety, obesity, and smoking status,
was obtained in a random sample of 1430
patients with incident AF from 2000-2010 and
1430 controls from Olmsted County, MN.
Controls were matched to cases 1:1 on sex and
age (within 5 years). Chronic conditions were
ascertained electronically requiring 2
occurrences of a diagnostic code; the duration
of each condition (up to 25 years) was
calculated. Logistic regression determined
associations of each condition with AF after
adjustment for all other conditions.
Results: Among the 1430 matched pairs
(median age 76 years, 48.6% men), the
prevalence of chronic conditions was higher in
AF cases compared to controls for all conditions
except asthma, dementia, depression, hepatitis,
and osteoporosis (figure). However, the
duration of the conditions were similar in AF
compared to controls, except for hypertension
(median duration 12.3 and 9.9 years in AF cases
and controls, respectively; p=0.002). After
adjusting for all other conditions, obesity,
hypertension, congestive heart failure, coronary
artery disease, chronic kidney disease, and
chronic obstructive pulmonary disease
remained significantly more common in AF
compared to controls (figure). Conditions with
the largest attributable risk of AF were
hypertension (25.4%), coronary artery disease
(17.7%), and congestive heart failure (12.3%).
Conclusions: AF patients have a higher
prevalence of many chronic conditions
compared to population controls. However,
besides hypertension, these comorbidities do
not develop earlier in AF. Nevertheless, the
excess comorbidity burden in AF is important to
characterize and understand as it may partly
explain the excess mortality and healthcare
utilization experienced by AF patients.
A.M. Chamberlain: None. M.C. Byrne: None. A.
Alonso: None. B.J. Gersh: None. S.M.
Manemann: None. J.M. Killian: None. S.A.
Weston: None. V.L. Roger: None.
National Center
P109
Effects of Tree Nuts on Blood Lipids,
Lipoproteins, and Blood Pressure: MetaAnalysis and Dose-Response of 61 Trials
Liana C Del Gobbo, Tufts Univ, Boston, MA;
Michael C Falk, Robin Feldman, Kara Lewis, Life
Science Res Organization, Bethesda, MD;
Dariush Mozaffarian, Tufts Univ, Boston, MA
Background: Accumulating evidence suggests
that nut intake may lower CVD. The effects of
nuts on major CVD risk factors, including doseresponses, and potential heterogeneity by nut
type and phytosterol content, are unclear.
Objective: We performed a meta-analysis of
controlled trials to investigate the effects of
nuts (walnuts, pistachios, macadamias, pecans,
cashews, almonds, hazelnuts, Brazil and mixed
nuts) on blood lipids (total cholesterol, LDL,
HDL, TG), lipoproteins (ApoA1, ApoB, ApoB100),
blood pressure, and inflammation in adults
(≥18y) without prevalent CVD.
Methods: Following PRISMA guidelines,
PubMed was searched through 2013, with data
extracted using standardized protocols. We
calculated weighted mean differences (WMD)
between nut intervention and control arms,
using fixed-effects meta-analysis. Doseresponses for nuts and phytosterol intake were
examined using linear regression and fractional
polynomial modeling. Heterogeneity by age,
sex, comparison diet, baseline risk factor level,
nut type, disease condition, duration, and
quality score was assessed using metaregression.
Results: Of 1301 articles, 61 trials met eligibility
criteria (n=2582). Nut intake (per daily serving,
28.4g) lowered total cholesterol (WMD: -4.7;
95% CI -5.3, -4.0), LDL (-4.8; 95% CI -5.5, -4.2),
ApoB (-3.7; 95% CI -5.2, -2.3), and TG (-1.1; -1.8,
-0.5) (all mg/dL). The dose-response relations
between nut intake and total cholesterol and
LDL were non-linear; stronger effects were
observed in trials providing ≥60g nuts/day.
Heterogeneity was not observed by nut type or
most other factors. For ApoB, stronger effects
were observed in populations with diabetes (11.5; -16.2, -6.8 mg/dL) than those without
diabetes (-2.5; -4.7, -0.3 mg/dL) (p=0.015). Little
evidence of publication bias was observed using
Egger’s and Begg’s tests.
Conclusions: Nut intake lowers total
cholesterol, LDL, ApoB, and TG, but not HDL,
other lipoproteins, blood pressure, or CRP, with
no significant differences in effects by nut type.
L.C. Del Gobbo: G. Consultant/Advisory Board;
Modest; ad hoc consulting for Life Sciences
Research Organization. M.C. Falk: G.
Consultant/Advisory Board; Modest;
International Tree Nut Council (ITNC). The ITNC
did not have any input on the design, conduct,
or findings of the work. R. Feldman: G.
or findings of the work. K. Lewis: G.
or findings of the work. D. Mozaffarian: G.
Consultant/Advisory Board; Modest; ad hoc
consulting for Life Sciences Research
Organization.
P110
Mean Daily Pedometer Step Count is
Associated With Weight Loss
Christopher C Imes, Lei Ye, Yaguang Zheng,
Juliet Mancino, Cynthia A. Danford, Meghan
Mattos, Edvin Music, Dara D. Mendez, Hu Lu,
Lin J. Ewing, Susan M. Sereika, Lora E. Burke,
Univ of Pittsburgh, Pittsburgh, PA
Introduction: Increased physical activity (PA),
along with reduced energy intake, are the key
strategies to achieve weight loss. However,
there are challenges to obtaining accurate PA
data. Many studies rely on self-report, which is
easily accessible and inexpensive but is known
to have numerous limitations. Pedometers are a
relatively inexpensive and accessible method to
objectively measure certain aspects of PA.
However, their limitations include the inability
to assess certain types of PA such as swimming
and cycling. The purpose of this analysis was to
examine the associations between self-reported
PA, pedometer step count data and weight loss
in a behavioral weight loss intervention.
Hypotheses: 1) Self-reported PA will not be
associated with weight loss. 2) Higher daily
pedometer step count will be associated with
greater weight loss.
Methods: This was a secondary analysis of 6month data from the Self Efficacy Lifestyle
Focus (SELF) Trial. Self-reported PA was
assessed using the Modifiable Activity
Questionnaire (MAQ), which provided mean
metabolic equivalent (MET) hours/week from
occupational and leisure activity during the
previous 6 months. MAQ data were collected at
baseline and 6 months and percent change in
MET hours was calculated. In the third week of
the intervention, participants were given a
pedometer (Omron HJ-720IT with 42-day
memory) and asked to monitor their daily steps.
Pedometer data were uploaded at the
intervention sessions. Mean daily step counts
for the first 6 months were calculated from 21
weeks of pedometer data. Linear regression and
ANOVA were used to examine the associations
between the measures of PA and percent
weight change at 6 months.
Results: The sample (N=130) was 83% female,
71.5% White with a mean (±SD) age of 53±9.5
years and a baseline body mass index of
33.5±3.9 kg/m2. From baseline to 6 months, the
mean percent weight change was -6.7±5.3%
(range -20.6 to 10.1%). The mean percent
change in MET hours/week was +85.6±238.6%.
Pedometers were worn on 77±34% of the days
to be monitored and recorded a mean daily
step count of 5155±2890. Percent change in
MET hours/week was not associated with
weight change (b=-.089, p=.346), whereas,
mean daily step count was associated with
weight change (b=-.463, p<.001). Additionally,
higher mean daily step count was associated
with greater mean weight loss, with -5.1±4.5%
weight loss for 7500 steps/day (p=.001).
Conclusions: Pedometer step count was
associated with weight loss while the selfreported PA measure was not. Given their
relatively low cost and reliability, pedometers
should be considered as a standard part of
weight management. Additionally, the use of a
pedometer with its daily feedback in displaying
the steps accrued may help motivate
participants to be more active.
C.C. Imes: None. L. Ye: None. Y. Zheng: None. J.
Mancino: None. C.A. Danford: None. M.
Mattos: None. E. Music: None. D.D. Mendez:
None. H. Lu: None. L.J. Ewing: None. S.M.
Sereika: None. L.E. Burke: None.
P111
A Cluster Randomized Controlled Trial to
Examine the Effects of Tai Chi and Walking
Exercises on Weight Loss, Metabolic Syndrome
Parameters, and Bone Mineral Density
Yao Jie Xie, Stanley Sai-chuen Hui, Timothy Chiyui Kwok, Jean Woo, Chinese Univ of Hong
Kong, Hong Kong, Hong Kong
Introduction: Tai Chi and walking are both
moderate-intensity physical activity (PA) that
can be easily practiced in daily life. The purpose
of this study was to better understand that
after practicing these two types of PAs in a
relative short term and keeping the stable
dietary intake in this period, how much body
weight would be reduced and what extent the
metabolic syndrome parameters would be
improved; and if a significant weight loss was
observed, whether this exercise-induced weight
loss had adverse effect on bone mineral density
(BMD).
Methods: Three-hundred seventy-four healthy
and physically inactive adults (45.8±5.3 years)
from 9 geographic areas in Hong Kong were
randomized to 12 weeks training (45 minutes
per day, 5 days per week) of Tai Chi (n=124) or
self-paced walking (n=121), or control group
(n=129) at area level. Body weight, fat and lean
mass, waist circumference, blood pressure and
regional BMD, as well as the fasting blood
samples were obtained at the beginning and
end of trial. Fasting blood glucose (FBG), total
cholesterol, high-density lipoprotein cholesterol
(HDL-C), low-density lipoprotein cholesterol
(LDL-C) and triglycerides were analyzed.
Results: On average, Tai Chi and walking groups
lost 0.50 and 0.76 kg of body weight, 0.47 and
0.59 kg of fat mass, respectively (all p<0.001).
No significant changes were observed for lean
mass and BMD. Two intervention groups had
significant improvements in waist
circumference and FBG. The between-group
difference of waist circumference and FBG was 3.7 cm and -0.18 mmol/L for Tai Chi vs. control;
and -4.1 cm and -0.22 mmol/L for walking vs.
control (all p<0.001). No significant differences
were observed regarding blood pressure, total
cholesterol, HDL-C, LDL-C and triglycerides
compared to control (all p>0.05). The effects on
all outcomes between Tai Chi and walking were
similar (all p>0.05). Among intervention groups,
change in lean mass, not fat mass or total
weight loss, was significantly correlated to the
change in BMD.
Conclusions: 12-week Tai Chi and walking
exercises can produce moderate weight loss
and improve the waist circumference and FBG
in middle-aged Hong Kong Chinese people, with
no additional effects on BMD.
Y. Xie: None. S. Hui: None. T. Kwok: None. J.
Woo: None.
P112
Changes in Lifestyle Behavior to Reduce
Uncontrolled Blood Pressure in the Faith Trial
Kristie J. Lancaster, New York Univ, New York,
NY; Antoinette M. Schoenthaler, New York Univ
Sch of Med, New York, NY; William Chaplin, St.
John's Univ, Queens, NY; Gbenga Ogedegbe,
New York Univ Sch of Med, New York, NY
Introduction: Modifying lifestyle behaviors is a
key method for controlling hypertension. This
strategy is extremely important for
hypertensive Black Americans, as they are more
likely to have uncontrolled blood pressure (BP),
have a higher risk of complications, and poorer
outcomes. To address this need, we conducted
a cluster-randomized controlled trial to reduce
BP through lifestyle modification that was
delivered by lay health advisors in Black
churches. The Faith-based Approaches in the
Treatment of Hypertension (FAITH) trial was
designed to evaluate the effectiveness of a 12week faith-based lifestyle intervention and
subsequent 3-month motivational interviewing
vs. health education control on BP reduction
among hypertensive Black adults. This study
examines the change in lifestyle behaviors
during the trial from baseline to 6 months.
Methods: We recruited 373 Black Americans
with uncontrolled hypertension from 32 urban
churches. BP was considered to be uncontrolled
if systolic BP (SBP)≥140 mmHg or diastolic BP
(DBP)≥90 mmHg, or DBP≥130 mmHg or DBP≥80
mmHg for participants with self-reported
diabetes or kidney disease The primary
outcome was within-participant change in BP
from baseline to 6 months. Lifestyle data
collected included the NCI fruit/vegetable
intake screener and % calories from fat
screener, the International Physical Activity
Questionnaire (IPAQ), medication adherence,
and measured height and weight.
Results: Participants’ mean age was 63.4 y,
76.4% were female, and 96.1% reported being
of African descent. The mean BMI was 32.1
kg/m2. At 6 months, the intervention was
associated with significant reduction in SBP but
not DBP compared with the control group (-16.0
mmHg vs -10.3 mmHg, p=0.017). There was no
significant change in number of servings of
fruits and vegetables consumed, minutes
walked per day, or weight for either group.
However, the intervention group had a slight
but significantly greater decrease of 1.08 %
calories from fat over time compared with the
control (p=0.018), but that change was not
related to change in SBP. Most notably, there
was a significant months x treatment
interaction on medication adherence the
intervention group had a greater decrease in
non-adherence score than the control (-0.84 vs
-0.30, p=0.28). This improvement in adherence
was related to decrease in SBP (p=0.019).
Conclusion: Community-based lifestyle
modification program led to significantly
reduced systolic BP; and this intervention effect
was mediated by improved medication
adherence. However, the 12-week intervention
resulted in little change in key diet and physical
activity behaviors found in other trials to
positively affect BP.
K.J. Lancaster: None. A.M. Schoenthaler:
None. W. Chaplin: None. G. Ogedegbe: None.
P113
Cardiovascular Risk Reduction in Kentucky
Inmates: Effect of a Fitness Training and Health
Education Intervention
Alison Connell, Debra Moser, Terry Lennie,
Misook Chung, Univ of Kentucky, Lexington, KY
Introduction
In state and federal prisons, approximately 20
percent of inmates have cardiovascular (CV)
disease which is the leading cause of death in
inmates. Inmates in the United States have high
rates of cigarette smoking and drug abuse,
lower socioeconomic and education levels, and
high stress living conditions which increase the
risk for cardiovascular disease. The purpose of
this study was to determine the impact of a
fitness training and health education
intervention on cardiovascular risk reduction in
inmates.
Hypothesis
Hypothesis: there will be a significant decline in
CV risk factors following the intervention in the
immediate intervention group versus wait-listcontrol intervention group at 3 months after
baseline.
Methods
The study enrolled 411 male inmates in four
Kentucky state prisons. The intervention
comprised 12-weeks of fitness training for 1hour twice a week and one hour a week health
education using a self-care approach. A multiple
baselines design was used in which all
participants received the intervention and all
had a 3-month run-in period to establish their
own baseline without intervention. Data were
gathered from inmates at four time points:
baseline, pre-intervention, immediately postintervention and 3 months post-intervention.
Outcome measures included body mass index
(BMI), waist circumference, blood pressure
(BP), high density lipoprotein (HDL), low density
lipoprotein (LDL), and triglycerides (TGL).
Results
The mean age of participants was 37.1 years
with a racial distribution similar to Kentucky
state prisons (66.8% Caucasian, 30.3% African
American). Inmates who participated in 80% or
more of the intervention had improvements in
BMI (p = < 0.001), waist circumference (p = <
0.001), systolic and diastolic BP (p = < 0.001),
HDL (p = 0.002), LDL (p = 0.003), and TGL (p =
0.06).
Conclusions
In conclusion, the combination of fitness
training with education on self-care
management of one’s health resulted in
improvements in cardiovascular disease
indicators in inmates. This may lead to lower
cardiovascular morbidity and mortality while in
prison and also upon release. After release from
prison, inmates have an adjusted risk of death
that is 3.5 times higher that of non-incarcerated
people with heart disease being the second
leading cause of death during this time period.
An intervention that improves the
cardiovascular health of inmates may help with
chronic disease management in prison systems
and may help to decrease the high mortality
rates for inmates upon release.
A. Connell: None. D. Moser: None. T. Lennie:
None. M. Chung: None.
P114
The Impact of Obesity and Weight Loss on
Nocturnal Blood Pressure Dipping
Arjun K Pandey, Cambridge Cardiac Care Ctr &
Waterloo Collegiate Inst, Waterloo, ON, Canada
In healthy individuals, sleep is associated with
at least a 10% dip in Blood Pressure (BP). A lack
of nocturnal BP dipping (LND) or a rise of BP
nocturnally (RBPN) is associated with an
increased risk of many cardiovascular diseases
including stroke, heart failure and renal failure.
Limited therapies exist for individuals with a
LND or a RBPN.
In this study, we examine a potential correlation
between obesity and a lack of nocturnal BP
dipping as well as the impact of weight loss on
nocturnal BP patterns. We assessed the
hypothesis that elevated BMI would correlate
to LND or RBPN and that weight loss would
improve nocturnal BP patterns.
We recruited 30 volunteers with a LND pattern,
30 volunteers with a RBPN pattern and 20
control volunteers, with a healthy nocturnal BP
dip. Individuals with sleep apnea were
excluded. 24-hour Ambulatory BP Monitor
readings and BMI measurements were
performed before and after a 2 month dietary
and lifestyle intervention to reduce weight,
employing the DASH diet and lifestyle program.
At baseline we observed a negative correlation
between BMI and nocturnal BP dipping: The
average BMI of the control group was 28.1
kg/m2. The average BMI of the LND group was
30.3 kg/m2 (mildly obese). The average BMI of
the RBPN group was 35.3 kg/m2 (severely
obese) (p<0.0001).
After the 2 month intervention, we observed
that individuals who achieved a weight loss of
5% or more (who previously experienced
abnormalities in nocturnal dip) had an average
8.4% dip in nocturnal BP, representing a
significant improvement in nocturnal BP
patterns. Those who did not achieve a 5%
weight loss & those who gained weight had
blood pressure that rose by 3.2% at night on
average (p<0.0001). Figure 1
The findings of this study suggest that obesity
may contribute to nocturnal BP abnormalities
and weight loss, through diet and lifestyle
modifications, may improve nocturnal blood
pressure patterns. The clinical implications of
this strategy on the development or progression
of cardiovascular diseases remain to be
determined.
A.K. Pandey: None.
P115
Effect of an Environmental Intervention on the
Nutrient Content of Food Served at Psychiatric
Rehabilitation Centers: Results From the
ACHIEVE Trial
Tiffany F Ho, Joseph V. Gennusa, Johns Hopkins
Univ Sch of Med, Baltimore, MD; Cheryl
Anderson, UC San Diego Sch of Med, San Diego,
CA; Arlene Dalcin, Lawrence J. Appel, Stacy
Goldsholl, Johns Hopkins Univ Sch of Med,
Baltimore, MD; Gerald Jerome, Towson Univ,
Baltimore, MD; Faith Dickerson, Sheppard Pratt
Health Systems, Baltimore, MD; Deborah
Young, Kaiser Permanente, Pasadena, CA; NaeYuh Wang, Courtney Cook, Gail L. Daumit, Johns
Hopkins Univ Sch of Med, Baltimore, MD
Introduction: Institutions that serve on-site
meals provide an unrealized opportunity to
improve health on a broad scale, especially for
underserved populations. Psychiatric
rehabilitation programs commonly serve meals
to adults with serious mental illness (SMI;
schizophrenia and bipolar disorder), a
population with a markedly increased
prevalence of obesity and high risk of
cardiovascular disease mortality. In the context
of a behavioral weight-loss trial incorporating
weight management counseling for persons
with SMI, we delivered an environmental-level
intervention, focused on the food environment.
Hypothesis: We hypothesized the
environmental intervention would reduce the
overall calories served at the psychiatric
rehabilitation program study sites.
Methods: We partnered with kitchen
supervisors to reduce calories and improve the
nutritional quality of meals served at psychiatric
rehabilitation programs. Intervention staff met
with kitchen staff at the beginning and followed
up quarterly to assess progress and to reinforce
key nutritional messages. Environmental
interventions included decreasing sugar
sweetened beverages, increasing whole grains,
and reducing saturated fat in meals. Breakfast
and lunch menus were collected at baseline and
18 months after intervention. We calculated
mean (SD) total energy and nutrient content of
each meal.
Results: Ten psychiatric rehabilitation programs
participated. Eight sites served breakfast and all
sites served lunch. Compared to baseline,
average breakfast calories decreased
significantly after 18-months from 568.4 to
457.1 (p=0.0048) and average lunch calories
decreased from 729.4 to 623.8 (p<0.0001).
Saturated fat in breakfast decreased by 1.9g
(p=0.015) and 1.8g for lunch (p=0.0061). Total
sugars at breakfast decreased from 53.3g to
40.1g (p=0.0008) and at lunch from 38.9g to
33.7g (p=0.004). Sodium was not significantly
changed for breakfast (713.5mg to 557.3mg,
p=0.148) but decreased by 412.4mg (1527.4mg
to 1115.1mg, p=0.0008) for lunch.
Conclusions: The environmental intervention
implemented at psychiatric rehabilitation
programs successfully reduced the amount of
calories, saturated fat, sugars, and sodium
served. This study suggests that modifying the
food environment at psychiatric rehabilitation
programs is feasible. Such programs can likely
be applied to other institutions that serve onsite meals, and may be especially important in
preventing cardiovascular disease in other
underserved populations.
T.F. Ho: None. J.V. Gennusa: None. C.
Anderson: None. A. Dalcin: None. L.J. Appel:
None. S. Goldsholl: None. G. Jerome: None. F.
Dickerson: None. D. Young: None. N. Wang:
None. C. Cook: None. G.L. Daumit: None.
P116
High Depressive Symptoms May Represent a
Barrier to Reach Ideal Cardiovascular Health. A
Cross-Sectional Analysis in 10 154 Participants
From the Paris Prospective Study III
Bamba Gaye, French Inst of Health and Medical
Res (U970), Univ Paris Descartes, Paris, France;
Christof Prugger, French Inst of Health and
Medical Res (U970), Paris, France; Pierre
Boutouyrie, Assistance Publique des Hôpitaux
de Paris (APHP), Paris, France; Frédérique
Thomas, Ctr d'Investigations Préventives et
Cliniques, Paris, France; Catherine Guibout,
French Inst of Health and Medical Res (U970),
Paris, France; Marie Cécile Perrier, French Inst
of Health and Medical Res - U970, Paris, France;
Bruno Pannier, Ctr d'Investigations Préventives
et Cliniques, Paris, France; Xavier Jouven,
French Inst of Health and Medical Res (U970) Assistance Publique des Hôpitaux de Paris
(APHP), Paris, France; Jean Philippe Empana,
French Inst of Health and Medical Res (U970),
Paris, France
Background
The Ideal Cardiovascular Health is a new tool
defined by the American Heart Association with
the aim to promote cardiovascular health by
assessing 7 modifiable health behaviors and
biological risk factors.
Hypothesis
We investigated the hypothesis that high
depressive symptoms represent a barrier to
reach ideal cardiovascular health. We further
explored the relationship of depressive
symptoms on the behavioral and biological
components of ICVH.
Methods
Between 2008 and 2012, 10 154 men and
women 50-75 years of age were examined in a
large health center and enrolled in the Paris
Prospective Study III. Ideal cardiovascular health
comprises 4 behavioral components
(nonsmoking, body mass index >18 kg/m2 and
<25 kg/m2, physical activity at goal level, and
pursuit of an appropriate diet) and 3 biological
components (untreated total cholesterol <200
mg/dL, untreated blood pressure <120/80
mmHg, and untreated fasting blood glucose
<100 mg/dL). Participants with 0-2, 3-4 and 5-7
ideal health components were categorized as
having poor, intermediate and ideal
cardiovascular health, respectively. High
depressive symptoms were defined as a score
>7 on the 13-item Questionnaire of Depression
2nd version, Abridged (QD2A) or the use of
antidepressants. Polytomous logistic regression
analysis was applied to quantify the association
of high depressive symptoms with intermediate
and ideal cardiovascular health with poor
cardiovascular health used as the reference
category. Separate linear regression analyses
were performed to examine the relationship of
the QD2A scale with the behavioral and the
biological cardiovascular health components.
Regression models were adjusted for age, sex,
living status, educational level and perceived
health.
Results
Mean age of participants was 59.1 (SD 6.3)
years and 60.2% were males. A total of 851
(8.6%) showed high depressive symptoms, 5.0%
in men and 14.2% in women. Poor,
intermediate and ideal cardiovascular health
was observed in respectively 32.3% (39.9% in
men and 20.0% in women), 51.3% (49.7% in
men and 54.0% in women) and 16.4% (10.7% in
men and 26.0% in women) of study
participants. Individuals with high depressive
symptoms had a 35% (odds ratio [OR] 0.65; 95%
confidence interval [CI] 0.54-0.78) and 43% (OR
0.57; 95% CI 0.44-0.74) decreased chance of
having an intermediate and ideal cardiovascular
health, respectively. The QD2A scale was
significantly associated with the behavioral
components β linear regression =-0.38,
p<0.001), but not the biological components
(β=-0.08, p=0.12). All these results were
consistent among men and women.
Conclusion
Participants with high depressive symptoms
have a substantially reduced chance of reaching
ideal cardiovascular health, especially its
behavioral components. High depressive
symptoms may represent a barrier to reach
ideal cardiovascular health.
B. Gaye: None. C. Prugger: None. P.
Boutouyrie: None. F. Thomas: None. C.
Guibout: None. M.C. Perrier: None. B. Pannier:
None. X. Jouven: None. J.P. Empana: None.
P117
Day to Day Variation in Self-Efficacy Associated
with Weight Loss and Risk of Dietary Lapses
Lora E Burke, Univ of Pittsburgh Sch of Nursing,
Pittsburgh, PA; Linda J Ewing, Univ of Pittsburgh
Sch of Med, Pittsburgh, PA; Saul Shiffman, Univ
of Pittsburgh, Pittsburgh, PA; Dan Siewiorek,
Asim Smailagic, Carnegie-Mellon Univ,
Pittsburgh, PA; Andrea Kriska, Univ of
Pittsburgh Graduate Sch of Public Health,
Pittsburgh, PA; Steven Rathbun, Univ of
Georgia, Athens, GA
Introduction: Ecological momentary assessment
(EMA) assesses individuals' experiences,
behaviors, and moods as they occur in real time
and in their own environment, making it useful
to understand the processes of behavior
change. We report the use of EMA to study the
triggers of lapses after intentional weight loss in
a 12-mo. study that includes a standard
behavioral weight loss intervention.
Purpose: We examined daily self-reports of selfefficacy and how they were related to
unplanned eating episodes (‘lapses’) and weight
change over the first 6 mos. of the study.
Hypothesis: Higher self-efficacy is related to
fewer “lapses” and better weight loss over time.
Methods: Participants were provided a
smartphone app programmed to administer
EMA assessments up to 5 randomly-selected
times/day. Each assessment included the selfefficacy query, How confident are you that if
you have an urge to go off your healthy lifestyle
plan, you can resist the urge? measured on a
scale of 1-10. Participants were weighed at
weekly, and after 3 months bi-weekly, group
sessions. To account for replicate observations
among subjects, generalized estimating
equations were used to fit logistic regression
models predicting lapses as a function of selfefficacy, adjusting for location (e.g., home,
work, restaurant) and social setting (e.g., with
others, alone).
Results: The sample (N = 151) was 90.7% female
and 79.5% White, and on average, 51.18 (10.22)
years of age with a mean BMI of 34.0 (4.6)
kg/m2. Of the 59,913 random assessments
conducted over 6 mos., eating episodes were
recorded in 7,991 (13.34%) of those
assessments, of which 881 (11.03%) were not
planned. Most of the 7,991 planned and
unplanned eating episodes were captured when
individuals were with others who were eating
(49%), or when completely alone (24%). After
adjusting for location and social setting, selfefficacy remained a significant predictor of a
lapse (p < 0.001). The odds of a lapse decreased
by 70% (95% CI, 64%, 76%) for every unit
increase in self efficacy. After controlling for
social setting, participants were estimated to
lose 0.35 more lbs/mo. (SE = 0.14; p = 0.02) for
each unit increase in self efficacy. Self-efficacy
maintained a stable level between 7.3 and 7.4
for the first 4 mos., before decreasing at a rate
of 0.11 points/month (SE = 0.04; p = 0.002) in
the last 2 mos. This temporal trend in selfefficacy was paralleled by a similar trend in
participants’ weights; they lost an average of
3.26 lbs/mo. (SE = 0.18) in the first 4 mos.
compared to only 0.59 lbs/mo. (SE = 0.29) in the
last 2 mos.
Conclusions: The data suggest that as selfefficacy decreased to near 7.0, individuals were
at greater risk to experience a lapse in their
diet, an integral part of the healthy lifestyle
plan. Targeting enhanced and sustained levels
of self-efficacy above 7 may enable a person to
resist lapses and prevent weight regain.
L.E. Burke: None. L.J. Ewing: None. S.
Shiffman: None. D. Siewiorek: None. A.
Smailagic: None. A. Kriska: None. S. Rathbun:
None.
P118
Changes in Physical Activity by Self-Weighing
Trajectory Groups
Yaguang Zheng, Susan M. Sereika, Linda J.
Ewing, Cynthia A. Danford, Bonny RocketteWagner, Christopher C. Imes, Hu Lu, Ran Sun,
Lora E. Burke, Univ of Pittsburgh, Pittsburgh, PA
Introduction: Numerous studies have
established a significant association between
regular self-weighing and weight loss; however,
few studies have examined how self-weighing
patterns are associated with lifestyle changes,
e.g. physical activity (PA). The aim was to
examine the association between frequency of
self-weighing and changes in PA levels.
Hypothesis: We hypothesized that higher
frequencies of self-weighing are associated with
greater increases in PA levels.
Methods: This was an analysis of data from a
12-mo behavioral weight loss intervention
study. Each subject was given a Wi-Fi scale and
instructed to weigh daily. The scale transmitted
weight values to a central server. PA was
objectively assessed by an accelerometer
(ActiGraph GT3x) at 0 and 6 mos. Participants
were instructed to wear the accelerometer for ≥
3 weekdays, one weekend day, ≥10 hours/day.
General linear model was used for data analysis.
Results: The sample (N=89) was largely female
(89.9%), White (82%), with a mean age (±SD) of
51.9±9.3 years, and a mean BMI of 33.6±4.5
kg/m2. Our previous analysis using group-based
trajectory modeling identified 3 self-weighing
patterns: high/consistent (self-weighed 5-6
days/week regularly); moderate/declined
(declined from 4-5 to 2 days/week);
minimal/declined (declined from 5-6 to 0
days/week). As shown in the table, compared
with minimal/declined self-weighing group, the
high/consistent group had a significant increase
in energy expenditure, steps, light and
moderate PA levels as well as average
activity/day, while the moderate/declined
group had a significant increase in steps and
average activity/day.
Conclusions: The differences in PA level changes
across the trajectory groups suggest that
improved adherence to self-weighing carried
over to improved PA behavior changes. It is
unclear if self-monitoring weight and observing
the results led participants to regulate their PA
behavior accordingly. Future research needs to
examine the mechanisms of how daily weighing
impacts the level of daily PA.
Y. Zheng: None. S.M. Sereika: None. L.J. Ewing:
None. C.A. Danford: None. B. RocketteWagner: None. C.C. Imes: None. H. Lu: None. R.
Sun: None. L.E. Burke: None.
P119
Tailored Lifestyle Intervention for Obese,
Sedentary Patients in Primary Care: Choose to
Lose Study
Charles B Eaton, Brown Univ, Pawtucket, RI;
Sheri Hartman, Univ of California at San Diego,
San Diego, CA; Patricia M Risica, Kim M Gans,
Brown Univ, Providence, RI; Bess H Marcus,
Univ of California at San Diego, San Diego, CA
Background: Poor diet and lack of physical
activity are linked conditions, both are risk
factors for obesity and cardiovascular disease
and prevalent in primary care. Studies of how to
accomplish effective changes in physical activity
and weight loss simultaneously in obese,
sedentary patients in primary care are limited.
In this report we present the findings of the
physical activity intervention.
Methods: We conducted a randomized,
controlled translational research trial of
behavioral Interventions in 207 obese,
sedentary patients recruited from 24 primary
care practices. Participants were 79% women,
17% minority, with a mean age of 48.8 years,
and 66% had at least one CVD risk factor. The
primary care physicians identified obese ,
sedentary patients motivated to lose weight
and increase physical activity , who were then
randomized to one of two experimental groups
( enhanced or standard). Both groups received 3
face-to-face visits with a lifestyle
counselor(baseline, 6 months and 12 months)
that included physical activity goal setting and
exercise log tracking. The enhanced
intervention also received frequent mailings
related to diet and exercise, monthly tailored
mailings using an expert system related to the
transtheoretical model of change for physical
activity, 2 DVDs related to exercise and monthly
phone calls by lifestyle counselors for the first
12 months related to diet and exercise . A
maintenance phase with twice monthly mailings
for 6 months and then monthly occurred for the
last 6 months. The trial was 24 months in
duration with follow-up research visits at 6, 12,
18 and 24 months. Statistical analysis used a
mixed model adjusted for age, gender, and race
accounting for clustering within primary care
practice site.
Results: The minutes of moderate and vigorous
physical activity(MVPA) per week for the
enhanced intervention group were 20.7, 95.7,
126.1, 103.7, 101.3 at baseline, 6,12, 18 and 24
months compared to 22.9, 68.3, 73.7, 63.7, 75.4
for the standard intervention group ( p=0.037
group*visit). Compared to baseline both groups
increased physical activity at each time point (
p<.001). Comparing enhanced to standard
interventions at each time point showed
increased physical activity for the enhanced
group at 12 months and 18 months, but by 24
months the differences were no longer
statistically significant ( p=.10)
Conclusion: A lifestyle intervention increased
physical activity over 24 months in primary care
practice in motivated obese, sedentary adults .
The added benefits of a tailored approach using
an expert system, appear to limited to 12 and
18 months of intervention. Much less contact
was provided between 18-24 months. Future
research should focus on the optimal dose of
the intervention to maintain increased physical
activity.
C.B. Eaton: None. S. Hartman: None. P.M.
Risica: None. K.M. Gans: None. B.H. Marcus:
None.
P120
Long-Term Adherence to Heart Healthy
Behaviors in Older Adults: A Theory-Based
Approach
Kathleen M Michael, Margaret Hammersla,
Jennifer Klinedinst, Barbara Resnick, Univ of
Maryland, Baltimore, MD
Despite evidence-based recommendations,
long-term adherence to heart-healthy
behaviors is generally low in older adults. Many
behavioral strategies have induced short term
improvements in physical activity, diet
adherence, and medication use, but sustained
change in health behaviors beyond six months
remains a challenge. No single approach seems
to result in durable, long-term lifestyle change.
We hypothesized that a Social-Ecological Model
incorporating Social Cognitive Theory,
combined with Diffusion of Innovation would
increase long term heart-healthy behaviors in
community-dwelling older adults. We
conducted a single group study using repeated
measures at baseline, 3, 6, 12 and 24 months to
evaluate adherence to exercise, diet, and
prescribed medications. We evaluated the
effects of a two phase theory-based behavioral
intervention on overall physical activity,
physical performance, fat and sodium intake,
prescribed medication use, blood pressure, self-
efficacy (exercise, diet, medications), resilience,
depression, and pain. Twenty-nine low income
seniors with cardiovascular risk factors
completed the intervention, which consisted of
a 12-week education and initiation phase led by
a nurse and lay exercise trainer in the
participants’ congregate residence. The second
phase focused on motivation and
dissemination. Ongoing health behaviors were
facilitated by 1) group intervention with social
support, 2) extended intervention exposure
over 24 months, with twice-weekly exercise
classes continued with the lay trainer and
within-community champions, 3) eminders and
cues, and 4) monthly inoculation visits by
healthcare providers to reinforce motivation
and target behaviors. Across the study, 50% of
the participants consistently attended the
classes and engaged in exercise activities. The
percentage of individuals participating in at
least 10 minutes of exercise per week
increased. Although below recommended
guidelines, the trend toward greater exercise
participation is encouraging given the
challenges to adherence noted in this
population. In addition we found that outcome
expectations for exercise increased significantly
(p = 0.05). Dietary intake showed significant
decreases in fat consumption (p = 0.001), and
medication adherence was consistently strong.
Results of the study demonstrate the feasibility
of using this model to successfully engage
participants within their own environment over
24 months, and to use lay trainers and
community champions to sustain the exercise
and education intervention with periodic
inoculations by healthcare providers. While
individual improvements were modest, they
nonetheless provide support for the efficacy of
theory-based interventions to facilitate longterm adherence to heart-healthy behaviors, and
may guide future work to develop and test
robust efficacy-enhancing interventions.
K.M. Michael: None. M. Hammersla: None. J.
Klinedinst: None. B. Resnick: None.
P121
Comparative Effectiveness Study of the
Diabetes Prevention Program in Families:
Preliminary Results
Jennifer Wessel, Erin O'Kelly-Phillips, Kelly
Palmer, Chandan Saha, Tamara Hannon, Aaron
Carroll, David G Marrero, Indiana Univ,
Indianapolis, IN
The prevalence of gestational diabetes (GDM) is
increasing substantially and currently affects up
to 14% of pregnancies. As many as 70% of
women with GDM will develop type 2 diabetes
(T2D) in the next 10 years. Moreover as many
as 40% of children exposed to in-utero diabetes
will develop obesity and T2D. The Diabetes
Prevention Program (DPP) is an evidence-based
lifestyle intervention that has been shown to
lower T2D risk by 58% in high-risk adults. Family
based lifestyle interventions that target either
children, parents or both have reported mixed
results. We modified the DPP curriculum to use
with families (DPPF) and recruited mothers with
a history of GDM and their children 8-15 years
old. We randomized n=130 families to test
which method of delivering the DPPF (mothers
only (M) or mothers and their children (M+C)) is
more effective at lowering families T2D risk.
Baseline characteristics of women were similar
among each intervention group (n=65 M and
n=65 M+C, respectively): age (38±8 vs 39±11,
P=0.5), ethnicity (Black 55% vs 55%, White 20%
vs 17%, Latino 20% vs 27%, other 5% vs 2%,
P=0.6), body mass index (BMI, 37±8 vs 38±7,
P=0.24), systolic blood pressure (SBP, 121±11 vs
122±13, P=0.8), diastolic blood pressure (DBP,
103±26 vs 105±21, P=0.6), HbA1c (5.6±0.4 vs
5.7±0.3, p=0.2). The majority of women selfreported low levels of physical activity (PA):
moderate PA (2 days or less per week, 42% vs
26%, P=0.06) or vigorous PA (2 days or less per
week, 38% vs 25%, P=0.1), and high levels of
sedentary activities (3 or more hours per day,
49% vs 58%, P=0.2). For diet related obesogenic
behaviors women self-reported high levels of
eating meals while watching TV (3 days or more
per week, 58% vs 74%, P=.06) and eating at
restaurants (3 days or more per week, 28% vs
41%, P=0.1). Follow-up is ongoing and currently
n=32 families have completed the 3-month
follow-up. Preliminary analyses of mothers
show decreases in HbA1c (-.01±.3 vs -.1±.2), SBP
(-9.7±30 vs -3.1±8), DBP (-8±19 vs -1±9) but not
BMI (0.07±1.6 vs 0.04±1.2); however results
were not significantly different by intervention
group.
J. Wessel: None. E. O'Kelly-Phillips: None. K.
Palmer: None. C. Saha: None. T. Hannon:
None. A. Carroll: None. D.G. Marrero: None.
P122
Fidelity to Motivational Interviewing and
Weight Loss in Young Adults: Cellphone
Intervention for You (CITY) Trial
Crystal C Tyson, Pao-Hwa Lin, Leonor C Corsino,
Bryan C Batch, John A Gallis, Steven C
Grambow, Jenifer Schwager, Duke Univ Medical
Ctr, Durham, NC; Denise Ernst, Denise Ernst
Training and Consultation, Portland, OR; Laura P
Svetkey, Duke Univ Medical Ctr, Durham, NC
Background: Weight loss interventions for
obese young adults may reduce serious health
complications later in life. Motivational
Interviewing (MI) is part of behavioral weight
loss intervention. Effective delivery of MI is
variable; therefore, we assessed whether
fidelity to MI was associated with change in
weight and dietary pattern in overweight/obese
young adults.
Methods: The Cellphone Intervention for You
(CITY) trial was a 24-month behavioral
intervention that randomized 365
overweight/obese (BMI >25 kg/m2) young
adults (aged 18-35 years) to a weight loss
program delivered by either mobile technology
or interventionist-led personal coaching (PC)
phone calls, or to a control condition. PC
participants attended a series of 6-weekly group
meetings immediately followed by monthly
audio-recorded phone calls conducted by an
interventionist trained to deliver weight loss
counseling using MI. We coded the first
monthly PC phone call using Motivational
Interviewing Treatment Integrity Version (MITI)
3.1.1 and evaluated the impact of MITI
summary scores on changes in weight and
Healthy Eating Index (HEI) at 6 months.
Results: Our study population was comprised of
74 participants with available audio-recordings.
There were 73% (N=54) women and 49%
minorities with a mean age of 29 ± 4 years and
a mean BMI of 34.7 ± 7.3 kg/m2. Mean change
in weight 6 months post-randomization was 3.1 ± 5.3 kg. Mean change in HEI was 3.3 ± 4.7.
Mean MITI summary scores for global spirit,
percent complex reflections and reflection-toquestion ratio were 3.9 ± 0.8, 0.6 ± 0.3, and 0.5
± 0.2, respectively. None were predictive of
weight change 6 months post-randomization
(table 1). Percent complex reflection was
predictive of HEI, with a counterintuitive
negative relationship (table 1).
Conclusions: In our study population of
overweight/obese young adults, greater fidelity
to MI in the first coaching call was not
associated with greater weight change or
improved HEI. Additional research is needed to
further explore the impact of MI on behavior.
C.C. Tyson: None. P. Lin: None. L.C. Corsino:
None. B.C. Batch: None. J.A. Gallis: None. S.C.
Grambow: None. J. Schwager: None. D. Ernst:
None. L.P. Svetkey: None.
P123
Life’s Simple 7 and Leukocyte Telomere Length
in American Indians: The Strong Heart Study
Jinying Zhao, Tulane Univ, New Orleans, LA;
Mihriye Mete, Sameer Desale, MedStar Health
Res Inst, Hyattsville, MD; Amanda M. Fretts M
Fretts, Univ of Washington, Seattle, WA; Shelley
A. Cole, Texas Biomedical Res Inst, San Antonio,
TX; Lyle G Best, Missouri Breaks Industries Res
Inc., Timber Lake, SD; Jue Lin, Tet Matsuguchi,
Elizabeth Blackburn, Univ of California San
Francisco, San Francisco, CA; Elisa T Lee, Univ of
Oklahoma Health Science Ctr, Oklahoma City,
OK; Barbara V Howard, MedStar Health Res
Inst, Hyattsville, MD
Background: Telomeres are the repeated DNA
sequences and associated proteins at the end of
chromosomes. Telomere length shortens
progressively with each cell division and has
been used as a marker of biological aging.
Shorter telomere length has been associated
with CVD and its risk factors. The AHA’s 2020
impact goal, summarized in Life’s Simple 7
(LS7), has also been associated with reduced
risk of CVD, but no study has examined the
potential influence of these goals on biological
aging assessed by telomere length.
Objective: To determine the association of LS7
with telomere length in American Indians, a
minority population suffering from
disproportionately high rates CVD and diabetes.
Methods: Leukocyte telomere length (LTL) was
measured by quantitative PCR in 3,577
American Indians in the Strong Heart Study, a
population-based study of CVD and its risk
factors in 13 tribes in Arizona, North/South
Dakota, and Oklahoma. LS7 metrics include 3
health factors (blood pressure, cholesterol,
blood glucose) and 4 behavioral factors
(smoking, physical activity, diet, and BMI). Each
of the 7 individual components was categorized
as poor, intermediate, or ideal health in
accordance with the AHA’s LS7 goals. A
composite score ranging from 0 to 7 was
created based on the total number of ideal
cardiovascular health metrics. This score was
further categorized as below average (0-1),
average (2-3) and above average (≥4)
cardiovascular health. Linear regression model
was used to test the association of each
individual metric with LTL, adjusting for age and
all other metrics. The association of LTL with the
composite score was similarly examined.
Results: The mean age was 40. Ideal levels of
the LS7 factors were observed in 42% for
smoking, 11% for physical activity, 17% for BMI,
0% for diet, 40% for blood pressure, 73% for
cholesterol, and 58% for fasting glucose. About
26%, 53% and 21% of the participants had
below average, average, and above average
cardiovascular health, respectively. LTL was
negatively associated with BMI (P=0.003) after
adjusting for age and all other six factors. No
independent association was observed between
LTL and the other individual health factors or
behaviors. Compared with participants with
below average composite score, those with
above average score had significantly longer LTL
(β = 0.041, P=0.001) after adjusting for age. This
association, however, was substantially
attenuated after excluding participants with
diabetes (β = 0.027, P=0.05).
Conclusions: Compared to the general U.S.
population, American Indians had low rate of
ideal cardiovascular health for 5 out of the Life’s
Simple 7 factors, including smoking, BMI,
physical activity, diet, and fasting glucose. The
achievement of 4 or more Life’s Simple 7 goals
is associated with longer telomere length,
suggesting that a favorable cardiovascular risk
profile may promote healthy aging, thereby
reducing cardiovascular risk.
J. Zhao: None. M. Mete: None. S. Desale:
None. A.M. Fretts: None. S.A. Cole: None. L.G.
Best: None. J. Lin: None. T. Matsuguchi:
None. E. Blackburn: None. E.T. Lee: None. B.V.
Howard: None.
P124
Ideal Cardiovascular Health During Adult Life
and Cardiovascular Structure and Function
among the Elderly
Amil M. Shah, Brian Claggett, Brigham and
Women's Hosp, Boston, MA; Aaron R. Folsom,
Pamela L. Lutsey, Univ of Minnesota,
Minneapolis, MN; Scott D. Solomon, Brigham
and Women's Hosp, Boston, MA
Introduction: The AHA has identified seven ideal
cardiovascular (CV) health metrics to target
primary prevention of CV disease, including
heart failure. The relationship between the
consistent attainment of these metrics in
adulthood and CV structure and function in
late-life is not well described.
Hypothesis: We hypothesized that the greater
number of ideal CV health metrics consistently
achieved in adulthood will be associated with
better cardiac and arterial function when
elderly.
Methods: The following six ideal CV health
metrics were assessed in Atherosclerosis Risk in
Communities (ARIC) study participants at 5
exam visits between 1987 and 2013 (visits 1-4 in
1987-98, visit 5 in 2011-13): nonsmoking, body
mass index <25 kg/m2, untreated total
cholesterol <200 mg/dL, untreated blood
pressure <120/<80 mmHg, fasting blood
glucose <100 mg/dL. Diet was not assessed due
to incomplete serial data. Ideal CV health
consistently attained was defined as the
minimum number of metrics attained at Visits 1
to 5, and was analyzed in relation to echo
measures of cardiac structure and function,
arterial stiffness, and soluble cardiac
biomarkers assessed at Visit 5 in 5,903
participants free of CV disease at Visit 5.
Results: At Visit 5, median age was 75.2 years
(IQR 71.7, 79.7), 42% were male, and 21% black.
At least 4 metrics were consistently attained in
6%, with 3, 2, 1, and 0 metrics consistently
attained in 14%, 35%, 35%, and 12%
respectively. Greater number of metrics
consistently attained was associated with better
LV structure, systolic and diastolic function, less
arterial stiffness, and lower NT-proBNP and high
sensitivity troponin T at Visit 5 (Table).
Conclusions: In this community-based cohort,
greater number of ideal CV health metrics
consistently attained over an approximately 26
year span was associated with better
cardiovascular structure and function when
elderly.
A.M. Shah: B. Research Grant; Modest;
Novartis, Gilead. B. Claggett: None. A.R.
Folsom: None. P.L. Lutsey: None. S.D. Solomon:
None.
P125
The Association Between Chronic Obstructive
Pulmonary Disease and Cognitive Status in an
Elderly Sample Using the Third National Health
and Nutrition Examination Survey
Ayesha Sherzai, Joshua Z Willey, Columbia Univ
Medical Ctr, New York, NY; Sonia Vega, Loma
Linda Univ Sch of Public Health, Loma Linda, CA;
Dean Sherzai, Cedars Sinai Medical Ctr, Los
Angeles, CA
Introduction: Dementia and cognitive
impairment is a major public health issue and is
likely related to complex interaction between
genetics and modifiable risk factors. Chronic
Obstructive Pulmonary Disease (COPD) has
been associated with dementia, but its
relationship with specific cognitive deficits has
not been previously explored.
Methods: Data was analyzed from the Third
National Health and Nutrition Examination
Survey (NHANES III). Cases of COPD were
defined by a ratio of forced expiratory volume
to forced vital capacity of < 0.7. The three
cognitive tests included 1) three word
immediate verbal memory test (9 points), 2)
delayed verbal memory test (9 points), and 3)
serial subtractions test (5 trials), as a surrogate
of executive function. The odds of having poor
cognitive status was assessed using logistic
regression models between COPD and each of
the three cognitive tests. Models were furthers
adjusted for demographic variables, including
age, sex, height, body mass index education,
race, poverty income ratio, and medical
coverage, smoking, and medical comorbidities.
Results: We identified individuals 60-89 years of
age (weighted N= 17,181,182) with a diagnosis
of COPD (mean age 71.5 ± 0.19 years, 50.1%
women, 85.9% non-Hispanic whites). In the
unadjusted model, there was a strong
association between COPD and poor scores for
immediate memory recall (<5 out of 9 points;
OR 2.18, 95% CI 1.81-2.62), delayed memory
recall (<4 out of 9 points; OR 2.25, 95% CI 1.852.70) and serial subtraction (< 5 trials correct;
OR 1.44, 95% CI 1.10-1.90). After adjusting for
socio-demographic and vascular variables,
these relationships remained robust for the
immediate and delayed recall tests. In contrast,
the association with serial subtraction test was
rendered insignificant after adjusting for sociodemographic factors (OR 1.05, 95% CI 0.691.60). Upon further adjusting for vascular risk
factors such as stroke, coronary heart disease,
hypertension, diabetes and congestive heart
failure, the odds for poor serial subtraction test
increased and became significant (OR 2.74, 95%
CI 1.17-6.40, p trend < 0.001).
Discussion: In this nationally representative
database, COPD is significantly associated with
impaired immediate and delayed memory, but
not with executive function. These results shed
light on differential susceptibility of the brain in
COPD and its relationship with vascular risk
factors.
A. Sherzai: None. J.Z. Willey: None. S. Vega:
None. D. Sherzai: None.
P126
Consumption of Fruits and Vegetables and Risk
of Frailty
Esther García-Esquinas, LM León-Muñoz,
Auxiliadora Graciani, Pilar Guallar-Castillón,
Fernando Rodríguez-Artalejo, Dept of
Preventive Med and Public Health. Sch of Med.
Univ Autónoma de Madrid/ IdiPAZ, and CIBER
of Epidemiology and Public Health (CIBERESP),
Madrid, Spain, Madrid, Spain
Background: Frailty is a geriatric syndrome
characterized by reduced physiologic reserve,
which is manifested by increased risk of falls,
disability, institutionalization or death. No
previous study has assessed he potential doseresponse relationship between fruits and
vegetables consumption and risk of frailty in
older adults.
Methods: This study included 2008 individuals
aged ≥60 yrs from the Seniors-ENRICA cohort
study. At baseline, food consumption was
obtained with a validated diet history.
According to the Spanish Society of Community
Nutrition, a portion of fruit was defined as 120200 gr and a portion of vegetables as 150-200
gr. Participants were followed up during 3.5
years to assess incident frailty, which was
defined as per the Fried criteria. Analyses were
performed with logistic regression and adjusted
for dietary and non-dietary confounders.
Results: During follow-up, 136 cases of incident
frailty were ascertained. The multivariate odds
ratios (95%CI) of frailty among those who
consumed 0, 1, 2, 3 ≥4 portions of fruit per day
were, respectively: 1.00, 1.03 (0.51-2.07), 0.71
(0.38-1.35), 0.41 (0.19-0.87) and 0.67 (0.261.74). The corresponding results among those
who consumed 0, 1, 2, 3 ≥4 portions of
vegetables a day were: 1.00, 0.68 (0.40-1.15),
0.52 (0.32-0.83), 0.46 (0.19-1.13) and 0.71
(0.15-3.33). When results for fruits and
vegetables were combined, a progressive
decreased risk of frailty was observed among
those who consumed 2, 3, 4 and 5 portions/day,
compared to those who consumed ≤1
portions/day: 0.39 (0.22-0.68), 0.45 (0.25-0.79),
0.34 (0.18-0.62) and 0.22 (0.10-0.49),
respectively. There was a threshold around 5
servings of fruits and vegetables, so that no
additional benefit was seen among participants
who consumed ≥6 portions/day: 0.39 (0.160.94).
Conclusion: Higher consumption of fruits and
vegetables is associated with lower risk of
frailty. These results provide support for the
current recommendation to increase
consumption of fruit and vegetables to promote
health in older adults.
E. García-Esquinas: None. L. León-Muñoz:
None. A. Graciani: None. P. Guallar-Castillón:
None. F. Rodríguez-Artalejo: None.
P127
Racial Disparities in Risk Factor Control in
Older Adults with Diabetes: The
Study
Christina Parrinello, Dept of Epidemiology,
Baltimore, MD; Ina Rastegar, Dept of
Epidemiology, Johns Hopkins Bloomberg Sch of
Public Health; Baltimore Polytechnic Inst,
Baltimore, MD; Job G Godino, Dept of
Public Health, Baltimore, MD; Michael D
Miedema, Minneapolis Heart Inst and
Minneapolis Heart Inst Fndn; Brigham and
Women’s Hosp and Boston VA Healthcare
System, Harvard Medical Sch, Minneapolis, MN;
Kunihiro Matsushita, Dept of Epidemiology,
Baltimore, MD; Elizabeth Selvin, Dept of
Public Health; Dept of Med, Johns Hopkins Univ,
Baltimore, MD
Background: Racial disparities in risk factor
control have been documented in middle-aged
adults, but much less is known about older
adults with diabetes. Our findings will inform
clinical guidelines on appropriate risk factor
control in older adults with diabetes.
Methods: In 2011-13, 6,538 ARIC participants
attended visit 5, and 4,988 provided data on all
key covariates used in these analyses. Of these,
31% had diagnosed diabetes (N=1,561, 72%
white, mean age=75 years) and were included
in this study. Tight control of risk factors was
defined according to American Diabetes
Association guidelines: hemoglobin A1c <7%;
low-density lipoprotein cholesterol <100 mg/dL;
systolic blood pressure (BP) <140 mmHg and
diastolic BP <80 mmHg. We evaluated risk
factor control overall and by race. We used
logistic regression and predictive margins to
assess independent associations of race with
tight risk factor control.
Results: Among older adults with diabetes, 64%
used glucose-lowering medication, 70% lipidlowering medication and 82% BP-lowering
medication. Only 5% of participants did not take
medication for any of these risk factors. Tight
control was observed in 72% for glucose, 64%
for lipids and 70% for BP. Only 34% had tight
control of all three. A higher proportion of
whites than blacks consistently achieved tight
control (Figure). In multivariable analyses of
persons with diabetes who were treated for risk
factors, racial disparities in tight control of lipids
and BP remained significant: adjusted
prevalence ratios and 95% CIs (white vs black)
were 1.04 (0.91, 1.17) for glucose, 1.21 (1.081.34) for lipids, 1.15 (1.03-1.26) for BP, and 1.33
(0.95, 1.70) for tight control of all three risk
factors.
Conclusions: Our results highlight racial
disparities in risk factor control in older adults
with diabetes that were not explained by
demographic or clinical characteristics. Further
studies are needed to elucidate the
determinants of disparities in risk factor control
and strategies to address these.
C. Parrinello: None. I. Rastegar: None. J.G.
Godino: None. M.D. Miedema: None. K.
Matsushita: None. E. Selvin: None.
P128
Walking May Be a Viable Alternative to
Recreational Physical Activity for Promoting
Physical and Mental Wellbeing Among the
Elderly
Rosemay A Remigio-Baker, Andrea LaCroix,
Jordan Carlson, Jacqueline Kerr, Matthew A
Allison, Univ of California, San Diego, La Jolla,
CA
INTRODUCTION:
Physical activity (PA) is a well-established
protective behavior consistently associated with
reduced risk of CVD morbidity and mortality. In
older populations, moderate or vigorous
activities (MVPA) are less common perhaps
because of physical limitations; walking has
been shown to have similar associations as
MVPA with CVD outcomes. MVPA has also been
associated with positive physical and mental
wellbeing. Little is known, however, about how
walking activities influence quality of life
measures including indicators of mental
wellness.
HYPOTHESIS:
We hypothesized that greater MVPA and
walking will be associated with higher levels of
both physical and mental wellbeing.
METHODS:
We evaluated the cross-sectional relationships
of MVPA and walking with physical and mental
wellbeing among 2,402 San Diego participants
in the Women’s Health Initiative using
multinomial logistic regression. MVPA was the
sum of moderate and vigorous activity in
hours/week, each calculated as ([number of
days/week in activity]*[number of minutes
[min]/day in activity])/60. Walking was defined
as ([number of days walking > 10 min without
stopping/week]*[number of min/day in
activity])/60. Responses for the number of
days/week in an activity included rarely/never,
once, 2-3, 4-6 or 7+. Responses for number of
min/day in an activity included <20, 20-39, 4059 or 60+. Measures of physical and mental
components of SF-36 were assessed as tertiles,
and odds ratios using the lower tertile as
reference were estimated. Covariates included
age, ethnicity, education, smoking status, and
comorbidity (presence of diabetes, arthritis,
myocardial infarction, cancer or hypertension).
RESULTS:
Walking was more prevalent than MVPA in this
cohort (86% vs. 57%).
There was a 14% (CI=1.07, 1.21) greater
likelihood of scoring in the middle vs lower
tertile of physical wellbeing per hour increase in
MVPA. This nearly doubled to 29% (CI=1.21,
1.36) when comparing upper to lower tertile
(trend p <0.001). There was a 20% (CI=1.12,
1.27) greater likelihood of scoring in the middle
vs lower tertile of physical wellbeing per hour
increase in walking, an estimate which also
increased when comparing upper to lower
tertile (OR=1.36, CI=1.28, 1.45, trend p <0.001).
Per hour increase in MVPA was also associated
with 8% (CI=1.02, 1.13) greater mental
wellbeing comparing middle to lower tertile.
The estimate was weaker and non-significant
comparing upper to lower tertile (trend
p=0.122). Per hour increase in walking was also
associated with 11% (CI=1.05, 1.17) greater
mental wellbeing comparing middle to lower
tertile. Although the estimate was weaker
comparing upper to lower tertile, significance
remained (trend p=0.018).
CONCLUSION: For an elderly population where
physical limitations may preclude moderate or
vigorous exercise, walking activities may
provide an alternate means to improve both
physical and mental wellbeing.
R.A. Remigio-Baker: None. A. LaCroix: None. J.
Carlson: None. J. Kerr: None. M.A. Allison:
None.
P129
Mid-Life Blood Lipid Levels, Blood Pressure and
Smoking in Men: Relation With 5-yr CHD
Incidence Compared to Associations With
Multi-Morbidity Among Survivors at Late Life
Uri Goldbourt, Tel Aviv Univ, Tel Aviv, Israel;
David Tanne, Sheba Medical Ctr, Tel Hashomer,
Israel
Background. Interest in understanding CHD risk
factors observable at earlier age and associated
with late-life morbidity has been increasing as
case fatality declined and life expectancy rose.
The Charlson Comorbidity Index (CCI)
developed in 1987 was designed to develop a
prospectively applicable method for classifying
comorbid conditions
Patients, methods. An extensive examination of
10,000 men, civil servants, aged 40-65 yr, took
place in 1963. They were reexamined in 1965
and 1968 and the 5-yr incidence of CHD was
assessed. Over three decades later, CCI was
available for 75% of the survivors, who were
insured with a large national HMO ("Clalit").
We grouped the CCI categories of 1-17 into
grouped scores (CCS) in five groups: CCI=7.
Odds ratios and hazard ratios (HR) for these
endpoints in relation to total HDL and non-HDL
cholesterol and risk factor levels were
estimated applying multiple logistic regression.
Results. The 5-yr incidence (1963-68) of CHD
was 27, 31, 48 and 68 per 1000 in the first to
fourth quartile of total serum cholesterol; and
30, 33, 41 and 64/1000 in corresponding
percentiles of non-HDL cholesterol.
Multivariate-adjusted hazard ratios for the
latter were 1, 1.12, 1.32 and 2.23 (p for
trend<0.0005) for the 4 quartiles respectively.
Among 2086 Clalit-insured men surviving by
2002, aged 79 yr and above (mean age 83.5±4.2
yr), using ordered logistic regression, baseline
blood levels of non-HDL cholesterol (OR=1.15,
95%CI 1.04-1.26) as well as HDL (OR=0.88 per 1
SD increment, 95%CI 0.80-0.96) were
associated with CCS under proportional odds
assumption. Also associated with survivors'
increased CCS, in addition to lipids, were age
(OR=1.12, CI 1.10-1.14 per one year), ever
smoking as of 1963 (OR=1.31, CI 1.11-1.54) and
the 1963 to 1968 systolic blood pressure
increment (OR=1.12 per mm, CI 1.02-1.24).
“Desirable weight" (20<BMI30 Kg/Sqm) were
associated with odds ratios (ORs) of 1.06, 1.22
and 1.31 of increased CCS, respectively, relative
to lean men (BMI<20 Kg/Sqm) [P for trend =
0.02], however adjustment for lipid levels
eliminated the association of baseline BMI with
2002 CCS.
Comment. Despite the remoteness of multimorbid classification in 2002 from baseline
levels in the mid 1960's, mid-life lipid
components which had remarkably predicted
the incidence of CHD were also related
moderately to late-life multi-morbidity, among
survivors aged>79 years, in addition to cigarette
smoking and blood pressure visit- to-visit
increment. The serum lipid levels also explained
away the increased late life survivors' morbidity
among mid-life overweight and obese men.
U. Goldbourt: None. D. Tanne: None.
P130
Statin Use is Associated With Prevalent
Depression in Asymptomatic Octogenarians
Kammarauche Asuzu, Duke Univ Hosp,
Durham, NC; Ehimen Aneni, Baptist Health
South Florida, Miami, FL; Andrea Placido
Esposito, Univ of Campinas, Campinas, Brazil;
Ebenezer Oni, Brooklyn Hosp, Brooklyn, NY;
Emir Veledar, Theodore Feldman, Arthur S
Agatston, Baptist Health South Florida, Miami,
FL; Wladimir Freitas, Univ of Campinas,
Campinas, Brazil; Raul D Santos, Univ of Sao
Paolo, Sao Paolo, Brazil; Luiz A Quaglia, Maria E
Guariento, Andrei Sposito, Univ of Campinas,
Campinas, Brazil; Khurram Nasir, Baptist Health
South Florida, Miami, FL
Introduction: Although inconsistent in
literature, several studies have demonstrated
an association between statins and depression.
However, virtually all of these studies have
been conducted in populations younger than 80
years. We examined the relationship between
statin use and depression in Octogenarians free
from clinical cardiovascular disease (CVD).
Methods: This is a cross-sectional analysis from
baseline data of 208 participants (78.8% female)
in a longitudinal community-based study of
healthy aging started in 2008. Participants were
free of known CVD, and other chronic diseases.
Depression was determined by meeting DSM-IV
criteria or a current use of antidepressant
following a clinical diagnosis. Information on
current use and type of statin used was also
collected.
Results: The prevalence of depression and
statin use was 19.8% and 39.1% respectively.
The prevalence of depression was significantly
higher among statin than nonstatin users
(p=0.004). In multivariate analysis controlling
for likely confounders, the odds of depression
was 2.5 times greater among statin users (95%
CI 1.1, 5.6). Among those with LDL-c
<130mg/dL, the prevalence of depression was
significantly higher in the group of statin users
compared to non-statin users (p 130mg/dL,
there was no significant difference in
depression prevalence (p=0.52). Also, the odds
of depression among persons with LDL-c levels
<130mg/dL was significantly higher among
statin users than non-users (Adjusted OR 4.5
95% CI 1.6, 12.8) while among those with LDL-c
>130mg/dL, there was no association between
depression and statin use (OR 1.6, 95%CI 0.4,
7.2).
Conclusion: Our findings suggest that among
healthy octogenarians, there is an association
between statin use and prevalent depression
that is modified by level of LDLc. Further studies
are required to define the temporal and doseresponse relationship between statin use,
types, and depression.
K. Asuzu: None. E. Aneni: None. A. Esposito:
None. E. Oni: None. E. Veledar: None. T.
Feldman: None. A.S. Agatston: None. W.
Freitas: None. R.D. Santos: None. L.A. Quaglia:
None. M.E. Guariento: None. A. Sposito:
None. K. Nasir: None.
P131
Is Older Age (≥ 65 years old) Associated with
Increased Mortality Following Extra-Corporeal
Membrane Oxygenation?
David L Narotsky, Matthew Mosca, Ming Liao,
Linda Mongero, James Beck, Matthew
Bacchetta, Heidi Mochari-Greenberger,
Columbia Univ Medical Ctr, New York, NY
Background: Extra-corporeal membrane
oxygenation (ECMO) is increasingly being used
as a life-saving bypass technique for patients
whose acute cardiopulmonary failure is
potentially reversible and refractory to
conventional care. Prognostic data for ECMO
among diverse patients are limited. The
purpose of this study was to evaluate the
association between age (≥ 65 vs. <65 years)
and 1-year mortality after ECMO, adjusted for
confounders.
Methods: This was a retrospective cohort
analysis of 131 consecutive adult patients (28%
≥65 years old, 26% racial/ethnic minority, 38%
female) enrolled in an ECMO database who
received veno-arterial ECMO at an academic
medical center between 2004-2013.
Demographics, comorbid conditions, admission
characteristics, and mortality status at 1 year
were obtained from the hospital clinical
information system, updated monthly with
Social Security Death Index data. Univariate and
multivariate adjusted Cox proportional hazard
analyses were conducted to evaluate the
associations between age strata and post-ECMO
mortality.
Results: The 1-year mortality rate post-ECMO
was 56% (n=73). Age ≥ 65 vs. <65 was
significantly associated with increased mortality
(HR=1.8; 95% CI=1.1-2.9); the association was
attenuated and did not retain statistical
significance after adjustment for comorbid
conditions (HR=1.4; 95% CI=0.8-2.5). Figure 1
illustrates mortality risk by age strata adjusted
for: a) demographics (race/ethnicity and sex)
and b) demographics and comorbid conditions.
Race/ethnicity and sex were not significantly
associated with 1-year mortality. Significant
predictors of mortality included: Medicaid vs.
other health insurance status, history of
coronary artery bypass graft surgery, peripheral
vascular disease, renal failure, dialysis, and
shock (p<0.05).
Conclusion: Older age (≥65) was not
independently associated with 1-year mortality
among ECMO patients, but may indicate higher
comorbidity, which was associated with
increased risk of mortality in the year following
ECMO.
D.L. Narotsky: None. M. Mosca: None. M. Liao:
None. L. Mongero: None. J. Beck: None. M.
Bacchetta: None. H. Mochari-Greenberger:
None.
P132
Association of Cardiovascular Risk Factors with
Cognitive Function: Results from the Italian
Health Examination Survey 2008-2012
Giovanni Viscogliosi, Simona Giampaoli, Istituto
Superiore di Sanità, Rome, Italy; Diego Vanuzzo,
Associazione Italiana Medici Cardiologi
Ospedalieri, Florence, Italy; Chiara
Donfrancesco, Francesco Dima, Serena
Vannucchi, Claudia Meduri, Istituto Superiore di
Sanità, Rome, Italy
Background
The increase in life expectancy has resulted in a
growing prevalence of cognitive impairment.
Several studies have explored the association
with cardiovascular (CV) risk factors (RF), but
methodological differences in RF collection and
definitions do not allow to draw inferences on
the general population. The aims of this study
was to describe the association between CVRF
(blood pressure, total and HDL cholesterol,
smoking habit) and cognitive function in a
random sample of community-dwelling older
population (65-79 years).
Methods
Data from the Italian Health Examination Survey
2008-2012, a nationwide cross-sectional
population-based survey, were used. Blood
pressure (BP), pulse pressure (PP) as the
difference between systolic (SBP) and diastolic
blood pressure (DBP), total (TC), high density
lipoprotein cholesterol (HDL) and TC-HDL were
assessed; cognitive function was investigated
using the Folstein’s Mini-mental state
examination (MMSE) test. Cognitive impairment
was defined by MMSE score < 1 standard
deviation, after controlling for age and
educational level. Multiple regression analysis
was performed adjusting for age, sex,
education, marital status and area of residence;
RF were entered as continuous variables.
Results
Out of 8714 adults (35-79 years), 1474 subjects
aged 65-79 years (71.5±4.4), 47% women, were
studied. Cognitive impairment was found in
13.9% of participants (15.8% in women vs
12.2% in men, p= 0.05). Stratifying participants
into RF tertiles, the lower the DBP the lower the
crude MMSE score (p for trend= 0.034),
whereas no differences were found for SBP and
PP; the lower the TC the lower the crude MMSE
(p for trend= 0.043), whereas no differences
were found for HDL and TC-HDL values.
Smokers were not characterized by lower
MMSE (26.0±3.4 vs 26.2±3.3). By multiple
regression analysis neither DBP (B=0.002;
95%CI= -0.013 - 0.018; p= 0.765) and TC (B= 0.001; 95%CI= -0.005 - 0.003; p= 0.770) resulted
associated to MMSE variability. Effect of DBP
and TC on MMSE appeared to be entirely
attributable to the age effect. MMSE variability
was explained only by age, educational level
and area of residence.
Conclusions
The direction of the association between CVRF
and cognitive function remains vague. Future
longitudinal studies describing changes in CVRF
throughout life in the general population are
deemed necessary to disentangle the predictive
contributions of age and cardiovascular risk
factors on cognitive function.
G. Viscogliosi: None. S. Giampaoli: None. D.
Vanuzzo: None. C. Donfrancesco: None. F.
Dima: None. S. Vannucchi: None. C. Meduri:
None.
P133
National and Regional Lipid Screening Rates in
Youth: A Synthesis of Available Evidence
Sean Gregory, Texas A&M Univ, College Station,
TX; Catherine McNeal, Baylor Scott & White
Health, Temple, TX; Justin Zachariah, Boston
Children's Hosp, Boston, MA; Debra Tan, Texas
A&M Univ, College Station, TX; Andrea CassidyBushrow, Henry Ford Hosp, Detroit, MI; Jeff
Tom, Kaiser Permanente, Honolulu, HI; Jeff
VanWormer, Marshfield Clinic Res Fndn,
Marshfield, WI; Eric Wright, Gesinger Ctr for
Health Res, Danville, PA; Laurel Copeland,
Baylor Scott & White Health, Temple, TX
Background: Lipid screening rates in U.S. youth
are very low compared to screening for other
risk factors such as hypertension. As a result,
few youth with familial hypercholesterolemia,
which substantially increases the risk of
developing Atherosclerotic Cardiovascular
Disease (ASCVD) in adulthood, are identified.
Published studies have reported greater than a
two-fold variation in lipid screening rates. The
purpose of this study is to examine the variation
and temporal trends in national and regional
lipid screening rates from 2002 - 2012 in order
to ascertain key variables that impact screening.
Methods: Lipid screening rates among 78k
youth from the National Ambulatory Medical
Care Survey (NAMCS), and among 660k youth
from 5 sites participating in the Pediatric
Cardiovascular Research Network (P-CVRN), a
practice-based cohort, were used in our
analyses. The annual proportion of youth, ages
2 to 21 years, receiving cholesterol screening
was calculated for each year over the study
period, 2002-2012.
Results: These data show an eight- to three-fold
variation in lipid screening rates over the past
decade.. Site-level variation, and the departure
from national NAMCS estimates, suggests
significant differences in practice patterns
across the United States. NAMCS national
estimates are significantly lower in each year of
the study compared to each of the 5 P-CVRN
sites. And, while lipid trends are generally
decreasing across P-CVRN sites, the NAMCS
screening rates have remained constant over
the same period.
Figure 1: Cholesterol Screening Rates among
Youth, 2002-2012
Conclusions: There are health-system factors
contributing to a high variation in lipid
screening rates among U.S. youth. Such data
also serve as a benchmark to measure the
uptake of the 2011 lipid screening guidelines
which recommend the addition of universal
screening. P-CVRN site estimates from a
practice-based cohort suggest screening rates
are higher than those determined through the
NAMCS sample.
S. Gregory: A. Employment; Significant; Texas
A&M University. C. McNeal: None. J. Zachariah:
None. D. Tan: None. A. Cassidy-Bushrow:
None. J. Tom: None. J. VanWormer: None. E.
Wright: None. L. Copeland: None.
P134
Cystatin C Predicts Diastolic Dysfunction in
Children with Chronic Kidney Disease,
Independent of Kidney Function
Tammy M Brady, Johns Hopkins Univ,
Baltimore, MD; Kelly C. McDermott, Michael F.
Schneider, Christopher Cox, Johns Hopkins Univ
Bloomberg Sch of Public Health, Baltimore, MD;
Bradley A. Warady, The Children's Mercy Hosp,
Kansas City, MO; Susan Furth, Children's Hosp
of Philadelphia, Philadelphia, PA; Mark
Mitsnefes, Cincinnati Children's Hosp Medical
Ctr, Cincinnati, OH
Background: Cystatin C is a surrogate marker of
kidney function but is also independently
associated with CVD outcomes. Our aims were
to (1) quantify the relationship between
cystatin C and diastolic function over time
among children with CKD and (2) determine if
any relationship persists after accounting for
kidney function.
Methods: Data from 561 participants enrolled
in the Chronic Kidney Disease in Children (CKiD)
cohort study were included. Participants have
biennial visits with local standardized
echocardiography and iohexol glomerular
filtration rate (iGFR) measurements. Diastolic
function was assessed centrally by E’/A’ from
Tissue Doppler.
Linear mixed models, adjusting for repeated
visits with a random subject effect, were used.
The longitudinal association of cystatin C with
change in log (E’/A’) was adjusted for age, sex,
race, BMI z-score, systolic and diastolic BP zscore, Calcium*Phosphorus product and length
of time with CKD. Regression coefficients were
transformed and interpreted as percent change
in E’/A’.Results: At baseline, median age was
11.3 yrs (IQR: 7.9, 14.8), 38% female, and 16%
AA. Median cystatin C was 1.5 mg/L (IQR: 1.2,
2.0), median GFR was 47.6 mL/min/1.73m2 (IQR:
36.5, 63.9) and median creatinine 1.2 mg/dL
(IQR: 0.8, 1.6). Median E’/A’ was 1.95 (IQR: 1.5,
2.4). Cystatin C and other measures of kidney
function predicted diastolic function when
assessed separately (Table). When assessed
together, cystatin C remained independently
associated while the effect of iGFR was
attenuated and insignificant.
Conclusions: Lower kidney function, as
assessed by Cystatin C and other measures, is
associated with diastolic dysfunction among
children with mild-moderate CKD over time.
However, only Cystatin C had an independent
relationship with diastolic function in this
patient population; the effect of iGFR was
attenuated and not significant after accounting
for Cystatin C. This suggests that Cystatin C has
the potential to contribute to CVD risk
stratification among children with CKD.
T.M. Brady: B. Research Grant; Significant;
National Institutes of Health, NHLBI K23 grant
award, National Institutes of Health, NIDDK R01
award Co-I, Clinician Scientist Award, Johns
Hopkins University. G. Consultant/Advisory
Board; Modest; National Kidney Foundation of
Maryland, Medical Advisory Board
Member. K.C. McDermott: None. M.F.
Schneider: None. C. Cox: None. B.A. Warady:
None. S. Furth: None. M. Mitsnefes: None.
P135
Body Mass Index and Indicators of Adiposity
Are Adversely Associated With Cardiovascular
Biomarkers in Youth With Type 1 Diabetes
Over 18 Months
Leah M Lipsky, Tonja R Nansel, Denise L Haynie,
NICHD, Bethesda, MD; Lori M Laffel, Sanjeev N
Mehta, Lisa K Volkening, Joslin Diabetes Ctr,
Boston, MA; Aiyi Liu, NICHD, Bethesda, MD
Hypothesis: The association of excess weight
with an adverse cardiometabolic profile in
patients with type 1 diabetes (T1D) is unclear.
The purpose of this study was to test the
hypothesis that increasing BMI and adiposity
indicators in youth with T1D are adversely
associated with glycemic control and
cardiovascular biomarkers.
Methods: Subjects were youth participants of a
family-based randomized controlled dietary
intervention (N=136, age=12.3±2.5y, baseline
A1c=8.1±1.1%). Glycemic control (A1c and 1,5Anhydroglucitol, 1,5-Ag), body mass index (BMI,
from measured height and weight), serum lipids
(total cholesterol, TC; HDL-cholesterol, HDL-C;
LDL-cholesterol, LDL-C; triglycerides, TG),
inflammation (c-reactive protein, CRP),
oxidative stress (8-iso-prostaglandin F2alpha, 8iso-PGF2α), adiponectin and blood pressure
(systolic, SBP; diastolic, DBP) were assessed at
baseline and every 6 months for 18 months.
Total and truncal lean, fat-free mass and
percent fat (%fat) were measured by Dual X-ray
Absorptiometry (DXA) scan at baseline, 12
months and 18 months. Multi-level linear mixed
effects regression models (with a random
intercept and a random slope for time) were
used to estimate associations of time-varying
BMI and body composition with time-varying
indicators of glycemic control and
cardiometabolic health. Covariates included
time, sex, height, baseline age, treatment
assignment, baseline diabetes duration, insulin
regimen, insulin dose/kg and physical activity.
Probability values <0.05 were considered to
indicate statistical significance.
Results: Time-varying BMI and body
composition indicators were differentially
associated with time-varying glycemic control
and cardiometabolic indicators. A1C was
unrelated to BMI and body composition,
although 1,5-Ag was inversely associated with
total %fat; inverse associations of 1,5-Ag with
BMI and trunk %fat approached statistical
significance (p=0.07). LDL-C was positively
associated with trunk fat and trunk %fat; TG
and HDL-C were positively associated with BMI
and trunk fat, and HDL-C was inversely
associated with total lean and trunk lean mass.
CRP was positively associated with BMI, and
with total and truncal fat and %fat. SBP and DBP
were positively associated with BMI, %fat, trunk
fat and trunk %fat. TC, 8-iso-PGF2α and
adiponectin were unrelated to BMI and body
composition.
Discussion: In a sample of youth with
moderately well-controlled T1D, time-varying
BMI and indicators of body fat were not
universally associated with time-varying
glycemic control and cardiometabolic indicators
over 18 months. Significant associations of
adiposity indicators, particularly BMI and trunk
fat, with hyperglycemic excursions (1,5-Ag),
several blood lipids (TG, HDL-C, and LDL-C), and
inflammation (8-iso-PGF2α) suggest a role of
excess body weight in the development of
cardiovascular risk in this sample.
L.M. Lipsky: None. T.R. Nansel: None. D.L.
Haynie: None. L.M. Laffel: None. S.N. Mehta:
None. L.K. Volkening: None. A. Liu: None.
P136
Childhood BMI Associated With Low HDL-c
Levels in Adolescence in a Chilean Cohort
Ann Von Holle, Kari North, Anne Justice, Univ of
North Carolina, Chapel Hill, Chapel Hill, NC;
Eastern Kang, Estela Blanco, Sheila Gahagan,
Univ of California, San Diego, San Diego, CA
Background: Global prevalence of childhood
obesity has reached epidemic proportions.
Elevated body mass index (BMI) leads to a
cascade of negative health outcomes including
hyperlipidemia, hypertension, and diabetes,
thus increasing risk for cardiovascular disease
(CVD). Some studies have documented an
association between early childhood obesity
and CVD risk factors. To date, studies have been
primarily cross sectional and in European
descent populations. Thus, the relationship
between childhood obesity and later CVD risk is
inadequately understood. To increase our
understanding of this complex relationship, this
study aims to assess the association between 5year BMI and HDL-c levels at 17 years in a
Chilean longitudinal cohort study.
Methods: We used longitudinal data from the
Santiago Longitudinal Cohort study. Participants
were enrolled as infants between 1991 and
1996. As such, they have experienced Chile’s
rapid modernization and dramatic changes in
diet, activity, and environment. At 5 years,
height and weight were measured to 0.1 kg
using a SECA scale and 0.1 cm using a Holtain
stadiometer. BMI (kg/m2) was calculated and
converted to z-scores (WHO Standards). HDL-C
was measured following standard protocols and
classified as low if HDL-c ≤ 40 mg/dL. We
implemented a logistic regression to assess the
association between BMI z-scores at age five
and clinically defined low HDL-c levels at age 17.
Covariates in the model included sex,
gestational age, maternal education, household
social status, and maternal age at birth.
Results: The total sample included 677 children
who had weight measurements at age five and
subsequent cardiovascular testing at age 17.
Descriptive statistics include: 47% female, mean
5-year BMI percentile was 72.5 ± 25.2, mean
17-year HDL-c was 40.2 ± 10.6, and 53% (n=359)
in the low HDL-c group. Mean 5-year BMI
percentile was higher in the low HDL-c group
than the high HDL-c group (75.2 ± 24.2 vs. 69.4
± 26.1). Without adjustment for relevant
confounders, BMI z-score was associated with
an odds ratio of 1.32 (95% CI: 1.13, 1.55; pvalue < 0.01) for the low HDL-c group compared
to the high HDL-c group. With adjustment for all
relevant confounders the adjusted odds ratio
was 1.36 (95% CI: 1.15, 1.60; p-value < 0.01).
Conclusions: Results from this study
demonstrate a positive association between 5year BMI and low HDL-c later in adolescence.
These results provide evidence that BMI, as
early as five years, is associated with
subsequent low HDL-c in adolescence, an
important CVD risk factor. This study finding
supports the importance of targeting childhood
obesity to help minimize future CVD risk.
A. Von Holle: None. K. North: None. A. Justice:
None. E. Kang: None. E. Blanco: None. S.
Gahagan: None.
P137
Updated Trends in CVD Risk Factors and
Rurality in Appalachian Children using
Surveillance, Clustered Statistical Design and
GIS Capabilities
Christa Lilly, Lesley Cottrell, Evan Fedorko,
Amna Umer, William Neal, West Virginia Univ,
Morgantown, WV
Research suggests a link between rurality and
CVD risk factors; however, our previous work
found that metropolitan (rather than rural)
areas were associated with CVD risk factors in
WV fifth grade children. Our goal is to examine
developmental trends as well as updated CVD
risk factors stratified by Rural-Urban Continuum
Code (RUCC) classification.
Coronary Artery Risk Detection in Appalachian
Communities (CARDIAC) data include 14,226
Kindergarten, 10,784 Second grade, 80,635 Fifth
grade, and 1,451 Teenage children. The
clustered analytic design nested children’s
results within zip code using a six-category
RUCC (Figure 1), and controlling for age, gender,
race, and maternal education. Least squares
means are reported. Outcomes included BMI
percent above ideal (BMI%) for all grades, and
HDL, LDL, and SBP for fifth grade.
Developmental Trends: Kindergarten:
Significant effect of RUCC on BMI%, p<0.0001,
Metro (M=10.11) and Town (10.43) had higher
means than Rural (6.66). Second grade: Metro
(16.82) and Town (16.41) had higher means
than Small Metro (12.48), Rural (10.48; p<
0.0001). Fifth grade: Metro (21.5) and Town
(21.5) had higher means than Large Metro
(17.78), Small Metro (17.86; p0.05).
CVD Risk Factors: Metro (49.31), Non-metro
Urban (49.28), and Town (49.76) had lower HDL
than Large Metro (M=52.9), Rural (52.54) and
Small Metro (51.36; p<0.05). Metro (95.76)
presented with higher LDL than Rural (89.11),
Town (90.25), Large Metro (91.08), Small Metro
(91.28) and Non-metro Urban (91.8; p<0.05).
Large Metro (108.97), Metro (109.03) and Town
(108.76) had higher SBP than Rural (106.95) and
Small Metro (107.28; p<0.05)
Results suggest that younger children from rural
areas had lower BMI% than metro and town
areas. This trend appears to reverse as children
enter middle and high school. Examination of
fifth grade CVD risks found mid-sized metro
areas presented with the worst outcomes.
C. Lilly: None. L. Cottrell: None. E. Fedorko:
None. A. Umer: None. W. Neal: None.
P138
Lifestyle Goals in Pediatric Preventive
Cardiology: Practical Clinical Application
Justin P Zachariah, Michael M Mendelson,
Suzanne Griggs, Heather H. Ryan, Annette L.
Baker, Lucy Buckley, Nirav K. Desai, Elizabeth
Yellen, Matthew W. Gillman, Sarah D. de
Ferranti, Boston Children's Hosp, Boston, MA
BACKGROUND: Lifestyle change is
recommended by the 2011 NHLBI Expert Panel
Integrated Guidelines as the cornerstone of
pediatric lipid management. Using a
Standardized Clinical Assessment and
Management Plan (SCAMP) (IRCDA Inc,
Boston MA) as an implementation tool, we
examined in a real-world setting the effect of
making 3 lifestyle goals on lipid levels in youth
referred to a pediatric Preventive Cardiology
clinic.
METHODS: Prospectively collected
anthropometric, clinical, and laboratory data
were analyzed on youth referred for lipid
abnormalities between September 2010 and
March 2014. Percent change in lipid fractions
from baseline to last follow-up was calculated.
Lifestyle recommendations given at initial visit
were predictors of interest considered
individually and as groups of 3. Multivariable
adjusted linear regression was used to identify
lifestyle combination trios that were associated
with dyslipidemia change.
RESULTS: Among 325 patients (55% female,
median follow-up time 17 [IQR 10,28] months;
mean age 13±4yrs], high LDL (>130 mg/dL) was
present in 62%, high TG (> 150 mg/dL) in 35%,
and low HDL (<40 mg/dL) in 28%. In those with
the relevant lipid abnormality, LDL decreased by
11±17%, TG declined by 22±35% and HDL
improved by 15±35%. Overall, BMI percentile
declined by 2 points. The most common
lifestyle goals given were ‘decrease
saturated/trans fat’ (63%), ‘increase
vegetables/fruit’ (61%), ‘increase exercise’
(55%), ‘continue exercise’ (35%), and ‘decrease
glycemic index’ (30%). In those with HDL<40
adjusted for age and sex, ‘increase fish and
nuts’ was associated with HDL improvement
(6.52mg/dL[ 2.38,10.66];p=0.002) but,
unexpectedly, ‘increase vegetables/fruit’ was
associated with worse HDL (-3.87mg/dL[95%CI6.75,-0.99]; p=0.01). In those with TG>150 as
expected, ‘decrease fast food/eating out’ was
associated with lower TG (37%[13,54];
p=0.006). After adjustment for age, sex,
baseline lipid level, and BMI percentile change,
the trio of ‘increasing vegetables/fruit’,
‘decreasing saturated/trans fat’, and ‘continue
exercise’ was associated with lower LDL (17.64mg/dL[-3.62,-31.56];p=0.01). Intriguingly,
substituting ‘increase exercise’ instead of
‘continue exercise’ in this trio was not
associated with lipid change.
CONCLUSIONS: In a real-world cohort of
dyslipidemic youth, providing lifestyle goals was
associated with favorable lipid changes, with
some combinations showing particular benefits.
More data is warranted to explore the effect of
specific lifestyle goal combinations in youth.
J.P. Zachariah: B. Research Grant; Significant;
NHLBI K23. M.M. Mendelson: None. S. Griggs:
None. H.H. Ryan: None. A.L. Baker: None. L.
Buckley: None. N.K. Desai: None. E. Yellen:
None. M.W. Gillman: None. S.D. de Ferranti:
None.
P139
Duration of Childhood Obesity and Relation to
Middle-Age Obstructive Sleep Apnea Risk: The
Bogalusa Heart Study
TIAN HU, Tulane Univ, New Orleans, LA; Suzie
Bertisch, Beth Israel Deaconess Medical Ctr,
Boston, MA; Wei Chen, Emily Harville, Tulane
Univ, New Orleans, LA; Susan Redline, Brigham
and Women's Hosp, Boston, MA; Lydia Bazzano,
Tulane Univ, New Orleans, LA
Background: Persons with obesity have a high
risk of obstructive sleep apnea (OSA); however,
the risk duration of childhood obesity confers
on later OSA is not clear.
Methods: We prospectively examined the
association between duration of overweight
and obesity (OW) in childhood and subsequent
risk of OSA in 844 middle-aged adults with ≥ 2
measures of body mass index (BMI) between 4
and 18 yrs of age. Childhood OW was defined
using age and gender specific BMI ≥85th
percentile based on 2000 CDC Growth Charts.
Duration of OW was calculated using the
presence or absence of OW at each follow-up
examination: For participants normal weight at
baseline who then became and remained OW
through the last examination, or participants
who were OW throughout, duration was
calculated as the cumulative number of
consecutive OW yrs. If participants were OW
then ever became normal weight during
childhood (N=84), duration was not calculated.
After an mean follow-up period of 35 years (in
2010; Interquartile: 1yr), high-risk for OSA, as
the primary outcome, was determined using
modified Berlin Questionnaire score which
excluded obesity as part of its definition.
Secondary outcomes included habitual snoring
and excessive sleepiness.
Results: Of those included in the analysis, 42.3%
were male and 33.6% were Black. At baseline
mean (SD) age was 9.9 (2.9) yrs and proportion
of OW individuals was 18.2%. At follow-up,
individuals were mean age of 42.8 (4.5) yrs and
had a mean BMI of 31 kg/m2. In total, 217
(25.7%) had elevated Berlin scores indicating
high-risk for OSA. Mean (SD) of OW duration
was 5.2 (2.5) yrs. In multivariate log-linear
regression models adjusted for baseline age,
race, sex, follow-up time, education, current
smoking status, regular alcohol consumption,
leisure-time physical activity and current OW
status, participants with an OW duration of 1-4
yrs, 4-8 yrs, and 8+ yrs were 1.19 (95% CI: 0.90 1.57), 1.23 (0.92 - 1.63), and 2.29 (1.67 - 3.15)
times more likely to be high-risk for OSA as
compared to those who were never OW.
Significant linear trends were present across
categories of OW duration (P for trend: 0.006).
Similar positive trend was observed for habitual
snoring but not for excessive sleepiness. There
was no significant effect modification by race or
sex.
Conclusion: This community-based cohort study
suggests that longer duration of OW in
childhood was associated with high-risk for OSA
in middle-age.
T. Hu: None. S. Bertisch: None. W. Chen:
None. E. Harville: None. S. Redline: None. L.
Bazzano: None.
P140
Association of Adult Stature With High Blood
Pressure and Diabetes: A Cross-Sectional Study
in Middle-Aged Mexican Women
Karl P Puchner, Inst of Tropical Med and Intl
Health, Charité-Univsmedizin, Berlin, Germany;
Eduardo Ortiz-Panozo, Isabel Vieitez, Martín
Lajous, Ruy Lopez-Ridaura, Natl Inst of Public
Health, Mexico, Cuernavaca, Mexico
Introduction: Evidence from developed
countries suggests that adult short stature may
be associated with cardiometabolic disease in
women. However, this association in low and
middle-income settings remains unclear.
stature is inversely associated with diabetes
(DM) and high-blood pressure (hBP) in the
Mexican setting.
Methods: We conducted a cross-sectional
analysis in a sample of 93,481 middle-aged
Mexican female teachers, participants of the
Mexican Teacher´s Cohort. In 2008 we asked all
cohort participants to self report current height
following specific measurement instructions. In
a validation study we observed a person
correlation coefficient of 0.84 between selfreport and standardized measurement made by
technician. We used a logistic multivariable
regression models to estimate the Odds Ratio of
self-reported DM or hBP in each stature quintile
using the tallest quintile as the reference
category.
Results: After adjusting for birth cohort,
ethnicity, family history of DM/hBP, birthweight, occupation of household’s head during
childhood, current socioeconomic status (SES)
and birthplace, stature was inversely associated
with DM, while no association was found with
hBP. The odds for DM were 9% higher in the
lowest quintile when compared to the upper
stature quintile. Stratification for residence
resulted in confirmation of these findings only
in participants living in urban in contrast to rural
environments.
Conclusion: We found an inverse association of
stature with DM but not with hBP. Our data
suggest that urban setting might be an
important effect modifier of this association,
which merits further investigation as it might
provide us with valuable insights into the
epidemiological transition of developing
countries.
K.P. Puchner: None. E. Ortiz-Panozo: None. I.
Vieitez: None. M. Lajous: None. R. LopezRidaura: None.
P141
Non-alcoholic Fatty Liver Disease, Insulin
Resistance, and the Risk of Incident Ischemic
Heart Disease and Stroke - The Kangbuk
Samsung Health Study
Yoosoo Chang, Seungho Ryu, Juhee Cho,
Kangbuk Samsung Hosp, Sungkyunkwan Univ,
Sch of Med, Seoul, Korea, Republic of; Sanjay
Rampal, Julius Ctr Univ of Malaya, Kuala
Lumpur, Malaysia; Yiyi Zhang, Johns Hopkins
Univ Bloomberg Sch of Public Health, Baltimore,
MD; Di Zhao, Johns Hopkins Univ Bloomberg
Sch of Public Health, baltimore, MD; Yuni Choi,
Jiin Ahn, Kangbuk Samsung Hosp,
Sungkyunkwan Univ, Sch of Med, Seoul, Korea,
Republic of; Miguel Cainzos-Achirica, Johns
Baltimore, MD; Roberto Pastor-Barriuso, Insto
de Salud Carlos III, Madrid, Spain; Joao A Lima,
Johns Hopkins Univ Sch of Med, Baltimore, MD;
Hocheol Shin, Kangbuk Samsung Hosp,
Republic of; Eliseo Guallar, Johns Hopkins Univ
Bloomberg Sch of Public Health, Baltimore, MD
Objective: Nonalcoholic fatty liver disease
(NAFLD) is associated with insulin resistance (IR)
and with other metabolic abnormalities, but the
association of NAFLD with the risk of clinical
cardiovascular disease (CVD) is controversial.
Furthermore, the risk associated with the
combination of NAFLD and IR has not been
evaluated in prospective studies. The aim of this
study was to evaluate the association of NAFLD
with or without IR on the incidence of coronary
heart disease (CHD) and stroke.
Methods: We performed a cohort study in
166,126 adults without CVD at baseline who
underwent a health checkup exam during 2008
- 2011 and were followed-up through
December 31, 2012 (average follow-up of 3.2
years). NAFLD was defined as hepatic steatosis
on ultrasonography in the absence of excessive
alcohol use or other identifiable causes. IR was
defined as a homeostasis model assessment of
IR (HOMA-IR) value ≥ 2.5. Incident
hospitalizations for CHD events and strokes
were ascertained through data linkage with the
Korean Health Insurance Review and
Assessment Service (HIRA) database.
Results: At baseline, the prevalence of NAFLD
and of IR were 25.1 and 6.3%, respectively.
During follow-up, 831 participants developed
CHD and 582 subjects developed stroke. After
adjusting for age, sex, center, year of screening
exam, BMI, smoking, alcohol intake, physical
activity, family history of CVD, and education,
the hazard ratios (95 % confidence intervals) for
CHD comparing NAFLD without IR, IR without
NAFLD, and NAFLD with IR vs. no NAFLD
without IR were 1.07 (0.91 - 1.27), 1.19 (0.74 1.91) and 1.55 (1.18 - 2.03), respectively. The
corresponding hazard ratios for stroke were
0.93 (0.75 - 1.16), 1.40 (0.83 - 2.35) and 1.82
(1.32 - 2.52), respectively. The P-values for the
interaction of NAFLD and IR for CHD and stroke
were 0.48 and 0.28, respectively. These
associations did not differ by clinically relevant
subgroups.
Conclusions: The combination of NAFLD and IR
was associated with an increased incidence of
CHD and of stroke, but this was not observed in
those with either NAFLD or IR alone. The
combination of NAFLD and IR may identify
individuals at high cardiometabolic risk who
may need to receive more intensive preventive
intervention.
Y. Chang: None. S. Ryu: None. J. Cho: None. S.
Rampal: None. Y. Zhang: None. D. Zhao:
None. Y. Choi: None. J. Ahn: None. M. CainzosAchirica: None. R. Pastor-Barriuso: None. J.
Lima: None. H. Shin: None. E. Guallar: None.
P142
Association of the Metabolic Syndrome With
Pulse Wave Velocity: The Atherosclerosis Risk
in Communities Study (ARIC)
Anna K. Poon, Michelle L. Snyder, Univ of North
Carolina at Chapel Hill, Chapel Hill, NC; Elizabeth
Selvin, Johns Hopkins Bloomberg Sch of Public
Health, Baltimore, MD; James S. Pankow, Univ
of Minnesota, Minneapolis, MN; David Couper,
Laura Loehr, Univ of North Carolina at Chapel
Hill, Chapel Hill, NC; Hirofumi Tanaka, Univ of
Texas at Austin, Austin, TX; Gerardo Heiss, Univ
Introduction: Arterial stiffness is an indicator of
subclinical cardiovascular disease (CVD) and is
associated with increased CVD risk. The
determinants of arterial stiffness may be
explained in part by a clustering of metabolic
abnormalities (as defined by the metabolic
syndrome). Our goal was to examine the
association of central and peripheral arterial
stiffness (as measured by carotid-femoral,
brachial-ankle, and femoral-ankle pulse wave
velocity) with the metabolic syndrome in older
adults. We predicted higher arterial stiffness
(i.e. higher pulse wave velocity measurements)
in persons with compared to persons without
the metabolic syndrome.
Methods: We analyzed 3542 persons without
diabetes at the ARIC Visit 5 examination in
2011-13 (61% female; 18% African American;
median age 75 yrs). The metabolic syndrome
was defined as ≥3 of the following: (1)
abdominal obesity (waist circumference ≥102
cm in males and ≥88 cm in females); (2)
hypertriglyceridemia (≥150 mg/dL), (3) low HDLcholesterol (<40 mg/dL in males and <50 mg/dL
in females), (4) high blood pressure (BP)
(systolic BP ≥130 mmHg and/or diastolic BP≥85
mmHg and/or BP-lowering medications), and
(5) high fasting glucose (≥100 mg/dL). Pulse
wave velocity (PWV) included carotid-femoral
PWV (cfPWV), brachial-ankle PWV (baPWV),
and femoral-ankle PWV (faPWV); values were
measured using the Colin VP-1000 Plus system
(Omron Co., Ltd., Kyoto, Japan). Multivariable
regression, with adjustment for age, sex, and
race-center, was used to evaluate the
association of cfPWV, baPWV, and faPWV with
the metabolic syndrome, with each component
metabolic abnormality, and with the number of
metabolic abnormalities.
Results: The prevalence of metabolic syndrome
was 49% (SE 2); the three metabolic
abnormalities with the highest prevalence were
abdominal obesity (63% (SE 1)), elevated fasting
glucose (60% (SE 1)), and high blood pressure
(76% (SE 1)). A majority of participants had two
(29% (SE 3)) or three (28% (SE 3)) metabolic
abnormalities. Persons with the metabolic
syndrome had a higher mean cfPWV (54 cm/s;
95% CI: 35, 73 cm/s), higher mean baPWV (22;
95% CI: 2, 42 cm/s, respectively), and lower
mean faPWV (-18 cm/s; 95% CI: -31, -6 cm/s)
compared to persons without the metabolic
syndrome. Each additional metabolic
abnormality was associated with a 28 cm/s
(95% CI: 20, 36 cm/s) higher cfPWV, 19 cm/s
(95% CI: 11, 27 cm/s) higher baPWV, and 6 cm/s
(95% CI: -11, -1 cm/s) lower faPWV.
Conclusion: Metabolic syndrome and each
additional metabolic abnormality was positively
associated with cfPWV and baPWV, and
inversely associated with faPWV in older adults.
Abdominal obesity, elevated fasting glucose,
and high blood pressure were the most
common metabolic abnormalities in this cohort
of older men and women. Having the metabolic
syndrome and its abnormalities may contribute
to arterial stiffness that is predictive of CVD
events and mortality.
A.K. Poon: None. M.L. Snyder: None. E. Selvin:
None. J.S. Pankow: None. D. Couper: None. L.
Loehr: None. H. Tanaka: None. G. Heiss: None.
P143
Circulating Level of Hepatocyte Growth Factor
and Incidence of Diabetes Mellitus: The MultiEthnic Study of Atherosclerosis
Michael P Bancks, Univ of Minnesota Sch of
Public Health, Minneapolis, MN; Suzette J
Bielinski, Paul A Decker, Mayo Clinic, Rochester,
MN; Naomi Q Hanson, Univ of Minnesota,
Minneapolis, MN; Nicholas B Larson, Hugues
Sicotte, Mayo Clinic, Rochester, MN; Christina L
Wassel, Univ of Pittsburgh Graduate Sch of
Public Health, Pittsburgh, PA; James S Pankow,
Univ of Minnesota Sch of Public Health,
Minneapolis, MN
Introduction: Increased levels of hepatocyte
growth factor (HGF), active in cell growth,
motility, and morphogenesis, are associated
with the presence of obesity, poor metabolic
health, and cardiovascular disease.
higher baseline levels of HGF will be associated
with increased risk of diabetes.
between HGF and incident diabetes in MESA,
including 5395 men and women 45-84 years of
age at enrollment (2000-02). Fasting serum HGF
was measured at baseline and on a subsample
of participants at exam 2 (n = 1915). From 200011, incidence of diabetes was ascertained over
4 follow-up examinations, determined by new
use of insulin or oral hypoglycemic medication
or fasting glucose ≥ 126 mg/dL. Cox regression
was used to estimate hazard ratios (HR) for
incident diabetes according to 1 standard
deviation unit (SDU) of HGF (1 SDU =256
pg/mL), before and after adjustment for age,
sex, race/ethnicity, education, study center,
smoking status, alcohol consumption, BMI, WC,
fasting glucose and insulin, CRP, and IL-6 levels.
Similarly, hazard ratios for incident diabetes
were estimated according to change in HGF
levels from exam 1 to exam 2 in the subsample.
Results: At baseline, older age, male sex,
current smoking, and higher body mass index
(BMI), waist circumference (WC), fasting
glucose and insulin, C-reactive protein (CRP)
and interleukin-6 (IL-6) levels were all
associated with higher levels of HGF, while
greater education and physical activity were
associated with lower serum HGF. Incidence of
diabetes in this analytic sample was 12% (n
cases = 670). Per 1 SDU increase in baseline HGF
level, unadjusted risk for diabetes increased
1.46 fold (95% CI=1.37, 1.56). After adjustment,
diabetes risk per 1 SDU increase in HGF was
attenuated but remained significantly increased
(HR=1.22; 95% CI=1.12, 1.32). No association
was found between change in HGF level
between exam 1 and exam 2 and incidence of
diabetes. There was no evidence of effect
modification by race/ethnicity for either
analysis.
Conclusion: In conclusion, in this ethnically
diverse U.S. adult population, higher levels of
serum HGF were independently associated with
increased incidence of diabetes.
M.P. Bancks: None. S.J. Bielinski: None. P.A.
Decker: None. N.Q. Hanson: None. N.B. Larson:
None. H. Sicotte: None. C.L. Wassel: None. J.S.
Pankow: None.
P144
Race and Vitamin D Binding Protein Gene
Polymorphisms Modify the Association
between 25-Hydroxyvitamin D and Incident
Diabetes: The Atherosclerosis Risk in
Jared P Reis, Natl Heart, Lung, and Blood Inst,
Bethesda, MD; Erin D Michos, Elizabeth Selvin,
Johns Hopkins Medical Insts, Baltimore, MD;
James S Pankow, Pamela L Lutsey, Univ of
Background: Low 25-hydroxyvitamin D
[25(OH)D] levels are associated with diabetes,
but few studies have examined racially diverse
populations while also accounting for potential
differences by race in common vitamin D
binding protein (DBP) gene polymorphisms.
DBP, the primary carrier protein for 25(OH)D, is
associated with lower bioavailable vitamin D
levels and may inhibit the action of vitamin D on
target cells. We sought to evaluate whether the
association between 25(OH)D and incident
diabetes may vary by race and key DBP gene
polymorphisms.
Methods: We studied 8,120 white and 2,102
black adults aged 46-70 years at baseline (199092) from the ARIC Study with follow-up for
incident diabetes during study visits conducted
in 1993-95 and 1996-98. Adjusted hazard ratios
(HR) and their 95% CIs for diabetes were
estimated according to 25(OH)D. Potential
effect modification by race or DBP gene
polymorphisms was tested with the inclusion of
multiplicative interaction terms.
Results: During follow-up there were 750
incident cases of diabetes. The association of
25(OH)D with diabetes varied by race (pinteraction 0.004). Among whites, compared to
those in the highest quintile of 25(OH)D, the
adjusted HRs (95% CIs) for diabetes among
those in quintiles 4 through 1 were 1.39 (1.06,
1.83), 1.06 (0.79, 1.42), 1.32 (0.99, 1.77), and
1.59 (1.17, 2.16), respectively (p-trend 0.01). No
association was observed among blacks (ptrend 0.12). Presence of the rs4588 A allele,
reported to be associated with high DBP levels,
modified the association between 25(OH)D and
diabetes among whites, but not blacks (pinteraction 0.01 and 0.38, respectively; Table).
Conclusions: Low 25(OH)D levels were
associated with risk for diabetes among whites,
but not blacks, with the strongest associations
observed among those genetically predisposed
to high DBP levels. The effects of vitamin D
supplementation for the prevention of diabetes
may differ by race and bioavailable vitamin D
levels.
J.P. Reis: None. E.D. Michos: None. E. Selvin:
None. J.S. Pankow: None. P.L. Lutsey: None.
P145
Evaluating the Diagnostic Efficacy of A1C,
Fructosamine and Glycated Albumin in
Determining Glucose Tolerance Status in
Africans: The Africans in America Study
Michelle T Duong, Caroline K Thoreson,
Stephanie T Chung, Paola C Aldana, Madia
Ricks, Lilian S Mabundo, Natl Insts of Health,
NIDDK, Bethesda, MD; David B Sacks, Natl Insts
of Health, Dept of Lab Med, Clinical Ctr,
Bethesda, MD; Anne E Sumner, Natl Insts of
Health, NIDDK, Bethesda, MD
As both diabetes and pre-diabetes are common
in Africa, screening tests must be rapid, simple,
and accurate. Hemoglobin A1C (A1C),
fructosamine, and glycated albumin (GA) are
screening tests of long term glycemia which
only require one blood sample obtained any
time of day without consideration of recent
nutrient intake. A1C is already recommended as
a screening test for diabetes by the American
Diabetes Association and the International
Diabetes Federation, but fructosamine and GA
are under active evaluation. Fructosamine is a
measure of circulating glycated protein. GA is a
subfraction of fructosamine. Data on the
effectiveness of fructosamine and GA in African
descent populations are scant. Therefore, our
goal was to compare the ability of A1C,
fructosamine, and GA to predict diabetes. Two
hour OGTT were performed in 230 African
immigrants (67% male; age 37±10y (mean±SD);
BMI: 27.6±4.6 kg/m2). Glucose tolerance
category was defined by 2h glucose levels
(normal: 2h glucose<140 mg/dL; pre-diabetes:
2h glucose ≥140 mg/dL and <200 mg/dL;
diabetes: 2h glucose ≥200 mg/dL). A1C was
measured in all participants while fructosamine
and GA levels were available in 153 of the
enrollees. Pre-diabetes was identified in 26%
(61/230) of the participants and diabetes was
detected in 7% (15/230). By one-way ANOVA,
A1C, fructosamine and GA were higher if
diabetes was present (all P<0.01) but did not
differ significantly in the normal and prediabetes categories. For the prediction of
diabetes, area under the receiver operator
characteristic (AUC-ROC) curves was higher for
GA than either fructosamine or A1C (Table).
Overall, in African immigrants, each of the three
tests was able to identify diabetes, but none
were able to distinguish between normal
glucose tolerance and pre-diabetes. Among the
three tests, GA may be the best predictor of
diabetes.
M.T. Duong: None. C.K. Thoreson: None. S.T.
Chung: None. P.C. Aldana: None. M. Ricks:
None. L.S. Mabundo: None. D.B. Sacks:
None. A.E. Sumner: None.
P146
Diabetes, Prediabetes and Risk of
Hospitalization: the Atherosclerosis Risk in
Andrea L Schneider, Hsin Chieh Yeh, Rita R.
Kalyani, Sherita H. Golden, Johns Hopkins Univ,
Baltimore, MD; Sally C. Stearns, Lisa Wruck, The
Hill, NC; Josef Coresh, Elizabeth Selvin, Johns
Introduction: Diabetes represents a significant
proportion of healthcare costs. The magnitude
of risk and types of hospitalizations that occur
in persons with prediabetes and diabetes are
not well characterized.
Hypothesis: We hypothesized that persons with
prediabetes and diabetes would have higher
rates of hospitalization, especially from
cardiovascular causes, than those without
diabetes, and that, in addition to hyper/hypoglycemia, infection would represent a
substantial burden of hospitalizations in
persons with diabetes.
Methods: Prospective analysis of 13,522
participants in the ARIC Study followed for a
median of 20 years (1990-2011) for
hospitalizations (primary ICD-9 code defined
cause). Self-reported history and clinical cutpoints of HbA1c were used to define diabetes
status at baseline. Negative binomial models
were used to calculate demographic-adjusted
rates of hospitalization with tests for interaction
by age, sex, and race.
Results: Mean age was 57 years, 56% were
female, 24% were black. Persons with diabetes
and HbA1c ≥7% had the highest rates of
hospitalization (3.1 times higher than those
without diabetes; 1.5 times higher than those
with diabetes and HbA1c <7%). Persons with
prediabetes had 1.3 times higher rates of
hospitalization than those without diabetes
(Table). Rates of hospitalization by diabetes
status were higher for blacks vs. whites (pinteraction=0.01) and men vs. women (pinteraction=0.02); there were trends for higher
rates among and older vs. younger (pinteraction=0.14). Among those with diabetes,
cardiovascular causes accounted for the highest
proportion of hospitalizations (45 vs. 39%
among those without diabetes), with hyper/hypoglycemia and infection causes accounting
for 12 and 10% of hospitalizations, respectively.
Conclusions: Persons with diabetes and
prediabetes are at a high risk of hospitalization,
but a significant proportion of hospitalizations
were for hyper-/hypoglycemia and infection,
which may be preventable with improved
glycemic control.
A.L.C. Schneider: None. H. Yeh: None. R.R.
Kalyani: None. S.H. Golden: None. S.C. Stearns:
None. L. Wruck: None. J. Coresh: None. E.
Selvin: None.
P147
Hemoglobin A1c Cut Points to Define Various
Glucose Intolerance Groups in a South Asian
Population
Mohan Thanikachalam, Tufts Univ Sch of Med,
Boston, MA; Vijaykumar Harivanzan, Sri
Ramachandra Univ, Porur, India; Vijay Nambi,
Baylor Sch of Med, Houston, TX; Sadagopan
Thanikachalam, Sri Ramachandra Univ, Porur,
India
Objective: American Diabetes Association (ADA)
has proposed a hemoglobin A1c cut point of
6.5% as a diagnostic test for diabetes (DM). It is
important to know whether this cut point
applies to populations worldwide. Here we
determine the A1c cut points for various levels
of glycemia in South Asian population, a ethnic
group with high susceptibility to type-2 DM.
Methodology: We conducted a cross-sectional
analysis in 6965 South Indians without history
of DM. All had fasting plasma glucose (FPG) and
2-hour post-prandial plasma glucose (PPG)
measurements after a 75-g glucose load and
were classified to have Impaired Fasting
Glucose (IFG; FPG ≥100 & ≤125 & PPG ≤139),
Impaired Glucose Tolerance (IGT; FPG ≤99 &
PPG ≥140 & ≤199), DM (FPG ≥126 or PPG ≥200)
and normal glucose tolerance (NGT; FPG ≤99 &
PPG ≤139) according to ADA criteria. A1c was
measured using BIORAD D-10 A1c analyzer.
Based on receiver operating characteristic
curves, optimum sensitivity and specificity were
derived for defining A1c cut points for DM, IFG,
and IGT & NGT.
Results: Mean ± SD values of A1c among
subjects with NGT, IFG, IGT, and DM were 5.62
± 0.46, 5.94 ± 0.53, 5.93 ± 0.53 & 7.71 ± 1.50,
respectively (p-trend <0.01). Distribution of A1c
levels in these various categories is shown in
the figure. To identify DM based on PPG, the
A1c cut point was 6.3% [area under the curve
(AUC) = 0.943; 89.0% sensitivity & 90.4%
specificity] and based on FPG the A1c cut point
was 6.6% [AUC = 0.983; sensitivity 95.1%, &
specificity 93.8%]. For IGT, the A1c cut point
was 5.8 [AUC = 0.580; 53.0% sensitivity & 58.9%
specificity] and for IFG A1c cut point was 5.7
[AUC = 0.593; 61.6% sensitivity & 52.6%
specificity].
Conclusion: In South Indian population, DM can
be defined by A1c cut point 6.3% & 6.6% based
on PPG & FPG levels, respectively. Whereas A1c
cut point was 5.7% and 5.8% for IFG & IGT,
respectively with <65% sensitivity and
specificity. Further studies in non-western
populations are needed before A1c can be
universally recommended as a diagnostic test
for diabetes and high-risk states (IGT and/or
IFG).
M. Thanikachalam: None. V. Harivanzan:
None. V. Nambi: None. S. Thanikachalam:
None.
P148
Neck Circumference as an Independent
Contributor to Cardio Metabolic Risk Factors ELSA BRASIL
Cristina P Baena, Paulo A Lotufo, São Paulo
Univ, São Paulo, Brazil; Maria J Fonseca,
Fundação Oswaldo Cruz, Rio de Janeiro, Brazil;
Isabela J Benseñor, São Paulo Univ, São Paulo,
Brazil
Background: Neck circumference is a proxy for
upper body fat and it is a simple
anthropometric measure. Therefore it could be
a useful tool to identify individuals with
cardiometabolic risk factors in the context of
primary care.
Hypothesis: Neck circumference is
independently associated to cardiometabolic
risk factors in an apparently healthy population.
Methods:This is a cross-sectional analysis of
baseline data of the Brazilian Longitudinal Study
of Adult Health (ELSA-Brasil), a cohort of 15105
civil servants aged 35-74 years. We excluded
from this analysis those who fulfilled American
Diabetes Association criteria for diabetes
diagnosis, were taking antihypertensive and/or
lipid-lowering drugs. A sex-specific analysis was
conducted. Partial correlation (age-adjusted)
was used. Risk factors were set as low
HDL<50mg/dL for women and <40mg/dL for
men, hypertriglyceridemia ≥ 150 mg/dl ,
hypertension as systolic blood pressure ≥130
mg/dl or diastolic blood pressure ≥85 mm Hg
and insulin resistance(HOMA-IR ≥ 75th
percentile). Logistic regression models were
built to analyze the association between
individual and clustered risk factors as
dependent variables and 1-SD increase in neck
circumference as independent variable.
Multiple adjustments were subsequently
performed for age, smoking, alcohol, body-mass
index, waist and physical activity. Receiver
Operating Curves were employed to find the
best NC cut-off points for clustered risk factors.
Results: We analyzed 3810 men (mean age=
49.0 ±8.3 yrs) and 4916 women (49.2 ±8.0 yrs).
Mean NC was 38.9 (±2.6)cm for men and
33.4(±2.6)cm for women. NC positively
correlated with systolic and diastolic blood
pressure (r=0.21 and r=0.27), HOMA - IR
(r=0.44), triglycerides (r=0.31) and negatively
correlated with HDL (r= -0.21) in men (p<0.001
for all) with similar results in women. Fully
adjusted Odds Ratio (OR) (95% CI) of risk factor
per SD increase in neck circumference in men
and women were 1.29(1.14;1.46) and
1.42(1.28;1.57) for insulin resistance;
1.24(1.11;1.39) and 1.25(1.11;1.40) for
hypertension; 1.33(1.19;1.49) and
1.42(1.29;1.63) for hypertriglyceridemia;
1.07(0.92;1.23) and 1.32 (1.19;1.43) for low
HDL. Fully adjusted OR (95% CI) of 2 clustered
risk factor per SD increase in neck
circumference in men and women were
1.29(1.14;1.48) and 1.37(1.21;1.54 ). Fully
adjusted OR (95% CI) of 3 or more clustered risk
factors per SD increase in neck circumference in
men and women were 1.33 (1.02;1.74) and 1.62
(1.33;1.92). Values of neck circumference of
>40 cm for men and >34.1 cm for women were
the best cut-off points for 3 or more clustered
risk factors.
Conclusion: Neck circumference is significantly
and independently associated to
cardiometabolic risk factors in a well-defined
non-treated population. It should be considered
as a marker of cardio metabolic risk factors in
primary care settings.
C.P. Baena: None. P.A. Lotufo: None. M.J.M.
Fonseca: None. I.J. Benseñor: None.
P149
The Impact on HbA1c of Adherence Measured
Over Multiple Short Intervals: A More Direct
Assessment of Biologic Response
Gregory A Nichols, A Gabriela Rosales, Teresa
M Kimes, Kaiser Permanente, Portland, OR;
Kaan Tunceli, Merck & Co, Whitehouse Stattion,
NJ; Karen Kurtyka, Rutgers Sch of Public Health,
Piscataway, NJ; Panagiotis Mavros, Merck & Co,
Whitehouse Stattion, NJ; John F Steiner, Kaiser
Permanente, Denver, CO
Adherence to medications is typically estimated
over a 6-12 month period and associated with a
mean biologic response over a similar
timeframe. Our objective was to examine the
relationship between a specific HbA1c
measurement and a measure of adherence
calculated from medication dispenses over the
preceding 90 days among patients who newly
initiated metformin therapy.We identified 3,109
persons with type 2 diabetes who initiated
metformin as their first ever anti-hyperglycemic
drug, analyzing all 9,918 HbA1c measurements
that occurred over the next 2 years. We used an
adaptation of the proportion of days covered
method for assessing medication adherence
that corresponded to an approximate 90-day
interval preceding an HbA1c measurement,
terming the adaptation the “interval-based
proportion of days covered” (IB-PDC). To
account for multiple observations per patient,
we analyzed the association between HbA1c
and IB-PDC within the generalized estimating
equation (GEE) framework. Analyses were
stratified by HbA1c prior to metformin initiation
using a cut-point of 8%.
After multivariable adjustment using 0%
adherence as the reference
category, IB-PDC 1-49% was not associated with
HbA1c. However, IB-PDC 50-79% was associated
with lower HbA1c values of 0.113 (95% CI:
0.025, 0.202) percentage points among patients
with pre-metformin HbA1c <8%, and 0.247
(0.104, 0.390) percentage points among those
with HbA1c >8% at metformin initiation. IB-PDC
>80% was associated with lower HbA1c of 0.175
(0.093, 0.257) and 0.453 (0.320, 0.586)
percentage points for those with HbA1c <8%
and >8%, respectively. When re-categorizing IBPDC into 10% bands using 0-49% as the
reference category, HbA1c associated with IBPDC 50-59% were not significantly different.
Among patients with HbA1c < 8% at metformin
initiation, all higher levels of IB-PDC were
significantly associated with lower HbA1c’s, and
IB-PDC >90% was associated with lower HbA1c
0.151 percentage points (95% CI 0.087, 0.216)
compared with IB-PDC < 50%. Larger effects
were seen among patients with pre-metformin
HbA1c > 8%, where IB-PDC 80-89% was
associated with HbA1c that was 0.534 (0.403,
0.666) percentage points lower than the
reference category.
Using this novel short-interval approach that
more closely associates the effects of
adherence with the expected biologic response,
better medication adherence in obtaining
prescriptions was associated with lower HbA1c
levels than has been previously reported. The
impact of this adherence measure on glycemic
control was dependent upon the HbA1c level
prior to initiating metformin.
G.A. Nichols: B. Research Grant; Significant;
Merck & Co, AstraZeneca, Novartis, BoehringerIngelheim. A.G. Rosales: None. T.M. Kimes:
None. K. Tunceli: A. Employment; Significant;
Merck & Co. K. Kurtyka: C. Other Research
Support; Significant; Merck & Co. P. Mavros: A.
Employment; Significant; Merck & Co. J.F.
Steiner: None.
P150
Weight-Loss Diets and 2-Year Change of
Circulating Amino Acids in Two Randomized
Intervention Trials
Yan Zheng, Harvard Sch of Public Health,
Boston, MA; Uta Ceglarek, Univ Hosp Leipzig,
Liebigstrasse, Germany; Tao Huang, Harvard Sch
of Public Health, Boston, MA; Lerong Li, Univ of
Texas, Houston, TX; Jennifer Rood, Donna H
Ryan, George A Bray, Pennington Biomedical
Res Ctr of the Louisiana State Univ System,
Baton Rouge, LA; Frank M Sacks, Harvard Sch of
Public Health, Boston, MA; Dan Schwarzfuchs,
Nuclear Res Ctr Negev, Dimona, Israel; Joachim
Thiery, Univ Hosp Leipzig, Liebigstrasse,
Germany; Iris Shai, Ben-Gurion Univ of the
Negev, Beer-Sheva, Israel; Lu Qi, Harvard Sch of
Public Health, Boston, MA
Background- Emerging evidence has related
circulating amino acids to diabetes and
cardiovascular risk. Little is known about how
diet modifications affect circulating amino
acids. The present study aimed to examine the
effects of weight-loss diets on long-term
changes in plasma amino acids, and their
relations with weight loss and metabolic
outcomes.
Methods and Results- We repeatedly measured
plasma amino acid profiles over 2 years among
overweight or obese participants from two
randomized dietary interventional weight-loss
trials: 774 from the Preventing Overweight
Using Novel Dietary Strategies trial (POUNDS
LOST) and 318 from Dietary Intervention
Randomized Controlled Trial (DIRECT). The
plasma levels of most amino acids decreased
from baseline during follow-up in both trials. In
the POUNDS LOST trial, compared to the highprotein diets, the average-protein weight-loss
diets showed a greater effect on decreasing
plasma levels of a diabetes-associated
branched-chain amino acid (BCAA) valine and
another amino acid methyl-histidine at 6
months, independent of weight change
(p<0.002). Furthermore, the changes of plasma
BCAA leucine/isoleucine, aromatic amino acid
tyrosine and phenylalanine, and four other
amino acids (alanine, sarcosine, hydroxyproline,
and methionine) were positively related to
concurrent weight loss, consistently in both
trials (5-13g weight loss per 1 unit decease in
log[amino acid in µmol/L], p<0.002). Moreover,
the changes in tyrosine and alanine were
positively related to changes in insulin
resistance, independent of weight change, in
both trials (p<0.05).
Conclusion- Our findings underscore the
potential importance of weight-loss dietary
interventions in improvement of amino acid
profiles and related cardiometabolic risk.
Y. Zheng: None. U. Ceglarek: None. T. Huang:
None. L. Li: None. J. Rood: None. D.H. Ryan:
None. G.A. Bray: None. F.M. Sacks: None. D.
Schwarzfuchs: None. J. Thiery: None. I. Shai:
None. L. Qi: None.
P151
Duration and Types of Statin Use and LongTerm Risk of Type 2 Diabetes Among Men and
Women with Hypercholesterolemia: Findings
From 3 Prospective Cohorts
Dong D Wang, Yanping Li, Harvard Sch of Public
Health, Boston, MA; An Pan, Natl Univ of
Singapore, Singapore, Singapore; Edward
Giovannucci, Walter Willett, Harvard Sch of
Public Health, Boston, MA; JoAnn Mason,
Brigham and Women’s Hosp and Harvard
Medical Sch, Boston, MA; Frank Hu, Harvard Sch
of Public Health, Boston, MA
Introduction
Although effective for cardiovascular disease
(CVD) prevention, statin use has been
associated with an elevated risk of type 2
diabetes (T2D). However, data on duration of
use and types of statins are still limited.
Hypothesis
We hypothesized that longer duration of statin
use was associated greater risk of T2D and the
association varied with different types of statin.
Methods:
We analyzed participants with self-reported
hypercholesterolemia from the Nurses’ Health
Study (NHS, 30 480 participants), the Nurses’
Health Study II (NHS II, 21 773 participants) and
the Health Professionals Follow-up Study (HPFS,
12 064 participants) who were free of diabetes,
CVD and cancer at baseline. Information on
statin use was self-reported by participants
every 2 years from 2000 for NHS and HPFS, and
1999 for NHS II. Incident cases of T2D were first
self-reported on the biennial questionnaires
and then confirmed by a validated
supplementary questionnaire through 2010 or
2011. Participants also reported their serum
cholesterol level every two years. Multivariable
Cox models were used to estimate the hazard
ratios (HRs) of developing T2D and their 95%
confidence intervals (CIs) by statin use status.
Results:
We documented a total of 4 555 incident T2D
cases during the follow-up. Compared to
nonusers, statin users had a significantly higher
risk of T2D after adjustment for potential
lifestyle confounding variables, hypertension
medication and self-reported serum cholesterol
levels (pooled HR, 1.38, 95% CI, 1.30-1.48).
Compared to non-use, the durations of statin
use of 1-3, 4-6 and ≥7 years were associated
with HRs of 1.30 (95% CI, 1.19, 1.42), 1.41(95%
CI, 1.29, 1.54) and 1.47 (95% CI, 1.33, 1.63),
respectively, with significant linear trends in
both the entire study population (P trend <
0.001) and statin users (P trend =0.05). The HRs
for T2D were 1.10 (95% CI, 0.84, 1.44) for
lovastatin, 1.17 (95% CI, 0.99, 1.39) for
pravastatin, 1.30 (95% CI, 1.14, 1.49) for
simvastatin, 1.36 (95% CI, 1.22, 1.52) for
atorvastatin and 1.56 (95% CI, 1.30, 1.86) for
rosuvastatin. In a series of sensitivity analyses
by excluding T2D cases in the early follow-up,
using propensity-score adjustment for potential
confounders and restricting analysis to only
new statin users, the results did not change
appreciably.
Conclusions:
The positive association between statin use and
T2D was more pronounced with longer duration
of use and the association varied with different
types of statins.
D.D. Wang: None. Y. Li: None. A. Pan: None. E.
Giovannucci: None. W. Willett: None. J. Mason:
None. F. Hu: None.
P152
Urinary isoflavonoids and Risk of Type 2
Diabetes: A Prospective Investigation in U.S.
Women
Ming Ding, Harvard Sch of Public Health,
Brookline, MA; Adrian Franke, Univ of Hawai‘i
Cancer Ctr, Honolulu, HI; Bernard Rosner, Rob
van Dam, Shelley Tworoger, Frank Hu, Harvard
Sch of Public Health, Boston, MA; Qi Sun,
Harvard Sch of Public Health, BOSTON, MA
ABSTRACT
Objective: To examine the association between
urinary excretions of isoflavonoids and risk of
type 2 diabetes (T2D).
Methods: Urinary excretions of daidzein and
genistein, as well as their metabolites
desmethylangolensin (DMA), dihydrogenistein
(DHGE), dihydrodaidzein (DHDE) were assayed
by liquid chromatography mass spectrometry
among 1,111 T2D nested case-control pairs
identified during 1995 - 2008 in the Nurses’
Health Study (NHS; aged 54 - 80y, 99%
postmenopausal) and NHSII (aged 33 - 52y, 22%
postmenopausal) who were free of diabetes,
cardiovascular disease, and cancer at urine
sample collection in 1995-2001. Incident selfreported T2D cases were confirmed using a
validated supplementary questionnaire.
Results: Total urinary isoflavones and all
individual metabolites except DMA were
associated with a lower risk of T2D in the NHS
but not in the younger women of the NHSII.
Compared to the lowest tertile of total urinary
isoflavones, the odds ratios (ORs) of T2D in the
middle and high tertile of NHS were 0.72 (95%
CI: 0.49, 1.04) and 0.57 (95% CI: 0.38, 0.85) (P
for trend = 0.01), respectively. In contrast, the
corresponding ORs (95% CIs) were 0.99 (0.65,
1.50) and 1.21 (0.79, 1.85) in NHSII. Significant
heterogeneity was found between the two
cohorts for the associations of daidzein, DMA,
and total isoflavones (P < 0.05). A significant
effect modification by postmenopausal
hormone use was found in the NHS, with a
stronger inverse association observed among
these postmenopausal women who did not use
hormone therapy.
Conclusions: Inverse associations between
urinary isoflavones and risk of T2D were found
in older women, especially those who did not
use postmenopausal hormone, whereas in
younger women no association was observed.
M. Ding: None. A. Franke: None. B. Rosner:
None. R. van Dam: None. S. Tworoger: None. F.
Hu: None. Q. Sun: None.
P153
Is a Continuous Metabolic Syndrome Score a
Better Predictor of Vascular Damage in Youth?
Elaine Urbina, Zhiqian Gao, Philip Khoury,
Connie McCoy, Lawrence Dolan, Thomas
Kimball, Cincinnati Childrens Hosp, Cincinnati,
OH
Obesity-related co-morbidities are increasing in
adults and in adolescents. Although metabolic
syndrome-like clustering of CV risk factors is
known to be associated with target organ
damage (TOD), how to define metabolic
syndrome in young subjects is controversial.
Gurka, et al used factor analysis of NHANES
data to develop a new sex- and race/ethnicityspecific continuous metabolic syndrome score
for adolescents. We compared the utility of this
score (G) to the adult ATP and WHO definition
in predicting presence of TOD in adolescents
and young adults evaluated in a study of the CV
effects of T2DM (N=779 age 17.9 + 3.3 yrs, 35%
male, 59% non-Caucasian, 1/3 Lean, 1/3 Obese,
1/3 T2DM). Anthropometry, BP, fasting glucose,
insulin, lipids, CRP, Brachial Distensibility
(BrachD, PulseMetric device), Pulse Wave
Velocity & Augmentation Index (PWV, AIx,
SphygmoCor device), and carotid intima-media
thickness (IMT) were obtained. Subjects were
classified as MS+ or - based on ATP and WHO
definitions and on a cut point of 0.75 as
suggested by Gurka. Prevalence of MS was
highest for G (43%) with similar prevalence for
ATP (28.2%) and WHO (26.2%) by McNemar
test. Adiposity was the major contributor to
classification of subjects as MS+, with
insulin/glucose the second contributor, then BP
and lipids regardless of MS definition used. G as
a continuous variable explained more of the
variance in all TOD measures than ATP or WHO.
Receiver operator characteristic curve analysis
determined that a G cutpoint of near 1 had the
best sensitivity and specificity for predicting
abnormal arterial stiffness and thickness. We
conclude that the continuous G score maybe
superior to ATP and WHO in predicting TOD as
it allows for assessment of severity of risk factor
clustering not possible with dichotomous
definitions. A continuous metabolic syndrome
score near 1 may be a useful screening tool to
identify youth at risk for TOD.
E. Urbina: B. Research Grant; Modest; 8 UL1
TR000077-04. B. Research Grant; Significant;
R01 HL105591. Z. Gao: None. P. Khoury:
None. C. McCoy: None. L. Dolan: B. Research
Grant; Modest; R01 HL105591. T. Kimball: B.
Research Grant; Modest; R01 HL105591.
P154
Pericardial Adiposity Predicts Incident
Diabetes: The Multi-Ethnic Study of
Atherosclerosis
Amy C. Alman, Univ of South Florida, Tampa,
FL; David R. Jacobs Jr, Univ of Minnesota,
Minneapolis, MN; Matthew A. Allison, Univ of
California San Diego, San Diego, CA; John Jeffrey
Carr, Vanderbilt Univ Medical Ctr, Nashville, TN;
Fang-Chi Hsu, Wake Forest Univ Sch of Med,
Winston-Salem, NC; James G. Terry, Vanderbilt
Univ Medical Ctr, Nashville, TN; Janet K. SnellBergeon, Univ of Colorado Denver, Aurora, CO;
Cora E. Lewis, Univ of Alabama at Birmingham,
Birmingham, AL; Alain G. Bertoni, Wake Forest
Univ Sch of Med, Winston-Salem, NC; David C.
Goff Jr, Colorado Sch of Public Health, Aurora,
CO; Jingzhong Ding, Wake Forest Univ Sch of
Med, Winston-Salem, NC
Pericardial adipose tissue (PAT) is ectopic fat
deep (epicardial adipose tissue) and superficial
(paracardial adipose tissue) to the pericardium
of the heart. PAT has been cross-sectionally
associated with diabetes, but the association
with development of diabetes is unclear. Using
data from the Multi-Ethnic Study of
Atherosclerosis (MESA), we tested whether PAT
at baseline was associated with incident
diabetes over nearly 10 years of follow-up. The
baseline visit (visit 1) was conducted between
2000-2002. Four follow-up visits were
conducted at 2 year intervals with visit 5
between 2010 and 2012. Diabetes was defined
as a fasting glucose ≥126 mg/dl or the use of
antidiabetic medication. Diabetes-free
participants at baseline were followed for
incident diabetes at any subsequent visit (visits
2-5). Volume of PAT was measured from
computed tomographic (CT) scans taken at
visits 1 - 4. CT scans were completed on all
participants at baseline. Repeat scans were
performed on random halves at visits 2 and 3,
and a subset at visit 4. Multivariable Cox
assess the association between PAT and
incident diabetes.
The figure presents the mean PAT by visit and
the mean PAT at baseline among those without
diabetes at any time during the study period
and those that develop diabetes over the 10
years of follow-up. In Cox regression models
adjusted for age, race, and sex, each SD
increment of baseline PAT (42.0 mL) was
associated with a hazard ratio (HR) for incident
diabetes of 1.6 (95% CI 1.5-1.7, p<0.0001). After
adjusting for baseline BMI and waist-to-hip
ratio, the HR was attenuated somewhat, but
remained significant: HR 1.3 (95% CI 1.2-1.4,
p<0.0001). Addition of waist circumference to
the model did not alter PAT results further.
We found that PAT was highly stable over time,
accumulating very slowly. Its baseline value
strongly predicts incident diabetes independent
of overall body mass and central fatness.
A.C. Alman: None. D.R. Jacobs: None. M.A.
Allison: None. J.J. Carr: None. F. Hsu: None. J.G.
Terry: None. J.K. Snell-Bergeon: None. C.E.
Lewis: None. A.G. Bertoni: None. D.C. Goff:
None. J. Ding: None.
P155
Weight Gain and Insulin Sensitivity in Adults
With and Without Type 1 Diabetes
Lindsey M Duca, Barbara Davis Ctr for
Childhood Diabetes, Aurora, CO; Irene E.
Schauer, Div of Endocrinology, Metabolism and
Diabetes, Dept of Med, Sch of Med, Aurora, CO;
Janet K. Snell-Bergeon, Barbara Davis Ctr for
Childhood Diabetes, Aurora, CO
People with type 1 diabetes mellitus (T1D) have
reduced insulin sensitivity (IS), which partially
explains their increased risk of cardiovascular
disease. However, there is limited data on how
weight gain alters IS in T1D, and so this study
aimed to analyze the effect of weight change on
IS components in T1D and non-diabetic (nonDM) adults.
This study included 1133 adults (T1D=528 and
non-DM n=605) with a mean ± SD age of 38 ± 9
years from the Coronary Artery Calcification in
Type 1 Diabetes cohort, examined at baseline
and after 6.2±0.6 years. Weight change was
categorized as follows: weight loss (WL), lost >
2%), weight stable (WS), within 2% of baseline,
and weight gain (WG), > 2%. Estimated IS (eIS)
was calculated by a model derived from a clamp
study (Table) at each visit. Multiple age and sex
adjusted least squares means were calculated
by weight change group and diabetes status,
and progression of coronary artery calcium
(CAC) was examined by logistic regression.
There was a significant improvement in eIS in
the T1D WL group, along with a greater
reduction in triglycerides and insulin dose and
increase in adiponectin compared to the other
weight change groups (Table). There was
significant increase in eIS among the non-DM
WL group, along with a reduction in
triglycerides, fasting glucose, HbA1c and DBP
and an increase in adiponectin. For each 2%
increase in weight, the odds ratio (OR) for
progression of CAC was 1.23 (95% CI 1.1-1.4,
p=0.002), after adjusting for age, sex, diabetes
status, and baseline BMI and CAC. The odds of
CAC progression were decreased by 40% (OR
0.6, 95% CI 0.5-0.8, p=0.0007) for each SD
increase in eIS, adjusting for the same variables.
In conclusion, over 6 years of follow-up, weight
loss increased eIS and related factors in both
people with and without T1D, but was not
associated with improved Hba1c in T1D.
Additionally, weight gain was associated with a
greater risk and eIS with a lower risk for CAC
progression, demonstrating the importance of
avoiding weight gain in prevention of subclinical
L.M. Duca: None. I.E. Schauer: None. J.K. SnellBergeon: None.
P156
Anger Expression and Incident Diabetes
Among African American Adults: The Jackson
Heart Study
Tracey H Taveira, VA Medical Ctr; Univ of Rhode
Island; Brown Univ, Providence, RI; Michelle L
Hershey, VA Medical Ctr, Providence, RI; Kristen
Knoph, VA Medical Ctr; Univ of Rhode Island,
Providence, RI; DeMarc Hickson, Univ of
Mississippi Medical Ctr Sch of Med, Jackson,
MS; Wen-Chih Wu, VA Medical Ctr; Univ of
Rhode Island; Brown Univ, Providence, RI
Purpose: Type 2 diabetes mellitus (T2DM) is
highly prevalent in African American (AA)
adults. Negative emotional states, such as
anger, have been linked to cardiovascular
disease (CVD) and CVD risk factors. However,
previous studies involving glucose metabolism
are conflicting and analyses exploring the
relationship between anger expression and
incident T2DM are limited, especially in AAs.
We hypothesize that high levels of anger
expression will be associated with increased
incident T2DM in AAs.
Methods: A cohort study was conducted on
5301 AAs recruited during 2000-2004, from 3
counties in Jackson, MS. All participants who
completed the Spielberger Anger Expression
scale at the baseline visit without diagnosed
T2DM were eligible for inclusion in this analysis.
This scale is a 16-item tool that measures
internalization of anger or anger-in (8 items)
and external expression of anger or anger-out
(8 items) among participants, with higher scores
signifying higher frequency of self-perceived
expression of anger-in and/or anger-out
behaviors. The primary outcome was diagnosis
of T2DM between 2005 and 2010. Subjects with
Anger expression scores in the highest quartile
(score >=15 /32 for anger-in and >=14/32 for
anger-out) were compared to the remaining
participants. We related anger-in scores with
incident T2DM using Cox proportional hazards
modeling and adjusted for potential
confounding (age, smoking status, education
level, and baseline levels of A1c and body mass
index). Since anger expression may vary by sex,
a stratified analysis by sex was conducted.
Analyses were repeated for anger-out as the
main exposure.
Results: A total of 2483 participants completed
the anger-in scale and 2525 participants
completed the anger-out scale. The cohort was
64.5% female with a mean age of 52.6 ± 12.6
years. After 7.0 ± 1.9 years of follow-up,
incident T2DM was highest amongst men with
an anger-in score in the highest quartile at
26.9%, followed by the remaining men at
21.8%, followed by the remaining women at
20.7% and then by women with the highest
quartile of anger-in score (19.5%), p = 0.21
amongst 4 groups. Cox modeling showed an
increase in hazards of incident T2DM among
men with an anger-in score in the highest
quartile compared to the remaining men,
adjusted Hazards Ratio 1.54, 95% CI 1.08 - 2.20
(p=0.017). A similar relationship was not found
in women (Hazards Ratio 0.77, 95% CI 0.571.06, p=0.107). There was no significant
relationship between anger-out scores and
incident T2DM.
Conclusions: African American men, but not
women, with high internalization of anger
(anger-in) were found to have an increased
incidence of T2DM over a 10-year follow-up
period. External expression of anger (anger-out)
was not related to incident T2DM. Further
studies exploring the underlying pathways of
this relationship and risk reduction strategies
may be warranted.
T.H. Taveira: None. M.L. Hershey: None. K.
Knoph: None. D. Hickson: None. W. Wu: None.
P157
Serum Vitamin D is Not Associated With Risk
of Incident Diabetes in African Americans: The
Jackson Heart Study
Jane L Harman, Natl Heart, Lung, and Blood
Inst, Bethesda, MD; Haiying Chen, Wake Forest
Univ, Winston-Salem, NC; Michael C Sachs, Natl
Cancer Inst, Bethesda, MD; Kristin G Hairston,
Wake Forest Univ, Winston-Salem, NC; Sherita
H Golden, Joshua J Joseph, Johns Hopkins Univ,
Baltimore, MD; Alain G Bertoni, Wake Forest
Univ, Winston-Salem, NC
- A recent meta-analysis of cohort studies with
participants primarily of European ancestry,
concluded that the risk of incident diabetes was
inversely proportional to serum 25-hydroxyvitamin D levels (25-OH-D). African Americans
have lower levels of vitamin D than European
Americans. But, lower levels of vitamin D do not
seem to carry the same risk for low bone
density or vascular calcification for African
Americans. We sought to test the hypothesis
that low vitamin D elevates the risk of diabetes
in African Americans.
- During 2001-5, 5301 African American adults
in Jackson, MS, were examined and blood
samples drawn; mean age was 55±13. Serum
25-OH-D2 and 25-OH-D3 were measured from
stored frozen serum; mean total 25-OH-D (25OH-D2 plus 25-OH-D3) =14.5±6.7ng/ml. A
seasonal pattern was evident for 25-OH-D3 but
not for 25-OH-D2 levels. A cosinor model
adjusted for seasonality of 25-OH-D3; mean
annualized concentrations and seasonal
amplitude were significantly higher for men and
for persons of normal BMI compared to
overweight or obese persons. Total 25-OH-D, as
the sum of predicted annualized mean 25-OHD3 and measured 25-OH-D2, was used in
subsequent analysis.
- The analysis evaluated 3363 participants after
exclusions for missing serum vitamin D (n=141),
prevalent diabetes (n=1152), incomplete
ascertainment of diabetes (n=62), or no followup (n=725). During a mean follow-up of 7.1
years, there were 584 new cases of diabetes.
Using a Cox Proportional Hazards model
controlling for age and sex, the risk of incident
diabetes was significantly and inversely
associated with total serum 25-OH-D; after
adding BMI to the model, 25-OH-D was not
significantly associated with risk of diabetes
(Table 1). Physical activity, smoking, and alcohol
use did not predict incident diabetes in any
model.
- In conclusion, we found that in this cohort of
African-Americans, with low mean 25-OH-D and
a relatively narrow range of 25-OH-D, the risk of
incident diabetes was not associated with
serum 25-OH-D levels after controlling for sex,
age, and BMI.
J.L. Harman: None. H. Chen: None. M.C. Sachs:
None. K.G. Hairston: None. S.H. Golden:
None. J.J. Joseph: None. A.G. Bertoni: None.
P158
Lower Extremity Peripheral Artery Disease and
Quality of Life among Older Individuals in the
Community: The Atherosclerosis Risk in
Aozhou Wu, Josef Coresh, Elizabeth Selvin,
Johns Hopkins Univ, Baltimore, MD; Hirofumi
Tanaka, Univ of Texas at Austin, Austin, TX;
Gerardo Heiss, Univ of North Carolina, Chapel
Hill, NC; Alan T. Hirsch, Univ of Minnesota,
Minneapolis, MN; Bernard Jaar, Kunihiro
Matsushita, Johns Hopkins Univ, Baltimore, MD
Background: Lower extremity peripheral
arterial disease (PAD), commonly identified by
an ankle-brachial Index (ABI) <0.9, increases
mortality risk and may impair mobility as well as
quality of life (QOL). However, most studies
assessing reduced QOL in the relation to PAD
rely on small data from vascular clinics, leaving
uncertainty about the impact of PAD on QOL in
the community.
Method: Using 5,610 ARIC visit 5 (2011-2013)
participants aged 66-90 years, we assessed the
associations of ABI with several QOL
parameters, including self-evaluated general
health status, mental status (the Center for
Epidemiologic Studies Depression [CES-D] score
and hopeless feeling), social aspect (work
interfered by pain and social activity interfered
by health status), and physical ability (limited
ability to climb stairs and need of walking
assistance). Logistic regression models were
applied to assess the association of ABI with
each QOL parameter, adjusting for potential
confounders including comorbidities such as
history of heart failure, coronary heart disease,
and stroke.
Result: With ABI 1.1-1.2 as a reference, lower
ABI was consistently associated with poor
status of all QOL parameters tested (Table),
with overall evident dose-response relationship.
Interestingly, a poor status of various QOL
parameters was observed even in borderline
low ABI (0.9-1.0) and low normal (1.0-1.1). High
ABI (>1.3), indicative of arterial stiffness, was
only significantly associated with limited ability
to climb stairs. Similar results for low ABI and
QOL were observed in both genders and white
and black participants.
Conclusion: Low ABI was independently and
consistently associated with poor status of wide
range of QOL domains, with potential important
implications on quality-maintained life in older
individuals. Further studies are warranted to
assess whether the association is due to PADrelated leg symptoms or weakness and/or
reflects the impact of systemic atherosclerosis
on QOL.
A. Wu: None. J. Coresh: None. E. Selvin:
None. H. Tanaka: None. G. Heiss: None. A.T.
Hirsch: None. B. Jaar: None. K. Matsushita:
None.
P159
Repeatability of Automated Determinations of
the Ankle Brachial Index The Atherosclerosis
Risk in Communities (ARIC) Study
Ada Al-Qunaibet, KSAU-HS, Riyadh, Saudi
Arabia and Univ of North Carolina at Chapel Hill,
Chapel Hill, NC; Michelle L Snyder, David
Couper, Univ of North Carolina at Chapel Hill,
Chapel Hill, NC; Hirofumi Tanaka, Univ of Texas
at Austin, Austin, TX; Susan Cheng, Harvard
Medical Sch, Boston, MA; Kunihiro Matsushita,
Baltimore, MD; Aaron R. Folsom, Univ of
Minnesota, Minneapolis, MN; Gerardo Heiss,
Hill, NC
Background: The ankle brachial index (ABI) is a
noninvasive and inexpensive means to assess
peripheral arterial disease (PAD) with
established validity. Low ABI values are
predictive of cardiovascular morbidity and allcause mortality. Automated, oscillometric
devices are commonly used to measure ABI in
clinical settings and population studies for timeefficiency and to reduce observer-dependent
variability. The repeatability of multi-limb
systolic blood pressure (SBP) and of ABI using
oscillometric devices has not been evaluated in
depth.
Objectives: Characterize the repeatability of
limb-specific SBP and of ABI in a multi-center,
community-based study of older adults.
Methods: A subset of ARIC study participants
(n=79; 58% women) with a mean age of 75.7
years underwent two examinations 4-8 weeks
apart, using standardized protocols. SBP in the
arms and ankles was measured twice in each
‘visit’ in the supine position after a 5 minute
rest, using the Omron Colin VP-1000 Plus
system (Omron Co., Ltd., Kyoto, Japan). Right
brachial SBP (RbSBP), left brachial SBP (LbSBP),
right ankle SBP (RaSBP), left ankle (LaSBP), right
ABI (RABI), and left ABI (LABI) were measured
concurrently. Analyses excluded 3 individuals
due to; ABI and SBP values >3 standard
deviations away from the mean, body mass
index > 40 kg/m2, major arrhythmias, and aortic
stenosis. Random-effects analysis of variance
was used to examine the deviation of within
visit, between visit, and between-participant
components from the grand mean. The intraclass correlation coefficient (ICC), the
corresponding 95% confidence intervals (95%
CI), minimal detectable change (MDC), and
minimal detectable difference (MDD) were
calculated.
Results: The grand means and standard
deviations (SD) were 137.6 ± 16.5 mmHg for
RbSBP, 138.2 ± 16.3 mmHg for LbSBP, 162.4 ±
23.6 mmHg for RaSBP, 161.8 ± 23.0 mmHg for
LaSBP, 1.16 ± 0.11 for RABI, 1.15 ± 0.11 for LABI.
Within-visit (instrument-related) variations
were 9.0% for RbSBP, 9.6% for LbSBP, 12.6% for
RaSBP, 10.1% for LaSBP, 22.7% for RABI, and
14.2% for LABI. The ICCs (95% CI) were 0.62
(0.49, 0.75) for RbSBP, 0.65 (0.53, 0.77) for
LbSBP, 0.61 (0.48, 0.74) for RaSBP, 0.66 (0.55,
0.78) for LaSBP, 0.48 (0.34, 0.64) for RABI, and
0.61 (0.48, 0.73) for LABI. The MDC was 28.5
mmHg for RbSBP, 26.9 mmHg for LbSBP, 41.3
mmHg for RaSBP, 37.0 mmHg for LaSBP, 0.22
for RABI, and 0.20 for LABI. The MDD for two
independent samples (N=100) was 8.5 mmHg
for RbSBP, 8.4 mmHg for LbSBP, 12.2 mmHg for
RaSBP, 11.8 mmHg for LaSBP, 0.06 for RABI and
LABI.
Conclusion: The short-term (4-8 week)
repeatabilities of automated, oscillometric
measures of the arm and ankle SBP, and of the
LABI are substantial. The MDC of the LABI is
approximately 1.7 SD. The estimated
repeatability of the RABI is moderate, and its
MDD is 2 SD. The average duration of the
automated measurements was 5 minutes and
the examinees considered them to be
comfortable.
A. Al-Qunaibet: None. M.L. Snyder: None. D.
Couper: None. H. Tanaka: None. S. Cheng:
None. K. Matsushita: None. A.R. Folsom:
None. G. Heiss: None.
P160
Ankle-Brachial Index and Fracture
Hospitalization in Middle-Aged Adults: The
Study
Shoshana Ballew, Yingying Sang, Andrea L
Schneider, Morgan Grams, Johns Hopkins Univ,
Baltimore, MD; Laura R Loehr, Univ of North
Carolina, Chapel Hill, NC; Hirofumi Tanaka, Univ
of Texas at Austin, Austin, TX; Gerardo Heiss,
Univ of North Carolina, Chapel Hill, NC;
Elizabeth Selvin, Josef Coresh, Kunihiro
Matsushita, Johns Hopkins Univ, Baltimore, MD
Background: Several studies indicate that lower
extremity peripheral artery disease (PAD),
commonly defined by an ankle-brachial index
(ABI) <0.9, can increase the risk of bone fracture
via its impact on physical function and mobility.
Because the majority of prior studies are limited
to older white male populations (age ≥65
years), uncertainty remains regarding this
association in non-whites, women, and younger
individuals.
Methods: We studied 15,160 ARIC participants
(age 45-64 years in 1987-1989) whose ABI was
measured in a randomly selected leg at
baseline. Hip or lower extremity fracturerelated diagnostic codes were identified
through active surveillance of hospitalizations.
We used Cox proportional hazards to estimate
the independent association between ABI
including high ABI (≥1.4), a condition shown in
PAD with vascular stiffness, and incident
fracture hospitalization, adjusting for potential
confounders.
Results: There were 668 hip or lower extremity
fracture hospitalizations during a median
follow-up of 22 years. In the crude model, there
was a dose-response relationship between low
ABI and fracture risk (Table). However, only ABI
0.9-1.1 remained statistically significant after
demographic adjustment compared to normal
ABI (1.1-1.4) and inclusion of other covariates
rendered this association non-significant. The
results were largely consistent among most
demographic and clinical subgroups, but we
observed increased risk of fracture in low ABI
(<0.9) among those with history of
cardiovascular disease and high ABI (≥1.4) in
men, in the fully adjusted model.
Conclusion: An independent association of ABI
with increased risk of hip or lower extremity
fracture hospitalization was not that evident
overall in our biracial population of middle-aged
adults. However, ABI may contribute to
increased risk of fracture in subgroups,
warranting further investigation.
S. Ballew: None. Y. Sang: None. A.L.C.
Schneider: None. M. Grams: None. L.R. Loehr:
None. H. Tanaka: None. G. Heiss: None. E.
Selvin: None. J. Coresh: None. K. Matsushita:
None.
P161
Peripheral Arterial Disease in Hispanic
Communities: Results from the Hispanic
Matthew A Allison, Univ of California San
Diego, La Jolla, CA; Franklyn Gonzales, Univ of
North Carolina, Chapel Hill, NC; Leopoldo Raij,
Univ of Miami, Miami, FL; Robert Kaplan,
Robert Ostfeld, Einstein Coll of Med, Bronx, NY;
Maria Pattany, Univ of Miami, Miami, FL;
Gerardo Heiss, Univ of North Carolina, Chapel
Hill, NC; Michael Criqui, Univ of California San
Diego, La Jolla, CA
Background: Compared to non-Hispanic Whites,
Hispanic Americans have a significantly lower
prevalence of peripheral arterial disease (PAD).
Since Hispanic ethnicity in the United States is
heterogeneous, the purpose of this study was
to determine the differential odds for PAD by
Hispanic/Latino subgroup.
Methods: Subjects were 9,648 men and women
over the age of 45 years enrolled in the Hispanic
Community Health Study - Study of Latinos
(HCHS-SOL) who were evaluated by extensive
survey information, relevant physical
measurements and fasting blood assays. The
ankle brachial index (ABI) was computed as the
higher of the posterior tibial and dorsalis pedis
systolic blood pressures (SBP) for each leg
divided by the higher brachial artery SBP. The
index ABI was the lower of the two. An ABI ≤
0.90 was criterion for the presence of PAD.
Results: The mean age was 56 years and 62%
were female. Thirty percent were Mexican
American, while 27% were Cuban American,
19% Puerto Rican American, 9% Dominican
American, 7% Central American, 5% South
American and 3% Mixed or Other Hispanic
ethnicities. Overall, the prevalence of an ABI ≤
0.90 (PAD), 0.90 to 0.99 (borderline), 1.0 to 1.39
(normal) and ≥ 1.40 (high) was 5.7, 19.3, 72.5
and 2.6%, respectively. Cuban Americans had
the highest prevalence of PAD (9.1%), followed
by Puerto Rican (5.9%), Central American
(5.3%), Mixed/Other (5.0%), Dominican (4.7%),
South American (4.6%) and Mexican Americans
(3.2%). The prevalence of an ABI ≥ 1.40 ranged
from 3.1% (South Americans) to 0.6%
(Mixed/Other). After multivariable adjustment,
and compared to Mexican Americans, Cuban
Americans had nearly a 3-fold higher odds for
PAD (OR = 2.85). The odds of PAD for the other
Hispanic/Latino groups ranged from 1.23 to
1.82. Although males had over a 3-fold higher
odds of an ABI ≥ 1.40 (OR = 3.55), the odds did
not differ significantly by Hispanic/Latino
ethnicity.
Conclusions: Compared to Mexican Americans,
all other Hispanic/Latino ethnic groups have a
significantly higher odds of having PAD, with the
odds being nearly 3-fold higher among Cuban
Americans.
M.A. Allison: None. F. Gonzales: None. L. Raij:
None. R. Kaplan: None. R. Ostfeld: None. M.
Pattany: None. G. Heiss: None. M. Criqui:
None.
P162
The Baseline Ankle Brachial Index (ABI), but
Not Change in the ABI, is Associated With 11Year Change in the SF-36: The San Diego
Population Study (SDPS)
Christina L Wassel, Univ of Pittsburgh,
Pittsburgh, PA; Matthew A Allison, Joachim H Ix,
Julie O Denenberg, Dena E Rifkin, Michael H
Criqui, Univ of California, San Diego, La Jolla, CA
Background: Lower extremity peripheral artery
disease (PAD) affects approximately 9 million
people in the US. Less well-recognized is that
PAD, even when asymptomatic, is associated
with decreased functional status and quality of
life. Previous studies have largely examined
associations of the ankle brachial index (ABI)
and quality of life in participants with PAD. To
our knowledge no studies have examined the
impact of ABI and change in ABI on change in
quality of life in a population-based setting.
Methods: The SDPS is a population-based
prospective study that evaluated non-Hispanic
White, African-American, Hispanic and Asian
men and women for lower extremity PAD at
two examinations approximately 11 years apart.
Participants completed the SF-36 questionnaire,
and 802 participants had ABI and SF-36 data
available at both examinations. Analyses were
restricted to these participants who also had a
baseline ABI<1.4. Growth curve models were
used to assess the associations of baseline ABI
and change in the ABI with change in the SF-36
physical component score (PCS) and mental
component score (MCS) over time. Change in
the ABI was defined as (follow-up ABI - baseline
ABI)/baseline ABI.
Results: Participants were on average 57±9
years of age at baseline, and 69±9 at follow-up.
At baseline, nearly 2 percent had ABI≤0.90, and
the mean±SD ABI was 1.12±0.10. After
adjustment for age, sex, race/ethnicity, BMI,
ever smoking, physical activity, hypertension,
diabetes, and dyslipidemia, each SD lower
baseline ABI was significantly associated with an
average change of -0.63 points (95% CI (-0.10, 1.17), p=0.02) on the PCS. This association was
marginally significant for the MCS (-0.54 points
(0.14, 1.22), p=0.12). Lower baseline ABI was
also associated with negative change in two SF36 subscales, physical functioning (p=0.02) and
vitality (p=0.01). Change in the ABI over 11
years was not associated with change in the
MCS (p=0.97) or PCS (p=0.41). Results were
similar when excluding participants with
ABI≤0.90.
Conclusions: A lower ABI at baseline is
associated with a significantly worse physical
functioning quality of life approximately 11
years later. However change in the ABI was not
significantly associated with change in quality of
life over this time period. Additional studies are
warranted in larger samples, especially to
confirm the lack of findings for change in ABI.
C.L. Wassel: None. M.A. Allison: None. J.H. Ix:
None. J.O. Denenberg: None. D.E. Rifkin:
None. M.H. Criqui: None.
P163
Healthful Dietary Patterns and the Risk of
Hypertension Among Women With a History of
Gestational Diabetes
Shanshan Li, Wei Bao, NIH, Rockville, MD;
Deirdre K. Tobias, Brigham and Women’s Hosp
and Harvard Medical Sch, Boston, MA; Yeyi Zhu,
NIH, Rockville, MD; Jorge E. Chavarro, Harvard
Sch of Public Health, Boston, MA; John P
Forman, Brigham and Women’s Hosp and
Harvard Medical Sch, Boston, MA; Frank B. Hu,
Harvard Sch of Public Health, Boston, MA; Cuilin
Zhang, NIH, Rockville, MD
Background: Women who developed
gestational diabetes (GDM) are at an increased
risk for hypertension, compared with parous
women without GDM. The role of diet in the
progression to hypertension among this highly
susceptible population is unknown.
Methods: We conducted a prospective cohort
study among 3,818 women with a history of
GDM in the Nurses’ Health Study II, as a part of
the ongoing Diabetes & Women’s Health Study.
These women were followed from 1991 until
2011. Incident hypertension was identified by
self-report with a previously validated
questionnaire. Adherence scores for the 2010
Alternative Health Eating Index (AHEI-2010), the
Alternate Mediterranean Diet (aMed) and the
Dietary Approaches to Stop Hypertension
(DASH) were computed for each participant;
higher scores indicate better diet quality. Cox
proportional hazard models were used
adjusting for major risk factors for
hypertension, including dietary and lifestyle
factors, medical history, reproductive factors
and medications.
Results: We documented 1,069 incident
hypertension cases during a median of 18.5
years follow-up. After multivariate adjustment,
the AHEI-2010, and DASH scores were
significantly and inversely associated with risk
of hypertension. Hazard ratio (HR) and 95%
confidence interval (CI) comparing the extreme
quartiles (highest vs. lowest) was 0.78 (0.630.96, P for linear trend=0.02) for AHEI-2010,
0.77 (0.62-0.96, P for trend=0.02) for DASH
score and 0.80 (0.65-0.99, P for trend=0.06) for
aMed score.
Conclusion: After GDM, adherence to a
healthful dietary pattern was related to a lower
risk of developing hypertension.
S. Li: None. W. Bao: None. D.K. Tobias:
None. Y. Zhu: None. J.E. Chavarro: None. J.P.
Forman: None. F.B. Hu: None. C. Zhang: None.
P164
Blood Pressure During Pregnancy and Risk of
Hypertension Later in Life: A Longitudinal
Study of POUCHMoms
Galit Levi Dunietz, Kelly L Strutz, Claudia B
Holzman, Yan Tian, David Todem, Bertha L
Bullen, Michigan State Univ, East Lansing, MI;
Janet M Catov, Univ of Pittsburgh, Pittsburgh,
PA
Objectives: Hypertensive disorders in pregnancy
carry a long-term risk of cardiovascular disease
(CVD) for women. However, future
hypertension status among pregnant women
who have moderately elevated blood pressure
(MEBP), that does not meet criteria for
hypertensive disorders is unknown. We,
therefore, investigated the risk of later
hypertension among women with MEBP in
pregnancy in addition to those diagnosed with
gestational hypertensive disorders.
Methods: Data are from the Pregnancy
Outcomes and Community Health (POUCH)
study, which enrolled pregnant women from 52
clinics in 5 Michigan Communities (1998-2004).
We included 667 women with abstracted
gestational BP measurements who also
participated in the POUCHMoms follow-up 7-15
years later. MEBP was defined as systolic BP
(SBP) ≥120mmHg or diastolic BP (DBP)
≥80mmHg among pregnant women who did not
have a hypertensive disorder. Hypertensive
disorders were defined as at least two SBP
measurements ≥140 or DBP measurements ≥90
or regular use of anti-hypertensives, with or
without proteinuria. Weighted multinomial
logistic regression models were run to estimate
the odds of prehypertension or hypertension at
follow-up, before and after controlling for
maternal prenatal confounders (e.g. age, parity,
race) and time between pregnancy and followup.
Results: The majority of participants (59.6%)
met the criteria for MEBP which was
significantly associated with hypertension at
follow-up before and after adjustment for
confounders (AOR=2.76; 95% CI 1.40, 5.46).
Significant associations were seen for MEBP
first identified prior to 20 weeks, and for MEBP
observed due to elevated SBP either alone or in
conjunction with elevated DBP. As expected,
gestational hypertensive disorders also were
associated with increased odds of hypertension
at follow-up (AOR=16.99; 95% CI 6.11, 47.24).
All of the above relationships held when body
mass index (BMI) at follow-up was added into
the models.
Conclusions: Moderately elevated blood
pressure in pregnancy may be a risk factor for
hypertensive disorders later in life and may
identify a group of women who need closer
surveillance for CVD risk in the years following
pregnancy. Elevated SBP appears to play a more
influential role than DBP in the observed
association.
G. Levi Dunietz: None. K.L. Strutz: None. C.B.
Holzman: None. Y. Tian: None. D. Todem:
None. B.L. Bullen: None. J.M. Catov: None.
P165
Effects of Lactation on Postpartum Blood
Pressure among Women with Gestational
Hypertension and Preeclampsia
Malamo Countouris, Univ of Pittsburgh Medical
Ctr, Pittsburgh, PA; Eleanor Bimla Schwarz, Univ
of California Davis, Sacramento, CA; Brianna
Rossiter, Univ of Pittsburgh Medical Ctr,
Pittsburgh, PA; Andrew Althouse, Magee
Womens Res Inst, Pittsburgh, PA; Janet Catov,
Univ of Pittsburgh Medical Ctr, Pittsburgh, PA
Introduction: Lactation is associated with
improved maternal blood pressure (BP) in later
life and in the postpartum period among
normotensive women. However, little is known
about whether lactation is also cardioprotective in women with pregnancy-related
hypertensive disorders. This study aimed to
characterize the relationship between lactation
and postpartum BP in women who remained
normotensive during pregnancy compared to
those who developed preeclampsia or
gestational hypertension.
Hypothesis: Lactation will be associated with
lower postpartum BP, particularly in women
with hypertensive disorders of pregnancy.
Methods: Data were obtained from a cohort of
normotensive women who participated in the
Prenatal Exposures & Preeclampsia Prevention
study (n=651; 65% African American; 83%
overweight or obese prior to pregnancy).
Women were enrolled during pregnancy and
attended a postpartum visit where data on
lactation and BP were collected following a
standardized protocol. Analysis of variance
(ANOVA) was used to assess the relationship
between lactation and postpartum BP in
women who remained normotensive during
pregnancy, developed gestational hypertension
(2 or more BP measurements >140/90), or
developed preeclampsia (gestational
hypertension plus proteinuria). Further analyses
adjusted for age, race, smoking, prepregnancy
weight, and time since delivery.
Results: A total of 439 women attended the
postpartum study visit (mean time since birth
8.5 months); 50 (11%) developed gestational
hypertension, and 38 (9%) preeclampsia.
Lactation was reported by 246 (56%) with 84
(19%) reporting lactation for ≥ 6 months.
Women who lactated were older, wealthier,
and more likely to plan to lactate compared to
those who did not lactate. There was no
association between lactation duration and
postpartum systolic BP for women who
remained normotensive during pregnancy
(never lactated: 111.0 mmHg vs. lactated ≥ 6
months: 112.9 mmHg, p=0.83) nor among
women who developed preeclampsia (never
lactated: 121.3 mmHg vs. lactated ≥ 6 months:
128.3 mmHg, p=0.35). However, greater
lactation duration was associated with lower
systolic BP among women who developed
gestational hypertension (never lactated: 127.8
mmHg vs. lactated ≥ 6 months: 109.4 mmHg,
p=0.04). This relationship remained significant
after adjusting for covariates. Similarly,
lactation was associated with lower postpartum
diastolic BP only for women with a history of
Conclusions: Lactation appears to lower
postpartum BP among women who develop
gestational hypertension, but do not develop
preeclampsia. Future work should investigate
the mechanisms driving the relationship
between lactation and postpartum BP in
M. Countouris: None. E. Schwarz: None. B.
Rossiter: None. A. Althouse: None. J. Catov:
None.
P166
Pregnancy Characteristics and Subclinical
Arterial Disease in the Adult Offspring
Inbal Boger-Megiddo, Univ of Washington,
Seattle, WA; Yechiel Friedlander, The Hebrew
Univ of Jerusalem, Jerusalem, Israel; Barbara
McKnight, Stephen M Schartz, Univ of
Washington, Seattle, WA; Michelle Williams,
Harvard Univ, Boston, MA; David S Siscovick,
The New York Acad of Med, New York, NY
Introduction: There is mounting evidence that
the intrauterine environment affects the risk of
cardiometabolic disease in the adult offspring.
Birth weight, pre-pregnancy BMI, and smoking
during pregnancy are associated with offspring
obesity, blood pressure, and changes in lipid
and glucose metabolism. We studied subclinical
disease mechanisms that may account, at least
in part, for this association by examining the
associations of birth weight, pre-pregnancy
BMI, and smoking during pregnancy with
offspring measurements of subclinical arterial
disease.
birth weight, pre-pregnancy BMI, and smoking
during pregnancy are associated with offspring
subclinical arterial characteristics at age 32.
Methods: Using the EndoPAT 2000 device we
measured the Augmentation Index (AI), a
measurement of arterial stiffness, and the
Reactive Hyperemia Index (RHI), a
measurement of endothelial function, in 400
subjects from the Jerusalem Perinatal Study
Family Follow-up Study (JPS1). The JPS1
includes data on maternal and pregnancy
characteristics collected from an interview
taken shortly after birth; weight, height, and BP
measurements collected at age 17; and a
detailed interview, and physical exam
conducted at age 32. We repeated our models
adjusting for offspring BMI at age 17 and age 32
and for other maternal and offspring lifestyle,
socioeconomic, and demographic
characteristics.
Results: We found an inverse linear association
between birth weight and AI (β=-0.439, 95% CI
(-0.830)-(-0.048) for a 100g increase in birth
weight) limited to females, that remained after
adjustment for offspring obesity but was
attenuated after adjustment for maternal and
offspring characteristics. We did not find an
association between birth weight and RHI. We
found a non-linear association between prepregnancy BMI and RHI that remained after
adjustment for maternal and offspring
characteristics, including offspring obesity. The
association had an inverse ‘U’ shape. For
example, compared to a pre-pregnancy BMI of
19 kg/m2, a pre-pregnancy BMI of 24 kg/m2
was associated with a 0.14 higher mean
offspring RHI (95% CI 0.004-0.28), while
compared to a pre-pregnancy BMI of 29 kg/m2,
a pre-pregnancy BMI of 34 kg/m2 was
associated with a 0.18 lower mean offspring RHI
(95% CI -0.40-0.002). We did not find an
association between pre-pregnancy BMI and
offspring AI. There was no evidence of an
association between smoking during pregnancy
and offspring arterial characteristics.
Conclusion: Our findings contribute to the
evidence that maternal pre-pregnancy BMI and
offspring birth weight may affect offspring
clinical cardiovascular health later in life, and
suggest that the effect may be partly due to
changes in offspring subclinical arterial
characteristics.
I. Boger-Megiddo: None. Y. Friedlander:
None. B. McKnight: None. S.M. Schartz:
None. M. Williams: None. D.S. Siscovick: None.
P167
Adult Stature Components and Systolic Blood
Pressure in a Middle Income Country. Evidence
from ELSA-Brasil.
Santiago Rodríguez López, Univ Autonoma
Madri, Madri, Spain; Isabela M Bensenor, Univ
of Sao Paulo, Sao Paulo, Brazil; M. Carmen
Molina, Federal Univesity Espirito Santo, Vitoria,
Brazil; Paulo A Lotufo, Univ of Sao Paulo, Sao
Paulo, Brazil
Introduction: Better childhood conditions mainly inferred from height and leg length- are
usually associated to lower levels of blood
pressure during adulthood in high-income
countries. However, evidence is mixed about
the nature of these associations in low- and
middle-income countries. Components of adult
height as the total height, trunk and leg lengths,
and leg-to-trunk ratio are important surrogate
variables of early life conditions of growth and
development of one individual.
early life conditions affect blood pressure
during adulthood differently according to
gender in the middle-income country like Brazil.
Methods: From 15105 participants aged 35-74
years enrolled in the Brazilian Longitudinal
Study of Adult Health (ELSA-Brasil), we analyzed
13571 with information about components of
height and systolic and diastolic blood
pressures. Trained nurses performed all
measures following a common protocol at each
clinical research site with good reliability.
Potential confounders were age, race, maternal
education, participant education, waist
circumference, weight change since age 20,
smoking habit, alcohol consumption, physical
activity, and use of anti-hypertensive
medication. Multiple linear regression was
applied for inference of associations among
these variables. The results are from the full
model of adjustment.
Results: Younger individuals were taller and had
longer trunks and legs. White individuals have
longer trunks and shorter legs compared to
black participants. People whose mothers with
lower education have shorter trunks and legs
compared to those with a higher educational
maternal background. For each 1-standarddeviation (1-SD) of total height, there was a
decrease of systolic blood pressure (mm Hg) of 0.803 (-1.226 to -0.380) for men, and -0.983 (1.335 to -0.631) for women. For leg length (1SD) there was an inverse correlation of systolic
diastolic blood (mm Hg) among men by -0.444 (0.880 to -0.009) and -0.915 (-1.284 to -0.546)
among women. Trunk length (1-SD) was
inversely associated to systolic blood pressure
(mm Hg) among men by -0.444 (-0.880 to 0.009) but not among women by -0.191 (-0.597
to 0.214). Leg-to-trunk ratio was inversely
associated to systolic blood pressure among
women, -0.669 (-1.014 to -0.324) but not
among men, -0.182 (-0.583; 0.218). A "posthoc" analysis revealed that the inverse
association of height-systolic blood pressure
was more pronounced for participants who are
White, with a college degree and who had a
mother with high educational background.
Conclusion: The protective effect of the
components of height on adult blood pressure
reported in high-income countries is also
present in a middle-income country like Brazil
with few variations according to gender.
S. Rodríguez López: None. I.M. Bensenor:
None. M. Molina: None. P.A. Lotufo: None.
P168
The Relationship of Urinary Sodium and
Potassium Excretion with Left Ventricular
Structure and Function in Patients with Chronic
Kidney Disease: Prospective Analyses from the
Chronic Renal Insufficiency Cohort Study
Katherine T Mills, Jing Chen, Tulane Univ, New
Orleans, LA; Wei Yang, Univ of Pennsylvania,
Philadelphia, PA; Lawrence J Appel, Johns
Hopkins Univ, Baltimore, MD; John Kusek, Natl
Inst of Diabetes and Digestive and Kidney
Diseases, NIH, Bethesda, MD; Arnold B Alper,
Patrice Delafontaine, Tulane Univ, New Orleans,
LA; Martin G. Keane, Temple Univ, Philadelphia,
PA; Emile R Mohler 3rd, Univ of Pennsylvania,
Philadelphia, PA; Akinlolu O Ojo, Univ of
Michigan, Ann Arbor, MI; Mahboob Rahman,
Case Western Reserve Univ, Cleveland, OH; Ana
C Ricardo, Univ of Illinois at Chicago, Chicago, IL;
Elsayed Z Soliman, Wake Forest Univ, WinstonSalem, NC; Susan P Steigerwalt, St. John Hosp
and Medical Ctr, Detroit, MI; Raymond R.
Townsend, Univ of Pennsylvania, Philadelphia,
PA; Jiang He, Tulane Univ, New Orleans, LA
Introduction: Patients with chronic kidney
disease (CKD) are at an increased risk of CVD
compared to the general population. Left
ventricular hypertrophy (LVH) is an
independent risk factor for CVD in the general
population and in CKD patients. In the general
population, sodium (Na) excretion is directly
associated with LVH. However, this association
has not been examined in patients with CKD.
Hypothesis: We hypothesized that in CKD
patients, urinary Na excretion would be directly
and urinary potassium (K) would be indirectly
associated with development of ejection
fraction (EF) < 50% and LVH and longitudinal
changes in EF and left ventricular mass index
(LVMI).
Methods: The Chronic Renal Insufficiency
Cohort Study (CRIC) is a prospective cohort
study of 3,939 participants with CKD. Dietary Na
and K excretion were assessed by averaging
three 24-hour urinary measures (over 2 years)
and calibrated to sex-specific mean 24-hour
urinary creatinine excretion. Echocardiograms
(ECHO) were conducted at follow-up years 1, 4,
and 7 and centrally analyzed to quantify EF and
LVMI. LVH is defined as LVMI ≥ 47 g/m2.7 in
women and LVMI ≥ 50 g/m2.7 in men. Log-linear
binomial and linear mixed effects models were
used.
Results: During follow-up, 676 participants
developed EF <50% and 238 developed LVH
among those with EF ≥ 50% or free of LVH at
the first ECHO, respectively. After multivariate
adjustment, participants in the highest quartile
of adjusted sodium excretion (>196.2 mmol/24
hours) had a relative risk of 1.31 (95% CI 1.08,
1.59) of developing an EF < 50% during followup compared to those in the lowest quartile
(<127.8 mmol/24 hours). Furthermore,
participants in the highest quartile of adjusted
urinary sodium excretion had a greater annual
decrease in ejection fraction (-1.36%, 95 CI: 1.53, -1.19%) compared to those in the lowest
quartile (-0.95%, 95% CI: -1.11, -0.79%; p for
trend across quartiles 0.0003). No significant
association was observed between K excretion
and development of EF < 50% or change in EF.
In addition, no association was observed
between adjusted Na or K excretion and
development of LVH or change in LVMI during
follow-up.
Conclusions: Higher Na excretion is associated
with a greater likelihood of developing an EF
<50% and a greater annual decrease in EF.
Further studies are needed to determine if
interventions to reduce high dietary sodium
could slow the decline in left ventricular
structure and function in patients with CKD.
K.T. Mills: None. J. Chen: None. W. Yang:
None. L.J. Appel: None. J. Kusek: None. A.B.
Alper: None. P. Delafontaine: None. M.G.
Keane: None. E.R. Mohler: None. A.O. Ojo:
None. M. Rahman: None. A.C. Ricardo:
None. E.Z. Soliman: None. S.P. Steigerwalt:
None. R.R. Townsend: None. J. He: None.
P169
Association of Kidney Function and Risk of
Hospitalized Bone Fracture
Natalie R Daya, Annie Voskertchian, Andrea L
Schneider, Shoshana Ballew, Mara McAdams
DeMarco, Josef Coresh, Lawrence Appel,
Elizabeth Selvin, Morgan E Grams, Johns
Introduction: Persons with end-stage renal
disease are at high risk of fracture. Less is
known about fracture risk in milder chronic
kidney disease (CKD), particularly in persons
with albuminuria but preserved estimated
glomerular filtration rate (eGFR), and whether
CKD-associated fracture risk varies by sex.
Methods: Participants from the ARIC study
were followed from 1996-2011. Kidney
function was assessed at baseline by eGFR and
urine albumin-to-creatinine ratio (ACR).
Fracture-related diagnostic codes were
identified through active surveillance of
hospitalizations. Cox proportional hazards
models were adjusted for demographic factors
and other established risk factors for
osteoporosis and fracture.
Results: Among 11,000 eligible participants
(mean age 63.3 years, 55.9% female, 21.9%
black), there were 722 fracture-related
hospitalizations during a median follow-up of
13 years. Below eGFR 60 ml/min/1.73 m2,
lower eGFR was associated with higher
fracture risk (adjusted hazard ratio (aHR) per
10 ml/min/1.73 m2 lower eGFR: 1.49; 95% CI,
1.27, 1.75), independent of ACR (Figure).
Above eGFR 60 ml/min/1.73 m2, there was no
association between eGFR and fracture risk.
There was a strong relationship between ACR
and fracture, independent of eGFR (aHR per
log-increase, 1.14; 95% CI, 1.08-1.20). More
severe stages of both GFR and albuminuria
conferred higher fracture risk. Even among
those with eGFR ≥60 ml/min/1.73 m2, persons
with ACR >300 mg/g or ACR 30-300 mg/g had
higher fracture risk than those with ACR
<30mg/g (adjusted incidence rate (aIR): 9.21;
95% CI, 5.00-17.12, aIR: 7.43; 95% CI, 5.59 9.89, aIR: 5.17; 95% CI, 4.76-5.60, respectively).
There was no difference in associations by sex
(eGFR: p for interaction= 0.9; albuminuria: p
for interaction= 0.6).
Conclusions: Low eGFR and albuminuria were
independent risk factors for fracture-related
hospitalization in both men and women in this
community-based population. Persons with
kidney disease might benefit from fracture
prevention strategies.
N.R. Daya: None. A. Voskertchian: None. A.L.C.
Schneider: None. S. Ballew: None. M.
McAdams DeMarco: None. J. Coresh: None. L.
Appel: None. E. Selvin: None. M.E. Grams:
None.
P170
The Association of Serum Potassium with
Mortality in Older Community-Dwelling
Individuals: The Cardiovascular Health Study
(CHS)
Jan M Hughes-Austin, Dena E Rifkin, Univ of
California, San Diego, La Jolla, CA; Ronit Katz,
Univ of Washington, Seattle, WA; Mark J
Sarnak, Tufts Univ, Boston, MA; Rajat Deo, Univ
of Pennsylvania, Philadelphia, PA; David S
Siscovick, New York Acad of Med, New York, NY;
Nona Sotoodehnia, Bruce M Psaty, Ian H De
Boer, Bryan R Kestenbaum, Univ of Washington,
Seattle, WA; Michael G Shlipak, Univ of
Joachim H Ix, Univ of California, San Diego, La
Jolla, CA
Background: High serum potassium (K) is
associated with death in chronic kidney disease
(CKD) patients, and in acute illness. Associations
in other settings are uncertain. We determined
associations between K concentrations and
total mortality, coronary heart disease (CHD)
death, and sudden cardiac death (SCD) in an
older, community-dwelling population.
Methods: Among 5137 CHS participants aged ≥
65 years at baseline, we evaluated associations
between serum K categories [< 4.0, 4.0-4.5, 4.55.0, & ≥ 5.0 mMol/dL] with CHD death, SCD, and
all-cause mortality using Cox proportional
hazards models. We also evaluated whether
associations differed by angiotensin converting
enzyme (ACE) inhibitor / angiotensin II receptor
blocker (ARB) use, diuretic use, and CKD status
[eGFR < 60 vs. higher]. All CHD and SCD events
were adjudicated by committee.
Results: Mean age was 72 years, 39% were
male, and 17% were Black. Individuals in the ≥
5.0 mMol/dL category were older, more
frequently men, diabetic, to have CKD, and to
use ACE/ARBs. They were also less likely to use
diuretics. Mean follow-up was 14 ± 6 years
during which there were 4122 total deaths
including 971 CHD deaths. Follow-up for SCD
was 12 ± 5 years during which there were 162
SCD events. In models adjusted for
demographics, CVD risk factors, eGFR, and use
of ACE/ARBs, diuretics and K supplements,
those with K ≥ 5.0 mMol/dL had 32% higher risk
of all-cause mortality (HR 1.32; 95% CI: 1.071.63) than the 4.0-4.5mMol/dL reference
category. The association was similar
irrespective of diuretic or ACE/ARB use or by
CKD status (pinteraction all > 0.18). Those with K <
4.0 mMol/dL had 14% higher risk of all-cause
mortality (HR 1.14; 95% CI: 1.05-1.23) than the
reference category; and this association was
limited to those with K < 4.0 mMol/dL and were
not on diuretics and did not have CKD (pinteraction
both < 0.02). No association of K < 4.0 mMol/dL
with mortality was observed in those on
diuretics or with CKD. There was no significant
association of either high or low K with either
CHD death (HR 1.08; 95% CI: 0.71-1.65; and HR
0.96; 95% CI: 0.81-1.13, respectively) or SCD
(HR 1.13; 95% CI: 0.41-3.11; and HR 1.01; 95%
CI: 0.68-1.50, respectively) in adjusted models.
Conclusions: Higher and lower serum K are
independently associated with all-cause
mortality but not CHD death or SCD in older
community-dwelling individuals. Mechanisms
linking high and low K with mortality from
diseases other than CHD and SCD require future
study.
J.M. Hughes-Austin: B. Research Grant;
Significant; ZS Pharma Support for Jan HughesAustin. D.E. Rifkin: None. R. Katz: None. M.J.
Sarnak: None. R. Deo: None. D.S. Siscovick:
None. N. Sotoodehnia: None. B.M. Psaty:
None. I.H. De Boer: None. B.R. Kestenbaum:
None. M.G. Shlipak: None. J.H. Ix: None.
P171
Hemoglobin A1c and Incident Albuminuria
Among Individuals Without Diabetes: The
Coronary Artery Risk Development in Young
Adults (CARDIA) Study
April P Carson, Paul Muntner, Univ of Alabama
at Birmingham, Birmingham, AL; Mercedes R
Carnethon, Northwestern Univ, Chicago, IL;
Myron D Gross, Univ of Minnesota,
Minneapolis, MN; Cora E Lewis, Univ of
Alabama at Birmingham, Birmingham, AL
Background: Higher hemoglobin A1c (HbA1c)
has been associated with an increased risk of
reduced estimated glomerular filtration rate
<60 mls/min/1.73m2 among individuals without
diabetes. However, it is unclear whether higher
HbA1c in the non-diabetic glycemic range also is
albuminuria. This study investigated the
association of HbA1c with incident albuminuria
in a biracial cohort of middle-aged men and
women without a history of diabetes in the
Coronary Artery Risk Development in Young
Adults (CARDIA) Study. Methods: The CARDIA
Study is a prospective cohort study of 5,115
African-American and white adults, age 18-30
years at baseline (1985-86), from four field
centers in the United States: Birmingham, AL;
Chicago, IL; Minneapolis, MN; and Oakland, CA.
Participants with prevalent diabetes (defined as
fasting glucose ≥126 mg/dL, 2-hour postchallenge glucose ≥ 200 mg/dL, HbA1c ≥ 6.5%,
or used diabetes medications) or albuminuria
(defined as a race- and sex-adjusted urine
albumin-to-creatinine ratio ≥ 25 mg/g) at the
year 20 examination (2005-06; baseline for this
analysis) were excluded. This study included
2174 participants who had HbA1c measured at
the year 20 examination and had urine albumin
and creatinine measured at the year 25
examination (2010-11). Poisson regression with
robust error variances was used to obtain risk
ratios (RR) and 95% confidence intervals (CI) for
the association of HbA1c, both as a continuous
variable and dichotomous variable using its
prediabetes cut-point, with albuminuria in
unadjusted models and models adjusted for
socio-demographics and cardiovascular risk
factors. Results: During the follow-up period,
103 (4.7%) participants developed incident
albuminuria. In unadjusted analyses, each 1%
increase in HbA1c was associated with incident
albuminuria (RR=2.55, 95% CI=1.48, 4.39). This
association was attenuated and not statistically
significant after adjustment for age, race, sex,
and education (RR=1.68, 95% CI=0.98, 2.88) and
further adjustment for cardiovascular risk
factors (RR=1.42, 95% CI=0.81, 2.50).
Additionally, individuals with HbA1c in the
prediabetes range (5.7%-6.4%) had an increased
risk of albuminuria (RR=1.59, 95% CI=1.04, 2.43)
compared with those with HbA1c in the normal
glycemic range (<5.7%) in the unadjusted
model. However, this association was
attenuated after adjustment for sociodemographics (RR=1.11, 95% CI=0.71, 1.72) and
cardiovascular risk factors (RR=0.98, 95%
CI=0.61, 1.55). Conclusions: After taking into
account socio-demographics and traditional
cardiovascular risk factors, HbA1c was not
associated with incident albuminuria among
individuals without diabetes.
A.P. Carson: C. Other Research Support;
Modest; Amgen, Inc. P. Muntner: C. Other
Research Support; Significant; Amgen, Inc.. M.R.
Carnethon: None. M.D. Gross: None. C.E.
Lewis: None.
P172
Prevalence of Reduced Estimated Glomerular
Filtration and Albuminuria In Clinically
Relevant Subgroups in a Representative Elderly
Population in Iceland
Meredith C Foster, Aghogho Okparavero,
Hocine Tighiouart, Tufts Medical Ctr, Boston,
MA; Vilmundur Gudnason, Icelandic Heart
Association, Kopavogur, Iceland; Olafur
Indridason, Hrefna Gudmundsdottir, Landspitali
Univ Hosp, Reykjavík, Iceland; Gudny
Eiriksdottir, Icelandic Heart Association,
Kopavogur, Iceland; Lesley A Inker, Andrew S
Levey, Tufts Medical Ctr, Boston, MA
Background: Chronic kidney disease is common
in the elderly, but limited data are available
describing the prevalence of the major
components of chronic kidney disease - reduced
glomerular filtration rate (eGFR) and kidney
damage - in clinically important subgroups in
this population.
Methods: Our study sample included 3173
adults (42% male, median [interquartile range]
age 80 [76-83] years) from the second visit of
the Age, Gene/Environment Susceptibility
Reykjavik study (AGES-RS II, 2007-11). eGFR was
estimated using the CKD-EPI 2012 creatininecystatin C equation and we defined reduced
eGFR as an eGFR<60mL/min/1.73m2. Urine
albumin and creatinine were used to calculate
the albumin-to-creatinine ratio (ACR, mg/g).
Kidney damage was evaluated as the presence
of albuminuria, defined as an ACR>30mg/g. We
estimated the prevalence of reduced eGFR and
albuminuria in subgroups defined by age, sex,
diabetes status, current smoking status, and
body mass index. We compared prevalence
estimates within subgroups using Chi-square
tests and tests for trend across multi-category
groups.
Results: Reduced eGFR was consistently more
common than albuminuria across subgroups
(Figure). The prevalence of reduced eGFR
increased across age and BMI categories (both
p-trend<0.001) and was higher in women
(p=0.02) and in those with diabetes (p<0.001),
but did not differ by smoking status (p=0.46).
The prevalence of albuminuria was higher with
age (p-trend<0.001), in participants with
diabetes (p<0.001), in men (p<0.001), and in
current smokers (p=0.004). In BMI groups, the
prevalence of albuminuria was highest in those
with a BMI<20 and was similar across the
remaining BMI categories (p-trend=0.03).
Conclusion: The prevalence of reduced eGFR
and albuminuria is high in the elderly, increases
with advancing age, and is dependent on other
demographic and clinical characteristics.
M.C. Foster: None. A. Okparavero: None. H.
Tighiouart: None. V. Gudnason: None. O.
Indridason: None. H. Gudmundsdottir:
None. G. Eiriksdottir: None. L.A. Inker: H.
Other; Modest; Dr Inker had a patent pending
for novel metabolites to estimate GFR. A.S.
Levey: H. Other; Modest; Dr Levey had a patent
pending for novel metabolites to estimate GFR..
P173
Racial Differences in the Association Between
Parity and Incident Stroke: The REasons for
(REGARDS) Study
Catherine J Vladutiu, Michelle Snyder, Univ of
Angela Malek, Medical Univ of South Carolina,
Charleston, SC; Alison M. Stuebe, Univ of North
Carolina at Chapel Hill, Chapel Hill, NC; Aleena
Mosher, Univ of Alabama at Birmingham,
Birmingham, AL; Dawn Kleindorfer, Univ of
Cincinnati, Cincinnati, OH; Virginia J. Howard,
Univ of Alabama at Birmingham, Birmingham,
AL
Background: Circulatory and vascular changes
occurring during pregnancy may increase the
risk of adverse cerebrovascular health
outcomes in later life. Previous studies have
examined the association between parity and
stroke, but the results have been inconsistent.
No studies have examined racial differences in
this association.
higher parity is associated with an increased risk
of stroke and that this association varies by race
in a large and diverse cohort of U.S. women.
Methods: The association between parity and
incident stroke was assessed among 8339 white
and 7037 black women, aged 45 years and
older, without a history of stroke who enrolled
in the REasons for Geographic and Racial
Differences in Stroke (REGARDS) Study between
2003 and 2007. Parity was assessed at baseline
and stroke cases were ascertained through
biannual follow-up interviews and adjudicated
with medical records through September 2013.
Cox proportional hazards models were used to
estimate hazard ratios (HR) for the association
between parity and stroke, adjusting for
baseline measures, including
sociodemographics (age, race, education,
marital status, income, region), behavioral
characteristics (smoking, alcohol), reproductive
history (menopause, oral contraceptive use,
hormone replacement therapy), and stroke risk
factors (history of hypertension, diabetes, and
heart disease).
Results: At baseline, 12.8% of white women and
16.2% of black women reported one prior live
birth, while 8.1% and 19.0%, respectively,
reported five or more prior live births. The
mean follow-up time for all women was 6.9
years (SD=2.5) and there were 457 incident
stroke cases (388 ischemic, 34 hemorrhagic,
and 35 unknown stroke types). A significant
interaction between race and parity was
detected (p=0.05). Among white women, those
with five or more live births had a higher risk of
stroke than those with only one prior live birth
(HR=1.3, 95% CI 0.8, 2.3), but the association
was attenuated after adjustment for stroke risk
factors and sociodemographic, behavioral, and
reproductive characteristics (HR=0.9, 95% CI
0.5, 1.6). For black women, those with five or
more live births had the highest risk of stroke as
compared to those with only one prior live birth
(HR=1.8, 95% CI 1.2, 2.8), but the association
was attenuated and no longer statistically
significant after adjustment for confounders
(HR=1.5, 95% CI 0.9, 2.4).
Conclusion: There were no statistically
significant associations observed between
higher parity and the risk of stroke in a diverse
cohort of U.S. women. Further analyses are
needed to elucidate the role of biological,
lifestyle, and psychosocial factors in the racespecific associations that were observed.
C.J. Vladutiu: None. M. Snyder: None. A.
Malek: None. A.M. Stuebe: None. A. Mosher:
None. D. Kleindorfer: None. V.J. Howard: None.
P174
Effects of Immediate Blood Pressure Reduction
on Death and Major Disability in Acute
Ischemic Stroke Patients According to Time
from Onset to Treatment
Tan Xu, Yonghong Zhang, Soochow Univ,
Suzhou, China; Yingxian Sun, China Medical
Univ, Liaoning, China; Chung-Shiuan Chen, Jing
Chen, Jiang He, Tulane Univ, New Orleans, LA;
for the CATIS investigators
Introduction: Although elevated blood pressure
(BP) is very common in patients with acute
ischemic stroke, the management of
hypertension among them remains
controversial.
Hypothesis: We tested the effects of immediate
BP reduction on death and major disability at 14
days or hospital discharge and 3-month followup in patients with acute ischemic stroke
according to time from stroke onset to initiation
of antihypertensive treatment (<12, 12-23, and
≥24 hours).
Methods: The China Antihypertensive Trial in
Acute Ischemic Stroke (CATIS) randomly
assigned patients with ischemic stroke within 48
hours of onset and elevated systolic BP (SBP) to
receive antihypertensive treatment (N=2,038)
or to discontinue all antihypertensive
medications (N=2,033) during hospitalization.
Study outcomes were assessed at 14 days or
hospital discharge and 3-month post-treatment
follow-up. The primary outcome was death and
major disability (modified Rankin Scale
score≥3), and secondary outcomes included
recurrent stroke and vascular events.
Results: Mean SBP was reduced 12.7% in the
antihypertensive treatment group and 7.2% in
the control group within 24 hours after
randomization (P<0.001). Mean SBP was 137.3
mmHg in the antihypertensive treatment group
and 146.5 in the control group at day 7 after
randomization (P<0.001). At 14 days or hospital
discharge, the primary and secondary outcomes
were not significantly different between
treatment and control groups according to time
from onset to treatment. At the 3-month
follow-up, death or major disability (odds ratio
0.73, 95% CI 0.55-0.97, p=0.03), recurrent
stroke (odds ratio 0.24, 95% CI 0.08-0.72,
p=0.01), and vascular events (odds ratio 0.41,
95% CI 0.18-0.96, p=0.04) were significantly
reduced in the antihypertensive treatment
group among participants with time from stroke
onset to treatment initiation ≥24 hours only.
Conclusion: Among patients with acute ischemic
stroke, BP reduction with antihypertensive
medications might reduce 3-month death and
major disability, recurrent stroke, and vascular
events among those who initiated
antihypertensive treatment after 24 hours from
stroke onset.
T. Xu: None. Y. Zhang: None. Y. Sun: None. C.
Chen: None. J. Chen: None. J. He: None.
P175
Maintaining Ideal Cardiovascular Health and
Freedom From Coronary Artery Calcification
Shih-Jen Hwang, Framingham Heart Study,
Framingham, MA; Oyere Onuma,
Joseph M Massaro, Boston Univ, Boston, MA;
Xiaoling Zhang, Yi-Ping Fu, Emily Manders,
Caroline S Fox, Framingham Heart Study,
Framingham, MA; Udo Hoffmann,
Christopher J O'Donnell, Framingham Heart
Study, Framingham, MA
Introduction: Ideal cardiovascular health (CVH),
as defined by American Heart Association
(AHA), is associated with low levels of
cardiovascular disease (CVD) risk factors and
freedom from coronary artery calcium (CAC).
Hypothesis: Baseline ideal CVH predicts
freedom from CAC progression. Methods: In the
Framingham Heart Study (FHS), we evaluated
prevalence of ideal CVH and investigated
associations between ideal CVH and CAC
progression. We included 1969 participants
who attended the first and second rounds of
the FHS Multi-Detector Computed Tomography
study (MDCT-I and MDCT-II). The presence and
burden of calcification was defined by a
modified Agatston score. We calculated the
repeatability of two CAC readings performed
during MDCT-I and quantified the uncertainty
estimate to define CAC progression. At followup, an increase in CAC score of 3.4 or higher
was defined as positive CAC progression for
those free of CAC at baseline. Using criteria
modified from the AHA’s Strategic Impact Goal,
we defined the prevalence of poor,
intermediate and ideal CVH using five of the
seven metrics: blood pressure, totalcholesterol, cigarette smoking, body mass
index, and fasting glucose. For each metric of
CVH, we assigned a score of 0, 1, and 2 points
for poor, intermediate, and ideal CVH,
respectively, to quantify CVH and extent of
change in ideal CVH. Baseline age, baseline CVH
status, and change in CVH category were
independent variables for logistic regression
models to test significant associations between
CAC progression and change in ideal CVH.
Results: The prevalence of ideal, intermediate,
and poor CVH for 1148 participants who were
free of baseline CAC were 15.77%, 43.73%,
40.51%, respectively. After an average 6.1 years
of follow-up, the prevalence of ideal,
intermediate, and poor CVH changed to 6.5%,
43.4%, and 50.1%, respectively, while the CAC
progression rates were 8.0%, 13.1%, and 21.6%,
respectively. In logistic regression models, there
was a non-significant trend for CAC progression
by CVH group. Compared to those with poor
CVH at baseline, the presence of ideal CVH at
baseline was significantly protective against the
occurrence of CAC progression; the hazard ratio
(HR) for occurrence of CAC progression was
0.36 (95%C.I. 0.19, 0.66, p<0.001). Compared to
those with intermediate CVH, there was
potential protection against CAC progression,
although the HR 0.66 was not statistically
significant (95%C.I. 0.36, 1.21, p=0.62).
Conclusions: In a community-based study, we
observed significant protection from
progression of CAC at follow-up for participants
who were free of CAC with ideal CVH at
baseline. These findings support continued
public health measures to promote ideal CVH.
S. Hwang: None. O. Onuma: None. J.M.
Massaro: None. X. Zhang: None. Y. Fu: None. E.
Manders: None. C.S. Fox: None. U. Hoffmann:
None. C.J. O'Donnell: None.
P176
The Prevalence and Correlates of Advanced
Atherosclerosis Among Those With Optimal
Low-Density Lipoprotein Cholesterol Levels:
The Multi-Ethnic Study of Atherosclerosis
(MESA)
Mahmoud S Al Rifai, Johns Hopkins, Baltimore,
MD; Ron Blankstein, Brigham and Women’s
Hosp, Boston, MA; Seth S. Martin, John W.
McEvoy, Michael J. Blaha, Roger Blumenthal,
Pamela Ouyang, Johns Hopkins, Baltimore, MD;
Khurram Nasir, Baptist Health South Florida,
Miami, FL; Joseph Yeboah, Wake Forest Baptist
Health, Winston-Salem, NC; Steven J. Shea,
Columbia Univ, New York, NY; Joseph F. Polak,
Tufts Medical Ctr, Boston, MA; Michael
Miedema, Minneapolis Heart Inst Fndn,
Minneapolis, MN
Introduction: The prevalence of atherosclerosis
and relative importance of traditional non-lipid
risk factors when low-density lipoprotein
cholesterol (LDL-C) is optimal remains unclear.
Indeed, some have argued that these risk
factors only induce atherogenesis when LDL-C is
elevated, but this has not been conclusively
demonstrated. Therefore, we examined the
association between non-lipid risk factors and
advanced subclinical atherosclerosis in
individuals with optimal untreated LDL-C (<70
mg/dL) within the Multi-Ethnic Study of
Atherosclerosis (MESA).
Hypothesis: We hypothesized that at optimal
LDL-C, 1) advanced atherosclerosis is common,
2) is associated with traditional non-lipid risk
factors, and 3) that this association is not
modified by LDL-C.
Methods: Of 5,565 MESA participants not on
lipid lowering therapy, 245 had optimal LDL-C of
100, 4th quartile of common carotid intima
media thickness (CIMT) adjusted for age and
gender, or increased burden of carotid plaque
by ultrasound. Within the entire untreated
MESA cohort, multiplicative interaction terms
were created between each risk factor and 1
unit standard deviation increase in LDL-C.
Results: The mean age was 62 years (±11), 45%
were male, 33% were white, 8% Chinese, 39%
black and 20% Hispanic. The age- and genderadjusted prevalence of CAC >100, 4th quartile
of CIMT, and increased burden of carotid
plaque was 16%, 20%, and 21%, respectively for
LDL-C 160 mg/dL. At optimal LDL-C, the
strongest correlates of advanced
atherosclerosis were advanced age, male sex,
current or former smoking [OR= 1.08 (1.011.15), 4.83 (1.43-16.38), 4.13 (1.37-12.43), and
5.12 (1.26-20.89) respectively]. Weaker
correlation was observed for systolic and
diastolic blood pressure. Family history of CHD
was not associated with any atherosclerotic
outcome and in sensitivity analysis neither was
low HDL-C (<40 mg/dL in men or <50 mg/dL in
women). There was no interaction between risk
factors and increasing LDL-C for the association
with any measure of atherosclerosis.
Conclusion: In conclusion, in the presence of
optimal LDL-C advanced atherosclerosis is not
uncommon and is associated with familiar
traditional risk factors. There is no interaction
between traditional risk factors and LDL-C,
suggesting that traditional risk factors have the
same atherogenic potential in patients with
optimal LDL-C. Patients with LDL-C <70 mg/dL
can develop atherosclerosis if other risk factors
such as smoking are present.
M.S. Al Rifai: None. R. Blankstein: None. S.S.
Martin: None. J.W. McEvoy: None. M.J. Blaha:
None. R. Blumenthal: None. P. Ouyang: H.
Other; Significant; Society of Women's Health
Research NIH Astra-Zeneca Cordex System
Inc. K. Nasir: None. J. Yeboah: None. S.J. Shea:
B. Research Grant; Significant; NIH research
funding. J.F. Polak: None. M. Miedema: None.
P177
Associations Between Complement Proteins
and Arterial Calcification in Midlife Women:
Role of Cardiovascular Fat, The Study of
Women’s Health Across the Nation (SWAN)
Nayana Nagaraj, Karen A. Matthews, Univ of
Pittsburgh, Pittsburgh, PA; Kelly J Shields,
Allegheny general hospital, Pittsburgh, PA;
Emma Barinas-Mitchel, Univ of Pittsburgh,
Pittsburgh, PA; Matthew Budoff, Los Angeles
biomedical research institute, Los Angeles, PA;
Samar R. El Khoudary, Univ of Pittsburgh,
Pittsburgh, PA
Background:
Risk of cardiovascular disease(CVD) in women
increases after the fifth decade of life. We have
previously shown that compared to
premenopausal women, postmenopausal
women have significantly higher levels of
complement protein C3 and cardiovascular fat.
We hypothesize that complement protein levels
in women transitioning through menopause are
positively associated with early markers of
vascular disease, arterial calcification, and that
this association will be explained by the higher
volumes of cardiovascular fat in women at
midlife.
Methods:
Pilot data from the Study of Women’s Health
Across the Nation(SWAN) were used.
Complement proteins C3 and C4 were
measured using frozen serum specimens by
immunoturbidimetric assay. Extent of
Aortic(AC) and coronary calcification(CAC) were
identified using EBCT scans and Agatston
scoring method, and were used as continuous
variables. Same CT scans were used to quantify
volumes of cardiovascular fat around the heart
(total heart adipose tissue: TAT) and the
descending aorta(peri-vascular adipose tissue:
PVAT). Tobit regression was used for statistical
analyses.
Results:
A total of 100 women (50% late
peri/postmenopausal; 73% Caucasian), mean
age 50.48±2.63 were included. In univariate
analyses, higher levels of C3 were significantly
associated with greater CAC [β(SE)=0.87(0.23),
P=0.0001] and AC [β(SE)=3.49(1.45), P=0.02],
while higher levels of C4 were significantly
associated with greater CAC only. Similar results
were seen after adjusting for age, race and
menopausal status. For CAC models, controlling
for TAT did not change the significant
associations with both C3 (P=0.008) and C4
(P=0.03). On the other hand, adjusting for PVAT
partially explained the association between C3
and CAC (P=0.02), while the association
between C4 and CAC disappeared (p=0.09). For
AC models, associations of C3 and C4 with AC
were more pronounced at greater volumes of
TAT (Interactions p<0.001) but not of PVAT.
Adjusting for PVAT eliminated the association
between AC and C3 (p=0.2)
Conclusion:
Higher levels of complement proteins were
significantly associated with greater CAC and AC
in women at midlife. The associations with CAC
were independent of TAT but not of PVAT,
while the associations with AC largely explained
by PVAT and modified by TAT. Our findings
extend support for the potential inflammatory
influence of small visceral adipose depots in the
development of arterial calcification and
possibly suggest PVAT as a local source for the
complement proteins. Early recognition of the
high complement protein levels and volumes of
cardiovascular fat in women at midlife could be
used in early diagnosis of subclinical CVD. These
findings need to be replicated in larger samples.
N. Nagaraj: None. K.A. Matthews: None. K.J.
Shields: None. E. Barinas-Mitchel: None. M.
Budoff: G. Consultant/Advisory Board; Modest;
Consultant to GE. S.R. El Khoudary: None.
P178
Association of Plasminogen Activator Inhibitor1 with Prevalence and Progression of
Subclinical Atherosclerosis: The Multi-Ethnic
Study of Atherosclerosis (MESA)
Sadiya Khan, Douglas E. Vaughan, Cheeling
Chan, Kiang Liu, Northwestern Univ Feinberg
Sch of Med, Chicago, IL; Mary Cushman, Univ of
Vermont Coll of Med, Colchester, VT; Donald
Lloyd-Jones, Northwestern Univ Feinberg Sch of
Med, Chicago, IL
Background: Elevated circulating levels of
plasminogen activator inhibitor-1 (PAI-1) have
been associated with myocardial infarction and
cardiovascular mortality. Since the fibrinolytic
system plays an integral role in the
pathogenesis of coronary artery disease, we
sought to examine the association of PAI-1 with
subclinical atherosclerosis.
Hypothesis: PAI-1 is associated with prevalent
CAC and predicts progression of CAC,
independent of traditional cardiovascular risk
factors and inflammatory markers.
Methods: We studied the cross-sectional
association of PAI-1 and CAC, as well as the
prospective association with progression of CAC
in a random sample from MESA who had PAI-1
measured at baseline and computed
tomography at baseline and follow-up.
Multivariable ordinal logistic regression was
used to estimate associations of PAI-1 levels
with baseline categories of CAC defined as 0, 199, 100-299, and ≥300 Agatston units.
Multivariable logistic regression analyses
examined CAC progression (defined using a
previously published algorithm as incident CAC,
increase of ≥10 Agatston units for baseline CAC
1-99, or increase of ≥10% in CAC score for
baseline CAC ≥100). Adjustment covariates
included demographics, risk factors, and
inflammatory markers.
Results: In 839 participants mean age was 59
years old; 59% and 47% were female and white,
respectively. At baseline, the highest (vs. the
lowest) tertile of PAI-1 was associated with an
odds ratio (OR) for being in a higher CAC
category of 1.50 (95% CI: 1.01 - 2.27, p < 0.05)
after multivariable adjustment. Over a median
follow-up of 8.5 years, the highest tertile of PAI1 was associated with a multivariable-adjusted
OR of 1.67 (95% CI 1.09-2.55, p<0.01) for CAC
progression (Table).
Conclusions: Higher levels of PAI-1 in middleage are associated with prevalent CAC and with
progression of CAC, independent of traditional
risk factors and inflammatory markers. These
data suggest a role for PAI-1 in the
pathogenesis of subclinical atherosclerosis
independent of inflammation.
S. Khan: None. D.E. Vaughan: None. C. Chan:
None. K. Liu: None. M. Cushman: None. D.
Lloyd-Jones: None.
P179
Associations of Early and Contemporary
Cardiovascular Risk Factors With Coronary
Artery Calcification
Eliseo Guallar, Di Zhao, Depts of Epidemiology
and Med, and Welch Ctr for Prevention,
MD; Roberto Pastor-Barriuso, Natl Ctr for
Epidemiology, Carlos III Inst of Health and
Consortium for Biomedical Res in Epidemiology
and Public Health (CIBERESP), Madrid, Spain;
Sanjay Rampal, Dept of Social and Preventive
Med, Julius Ctr Univ of Malaya, Faculty of Med,
Univ of Malaya, Kuala Lumpur, Malaysia;
Yoosoo Chang, Seungho Ryu, Yuni Choi, Ctr for
Sch of Med, Seoul, Korea, Republic of; Joao
of Med, Baltimore, MD; So Yeon Lim, Miguel
Cainzos Achirica, Depts of Epidemiology and
MD; Hocheol Shin, Dept of Family Med,
Kangbuk Samsung Hosp and Sungkyunkwan
Univ Sch of Med, Seoul, Korea, Republic of;
Juhee Cho, Ctr for Cohort Studies, Total
Hosp, Sungkyunkwan Univ, Sch of Med, Seoul,
Korea, Republic of; Yiyi Zhang, Depts of
Health, Baltimore, MD
Objective: Traditional cardiovascular disease
(CVD) risk factors are key determinants of
atherosclerosis and essential components of
preventive interventions. However, it is unclear
whether the associations between risk factors
and atherosclerosis are time-dependent and
whether early or contemporary risk factor levels
are more important determinants of CVD risk.
Hypothesis: The aim of this study was to test
the hypothesis that early (up to 10 years
previous) CVD risk factor levels are stronger
determinants of coronary artery calcium (CAC),
a measure of subclinical atherosclerosis,
compared to contemporary levels or risk
factors.
Methods: We conducted a cohort study of
45,933 young and middle-aged men and
women without clinically evident CVD who
underwent repeated comprehensive health
exams from 2002-2013 and had a measurement
of CAC score by computed tomography during
2010-2013. The time-dependent associations of
CAC with cardiovascular risk factors measured
at different time points prior to the CAC
assessment were examined using robust Tobit
and logistic regression models.
Results: Early measures of BMI, total and LDL
cholesterol, triglycerides, SBP and DBP were
more strongly associated with the presence and
severity of coronary calcification compared to
contemporary measures, whereas
contemporary HDL was more strongly
associated with CAC compared to earlier
measures. For BMI, total and LDL cholesterol,
triglycerides, SBP and DBP, the strength of the
association with CAC scores increased linearly
with increasing distance from the time of CAC
measurement (Figure).
Conclusions: In this large sample of young and
middle-aged adults, the association between
traditional risk factors and CAC score was
stronger for early compared to contemporary
measures for all risk factors except HDL. These
findings underscore the importance of longterm trajectories in the pathogenesis of
atherosclerosis as well as the potential benefit
of early CVD risk assessment.
E. Guallar: None. D. Zhao: None. R. PastorBarriuso: None. S. Rampal: None. Y. Chang:
None. S. Ryu: None. Y. Choi: None. J. Lima:
None. S. Lim: None. M. Cainzos Achirica:
None. H. Shin: None. J. Cho: None. Y. Zhang:
None.
P180
Ten-Year and Lifetime Cardiovascular Risk and
Subclinical Cardiovascular Disease in Mexican
Women
Andrea Luviano, Eduardo Ortiz-Panozo, Elsa
Yunes, Insto Nacional de Salud Pública, Mexico
City, Mexico; Carlos Cantu-Brito, Fernando
Flores, Insto Nacional de Ciencias Médicas y
Nutrición Salvador Zubirán, Mexico City,
Mexico; Andrés Catzin-Kuhlmann, Martín
Lajous, Ruy Lopez-Ridaura, Insto Nacional de
Salud Pública, Mexico City, Mexico
Introduction: Estimates of Lifetime
Cardiovascular Risk may identify individuals
with different levels of cardiovascular disease
(CVD) risk within the low short-term risk (10year risk) for coronary heart disease (CHD)
category defined by the Framingham Risk Score.
Evidence of the applicability of this risk
stratification in relatively young people is
limited, especially among Hispanics.
the risk categories from the combination of
these two risk stratification scales are positively
associated with subclinical CVD in Mexican
women.
Methods: We calculated 10-year CHD risk using
the Framingham Risk Score and lifetime CVD
risk based on risk factor burden in 759 women
in Southern Mexico from the Mexican Teachers’
Cohort and evaluated the presence of
subclinical CVD. We evaluated common carotid
intima-media thickness (IMT), ankle-brachial
index (ABI), and inter-arm blood pressure
difference (IAD) using standard protocols and
performed laboratory analyses from a fasting
blood draw. We defined three risk strata: Low
10-year (<10%)/Low lifetime risk, Low 10-year
(<10%)/High lifetime risk, and High 10-year risk
(≥10%). We evaluated outcome measures
continuously and estimated the prevalence of
subclinical CVD for each risk strata. We defined
subclinical CVD as IMT ≥0.8 mm or
atheromatous plaque, ABI <0.90, systolic IAD
≥20 mmHg or diastolic IAD ≥10 mmHg. We
calculated the sensibility and specificity of the
predicted risk categories to detect subclinical
CVD.
Results: Women evaluated had a mean age of
48.4 years, 22.5% (n=171) were classified as
High 10-year CHD Risk, 58.8% (n=446) as Low
10-year/High lifetime risk and 18.7% (n=142) as
Low 10-year/Low lifetime risk. We observed
significant increase in IMT measurement
according to increasing risk categories: 0.656
mm (±0.062), 0.704mm (±0.085), and 0.739mm
(±0.089) (p= <0.001). We found similar
significant trends in ABI (p= 0.001), systolic IAD
(p= <0.001), and diastolic IAD (p= <0.001). We
observed a significant higher prevalence of at
least one subclinical CVD as the risk category
increased: 10.6%, 26.9%, and 45.6% (p=
<0.001). The sensitivity and specificity of the
combination of these scores to detect
subclinical CVD was of 93% and 23%, whereas
only considering the high vs. low 10-year risk
categories these parameters were 37% and 83%
respectively.
Conclusion: The combination of these shortterm and lifetime risk scores accurately identify
differences in objective measurements of
subclinical cardiovascular disease in Mexican
women. Further calibration of these risk scores
is needed to incorporate them in the risk
assessment tools to identify individuals at risk
for the implementation of preventive strategies
in the Mexican population.
A. Luviano: None. E. Ortiz-Panozo: None. E.
Yunes: None. C. Cantu-Brito: None. F. Flores:
None. A. Catzin-Kuhlmann: None. M. Lajous: B.
Research Grant; Modest; Unrestricted
Investigator-initiated Grant. R. Lopez-Ridaura:
B. Research Grant; Modest; Unrestricted
Investigator-initiated Grant.
P181
Lung Function and Arterial Stiffness in
Apparently Healthy Men and Women: The
Kangbuk Samsung Health Study
So Yeon Lim, Depts of Epidemiology and Med,
and Welch Ctr for Prevention, Epidemiology,
and Clinical Res, Johns Hopkins Univ Bloomberg
Sch of Public Health., Baltimore, MD; João A.C.
of Med, Baltimore, MD; Di Zhao, Depts of
Health., Baltimore, MD; Sanjay Rampal, Depts
of Epidemiology and Med, and Welch Ctr for
Health. Baltimore, Maryland, USA., Dept of
Social and Preventive Med, Kuala Lumpur,
Malaysia; Yiyi Zhang, Depts of Epidemiology and
Univ Bloomberg Sch of Public Health.,
Baltimore, MD; Juhee Cho, Johns Hopkins Univ
Bloomberg Sch of Public Health. USA., Kangbuk
Samsung Hosp, Sungkyunkwan Univ. South
Korea., Samsung Advanced Inst for Health
Sciences and Technology, Sungkyunkwan Univ.,
Seoul, Korea, Republic of; Roberto PastorBarriuso, Natl Ctr for Epidemiology, Carlos III
Inst of Health and Consortium for Biomedical
Res in Epidemiology and Public Health
(CIBERESP)., Madrid, Spain; Miguel CainzosAchirica, Depts of Epidemiology and Med, and
Welch Ctr for Prevention, Epidemiology, and
Clinical Res, Johns Hopkins Univ Bloomberg Sch
of Public Health., Baltimore, MD; Salvador Bello,
Dept of Respiratory Diseases, Hosp Univrio
Miguel Servet., Zaragoza, Spain; Yuni Choi, Ctr
for Cohort Studies, Total Healthcare Ctr,
Sch of Med., Seoul, Korea, Republic of; Yoosoo
Chang, Seungho Ryu, Ctr for Cohort Studies,
Total Healthcare Ctr, Kangbuk Samsung Hosp,
Sungkyunkwan Univ Sch of Med., Dept of
Occupational and Environmental Med, Kangbuk
Samsung Hosp, Sungkyunkwan Univ Sch of
Med., Seoul, Korea, Republic of; Hocheol Shin,
Ctr for Cohort Studies, Total Healthcare Ctr,
Sch of Med., Dept of Family Med, Kangbuk
Samsung Hosp and Sungkyunkwan Univ Sch of
Med., Seoul, Korea, Republic of; Seong Yong
Lim, Div of Pulmonary and Critical Care Med,
Dept of Med, Kangbuk Samsung Hosp and
Sungkyunkwan Univ Sch of Med., Seoul, Korea,
Republic of; Eliseo Guallar, Depts of
Health., Baltimore, MD
Introduction: The association between lung
function and arterial stiffness in young and
middle-aged asymptomatic adults is uncertain.
declining lung function is associated with
increasing and arterial stiffness in a large
sample of young and middle-age asymptomatic
men and women.
Methods: Cross-sectional study of 95,705 men
and women without a history of cardiovascular
disease, obstructive lung disease, or cancer who
underwent a health screening examination
during 2006 - 2012. Prediction equations were
used to estimate the percentage of predicted
forced vital capacity (FVC) and forced expiratory
volume in one second (FEV1) from age-, height-,
and weight-adjusted population norms. Pulse
wave velocity (PWV) was obtained from
bilateral brachial and posterior tibial artery
pressure waveforms recorded using the
oscillometric method.
Results: The mean age of study participants was
42.7 years in men and 40.7 years in women;
63.9% of study participants were men. In
multivariable adjusted linear regression models,
PWV ratios comparing men with FVC < 60
%predicted to those with FVC ≥ 100 %predicted
were 1.08 (95% confidence interval 1.06 to
1.09), 1.08 (1.05 to 1.11), 1.07 (1.04 to 1.09),
and 1.09 (1.06 to 1.11) among all, never,
former, and current smoking men, respectively.
The corresponding PWV ratios in women were
1.02 (1.00 to 1.03), 1.02 (1.00 to 1.03), 0.98
(0.91 to 1.06), and 1.06 (0.94 to 1.19). Similar
results were observed for FEV1 in men and
women. In spline regression models, adjusted
PWV ratios increased with decreasing levels of
FVC and FEV1 in both men and women (Figure).
Conclusions: Declining lung function was
associated with increased arterial stiffness in
apparently healthy young and middle aged men
and women, regardless of smoking exposure.
This association was observed in asymptomatic
participants with preserved lung function. Lung
function may thus be an important determinant
of arterial stiffness and vascular aging later in
life.
S. Lim: None. J. Lima: None. D. Zhao: None. S.
Rampal: None. Y. Zhang: None. J. Cho: None. R.
Pastor-Barriuso: None. M. Cainzos-Achirica:
None. S. Bello: None. Y. Choi: None. Y. Chang:
None. S. Ryu: None. H. Shin: None. S. Lim:
None. E. Guallar: None.
P182
Aortic Arch Pulse Wave Velocity Assessed by
MRI as a Predictor of All-Cause Mortality and
Incident Cardiovascular Events: The MultiEthnic Study of Atherosclerosis (MESA)
Yoshiaki Ohyama, Bharath Ambale-Venkatesh,
Chikara Noda, Jang Young Kim, Atul Chugh,
Gisela Teixido Tura, Johns Hopkins Univ,
Baltimore, MD; Chia-Ying Liu, Natl Inst of Health
Clinical Ctr, Bethesda, MD; Alban Redheuil, Inst
de Cardiologie, Groupe Hospier Pitié
Salpêtrière, Paris, France; Colin Wu, Natl Heart,
Lung and Blood Inst, Bethesda, MD; Gregory
Hundley, Wake Forest Sch of Med, WinstonSalem, NC; David Bluemke, Natl Insts of Health
Clinical Ctr, Bethesda, MD; Eliseo Guallar, Johns
Baltimore, MD; Joao Lima, Johns Hopkins Univ,
Baltimore, MD
Background
The carotid-femoral pulse wave velocity (PWV)
assessed by tonometry is predictive of future
cardiovascular disease (CVD) events. However,
the predictive value of aortic arch PWV
assessed by MRI for mortality and CVD events
has not been established in the general
population. The aim of this study was to
evaluate the association of arch PWV with allcause mortality and incident CVD events over
10 years in the Multi-Ethnic Study of
Atherosclerosis (MESA).
Method
Aortic arch PWV was measured using phase
contrast (PC) cine MRI at the level of the
pulmonary artery bifurcation for transit time
and black blood sagittal image for transit length
at baseline in 3537 MESA participants free of
overt CVD. Cox regression was used to evaluate
the risk of death and incident CVD in relation to
arch PWV adjusted for age, gender, race, and
CV risk factors.
Results
At baseline, participants were aged 62 ± 10
years; 53% women; 36% White, 15% Chinese,
29% African American, 20% Hispanic; 45%
hypertension. The mean value of arch PWV was
9.0 ± 6.3 m/s. There were 418 deaths and 236
CVD events over 10-year follow-up. There was
significant interaction between arch PWV and
mean age for both outcomes, so we stratified
by age; below 60 years (n=1503) and above 60
years (n=2034). Increased PWV had a trend with
increased risk of all-cause mortality with a
hazard ratio for the 4th vs 1st quartile of PWV
of 2.1 (95%CI: 1.0-4.6, p=0.05) independent of
risk factors in age below 60 years group. There
was no significant association of PWV with
incident CVD in age below 60 years after
adjustment for risk factors. In age above 60
years group, increased PWV was not associated
with either all-cause mortality or incident CVD
events in univariate or multivariate analysis
(Table).
Conclusion
Arch PWV assessed by MRI is not a significant
predictor of all-cause mortality and incident
CVD events among individuals without overt
CVD.
Y. Ohyama: None. B. Ambale-Venkatesh:
None. C. Noda: None. J. Kim: None. A. Chugh:
None. G. Teixido Tura: None. C. Liu: None. A.
Redheuil: None. C. Wu: None. G. Hundley:
None. D. Bluemke: None. E. Guallar: None. J.
Lima: None.
P183
Repeatability of Pulse Wave Velocity: The
Study
Michelle Snyder, Univ of North Carolina at
Chapel Hill, Chapel Hill, NC; Hirofumi Tanaka,
Univ of Texas at Austin, Austin, TX; Priya Palta,
Mehul Patel, Ricky Camplain, David Couper,
Hill, NC; Susan Cheng, Harvard Medical Sch,
Boston, MA; Ada Al Qunaibet, Anna Poon,
Gerardo Heiss, Univ of North Carolina at Chapel
Hill, Chapel Hill, NC
Background: Despite the growing use of pulse
wave velocity (PWV), a measure of arterial
stiffness that is predictive of cardiovascular
disease and all-cause mortality, the
repeatability of central, lower-extremity, and
composite measures of PWV has not been
examined.
Objectives: Characterize the repeatability of
PWV in a multi-center, population-based study
of older adults.
Methods: We included a subset of the ARIC visit
5 (2011-2013) participants (n=79; mean age
75.7 years; 46 females) from the following four
United States communities: Forsyth County, NC;
Jackson, MS; Minneapolis, MN; and Washington
County, MD who underwent two standardized
exams 4-8 weeks apart. At each exam, trained
and certified technicians obtained two PWV
measurements following a standardized
protocol using the VP-1000 Plus system (Omron
Co., Ltd., Kyoto, Japan). Measurements included
carotid-femoral PWV (cfPWV), right brachialankle PWV (baPWV) and right femoral-ankle
PWV (faPWV). We excluded participants with
evidence of a major arrhythmia on a 12-lead
electrocardiogram, aortic stenosis, body mass
index >40 kg/m2, and excluded PWV values >3
standard deviations away from the mean. We
used random-effects mixed models to parse the
variance of the measures into their betweenparticipant, between-visit, and within-visit
components, then calculated the intra-class
correlation coefficient (ICC) and estimated the
number of replicates needed to achieve an ICC
of 0.9 using the Spearman-Brown formula and
the lower bound of the ICC 95% confidence
interval (95% CI). We also calculated the
minimal detectable change (MDC; 95%
confidence) and minimal detectable difference
(MDD).
Results: Between-participant variation
accounted for 69% to 84% of the total variation
in cfPWV, baPWV and faPWV. The ICCs (95%
CIs) were 0.70 (0.59, 0.81) for cfPWV, 0.84
(0.78, 0.90) for baPWV, and 0.69 (0.59, 0.79) for
faPWV. The number of replicates to achieve an
ICC of 0.90 was 6 for cfPWV and faPWV and 3
for baPWV. The overall means and standard
deviations (SD) were 1,198.9 ± 269.6 cm/s for
cfPWV, 1,742.0 ± 328.3 cm/s for baPWV, and
1,063.4 ± 189.4 cm/s for faPWV. The MDC
between repeat measures within an individual
was 411.0 cm/s for cfPWV, 370.6 cm/s for
baPWV, and 301.4 cm/s for faPWV. The MDD
for two independent samples of 100 per group
was 139.3 cm/s for cfPWV, 172.3 cm/s for
baPWV, and 100.4 cm/s for faPWV.
Conclusion: The repeatability is excellent for
baPWV and fair for cfPWV and faPWV. The MDC
was approximately 1 SD for baPWV and 1.5 SDs
for cfPWV and faPWV and the MDD for 100 per
group was approximately 0.5 SD for cfPWV,
baPWV and faPWV. Averaging replicates would
reduce the effects of measurement variability.
These results support the use of PWV in clinical
and epidemiologic studies; however, to
minimize potential bias, studies need to
consider measurement variability in design
development and in the analysis and
interpretation of results.
M. Snyder: None. H. Tanaka: None. P. Palta:
None. M. Patel: None. R. Camplain: None. D.
Couper: None. S. Cheng: None. A. Al Qunaibet:
None. A. Poon: None. G. Heiss: None.
P184
Pulse Wave Velocity is Associated With
Coronary Calcification and Improves its
Prediction in Young And Middle-Aged
Asymptomatic Adults: The Kangbuk Samsung
Health Study
Miguel Cainzos-Achirica, Welch Ctr for
Prevention, Epidemiology and Clinical Res,
Johns Hopkins Univ, Baltimore, MD; Sanjay
Rampal, Dept of Social and Preventive Med,
Julius Ctr Univ of Malaya, Faculty of Med, Univ
of Malaya, Kuala Lumpur, Malaysia; Yoosoo
Chang, Seungho Ryu, Ctr for Cohort Studies,
Total Healthcare Screening Ctr, Kangbuk
Samsung Hosp, Sungkyunkwan Univ, Sch of
Med, Seoul, Korea, Republic of; Yiyi Zhang, Di
Zhao, Welch Ctr for Prevention, Epidemiology
and Clinical Res, Johns Hopkins Univ, Baltimore,
MD; Juhee Cho, Yuni Choi, Ctr for Cohort
Studies, Total Healthcare Screening Ctr,
Sch of Med, Seoul, Korea, Republic of; Roberto
Pastor-Barriuso, Natl Ctr for Epidemiology, Insto
de Salud Carlos III, Madrid, Spain; So Yeon Lim,
Welch Ctr for Prevention, Epidemiology and
Clinical Res, Johns Hopkins Univ, Baltimore, MD;
Joao Lima, Div of Cardiology, Johns Hopkins
Univ Sch of Med, Baltimore, MD; Hocheol Shin,
Ctr for Cohort Studies, Total Healthcare
Screening Ctr, Kangbuk Samsung Hosp,
Republic of; Eliseo Guallar, Welch Ctr for
Prevention, Epidemiology and Clinical Res,
Johns Hopkins Univ, Baltimore, MD
Introduction
The role of pulse wave velocity (PWV) in
assessing cardiovascular disease (CVD) risk in
asymptomatic non-elderly adults is unclear.
PWV assessment, however, is readily available,
non-invasive, cheap, and does not involve
radiation exposure.
Hypothesis
The aim of our study was to evaluate the
hypothesis that brachial-ankle PWV was
associated with coronary artery calcium (CAC)
in a large sample of young and middle-aged
asymptomatic adults, and that PWV increases
the predictive value of traditional CVD risk
factors for predicting the presence of CAC.
Methods
Cross-sectional study of 15,009 asymptomatic
men and women without a history of
cardiovascular disease who underwent a health
screening program that included both PWV and
CAC measurements. Brachial-ankle PWV was
obtained from bilateral brachial and posterior
tibial artery pressure waveforms using the
oscillometric method. Robust tobit regression
was used to assess the association between
PWV and natural log(CAC+1) and logistic
regression was used to model the presence of
detectable CAC (CAC>0) and CAC>100 adjusting
for multiple CVD risk factors. Measures of
calibration and discrimination were calculated
to test the incremental value of adding PWV to
traditional risk factors in predicting prevalent
CAC.
Results
The mean age of the study participants was
41.6 years (SD 7.2) and 83% (12,452) were men.
Subjects with higher PWV had generally less
favorable CVD risk profiles. The multivariableadjusted CAC score ratios (95% confidence
interval) comparing quintiles 2 - 5 of PWV to the
first quintile were 1.21 (0.78, 1.86), 1.54 (1.01,
2.33), 1.98 (1.30, 3.01), and 2.83 (1.84, 4.37),
respectively (P trend 100 were consistent with
the results for CAC ratios. The addition of PWV
to traditional risk factors significantly improved
the discrimination and calibration of models for
predicting the prevalence of detectable CAC
(net reclassification index [NRI] for predicting
detectable CAC and CAC score > 100 of 0.167
and 0.252, respectively; both p<0.001).
Conclusions
In this large sample of young and middle-aged
asymptomatic adults, brachial-ankle PWV was
independently associated with the presence
and the extent of CAC. PWV measurements
improve the prediction of detectable CAC
compared to traditional CVD risk factors and
may help identify young and middle-age
subjects with increased risk of subclinical
disease.
M. Cainzos-Achirica: None. S. Rampal: None. Y.
Chang: None. S. Ryu: None. Y. Zhang: None. D.
Zhao: None. J. Cho: None. Y. Choi: None. R.
Pastor-Barriuso: None. S. Lim: None. J. Lima:
None. H. Shin: None. E. Guallar: None.
P185
A Differential Prospective Association Between
Serum Carotenoids and Tocopherols Occurs
with Coronary Artery Calcification
Myron D Gross, Univ of Minnesota,
Minneapolis, MN; Atsushi Hozawa, Tohoku
Univ, Sendai, Japan; Andrew Odegaard, Univ of
Minnesota, Minneapolis, MN; John J Carr,
Vanderbilt Univ, Nashville, TN; Otto Sanchez,
Univ of Minnesota, Minneapolis, MN; Jose R
Suarez, Univ of California San Diego, San Diego,
CA; David R Jacobs Jr, Univ of Minnesota,
Minneapolis, MN
Dietary carotenoids and tocopherols, but not
supplements, have been associated with the
prevention of cardiovascular disease. To better
understand this observation, we examined the
association between the carotenoids and
tocopherols and the incidence of coronary
artery calcification (CAC) a measure of
subclinical coronary artery disease. Circulating
carotenoids and tocopherols reflect their
dietary intakes and post-intake metabolism. We
evaluated the sum of carotenoids (4 of the 5
major circulating carotenoids (Sum4Carot):
zeaxanthin/lutein, beta-cryptoxanthin, alphacarotene and beta-carotene, excluding
lycopene. Alpha and gamma-tocopherol were
evaluated as individual variables. In this study,
serum carotenoids and tocopherols were
measured by HPLC in CARDIA exam year 15.
CAC was measured at exam years 15, 20, and 25
by computed tomography (CT) and expressed as
incidence (present or absent among those with
no CAC at year 15). Associations were analyzed
by Cox Proportional Hazards methods. Results:
See table below. A significant (p for
trend<0.007) inverse association was found
between the year 15 Sum4Carot and CAC. The
association remained significant following
adjustment for CVD-related factors (model
specified in tabular footnote). Year 15 alphatocopherol was not associated with CAC, but
gamma-tocopherol had a positive association
with CAC (p<0.0001). The association of
carotenoids with CAC occurred in middle aged
adults (mean age 50, exam year 25). While all of
these compounds are antioxidants, high levels
of carotenoids were associated with less
incident CAC, while high gamma-tocopherol
associated with more incident CAC, and alphatocopherol had a neutral association. Thus,
these compounds may be associated with CVD
through non-antioxidative mechanisms. The
association of carotenoids and tocopherols
measured in early middle-age (mean age 40,
year 15) with the development of CAC through
middle-age emphasize the importance of diet
and lifestyle throughout the lifecourse.
M.D. Gross: None. A. Hozawa: None. A.
Odegaard: None. J.J. Carr: None. O. Sanchez:
None. J.R. Suarez: None. D.R. Jacobs: None.
P186
Quality of Total Heart Adipose Tissue May
Contribute to the Presence and Extent of
Coronary Artery Calcification in Women at
Midlife: The Study of Women’s Health Across
the Nation
Carrie L Hanley, Univ of Pittsburgh, Graduate
Sch of Public Health, Pittsburgh, PA; Karen
Matthews, Univ of Pittsburgh, Sch of Med,
Pittsburgh, PA; Maria M. Brooks, Univ of
Pittsburgh, Graduate Sch of Public Health,
Pittsburgh, PA; Imke Janssen, Rush Univ Medical
Ctr, Dept of Preventive Med, Chicago, IL;
Matthew J. Budoff, Los Angeles Biomedical Res
Inst, Torrance, CA; Akira Sekikawa, Univ of
Pittsburgh, Graduate Sch of Public Health,
Pittsburgh, PA; Suresh Mulukutla, Univ of
Pittsburgh, Sch of Med, Pittsburgh, PA; Samar R.
El Khoudary, Univ of Pittsburgh, Graduate Sch
of Public Health, Pittsburgh, PA
Background: The location and quantity of
specific adipose tissue depots have been shown
to be independent predictors of subclinical
atherosclerosis. Most recently, attention has
been focused on the quality of these fat depots
as a novel marker of CVD risk. Adipose tissue
attenuation, measured via radiodensity in
computed tomography (CT) Hounsfield units
(HU), is one such marker of fat quality. Our
objective was to determine the cross-sectional
association between total heart adipose tissue
(TAT) radiodensity and coronary artery
calcification (CAC) in women at midlife, a time
period marked with an increase in CVD risk.
Methods: Participants from the Study of
Women’s Health Across the Nation (SWAN)
Ectopic Cardiovascular Fat Ancillary Study were
evaluated. CAC and TAT were measured using
electron-beam CT. CAC was evaluated as 1)
presence of CAC (CAC Agatston score >10), and
2) extent of CAC (continuous Agatston score).
TAT radiodensity was evaluated as tertiles of
HU (lowest tertile, -91 to -81 HU; middle tertile,
-80 to -78 HU; highest tertile -77 to -67 HU).
Logistic (for CAC presence) and Tobit regression
(for CAC extent) were used for statistical
analyses.
Results: A total of 495 women with a mean age
of 51 years were examined. This sample of
women was 63% white, 37% black, 54% pre/early peri-menopausal, 35% late peri/postmenopausal, and 11% used hormones. In
unadjusted logistic and Tobit regression models
(Table 1), the tertiles of TAT were significantly
and inversely associated with the presence and
extent of CAC. In fully adjusted models, the
middle tertile remained significantly inversely
associated with the presence and extent of CAC
compared to the lowest tertile, but the adjusted
estimates for the highest tertile were
attenuated and non-significant (Table 1).
Conclusions: There appears to be an inverse
relationship between TAT radiodensity and CAC
which is more pronounced for those with midrange radiodensity values. These results merit
further investigation.
C.L. Hanley: None. K. Matthews: None. M.M.
Brooks: None. I. Janssen: None. M.J. Budoff:
None. A. Sekikawa: None. S. Mulukutla:
None. S.R. El Khoudary: None.
P187
Aortic Arch Width is Associated with Increasing
Age and Cardiovascular Disease Risk Factors:
The Framingham Heart Study
Saadia Qazi, Philimon Gona, Rebecca M
Musgrave, Caroline S Fox, The NHLBI's
Framingham Heart Study, Framingham, MA;
Joseph M Massaro, Boston Univ, Boston, MA;
Udo Hoffmann, Massachusetts General Hosp,
Boston, MA; Michael L Chuang, Christopher J
O'Donnell, The NHLBI's Framingham Heart
Study, Framingham, MA
Introduction: Aortic arch geometry changes
with aging: curvature decreases and aortic arch
width (AAW) increases. AAW can be easily
measured using thoracic multidetector
computed tomography (MDCT). In addition to
greater age, increases in AAW may also occur
due to other cardiovascular disease (CVD) risk
factors, but the distribution and determinants
of excess AAW are unknown. We hypothesized
that, in addition to increasing age, standard
CVD risk factors are associated with increased
AAW in community-dwelling adults.
Methods: 3026 (1560 men) Offspring and Third
Generation cohort participants (men ≥35y;
women ≥40y) underwent thoracic MDCT (20022005) and had complete risk factor profiles.
AAW was defined as the distance between
centroids of the ascending and descending
aorta at the level of main pulmonary artery
bifurcation. A healthy referent group free of
CVD, hypertension, dyslipidemia, smoking, and
diabetes was used to generate sex and 10-year
age group specific upper 90th percentile (P90)
cutpoints for AAW. Multivariable-adjusted,
step-wise logistic regression was used to
determine associations between high (≥referent
P90) AAW and candidate risk factors in the
overall study group.
Results: 1471 participants (738 M) met referent
group criteria: AAW was greater in men than
women (p<0.0001). In each sex, AAW increased
substantially with greater age-group (p for
trend <0.0001 both). Mean (±SD) and P90 AAW
values are shown in the Table. In the entire
study population, high AAW was associated
with body mass index (OR=1.12; 95%
confidence interval 1.10-1.14), diastolic BP
(OR=1.46/10mmHg; 1.26-1.70), log pack-years
(OR=1.09; 1.03-1.14), and prevalent CVD
(OR=1.82; 1.21-2.74) in multivariable models.
Conclusions: AAW increases with greater age,
obesity, diastolic blood pressure, and cigarette
smoking in both men and women. High AAW is
also associated with prevalent CVD. These
findings lay the groundwork for assessment of
the potential clinical utility of AAW.
S. Qazi: None. P. Gona: None. R.M. Musgrave:
None. C.S. Fox: None. J.M. Massaro: None. U.
Hoffmann: None. M.L. Chuang: None. C.J.
O'Donnell: None.
P188
“False Positive” Stress Testing: Does
Endothelial Vascular Dysfunction Explain STSegment Depression in the Absence of Clinical
Coronary Artery Disease in Women?
Shilpa Agrawal, UCLA David Geffen Sch of Med,
Los Angeles, CA; Puja Mehta, Cedars Sinai
Medical Ctr, Los Angeles, CA; Tara Sedlak, Univ
of British Columbia, Vancouver, BC, Canada;
Zachary Hobel, Chrisandra Shufelt, Erika Jones,
Cedars Sinai Medical Ctr, Los Angeles, CA; Paul
Kligfield, New York-Presbyterian/Weill Cornell,
New York, NY; David Mortara, UCSF Sch of
Nursing, San Francisco, CA; Michael Laks, UCLA
David Geffen Sch of Med, Los Angeles, CA; Noel
Bairey Merz, Cedars Sinai Medical Ctr, Los
Angeles, CA
Background: Current guidelines do not endorse
exercise electrocardiography (Ex-ECG) screening
in asymptomatic adults due to poor diagnostic
accuracy for clinical coronary artery disease
(CAD), however Ex-ECG combined with other
variables paradoxically has strong prognostic
accuracy for cardiovascular mortality. Ex-ECG ST
segment depression “false positive” results are
common in women, who have higher rates of
vascular dysfunction such as Raynaud’s and
migraines compared to men. We hypothesized
that ST segment depression indicates
endothelial vascular dysfunction, which is
known to predict an adverse prognosis. To test
this hypothesis, we evaluated the relationship
between Ex-ECG and peripheral endothelial
vascular function in asymptomatic women.
Methods: Asymptomatic women with no
cardiac risk factors and normal resting ECG
underwent maximal Bruce protocol Ex-ECG
testing (GE Healthcare). Computer-generated
Ex-ECG ST segment values were independently
verified by 2 cardiologists. Based on established
methods, endothelial vascular function was
assessed by calculating reactive hyperemia
index (RHI) using peripheral vascular testing
(Endopat, Itamar). As established previously,
RHI <1.68 is abnormal and indicates endothelial
vascular dysfunction.
Results: Among 35 women, mean age 54±8
years and BMI 24±4, there were 5 (14%) women
with abnormal RHI. Women with abnormal RHI
had a greater (more abnormal) ST/HR slope, a
trend toward greater peak ST depression, and
achieved lower METs than women with normal
RHI (Table 1).
Conclusion: Among asymptomatic women,
endothelial vascular dysfunction was associated
with abnormal Ex-ECG results characterized by
greater ST/HR slope, greater ST depression, and
lower exercise capacity. These findings suggest
that “false positive” ST-segment depression in
the absence of clinical CAD in women may be
explained by endothelial vascular dysfunction.
Our study further suggests that endothelial
vascular dysfunction may explain the Ex-ECG
diagnostic/prognostic paradox.
S. Agrawal: None. P. Mehta: B. Research Grant;
Significant; General Electric (GE), Gilead. E.
Honoraria; Modest; Little Company of Mary
lecture, Dignity Health lecture, Kaiser
Permanente lecture, San Diego Institute of
Cardiology, Emory. T. Sedlak: None. Z. Hobel:
None. C. Shufelt: None. E. Jones: None. P.
Kligfield: None. D. Mortara: None. M. Laks:
None. N. Bairey Merz: B. Research Grant;
Modest; Microvascular, Normal Control. B.
Research Grant; Significant; WISE CVD, R WISE,
FAMRI. E. Honoraria; Modest; Mayo Foundation
lectures, Bryn Mawr Hospital lectures, Practice
Point Communications lectures, Allegheny
General Hospital lectures, Duke lecture,
Japanese Circ Society lectures, UCSF lectures,
Vox Media lectures, Emory lectures, PCNA
lectures, Kaiser Permanente lectures. G.
Consultant/Advisory Board; Modest; Gilead
grant review committee, Garden State AHA,
Victor Change Cardiac Research Institute
(Australia), University of New Mexico, NIH-SEP
grant review study section. G.
Consultant/Advisory Board; Significant;
Research Triangle Institute International.
P189
Cardiovascular Risk Factors in Adolescence and
Young Adulthood Predict Carotid Intima-Media
Thickness in Early and Middle Adult Life
Amber L Fyfe-Johnson, Julia Steinberger, Alan R
Sinaiko, Alvaro Alonso, Donald R Dengel, David
R Jacobs, Univ of Minnesota, Minneapolis, MN
Introduction: Cardiovascular (CV) risk factors
measured in childhood and adulthood are
positively associated with increased carotid
intima-media thickness (cIMT) later in life. In
particular, body mass index (BMI), systolic
blood pressure (SBP), and lipids are implicated.
However, questions remain regarding
prediction of cIMT from adolescent and young
adult CV risk factors.
Hypothesis: CV risk factors are positively
associated with young adult and early middle
age cIMT thickening, both cross-sectionally and
longitudinally.
Methods: CV risk factors (BMI, SBP, metabolic
syndrome [MetS, mean of CV risk factor zscores]) were measured in two pediatric cohort
studies. The Insulin Study measured CV risk
factors in 305 adolescents at mean ages 15 and
22 years, with cIMT measured at mean age 22
years. The Prevention of High Blood Pressure in
Children Study measured CV risk factors in 444
individuals at mean ages 24 and 38 years, with
cIMT measured at mean age 38 years.
Predictors were categorized into quartiles; cIMT
was measured by ultrasonography. Linear
regression models were used to predict cIMT
and adjust for potential confounding variables.
Differences between risk factor quartile 4 and
quartile 1 (Q4-Q1) were used in analyses, with a
p-test for trend based on continuous predictors.
Results: Positive cross sectional associations
were found between CV risk factors at ages 24
and 38 and cIMT at 38 (Table). Positive
longitudinal associations were found between
BMI (Q4-Q1: 0.024 mm, p=0.0001) and MetS
score (Q4-Q1: 0.019 mm, p=0.004) at age 15
and cIMT at age 22, and between BMI (Q4-Q1:
0.045 mm, p=0.01) and MetS score (Q4-Q1:
0.048 mm, p<0.0001) at age 24 and cIMT at age
38 (Table). SBP at ages 24 and 38 was predictive
of cIMT at age 38.
Conclusions: These findings suggest that CV risk
factors beginning in adolescence predict cIMT
thickening in young adulthood, and this
predictive association continues into middle
age. This supports early identification of CV risk,
and initiation of preventive strategies to reduce
early CV disease.
A.L. Fyfe-Johnson: None. J. Steinberger:
None. A.R. Sinaiko: None. A. Alonso:
None. D.R. Dengel: None. D.R. Jacobs: None.
P190
The Associations of Brachial Artery Shear Rate
and Endothelial Dysfunction with Age Related
Carotid Distensibility
Dhananjay Vaidya, Johns Hopkins Univ,
Baltimore, MD; Yan Zhang, Sun Yat-sen Univ,
Guangzhou, China; Brian G Kral, Lisa R Yanek,
Lewis C Becker, Diane M Becker, Johns Hopkins
Univ, Baltimore, MD
Loss of carotid artery distensibility (CD) with age
portends of clinical cerebrovascular disease.
Endothelial dysfunction mediated by impaired
nitric oxide vascular dilatation precedes
vascular remodeling and age-related stiffening
of arteries. However, it is unknown whether
endothelial dysfunction contributes to loss of
vascular distensibility with age.
Methods: We examined 828 asymptomatic
healthy subjects in the GeneSTAR family cohort,
identified from index cases with early-onset
coronary artery disease. We determined mean
CD of both common carotid arteries using
ultrasound; CD was quantified as the pulsatile
change in lumen diameter/diastolic lumen
diameter/brachial pulse pressure. Vascular
shear rate (SR) was determined in the brachial
artery as 4 × maximum blood flow
velocity/maximum lumen diameter, and
brachial flow mediated dilatation (FMD), a
measure of endothelial dysfunction, as %
change in diastolic diameter during reactive
hyperemia. We tabulated both rest and
hyperemic responses by age, sex and raceindexed tertiles of CD generated by quantile
regression. Generalized estimating equations
(GEE) were used to estimate the family
correlation corrected associations of CD with
FMD and SR.
Results: The sample was 60% female, 40%
African American, with mean age 52 (SD 12)
years. While SR was significantly associated
with higher tertiles of CD, FMD was not (Table).
Adjusted for age, sex and race, every 540/s (1
SD) higher of shear rate was significantly
associated with a 6.2% higher CD (p = 0.019) but
FMD was not associated at all (p = 0.54). This
pattern remained after adjustment for LDL and
HDL- cholesterol, hypertension, diabetes and
smoking (p = 0.03 and 0.95, respectively).
Conclusion: Higher vascular shear rate is
associated with preserved arterial distensibility
indexed for age. FMD is not related to CD. The
pathophysiological interpretations of this
finding need further study before either CD or
vascular shear rate can be used for assessing
stoke risk in a population at increased risk for
vascular disease.
D. Vaidya: B. Research Grant; Significant; NIH.
G. Consultant/Advisory Board; Modest; MBC
Inc.. Y. Zhang: None. B.G. Kral: None. L.R.
Yanek: None. L.C. Becker: B. Research Grant;
Significant; NIH. D.M. Becker: B. Research
Grant; Significant; NIH.
P191
Carotid Intima-Media Thickness is Associated
with Systolic Blood Pressure, Body-Mass Index
and LDL Cholesterol in Low-Risk Individuals. A
Cross-Sectional Analysis of the Brazilian
Longitudinal Study of Adult Health (ELSABrasil).
Itamar S Santos, Márcio S Bittencourt, Ilka R
Oliveira, Angelita G Souza, Danilo P Meireles,
Univ of Sao Paulo, São Paulo, Brazil; Tatjana
Rundek, Univ of Miami, Miami, FL; Murilo
Foppa, Federal Univ of Rio Grande do Sul, Porto
Alegre, Brazil; Daniel C Bezerra, Oswaldo Cruz
Fndn, Rio de Janeiro, Brazil; Leonard H Roelke,
Federal Univ of Espirito Santo, Vitória, Brazil;
Isabela M Benseñor, Paulo A Lotufo, Univ of Sao
Paulo, São Paulo, Brazil
Introduction: Carotid intima-media thickness
(cIMT) is a noninvasive measurement of early
atherosclerosis by ultrasound. Determinants of
cIMT in individuals without classical
cardiovascular (CV) risk factors are poorly
studied.
systolic blood pressure (SBP), body-mass index
(BMI), serum glucose and LDL cholesterol (LDLc) are associated with maximal cIMT values in
low-risk individuals (no hypertension, diabetes,
dyslipidemia or prior CV disease, no CV
medications, no current or past smoking and a
BMI < 30 kg/m2).
Methods: We used data from the Brazilian
Longitudinal Study of Adult Health (ELSA-Brasil)
baseline. ELSA-Brasil is a multicenter cohort of
15,105 civil servants aged 35-74 years in six
Brazilian cities. Baseline assessment included
cIMT measurements in both common carotid
arteries. SBP, BMI, serum glucose and LDL-c
values were standardized. We used multiple
linear regression models to study the
association of SBP, BMI, serum glucose and LDLc with maximal cIMT (in mm).
Results: We analyzed 1,569 ELSA-Brasil low-risk
participants with complete cIMT data. There
were 1,024 (65.3%) women and 924 (58.9%) of
White race. Mean ± standard deviation (SD) for
continuous variables were: age 46.1 ± 7.7 years;
SBP 111.2 ± 10.8 mmHg; BMI 24.0 ± 2.9 kg/m2;
serum glucose 99.7 ± 7.8 mg/dl; LDL-c 105.6 ±
17.1 mg/dl and maximal cIMT 0.700 ± 0.136
mm. The table shows the beta-coefficients
associated to one standard deviation increase in
SBP, BMI, serum glucose and LDL-c.
Conclusions: Even in a low-risk subsample,
excluding individuals with hypertension,
dyslipidemia or obesity, SBP, BMI and LDL-c
were positively associated with higher maximal
cIMT. This probably reflects a continuum of risk
for atherosclerotic disease mediated by these
measurements that do not evanesce with the
exclusion of subjects who fulfill current
diagnostic criteria for these conditions.
I.S. Santos: None. M.S. Bittencourt:
None. I.R.S. Oliveira: None. A.G. Souza:
None. D.P. Meireles: None. T. Rundek:
None. M. Foppa: None. D.C. Bezerra: None. L.H.
Roelke: None. I.M. Benseñor: None. P.A.
Lotufo: None.
P192
Chronic Kidney Disease and the Risk of Venous
Thromboembolism in the REasons for
(REGARDS) Study
Katharine L Cheung, Neil A. Zakai, Peter Callas,
Univ of Vermont, Burlington, VT; Aaron R
Folsom, Univ of Minnesota, Minneapolis, MN;
Carmen A. Peralta, Univ of California San
Francisco, San Francisco, CA; Suzanne E Judd,
Univ of Alabama, Birmingham, AL; Manjula
Kurella Tamura, Stanford Univ Sch of Med and
VA Palo Alto Health Care System, Geriatrics Res
Education and Clinical Ctr, Palo Alto, CA; Mary
Cushman, Univ of Vermont, Burlington, VT
Background: Chronic kidney disease (CKD) is a
recently identified risk factor for venous
thromboembolism (VTE) in whites, but there is
little data available in blacks and it is not known
which measure of CKD is best able to predict
VTE.
Hypothesis: CKD by 4 different measures will be
independently associated with VTE.
Methods: REGARDS enrolled 30,239 black and
white men and women age 45 and older
between 2003-7. We validated 298 VTE events
by medical record review over 3.5 years followup. Hazard ratios (HRs) of VTE were calculated
for categories of the CKD-EPI creatinine
(eGFRcr), cystatin C (eGFRcys) and combined
creatinine-cystatin C (eGFRcr-cys) equations,
and urinary albumin-creatinine ratio (ACR) <30,
30-<300 and ≥300mg/g. Models were adjusted
for covariates shown in the table. We tested for
interactions of each CKD measure with race, sex
and age. We calculated the C-index for each
CKD measure in predicting VTE.
Results: Unadjusted C-indices for eGFRcr,
eGFRcys, eGFRcr-cys and ACR were 0.59, 0.63,
0.63 and 0.55, respectively. There was a graded
increase in incidence rates and HRs of VTE by
eGFR (see table), but no association between
ACR and VTE (not shown). There was modest
confounding by demographic factors but not by
other risk factors. There were no interactions
between any of the 4 CKD measures and age or
race. A significant interaction for sex and
eGFRcr and eGFRcys, with stronger associations
in women than men, did not persist after
adjustment for covariates.
Conclusions: In this biracial cohort, CKD was
associated with increased risk of VTE across
categories of worsening eGFR. Cystatin-based
eGFR equations had better discrimination than
the creatinine based equation.
K.L. Cheung: None. N.A. Zakai: None. P. Callas:
None. A.R. Folsom: None. C.A. Peralta: B.
Research Grant; Modest; Labcorp Inc.. S.E.
Judd: None. M. Kurella Tamura: None. M.
Cushman: None.
P193
Infection Type and Severity are Risk Factors for
Hospital-Acquired Venous Thromboembolism
in Medical Inpatients
Samuel Merrill, Michael Desarno, Damon
Houghton, Christopher Huston, Peter Callas,
Allen Repp, Mary Cushman, Neil Zakai, Univ of
Vermont, Burlington, VT
Introduction: Hospital-acquired venous
thromboembolism (HAVTE) leads to increased
length of stay, cost, morbidity, and is a target of
government quality measures. How infection
relates to HAVTE risk is unknown. We wished to
identify infection-related risk factors for HAVTE
to help identify at-risk patients and to guide
prevention efforts.
Hypothesis: We hypothesized that increased
infection severity, affected organ system, and
positive microbiology culture results were
associated with HAVTE in medical inpatients.
Methods: HAVTE between 2009-2012 were
identified by ICD-9 codes with confirmatory
imaging at a 500 bed teaching hospital. ICD-9
codes, microbiology results, lab and vital sign
data, and medication records were used to
classify infections as presented in the Table.
Logistic regression was used to determine odds
ratios (OR) and 95% confidence intervals (CI) for
HAVTE adjusting for known HAVTE risk factors
in the MITH score, a previously developed
HAVTE risk score for medical inpatients. Models
incorporated known HAVTE risk factors and
assessed each variable from the Table
individually.
Results: In 20,327 medical admissions there
were 113 hospital-acquired HAVTE (incidence:
0.56%). The table presents the association
between infection-related risk factors and
HAVTE. Septic shock (OR 7.48), sepsis (OR 5.9),
and MSSA culture isolate (OR 6.39) had the
greatest point-estimates of HAVTE after
adjusting for known HAVTE risk factors.
Conclusions: Infection severity, affected organ
system, and microbiologic etiology were risk
factors for HAVTE after adjusting for known risk
factors. The relationship between these risk
factors and thrombosis is likely complex, but
these risk factors are easily measureable using
the electronic health record. These results may
help facilitate HAVTE prevention by further
identifying high risk patients.
S. Merrill: None. M. Desarno: None. D.
Houghton: None. C. Huston: None. P. Callas:
None. A. Repp: None. M. Cushman: None. N.
Zakai: None.
P194
Long-Term Impact of a Community Health
Worker Intervention on Diabetes Control in
American Samoa
Mayuree Rao, Judith D. DePue, The Warren
Alpert Medical Sch of Brown Univ, Providence,
RI; Shira Dunsiger, Ctrs for Behavioral and
Preventive Med, The Miriam Hosp, Providence,
RI; Mohammad Elsayed, The Warren Alpert
Medical Sch of Brown Univ, Providence, RI;
Ofeira Nu'usolia, Tafuna Clinic, American Samoa
Community Health Ctrs, Dept of Health, Tafuna,
American Samoa; Stephen T. McGarvey, Intl
Health Inst & Dept of Epidemiology, Brown Univ
Sch of Public Health, Providence, RI
Introduction-Diabetes Care in American Samoa
(DCAS) was a randomized controlled trial of a 12
month community health worker (CHW)facilitated intervention which demonstrated
improved HbA1c levels compared to usual care.
These results add to growing evidence
supporting the role of CHWs in diabetes care.
However, most CHW programs are time-limited,
and few pursue long-term follow-up of
participants. Little is known about whether
short-term CHW programs achieve sustained
improvements in diabetes control over time.
Hypothesis-We hypothesized that HbA1c would
increase over time in the experimental group of
DCAS after CHW intervention completion. In the
waitlist usual care group, which received the
intervention at the end of DCAS, we expected
HbA1c to decrease during the intervention and
increase after completion.
Methods-We retrospectively collected HbA1c
measurements from medical records of DCAS
participants (n=268). We used mixed-effects
regression models to assess change in HbA1c
over time in each trial arm for 3 time periods:
DCAS (intervention in experimental group), 1
year after DCAS (intervention in waitlist group),
and 1 to 2 years after DCAS. Models were
adjusted for baseline characteristics measured
during DCAS.
Results-In the experimental group, HbA1c did
not significantly change over time during DCAS
(intervention period), but decreased by
0.88/year (95% CI -1.31, -0.45) during the 1 year
after intervention completion (Table). No
significant change was observed the following
year. In the waitlist group, HbA1c did not
significantly change during DCAS (usual care)
but decreased by 1.31/year (-1.72, -0.91) during
the intervention. During the 1 year after
intervention completion, HbA1c increased by
1.18/year (0.42, 1.93).
Conclusions-Both trial arms experienced initial
improvements in glycemic control, but HbA1c
later plateaued or increased. These results
suggest that time-limited CHW programs may
have short-term effects on diabetes control, but
standing programs may be needed for sustained
impact.
M. Rao: None. J.D. DePue: None. S. Dunsiger:
None. M. Elsayed: None. O. Nu'usolia:
None. S.T. McGarvey: None.
P195
Hypertension is Associated With an Abnormal
Pressor Response to Voluntary Apnea
Noah Jouett, Ryan Mason, Dorene Niv, Univ of
North Texas Health Science Ctr, Fort Worth, TX;
Donald E. Watenpaugh, Sleep Consultants of
Texas, Fort Worth, TX; Michael L. Smith, Univ of
North Texas Health Science Ctr, Fort Worth, TX
Background: Cardiovascular diseases are
commonly associated with elevated
sympathetic nerve activity (SNA). Previously, we
have shown that the blood pressure response
to a voluntary apnea is closely correlated with
the SNA response in patients with sleep
disordered breathing (SDB) and thus may serve
as an index of SNA responsiveness. In the
current study, we hypothesized that the pressor
response to apnea is 1) reduced with effective
treatment of SDB in SDB patients, and 2) that it
is exaggerated in hypertensive patients (HTN)
when compared to healthy control subjects.
Methods: 22 OSA patients (14 treated and 8
untreated), 19 treated hypertensive patients
and 23 healthy normotensive control subjects
were recruited from the UNTHSC Primary Care
Center and Sleep Consultants of Texas. Subjects
completed a medical history questionnaire and
Epworth Sleepiness survey. Blood pressure was
measured by standard auscultatory assessment
in the seated position. Baseline blood pressure
was obtained in triplicate during quiet rest.
Then after practicing a voluntary breath hold,
subjects repeated three voluntary 20-second
breath holds each beginning at end-expiration.
Comparisons were made 1) between treated
and untreated SDB patients, and 2) between
HTN patients and healthy control subjects using
a Student t test.
Results: Importantly, as in prior studies the
pressor response to apnea was not different
from zero in the healthy control subjects (-1.0 ±
4.2 mmHg, p>0.05). In the SDB patients, the
pressor response was significantly greater than
zero in both treated (11.4 ± 3.9 mm Hg) and
untreated (24.5 ± 9.8 mm Hg) SDB patients
(p<0.001), and was significantly reduced in the
treated SDB patients (p<0.001). In addition, the
pressor response was significantly greater in the
HTN patients (10.5 ± 5.3 mmHg, p<0.001)
compared to the healthy control subjects.
Conclusions: These data support our
hypotheses that the pressor response to
voluntary apnea is exaggerated in both
untreated SDB and treated HTN patients and
that effective treatment of SDB reduces this
response, but does not normalize the response.
These data suggest that the pressor response to
apnea may be a simple physiologic index of
exaggerated sympathetic responsiveness.
N. Jouett: None. R. Mason: None. D. Niv:
None. D.E. Watenpaugh: None. M.L. Smith:
None.
P196
Bidirectional Association Between
Hypertension and Gout: The Singapore Chinese
Health Study
An Pan, Natl Univ of Singapore, Singapore,
Singapore; Gim Gee Teng, Natl Univ Health
System, Singapore, Singapore; Jian-Min Yuan,
Univ of Pittsburgh Cancer Inst, Pittsburgh, PA;
Woon-Puay Koh, Duke-NUS Graduate Medical
Sch Singapore, Singapore, Singapore
Introduction: Although it has been hypothesized
that the hypertension-gout relation is
bidirectional, few studies have addressed this
hypothesis in a prospective setting, particularly
in the Asian populations.
Methods: We analyzed data from the Singapore
Chinese Health Study (SCHS), a cohort of 63,257
Chinese aged 45-74 years at recruitment from
1993-98. The information about self reports of
physician-diagnosed hypertension and gout was
enquired at follow-ups I (1999-2004) and II
(2006-2010). We included participants with
complete data for both follow-ups and who
were free of heart disease, stroke and cancer at
follow-up I. For the analysis of hypertension and
risk of incident gout, participants with prevalent
gout were further excluded and the final
analysis included 31,694 participants. For the
analysis of gout and risk of incident
hypertension, participants with prevalent
hypertension were further excluded and the
final analysis included 20,490 participants. Cox
estimate multivariable-adjusted relative risks
(RRs) and 95% confidence intervals (CIs) with
adjustment for age, sex, years of interview,
dialect group, education, smoking status,
alcohol intake, physical activity, body mass
index (BMI) and history of diabetes.
Results: The mean age of the participants at
baseline was 60.1 (SD 7.3) years, and the
average follow-up year was 6.8 (SD 1.4) years.
In the analysis of hypertension and risk of gout,
836 incident cases were identified. Compared
to normotensive participants, hypertensive
patients had a 93% increased risk of developing
gout (RR 1.93; 95% CI 1.66-2.24). The
association was slightly stronger in women (RR
2.09; 95% CI 1.69-2.58) compared to men (RR
1.72; 95% CI 1.39-2.14; P for interaction=0.056).
The association was also stronger in normal
weight adults (BMI <24 kg/m2; RR 2.25; 95% CI
1.82-2.77) compared to overweight/obese
individuals (BMI ≥24 kg/m2; RR 1.66; 95% CI
1.34-2.04; P for interaction=0.03). In the parallel
analysis of gout and risk of hypertension, 5491
participants reported to have newly diagnosed
hypertension during the follow-up. Compared
to participants without gout, those with gout
had a 17% increased risk of developing
hypertension (RR 1.17; 95% CI 1.01-1.35). The
association was evident in men (RR 1.29; 95% CI
1.07-1.55) but not in women (RR 0.94; 95% CI
0.73-1.20; P for interaction=0.03). The
association was present in normal weight adults
(RR 1.34; 95% CI 1.09-1.64) but not among
overweight/obese individuals (RR 0.99; 95% CI
0.80-1.23; P for interaction=0.03).
Conclusions: Our results provide compelling
evidence that the hypertension-gout
association is bidirectional in Chinese
population. The potential interactions of the
bidirectional association with sex and obesity
deserve further investigations.
A. Pan: None. G. Teng: None. J. Yuan:
None. W. Koh: None.
P197
Methods to Account for Antihypertensive
Drugs for Estimating Underlying Blood
Pressure: The Atherosclerosis Risk in
Poojitha Balakrishnan, Elizabeth Colantuoni,
Johns Hopkins Sch of Public Health, Baltimore,
MD; J Hunter Young, Johns Hopkins Sch of Med,
Baltimore, MD; Terri Beaty, Kunihiro
Matsushita, Johns Hopkins Sch of Public Health,
Baltimore, MD
Introduction: Antihypertensive drugs are widely
used to lower blood pressure (BP), particularly
among older adults. Thus considerations are
required in epidemiological studies dealing with
the “underlying” BP (BP that would have been if
antihypertensive drugs were not provided), e.g.
studies exploring natural history of BP.
Materials and Methods: We compared three
methods proposed in literature for accounting
for antihypertensive drugs in the ARIC study,
which consists of 45-64 years old with ~25 years
of follow-up data (1987-2013). Method 1 simply
adds a constant of 10 mmHg to systolic blood
pressure (SBP) and 5 mmHg to diastolic blood
pressure (DBP) to the measured BP. Method 2
adds a constant derived from the expected drug
class effects as reported by short-term clinical
trials (e.g. angiotensin converting enzyme
inhibitors, alpha blockers, beta blockers,
calcium channel blockers, diuretics,
miscellaneous). Method 3 uses truncated
normal regression to incorporate covariates
(e.g. age, sex, race, BMI, height, sex-height
interaction), where the distribution of BP is
assumed to be normal and requires the
underlying BP to be greater than or equal to the
measured BP. We examined these methods by
observing the distribution of underlying BP
compared to the measured BP on
antihypertensive drugs.
Results: The prevalence of antihypertensive
drug use in ARIC is as follows: 30% in Visit 1
(4370/14659), 33% in Visit 2 (4732/14299), 38%
in Visit 3 (4874/12842), 44% in Visit 4
(5095/11610) and 76% in Visit 5 (4904/6469).
Method 3 compared to methods 1 and 2
creates a distribution of underlying BP that is
shifted more to the right and with less variation.
This trend for SBP and DBP was true for all visits
and more noticeable with each subsequent visit
(Visit 5 SBP illustrated in figure).
Conclusions: Overall, truncated normal
regression (method 3) yields more plausible and
stable underlying BP compared to methods 1
and 2. Estimation of underlying BP can be used
in epidemiological to investigate the natural
history of BP, such as in genetic studies.
P. Balakrishnan: None. E. Colantuoni: None. J.
Young: None. T. Beaty: None. K. Matsushita:
None.
P198
Clinic versus Out-of-Clinic Daytime Blood
Pressure Among Older Adults: Data From the
Jackson Heart Study
Rikki M Tanner, Univ of Alabama at
Birmingham, Birmingham, AL; Daichi Shimbo,
Samantha Seals, Univ of Mississippi Medical Ctr,
Jackson, MS; Gbenga Ogedegbe, New York Univ
Sch of Med, New York, NY; Paul Muntner, Univ
of Alabama at Birmingham, Birmingham, AL
In the US, antihypertensive medication
treatment decisions are primarily based on
blood pressure (BP) measurements obtained in
the clinic setting. The optimal systolic BP (SBP)
goal for adults ≥60 years is controversial and a
large difference between clinic and out-of-clinic
daytime BP, a white-coat effect, may be present
in older individuals. We estimated the whitecoat effect and calculated the percentage of
untreated and treated adults <60 and ≥60 years
with elevated clinic BP (defined as SBP/diastolic
BP [DBP] ≥140/90 mmHg), but non-elevated
out-of-clinic daytime BP (“daytime BP”, defined
as SBP/DBP <135/85 mmHg) among 257
African-American participants in the Jackson
Heart Study with at least 10 daytime
ambulatory BP measurements. For the overall
population, the white-coat effect for SBP was
12.2 mmHg (95% confidence interval [CI]: 9.215.1) in older adults and 8.4 mmHg (95% CI: 5.711.1) in younger adults (p=0.06). After
multivariable (MV) adjustment, this difference
was 1.3 mmHg. Among those without diabetes
or chronic kidney disease (CKD), the white coat
effect for SBP was 15.2 mmHg (95% CI: 10.120.2) and 8.6 mmHg (95% CI: 5.0-12.3) for older
and younger adults, respectively (p=0.04). After
MV adjustment, this difference was 5.9 mmHg.
Also, SBP ≥150 mmHg versus <150 mm Hg was
associated with a larger white-coat effect in the
overall population after MV adjustment. Among
those without CKD or diabetes, older age and
SBP ≥150 mmHg were associated with a larger
white-coat effect after MV adjustment. Among
younger and older participants with elevated
clinic BP, the prevalence of non-elevated
daytime BP was 34% (95% CI: 26%-44%) and
32% (95% CI: 24%-40%), respectively (p=0.64),
in the overall population and 35% (95% CI: 24%48%) and 43% (95% CI: 31%-56%), respectively,
for those without CKD or diabetes (p=0.37). In
conclusion, a large white-coat effect was
present among older adults. These data suggest
a role for ambulatory blood pressure
monitoring in preventing potential overtreatment for hypertension among older adults.
R.M. Tanner: None. D. Shimbo: B. Research
Grant; Significant; National Heart, Lung, and
Blood Institute. S. Seals: None. G. Ogedegbe: B.
Research Grant; Significant; National Heart,
Lung, and Blood Institute. P. Muntner: B.
Research Grant; Significant; Amgen, Inc.. G.
Consultant/Advisory Board; Modest; Amgen,
Inc..
P199
Low Diastolic Blood Pressure and Risk of
Stroke in the Setting of Intensive Systolic Blood
Pressure Control: The SPS3 study
Michelle C Odden, Oregon State Univ, Corvallis,
OR; Carmen Peralta, Univ of California, San
Francisco, San Francisco, CA; Leslie McClure,
Univ of Alabama, Birmingham, AL; Carole
White, Univ of Texas Health Sciences Ctr, San
Antonio, TX; Pablo Pergola, Renal Associates PA,
San Antonio, TX; Oscar Benevente, Univ of
British Columbia, Vancouver, BC, Canada; B.
Peter Sawaya, Univ of Kentucky, Lexington, KY
There are conflicting results on the effect of
lowering diastolic blood pressure (DBP) in the
setting of treatment for high systolic blood
pressure (SBP). We examined the impact of DBP
on outcomes in the Secondary Prevention of
Small Subcortical Strokes (SPS3) study. SPS3 is
an international randomized clinical trial of
antiplatelet therapy and optimal level of SBP
control for secondary prevention of lacunar
stroke (NCT00059306). Participants were
randomized to two groups targeting “higher”
(130-149 mmHg), and “lower” (<130 mmHg)
SBP. The primary outcome was all stroke. The
present study includes 2,748 participants
followed for a mean of 3.7 (SD 2.0) years.
Multivariable models were adjusted for
demographic and health variables, baseline SBP
and DBP, randomization group, and medication
use. Over the follow-up period, the mean
achieved DBP was 75 mmHg (5% decrease from
baseline) in the higher group and 69 mmHg
(12% decrease) in the lower group. There was a
J-shaped association between DPB and stroke
(Figure); the lowest risk of stroke was at 67
mmHg. Above this level, higher DBP was
associated with an increased risk of stroke
(adjusted hazard ratio per SD DBP (8.2 mmHg):
1.7, 95% confidence interval: 1.2, 2.3), major
vascular events (1.9, 95% CI: 1.4, 2.5), and
death (1.6, 95% CI: 1.1, 2.3). Below this level,
higher DBP was associated with a lower risk of
stroke (0.45, 95% CI: 0.23, 0.87) and major
vascular events (0.49, 95% CI: 0.26, 0.90), but
not death (1.3, 95% CI: 0.66, 2.7). In conclusion,
among patients with recent lacunar stroke, both
high and very low DBP levels are associated
with an increased risk of stroke. Further study
of the potential harms of very low DBP in the
setting of treatment for SBP is warranted.
M.C. Odden: None. C. Peralta: None. L.
McClure: None. C. White: None. P. Pergola:
None. O. Benevente: None. B.P. Sawaya: None.
P200
HEALS Behavioral Lifestyle Intervention
Through African American Church for
Hypertension Control: A Pilot Study
Sunita Dodani, Sahel Arora, Univ of Florida,
Jacksonville, FL; Claudia Sealey-Potts, Univ of
North Florida, Jacksonville, FL; Dale Kraemer,
Petra Aldridge, Univ of Florida, Jacksonville, FL;
Catherine Christy, Univ of North Florida,
Jacksonville, FL
Objective: Hypertension (HTN), also known as
high blood pressure, is a highly prevalent risk
factor for cardiovascular, cerebrovascular, and
renal diseases, which disproportionately affects
African Americans (AAs). Besides medications,
lifestyle interventions have been effective in
lowering BP. We hereby present a unique, faithbased, socio-culturally tailored, HTN control
program called Healthy Eating And Living
Spiritually (HEALS) in AA churches. The objective
of this pilot study was to develop, implement
and assess the efficacy of HEALS. Methods:
HEALS is a faith-based program that was
developed and modified using the PREMIER
program (including DASH diets) into a culturally
appropriate CBPR program for AA churches.
Trained church members delivered the program
to the high-risk church members. Target
population included church parishioners 25-75
years, with newly diagnosed HTN/pre-HTN or
known HTN as per JNC VII classification. Results:
After the screening process, 51 church
members were eligible, however 36 participants
provided consent and 32 (90%) complete 3months HEALS program and provided
information on study outcomes. At the end of 3
months, there was a reduction of 6.72 mmHg
(p=.04) and 4.02 mmHg (p=.007) in systolic and
diastolic blood pressures, respectively. In
addition to the blood pressure, we recorded a
reduction of 1.7kg (p=.002) in participants’
weight. We also noticed a positive change in the
participants’ nutrition at the end of 3-months.
The nutrition analysis of a 24-recall revealed
that 44% (14 of 32) of participants were in line
with DASH recommendations to consume 2,300
mg of sodium or less per day to lower blood
pressure. Food frequency data showed that
28% (9 of 32) of respondents consumed fruit
every day, with an additional 16% (5 of 32)
consuming fruit every week. Conclusion: This
study presents an efficacious and feasible
model for HTN control using faith-based and
CBPR approaches within AA churches. Program
effectiveness will be assessed in a randomized
controlled design and is underway. If successful,
the long-term goal is to have nationwide
expansion of the HEALS program in AA churches
as well as in other ethnic minority groups with
high hypertension burden to reduce HTN
related health disparities, with potentially a
major public health impact.
S. Dodani: None. S. Arora: None. C. SealeyPotts: None. D. Kraemer: None. P. Aldridge:
None. C. Christy: None.
P201
Rural/Urban Differences in the Prevalence of
Stroke Risk Factors
Erica L. Dawson, Univ Alabama Birmingham,
Birmingham, AL; John Higginbotham, Univ
Alabama, Tuscaloosa, AL; Dawn O. Kleindorfer,
Univ of Cincinnati, Cincinnati, OH; Elsayed Z.
Soliman, Wake Forest Univ, Winston-Salem, NC;
Mary Cushman, Univ of Vermont, Burlington,
VT; Monika M. Safford, Virginia J. Howard, Univ
Alabama Birmingham, Birmingham, AL; Brett M.
Kissela, Univ of Cincinnati, Cincinnati, OH;
Suzanne E. Judd, George Howard, Univ Alabama
Birmingham, Birmingham, AL
Introduction: Despite previously reported
higher stroke (and heart disease) mortality in
rural areas, there are few data on the presence
or magnitude of rural-urban disparities in the
prevalence of stroke risk factors.
Methods: Participants (n = 28,242) of the
REasons for Geographic And Racial Differences
in Stroke (REGARDS) study were categorized
into the 6-level ordinal National Center for
Health Statistics Urban-Rural Classification
Scheme. The prevalence of 6 traditional risk
factors (hypertension, diabetes, cigarette
smoking, atrial fibrillation, left ventricular
hypertrophy and heart disease) and estimated
10-year risk of stroke (indexed by the
Framingham Stroke Risk Function score) was
assessed across the rural-urban scale in models
adjustment for demographic factors (age, race,
sex, and state of residence) and after further
adjustment for community-level socioeconomic
status disadvantage.
Results: Hypertension, diabetes and heart
disease were all more prevalent in rural regions
(p < 0.05); with respective odds 1.25-times (95%
CI: 1.11 - 1.42), 1.15-times (95% CI: 0.99 - 1.33),
and 1.19-times (95% CI: 1.02 - 1.39) greater in
the most rural as compared to the most urban
regions (see Table). The estimated 10-year risk
of stroke was also greater in rural areas;
however, the estimated magnitude of increased
stroke risk was relatively small. Adjustment for
neighborhood-level socioeconomic status
disadvantage attenuated some, but not all, of
these relationships (for example, hypertension
OR: 1.25 to 1.21, diabetes OR: 1.15 to 1.00,
heart disease OR: 1.19 to 1.10).
Discussion: These data suggest that while some
of the increased stroke mortality in rural areas
may be due to an increased burden of stroke
risk factors in rural areas, the contribution of
risk factors is quite inconsistent across the
rural-urban spectrum. This association was
attenuated by the adjustment for
socioeconomic status, which suggests that
some of the higher stroke risk in rural counties
may be due to their lower level of
socioeconomic status.
E.L. Dawson: None. J. Higginbotham:
None. D.O. Kleindorfer: None. E.Z. Soliman:
None. M. Cushman: None. M.M. Safford:
None. V.J. Howard: None. B.M. Kissela:
None. S.E. Judd: None. G. Howard: None.
P202
Association of Masked Hypertension and
Prehypertension with Subclinical
Cardiovascular Disease in the Jackson Heart
Study
Nicole Redmond, John N. Booth III, Rikki M.
Tanner, Univ of Alabama at Birmingham,
Birmingham, AL; Keith M. Diaz, Marwah
Abdalla, Columbia Univ, New York, NY; Mario
Sims, Univ of Mississippi Medical Ctr, Jackson,
MS; Paul M. Muntner, Univ of Alabama at
Background: Masked hypertension (MHT),
defined as non-elevated clinic blood pressure
(CBP) and elevated blood pressure on
ambulatory blood pressure (ABP) monitoring
(ABPM), and prehypertension (PHT) are
individually associated with increased
cardiovascular disease (CVD) risk. The degree of
diagnostic overlap between PHT and MHT and
their associations with subclinical CVD including
left ventricular mass index (LVMI) or common
carotid intima-media thickness (CCIMT) is
poorly characterized among African-Americans
(AAs).
Methods: In the Jackson Heart Study (JHS), a
large community-based cohort of AAs in
Jackson, MS, CBP measurements and 24-hour
ABPM were obtained at baseline (2000-2004)
using standardized protocols. Analyses were
restricted to 391 participants who were not
taking antihypertensive medications with
complete data for CBP, ABPM, LVMI measured
with 2D echocardiography, and CCIMT taken
from carotid ultrasound. Clinic hypertension
(HTN) was defined as ≥140/90 mmHg. Nonelevated CBP was defined as <140/90 mmHg
and includes both PHT (systolic CBP 120-139
mmHg or diastolic CBP 80-89 mmHg) and
normal CBP (<120/80 mmHg). MHT was defined
as non-elevated CBP and elevated ABP (awake
ABP ≥135/85 mmHg).
Results: Of the 391 participants, 74 (18.9%) had
HTN. Among the 317 participants with nonelevated CBP, 185 (58.4%) had PHT and 68
(21.5%) had MHT; 68 (21.5%) had MHT (59 in
those with PHT, and 9 in those with normal
CBP). In a fully-adjusted model (see Table),
compared to participants with both PHT and
MHT, LVMI and CCIMT was less among
participants with non-elevated CBP (including
those with normal CBP and PHT) and without
MHT. There was no difference in LVMI and
CCIMT in individuals with PHT and MHT vs.
those with normal CBP and MHT.
Conclusions: For AAs with non-elevated CBP,
LVMI and CCIMT were the highest among
individuals with MHT, regardless of whether
PHT was present. This finding supports using
ABPM to detect MHT among AAs with nonelevated CBP.
N. Redmond: None. J.N. Booth: None. R.M.
Tanner: None. K.M. Diaz: None. M. Abdalla:
None. M. Sims: None. P.M. Muntner: None. D.
Shimbo: None.
P203
Protective Factors Against Hypertension
Progression Among Non-Hypertensive African
Americans: The Jackson Heart Study
Matthew D Ritchey, Jason Baumgardner,
Fleetwood Loustalot, Giuseppina Imperatore,
Ctrs for Disease Control and Prevention,
Atlanta, GA; Adolfo Correa, Jackson Heart
Study, Jackson, MS
Background: Hypertension (HTN) is a major
cardiovascular disease risk factor. African
Americans are particularly at risk
for developing HTN and having HTN-related
health events. This study aimed to
determine the percentage of the initial
normotensive African American Jackson
Heart Study (JHS) cohort participants who
remained normotensive during
follow-up and factors associated with remaining
normotensive.
Methods: JHS participants without HTN
(i.e., blood pressure (BP) <140/90 mm Hg and
no current antihypertensive
medication use) at baseline exam (2000-2004;
n=1,543; median age: 48.1 years)
were followed and their BP ascertained at exam
2 (2005-2008; median follow-up: 4.8
years). HTN non-progression rates among
participants were described by gender
and baseline age and JNC VI normotensive BP
category (optimal, ≤119/79
mm Hg; normal, 120-129/80-84 mm Hg; and
high normal, 130-139/85-89 mm Hg).
Multivariable logistic regression models,
stratified by gender, examined
possible associations of non-modifiable (e.g.,
age) and modifiable (e.g., cigarette
use) factors with remaining normotensive
(P<.05).
Multiple imputation was used to account for
missing covariate data.
Results: Overall, 64.7% of the participants
remained normotensive at follow-up, including:
62.3% of women; 68.6% of men; 78.9%,
63.7%, and 52.6% of participants aged 18-39,
40-59, and 60-94 years,
respectively; and 79.6%, 60.3%, and 40.2% of
participants with optimal, normal,
or high-normal BP status at baseline,
respectively. Factors associated with
non-progression were identified (Figure).
Conclusion: About two-thirds of JHS
participants who were
normotensive at baseline remained
normotensive after 5 years of follow-up, a
substantially lower rate than reported in other
cohort studies with smaller
proportions of African American participants.
Multiple gender-specific modifiable
protective factors were identified that could be
useful in the development of interventions
to help African Americans remain
normotensive.
M.D. Ritchey: None. J. Baumgardner: None. F.
Loustalot: None. G. Imperatore: None. A.
Correa: None.
P204
Joint Association Between Birth Weight At
Term And Later Life Adherence To A Healthy
Lifestyle With Risk Of Hypertension
Yanping Li, Harvard Sch of Public Health,
Brookline, MA; Sylvia H. Ley, Tyler J.
VanderWeele, Harvard Sch of Public Health,
Boston, MA; Gary C. Curhan, Janet W. RichEdwards, Harvard Medical Sch, Boston, MA;
Willett C. Walter, Harvard Sch of Public Health,
Boston, MA; John P. Forman, Harvard Medical
Sch, Boston, MA; Frank B. Hu, Lu Qi, Harvard
Sch of Public Health, Boston, MA
Objective: to prospectively assesse the joint
association between birth weight and
established lifestyle risk factors in adulthood
with incident hypertension, and to quantity
decompose the attributing effects to birth
weight only, to adulthood lifestyle only and to
their interaction.
Methods: We followed 52,114 women from the
Nurses' Health Study II without
hypercholesterolemia, diabetes, cardiovascular
disease, cancer, prehypertension and
hypertension at baseline (1991-2011). Women
born preterm, of a multiple pregnancy, or who
were missing birth weight data were excluded.
Unhealthy adulthood lifestyle was defined by
compiling status scores of body mass index
(BMI), physical activity, alcohol consumption,
the Dietary Approaches to Stop Hypertension
(DASH) diet, and the use of nonnarcotic
analgesics.
Results: We documented 12,588 incident cases
of hypertension during 20 years of follow-up.
The risk of hypertension associated with a
combination of low birth weight at term and
unhealthy lifestyle factors (RR 1.95; 95%CI:
1.83-2.07) was more than the addition of the
risk associated with each individual factor,
indicating a significant interaction on an
additive scale (Pinteraction<0.001). The proportions
of the association attributable to lower term
birth weight alone, unhealthy lifestyle alone,
and their joint effect were 23.9% (95%CI: 16.631.2), 63.7% (95%CI: 60.4-66.9), and 12.5%
(95%CI: 9.87-15.0), respectively. Compared to
the rest of the cohort, women with a birth
weight at term ≥2.5kg and all the five healthy
lifestyle factors had a multivariable-RR of 0.34
(95%CI: 0.26 to 0.43) for hypertension; and the
PAR% of hypertension for not being in this
group was 66.2% (95%CI: 56.9-73.8).
Conclusion: Our findings suggest that a
combination of a healthy birth weight and a
healthy adulthood lifestyle could prevent 66%
of the cases of hypertension in this population,
and the combined effects of lower birth weight
at term and unhealthy lifestyle with the risk of
hypertension are greater than additive.
Y. Li: None. S.H. Ley: None. T.J. VanderWeele:
None. G.C. Curhan: None. J.W. Rich-Edwards:
None. W.C. Walter: None. J.P. Forman:
None. F.B. Hu: None. L. Qi: None.
P205
Potential Impact of the 2014 High Blood
Pressure Guideline on Adults in China and the
US
Qi Zhao, Tulane Univ, New Orleans, LA;
Wenying Yang, China-Japan Friendship Hosp,
Beijing, China; Lydia A Bazzano, Paul K Whelton,
Chung-Shiuan Chen, Tulane Univ, New Orleans,
LA; Jianzhong Xiao, China-Japan Friendship
Hosp, Beijing, China; Jiang He, Tulane Univ, New
Orleans, LA
Introduction Compared with the JNC 7
guideline, the 2014 evidence-based guideline
for the management of high blood pressure
(BP) relaxed the BP thresholds for initiating drug
treatment and treatment goals for older adults
(≥60 years) and for those with diabetes and
chronic kidney disease.
Hypothesis The aim of this study was to
estimate the proportions and absolute numbers
of adults who would be potentially affected by
the new guideline and to compare their
cardiovascular disease (CVD) risks with the total
adult populations in China and the US,
respectively.
Methods Data from the China National
Diabetes and Metabolic Disorders Study
conducted in 2007-08 (n=40,071) and the US
NHANES conducted in 2005-12 (n=9,922) were
used in this analysis. Both studies were
conducted in nationally representative samples
using standard measurement methods.
Results Among Chinese and US adults (≥20
years) who were eligible for treatment under
JNC 7, 11.5% (95% CI, 10.4-12.6%; 32.5 million)
and 5.0% (95% CI, 4.2-6.0%; 3.5 million) would
not meet criteria for initiating drug treatment
under 2014 guidelines, while 3.0% (95% CI,
2.3%-4.0%; 8.5 million) and 9.1% (95% CI, 8.0%10.4%; 6.3 million) would be reclassified as
meeting BP goals, respectively. Furthermore,
50.8% (95% CI, 48.5-53.1%) of US and 7.5%
(95% CI, 6.7%-8.4%) of Chinese adults who were
eligible for treatment under JNC 7 had met
more stringent JNC 7 goals by treatment and
would require less intensive or no treatment
under the 2014 guideline. Compared to the
total adult population and treated patients at
JNC 7 goal, those who were potentially affected
by the 2014 guideline had greater CVD risks in
both China and the US (Table).
Conclusion The 2014 BP guideline will affect BP
control in a substantial proportion of
hypertensive patients in both China and the US.
More worrisome, those affected are at greater
risk for CVD compared to the total adult
population and hypertensive patients treated to
the JNC 7 BP goal in both countries.
Q. Zhao: None. W. Yang: None. L.A. Bazzano:
None. P.K. Whelton: None. C. Chen: None. J.
Xiao: None. J. He: None.
P206
Ambulatory Blood Pressure Monitoring
Phenotypes Among Individuals With and
Without Diabetes: The Jackson Heart Study
Samantha G Bromfield, Univ of Alabama at
Columbia Univ, New York, NY; Alain Bertoni,
Wake Forest Baptist Medical Inst, WinstonSalem, NC; Mario Sims, Univ of Mississippi
Medical Ctr, Jackson, MS; April P Carson, Paul
Muntner, Univ of Alabama at Birmingham,
Birmingham, AL
Several ambulatory blood pressure monitoring
(ABPM) phenotypes including masked
hypertension are associated with an increased
risk for cardiovascular disease (CVD). Diabetes is
associated with CVD risk as well as a higher
prevalence of hypertension. However, little is
known about whether ABPM phenotypes differ
between individuals with versus without
diabetes. We evaluated the association
between diabetes and ABPM phenotypes
including clinic hypertension, awake
hypertension, sustained hypertension,
nocturnal hypertension, non-dipping pattern,
white coat hypertension, and masked
hypertension in the Jackson Heart Study (JHS).
Baseline data collection included two clinic
blood pressure measurements using
standardized protocols. ABPM measurements
were taken in the 24 hours following the
baseline visit. Diabetes was defined as fasting
glucose ≥126 mg/dL, hemoglobin A1c ≥6.5%, or
use of diabetes medications. Of the 1,032 JHS
participants with valid ABPM data (67.7%
female, mean age 59.2 years), 253 (24.5%) had
diabetes. The prevalence of clinic hypertension
was similar for participants with and without
diabetes (Table 1). After multivariable
adjustment, diabetes was associated with an
increased prevalence ratio of awake, sustained,
and masked hypertension and a lower
prevalence ratio of white coat hypertension
compared with individuals without diabetes. In
summary, there was an increased prevalence of
adverse blood pressure phenotypes among
individuals with versus those without diabetes
that was not captured in the clinic setting alone.
The role of ABPM for identifying high risk
individuals with diabetes should be further
investigated.
S.G. Bromfield: None. D. Shimbo: None. A.
Bertoni: None. M. Sims: None. A.P. Carson: B.
Research Grant; Modest; Amgen Inc. P.
Muntner: B. Research Grant; Significant; Amgen
Inc.
P207
Incidence of Hypertension in Colombia Similar
to That Observed Decades Ago in Developed
Countries: An Observation From the
Chicamocha Cohort Study
Juan C. Villar, Luz X. Martínez, Yeny Z.
Castellanos, Skarlet M. Vásquez, Víctor M.
Herrera, Univ Autónoma de Bucaramanga,
Floridablanca, Colombia
Background. Overweight is a modifiable risk
factor for high blood pressure (BP). Despite the
increasing prevalence of both conditions in the
Latin American population, there are no
estimates of either the incidence of
hypertension or the impact of overweight on it
that inform the design and evaluation of
individual and community-based preventive
interventions in the region. Methods. We
conducted a prospective cohort study in a
sample of normotensive, blood donors from
Bucaramanga, Colombia, who were free of
transfusion-transmitted infectious and
cardiovascular diseases at baseline. Participants
were re-evaluated after a median follow-up of
12 years to determine the incidence of
hypertension defined as: 1) Self-reported
diagnosis with evidence of pharmacological
treatment; 2) Systolic BP >140 mmHg or
diastolic BP >90 mmHg (average of two
measures in seated position); or 3) Current
systolic/diastolic BP >120/80 mmHg with
evidence of increments >10/5 mmHg from
baseline. We estimated crude incidence rates of
hypertension and age- and sex-adjusted hazard
ratios (HRs) for baseline overweight (body mass
index ≥25 kg/m2) using Cox regression analysis.
The population attributable fraction (PAF) for
overweight was also assessed. Results. We
followed 594 participants (baseline mean age =
38.0 years; 64% male; adherence rate = 78%) at
risk of hypertension among which we observed
164 incident cases: Cumulative incidence of
27.6%; incidence rate of 23.4 cases per 1,000
person-years. Incidence rate was similar in men
and women (23.4 vs. 23.2 per 1,000 personyears; p>0.05) and tended to increase with age
(17.4, 21.2, and 27.8 per 1,000 person-years
among participants <30, 30-39, and ≥40 years
old, respectively; p>0.05). Participants with
overweight at baseline had twice the risk of
developing hypertension than participants with
normal weight (adjusted-HR = 2.00, 95%CI:
1.11, 3.61). The estimated PAF was 25.7%,
considering a national prevalence of overweight
equal to 34.6%. Conclusion. The incidence of
hypertension in our study is similar to that
reported two decades ago in cohorts from
developed countries, which is consisting with
the ongoing epidemiological transition in Latin
America. We also confirmed the role of
overweight as a risk factor for hypertension,
accounting for about 1 out 4 incident cases. This
finding highlights the importance of addressing
overweight in our population.
J.C. Villar: None. L.X. Martínez: None. Y.Z.
Castellanos: None. S.M. Vásquez: None. V.M.
Herrera: None.
P208
Comparison of Hypertension and Treatment
Prevalence Across Geographic Regions in Three
National Surveys
Angela M Thompson-Paul, Jason L.
Baumgardner, Cathleen Gillespie, Jing Fang,
Fleetwood Loustalot, Ctrs for Disease Control
and Prevention, Chamblee, GA
Background: Geographic disparities have been
reported in prevalence, awareness, and
treatment of hypertension. Several communitybased national surveillance systems assess
hypertension allowing for comparison of
estimates. The objectives of this study were to
compare hypertension estimates across surveys
and to examine geographic differences in the
findings.
Methods: Using data from the National Health
and Nutrition Examination Survey (NHANES)
2007-2010, the National Health Interview
Survey (NHIS) 2008, and the Behavioral Risk
Factor Surveillance Survey (BRFSS) 2009, we
calculated prevalence estimates of measured
hypertension (an average systolic BP ≥140 mm
Hg or an average diastolic BP ≥90 mm Hg or
self-reported current use of BP-lowering
medication), self-reported hypertension (having
ever been told that one has hypertension), and
treatment, nationally and regionally.
Results: Nationally, 30.5% of adults have
hypertension with higher prevalence in the
Midwest (33.0%) and South (32.6%) and lower
prevalence in the West (26.0%) and Northeast
(28.0%) (NHANES). In all surveys, self-reported
hypertension was highest in the South (range:
31.1% [NHIS] - 32.8% [NHANES],) and lowest in
the West (range: 23.6% [NHIS] - 27.0% [BRFSS]).
In all surveys and all regions, more than twothirds of participants who were aware of their
high blood pressure reported receiving
treatment. Treatment prevalence was lowest in
the West (range: 69.7% [NHIS] - 74.5% [BRFSS]),
highest in the South in NHIS (77.5%) and BRFSS
(81.4%), and highest in the Northeast in
NHANES (78.3%).
Conclusions: Similar estimates showing regional
differences in measured and self-reported
hypertension and treatment were found across
all three national surveys. In addition, low
treatment has been identified in regions with
low prevalence. As recognized in many national
initiatives (e.g., Million Hearts), improving
hypertension treatment and control requires
multi-level interventions across community and
clinical settings.
A.M. Thompson-Paul: None. J.L. Baumgardner:
None. C. Gillespie: None. J. Fang: None. F.
Loustalot: None.
P209
Proportion of Brazilian Adults Potentially
Affected by the 2014 Hypertension Guideline
(“2014 BP guideline”). Results from ELSABrasil.
Paulo A Lotufo, Univ of Sao Paulo, Sao Paulo,
Brazil; Paulo R Vasconcelos, Oswaldo Cruz Fndn,
Rio de Janeiro, Brazil; Marcio S Bittencourt, Univ
of Sao Paulo, Sao Paulo, Brazil; Dora Chor,
Oswaldo Cruz Fndn, Rio de Janeiro, Brazil;
Isabela M Bensenor, Univ of Sao Paulo, Sao
Paulo, Brazil
Introduction: The new 2014 hypertension
guideline released by the panel members
appointed to the Eighth Joint National
Committee (“2014 BP guideline”) proposed less
restrictive blood pressure targets for adults
older than 60 years and for those with diabetes
and renal impairment.
the proportion of Brazilian aged 35-74 years-old
potentially affected by new proposals for
management of hypertension will be different
according to age-strata.
Methods: We evaluated hypertension control
and treatment and the proportion of
participants estimated to meet guideline-based
blood pressure targets under the 2014
hypertension guideline and under the previous
seventh Joint National Committee on
Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 7)
guideline using data from the Brazilian
Longitudinal Study of Adult Health (ELSA-Brasil)
with 15105 participants enrolled between 20082010 living in six different cities.
Results: The proportion of adults (35-59 years)
with treatment-eligible hypertension under the
JNC 7 guideline was 31.3 % (95%Confidence
Interval, 30.5%-32.1%) and decreased to 29.8 %
(29.0%-30.6%) under the 2014 BP guideline.
Larger declines were observed among older
adults (60-74 years), decreasing from 60.6%
(58.9%-62.3%) under JNC7 to 55.8% (54.1%57.5%) under the “2014 BP guideline”. Overall,
the proportion of adults with treatment-eligible
hypertension who may be eligible for less
stringent or no blood pressure therapy
decreased 2.2% (1.9%-2.3%). This difference
was more pronounced among men, 2.7% (
2.3%-3.1%) compared to women, 1.8% (1.5%2.5%): people aged 60-74 years-old, 4.5% (3.8%5.2%) compared to younger participants, 1.5%
(1.3%-1.7%); people with diabetes, 5.6% (4.0%5.2%) compared to participants without
diabetes, 1.4% (1.2%-1.6%); and among
participants who had glomerular filtration rate
fewer than 60 ml/min/1.72 m2, 11.5% (9.5%13.5%) compared to people with normal renal
function, 1.5% (1.3%-1.7%). No differences
were observed according to race or previous
cardiovascular diseases. Regard to control of
blood pressure, the proportion of treated
participants who achieved the BP targets
increased slightly among participants aged 6074 years from 53.3% (51.6%-55.0%) for the JNC7 definition to 56.7% (55.0%-58.4%) under the
2014 BP guideline. In contrast, for people aged
35-59 years, the proportion of people under BP
control was reduced from 55.5% (54.7%-56.3%)
for the JNC7 definition to 53.8% (53.0%-54.6%)
under the 2014 BP guideline.
Conclusion: Compared with the JNC 7 guideline,
the 2014 BP guideline was associated with a
reduction in the proportion of Brazilian aged
35-74 year recommended for hypertension
treatment and a modest increase in the
proportion of elderly considered to have
achieved goal blood pressure.
P.A. Lotufo: None. P.R. Vasconcelos:
None. M.S. Bittencourt: None. D. Chor:
None. I.M. Bensenor: None.
P210
Lipoprotein Profiles in Patients With and
Without Psoriasis
Paulo A Lotufo, Univ of Sao Paulo, Sao Paulo,
Brazil; Steven Jones, Michael Blaha, Johns
Hopkins Univ, Baltimore, MD; Cid Sabbag, Raul
Dias-Santos, Univ of Sao Paulo, Sao Paulo,
Brazil; Peter P Toth, Univ of Illinois, Chicago, IL;
Isabela M Bensenor, Univ of Sao Paulo, Sao
Paulo, Brazil
Introduction: Psoriasis is associated with
chronically heightened systemic inflammatory
tone and increased risk for cardiovascular
disease. It remains to be established if the
psoriatic state itself associates with
dyslipidemia.
Hypothesis: The lipid profile of patients with
psoriasis is more atherogenic compared to
disease-free control patients.
Methods: The concentration and size of
lipoprotein particles were measured using
nuclear magnetic resonance spectroscopy in
221 patients with a diagnosis of psoriasis (53.6%
men; mean age=56.6 years; mild cases=31%;
moderate/severe only skin=27%;
arthritis=27%)) and 689 disease-free persons
matched by sex and age. We compared means
of lipoprotein particle concentration and size
using a univariate general linear model and
adjusting for body-mass index, waist
circumference, diabetes, use of lipid loweringdrugs, as well as duration/severity of psoriasis.
Results: Patients with psoriasis were more
overweight, had larger waist circumference,
and a higher frequency of diabetes and use of
lipid-lowering drugs. Total LDL particle means
(nmol/L) for the psoriasis and control groups
were 1436 (1378-1494) vs. 1420 (1388-1452)
(P=0.4), respectively. The mean concentration
of IDL was higher in patients with psoriasis
compared to controls: 143.6 (130.7-156.5) vs.
106.1 (99.1-113.2), P<0.01. Large and small LDL
particle concentrations were similar between
groups. Large VLDL/chylomicron particle
concentrations (nmol/L) were higher in
psoriasis patients compared to controls 6.1 (5.27.0) vs. 4.0 (3.6-4.5) (P<0.01). Total HDL particle
and subfractions were not statistically different
between groups. The mean size (nm) of VLDL
was higher in psoriasis patients: 50.2 (49.2-51.2)
vs. 46.2 (45.6-46.7) (P<0.001) for psoriasis and
controls, respectively. In contrast, mean sizes of
LDL and HDL particles were similar (P=0.3).
Adjustment for covariates above mentioned did
not change these findings. The
absence/presence of arthritis did not change
the results.
Conclusion: Patients with psoriasis have a more
atherogenic lipid profile compared to controls
with higher levels of IDL and VLDL of large and
small size. In addition, the greater mean size of
VLDL particles in psoriasis compared to controls
suggests enhanced secretion of triglyceride
loaded VLDL, impaired lipolysis and impaired
clearance of remnant IDL.
P.A. Lotufo: None. S. Jones: B. Research Grant;
Modest; Atherotech. G. Consultant/Advisory
Board; Modest; Atherotech. M. Blaha: None. C.
Sabbag: None. R. Dias-Santos: D. Speakers
Bureau; Modest; Astra Zeneca, Genzyne,
Amgen, Sanofi. G. Consultant/Advisory Board;
Modest; Pfizer, Eli Lilly. P.P. Toth: None. I.M.
Bensenor: None.
P211
Age-Related Trajectories of Lipids and
Lipoproteins: The Impact of Cardiorespiratory
Fitness
Yong-Moon Park, Xuemei Sui, Junxiu Liu, Arnold
Sch of Public Health, Univ of South Carolina,
Columbia, SC; Haiming Zhou, Sch of Art and
Science, Univ of South Carolina, Columbia, SC;
Peter F Kokkinos, Veterans Affairs Medical Ctr,
Washington, DC; Carl J Lavie, Carl J Lavie, John
Ochsner Heart and Vascular Inst, Ochsner
Clinical Sch, Univ of Queensland Sch of Med,
New Orleans, LA; Steven N Blair, Arnold Sch of
Public Health, Univ of South Carolina, Columbia,
SC
Introduction: Although age-related longitudinal
changes of lipids and lipoproteins have been
described, there are limited data on these
trajectories for the life course in adults.
Furthermore, evidence on the effect of
cardiorespiratory fitness (CRF) on these
trajectories is scarce.
Hypothesis: We assessed the longitudinal, aging
trajectory of total cholesterol (TC), low-density
lipoprotein cholesterol (LDL-C), triglycerides
(TG), high-density lipoprotein cholesterol (HDLC) and non- high-density lipoprotein cholesterol
(non-HDL-C), and then determined whether CRF
modifies the age-associated trajectory of TC,
LDL-C, TG, HDL-C, and non-HDL-C in healthy
men.
Methods: Data came from 11,418 men aged 2090 years without known high cholesterol, high
triglycerides, cardiovascular disease, and cancer
at baseline and during the follow-up from the
Aerobics Center Longitudinal Study. There were
43,821 observations spanning from 2 to 25
(mean, 3.5) health examinations between 1970
and 2006. CRF was quantified by a maximal
treadmill exercise test. Marginal models using
generalized estimating equations were applied.
Results: TC, LDL-C, TG, and non-HDL-C
presented similar inverted U-shaped quadratic
trajectories with aging in which gradual
increases were noted until the middle 40s to
the early 50s with the subsequent declines (all
P<0.0001); whereas HDL-C showed a steady
increase with aging (P<0.0001). CRF was
consistently shown as a protective factor for
abnormal lipid and lipoprotein profiles, and this
prominent effect most appears between early
20s and early 60s for TC, LDL-C, and non-HDL-C;
early 20s and mid 70s for TG and HDL-C.
Compared to men with higher CRF, those with
lower CRF developed abnormal values around
middle 20s through late 30s: TC (≥200 mg/dl),
LDL-C (≥130 mg/dl), non-HDL-C (≥160 mg/dl),
and TG/HDL-C ratio (≥3.0). Especially, abnormal
values for TC and LDL-C in men with low CRF
were observed around 15 years earlier
compared to those with high CRF, respectively.
After adjusting for time varying covariates such
as waist circumference, percent body fat,
fasting plasma glucose, systolic and diastolic
blood pressure, smoking status, alcohol drinking
status, and physical activity habit, a significant
interaction was found between age and CRF in
each trajectory, indicating that CRF was more
strongly associated with the aging trajectories
of lipids and lipoproteins in young to middleaged men than in older men.
Conclusions: Our investigation reveals a
differential trajectory of lipids and lipoproteins
with aging according to CRF in healthy men, and
suggests that promoting increased CRF levels
may help delay the development of
dyslipidemia.
Y. Park: None. X. Sui: None. J. Liu: None. H.
Zhou: None. P.F. Kokkinos: None. C.J. Lavie:
None. C.J. Lavie: None. S.N. Blair: None.
P212
Reduced High-Density Lipoprotein Efflux in
Psoriasis Relates to Increased Coronary Plaque
Burden by Quantitative CT Angiography
Taufiq Salahuddin, Balaji Natarajan, Mariana
Selwaness, Ahmed Sadek, Martin Playford, Julia
Doveikis, David Bluemke, Nehal N Mehta, Natl
Heart, Lung and Blood Inst, Bethesda, MD
INTRODUCTION
Psoriasis is known to increase cardiovascular
risk, possibly due to the presence of
inflammatory, lipid-rich, non-calcified plaques
in the coronary arteries. Psoriasis is also known
to decrease HDL activity. However, whether
having abnormal or low-functioning HDL
increases arterial disease is currently unknown.
HYPOTHESIS
We aimed to test our hypothesis that coronary
plaque burden assessed by quantitative CT
angiography is related to HDL efflux capacity
and other cardiometabolic parameters in a wellphenotyped psoriasis cohort (NCT# 01778569).
METHODS
Psoriasis patients (N=67) underwent coronary
CT angiography (Toshiba 320 slice). Coronary
plaque was assessed using QAngio CT (Medis,
The Netherlands). Total (TB), dense calcium
(DCB), and non-calcified burden (NCB) plaque
indices were calculated by dividing total vessel
plaque volume by total vessel length. We also
performed deep phenotyping for lipid markers
including HDL efflux capacity and other
cardiometabolic parameters.
RESULTS
The study population was middle aged (52.2 ±
12.4 yr), had relatively low Framingham Risk
Score (median 4%, IQR 2-7%), and had normal
Apo A1 (156 ± 26.3 mg/dL) and HDL levels (54 ±
17 mg/dL). However, HDL efflux capacity was
similar to that in coronary artery disease (0.95 ±
0.17). In univariate regression, NCB increased as
HDL efflux capacity decreased (β= -0.84, p=0.01)
and was robust to adjustment for
cardiometabolic risk factors (β= -0.67, p=0.03).
Furthermore, when stratified by median HDL
efflux (0.94), patients having lower HDL efflux
capacity had higher TB and NCB (TB 3.80 ± 0.82,
4.17 ± 0.97 mm2, p=0.003; NCB 3.59 ± 0.68, 3.94
± 0.75 mm2, p=0.001 in the low and high HDL
efflux groups, respectively). Additional biologic
relations in univariate regression are shown in
Table 1.
CONCLUSIONS
We show that HDL efflux is negatively
associated with coronary plaque burden
measured by quantitative CT angiography. Low
HDL efflux may therefore be a strong biomarker
for subclinical coronary atherosclerosis.
T. Salahuddin: None. B. Natarajan: None. M.
Selwaness: None. A. Sadek: None. M. Playford:
None. J. Doveikis: None. D. Bluemke:
None. N.N. Mehta: None.
P213
Regular Exercise Improves the Lipoprotein
Subclass Profile: Meta-Analysis of 10 Exercise
Training Intervention Groups
Mark A Sarzynski, Tuomo Rankinen, Jeffrey
Burton, Timothy S Church, Pennington
Biomedical Res Ctr, Baton Rouge, LA; JeanPierre Després, Ctr de Recherche de l'Inst
Univire de Cardiologie et de Pneumologie de
Québec, Québec City, QC, Canada; James M
Hagberg, Univ of Maryland, College Park, MD;
Arthur S. Leon, Univ of Minnesota, Minneapolis,
MN; Catherine R. Mikus, Duke Univ Sch of Med,
Durham, NC; Dabeeru C. Rao, Washington Univ
Sch of Med, St. Louis, MO; Richard L. Seip,
Hartford Hosp, Hartford, CT; James S. Skinner,
Indiana Univ, Bloomington, IN; Cris A. Slentz,
Duke Univ Sch of Med, Durham, NC; Paul D
Thompson, Hartford Hosp, Hartford, CT;
Kenneth R Wilund, Univ of Illinois, UrbanaChampaign, IL; William E. Kraus, Duke Univ Sch
of Med, Durham, NC; Claude Bouchard,
Pennington Biomedical Res Ctr, Baton Rouge,
LA
OBJECTIVE: The goal was to examine
lipoprotein subclass responses to regular
exercise as measured in 10 exercise
interventions derived from six cohorts. We
hypothesized that regular exercise has
beneficial effects on the overall lipoprotein
subclass profile in previously sedentary adults.
METHODS: NMR spectroscopy (LipoScience Inc.,
Raleigh, NC) was used to quantify average
particle size, total and subclass concentrations
of very low-density lipoprotein, low-density
lipoprotein, and high-density lipoprotein
particles (VLDL-P, LDL-P, and HDL-P
respectively) before and after an exercise
intervention in 1,430 adults from six studies,
encompassing 10 exercise training groups:
APOE (N=106), DREW (N=298), GERS (N=79),
HERITAGE (N=715), STRRIDE I (N=130) and II
(N=102). Random-effects meta-analysis was
performed to quantify the overall mean change
across the unadjusted and adjusted mean
change estimates from each exercise group of
each study. A Bonferroni-adjusted p-value ≤
0.003 was considered statistically significant.
RESULTS: Meta-analysis of unadjusted data
found that regular exercise induced significant
decreases in the concentration of large VLDL-P
(P=1.2x10-6) and mean VLDL-P size (P=9.0x10-5),
with significant increases in the concentration
of large LDL-P (P=4.9x10-13). The changes in
large VLDL-P and large LDL-P concentration and
VLDL-P size remained significant after
adjustment for age, sex, race, baseline body
mass index, and baseline trait value (Figure 1);
while the increase in LDL-P size (P=0.003)
became significant after adjustment. Nominally
significant decreases in the concentration of
small LDL-P (P=0.004) and medium HDL-P
(P=0.007) and increases in large HDL-P
(P=0.008) were observed in the adjusted metaanalysis.
CONCLUSIONS: Despite differences in exercise
programs and study populations, regular
exercise led to significant improvements in the
lipoprotein subclass profile across 10 exercise
interventions, as highlighted by changes in VLDL
and LDL subfractions.
M.A. Sarzynski: None. T. Rankinen: None. J.
Burton: None. T.S. Church: None. J. Després:
None. J.M. Hagberg: None. A.S. Leon:
None. C.R. Mikus: None. D.C. Rao: None. R.L.
Seip: None. J.S. Skinner: None. C.A. Slentz:
None. P.D. Thompson: None. K.R. Wilund:
None. W.E. Kraus: None. C. Bouchard: None.
P214
Patient and Physician Factors Influence
Decision-Making in Hypercholesterolemia
Michel Krempf, Hôpital Laënnec, Nantes,
France; Ross J Simpson Jr., Univ of North
Carolina, Chapel Hill, NC; Dena R Ramey, Merck
& Co, Inc, Whitehouse Station, NJ; Philippe
Brudi, Merck & Co, Whitehouse Station, NJ;
Hilde Giezek, MSD Inc, Brussels, Belgium;
Raymond Lee, Merck & Co, Inc, Whitehouse
Station, NJ; Michel Farnier, Point Medical, Dijon,
France
Objectives: Little is known about how patient
factors influence physicians’ treatment
decision-making in hypercholesterolemia. We
surveyed physicians’ treatment
recommendations in high-risk patients with
LDL-C not controlled on statin monotherapy.
Methods: Physicians completed a questionnaire
pre-randomization for each patient in a doubleblind trial (NCT01154036) assessing LDL-C goal
attainment rates with different treatment
strategies. Patients had LDL-C ≥100 mg/dL after
5 weeks’ atorvastatin 10 mg/day and before
randomization. Physicians were asked about
treatment recommendations for three
scenarios: (1) LDL-C near goal (100-105 mg/dL),
(2) LDL-C far from goal (120 mg/dL), then (3)
known baseline LDL-C of enrolled patients on
atorvastatin 10 mg/day. Factors considered in
their choice were specified. Physicians had been
informed of projected LDL-C reductions for each
treatment strategy in the trial. Regression
analysis identified prognostic factors associated
with each scenario, and projected LDL-C values
for physicians’ treatment choices were
compared to actual LDL-C values achieved in
the trial.
Results: Physicians at 296 sites completed
questionnaires for 1535 patients. The most
common treatment strategies for all three
scenarios were: 1) not to change therapy, 2)
double atorvastatin dose, 3) add ezetimibe, 4)
double atorvastatin dose and add ezetimibe.
Doubling atorvastatin dose was the most
common treatment recommendation in all
scenarios (43-52% of patients). ‘No change in
therapy’ was recommended in 6.5% of patients
when LDL-C was assumed far from goal.
Treatment recommendations were more
aggressive if actual LDL-C was known or
considered far from goal. When compared with
the ‘no change in therapy’ recommendation, CV
risk factors and desire to achieve a more
aggressive LDL-C goal were generally
considered in decision-making for each
treatment choice, regardless of LDL-C scenario.
Patients randomized to a more aggressive
regimen than recommended by physicians had
larger reductions in LDL-C: the actual reduction
in LDL-C in patients randomized to ‘add
ezetimibe’ was -20.8% versus a projected
reduction of -10.0% when physicians
recommended ‘doubling atorvastatin dose’.
Conclusions: This study provides insight into
physicians’ perspectives on clinical
management of hypercholesterolemia and
highlights a gap in knowledge translation from
guidelines to clinical practice. Targeting lower
LDL-C and CV risk were key drivers in clinical
decision-making but, generally, physicians were
more conservative in their treatment choice
than guidelines recommend, which may result
in poorer LDL-C reduction. When compared
with actual outcomes, projected LDL-C control
was better if physicians used more
comprehensive strategies rather than simply
doubling the statin dose.
M. Krempf: B. Research Grant; Modest;
Abbott, Amgen, Astra Zeneca, BMS, Merck and
Co, Novartis, Pfizer, Roche, Sanofi-Aventis. G.
Consultant/Advisory Board; Modest; Abbott,
Amgen, Astra Zeneca, BMS, Merck and Co,
Novartis, Pfizer, Roche, Sanofi-Aventis. R.J.
Simpson: C. Other Research Support;
Significant; Merck, Amgen. E. Honoraria;
Significant; Merck, Pfizer. D.R. Ramey: A.
Employment; Significant; Merck & Co, Inc.. F.
Ownership Interest; Modest; Merck. P. Brudi: A.
Employment; Significant; Merck & Co, Inc. H.
Giezek: A. Employment; Significant; Merck &
Co, Inc. R. Lee: A. Employment; Significant;
Merck & Co, Inc. M. Farnier: C. Other Research
Support; Significant; Amgen, Merck, Sanofi. D.
Speakers Bureau; Modest; Amgen, Sanofi. D.
Speakers Bureau; Significant; Merck. E.
Honoraria; Modest; Abbott, Eli Lilly, Pfizer. G.
AstraZeneca, Roche, Kowa, Recordati, SMB, Eli
Lilly. G. Consultant/Advisory Board; Significant;
Amgen, Sanofi, Merck.
P215
Associations of Yerba Mate Tea Drinking With
Blood Lipids, Apolipoproteins, and C-Reactive
Protein Among South American Adults
Natalia Elorriaga, Rosana Poggio, Laura
Gutierrez, Vilma E Irazola, Maria D Defago,
Gabriela Corrmick, IECS, Ciudad Autónoma de
Buenos Aires, Argentina; Goodarz Danaei,
Dariush Mozaffarian, Tuft Univ, Boston, MA;
Adolfo L Rubinstein, IECS, Ciudad Autónoma de
Buenos Aires, Argentina
Background- Yerba mate tea, made from tree
leaves of Ilex paraguariensis, is a widely
consumed beverage in South America. Animal
studies have reported improvement in serum
lipids parameters and reduction in cholesterol
content and size of aortic lesions with
consumption of ilex paraguariensis extracts,
that contain potentially bioactive saponin,
phenolic compounds and methilxanthines. Few
studies have been conducted in humans, mostly
pilot studies. Evidence on the association
between mate tea consumption and lipid
profile, Apolipoprotein (Apo) AI, Apo B and Creactive protein (CRP) in humans are sparse. We
assessed these associations among adults from
Argentina, Chile and Uruguay.
Methods- CESCAS I (Center of Excellence in
Cardiovascular Health of South America Study I)
study is an observational population-based
prospective cohort study of 7,600 participants
from general population of four cities in the
three countries. We conducted a cross-sectional
analysis in a randomly selected subsample of
988 subjects aged 35 to 74 years. Participants
with previous cardiovascular events or receiving
lipid-lowering agents were excluded. Mate
consumption and other dietary habits were
assessed using a previously validated 126-item
food frequency questionnaire. Multivariable
linear regression models were used to examine
the associations between Apo AI, B, CRP, and
other lipids by tertiles (T) of mate tea
consumption. The models adjusted for age,
smoking status, body mass index, physical
activity, alcohol intake, ‘prudent’ or ‘Western’
diet-pattern scores (identified by principal
component analysis), added sugar to the mate,
and presence of diabetes.
Results- The sample included 418 men and 570
women. The proportion of mate drinkers (at
least once a month during last year) were 40%
in Temuco (Chile), 84% in Canelones (Uruguay),
89% in Marcos Paz and 91% in Bariloche
(Argentina). Median mate intake across tertiles
was 0, 590 and 1875ml/day in men and 0, 625
and 1875ml/day in women, respectively. Higher
mate consumption (T3 vs. T1) was
independently associated with higher levels of
Apo AI in both men (5.1mg/L, 95% CI, 0.1 to
10.1) and women (6.7mg/L, 95% CI, 1.5 to 11.9).
In men higher mate consumption was also
associated with lower levels of triglycerides (49mg/dL, 95% CI, -11 to -86) and in women with
slightly lower Apo B/AI ratio (-0.05, 95% CI, 0.001 to -0.06). Differences in total cholesterol,
HDL cholesterol, LDL cholesterol, Apo B, and
CRP were not statistically significant.
Conclusions-Among generally healthy adults,
higher consumption of mate during the past 12
months was associated with higher levels of
APO-A1 in both men and women, and with
lower triglycerides levels in men.
N. Elorriaga: None. R. Poggio: None. L.
Gutierrez: None. V.E. Irazola: None. M.D.
Defago: None. G. Corrmick: None. G. Danaei:
None. D. Mozaffarian: None. A.L. Rubinstein:
None.
P216
The Association Between Reduction in
Inflammation and Changes in Lipoprotein
Levels and HDL Cholesterol Efflux Capacity in
Rheumatoid Arthritis
Katherine Liao, Brigham and Women's Hosp,
Boston, MA; Martin Playford, NIH/NHLBI,
Bethesda, MD; Michelle Frits, Jonathan Coblyn,
Christine Iannaccone, Michael Weinblatt, Nancy
Shadick, Brigham and Women's Hosp, Boston,
MA; Nehal Mehta, NIH/NHLBI, Bethesda, MD
Background
Potent anti-inflammatory RA treatments are
associated with reduced cardiovascular (CV)
risk as well as increases in low density
lipoprotein (LDL). This apparent paradox may
be explained by favorable changes in other
lipid measurements. The objective of this
study was to determine the longitudinal
association between changes in inflammation
with advanced lipoprotein measurements and
HDL cholesterol efflux capacity.
Methods and Results
We conducted this study in a longitudinal RA
cohort from a large academic center. We
included subjects with hsCRP reduction
≥10mg/L at two time points one year apart.
Subjects on statins during the study period or 6
months prior were excluded. We measured
total cholesterol (TC), LDL, high density
lipoprotein (HDL), apolipoprotein B (apoB),
apoA1, and HDL cholesterol efflux capacity at
baseline and one year follow-up. We
determined the correlations between
reduction in hsCRP and change in lipid
parameters using the Pearson test.
We studied 90 RA subjects, mean age 57 years,
89% female, all subjects were on disease
modifying anti-rheumatic drugs; median
baseline hsCRP was 28.6mg/L and follow-up
4.3 mg/L (reduction of 85%, p<0.0001). We
observed significant correlations between a
reduction in hsCRP with increases in LDL
(r=0.25,p=0.02, Figure 1a), HDL (r=0.23,
p=0.03), apoA1 (r=0.27, p=0.01 and HDL
cholesterol efflux capacity (r=0.24, p=0.02), an
overall improvement of efflux capacity of 5.7%
(p=5x10-4, Figure 1b).
Conclusion
Reduction in inflammation was associated
increased LDL levels, and concomitant
increases in HDL, ApoA1, and improvements in
HDL cholesterol efflux capacity. These findings
provide further insight into lipid modulation
and the beneficial effect of reduction in
inflammation on lipids in vivo.
K. Liao: None. M. Playford: None. M. Frits:
None. J. Coblyn: G. Consultant/Advisory Board;
Modest; CVS-Caremark. C. Iannaccone: None.
M. Weinblatt: B. Research Grant; Significant;
Bristol Myers Squibb, UCB, Crescendo
Bioscience. G. Consultant/Advisory Board;
Modest; Medimmune, AstraZeneca, Amgen,
Abbvie, Bristol Myers Squibb, Crescendo
Bioscience, Lilly, Pfizer, UCB, Roche. N. Shadick:
B. Research Grant; Significant; Crescendo
Bioscience, Amgen, UCB, Abbvie, Bristol Myers
Squibb, Genentech. N. Mehta: None.
P217
Reduced Lipoprotein-Associated
Phospholipase A2 Activity Levels are Linked to
Apolipoprotein C3 Loss-of-Function Mutations:
The Atherosclerosis Risk in Communities Study
Yashashwi Pokharel, Wensheng Sun, Baylor Coll
of Med, Houston, TX; Linda Polfus, The Univ of
Texas Health Science Ctr at Houston, Houston,
TX; Aaron Folsom, Univ of Minnesota,
Minneapolis, MN; Gerardo Heiss, The Univ of
Richey Sharrett, Johns Hopkins Univ, Baltimore,
MD; Christie Ballantyne, Ron Hoogeveen, Baylor
Coll of Med, Houston, TX
Introduction: Higher lipoprotein-associated
phospholipase A2 (LpPLA2) levels are associated
with higher CHD risk. LpPLA2 is primarily
transported in LDL particles and was shown to
be associated positively with LDL-C but
negatively with HDL-C levels. The mechanism
for the negative association with HDL-C is
unclear. One hypothesis is that LpPLA2 is
increased in small dense LDL (sdLDL) generated
with delayed clearance of lipoproteins as
exhibited in atherogenic dyslipidemia.
Apolipoprotein C3 (ApoC3) was shown to inhibit
lipoprotein lipase’s lipolytic activity. ApoC3 lossof-function (LOF) mutations are associated with
lower triglycerides and sdLDL levels and higher
HDL-C levels, reduced postprandial lipemia and
reduced CHD risk. However, the association of
ApoC3 LOF mutations with LpPLA2 activity is
not known. We hypothesized that LpPLA2
activity levels will be lower with ApoC3 LOF
mutation.
Methods: In 4453 individuals of European
ancestry in the Atherosclerosis Risk in
Communities (ARIC) study we examined LpPLA2
activity levels in ApoC3 LOF mutation carriers
and non-carriers.
Results: There were 23 heterozygotes for ApoC3
LOF mutation in 3 variants (T5 gene based test p
value=3.09 x10-3). LpPLA2 activity was inversely
correlated with HDL-C (r= - 0.50) and directly
correlated with LDL-C (r= 0.37) (p<0.0001 for
both). There was no significant difference in
total cholesterol and LDL-C levels in carriers vs.
non-carriers (Table). Triglycerides, sdLDL-C
levels and total cholesterol/HDL-C ratio were
lower but HDL-C levels were higher in carriers
than non-carriers. LpPLA2 activity was
significantly lower in APOC3 carriers than in
non-carriers.
Conclusion: Although there was no significant
difference in LDL-C levels between ApoC3
carriers vs. non-carriers, ApoC3 LOF was
associated with reduced LpPLA2 activity and
sdLDL-C, supporting the concept that the
inverse association between LpPLA2 and HDL-C
could be related to more rapid removal of
apolipoprotein B containing lipoproteins and
sdLDL.
Y. Pokharel: None. W. Sun: None. L. Polfus:
None. A. Folsom: None. G. Heiss: None. R.
Sharrett: None. C. Ballantyne: None. R.
Hoogeveen: B. Research Grant; Significant;
diaDexus (to Baylor College of Medicine), Denka
Seiken (to Baylor College of Medicine).
P218
Extremely Elevated HDL-Cholesterol Levels Are
Independently Associated With Lower Carotid
Intima-Media Thickness: Data From the ELSABrasil
Antonio G Laurinavicius, Insto do Coração da
Faculdade de Medicina da Univ de São Paulo,
São Paulo, Brazil; Itamar S. Santos, Hosp
Universitário da Univ de São Paulo, São Paulo,
Brazil; Raul D. Santos, Insto do Coração da
Faculdade de Medicina da Univ de São Paulo,
São Paulo, Brazil; Isabela M. Bonsenor, Paulo A.
Lotufo, Hosp Universitário da Univ de São
Paulo, São Paulo, Brazil
Introduction. HDL-cholesterol (HDL-c) is a
strong, traditional negative cardiovascular (CV)
risk factor. However, some reports suggest that
extremely elevated HDL-c, i.e.
hyperalphalipoproteinemia (HALP), may mark
dysfunctional HDL particles, paradoxically
conferring increased CV risk. Moreover,
therapies aimed to increase HDL-c levels
through CETP inhibition failed to demonstrate
CV risk reduction despite substantial increase in
HDL-c. Carotid Intima-Media Thickness (cIMT) is
a reliable surrogate for atherosclerotic disease,
validated for CV risk assessment. We studied
cIMT among individuals with HALP.
Hypothesis. We assessed the hypothesis that
HALP is independently associated with lower
cIMT when compared with HDL-c levels on
usual normal range.
Methods. The Brazilian Longitudinal Study for
Adult Health (ELSA-Brasil) enrolled 15,105
subjects aged 35-74 years between 2008-10 for
long-term follow-up, which included IMT
measurements in both common carotid arteries
and assessment of lipid profile. Two groups
were considered for the present analysis: those
with “normal” HDL-c levels (HDL-c 40-50mg/dL
for men; 50-60mg/dL for women) and those
with HALP (HDL-c ≥90mg/d

EPI/Lifestyle 2015 Scientific Sessions Abstracts

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