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1.  Prevalence of Major Cardiovascular Risk Factors and Cardiovascular Diseases Among Hispanic/Latino Individuals of Diverse Backgrounds in the United States 
Major cardiovascular diseases (CVDs) are leading causes of mortality among US Hispanic and Latino individuals. Comprehensive data are limited regarding the prevalence of CVD risk factors in this population and relations of these traits to socioeconomic status (SES) and acculturation.
To describe prevalence of major CVD risk factors and CVD (coronary heart disease [CHD] and stroke) among US Hispanic/Latino individuals of different backgrounds, examine relationships of SES and acculturation with CVD risk profiles and CVD, and assess cross-sectional associations of CVD risk factors with CVD.
Design, Setting, and Participants
Multicenter, prospective, population-based Hispanic Community Health Study/Study of Latinos including individuals of Cuban (n =2201), Dominican (n = 1400), Mexican (n=6232), Puerto Rican (n=2590), Central American (n=1634), and South American backgrounds (n = 1022) aged 18 to 74 years. Analyses involved 15 079 participants with complete data enrolled between March 2008 and June 2011.
Main Outcome Measures
Adverse CVD risk factors defined using national guidelines for hypercholesterolemia, hypertension, obesity, diabetes, and smoking. Prevalence of CHD and stroke were ascertained from self-reported data.
Age-standardized prevalence of CVD risk factors varied by Hispanic/Latino background; obesity and current smoking rates were highest among Puerto Rican participants (for men, 40.9% and 34.7%; for women, 51.4% and 31.7%, respectively); hypercholesterolemia prevalence was highest among Central American men (54.9%) and Puerto Rican women (41.0%). Large proportions of participants (80% of men, 71% of women) had at least 1 risk factor. Age- and sex-adjusted prevalence of 3 or more risk factors was highest in Puerto Rican participants (25.0%) and significantly higher (P<.001) among participants with less education (16.1%), those who were US-born (18.5%), those who had lived in the United States 10 years or longer (15.7%), and those who preferred English (17.9%). Overall, self-reported CHD and stroke prevalence were low (4.2% and 2.0% in men; 2.4% and 1.2% in women, respectively). In multivariate-adjusted models, hypertension and smoking were directly associated with CHD in both sexes as were hypercholesterolemia and obesity in women and diabetes in men (odds ratios [ORs], 1.5–2.2). For stroke, associations were positive with hypertension in both sexes, diabetes in men, and smoking in women (ORs, 1.7–2.6).
Among US Hispanic/Latino adults of diverse backgrounds, a sizeable proportion of men and women had adverse major risk factors; prevalence of adverse CVD risk profiles was higher among participants with Puerto Rican background, lower SES, and higher levels of acculturation.
PMCID: PMC3777250  PMID: 23117778
2.  Status of Cardiovascular Disease and Stroke in Hispanics/Latinos in the United States 
Circulation  2014;130(7):593-625.
Background and Purpose
This American Heart Association (AHA) scientific statement provides a comprehensive overview of current evidence on the burden cardiovascular disease (CVD) among Hispanics in the United States. Hispanics are the largest minority ethnic group in the United States, and their health is vital to the public health of the nation and to achieving the AHA’s 2020 goals. This statement describes the CVD epidemiology and related personal beliefs and the social and health issues of US Hispanics, and it identifies potential prevention and treatment opportunities. The intended audience for this statement includes healthcare professionals, researchers, and policy makers.
Writing group members were nominated by the AHA’s Manuscript Oversight Committee and represent a broad range of expertise in relation to Hispanic individuals and CVD. The writers used a general framework outlined by the committee chair to produce a comprehensive literature review that summarizes existing evidence, indicate gaps in current knowledge, and formulate recommendations. Only English-language studies were reviewed, with PubMed/MEDLINE as our primary resource, as well as the Cochrane Library Reviews, Centers for Disease Control and Prevention, and the US Census data as secondary resources. Inductive methods and descriptive studies that focused on CVD outcomes incidence, prevalence, treatment response, and risks were included. Because of the wide scope of these topics, members of the writing committee were responsible for drafting individual sections selected by the chair of the writing committee, and the group chair assembled the complete statement. The conclusions of this statement are the views of the authors and do not necessarily represent the official view of the AHA. All members of the writing group had the opportunity to comment on the initial drafts and approved the final version of this document. The manuscript underwent extensive AHA internal peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.
This statement documents the status of knowledge regarding CVD among Hispanics and the sociocultural issues that impact all subgroups of Hispanics with regard to cardiovascular health. In this review, whenever possible, we identify the specific Hispanic subgroups examined to avoid generalizations. We identify specific areas for which current evidence was less robust, as well as inconsistencies and evidence gaps that inform the need for further rigorous and interdisciplinary approaches to increase our understanding of the US Hispanic population and its potential impact on the public health and cardiovascular health of the total US population. We provide recommendations specific to the 9 domains outlined by the chair to support the development of these culturally tailored and targeted approaches.
Healthcare professionals and researchers need to consider the impact of culture and ethnicity on health behavior and ultimately health outcomes. There is a need to tailor and develop culturally relevant strategies to engage Hispanics in cardiovascular health promotion and cultivate a larger workforce of healthcare providers, researchers, and allies with the focused goal of improving cardiovascular health and reducing CVD among the US Hispanic population.
PMCID: PMC4577282  PMID: 25098323
AHA Scientific Statements; cardiovascular disease; Hispanic; Latino; stroke
3.  Racial/Ethnic Differences in the Development of Disability among Older Adults 
American journal of public health  2007;97(12):2209-2215.
This study investigates differences in developing activities of daily living (ADL) disability among non-Hispanic Whites, African Americans, Hispanics interviewed in Spanish (Hispanic/Spanish), and Hispanics interviewed in English (Hispanic/English)
Six-year risk for disability development is estimated from 8161 participants age 65 or older free of baseline disability in a population-based sample. Mediating factors amenable to clinical and public health intervention on racial/ethnic difference are evaluated.
The risk for developing disability among Hispanic/English was similar to Whites (hazard ratio [HR] = 0.99, 95% confidence interval [CI]: 0.6, 1.4), but substantially elevated for African Americans (HR=1.6, 95%CI: 1.3, 1.9) and Hispanic/Spanish (HR=1.8, 95%CI: 1.4, 2.1). Adjustment for demographics, health, and socioeconomic status reduced a large portion of those disparities (African American adjusted HR=1.1, Hispanic/Spanish adjusted HR=1.2).
Excess risks for developing disability among older African Americans and Hispanic/Spanish compared to Whites are largely attenuated by health and socioeconomic differences. Language and culture specific programs to increase physical activity and promote weight maintenance may prove to be efficient strategies to both reduce national ADL disability rates in the future and reduce racial/ethnic disparities in disability.
PMCID: PMC2089103  PMID: 17971548
ADL; African American; Hispanic; Chronic Disease; Aging
4.  Associations of chronic stress burden, perceived stress, and traumatic stress with cardiovascular disease prevalence and risk factors in the HCHS/SOL Sociocultural Ancillary Study 
Psychosomatic medicine  2014;76(6):468-475.
The current study examined multiple stress indicators (chronic, perceived, traumatic) in relation to prevalent coronary heart disease (CHD), stroke, and major cardiovascular disease (CVD) risk factors (i.e., diabetes, dyslipidemia, hypertension, current smoking) in the multi-site Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study (2010–2011).
Participants were 5313 men and women, 18–74 years old, representing diverse Hispanic/Latino ethnic backgrounds, who underwent a comprehensive baseline clinical exam and sociocultural exam with measures of stress.
Chronic stress burden was related to a higher prevalence of CHD after adjusting for sociodemographic, behavioral and biological risk factors [OR (95% CI) = 1.22, (1.10–1.36)] and related to stroke prevalence in the model adjusted for demographic and behavioral factors [OR (95% CI) = 1.26, (1.03–1.55∂)]. Chronic stress was also related to a higher prevalence of diabetes [OR=1.20, (1.11–1.31)] and hypertension [OR=1.10 (1.02–1.19)] in individuals free from CVD (N=4926). Perceived stress [OR=1.03 (1.01–1.05)] and traumatic stress [OR=1.15 (1.05–1.26)] were associated with a higher prevalence of smoking. Participants who reported a greater number of lifetime traumatic events also unexpectedly showed a lower prevalence of diabetes [OR=.89 (.83–.97)] and hypertension [OR=.88 (.82–.93)]. Effects were largely consistent across age and sex groups.
The study underscores the utility of examining multiple indicators of stress in relation to health, since the direction and consistency of associations may vary across distinct stress conceptualizations. In addition, the study suggests that chronic stress is related to higher CVD risk and prevalence in Hispanics/Latinos, the largest U.S. ethnic minority group.
PMCID: PMC4349387  PMID: 24979579
Cardiovascular Disease; Coronary Heart Disease; Hispanic; Latino; Stress
5.  Relationship of Change in Traditional Cardiometabolic Risk Factors to Change in Coronary Artery Calcification Among Individuals with Detectable Subclinical Atherosclerosis: The Multi-Ethnic Study of Atherosclerosis 
Data describing relationships between change in risk factors and coronary artery calcification (CAC) are lacking and could inform optimal cardiovascular disease prevention and treatment strategies. This study aimed to examine how change in traditional cardiometabolic risk factors related to change in CAC among individuals with detectable subclinical atherosclerosis.
Latent growth modeling was used to examine change in cardiometabolic risk factors (waist circumference, body mass index, systolic and diastolic blood pressure, high- and low-density lipoprotein cholesterol, triglycerides, and glucose) related to change in CAC up to an average 4.9-year follow-up in a multi-ethnic cohort of 3,398 asymptomatic individuals (57.8% men) who had detectable CAC (score > 0) at baseline, adjusting for baseline risk factor levels and CAC values, age, gender, race/ethnicity, smoking, family history of CVD, income, and use of antihypertensive, lipid-lowering, and glucose-lowering medications.
Greater declines in blood pressure (systolic and diastolic) and low-density lipoprotein cholesterol at follow-up were each associated with greater CAC progression. The observed inverse associations were attributable to greater CAC progression in participants taking antihypertensive and lipid-lowering drugs who, as expected, had declines in blood pressure and lipid levels, respectively. These inverse associations did not emerge in participants not taking these medications.
Among individuals with subclinical atherosclerosis, the unexpected inverse associations observed between change in blood pressure and lipid levels with CAC progression emphasize the importance of considering medication use, and, when feasible, the severity and duration of disease, in exploring associations between risk factors and CAC change.
PMCID: PMC4060615  PMID: 24698232
risk factors; coronary artery calcification; atherosclerosis
6.  Prevalence of Hypertension, Awareness, Treatment, and Control in the Hispanic Community Health Study/Study of Latinos 
American Journal of Hypertension  2014;27(6):793-800.
The prevention and control of hypertension is an essential component for reducing the burden of cardiovascular diseases. Here we describe the prevalence of hypertension in diverse Hispanic/Latino background groups and describe the proportion who are aware of their diagnosis, receiving treatment, and having their hypertension under control.
The Hispanic Community Health Study/Study of Latinos is a longitudinal cohort study of 16,415 Hispanics/Latinos, aged 18–74 years from 4 US communities (Bronx, NY; Chicago, IL; Miami, FL; and San Diego, CA). At baseline (2008–2011) the study collected extensive measurements and completed questionnaires related to research on cardiovascular diseases. Hypertension was defined as measured blood pressure ≥140/90mm Hg or use of antihypertensive medication.
The total age-adjusted prevalence of hypertension in this study was 25.5% as compared with 27.4% in non-Hispanic whites in the National Health and Nutrition Examination Survey. Prevalence of hypertension increased with increasing age groups and was highest in Cuban, Puerto Rican, and Dominican background groups. The percent with hypertension who were aware, being treated with medication, or had their hypertension controlled was lower compared with US non-Hispanic whites with hypertension and it was lowest in those without health insurance.
These findings indicate a significant deficit in treatment and control of hypertension among Hispanics/Latinos residing in the United States, particularly those without health insurance. Given the relative ease of identification of hypertension and the availability of low-cost medications, enabling better access to diagnostic and treatment services should reduce the burden of hypertension in Hispanic populations.
PMCID: PMC4017932  PMID: 24627442
blood pressure; epidemiology; Hispanics; hypertension; Latinos; medically uninsured; socioeconomic status.
Background and Purpose
Since the diagnosis and treatment of carotid artery disease may reduce the rate of stroke, the aim of this study was to determine whether a diet intervention was associated with incident carotid artery disease.
Participants were 48,835 postmenopausal women aged 50 to 79 years who were randomly assigned to either the intervention or comparison group in the WHI Diet Modification Trial. Incident carotid artery disease was defined as an overnight hospitalization with either symptoms or a surgical intervention to improve flow.
After a mean follow-up of 8.3 years from 1994 – 2005, there were 297 (0.61%) incident carotid artery events. Contrasted to the comparison group, the risk of incident carotid disease did not differ from those assigned to the intervention group (HR: 1.08, 95% CI: 0.9 - 1.4). In secondary analysis, there was no significant effect of the intervention on the risk for incident carotid disease during the five years of post-intervention follow-up from 2005 to 2010 (1.24, 0.9 - 1.7) and no significant effect during cumulative follow-up from 1994 to 2010 (1.13, 0.9 – 1.4).
Among postmenopausal women, a dietary intervention aimed at reducing total fat intake and encouraging increased intake of fruit, vegetables and grains, did not significantly change the risk for incident carotid artery disease.
PMCID: PMC4259099  PMID: 24743440
diet; carotid artery disease; trial; women
8.  Markers of Inflammation and Coagulation after Long-Term Exposure to Coarse Particulate Matter: A Cross-Sectional Analysis from the Multi-Ethnic Study of Atherosclerosis 
Environmental Health Perspectives  2015;123(6):541-548.
Toxicological research suggests that coarse particles (PM10–2.5) are inflammatory, but responses are complex and may be best summarized by multiple inflammatory markers. Few human studies have investigated associations with PM10–2.5 and, of those, none have explored long-term exposures. Here we examine long-term associations with inflammation and coagulation in the Multi-Ethnic Study of Atherosclerosis.
Participants included 3,295 adults (45–84 years of age) from three metropolitan areas. Site-specific spatial models were used to estimate 5-year concentrations of PM10–2.5 mass and copper, zinc, phosphorus, silicon, and endotoxin found in PM10–2.5. Outcomes included interleukin-6, C-reactive protein, fibrinogen, total homocysteine, D-dimer, factor VIII, plasmin–antiplasmin complex, and inflammation and coagulation scores. We used multivariable regression with multiply imputed data to estimate associations while controlling for potential confounders, including co-pollutants such as fine particulate matter.
Some limited evidence was found of relationships between inflammation and coagulation and PM10–2.5. Endotoxin was the PM10–2.5 component most strongly associated with inflammation, with an interquartile range (IQR) increase (0.08 EU/m3) associated with 0.15 (95% CI: 0.01, 0.28; p = 0.03) and 0.08 (95% CI: –0.07, 0.23; p = 0.28) higher inflammation scores before and after control for city, respectively. Copper was the component with the strongest association with coagulation, with a 4-ng/m3 increase associated with 0.19 (95% CI: 0.08, 0.30; p = 0.0008) and 0.12 (95% CI: –0.05, 0.30; p = 0.16) unit higher coagulation scores before and after city adjustment, respectively.
Our cross-sectional analysis provided some evidence that long-term PM10–2.5 exposure was associated with inflammation and coagulation, but associations were modest and depended on particle composition.
Adar SD, D’Souza J, Mendelsohn-Victor K, Jacobs DR Jr, Cushman M, Sheppard L, Thorne PS, Burke GL, Daviglus ML, Szpiro AA, Diez Roux AV, Kaufman JD, Larson TV. 2015. Markers of inflammation and coagulation after long-term exposure to coarse particulate matter: a cross-sectional analysis from the Multi-Ethnic Study of Atherosclerosis. Environ Health Perspect 123:541–548;
PMCID: PMC4455582  PMID: 25616153
9.  Applying Recovery Biomarkers to Calibrate Self-Report Measures of Energy and Protein in the Hispanic Community Health Study/Study of Latinos 
American Journal of Epidemiology  2015;181(12):996-1007.
We investigated measurement error in the self-reported diets of US Hispanics/Latinos, who are prone to obesity and related comorbidities, by background (Central American, Cuban, Dominican, Mexican, Puerto Rican, and South American) in 2010–2012. In 477 participants aged 18–74 years, doubly labeled water and urinary nitrogen were used as objective recovery biomarkers of energy and protein intakes. Self-report was captured from two 24-hour dietary recalls. All measures were repeated in a subsample of 98 individuals. We examined the bias of dietary recalls and their associations with participant characteristics using generalized estimating equations. Energy intake was underestimated by 25.3% (men, 21.8%; women, 27.3%), and protein intake was underestimated by 18.5% (men, 14.7%; women, 20.7%). Protein density was overestimated by 10.7% (men, 11.3%; women, 10.1%). Higher body mass index and Hispanic/Latino background were associated with underestimation of energy (P < 0.05). For protein intake, higher body mass index, older age, nonsmoking, Spanish speaking, and Hispanic/Latino background were associated with underestimation (P < 0.05). Systematic underreporting of energy and protein intakes and overreporting of protein density were found to vary significantly by Hispanic/Latino background. We developed calibration equations that correct for subject-specific error in reporting that can be used to reduce bias in diet-disease association studies.
PMCID: PMC4462334  PMID: 25995289
biological markers; calibration equations; dietary measurement error; Hispanics/Latinos; 24-hour dietary recall; nutrition assessment
10.  Association of Depressive Symptoms, Trait Anxiety, and Perceived Stress with Subclinical Atherosclerosis: Results from the Chicago Healthy Aging Study (CHAS) 
Preventive medicine  2014;61:54-60.
Examine the association between multiple psychological factors (depressive symptoms, trait anxiety, perceived stress) and subclinical atherosclerosis in older age.
This cross-sectional study included 1,101 adults ages 65-84 from the Chicago Healthy Aging Study (CHAS—2007-2010). Previously validated self-report instruments were used to assess psychological factors. Noninvasive methods were used to assess subclinical atherosclerosis in two regions of the body, i.e., ankle-brachial blood pressure index (ABI) and coronary artery calcification (CAC). Multivariate logistic regression was used to examine the association between each psychological measure and subclinical atherosclerosis, after adjustment for socio-demographic factors, sleep quality, young adulthood/early middle age and late life CVD risk status, and psychological ill-being as appropriate.
The burden of major cardiovascular disease risk factors did not significantly differ across tertiles of psychological factors. In multivariate adjusted models, trait anxiety was associated with calcification: those in the second tertile were significantly more likely to have CAC>0 compared to those in the lowest anxiety tertile [OR=1.68; 95%CI=1.09-2.58], but no significant difference was observed for Tertile III of trait anxiety [OR=1.31; 95%CI=0.75-2.27]. No association was seen between psychological measures and ABI.
Of several psychological factors, only trait anxiety was significantly associated with CAC.
PMCID: PMC4153417  PMID: 24434161
ankle brachial index; cardiovascular risk; coronary artery calcification; older adults; population study; psychological factors; subclinical atherosclerosis
11.  Is Acculturation Related to Obesity in Hispanic/Latino Adults? Results from the Hispanic Community Health Study/Study of Latinos 
Journal of Obesity  2015;2015:186276.
Background. The study examined the association of obesity with acculturation in a large and diverse sample of US Hispanic/Latino adults. Methods. The Hispanic Community Health Study (HCHS)/Study of Latinos (SOL) is a community-based cohort study of Hispanic/Latino adults aged 18–74 years (N = 16,415) from four urban areas. Height and weight were directly measured using a standardized protocol. Acculturation was assessed by the Short Acculturation Scale for Hispanics (SASH). Other immigration related variables included place of birth, length of residency in the US, and age at immigration. Odds ratios were calculated to assess the association of overweight, moderate obesity, and extreme obesity (≥40 kg/m2) with acculturation and sociodemographic variables. Results. The prevalence of obesity was 42.4% for women and 36.5% for men and varied by field center and Hispanic/Latino background. The strongest predictor of moderate and extreme obesity was length of residency in mainland US. This association was consistent across Hispanic/Latino backgrounds. Acculturation was not significantly associated with obesity. Discussion. The burden of obesity is high among Hispanic/Latino adults. The study findings suggest that prolonged exposure to the environments in these communities, rather than acculturation, is an important risk factor for obesity in this population.
PMCID: PMC4393894  PMID: 25893114
12.  Selenium exposure and depressive symptoms: the Coronary Artery Risk Development in Young Adults Trace Element Study 
Neurotoxicology  2014;41:167-174.
Selenium is an essential trace element important to neurotransmission, but toxic at high levels. Some studies suggest beneficial effects on mood. We assessed the association of selenium exposure with presence of depressive symptoms. Selenium exposure was measured in toenail samples collected in 1987 from 3,735 US participants (age 20–32 years) and depressive symptoms assessed in 1990, 1995, 2000, 2005, and 2010 using the Center for Epidemiologic Studies Depression Scale (CES-D). Binary and polytomous logistic regression models were used to assess the relation of log2(selenium) and selenium quintiles with presence of depressive symptoms (CES-D score ≥ 27 or on antidepressant medication). Relative to selenium quintile 1, the adjusted odds ratio (OR) for having depressive symptoms in 1990 for quintile 5 was 1.59 (95% CI: 1.01, 2.51) and a unit increase in log2(selenium), which represents a doubling of the selenium level, was associated with an OR=2.03 (95% CI: 1.12, 3.70). When examining 1, 2 or 3+ exams vs no exams with symptoms, the OR for quintile 5 was 1.73 (1.04, 2.89) for 3+ exams and for one exam and two exams, there were no associations. In a generalized estimating equations longitudinal model, a doubling of the selenium level was associated with a 56% higher odds of having depressive symptoms at an exam. Contrary to previously reported findings related to mood, higher level of selenium exposure was associated with presence of elevated depressive symptoms. More research is needed to elucidate the role of selenium in depressive disorders.
PMCID: PMC4030293  PMID: 24560993
depression; selenium; trace element; epidemiology
13.  The Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study: Sample, Design, and Procedures 
Ethnicity & disease  2014;24(1):77-83.
The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study aims to examine associations between sociocultural and psychosocial factors and cardiovascular disease (CVD) and metabolic syndrome prevalence in Hispanics/Latinos. The conceptual framework is based on the Reserve Capacity and Lifespan Biopsychosocial Models, which emphasize multiple risk and protective pathways underlying socioeconomic and ethnic influences in health. This study describes the rationale, participants, and procedures for the HCHS/SOL Sociocultural Ancillary Study.
Design and Setting
The Sociocultural Ancillary Study to the HCHS/SOL is a cross-sectional cohort study with future opportunities for prospective investigation.
Participants were 5,313 adults, aged 18-74 years, of self-identified Hispanic/Latino descent and representing multiple Hispanic/Latino background groups, recruited from the Bronx, NY, Chicago, IL, Miami, FL, and San Diego, CA.
Participants completed an interview-administered sociocultural assessment battery within 9 months of their HCHS/SOL clinical baseline exam.
Outcome Measures
The primary outcomes are CVD and the metabolic syndrome and its component risk factors.
The Sociocultural Ancillary Study sample is broadly representative of the HCHS/SOL cohort. Weighted demographics are: 55% male, 56% 18-44 years, 44% 45 years and older, and 37% Mexican, 20% Cuban, 16% Puerto Rican, 12% Dominican, 8% Central American, and 5% South American descent.
By testing theoretically driven hypotheses concerning sociocultural and psychosocial factors in CVD, the Sociocultural Ancillary Study seeks to inform future prevention and intervention efforts for U.S. Hispanic/Latinos.
PMCID: PMC3986116  PMID: 24620452
Cardiovascular Disease; Culture; Hispanic; Latino; Metabolic Syndrome; Psychosocial Factors; Social Factors
14.  Dietary and Urinary Metabonomic Factors Possibly Accounting for Higher Blood Pressure of African-Americans Compared to White Americans – – The INTERMAP Study RR 
Hypertension  2013;62(6):1074-1080.
African-Americans compared to non-Hispanic-White-Americans have higher systolic, diastolic blood pressure and rates of prehypertension/hypertension. Reasons for these adverse findings remain obscure. Analyses here focused on relations of foods/nutrients/urinary metabolites to higher African-American blood pressure for 369 African-Americans compared to 1,190 non-Hispanic-White-Americans ages 40-59 from 8 population samples. Standardized data were from four 24-hour dietary recalls/person, two 24-h urine collections, 8 blood pressure measurements; multiple linear regression quantitating role of foods, nutrients, metabolites in higher African-American blood pressure. Compared to non-Hispanic-White-Americans, African-Americans average systolic/diastolic pressure was higher by 4.7/3.4 mm Hg (men) and 9.0/4.8 mm Hg (women). Control for higher body mass index of African-American women reduced excess African-American systolic/diastolic pressure to 6.8/3.8 mm Hg. African American intake of multiple foods, nutrients related to blood pressure was less favorable - - less vegetables, fruits, grains, vegetable protein, glutamic acid, starch, fiber, minerals, potassium; more processed meats, pork, eggs, sugar-sweetened beverages, cholesterol, higher sodium to potassium ratio. Control for 11 nutrient and 10 non-nutrient correlates reduced higher African-American systolic/diastolic pressure to 2.3/2.3 mm Hg (52% and 33% reduction) (men) and to 5.3/2.8 mm Hg (21% and 27% reduction) (women). Control also for foods/urinary metabolites had little further influence on higher African-American blood pressure. Multiple nutrients with less favorable intakes by African-Americans than non-Hispanic-White-Americans account at least in part for higher African-American blood pressure. Improved dietary patterns can contribute to prevention/control of more adverse African-American blood pressure levels.
PMCID: PMC3912568  PMID: 24101663
African-American; blood pressure; nutrient; food intake; urinary metabolites
15.  Relations of raw and cooked vegetable consumption to blood pressure: The INTERMAP Study 
Journal of human hypertension  2013;28(6):353-359.
Inverse associations have been reported of overall vegetable intake to blood pressure (BP); whether such relations prevail for both raw and cooked vegetables has not been examined. Here we report cross-sectional associations of vegetable intakes with BP for 2,195 Americans ages 40–59 in the International Study of Macro/Micronutrients and Blood Pressure (INTERMAP) using four standardized multi-pass 24-hour dietary recalls and eight BP measurements. Relations to BP of raw and cooked vegetables consumption, and main individual constituents were assessed by multiple linear regression. Intakes of both total raw and total cooked vegetables considered separately were inversely related to BP in multivariate-adjusted models. Estimated average systolic BP differences associated with 2 SD differences in raw vegetable intake (68 g/1,000 kcal) and cooked vegetable intake (92 g/1,000 kcal) were −1.9 mm Hg (95% CI: −3.1, −0.8; P=0.001) and −1.3 mm Hg (95% CI: −2.5, −0.2; P=0.03) without body mass index (BMI) in the full model; −1.3 mm Hg (95% CI: −2.4, −0.2; P=0.02) and −0.9 mm Hg (95% CI: −2.0, 0.2; P=0.1) with additional adjustment for BMI. Among commonly consumed individual raw vegetables, tomatoes, carrots, and scallions related significantly inversely to BP. Among commonly eaten cooked vegetables, tomatoes, peas, celery, and scallions related significantly inversely to BP.
PMCID: PMC4013197  PMID: 24257514
cooked vegetables; raw vegetables; blood pressure; population study
16.  Major and Minor Electrocardiographic Abnormalities and their Association with Underlying Cardiovascular Disease and Risk Factors in Hispanics/Latinos (From the Hispanic Community Health Study/Study of Latinos [HCHS/SOL]) 
The American journal of cardiology  2013;112(10):10.1016/j.amjcard.2013.08.004.
The association of ECG abnormalities with cardiovascular disease and risk factors has been extensively studied in Whites and African Americans. Comparable data have not been reported in Hispanics/Latinos. The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) is a multicenter community based prospective cohort study of men and women of diverse backgrounds ages 18 to 74 years who self-identified as Hispanic/Latinos. Participants (N=16,415), enrolled between March 2008 and June 2011. We describe the prevalence of minor and major ECG abnormalities and examine their cross-sectional associations with cardiovascular disease and risk factors. The Minnesota code criteria were used to define minor and major abnormalities of the ECG. Prior cardiovascular disease and risk factors were based on data obtained at baseline examination. Significant differences in prevalent ECG findings were found between men and women. Major ECG abnormalities were present in 9.2 %( 95% confidence interval [CI], 8.3–10.1) of men and 6.6% (95% CI, 5.8–7.3) of women (P<.0001). The odds of having major ECG abnormalities significantly increased with age, presence of 3 or more cardiovascular risk factors and prevalent cardiovascular disease, in both men and women. Significant differences in major ECG abnormalities were found among the varying groups; Puerto Ricans and Dominicans had more major abnormalities compared to Mexican men and women. In conclusion, a large cohort of Hispanic/Latino men and women, prevalence of major abnormalities were low yet strong associations of major ECG abnormalities with cardiovascular disease and risk factors were observed in both men and women.
PMCID: PMC3864828  PMID: 24055066
Electrocardiogram; Hispanic Community Health Study/Study of Latinos (SOL); cardiovascular risk factors
17.  Quantifying the contributions of behavioral and biological risk factors to socioeconomic disparities in coronary heart disease incidence: The MORGEN study 
European journal of epidemiology  2013;28(10):10.1007/s10654-013-9847-2.
Quantifying the impact of different modifiable behavioral and biological risk factors on socioeconomic disparities in coronary heart disease (CHD) may help inform targeted, population-specific strategies to reduce the unequal distribution of the disease. Previous studies have used analytic approaches that limit our ability to disentangle the relative contributions of these risk factors to CHD disparities. The goal of this study was to assess mediation of the effect of low education on incident CHD by multiple risk factors simultaneously. Analyses are based on 15,067 participants of the Dutch Monitoring Project on Risk Factors for Chronic Diseases aged 20–65 years examined 1994–1997 and followed for events until January 1, 2008. Path analysis was used to quantify and test mediation of the low education-CHD association by behavioral (current cigarette smoking, heavy alcohol use, poor diet, and physical inactivity) and biological (obesity, hypertension, diabetes, and hypercholesterolemia) risk factors. Behavioral and biological risk factors accounted for 56.6% (95% CI: 42.6%–70.8%) of the low education-incident CHD association. Smoking was the strongest mediator, accounting for 27.3% (95% CI: 17.7%–37.4%) of the association, followed by obesity (10.2%; 95% CI: 4.5%–16.1%), physical inactivity (6.3%; 95% CI: 2.7%–10.0%), and hypertension (5.3%; 95% CI: 2.8%–8.0%). In summary, in a Dutch cohort, the majority of the relationship between low education and incident CHD was mediated by traditional behavioral and biological risk factors. Addressing barriers to smoking cessation, blood pressure and weight management, and physical activity may be the most effective approaches to eliminating socioeconomic inequalities in CHD.
PMCID: PMC3844527  PMID: 24037117
socioeconomic status; coronary heart disease; health behaviors; risk factors
18.  Intakes of long-chain n-3 polyunsaturated fatty acids and fish in relation to measurements of subclinical atherosclerosis 
Data on the relations of different types of fish meals and long-chain n-3 polyunsaturated fatty acids (n-3 PUFAs) with measures of atherosclerosis are sparse.
We examined intakes of long-chain n-3 PUFAs and fish in relation to clinical measures of subclinical atherosclerosis.
A cross-sectional study was conducted in 5,488 multiethnic adults aged 45–84 years and free of clinical cardiovascular disease. Diet was assessed using self-administered food frequency questionnaires. Subclinical atherosclerosis was determined by common carotid intima-media thickness (cCIMT, >80th percentile), internal CIMT (iCIMT, >80th percentile), coronary artery calcium score (CAC, >0) or ankle-brachial index (ABI, <0.90), respectively.
After adjustment for potential confounders, intakes of long-chain n-3 PUFAs and non-fried (broiled, steamed, baked or raw) fish were inversely related to subclinical atherosclerosis determined by cCIMT but not iCIMT, CAC or ABI. The multivariable odds ratio comparing the highest to the lowest quartile of dietary exposures in relation to subclinical atherosclerosis determined by cCIMT was 0.69 (95% CI: 0.55, 0.86; p for trend<0.01) for n-3 PUFA intake, 0.80 (95% CI: 0.64, 1.01; p=0.054) for non-fried fish and 0.90 (95% CI: 0.73, 1.10; p=0.33) for fried fish consumption.
This study indicates that dietary intake of long-chain n-3 PUFAs or non-fried fish is associated with lower prevalence of subclinical atherosclerosis classified by cCIMT although significant changes in iCIMT, CAC and ABI were not observed. Our findings also suggest that the association of fish and atherosclerosis may vary depending on the type of fish meal consumed and the measures of atherosclerosis.
PMCID: PMC4151325  PMID: 18842801
long-chain n-3 polyunsaturated fatty acids; fish; fish oil; biomarker; subclinical atherosclerosis; multi-ethnicities
19.  Chicago Healthy Aging Study: Objectives and Design 
American Journal of Epidemiology  2013;178(4):635-644.
Investigators in the Chicago Healthy Aging Study (CHAS) reexamined 1,395 surviving participants aged 65–84 years (28% women) from the Chicago Heart Association Detection Project in Industry (CHA) 1967–1973 cohort whose cardiovascular disease (CVD) risk profiles were originally ascertained at ages 25–44 years. CHAS investigators reexamined 421 participants who were low-risk (LR) at baseline and 974 participants who were non-LR at baseline. LR was defined as having favorable levels of 4 major CVD risk factors: serum total cholesterol level <200 mg/dL and no use of cholesterol-lowering medication; blood pressure 120/≤80 mm Hg and no use of antihypertensive medication; no current smoking; and no history of diabetes or heart attack. While the potential of LR status in overcoming the CVD epidemic is being recognized, the long-term association of LR with objectively measured health in older age has not been examined. It is hypothesized that persons who were LR in 1967–1973 and have survived to older age will have less clinical and subclinical CVD, lower levels of inflammatory markers, and better physical performance/functioning and sleep quality. Here we describe the rationale, objectives, design, and implementation of this longitudinal epidemiologic study, compare baseline and follow-up characteristics of participants and nonparticipants, and highlight the feasibility of reexamining study participants after an extended period postbaseline with minimal interim contact.
PMCID: PMC3816341  PMID: 23669655
cardiovascular disease; epidemiologic studies; follow-up examination; risk factors
20.  Status of Cardiovascular Health in US Adults: Prevalence Estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008 
Circulation  2011;125(1):45-56.
The American Heart Association's 2020 Strategic Impact Goals define a new concept, “cardiovascular (CV) health”; however, current prevalence estimates of the status of CV health in U.S. adults according to age, sex and race/ethnicity have not been published.
Methods and Results
We included 14,515 adults (≥20 years) from the 2003-2008 National Health and Nutrition Examination Surveys. Participants were stratified by young (20-39 years), middle (40-64 years), and older ages (65+ years). CV health behaviors (diet, physical activity, body mass index, smoking) and CV health factors (blood pressure, total cholesterol, fasting blood glucose, smoking) were defined as poor, intermediate, or ideal. Less than 1% of adults exhibited ideal CV health for all 7 metrics. For CV health behaviors, non-smoking was most prevalent (range:60.2-90.4%) while ideal Healthy Diet Score was least prevalent (range:0.2-2.6%) across groups. Prevalence of ideal BMI (range:36.5-45.3%) and ideal physical activity levels (range:50.2-58.8%) were higher in young adults compared to middle or older ages. Ideal total cholesterol (range:23.7-36.2%), blood pressure (range:11.9-16.3%) and fasting blood glucose (range:31.2-42.9%) were lower in older adults compared with young and middle age adults.Prevalence of poor CV health factors was lowest in young age but higher at middle and older ages. Prevalence estimates by age and sex were consistent across race/ethnic groups.
These prevalence estimates of CV health represent a starting point from which effectiveness of efforts to promote CV health and prevent CV disease can be monitored and compared in U.S. adult populations.
PMCID: PMC4077723  PMID: 22095826
Cardiovascular Diseases; Diet; Epidemiology; Obesity; Risk Factors
21.  Glutamic Acid – the Main Dietary Amino Acid – and Blood Pressure: The INTERMAP Study 
Circulation  2009;120(3):221-228.
Data are available indicating an independent inverse relationship of dietary vegetable protein to the blood pressure (BP) of individuals. Here we assess whether BP is associated with glutamic acid intake (the predominant dietary amino acid, especially in vegetable protein) and with each of four other amino acids higher relatively in vegetable than animal protein (proline, phenylalanine, serine, cystine).
Methods and Results
Cross-sectional epidemiological study; 4,680 persons ages 40–59 -- 17 random population samples in China, Japan, U.K., U.S.A.; BP measurement 8 times at 4 visits; dietary data (83 nutrients, 18 amino acids) from 4 standardized multi-pass 24-hour dietary recalls and 2 timed 24-hour urine collections. Dietary glutamic acid (percent of total protein intake) was inversely related to BP. Across multivariate regression models (Model 1 controlled for age, gender, sample, through Model 5 controlled for 16 non-nutrient and nutrient possible confounders) estimated average BP differences associated with glutamic acid intake higher by 4.72% total dietary protein (2 s.d.) were −1.5 to −3.0 mm Hg systolic and −1.0 to −1.6 mm Hg diastolic (Z-values −2.15 to −5.11). Results were similar for the glutamic acid-BP relationship with each other amino acid also in the model, e.g., with control for 15 variables plus proline, systolic/diastolic pressure differences −2.7/−2.0 (Z −2.51, −2.82). In these 2-amino acid models, higher intake (2 s.d.) of each other amino acid was associated with small BP differences and Z-values.
Dietary glutamic acid may have independent BP lowering effects, possibly contributing to the inverse relation of vegetable protein to BP.
PMCID: PMC4048930  PMID: 19581495
dietary amino acids; glutamic acid; blood pressure; population study
22.  Associations of Stressful Life Events and Social Strain With Incident Cardiovascular Disease in the Women's Health Initiative 
Epidemiologic studies have yielded mixed findings on the association of psychosocial stressors with cardiovascular disease (CVD) risk. In this study, we examined associations of stressful life events (SLE) and social strain with incident coronary heart disease (CHD) and stroke (overall, and for hemorrhagic and ischemic strokes) independent of sociodemographic characteristics, and we evaluated whether these relationships were explained by traditional behavioral and biological risk factors.
Methods and Results
Data from approximately 82 000 Women's Health Initiative Observational Study participants were used for the SLE and social strain analyses, respectively. Participants were followed for events for up to 18.0 years (median, 14.0). Separate Cox proportional hazards models were generated to estimate associations of each stress measure with incident CVD. After adjusting for sociodemographic characteristics and depressive symptoms, higher SLE and social strain were associated with higher incident CHD and stroke (each P trend <0.05). Hazard ratios and 95% confidence intervals were 1.12 (1.01, 1.25) for incident CHD and 1.14 (1.01, 1.28) for incident stroke among participants reporting high versus low SLE. Findings were similar for social strain. Associations were attenuated with further adjustment for mediating behavioral and biological risk factors. Findings were similar for associations of SLE with ischemic stroke and hemorrhagic stroke, but social strain was only associated with ischemic stroke.
Higher SLE and social strain were associated with higher incident CVD independent of sociodemographic factors and depressive symptoms, but not behavioral and biological risk factors.
PMCID: PMC4309050  PMID: 24973226
cardiovascular diseases; epidemiology; stress
23.  Lifetime Risk for Heart Failure Among White and Black Americans: Cardiovascular Lifetime Risk Pooling Project 
To estimate lifetime risk for HF by sex and race.
Prior estimates of lifetime risk for developing heart failure (HF) range from 20% to 33% in predominantly white cohorts. Short-term risks for HF appear higher for blacks than whites, but only limited comparisons of lifetime risk for HF have been made.
Using public-release and internal datasets from NHLBI-sponsored cohorts, we estimated lifetime risks for developing HF to age 95, with death free of HF as the competing event, among participants in Chicago Heart Association Detection Project in Industry (CHA), Atherosclerosis Risk in Communities (ARIC), and Cardiovascular Health Study (CHS) cohorts.
There were 39,578 participants (33,652 [85%] white; 5,926 [15%] black) followed for 716,976 person-years; 5,983 participants developed HF. At age 45 years, lifetime risks for HF through age 95 years in CHA and CHS were 30-42% in white men, 20-29% in black men, 32-39% in white women, and 24-46% in black women. Results for ARIC demonstrated similar lifetime risks for HF in blacks and whites through age 75 years (limit of follow-up). Lifetime risk for HF was higher with higher BP and BMI at all ages in both blacks and whites and did not diminish substantially with advancing index age.
These are among the first data to compare lifetime risks for HF between blacks and whites. Lifetime risks for HF are high and appear similar for black and white women, yet are somewhat lower for black compared with white men due to competing risks.
PMCID: PMC3618527  PMID: 23500287
lifetime risk; heart failure; epidemiology
24.  Nutrient and food intakes of middle-aged adults at low risk of cardiovascular disease: the international study of macro-/micronutrients and blood pressure (INTERMAP) 
European journal of nutrition  2011;51(8):917-926.
Individuals with favorable levels of readily measured cardiovascular disease (CVD) risk factors (low risk, LR) experience low long-term rates of CVD mortality and greater longevity. The purpose of the current study was to compare nutrient/food intakes of LR participants with participants not LR in the INTERMAP study.
Men and women (40–59 years) from 17 population samples in four countries (China, Japan, UK, US) provided four 24-h dietary recalls and two timed 24-h urine collections. LR was defined as meeting all of the following CVD risk criteria: systolic/diastolic blood pressure (BP) ≤120/≤80 mmHg; no drug treatment for high BP, hyperlipidemia, or CVD; non-smoking; BMI <25.0 kg/m2 (US, UK) or <23.0 kg/m2 (China, Japan); alcohol consumption <26.0 g/day (men)/<13.0 g/day (women); and no history of diabetes or CVD. Multivariate logistic regression was used to examine associations of nutrient/food intakes with LR.
LR individuals reported higher intake of vegetable protein, fiber, magnesium, non-heme iron, potassium; lower energy intake; lower intake of cholesterol, saturated fatty acids, animal protein; and lower 24-h urinary sodium compared with individuals not LR. With regard to foods, LR individuals reported higher intake of fruits, vegetables, grains, pasta/rice, fish; lower intakes of meats, processed meats, high-fat dairy, and sugar-sweetened beverages than individuals not LR.
Lower energy intake and differential intake of multiple specific nutrients and foods are characteristic of individuals at low risk for developing CVD. Identification of dietary habits associated with LR is important for further development of public health efforts aimed at reduction/prevention of CVD.
PMCID: PMC3939781  PMID: 22057680
Cardiovascular disease; Diet; Foods; Low cardiovascular risk; Nutrients; Risk factors
25.  Relationship of Body Mass Index in Young Adulthood and Health-Related Quality of Life Two Decades Later: The Coronary Artery Risk Development in Young Adults (CARDIA) Study 
International journal of obesity (2005)  2010;35(1):10.1038/ijo.2010.120.
The expanding overweight and obesity epidemic notwithstanding, little is known about their long-term effect on health-related quality of life (HRQoL). The main objective of this study was to investigate whether overweight (body mass index [BMI] 25–<30 kg/m2) and obese (BMI ≥ 30 kg/m2) young adults have poorer HRQoL 20 years later.
The authors studied 3014 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study, a longitudinal, community-dwelling, biracial cohort from four cities. BMI was measured at baseline and 20 years later. HRQoL was assessed via the physical component summary (PCS) and the mental component summary (MCS) scores of the Medical Outcomes Study 12-Item Short Form Health Survey at year 20. Higher PCS or MCS scores indicate better HRQoL.
Mean year 20 PCS score was 52.2 for normal weight participants at baseline, 50.3 for overweight, and 46.4 for obese (P-trend <0.001). This relation persisted after adjustment for baseline demographics, general health, and physical and behavioral risk factors and after further adjustment for 20-year changes in risk factors. No association was observed for MCS scores (P-trend 0.43).
Overweight and obesity in early adulthood are adversely associated with self-reported physical HRQoL, but not mental HRQoL 20 years later.
PMCID: PMC3875360  PMID: 20548305

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