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1.  The Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study: Sample, Design, and Procedures 
Ethnicity & disease  2014;24(1):77-83.
Objectives
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
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.
Intervention
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.
Results
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.
Conclusions
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
2.  Prevalence of Major Cardiovascular Risk Factors and Cardiovascular Diseases Among Hispanic/Latino Individuals of Diverse Backgrounds in the United States 
Context
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.
Objectives
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.
Results
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).
Conclusion
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.
doi:10.1001/jama.2012.14517
PMCID: PMC3777250  PMID: 23117778
3.  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.
doi:10.1161/HYPERTENSIONAHA.113.01810
PMCID: PMC3912568  PMID: 24101663
African-American; blood pressure; nutrient; food intake; urinary metabolites
4.  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.
doi:10.1038/jhh.2013.115
PMCID: PMC4013197  PMID: 24257514
cooked vegetables; raw vegetables; blood pressure; population study
5.  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.
doi:10.1016/j.amjcard.2013.08.004
PMCID: PMC3864828  PMID: 24055066
Electrocardiogram; Hispanic Community Health Study/Study of Latinos (SOL); cardiovascular risk factors
6.  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.
doi:10.1007/s10654-013-9847-2
PMCID: PMC3844527  PMID: 24037117
socioeconomic status; coronary heart disease; health behaviors; risk factors
7.  Intakes of long-chain n-3 polyunsaturated fatty acids and fish in relation to measurements of subclinical atherosclerosis 
Background
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.
Objective
We examined intakes of long-chain n-3 PUFAs and fish in relation to clinical measures of subclinical atherosclerosis.
Design
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.
Results
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.
Conclusions
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
8.  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.
doi:10.1093/aje/kwt020
PMCID: PMC3816341  PMID: 23669655
cardiovascular disease; epidemiologic studies; follow-up examination; risk factors
9.  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.
Background
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.
Conclusions
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.
doi:10.1161/CIRCULATIONAHA.111.035733
PMCID: PMC4077723  PMID: 22095826
Cardiovascular Diseases; Diet; Epidemiology; Obesity; Risk Factors
10.  Glutamic Acid – the Main Dietary Amino Acid – and Blood Pressure: The INTERMAP Study 
Circulation  2009;120(3):221-228.
Background
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.
Conclusions
Dietary glutamic acid may have independent BP lowering effects, possibly contributing to the inverse relation of vegetable protein to BP.
doi:10.1161/CIRCULATIONAHA.108.839241
PMCID: PMC4048930  PMID: 19581495
dietary amino acids; glutamic acid; blood pressure; population study
11.  Associations of Stressful Life Events and Social Strain With Incident Cardiovascular Disease in the Women's Health Initiative 
Background
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.
Conclusions
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.
doi:10.1161/JAHA.113.000687
PMCID: PMC4309050  PMID: 24973226
cardiovascular diseases; epidemiology; stress
12.  Racial/Ethnic Differences in the Development of Disability among Older Adults 
American journal of public health  2007;97(12):2209-2215.
Objective
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)
Methods
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.
Results
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).
Conclusion
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.
doi:10.2105/AJPH.2006.106047
PMCID: PMC2089103  PMID: 17971548
ADL; African American; Hispanic; Chronic Disease; Aging
13.  Lifetime Risk for Heart Failure Among White and Black Americans: Cardiovascular Lifetime Risk Pooling Project 
Objective
To estimate lifetime risk for HF by sex and race.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1016/j.jacc.2013.01.022
PMCID: PMC3618527  PMID: 23500287
lifetime risk; heart failure; epidemiology
14.  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.
Purpose
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1007/s00394-011-0268-2
PMCID: PMC3939781  PMID: 22057680
Cardiovascular disease; Diet; Foods; Low cardiovascular risk; Nutrients; Risk factors
15.  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.
Objective
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.
Methods
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.
Results
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).
Conclusion
Overweight and obesity in early adulthood are adversely associated with self-reported physical HRQoL, but not mental HRQoL 20 years later.
doi:10.1038/ijo.2010.120
PMCID: PMC3875360  PMID: 20548305
16.  Maintaining a High Physical Activity Level Over 20 Years and Weight Gain 
JAMA : the journal of the American Medical Association  2010;304(23):10.1001/jama.2010.1843.
Context
Data supporting physical activity guidelines to prevent long-term weight gain are sparse, particularly during the period when the highest risk of weight gain occurs.
Objective
To evaluate the relationship between habitual activity levels and changes in body mass index (BMI) and waist circumference over 20 years.
Design, Setting, and Participants
The Coronary Artery Risk Development in Young Adults (CARDIA) study is a prospective longitudinal study with 20 years of follow-up, 1985-86 to 2005-06. Habitual activity was defined as maintaining high, moderate, and low activity levels based on sex-specific tertiles of activity scores at baseline. Participants comprised a population-based multi-center cohort (Chicago, Illinois; Birmingham, Alabama; Minneapolis, Minnesota; and Oakland, California) of 3554 men and women aged 18 to 30 years at baseline.
Main Outcome Measures
Average annual changes in BMI and waist circumference
Results
Over 20 years, maintaining high levels of activity was associated with smaller gains in BMI and waist circumference compared with low activity levels after adjustment for race, baseline BMI, age, education, cigarette smoking status, alcohol use, and energy intake. Men maintaining high activity gained 2.6 fewer kilograms (+ 0.15 BMI units per year; 95 % confidence interval [CI] 0.11-0.18 vs +0.20 in the lower activity group; 95% CI, 0.17-0.23) and women maintaining higher activity gained 6.1 fewer kilograms (+0.17 BMI units per year; 95 % CI, 0.12-0.21 vs. +0.30 in the lower activity group; 95 % CI, 0.25-0.34). Men maintaining high activity gained 3.1 fewer centimeters in waist circumference (+0.52 cm per year; 95 % CI, 0.43-0.61 cm vs 0.67 cm in the lower activity group; 95 % CI, 0.60-0.75) and women maintaining higher activity gained 3.8 fewer centimeters (+0.49 cm per year; 95 % CI, 0.39-0.58 vs 0.67 cm in the lower activity group; 95 % CI, 0.60-0.75).
Conclusion
Maintaining high activity levels through young adulthood may lessen weight gain as young adults transition to middle age, particularly in women.
doi:10.1001/jama.2010.1843
PMCID: PMC3864556  PMID: 21156948
17.  Understanding Ethnic and Nativity-Related Differences in Low Cardiovascular Risk Status among Mexican-Americans and Non-Hispanic Whites 
Preventive medicine  2012;55(6):597-602.
Objective
Recent guidelines highlight the importance of improving cardiovascular health in the general population in addition to disease prevention among high risk individuals. We investigated factors associated with ethnic and nativity-related differences in the prevalence of low cardiovascular risk (optimal levels of all major cardiovascular risk factors).
Methods
We used logistic regression to estimate differences in likelihood of being low risk (not currently smoking; no diabetes; untreated total cholesterol < 200 mg/dL; untreated blood pressure <120/<80; and body mass index < 25 kg/m2) among 8,693 foreign- and U.S.-born Mexican-American and non-Hispanic White 2003–2008 U.S. National Health and Nutrition Examination Survey participants before and after adjustment for socioeconomic, lifestyle, and acculturation-related factors.
Results
Foreign-born Mexican-Americans were more likely to be low risk than non-Hispanic Whites after adjustment for all covariates (Odds Ratio [OR]: 1.53; 95% Confidence Interval [CI]: 1.00, 2.34). In contrast, U.S.-born Mexican-Americans were less likely to be low risk compared to Whites (OR: 0.60; 95% CI: 0.43, 0.84). Differences between foreign-born and U.S.-born Mexican-Americans were largely attenuated after adjustment for acculturation indicators.
Conclusions
Our findings support the healthy migrant hypothesis and suggest acculturation-related factors may be important drivers of ethnic and nativity-related differences in low cardiovascular risk.
doi:10.1016/j.ypmed.2012.09.019
PMCID: PMC3544946  PMID: 23036519
health disparities; cardiovascular; acculturation; Hispanics/Latinos
18.  Prospective Study of Particulate Air Pollution Exposures, Subclinical Atherosclerosis, and Clinical Cardiovascular Disease 
American Journal of Epidemiology  2012;176(9):825-837.
The Multi-Ethnic Study of Atherosclerosis and Air Pollution (MESA Air) was initiated in 2004 to investigate the relation between individual-level estimates of long-term air pollution exposure and the progression of subclinical atherosclerosis and the incidence of cardiovascular disease (CVD). MESA Air builds on a multicenter, community-based US study of CVD, supplementing that study with additional participants, outcome measurements, and state-of-the-art air pollution exposure assessments of fine particulate matter, oxides of nitrogen, and black carbon. More than 7,000 participants aged 45–84 years are being followed for over 10 years for the identification and characterization of CVD events, including acute myocardial infarction and other coronary artery disease, stroke, peripheral artery disease, and congestive heart failure; cardiac procedures; and mortality. Subcohorts undergo baseline and follow-up measurements of coronary artery calcium using computed tomography and carotid artery intima-medial wall thickness using ultrasonography. This cohort provides vast exposure heterogeneity in ranges currently experienced and permitted in most developed nations, and the air monitoring and modeling methods employed will provide individual estimates of exposure that incorporate residence-specific infiltration characteristics and participant-specific time-activity patterns. The overarching study aim is to understand and reduce uncertainty in health effect estimation regarding long-term exposure to air pollution and CVD.
doi:10.1093/aje/kws169
PMCID: PMC3571256  PMID: 23043127
air pollution; atherosclerosis; cardiovascular diseases; environmental exposure; epidemiologic methods; particulate matter
19.  Diet composition and activity level of at risk and metabolically healthy obese American adults 
Obesity (Silver Spring, Md.)  2013;21(3):10.1002/oby.20257.
Obesity often clusters with other major cardiovascular disease risk factors, yet a subset of the obese appears to be protected from these risks. Two obesity phenotypes are described, 1) “metabolically healthy” obese, broadly defined as body mass index (BMI) ≥ 30 kg/m2 and favorable levels of blood pressure, lipids, and glucose; and 2) “at risk” obese, BMI ≥ 30 with unfavorable levels of these risk factors. More than 30% of obese American adults are metabolically healthy. Diet and activity determinants of obesity phenotypes are unclear. We hypothesized that metabolically healthy obese have more favorable behavioral factors, including less adverse diet composition and higher activity levels than at risk obese in the multi-ethnic group of 775 obese American adults ages 40–59 years from the International Population Study on Macro/Micronutrients and Blood Pressure (INTERMAP) cohort. In gender stratified analyses, mean values for diet composition and activity behavior variables, adjusted for age, race, and education, were compared between metabolically healthy and at risk obese. Nearly 1 in 5 (149/775, or 19%) of obese American INTERMAP participants were classified as metabolically healthy obese. Diet composition and most activity behaviors were similar between obesity phenotypes, although metabolically healthy obese women reported higher sleep duration than at risk obese women. These results do not support hypotheses that diet composition and/or physical activity account for the absence of cardiometabolic abnormalities in metabolically healthy obese.
doi:10.1002/oby.20257
PMCID: PMC3416914  PMID: 23592673
20.  ASSOCIATION OF SODIUM AND POTASSIUM INTAKE WITH LEFT VENTRICULAR MASS: CORONARY ARTERY RISK DEVELOPMENT IN YOUNG ADULTS 
Hypertension  2011;58(3):410-416.
High salt intake may affect left ventricular mass (LVM). We hypothesized that urinary sodium (UNa) and sodium / potassium ratio (UNa/K) are associated with LVM in a predominantly normotensive cohort young adults. The Coronary Artery Risk Development in Young Adults (CARDIA) study is a multicenter cohort of black and white men and women aged 30 ± 3.6 years at the time of baseline echocardiographic examination (1990–1991). Two-dimensionally guided M-mode LVM indexed to body size (gm/m2.7) was calculated and urinary sodium (UNa) and potassium (UK) excretion assessed (average of three 24-hour urinary samples, n=1,042). Linear and logistic regression analysis was used. Participants were 57% women, and 55% black. Only 4% were hypertensive. Mean±SD UNa, UK, and UNa/K ratio were 175.6±131.0 mmol/24hour, 56.4±46.3 mmol/24hour and 3.4±1.4, respectively. Participants in the highest vs. lowest UNa excretion quartile had the greatest LVM (37.5 vs. 34.0 g/m2.7, p<0.001). Adjusted for age, sex, education and race, LVM averaged 0.945gm/m2.7 higher per SD of UNa/K (p=0.001). The relationship between UNa/K and LVM persisted among 399 participants with repeat echocardiographic measures five years later. In logistic regression analysis adjusted for age, sex, education and race, each SD higher baseline UNa/K was associated with 23% and 38% greater chance of being in the highest quartile of LVM at baseline (OR 1.23; p=0.005) and five years later (OR 1.38; p=0.02). A higher sodium to potassium excretion ratio is significantly related to cardiac structure even among healthy young adults.
doi:10.1161/HYPERTENSIONAHA.110.168054
PMCID: PMC3726308  PMID: 21788603
urinary sodium; urinary potassium; sodium / potassium ratio; left ventricular mass
21.  Self-perceived physical health predicts cardiovascular disease incidence and death among postmenopausal women 
BMC Public Health  2013;13:468.
Background
Physical and Mental Component Summary (PCS, MCS, respectively) scales of SF- 36 health-related-quality-of-life have been associated with all-cause and cardiovascular disease (CVD) mortality. Their relationships with CVD incidence are unclear. This study purpose was to test whether PCS and/or MCS were associated with CVD incidence and death.
Methods
Postmenopausal women (aged 50–79 years) in control groups of the Women’s Health Initiative clinical trials (n = 20,308) completed the SF-36 and standardized questionnaires at trial entry. Health outcomes, assessed semi-annually, were verified with medical records. Cox regressions assessed time to selected outcomes during the trial phase (1993–2005).
Results
A total of 1075 incident CVD events, 204 CVD-specific deaths, and 1043 total deaths occurred during the trial phase. Women with low versus high baseline PCS scores had less favorable health profiles at baseline. In multivariable models adjusting for baseline confounders, participants in the lowest PCS quintile (reference = highest quintile) exhibited 1.8 (95%CI: 1.4, 2.3), 4.7 (95%CI: 2.3, 9.4), and 2.1 (95%CI: 1.7, 2.7) times greater risk of CVD incidence, CVD-specific death, and total mortality, respectively, by trial end; whereas, MCS was not significantly associated with CVD incidence or death.
Conclusion
Physical health, assessed by self-report of physical functioning, is a strong predictor of CVD incidence and death in postmenopausal women; similar self-assessment of mental health is not. PCS should be evaluated as a screening tool to identify older women at high risk for CVD development and death.
doi:10.1186/1471-2458-13-468
PMCID: PMC3706392  PMID: 23672763
Physical component summary; Mental component summary; Cardiovascular disease; All-cause death
22.  Chronic Kidney Disease in United States Hispanics: A Growing Public Health Problem 
Ethnicity & disease  2009;19(4):466-472.
Hispanics are the fastest growing minority group in the United States. The incidence of end-stage renal disease (ESRD) in Hispanics is higher than non-Hispanic Whites and Hispanics with chronic kidney disease (CKD) are at increased risk for kidney failure. Likely contributing factors to this burden of disease include diabetes and metabolic syndrome, both are common among Hispanics. Access to health care, quality of care, and barriers due to language, health literacy and acculturation may also play a role. Despite the importance of this public health problem, only limited data exist about Hispanics with CKD. We review the epidemiology of CKD in US Hispanics, identify the factors that may be responsible for this growing health problem, and suggest gaps in our understanding which are suitable for future investigation.
PMCID: PMC3587111  PMID: 20073150
Chronic Kidney Disease; Hispanics; Health Care Disparities
23.  Healthy Lifestyle through Young Adulthood and Presence of Low Cardiovascular Disease Risk Profile in Middle Age: The Coronary Artery Risk Development in (Young) Adults (CARDIA) Study 
Circulation  2012;125(8):996-1004.
Background
A low cardiovascular disease (CVD) risk profile (untreated cholesterol < 200 mg/dl, untreated blood pressure < 120/<80 mmHg, never smoking, and no history of diabetes and myocardial infarction) in middle age is associated with markedly better health outcomes in older age, but few middle aged adults have this low risk profile. We examined whether adopting a healthy lifestyle throughout young adulthood is associated with presence of the low CVD risk profile in middle age.
Methods and Results
The CARDIA study sample consisted of 3,154 black and white participants aged 18 to 30 years at Year 0 (Y0, 1985-86) who attended the Year 0, 7 and 20 (Y0, Y7 and Y20) examinations. Healthy lifestyle factors (HLFs) defined at Y0, Y7 and Y20 included: 1) Average BMI < 25 kg/m2; 2) No or moderate alcohol intake; 3) higher healthy diet score; 4) higher physical activity score; and 5) Never smoking. Mean age (25 years) and percentage of women (56%) were comparable across groups defined by number of HLFs. The age-, sex- and race-adjusted prevalences of low CVD risk profile at Y20 were 3.0%, 14.6%, 29.5%, 39.2% and 60.7% for people with 0 or 1, 2, 3, 4, and 5 HLFs, respectively (p-trend <0.0001). Similar graded relationships were observed for each sex-race group (all p-trend<0.0001).
Conclusions
Maintaining a healthy lifestyle throughout young adulthood is strongly associated with low CVD risk profile in middle age. Public health and individual efforts are needed to improve adoption and maintenance of healthy lifestyles in young adults.
doi:10.1161/CIRCULATIONAHA.111.060681
PMCID: PMC3353808  PMID: 22291127
epidemiology; follow-up studies; risk factors; prevention
24.  Prevalence of Electrocardiographic Abnormalities in a Middle-Aged, Biracial Population: Coronary Artery Risk Development in Young Adults (CARDIA) Study 
Journal of electrocardiology  2010;43(5):385.e1-385.e9.
Background
Few studies to date have described the prevalence of electrocardiographic (ECG) abnormalities in a biracial middle-aged cohort.
Methods and Results
Participants underwent measurement of traditional risk factors and 12-lead ECGs coded using both Minnesota Code (MC) and Novacode (NC) criteria. Among 2585 participants, of whom 57% were women and 44% were black (mean age 45 years), the prevalence of major and minor abnormalities were significantly higher (all P<0.001) among black men and women compared to whites. These differences were primarily due to higher QRS voltage and ST/T wave abnormalities among blacks. There was also a higher prevalence of Q waves (MC 1-1, 1-2, 1-3) than described by previous studies. These racial differences remained after multivariate adjustment for traditional cardiovascular (CV) risk factors.
Conclusions
Black men and women have a significantly higher prevalence of ECG abnormalities, independent of traditional CV risk factors, than whites in a contemporary cohort middle-aged participants.
doi:10.1016/j.jelectrocard.2010.02.001
PMCID: PMC3569004  PMID: 20374967
25.  Prospective Relationship of Low Cardiovascular Risk Factor Profile at Younger Ages to Ankle-Brachial Index: 39-Year Follow-Up—The Chicago Healthy Aging Study 
Background
Data are sparse regarding the long-term association of favorable levels of all major cardiovascular disease risk factors (RFs) (ie, low risk [LR]) with ankle-brachial index (ABI).
Methods and Results
In 2007–2010, the Chicago Healthy Aging Study reexamined a subset of participants aged 65 to 84 years from the Chicago Heart Association Detection Project in Industry cohort (baseline examination, 1967–1973). RF groups were defined as LR (untreated blood pressure ≤120/≤80 mm Hg, untreated serum cholesterol <200 mg/dL, body mass index <25 kg/m2, not smoking, no diabetes) or as 0 RFs, 1 RF, or 2+ RFs based on the presence of blood pressure ≥140/≥90 mm Hg or receiving treatment, serum cholesterol ≥240 mg/dL or receiving treatment, body mass index ≥30 kg/m2, smoking, or diabetes. ABI at follow-up was categorized as indicating PAD present (≤0.90), as borderline PAD (0.91 to 0.99), or as normal (1.00 to 1.40). We included 1346 participants with ABI ≤1.40. After multivariable adjustment, the presence of fewer baseline RFs was associated with a lower likelihood of PAD at 39-year follow-up (P for trend is <0.001). Odds ratios (95% CIs) for PAD in persons with LR, 0 RFs, or 1 RF compared with those with 2+ RFs were 0.14 (0.05 to 0.44), 0.28 (0.13 to 0.59), and 0.33 (0.16 to 0.65), respectively; findings were similar for borderline PAD (P for trend is 0.005). The association was mainly due to baseline smoking status, cholesterol, and diabetes. Remaining free of adverse RFs or improving RF status over time was also associated with PAD.
Conclusions
LR profile in younger adulthood (ages 25 to 45) is associated with the lowest prevalence of PAD and borderline PAD 39 years later.
doi:10.1161/JAHA.112.001545
PMCID: PMC3540658  PMID: 23316312
aging; atherosclerosis; cardiovascular disease; peripheral artery disease; risk factors

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