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1.  Association of Lipids With Incident Heart Failure Among Adults With and Without Diabetes Mellitus 
Circulation. Heart failure  2013;6(3):371-378.
Background
Dyslipidemia is a known risk factor for coronary disease, but its role in heart failure (HF) development is less well-defined.
Methods and Results
We included 5688 participants, aged 45 to 84 years, without clinical cardiovascular disease, and not receiving lipid-lowering medications at baseline, from the Multiethnic Study of Atherosclerosis. Cox-proportional hazards models were used to evaluate associations of triglyceride, total cholesterol/high-density lipoprotein–cholesterol (HDL-C) ratio, HDL-C, and non HDL-C with incident HF. We investigated for effect-modification by diabetes mellitus status and sex. During a median follow-up of 8.5 years, there were 152 incident HF cases. There were no interactions by sex. We observed significant interactions between triglyceride and diabetes mellitus (Pinteraction<0.05). We stratified our analyses by diabetes mellitus status. In participants with diabetes, the hazard ratios were 2.03 (0.97–4.27) and 1.68 (1.18–2.38) for high triglyceride and log of triglyceride, respectively, after adjusting for confounders, comorbidities, and diabetes mellitus severity/treatment. The association of high triglyceride with incident HF was attenuated by interim myocardial infarction. The hazard ratios were greatest in participants with diabetes who also had high triglyceride, low HDL-C, or high total cholesterol/HDL-C ratio (3.59 [2.03–6.33], 3.62 [2.06–6.36], and 3.54 [1.87–6.70], respectively). Lipid measures were not associated with incident HF in individuals without diabetes.
Conclusions
The risk of incident HF is greater in individuals with diabetes mellitus who also have high triglyceride, low HDL-C, or high total cholesterol/HDL-C ratio. The association of high triglyceride with incident HF is partly mediated by myocardial infarction.
doi:10.1161/CIRCHEARTFAILURE.112.000093
PMCID: PMC3991930  PMID: 23529112
diabetes mellitus; heart failure; lipids
2.  Genetic variants associated with VLDL, LDL and HDL particle size differ with race/ethnicity 
Human genetics  2012;132(4):405-413.
Background
Specific constellations of lipoprotein particle features, reflected as differences in mean lipoprotein particle diameters, are associated with risk of insulin resistance (IR) and cardiovascular disease (CVD). The associations of lipid profiles with disease risk differ by race/ethnicity, the reason for this is not clear. We aimed to examine whether there were additional genetic differences between racial / ethnic groups on lipoprotein profile.
Methods and results
Genotypes were assessed using the Affymetrix 6.0 array in 817 related Caucasian participants of the Genetics of Lipid Lowering Drugs and Diet Network (GOLDN). Association analysis was conducted on fasting mean particle diameters using linear models, adjusted for age, sex and study center as fixed effects, and pedigree as a random effect. Replication of associations reaching P<1.97 * 10−05 (the level at which we achieved at least 80% power to replicate SNP-phenotype associations) was conducted in the Caucasian population of the Multi-Ethnic Study of Atherosclerosis (MESA; N=2430). Variants which replicated across both Caucasian populations were subsequently tested for association in the African-American (N=1594), Chinese (N=758) and Hispanic (N=1422) populations of MESA. Variants in the APOB gene region were significantly associated with mean VLDL diameter in GOLDN, and in the Caucasian and Hispanic populations of MESA, while variation in the hepatic lipase (LIPC) gene was associated with mean HDL diameter in both Caucasians populations only.
Conclusions
Our findings suggest the genetic underpinnings of mean lipoprotein diameter differ by race/ethnicity. As lipoprotein diameters are modifiable, this may lead new strategies to modify lipoprotein profiles during the reduction of IR that are sensitive to race / ethnicity.
doi:10.1007/s00439-012-1256-1
PMCID: PMC3600091  PMID: 23263444
Lipoprotein size; race / ethnicity; ApoB; Hepatic Lipase; NMR
3.  The Healthy Living Partnerships to Prevent Diabetes Study 
American journal of preventive medicine  2013;44(4 0 4):S324-S332.
Background
Since the Diabetes Prevention Project (DPP) demonstrated that lifestyle weight-loss interventions can reduce the incidence of diabetes by 58%, several studies have translated the DPP methods to public health–friendly contexts. Although these studies have demonstrated short-term effects, no study to date has examined the impact of a translated DPP intervention on blood glucose and adiposity beyond 12 months of follow-up.
Purpose
To examine the impact of a 24-month, community-based diabetes prevention program on fasting blood glucose, insulin, insulin resistance as well as body weight, waist circumference, and BMI in the second year of follow-up.
Design
An RCT comparing a 24-month lifestyle weight-loss program (LWL) to an enhanced usual care condition (UCC) in participants with prediabetes (fasting blood glucose=95–125 mg/dL). Data were collected in 2007–2011; analyses were conducted in 2011–2012.
Setting/participants
301 participants with prediabetes were randomized; 261 completed the study. The intervention was held in community-based sites.
Intervention
The LWL program was led by community health workers and sought to induce 7% weight loss at 6 months that would be maintained over time through decreased caloric intake and increased physical activity. The UCC received two visits with a registered dietitian and a monthly newsletter.
Main outcome measures
The main measures were fasting blood glucose, insulin, insulin resistance, body weight, waist circumference, and BMI.
Results
Intent-to-treat analyses of between-group differences in the average of 18- and 24-month measures of outcomes (controlling for baseline values) revealed that the LWL participants experienced greater decreases in fasting glucose (−4.35 mg/dL); insulin (−3.01 μU/ml); insulin resistance (−0.97); body weight (−4.19 kg); waist circumference (−3.23 cm); and BMI (−1.40), all p-values <0.01.
Conclusions
A diabetes prevention program administered through an existing community-based system and delivered by community health workers is effective at inducing significant long-term reductions in metabolic indicators and adiposity.
Trial registration
This study is registered at Clinicaltrials.gov NCT00631345.
doi:10.1016/j.amepre.2012.12.015
PMCID: PMC3731757  PMID: 23498294
4.  Cost of a Group Translation of the Diabetes Prevention Program 
American journal of preventive medicine  2013;44(4 0 4):10.1016/j.amepre.2012.12.016.
Background
Although numerous studies have translated the Diabetes Prevention Program lifestyle intervention into various settings, no study to date has reported a formal cost analysis.
Purpose
To describe costs associated with the Healthy Living Partnerships to Prevent Diabetes (HELP PD) trial.
Design
HELP PD was a 24-month RCT testing the impact of a lifestyle weight-loss intervention administered through a diabetes education program and delivered by community health workers (CHWs) on blood glucose and body weight among prediabetics.
Setting/participants
In all, 301 participants with prediabetes were randomized in Forsyth County NC. Data reported in these analyses were collected in 2007–2011 and analyzed in 2011–2012.
Intervention
The lifestyle weight-loss group had a 7% weight loss goal achieved and maintained by caloric restriction and increased physical activity. The usual care group received two visits with a registered dietitian and monthly newsletters.
Main outcome measures
Measures are direct medical costs, direct nonmedical costs and indirect costs over the 2-year study period. Research costs are excluded.
Results
The direct medical cost (in 2010 dollars) to identify one participant was $16.85. Direct medical costs per capita for participants in the usual care group were $142 and $850 for lifestyle weight-loss participants. Per capita direct costs of care outside the study were $7454 for the usual care group and $5177 for the lifestyle weight-loss group. Per capita direct nonmedical costs were $12,881 for the usual care group and $13,836 for the lifestyle weight-loss group. The lifestyle weight-loss group in HELP PD cost $850 in direct medical costs for 2 years, compared to $2631 in direct medical costs for the first 2 years of DPP.
Conclusions
A community-based translation of the DPP can be delivered effectively and with reduced costs.
doi:10.1016/j.amepre.2012.12.016
PMCID: PMC3839056  PMID: 23498303
5.  Reduction in Observation Unit Length of Stay with Coronary Computed Tomography Angiography Depends on Time of Emergency Department Presentation 
Objectives
Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS, and if there are disparities in testing modality use, based upon the time of patient presentation to the ED.
Methods
The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hrs. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using four hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race.
Results
Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (IQR 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After adjusting for age, race, and sex, patients presenting between 08:00 and 11:59 hrs not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing.
Conclusions
In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hrs. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.
doi:10.1111/acem.12094
PMCID: PMC3607957  PMID: 23517254
6.  The Relationship between Measures of Obesity and Incident Heart Failure: The Multi-Ethnic Study of Atherosclerosis 
Obesity (Silver Spring, Md.)  2013;21(9):1915-1922.
Objective
To evaluate the strength of association of body mass index (BMI) and waist circumference (WC) with incident heart failure (HF), exploring our associations by ethnicity and age.
Design and Methods
We included 6,809 participants, aged 45–84 years, without clinical cardiovascular disease (2000–2002), from the Multi-Ethnic Study of Atherosclerosis. Cox-Proportional hazards models were used to examine associations of BMI and WC with incident HF. The predictive abilities of BMI and WC were compared using receiver operating characteristic curves.
Results
Over a median follow-up of 7.6 years, there were 176 cases. BMI and WC were associated with incident HF in men [1.33 (1.10–1.61) and 1.38 (1.18–1.62) respectively] and women [1.70 (1.33–2.17) and 1.64 (1.29–2.08) respectively]. These associations became non-significant after adjusting for obesity-related conditions (hypertension, dysglycemia, hypercholesterolemia, left ventricular hypertrophy, kidney disease and inflammation). The associations of BMI and WC did not vary significantly by ethnicity or age-group, but were inverse in Hispanic men. The area under the curve for BMI and WC was 0.749 and 0.750, respectively, in men and 0.782 and 0.777, respectively, in women.
Conclusions
The association between obesity and incident HF is largely mediated by obesity-related conditions. BMI and WC have similar predictive abilities for incident HF.
doi:10.1002/oby.20298
PMCID: PMC3664654  PMID: 23441088
Obesity; heart failure; body mass index and waist circumference
7.  The Neighborhood Energy Balance Equation: Does Neighborhood Food Retail Environment + Physical Activity Environment = Obesity? The CARDIA Study 
PLoS ONE  2013;8(12):e85141.
Background
Recent obesity prevention initiatives focus on healthy neighborhood design, but most research examines neighborhood food retail and physical activity (PA) environments in isolation. We estimated joint, interactive, and cumulative impacts of neighborhood food retail and PA environment characteristics on body mass index (BMI) throughout early adulthood.
Methods and Findings
We used cohort data from the Coronary Artery Risk Development in Young Adults (CARDIA) Study [n=4,092; Year 7 (24-42 years, 1992-1993) followed over 5 exams through Year 25 (2010-2011); 12,921 person-exam observations], with linked time-varying geographic information system-derived neighborhood environment measures. Using regression with fixed effects for individuals, we modeled time-lagged BMI as a function of food and PA resource density (counts per population) and neighborhood development intensity (a composite density score). We controlled for neighborhood poverty, individual-level sociodemographics, and BMI in the prior exam; and included significant interactions between neighborhood measures and by sex. Using model coefficients, we simulated BMI reductions in response to single and combined neighborhood improvements. Simulated increase in supermarket density (from 25th to 75th percentile) predicted inter-exam reduction in BMI of 0.09 kg/m2 [estimate (95% CI): -0.09 (-0.16, -0.02)]. Increasing commercial PA facility density predicted BMI reductions up to 0.22 kg/m2 in men, with variation across other neighborhood features [estimate (95% CI) range: -0.14 (-0.29, 0.01) to -0.22 (-0.37, -0.08)]. Simultaneous increases in supermarket and commercial PA facility density predicted inter-exam BMI reductions up to 0.31 kg/m2 in men [estimate (95% CI) range: -0.23 (-0.39, -0.06) to -0.31 (-0.47, -0.15)] but not women. Reduced fast food restaurant and convenience store density and increased public PA facility density and neighborhood development intensity did not predict reductions in BMI.
Conclusions
Findings suggest that improvements in neighborhood food retail or PA environments may accumulate to reduce BMI, but some neighborhood changes may be less beneficial to women.
doi:10.1371/journal.pone.0085141
PMCID: PMC3874030  PMID: 24386458
8.  Translating Diabetes Prevention Programs 
North Carolina medical journal  2011;72(5):405-408.
Numerous studies have translated the Diabetes Prevention Program (DPP) for community-based settings, and the results are encouraging. This commentary discusses one community-based DPP translational study, Healthy Living Partnerships to Prevent Diabetes, in detail, as well as the implications of DPP translational studies for public policy.
PMCID: PMC3809057  PMID: 22416527
9.  Health care access and weight change among young adults: The Coronary Artery Risk Development in Young Adults (CARDIA) Study 
Public health nutrition  2012;16(10):1796-1800.
Objective
Health care access is associated with improved control of multiple chronic diseases, but the association between health care access and weight change is unclear. This study aims to test the association between health care access and weight change.
Design
The Coronary Artery Risk Development in Young Adults (CARDIA) study is a multi-center population-based prospective study. Weight change was calculated at 3 and 13 years after CARDIA year 7 (1992–1993). Health care access was defined as no barriers or one or more barriers to access (health insurance gap, no usual source of care, not seeking care due to expense). Intermediary variables evaluated included history of dieting, and use of diet pills, meal replacements, or weight control programs.
Setting
Four cities in the United States.
Subjects
Participants were aged 18–30 years at baseline (1985–1986). Analyses include 3922 black and white men and women with relevant data from CARDIA years 7, 10, and 20 (1992–1993, 1995–1996, and 2005–2006, respectively).
Results
Mean weight change was +4.9 pounds by 3 years and +18.7 pounds by 13 years, with no differences by health care access. Being on a weight-reducing diet was not consistently associated with health care access across examinations. Use of diet pills, meal replacements or organized weight control programs was low, and did not vary by health care access.
Conclusions
Weight gain was high irrespective of health care access. Public health and clinical approaches are needed to address weight gain.
doi:10.1017/S1368980012003813
PMCID: PMC3574627  PMID: 22894769
health care accessibility; body weight change
10.  Relationship of Weekly Activity Minutes to Metabolic Syndrome in Prediabetes: The Healthy Living Partnerships to Prevent Diabetes 
Background
Physical inactivity contributes to metabolic syndrome (MetS) in overweight/obesity. However, little is known about this relationship in prediabetes.
Methods
The study purpose is to examine relationships between physical activity (PA) and MetS in prediabetes. The Healthy Living Partnerships to Prevent Diabetes tested a community translation of the Diabetes Prevention Program (DPP). Three hundred one overweight/obese prediabetics provided walking minutes/week (WM) and total activity minutes/week (AM) via the International Physical Activity Questionnaire. MetS was at least 3 of waist (men ≥ 102 cm, women ≥ 88 cm), triglycerides (≥150 mg·dl), blood pressure (≥130·85 mm Hg), glucose (≥100mg·dl), and HDL (men < 40mg·dl, women < 50mg·dl).
Results
The sample was 57.5% female, 26.7% nonwhite/Hispanic, 57.9 ± 9.5 years and had a body mass index (BMI) 32.7 ± 4 kg·m2. Sixty percent had MetS. Eighteen percent with MetS reported at least 150 AM compared with 29.8% of those without MetS. The odds of MetS was lower with greater AM (Ptrend = .041) and WM (Ptrend = .024). Odds of MetS with 0 WM were 2.08 (P = .046) and with no AM were 2.78 (P = .009) times those meeting goal. One hour additional WM led to 15 times lower MetS odds.
Conclusions
Meeting PA goals reduced MetS odds in this sample, which supported PA for prediabetes to prevent MetS.
PMCID: PMC3765007  PMID: 23036940
obesity; walking; physical activity
11.  Future Directions for Cardiovascular Disease Comparative Effectiveness Research 
Comparative effectiveness research (CER) aims to provide decision-makers the evidence needed to evaluate the benefits and harms of alternative clinical management strategies. CER has become a national priority, with considerable new research funding allocated. Cardiovascular disease is a priority area for CER. This workshop report provides an overview of CER methods, with an emphasis on practical clinical trials and observational treatment comparisons. The report also details recommendations to the National Heart Lung and Blood Institute for a new framework for evidence development to foster cardiovascular CER, and specific studies to address eight clinical issues identified by the Institute of Medicine as high priorities for cardiovascular CER.
doi:10.1016/j.jacc.2011.12.057
PMCID: PMC3416944  PMID: 22796257
comparative effectiveness; research methods; clinical trials
12.  Population shifts and the future of stroke: forecasts of the future burden of stroke 
Population distribution estimates by age and race/ethnicity from the U.S. Census Bureau for the years 2010 and 2050 were combined with estimates of stroke incidence from population-based surveillance studies to forecast the distribution of incident stroke cases for the years 2010 and 2050. Over these 40 years, the number of incident strokes will more than double, with the majority of the increase among the elderly (age 75+) and minority groups (particularly Hispanics). These increases are likely to present major logistical, scientific, and ethnical issues in the near future.
doi:10.1111/j.1749-6632.2012.06665.x
PMCID: PMC3727892  PMID: 22994216
stroke; incidence; aging; race; projections
13.  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
14.  Exercise Training Improves Heart Rate Variability in Older Patients with Heart Failure: A Randomized, Controlled, Single-Blinded Trial 
Background
Reduced heart rate variability (HRV) in older patients with heart failure (HF) is common and indicates poor prognosis. Exercise training (ET) has been shown to improve HRV in younger patients with HF. However the effect of ET on HRV in older patients with HF is not known.
Methods and Results
Sixty-six participants (36% males), age 69±5 years, with HF and both preserved ejection fraction (HFPEF) and reduced ejection fraction (HFREF), were randomly assigned to 16 weeks of supervised ET (ET group) versus attention-control (AC group). Two HRV parameters (the standard deviation of all normal RR intervals (SDNN) and the root mean square of successive differences in normal RR intervals (RMSSD)) were measured at baseline and after completion of the study. When compared with the AC group, the ET group had a significantly greater increase in both SDNN (15.46 ± 5.02 ms in ET versus 2.37 ± 2.13 ms in AC, P = 0.016), and RMSSD (17.53 ± 7.83 ms in ET versus 1.69 ± 2.63 ms in AC, P = 0.003). This increase was seen in both genders and HF categories.
Conclusion
ET improves HRV in older patients with both HFREF and HFPEF.
doi:10.1111/j.1751-7133.2011.00282.x
PMCID: PMC3400715  PMID: 22536936
15.  The Impact of Frequent and Unrecognized Hypoglycemia on Mortality in the ACCORD Study 
Diabetes Care  2012;35(2):409-414.
OBJECTIVE
The aim of this study was to examine the relationship between frequent and unrecognized hypoglycemia and mortality in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study cohort.
RESEARCH DESIGN AND METHODS
A total of 10,096 ACCORD study participants with follow-up for both hypoglycemia and mortality were included. Hazard ratios (95% CIs) relating the risk of death to the updated annualized number of hypoglycemic episodes and the updated annualized number of intervals with unrecognized hypoglycemia were obtained using Cox proportional hazards regression models, allowing for these hypoglycemia variables as time-dependent covariates and controlling for the baseline covariates.
RESULTS
Participants in the intensive group reported a mean of 1.06 hypoglycemic episodes (self-monitored blood glucose <70 mg/dL or <3.9 mmol/L) in the 7 days preceding their regular 4-month visit, whereas participants in the standard group reported an average of 0.29 episodes. Unrecognized hypoglycemia was reported, on average, at 5.8% of the intensive group 4-month visits and 2.6% of the standard group visits. Hazard ratios for mortality in models including frequency of hypoglycemic episodes were 0.93 (95% CI 0.9–0.97; P < 0.001) for participants in the intensive group and 0.98 (0.91–1.06; P = 0.615) for participants in the standard group. The hazard ratios for mortality in models, including unrecognized hypoglycemia, were not statistically significant for either group.
CONCLUSIONS
Recognized and unrecognized hypoglycemia was more common in the intensive group than in the standard group. In the intensive group of the ACCORD study, a small but statistically significant inverse relationship of uncertain clinical importance was identified between the number of hypoglycemic episodes and the risk of death among participants.
doi:10.2337/dc11-0996
PMCID: PMC3263892  PMID: 22179956
16.  Effectiveness of a Web-Based Colorectal Cancer Screening Patient Decision Aid 
Background
Colorectal cancer (CRC) screening reduces mortality yet remains underutilized. Low health literacy may contribute to this underutilization by interfering with patients’ ability to understand and receive preventive health services.
Purpose
To determine if a web-based multimedia CRC screening patient decision aid, developed for a mixed-literacy audience, could increase CRC screening.
Design
RCT. Patients aged 50–74 years and overdue for CRC screening were randomized to the web-based decision aid or a control program seen immediately before a scheduled primary care appointment.
Setting/Participants
A large community-based, university-affiliated internal medicine practice serving a socioeconomically disadvantaged population.
Main Outcome Measures
Patients completed surveys to determine their ability to state a screening test preference and their readiness to receive screening. Charts were abstracted by masked observers to determine if screening tests were ordered and completed.
Results
Between November 2007 and September 2008, a total of 264 patients enrolled in the study. Data collection was completed in 2009, and data analysis was completed in 2010. A majority of participants (mean age 57.8 years) were female (67%), African-American (74%), had annual household incomes of < $20,000 (76%), and had limited health literacy (56%). When compared to control participants, more decision-aid participants had a CRC screening preference (84% vs 55%, p<0.0001), and an increase in readiness to receive screening (52% vs 20%, p=0.0001). More decision-aid participants had CRC screening tests ordered (30% vs 21%) and completed (19% vs 14%), but no statistically significant differences were seen (AORs 1.6 [95% CI 0.97, 2.8] and 1.7 [95% CI 0.88, 3.2] respectively). Similar results were found across literacy levels.
Conclusions
The web-based decision aid increased patients’ ability to form a test preference and their intent to receive screening, regardless of literacy level. Further study should examine ways the decision aid can be combined with additional system changes to increase CRC screening.
doi:10.1016/j.amepre.2011.02.019
PMCID: PMC3480321  PMID: 21565651
17.  The Effect of Including Cystatin C or Creatinine in a Cardiovascular Risk Model for Asymptomatic Individuals 
American Journal of Epidemiology  2011;174(8):949-957.
The authors studied the incremental value of adding serum cystatin C or creatinine to the Framingham risk score variables (FRSVs) for the prediction of incident cardiovascular disease (CVD) among 6,653 adults without clinical CVD utilizing the Multi-Ethnic Study of Atherosclerosis (2000–2008). CVD events included coronary heart disease, heart failure, stroke, and peripheral arterial disease. Variables were transformed to yield optimal prediction of 6-year CVD events in sex-stratified models with FRSVs alone, FRSVs + cystatin C, and FRSVs + creatinine. Risk prediction in the 3 models was assessed by using the C statistic, and net reclassification improvement was calculated. The mean ages were 61.9 and 64.6 years for individuals with and without diabetes, respectively. After 6 years of follow-up, 447 (7.2%) CVD events occurred. In the total cohort, no significant change in the C statistic was noted with FRSVs + cystatin C and FRSVs + creatinine compared with FRSVs alone, and net reclassification improvement for CVD risk was extremely small and not significant with the addition of cystatin C or creatinine to FRSVs. Similar findings were noted after stratifying by baseline presence of diabetes. In conclusion, the addition of cystatin C or serum creatinine to FRSVs does not improve CVD risk prediction among adults without clinical CVD.
doi:10.1093/aje/kwr185
PMCID: PMC3218629  PMID: 21880578
cardiovascular diseases; creatinine; cystatin C; risk model
18.  Racial and Geographic Differences in Prevalence, Awareness, Treatment and Control of Dyslipidemia: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study 
Neuroepidemiology  2011;37(1):39-44.
Background/Aims
There are racial and geographic disparities in stroke mortality, with higher rates among African Americans (AAs) and those living in the southeastern US (‘stroke belt’). Racial and geographic differences in dyslipidemia prevalence, awareness, treatment and control may, in part, account for the observed disparities in stroke mortality.
Methods
Reasons for Geographic and Racial Differences in Stroke (REGARDS) is a national observational study of community-dwelling black and white participants aged 45 and older, with oversampling from the stroke belt. As of January 15, 2007, 26,122 participants were enrolled and a fasting lipid panel was available of 21,068. Awareness, treatment and control of dyslipidemia were estimated overall and compared across race-sex-region strata.
Results
There were 55% of the participants with dyslipidemia and no racial differences in prevalence. Adjusting for demographic and established stroke risk factors, AAs had a lower prevalence (OR 0.74; 95% CI: 0.66, 0.77) and were less likely to be aware (0.69; 0.61, 0.78), treated (0.77; 0.67, 0.89) and controlled (0.67; 0.58, 0.77) than whites. There was lower control outside of the stroke belt (0.87; 0.76, 0.99).
Conclusion
Racial, but not geographic, differences in dyslipidemia management may play a role in the excess stroke burden in the Southeast.
doi:10.1159/000328258
PMCID: PMC3171279  PMID: 21822024
Cholesterol; Risk factors; Risk factor management; Racial differences; Stroke prevention
19.  Can the HEART Score Safely Reduce Stress Testing and Cardiac Imaging in Patients at Low Risk for Acute Coronary Syndrome? 
Critical Pathways in Cardiology  2011;10(3):128-133.
Background
Patients with low risk chest pain have high utilization of stress testing and cardiac imaging, but low rates of acute coronary syndrome (ACS). The objective of this study was to determine if the HEART score could safely reduce objective cardiac testing in patients with low risk chest pain.
Methods
A cohort of chest pain patients was identified from an Emergency Department-based observation unit registry. HEART scores were determined using registry data elements and blinded chart review. HEART scores were dichotomized into low (0–3) or high risk (>3). The outcome was MACE; a composite endpoint of all cause mortality, myocardial infarction, or coronary revascularization during the index visit or within 30 days. Sensitivity, specificity, and potential reduction of cardiac testing were calculated.
Results
Over 28 months, the registry included 1070 low risk chest pain patients. MACE occurred in 0.6% (5/904) of patients with low-risk HEART scores compared to 4.2% (7/166) with a high-risk HEART scores, OR=7.92, (95%CI 2.48–25.25). A HEART score >3 was 58% sensitive (95% CI 32–81%) and 85% specific (95% CI 83–87%) for MACE. The HEART score missed 5 cases of ACS among 1070 patients (0.5%) and could have reduced cardiac testing by 84.5% (904/1070). Combination of serial troponin > 0.065 ng/ml or HEART score >3 resulted in 100% sensitivity (95% CI 72–100%), specificity of 83% (95%CI 81–85%), and potential reduction in cardiac testing of 82% (879/1070).
Conclusions
If used to guide stress testing and cardiac imaging, the HEART score could substantially reduce cardiac testing in a population with low pre-test probability of ACS.
doi:10.1097/HPC.0b013e3182315a85
PMCID: PMC3289967  PMID: 21989033
HEART score; chest pain; cardiac testing; observation; risk stratification
20.  High-Density Lipoprotein Cholesterol and Particle Concentrations, Carotid Atherosclerosis and Coronary Events: The Multi-Ethnic Study of Atherosclerosis 
Objectives
To evaluate independent associations of high density lipoprotein cholesterol (HDL-C) and particle (HDL-P) concentrations with carotid intima-media thickness (cIMT) and incident coronary heart disease (CHD).
Background
HDL-C is inversely related to CHD, but also to triglycerides, LDL particles (LDL-P), and related metabolic risk. HDL-P associations with CHD may be partially independent of these factors.
Methods
In a multi-ethnic study of 5598 men and women ages 45-84, without baseline CHD, excluding subjects on lipid-lowering medications, triglycerides >400 mg/dl or missing values, we evaluated associations of HDL-C and NMR-spectroscopy-measured HDL-P with cIMT and incident CHD (myocardial infarction, CHD death, angina, n=227 events, 6.0 years mean follow-up). All models were adjusted for age, sex, ethnicity, hypertension and smoking.
Results
HDL-C and HDL-P correlated with each other (π=0.69) and LDL-P (π = −0.38, −0.25, respectively), p<0.05 for all. For (1-SD) higher HDL-C (15 mg/dl) or HDL-P (6.64 μmol/l), cIMT differences (95%CI) were −26.1(−34.7,−17.4) and −30.1 (−38.8,−21.4) μm, and CHD hazard ratios (HR (95%CI)) were 0.74 (0.63, 0.88) and 0.70 (0.59, 0.82), respectively. Adjusted for each other and LDL-P, HDL-C was no longer associated with cIMT (2.3 (−9.5, 14.2) μm) or CHD (0.97(0.77, 1.22)), but HDL-P remained independently associated with cIMT (−22.2(−33.8,−10.6) μm) and CHD (0.75 (0.61, 0.93)). Interactions by sex, ethnicity, diabetes and high-sensitivity C-reactive protein were not significant.
Conclusions
Adjusting for each other and LDL-P substantially attenuated associations of HDL-C, but not HDL-P, with cIMT and CHD. Potential confounding by related lipids or lipoproteins should be carefully considered when evaluating HDL-related risk.
doi:10.1016/j.jacc.2012.03.060
PMCID: PMC3411890  PMID: 22796256
Lipids; lipoproteins; high-density lipoprotein cholesterol; high-density lipoprotein particles; cardiovascular disease
21.  Baseline comparison of three health utility measures and the feeling thermometer among participants in the action to control cardiovascular risk in diabetes trial 
Background
Health utility (HU) measures are used as overall measures of quality of life and to determine quality adjusted life years (QALYs) in economic analyses. We compared baseline values of three HUs including Short Form 6 Dimensions (SF-6D), and Health Utilities Index, Mark II and Mark III (HUI2 and HUI3) and the feeling thermometer (FT) among type 2 diabetes participants in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. We assessed relationships between HU and FT values and patient demographics and clinical variables.
Methods
ACCORD was a randomized clinical trial to test if intensive controls of glucose, blood pressure and lipids can reduce the risk of major cardiovascular disease (CVD) events in type 2 diabetes patients with high risk of CVD. The health-related quality of life (HRQOL) sub-study includes 2,053 randomly selected participants. Interclass correlations (ICCs) and agreement between measures by quartile were used to evaluate relationships between HU’s and the FT. Multivariable regression models specified relationships between patient variables and each HU and the FT.
Results
The ICCs were 0.245 for FT/SF-6D, 0.313 for HUI3/SF-6D, 0.437 for HUI2/SF-6D, 0.338 for FT/HUI2, 0.337 for FT/HUI3 and 0.751 for HUI2/HUI3 (P < 0.001 for all). Common classification by quartile was found for the majority (62%) of values between HUI2 and HUI3, which was significantly (P < 0.001) higher than between other HUs and the FT: SF-6D/HUI3 = 40.8%, SF-6D/HUI2 = 40.9%, FT/HUI3 = 35.0%, FT/HUI2 = 34.9%, and FT/SF-6D = 31.9%. Common classification was higher between SF-6D/HUI2 and SF-6D/HUI3 (P < 0.001) than between FT/SF-6D, FT/HUI2, and FT/HUI3. The mean difference in HU values per patient ranged from −0.024 ± 0.225 for SF-6D/ HUI3 to −0.124 ± 0.133 for SF-6D/HUI2. Regression models were significant; clinical and demographic variables explained 6.1% (SF-6D) to 7.7% (HUI3) of the variance in HUs.
Conclusions
The agreements between the different HUs were poor except for the two HUI measures; therefore HU values derived different measures may not be comparable. The FT had low agreement with HUs. The relationships between HUs and demographic and clinical measures demonstrate how severity of diabetes and other clinical and demographic factors are associated with HUs and FT measures.
Trial registration
ClinicalTrials.gov Identifier: NCT00000620
doi:10.1186/1475-2840-11-35
PMCID: PMC3395556  PMID: 22515638
Diabetes mellitus, Type 2/*complications /physiopathology/psychology; Health status indicators; Randomized controlled clinical trial; Humans; Regression analysis; Glycemic control
22.  One-Year Results of a Community-Based Translation of the Diabetes Prevention Program 
Diabetes Care  2011;34(7):1451-1457.
OBJECTIVE
Although the Diabetes Prevention Program (DPP) and the Finnish Diabetes Prevention Study (FDPS) demonstrated that weight loss from lifestyle change reduces type 2 diabetes incidence in patients with prediabetes, the translation into community settings has been difficult. The objective of this study is to report the first-year results of a community-based translation of the DPP lifestyle weight loss (LWL) intervention on fasting glucose, insulin resistance, and adiposity.
RESEARCH DESIGN AND METHODS
We randomly assigned 301 overweight and obese volunteers (BMI 25–40 kg/m2) with fasting blood glucose values between 95 and 125 mg/dL to a group-based translation of the DPP LWL intervention administered through a diabetes education program (DEP) and delivered by community health workers (CHWs) or to an enhanced usual-care condition. CHWs were volunteers with well-controlled type 2 diabetes. A total of 42.5% of participants were male, mean age was 57.9 years, 26% were of a race/ethnicity other than white, and 80% reported having an education beyond high school. The primary outcome is mean fasting glucose over 12 months of follow-up, adjusting for baseline glucose.
RESULTS
Compared with usual-care participants, LWL intervention participants experienced significantly greater decreases in blood glucose (−4.3 vs. −0.4 mg/dL; P < 0.001), insulin (−6.5 vs. −2.7 μU/mL; P < 0.001), homeostasis model assessment of insulin resistance (−1.9 vs. −0.8; P < 0.001), weight (−7.1 vs. −1.4 kg; P < 0.001), BMI (−2.1 vs. −0.3 kg/m2; P < 0.001), and waist circumference (−5.9 vs. −0.8 cm; P < 0.001).
CONCLUSIONS
This translation of the DPP intervention conducted in community settings, administered through a DEP, and delivered by CHWs holds great promise for the prevention of diabetes by significantly decreasing glucose, insulin, and adiposity.
doi:10.2337/dc10-2115
PMCID: PMC3120203  PMID: 21593290
23.  Attrition in a Multidisciplinary Pediatric Weight Management Clinic 
Childhood obesity (Print)  2011;7(3):185-193.
Background
Pediatric weight management clinics experience significant dropout, and few studies have investigated this problem. The objective of this study was to identify family and clinic characteristics associated with attrition from a tertiary care pediatric weight management clinic.
Methods
This was a prospective and retrospective clinical database study of a multidisciplinary clinic for obese children 2–18 years with a weight-related co-morbidity. All patients seen between November, 2007, and July, 2009, were included. Characteristics of Active and Inactive families were compared using chi-squared and t-tests, and logistic regression was used to identify independent correlates of program status. A one-page survey was mailed to all Inactive families.
Results
A total of 133 patients were seen during the study period. Their mean age was 12 years old, mean BMI was 38 kg/m2, 53% were female, 52% represented racial/ethnic minorities, and 50% were Medicaid recipients. In all, 32% dropped out of treatment. Inactive children had significantly lower BMI z-scores, were older, and were more likely to have poor school performance than active children. Similar results were found on regression analysis: Children with higher BMI z-scores, commercial insurance, average school performance, and a major weight-related co-morbidity were less likely to be inactive. The most common parent-reported reasons for dropping out were: Child not wanting to make changes, weight not improving, child desired to leave program, and program not meeting parent or child’s expectations.
Conclusions
Attrition from pediatric weight management treatment is high, with age, weight, school performance, and health associated with dropout. Parents mostly reported child-related issues, including lack of weight loss, as reasons for dropout.
doi:10.1089/chi.2011.0010
PMCID: PMC3181116  PMID: 21966612
24.  Attrition in a Multidisciplinary Pediatric Weight Management Clinic 
Childhood Obesity  2011;7(3):185-193.
Abstract
Background
Pediatric weight management clinics experience significant dropout, and few studies have investigated this problem. The objective of this study was to identify family and clinic characteristics associated with attrition from a tertiary care pediatric weight management clinic.
Methods
This was a prospective and retrospective clinical database study of a multidisciplinary clinic for obese children 2–18 years with a weight-related co-morbidity. All patients seen between November, 2007, and July, 2009, were included. Characteristics of Active and Inactive families were compared using chi-squared and t-tests, and logistic regression was used to identify independent correlates of program status. A one-page survey was mailed to all Inactive families.
Results
A total of 133 patients were seen during the study period. Their mean age was 12 years old, mean BMI was 38 kg/m2, 53% were female, 52% represented racial/ethnic minorities, and 50% were Medicaid recipients. In all, 32% dropped out of treatment. Inactive children had significantly lower BMI z-scores, were older, and were more likely to have poor school performance than active children. Similar results were found on regression analysis: Children with higher BMI z-scores, commercial insurance, average school performance, and a major weight-related co-morbidity were less likely to be inactive. The most common parent-reported reasons for dropping out were: Child not wanting to make changes, weight not improving, child desired to leave program, and program not meeting parent or child's expectations.
Conclusions
Attrition from pediatric weight management treatment is high, with age, weight, school performance, and health associated with dropout. Parents mostly reported child-related issues, including lack of weight loss, as reasons for dropout.
doi:10.1089/chi.2011.0010
PMCID: PMC3181116  PMID: 21966612
25.  Blood Pressure and the Risk of Developing Diabetes in African Americans and Whites 
Diabetes Care  2011;34(4):873-879.
OBJECTIVE
We examined the association between high blood pressure and incident type 2 diabetes in African Americans and whites aged 35–54 years at baseline.
RESEARCH DESIGN AND METHODS
We combined data from the Atherosclerosis Risk in Communities (ARIC) study, the Coronary Artery Risk Development in Young Adults (CARDIA) study, and the Framingham Heart Study offspring cohort. Overall, 10,893 participants (57% women; 23% African American) were categorized by baseline blood pressure (normal, prehypertension, hypertension) and examined for incident diabetes (median follow-up 8.9 years).
RESULTS
Overall, 14.6% of African Americans and 7.9% of whites developed diabetes. Age-adjusted incidence was increasingly higher across increasing blood pressure groups (P values for trend: <0.05 for African American men; <0.001 for other race-sex groups). After adjustment for age, sex, BMI, fasting glucose, HDL cholesterol, and triglycerides, prehypertension or hypertension (compared with normal blood pressure) was associated with greater risks of diabetes in whites (hazard ratio [HR] for prehypertension: 1.32 [95% CI 1.09–1.61]; for hypertension: 1.25 [1.03–1.53]), but not African Americans (HR for prehypertension: 0.86 [0.63–1.17]; for hypertension: 0.92 [0.70–1.21]). HRs for developing diabetes among normotensive, prehypertensive, and hypertensive African Americans versus normotensive whites were: 2.75, 2.28, and 2.36, respectively (P values <0.001).
CONCLUSIONS
In African Americans, higher diabetes incidence among hypertensive individuals may be explained by BMI, fasting glucose, triglyceride, and HDL cholesterol. In whites, prehypertension and hypertension are associated with greater risk of diabetes, beyond that explained by other risk factors. African Americans, regardless of blood pressure, have greater risks of developing diabetes than whites.
doi:10.2337/dc10-1786
PMCID: PMC3064044  PMID: 21346180

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