Women with a history of gestational diabetes mellitus (GDM) have elevated risk of developing type 2 diabetes. Diet quality plays an important role in the prevention of type 2 diabetes. We compared diet quality among childbearing women with a history of GDM with the diet quality of childbearing women without a history of GDM.
We used data from the National Health and Nutrition Examination Survey for 2007 through 2010. We included women without diabetes aged 20 to 44 years whose most recent live infant was born within the previous 10 years and who completed two 24-hour dietary recalls. The Healthy Eating Index (HEI)-2010 estimated overall and component diet quality. Multivariable linear regression models estimated the association between a history of GDM and current diet quality, adjusting for age, education, smoking status, and health risk for diabetes.
A history of GDM was reported by 7.7% of women. Compared with women without a history of GDM, women with a history of GDM had, on average, 3.4 points lower overall diet quality (95% confidence interval [CI], −6.6 to −0.2) and 0.9 points lower score for consumption of green vegetables and beans (95% CI, −1.4 to −0.4). Other dietary component scores did not differ by history of GDM.
In the United States, women with a history of GDM have lower diet quality compared with women who bore a child and do not have a history of GDM. Improving diet quality may be a strategy for preventing type 2 diabetes among childbearing women.
Nighttime blood pressure (BP) dipping can be quantified as the ratio of mean nighttime (sleep) BP to mean daytime (awake) BP. People whose dipping ratio is 0.90 have been referred to as nondippers, and nondipping is associated with cardiovascular disease events. We examined the relationship between systolic nighttime BP dipping in young adults and presence of coronary artery calcium (CAC) 10-15 years later using data from the ambulatory BP monitoring substudy of the Coronary Artery Risk Development in Young Adults (CARDIA) study. Among 239 participants with adequate measures of both nighttime and daytime readings and coronary artery calcium, the systolic BP dipping ratio ranged from 0.72 to 1.24 (mean 0.88, SD 0.06), and CAC was present 10 to 15 years later in 54 participants (22.6%). Compared to those whose systolic BP dipping ratio ranged from 0.88 to 0.92 (Quartile 3), the 57 participants (23.9%) with less pronounced or absent dipping (ratio 0.92 to 1.24, Quartile 4) had an unadjusted odds ratio of 4.08 (95% CI 1.48-11.2) for presence of CAC. The 60 participants (25.1%) with a more pronounced dipping (ratio 0.72 to 0.85, Quartile 1) also had greater odds for presence of CAC (OR 4.76; 95% CI 1.76-12.9). When modeled as a continuous predictor, a U-shaped relationship between systolic BP dipping ratio and future CAC was apparent, and persisted after adjustment for multiple potential confounders (p<0.001 for quadratic term). Both failure of systolic BP to dip sufficiently and “overdipping” during nighttime may be associated with future subclinical coronary atherosclerosis.
ambulatory blood pressure; diurnal blood pressure; blood pressure dipping; coronary artery calcium; subclinical atherosclerosis
Aflatoxins are fungal metabolites that contaminate staple food crops in many developing countries. Up to 40% of women attending a prenatal clinic in Africa may be anemic. In a cross-sectional study of 755 pregnant women, Aflatoxin B1-lysine adducts (AF-ALB) levels were determined by high-performance liquid chromatography. Participants were divided into quartiles “low,” “moderate,” “high,” and “very high.” Anemia was defined as hemoglobin levels < 11 g/dL. Logistic regression was used to examine the association of anemia with AF-ALB. The mean AF-ALB level was 10.9 pg/mg (range = 0.44–268.73 pg/mg); 30.3% of participants were anemic. The odds of being anemic increased 21% (odds ratio [OR], 1.21, P = 0.01) with each quartile of AF-ALB reaching an 85% increased odds in the “very high” compared with the “low” category (OR, 1.85; confidence interval [CI], 1.16–2.95). This association was stronger among women with malaria and findings were robust when women with evidence of iron deficiency anemia were excluded. This study found a strong, consistent association between anemia in pregnancy and aflatoxins.
Overweight and obesity are prevalent among young women and are greater among minority and low-income women. The postpartum period is critical in women’s weight trajectories as many women do not lose their pregnancy weight, and others lose some and then plateau or experience weight gain. Excess weight puts women at greater risk of chronic disease and thus weight loss in the postpartum period may be key to the long-term health of young women. This paper describes the design and methods of a randomized clinical trial of Fresh Start, an innovative narrative-based group intervention aimed at promoting postpartum weight loss among low-income, diverse women.
Study participants were recruited from the five sites of the Women, Infants and Children (WIC) program in central Massachusetts. Participants were English-speaking, age ≥ 18 years, 6 weeks to 6 months postpartum, with a body mass index (BMI) ≥ 27 kg/m2. The Fresh Start postpartum weight loss intervention, adapted from the Diabetes Prevention Program (DPP) in collaboration with WIC staff and clients, consisted of an 8-week group-based curriculum followed by nine monthly telephone calls. It included a narrative component (i.e., storytelling), group discussions, print materials and access to exercise facilities. The study is a two-arm randomized controlled trial. The control condition included print materials and access to exercise facilities. In-person assessments were conducted at baseline and at 6 and 12 months following the eight-week intervention phase.
The Fresh Start intervention translated key elements of an evidence-based weight loss protocol into a format that is hypothesized to be relevant, acceptable and effective for the target audience of low-SES postpartum women. This novel intervention was developed in collaboration with WIC to be sustainable within the context of its clinics, which reach approximately 9 million individuals per year across the U.S. via 10,000 clinics.
clinicaltrials.gov NCT02176915. Registered 25 June 2014.
Postpartum weight loss; Obesity; Women; Health disparities; Randomized clinical trial; Narrative interventions
The present study characterizes the tobacco use, quitting behaviors, and health characteristics of cigarette smokers who did not change their smoking pattern over the past 6 months and have used electronic cigarettes (ECs) in the past 30 days. This is an important subpopulation to characterize if EC dual use with cigarettes continues to grow.
Participants (N = 2,376) from a research survey panel completed an online cross-sectional survey between June and August 2012. Sampling was stratified to recruit equal numbers of cigarette smoking participants by race/ethnicity (Black, Hispanic, and Caucasian) and smoking frequency (nondaily and daily). All displayed a stable rate of smoking for the past 6 months and were not currently in treatment. Bivariate and multivariate analyses were used to examine correlates of current EC use (any use within the past 30 days).
Current EC use was reported by 9.2% (n = 219) of the total sample. Of current EC users, 44% reported having used ECs as a quit method. Bivariate and multivariate analyses showed that current EC use was significantly associated with greater nicotine dependence, concurrent poly-tobacco use, more past-year quit attempts, past use of multiple cessation methods, and more depressive symptoms. No demographic variables were significantly associated with current EC use.
This study suggests that stable smokers who currently use ECs possess characteristics that are associated with difficulty in achieving smoking cessation. These characteristics should be considered when examining the effectiveness of ECs on cessation and in designing future cessation trials using ECs.
There are limited population-based data available describing trends in the long-term prognosis of patients discharged from the hospital after an initial acute myocardial infarction (AMI). Our objectives were to describe multi-decade trends in post-discharge mortality, and their association with hospital management practices, among patients discharged from all central Massachusetts (MA) medical centers after a first AMI. Residents of the Worcester, MA, metropolitan area discharged from all central MA hospitals after a first AMI between 1975 and 2009 comprised the study population (n=8,728). Multivariable-adjusted logistic regression analyses were used to examine the association between year of hospitalization and 1-year post-discharge mortality. The average age of this population was 66 years and 40% were women. Patients hospitalized in 1999-2009, as compared with those discharged in 1975-1984, were older, more likely to be women, and have multiple previously-diagnosed comorbidities. Hospital use of invasive cardiac interventions and medications increased markedly over time. Unadjusted 1-year mortality rates were 12.9%, 12.5%, and 15.8% for patients discharged during 1975-1984, 1986-1997, and 1999-2009, respectively. After adjusting for several demographic characteristics, clinical factors, and in-hospital complications, there were no significant differences in the odds of dying at 1 year post-discharge during the years under study. After further adjustment for hospital treatment practices, the odds of dying at 1 year post-discharge was 2.43 (95% confidence intervals=1.83-3.23) times higher in patients hospitalized in1999-2009 than in 1975-1984. In conclusion, the increased use of invasive cardiac interventions and pharmacotherapies was associated with enhanced long-term survival among patients hospitalized for a first AMI.
epidemiology; mortality; acute myocardial infarction
The purpose of this study was to examine decade-long trends (2001–2011) in, and factors associated with, door-to-balloon time within 90 minutes of hospital presentation among patients hospitalized with ST-segment elevation myocardial infarction (STEMI) who received a primary percutaneous coronary intervention (PCI).
Residents of central Massachusetts hospitalized with STEMI who received a primary PCI at two major PCI-capable medical centers in central Massachusetts on a biennial basis between 2001 and 2011 comprised the study population (n=629). Multivariable regression analyses were used to examine factors associated with failing to receive a primary PCI within 90 minutes after emergency department (ED) arrival.
The average age of this patient population was 61.9 years; 30.5% were women, and 91.7% were White. During the years under study, 50.9% of patients received a primary PCI within 90 minutes of ED arrival; this proportion increased from 2001/2003 (17.2%) to 2009/2011 (70.5%) (P<0.001). Having previously undergone coronary artery bypass graft surgery, arriving at the ED by car/walk-in and during off-hours were significantly associated with a higher risk of failing to receive a primary PCI within 90 minutes of ED arrival.
The likelihood of receiving a timely primary PCI in residents of central Massachusetts hospitalized with STEMI at the major teaching/community medical centers increased dramatically during the years under study. Several groups were identified for purposes of heightened surveillance and intervention efforts to reduce the likelihood of failing to receive a timely primary PCI among patients acutely diagnosed with STEMI.
epidemiology; ST-segment elevation myocardial infarction; percutaneous coronary intervention
There are limited data available describing relatively contemporary trends in 30‐day rehospitalizations among patients who survive hospitalization after an acute myocardial infarction (AMI) in the community setting. We examined decade‐long (2001–2011) trends in, and factors associated with, 30‐day rehospitalizations in patients discharged from 3 central Massachusetts hospitals after AMI.
Methods and Results
Residents of the Worcester, MA, metropolitan area discharged after AMI from 3 central Massachusetts hospitals on a biennial basis between 2001 and 2011 comprised the study population (N=4810). Logistic regression analyses were used to examine the association between selected factors and 30‐day rehospitalizations. The average age of this population was 69 years, 42% were women, and 92% were white. During the years under study, 18.5% of patients were rehospitalized within 30 days after hospital discharge. Crude 30‐day rehospitalization rates decreased from 20.5% in 2001–2003 to 15.8% in 2009–2011. After adjusting for several patient characteristics, there was a reduced odds of being rehospitalized in 2009–2011 (odds ratio 0.74, 95% CI 0.61–0.91) compared with 2001–2003; this trend was slightly attenuated after further adjustment for hospital treatment practices. Female sex, having previously diagnosed heart failure and chronic kidney disease, and the development of in‐hospital cardiogenic shock and heart failure were associated with an increased odds of being rehospitalized.
While the likelihood of subsequent short‐term rehospitalizations remained frequent, we observed an encouraging decline during the most recent years under study. Several high‐risk groups were identified for purposes of heightened surveillance and intervention efforts to reduce the likelihood of being readmitted.
acute myocardial infarction; readmission; rehospitalization
To review the impact of sleep, stress, and/or depression on postpartum weight retention.
We searched three electronic databases, PubMed, ISI Web of Science, and PsycInfo. Studies were included if they were published between January 1990 and September 2013 in English, measured sleep, stress, and/or depression in the postpartum period and assessed the association of these factors with postpartum weight retention. Two reviewers reviewed included articles and rated study quality using a modified version of the Downs and Black scale.
Thirteen studies met our pre-defined eligibility criteria, reporting on 9 study samples. Two were cross-sectional studies and eleven were longitudinal studies. The study sample size ranged from 74 to 37,127. All four studies examining short sleep duration and postpartum weight retention reported a positive association. The four studies examining postpartum stress and weight retention reported non-significant associations only. Of 7 studies examining postpartum depression and weight retention, 3 reported non-significant associations, and 4 reported positive associations.
Research investigating the impact of postpartum sleep, stress, depression and weight retention is limited. Future longitudinal studies are needed.
sleep duration; stress; depression; postpartum weight retention; postpartum women
A prediction model was developed in the Framingham Heart Study (FHS) to evaluate short-term risk of hypertension. Our goal was to determine the predictive ability of the FHS hypertension model in a cohort of young adults advancing into middle age and compare it with the predictive ability of prehypertension, and individual components of the FHS model. We studied 4,388 participants, age 18-30 years without hypertension at baseline, enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) Study who participated in 2 consecutive exams occurring 5 years apart between the baseline (1985-1986) and Year 25 examination (2010-2011). Weibull regression was used to assess the association of the FHS model overall, individual components of the FHS model, and prehypertension with incident hypertension. Over the 25 year follow-up period, 1179 participants developed incident hypertension. The FHS hypertension model (c-index=0.84, 95% CI=0.83, 0.85) performed well in discriminating those who did and did not develop hypertension and was better than prehypertension alone (c-index=0.71, 95% CI=0.70, 0.73). The predicted risk from the FHS hypertension model was systematically lower than the observed hypertension incidence initially (χ2= 249.4; p<0.001), but demonstrated a good fit after recalibration (χ2= 14.6; p=0.067). In summary, the FHS model performed better than prehypertension and may be a useful tool for identifying young adults with a high risk for developing hypertension.
hypertension; prehypertension; epidemiology; risk
Cognitive impairment (CI), highly prevalent in patients with heart failure (HF), increases risk for hospitalization, and mortality. However, the course of cognitive change in HF is not well characterized. The purpose of this systematic review was to examine the available evidence regarding longitudinal changes in cognitive function in patients with HF.
Methods and Results
A literature search of several electronic databases was performed. Studies published from January 1st, 1980 to September 30th, 2012 that used validated measures to diagnose HF and assess cognitive function two or more times in adults with HF were eligible for inclusion. Change in cognitive function was examined in the context of HF treatments applied (e.g., medication initiation, left ventricular assist device implantation), length of follow-up, and by comparison group. 15 studies met eligibility criteria. Significant decline in cognitive function was noted among patients with HF followed up for >1 year. Improvements in cognition were observed among patients with HF undergoing interventions to improve cardiac function (e.g., heart transplant) and among patients examined over short time periods (< 1 year). Studies comparing HF patient to their own baseline tended to report improvements while studies using a comparison group without HF tended to report declines or stability in cognition over time among patients with HF.
Patients with HF are at increased risk for cognitive decline but this risk appears to be modifiable with cardiac treatment. Further research is needed to identify the mechanisms that cause cognitive change in HF.
heart failure; cognition; epidemiology
To analyze the association between the pictorial graphic health warnings on
cigarette packs and their impact on intention to quit smoking among
Population-based cross-sectional study among 265 women daily smokers in the
State of Paraná in 2010. The sample size was calculated using cluster
sampling. Participants were asked whether they had seen any pictorial
graphic health warnings in the past 30 days, whether these warnings made
them think about quitting, and intensity of these thoughts. The data was
analyzed using logistic regression and the independent variables included
age, educational attainment, whether they had children, whether they had
attempted to quit smoking in the past 12 months, age of smoking initiation,
number of cigarettes smoked per day, their town of residence, and how soon
after waking do they smoke their first cigarette.
Participants (91.7%) reported seeing the pictorial graphic health warnings in
the past 30 days. Women with elementary education or below and women with
some/complete high school education were more likely to think about quitting
smoking after seeing the pictorial graphic health warningsthan women with
higher education (OR = 4.85; p = 0.0028 and OR = 2.91; p = 0.05),
respectively). Women who attempted to quit smoking in the past 12 months
were more likely to think about quitting than women who had not (OR = 2.49;
p = 0.001). Quit attempts within the last 12 months were associated with
intensity of these thoughts (OR = 2.2; p = 0.03).
Results show an association between pictorial graphic health warnings and
intent to quit smoking among women with warnings having a greater impact
among women with less education and who had attempted to quit smoking within
the past year. Tobacco control strategies should be implemented across all
groups of women regardless of their educational attainment.
Women; Tobacco-Derived Products Publicity; Health Knowledge, Attitudes, Practice; Smoking Cessation, psychology; Cross-Sectional Studies
Nondippers (people whose sleep systolic blood pressure (SBP) fails to decrease >10% from daytime SBP) have increased risk of cardiovascular disease. The prevalence of nondipping in younger adults has not been well-studied, nor has its value for predicting hypertension. We examined the prevalence of nondipping in a sub-study of the Coronary Artery Risk Development in Young Adults (CARDIA) Study. We used Cox regression to estimate the hazard ratio (HR) conferred by nondipping for incident prehypertension or hypertension (preHTN/HTN) over 15 years. Of the 264 non-hypertensive participants at baseline, 118 (45%) were nondippers. Blacks were more likely than Whites to be nondippers (52% vs 33%, p=0.004). The incidence rate of preHTN/HTN was 29.2/1000 person-years among dippers and 36.2/1000 person-years among nondippers. Compared to those in the lowest quartile of nighttime to daytime SBP, those in the highest quartile were more likely to develop preHTN/HTN (HR 1.61; p =0.06), but this relationship was attenuated after adjustment (HR 1.34; p =0.27). Our results demonstrate that nondipping is common in young, nonhypertensive adults, and is more common in Blacks than Whites. Nondipping might predate a meaningful clinically detected increase in BP in some people, but more research in larger study samples is needed.
diurnal blood pressure; blood pressure dipping; hypertension
Background and Purpose
We propose to study possible differences in the associations between risk factors for cardiovascular disease (myocardial infarction and stroke) and Carotid Intima-Media thickness (IMT) measurements made at three different levels of the carotid bifurcation. Methods: Cross-sectional study of a cohort of Whites and African Americans of both genders with mean age 45 years. Traditional cardiovascular risk factors were determined in cohort members. Carotid IMT was measured from high-resolution B-mode ultrasound images at three levels: the common carotid artery (CCA), the carotid artery bulb (Bulb) and the internal carotid artery (ICA). Associations with risk factors were evaluated by multivariate linear regression analyses.
Of 3258 who underwent carotid IMT measurements, CCA, Bulb, and ICA IMT were measured at all three separate levels in 3023 (92.7%). A large proportion of the variability of CCA IMT was explained by cardiovascular risk factors (26.8%) but less so for the Bulb (11.2%) and ICA (8.0%). Carotid IMT was consistently associated with age, LDL-cholesterol, smoking and hypertension in all segments. Associations with fasting glucose and diastolic blood pressure were stronger for CCA than for the other segments. Hypertension, diabetes and current smoking had qualitatively stronger associations with Bulb IMT, and LDL cholesterol with ICA IMT. Conclusion: In our cohort of relatively young white and African-American men and women, a greater proportion of the variability in common carotid IMT can be explained by traditional cardiovascular risk factors than for the carotid artery bulb and internal carotid arteries.
Carotid Intimal Medial Thickness; Risk Factors; Carotid Ultrasound
The relation between alcohol consumption and incident hypertension is unclear, and most observational studies have not accounted for socioeconomic factors. This study examined the association between alcohol consumption in a diverse group of young adults and incident hypertension over 20 years. Participants (n = 4,711) were from the Coronary Artery Risk Development in Young Adults Study cohort, recruited in 1985 (aged 18–30 years) from Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California. The 20-year incidence of hypertension for never, former, light, moderate, and at-risk drinkers was 25.1%, 31.8%, 20.9%, 22.2%, and 18.8%, respectively (P < 0.001). Race, gender, age, family history of hypertension, body mass index, income, education, and difficulty paying for basics and medical care were associated with hypertension. Adjustment using Cox proportional hazard models revealed no association between baseline alcohol consumption and incident hypertension, except among European-American women in whom any current alcohol consumption was associated with lower risk of incident hypertension. The lack of association between alcohol and hypertension in the majority of this socioeconomically diverse cohort is not definitive. Future studies should include social factors, such as income and education, and consider additional characteristics that may modify or confound associations between alcohol and blood pressure.
African continental ancestry group; alcohol drinking; cohort studies; European continental ancestry group; hypertension; incidence
Sleep duration has been inversely associated with body mass index (BMI). We examined the relationship between self-reported sleep duration and BMI, waist circumference, and percent body fat in Black and White individuals from the CARDIA study. Box-Tidwell regression models were adjusted for age and race (Model 1), additional lifestyle and demographic variables (Model 2), and physical activity (Model 3). There were significant interactions between sleep and gender for the main outcome variables. In men, there was a trend for an inverse relationship between reported sleep duration and BMI in Model 2 (β = −0.20, P = .053) but not model 3 (β = −0.139, P = .191). In women, inverse relationships were observed between sleep duration and BMI (β = −0.294, P = .005) and waist circumference (β = −0.442, P = .059), in Model 2. These associations became nonsignificant in model 3 (BMI: β = −0.172, P = .084; waist circumference: β = −0.161, P = .474). Our results are consistent with previous findings that sleep is associated with BMI and other body composition variables. However, the relationship between self-reported sleep duration and body composition may be stronger in women than in men.
Alabama Medicaid reimburses “objective” vision screening (VS), i.e, by acuity or similar quantitative method, and well child checks (WCCs) separately. We analyzed the frequency each service was obtained.
Claims for WCC and VS provided between 10/1/2002 and 9/30/2003 for children ages 3-18 years, and summary data for all enrolled children, were obtained from Alabama Medicaid. We used univariate analysis followed by logistic regression to explore the potential influence of factors (patient age, provider type, and provider’s volume of WCCs) on the receipt of VS at preschool ages.
Children receiving WCCs were 55% African-American, 40% white, and 5% other. Percentages of children with WCC claims were highest at 4 years (57%) and thereafter declined to 30% at 6-14 years and to less than 10% at 18 years. Nearly all VS (>98% at each age) occurred the same day as the WCC. Pediatricians provided 68% of all WCCs. Multivariate analysis, after adjusting for nesting of preschool patients within provider, showed the odds of VS were increased by patient age (5 years vs. 3 years OR=3.57, p<0.0001), non-physician provider type (non-physician vs. pediatrician OR=1.80, p=0.0004) and high WCC volume (at or above vs. below the median number (N=8) of WCC per provider per year (OR=7.11, p<0.0001)). Because VS rates were high when attendance to WCC visits was low, few enrolled children received vision screening at any age (6% at age 3, 13% at age 4, and a maximum of 20% at age 5).
National efforts to reduce preventable vision loss from amblyopia are hampered because children are not available for screening and because providers miss many opportunities to screen vision at preschool age. Efforts to improve vision screening should target pediatrician-led practices, since these serve greater numbers of children.
preschool; well child care; vision screening
Objective To assess whether active and passive smokers are more likely than non-smokers to develop clinically relevant glucose intolerance or diabetes.
Design Coronary artery risk development in young adults (CARDIA) is a prospective cohort study begun in 1985-6 with 15 years of follow-up.
Setting Participants recruited from Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California, USA.
Participants Black and white men and women aged 18-30 years with no glucose intolerance at baseline, including 1386 current smokers, 621 previous smokers, 1452 never smokers with reported exposure to secondhand smoke (validated by serum cotinine concentrations 1-15 ng/ml), and 1113 never smokers with no exposure to secondhand smoke.
Main outcome measure Time to development of glucose intolerance (glucose ≥ 100 mg/dl or taking antidiabetic drugs) during 15 years of follow-up.
Results Median age at baseline was 25, 55% of participants were women, and 50% were African-American. During follow-up, 16.7% of participants developed glucose intolerance. A graded association existed between smoking exposure and the development of glucose intolerance. The 15 year incidence of glucose intolerance was highest among smokers (21.8%), followed by never smokers with passive smoke exposure (17.2%), and then previous smokers (14.4%); it was lowest for never smokers with no passive smoke exposure (11.5%). Current smokers (hazard ratio 1.65, 95% confidence interval 1.27 to 2.13) and never smokers with passive smoke exposure (1.35, 1.06 to 1.71) remained at higher risk than never smokers without passive smoke exposure after adjustment for multiple baseline sociodemographic, biological, and behavioural factors, but risk in previous smokers was similar to that in never smokers without passive smoke exposure.
Conclusion These findings support a role of both active and passive smoking in the development of glucose intolerance in young adulthood.