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1.  Evaluating the Framingham Hypertension Risk Prediction Model in Young Adults: The Coronary Artery Risk Development in Young Adults (CARDIA) Study 
Hypertension  2013;62(6):1015-1020.
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.
doi:10.1161/HYPERTENSIONAHA.113.01539
PMCID: PMC4019674  PMID: 24041951
hypertension; prehypertension; epidemiology; risk
2.  Cognitive Change in Heart Failure: A Systematic Review 
Circulation. Cardiovascular quality and outcomes  2013;6(4):10.1161/CIRCOUTCOMES.113.000121.
Background
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.
Conclusions
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.
doi:10.1161/CIRCOUTCOMES.113.000121
PMCID: PMC3872030  PMID: 23838109
heart failure; cognition; epidemiology
3.  Pictorial health warnings on cigarette packs and the impact on women 
Revista de Saúde Pública  2013;47(6):1123-1129.
OBJECTIVE
To analyze the association between the pictorial graphic health warnings on cigarette packs and their impact on intention to quit smoking among women.
METHODS
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.
RESULTS
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).
CONCLUSIONS
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.
doi:10.1590/S0034-8910.2013047004782
PMCID: PMC4206097  PMID: 24626550
Women; Tobacco-Derived Products Publicity; Health Knowledge, Attitudes, Practice; Smoking Cessation, psychology; Cross-Sectional Studies
4.  NIGHTTIME BLOOD PRESSURE DIPPING IN YOUNG ADULTS AND CORONARY ARTERY CALCIUM 10-15 YEARS LATER: THE CARDIA STUDY 
Hypertension  2012;59(6):1157-1163.
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.
doi:10.1161/HYPERTENSIONAHA.112.191536
PMCID: PMC3369268  PMID: 22547435
ambulatory blood pressure; diurnal blood pressure; blood pressure dipping; coronary artery calcium; subclinical atherosclerosis
5.  Diurnal blood pressure pattern and development of prehypertension or hypertension in young adults: the CARDIA study 
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.
doi:10.1016/j.jash.2010.12.002
PMCID: PMC3061433  PMID: 21269909
diurnal blood pressure; blood pressure dipping; hypertension
6.  Association between Anemia and Aflatoxin B1 Biomarker Levels among Pregnant Women in Kumasi, Ghana 
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.
doi:10.4269/ajtmh.2010.09-0772
PMCID: PMC2963973  PMID: 21036841
7.  Segment-Specific Associations of Carotid IMT with Cardiovascular Risk Factors: The Coronary Artery Risk Development in Young Adults (CARDIA) Study 
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.
Results
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.
doi:10.1161/STROKEAHA.109.566596
PMCID: PMC3163306  PMID: 19910544
Carotid Intimal Medial Thickness; Risk Factors; Carotid Ultrasound
8.  Alcohol Consumption in Young Adults and Incident Hypertension: 20-Year Follow-up From the Coronary Artery Risk Development in Young Adults Study 
American Journal of Epidemiology  2010;171(5):532-539.
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.
doi:10.1093/aje/kwp417
PMCID: PMC2842215  PMID: 20118194
African continental ancestry group; alcohol drinking; cohort studies; European continental ancestry group; hypertension; incidence
9.  Gender Differences in the Association between Sleep Duration and Body Composition: The Cardia Study 
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.
doi:10.1155/2010/726071
PMCID: PMC2798113  PMID: 20049158
10.  Quantitative Pediatric Vision Screening in Primary Care Settings in Alabama 
Purpose
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.
Methods
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.
Results
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).
Conclusions
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.
doi:10.1097/OPX.0b013e318185282a
PMCID: PMC2766866  PMID: 18772721
preschool; well child care; vision screening
11.  Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study 
BMJ : British Medical Journal  2006;332(7549):1064-1069.
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.
doi:10.1136/bmj.38779.584028.55
PMCID: PMC1458534  PMID: 16603565

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