Income Disparities in Absolute Cardiovascular Risk and Cardiovascular Risk Factors in the United States, 1999-2014

Genome-wide transcriptome differences associated with perceived discrimination in an urban, community-dwelling middle-aged cohort

Discrimination is a social adversity that is linked to several age-related outcomes. However, the molecular drivers of these observations are poorly understood. Social adverse factors are associated with proinflammatory and interferon gene expression, but little is known about whether additional genes are associated with discrimination among both African American and White adults. In this study, we examined how perceived discrimination in African American and White adults was associated with genome-wide transcriptome differences using RNA sequencing. Perceived discrimination was measured based on responses to self-reported lifetime discrimination and racial discrimination. Differential gene expression and pathway analysis were conducted in a cohort (N = 59) stratified by race, sex, and overall discrimination level. We found 28 significantly differentially expressed genes associated with race among those reporting high discrimination. Several of the upregulated genes for African American versus White adults reporting discrimination were related to immune function IGLV2-11, S100B, IGKV3-20, and IGKV4-1; the most significantly downregulated genes were associated with immune modulation and cancer, LUCAT1, THBS1, and ARPIN. The most enriched gene ontology biological process between African American and White men reporting high discrimination was the regulation of cytokine biosynthetic processes. The immune response biological process was significantly lower for African American women compared to White women reporting high discrimination. Discrimination was associated with the expression of small nucleolar RNAs, long noncoding RNAs, and microRNAs associated with energy homeostasis, cancer, and actin. Understanding the pathways through which adverse social factors like discrimination are associated with gene expression is crucial in advancing knowledge of age-related health disparities.

Examining Symptom Management and Quality of Life of Loop Diuretic-Induced Overactive Bladder Among Heart Failure Patients: Physician and Patient Perspectives

Loop diuretics are strongly recommended in patients with chronic congestive heart failure (HF) to alleviate signs and symptoms of fluid overload. Loop diuretics help relieve congestive symptoms and reduce mortality, but may have side effects. This survey study examined the impact of loop diuretic-induced overactive bladder (LD-OAB) symptoms on quality of life (QOL) in HF patients; and management of OAB by HF patients and physicians. We found that (1) HF patients noted less severity of symptoms but similar QOL with non-HF. (2) HF patients (58.8%) self-managed and underreported symptoms to physicians compared to non-HF (74.8%); accordingly 65% of physicians noticed and managed symptoms. (3) Patients used mechanical solutions (pads/diapers, Kegel exercises, and fluid reduction), and physicians adjusted diuretic doses or prescribed medications for OAB. Our study highlighted that HF patients' QOL associated with bladder symptoms was not better than the non-HF group despite milder symptoms. Many HF patients either did not report or coped with/self-managed their loop diuretic-induced bladder symptoms, pointing to a need for better awareness of patient experiences and patient-physician communication.

Association between Healthy Eating Index-2020, alternative Mediterranean Diet scores, and gastrointestinal cancer risk in NHANES 2005-2018

Diet quality is closely related to the occurrence of gastrointestinal (GI) cancers; however, few studies have investigated the association between the Healthy Eating Index (HEI-2020) and the alternative Mediterranean diet (aMED) scores and GI (GI) cancers. This study aims to assess the association between HEI-2020, aMED scores and GI cancers. Information from a total of 26,320 participants was included in the National Health and Nutrition Examination Survey (NHANES). In our sub-analysis, we focused on participants with complete dietary and health data, specifically assessing the relationship between diet quality and GI cancers outcomes. The 24-hour recall questionnaire was used to collect and assess the participants' average dietary intake. Diagnoses of GI cancers were based on self-reported medical history confirmed through physician interviews or linked cancer registry data, ensuring diagnostic reliability. Logistic regression models, restricted cubic splines (RCS), subgroup analysis, and interaction methods were employed to fully evaluate the associations between HEI-2020, aMED scores, and GI cancers. Mediation analysis was also conducted to identify potential mediators of this relationship. Even after fully adjusting for potential confounders, participants with high adherence to the HEI-2020-2020 and aMED scores were significantly associated with a reduced risk of GI cancers. Compared to the lowest tertile of HEI-2020, participants in the highest tertile had a 30% reduced risk of GI cancers (OR 0.70, 95% CI 0.50 to 0.98, p = 0.037). Compared to the lowest tertile of aMED scores, participants in the highest tertile had a 37% reduced risk of GI cancers (OR 0.63, 95% CI 0.44 to 0.92, p = 0.014). RCS analysis indicated that both HEI-2020 and aMED scores were significantly associated with GI cancers; however, no significant non-linear relationship was observed. The primary findings confirm that higher adherence to HEI-2020 and aMED scores is associated with a lower risk of GI cancers. These results suggest that maintaining a high-quality diet may play a crucial role in the prevention and management of these cancers. Further research is needed to elucidate the mechanisms and effects of healthy diet management and high-quality diets in the prevention of GI cancers.

Closing the Gap: Digital Innovations to Address Hypertension Disparities

PURPOSE OF REVIEW

Significant inequities persist in hypertension detection and control, with minoritized populations disproportionately experiencing organ damage and premature death due to uncontrolled hypertension. Remote blood pressure monitoring combined with telehealth visits (RBPM) is proving to be an effective strategy for controlling hypertension. Yet there are challenges related to technology adoption, patient engagement and social determinants of health (SDoH), contributing to disparities in patient outcomes. This review summarizes the evidence to date for RBPM, focusing on the potential to advance health equity in blood pressure control and the existing levers for largescale implementation.

RECENT FINDINGS

Several studies demonstrate the promise of RBPM programs to address health disparities through: (1) the use of cellular-enabled blood pressure machines that do not require internet access or smart devices to connect readings into the medical record; (2) emphasis on home blood pressure monitoring to illuminate the daily factors that influence blood pressure control, thereby increasing patient empowerment; (3) adoption of standardized algorithms for hypertension management; and (4) integration of services to address SDoH. Multidisciplinary, non-physician care teams that include nurses, pharmacists, and community health workers are integral to this model. However, most studies have not embraced all aspects of RBPM, and implementation is challenging as current payment models do not support the digital components of RBPM or a diverse workforce of hypertension providers.

CONCLUSION

To address hypertension disparities, RBPM programs need to integrate digital technology that is accessible to all users as well as multidisciplinary care teams that attend to the medical and social needs of populations experiencing health inequities.

Association between NAFLD and liver fibrosis with nutritional risk index based on the NHANES 2017-2018

BACKGROUND

Nutrition and its associated inflammation have been acknowledged as vital factors in the etiopathogenesis of non-alcoholic fatty liver disease (NAFLD) and liver fibrosis. The nutritional risk index (NRI) has been widely recognized as a valid indicator of nutritional status in several diseases, including osteoporosis and cardiovascular disease. However, the role of NRI in NAFLD and liver fibrosis remains unclear.

METHODS

Participants were selected from the National Health and Nutrition Examination Survey data for the 2017-2018 cycle. Association between NRI and both NAFLD and liver fibrosis was evaluated using multiple logistic regression and restricted cubic spline (RCS) analysis. Mediation analysis was employed to assess the influence of inflammation on the association between NRI and both NAFLD and liver fibrosis.

RESULTS

Compared to their respective control groups, individuals with NAFLD and liver fibrosis exhibited higher NRI levels. Multiple logistic regression analyses indicated that NRI was positively associated with the odds of NAFLD and liver fibrosis across both continuous scales and quantile groups, with adjustments for relevant covariables. The RCS model demonstrated a dose-response effect between NRI and the odds of NAFLD, but not with liver fibrosis. Receiver operating characteristic (ROC) analysis revealed the area under the ROC curves of 0.798 and 0.775 for NAFLD and liver fibrosis, respectively. Mediation analysis showed that inflammation accounted for 3.139% of the effect of NRI on the odds of NAFLD, suggesting inflammation might partially mediate the impact of NRI on NAFLD.

CONCLUSIONS

Our findings indicate that NRI may serve as a potential associated marker for these liver diseases, underscoring the importance of nutritional status in their etiopathogenesis.

Associations of healthy lifestyle and family income to poverty ratio with all-cause mortality among people with prediabetes and diabetes: a prospective cohort study

BACKGROUND

Family income to poverty ratio (PIR) may have independent effects on diet and lifestyle factors and the development of prediabetes and diabetes, as well as on mortality. It is unclear how the protective effect of a healthy lifestyle against death differs between individuals with different glucose metabolic profiles and whether PIR mediates this effect. This study aimed to explore whether healthy lifestyle and family PIR reduced the risk of all-cause mortality in participants with different metabolic status and the mediating role of PIR.

SUBJECTS AND METHODS

In total, 21,411 participants from the 2001-2018 National Health and Nutrition Examination Survey (NHANES) and follow-up until 2019 were included. The weighted healthy lifestyle score was constructed based on smoking, alcohol consumption, physical activity, diet (HEI-2015), and body mass index. Generalized linear regression models were used to analyze the association between healthy lifestyle, PIR, and all-cause mortality. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals, Kaplan-Meier survival curve was used to analyze the all-cause mortality associated with PIR and lifestyle. Furthermore, the mediation proportion of PIR in all-cause mortality attributed to healthy lifestyle was analyzed among participants with normal glucose regulation, prediabetes, or diabetes after multivariable adjustment.

RESULTS

There were significant differences in healthy lifestyle and PIR among people with normal glucose regulation, prediabetes and diabetes. During a mean follow-up of 92 months, participants with prediabetes or diabetes were also likely to have a higher mortality rate, respectively 583 (8.3%) and 263 (12.7%). More than 2 healthy lifestyles were associated with 42% (HR, 0.58; 95% CI, 0.35-0.95) to 76% (HR, 0.24; 95% CI, 0.12-0.44) reduced risk of all-cause mortality among participants with prediabetes, but among those with diabetes, who had ≥ 4 healthy lifestyles were associated with 72% reduced risk of all-cause mortality (HR, 0.28; 95% CI, 0.09-0.90). The middle and high PIR were associated with at least a 37% (HR, 0.63; 95% CI, 0.47-0.83) to 65% (HR, 0.35; 95% CI, 0.18-0.68) lower risk of all-cause mortality in participants with prediabetes and diabetes. Furthermore, PIR mediated 5.81-14.93% and 7.72-10.10% of the association between healthy lifestyle and all-cause mortality among normal glucose regulation and prediabetic participants, respectively. However, the mediating effect of PIR was not significant among diabetic participants.

CONCLUSIONS

Our findings highlight the importance of promoting adherence to a healthy lifestyle and improving PIR in prediabetic patients to reduce the risk of all-cause mortality, and the protective effect is more significant with more healthy lifestyles and higher PIR. This study can help clinicians and health systems develop more targeted treatments for people with different metabolic levels.

Associations of the hs-CRP/HDL-C ratio with cardiovascular disease among US adults: Evidence from NHANES 2015-2018

BACKGROUND AND AIMS

Inflammation, lipid signaling, and their interplay are involved in the pathogenesis and development of cardiovascular diseases (CVDs), while the relationships of composite indices combining inflammation and lipids with CVD remained inexplicit.

METHODS AND RESULTS

Our study enrolled 8581 adults from the National Health and Nutrition Examination Survey 2015-2018. Logistic regression model was applied to assess the associations of high-sensitivity C-reactive protein (hs-CRP)-to-high-density lipoprotein cholesterol (HDL-C) ratio with CVD prevalence. Potential mediating effects of hypertension, diabetes, hypercholesterolemia, and obesity on significant associations were explored. Receiver operating characteristic (ROC) curves were generated to compare diagnostic values of the hs-CRP/HDL-C ratio, HDL-C, and hs-CRP. Compared with those in the first quartile of the hs-CRP/HDL-C ratio, participants in the fourth quartile presented higher risks of CVD subtypes and total CVD. Each one-unit increment of the log-transformed hs-CRP/HDL-C ratio was associated with a 25 % increase in CVD risk (95 % confidence interval: 1.11, 1.41) with significant uptrends across the hs-CRP/HDL-C ratio quartiles. Four metabolic disorders significantly mediated associations of the hs-CRP/HDL-C ratio with CVDs. Younger participants were more sensitive to higher hs-CRP/HDL-C ratio with significant interactions in CVD. ROC curves further illustrated the relatively good diagnostic efficacy of the hs-CRP/HDL-C ratio for CVD.

CONCLUSION

The hs-CRP/HDL-C ratio was a significant risk factor for CVD among US adults, in which hypertension, diabetes, hypercholesterolemia, and obesity played important mediating roles. Early attention to people with elevated hs-CRP/HDL-C ratio would be helpful for CVD risk reduction.

Higher socioeconomic status is associated with higher ultra-processed food intake: a cross-sectional analysis

OBJECTIVE

To explore the differences in ultra-processed food (UPF) consumption across different socioeconomic status (SES) levels.

METHODS

Data on UPF consumption (grams/day) were derived from the 2017-2018 National Health and Nutrition Examination Survey. The analysis controlled for age, marital status, race, and sex. A restricted cubic spline (RCS) model was applied to examine the nonlinear response curve.

RESULTS

UPF consumption increased with higher poverty income ratio (PIR), the ratio of household income to the established poverty line. Compared to the low PIR group, the medium group showed a non-significant increase (β = 34.23[95%CI: -28.81, 97.28], p = 0.287), while the high group exhibited a significant increase (β = 115.15[95%CI: 43.53, 186.76], p = 0.002). A linear positive correlation was observed in RCS analysis (p-nonlinear = 0.166, p-overall < 0.001).

CONCLUSIONS

The study highlights that higher SES is associated with greater consumption of UPF in the US. The findings suggest that policy interventions should take SES into consideration.

Dietary patterns derived by reduced rank regression, macronutrients as response variables, and variation by economic status: NHANES 1999-2018

PURPOSE

Macronutrient intakes vary across people and economic status, leading to a disparity in diet-related metabolic diseases. This study aimed to provide insight into this by: (1) identifying dietary patterns in adults using reduced rank regression (RRR), with macronutrients as response variables, and (2) investigating the associations between economic status and macronutrient based dietary patterns, and between dietary patterns with central obesity (waist circumference) and systemic inflammation (C-reactive protein [CRP]).

METHODS

41,849 US participants from the National Health and Nutrition Examination Survey (NHANES), 1999-2018 were included. The percentages of energy from protein, carbohydrates, saturated fats, and unsaturated fats were used as response variables in RRR. Multivariable generalized linear models with Gaussian distribution were employed to investigate the associations.

RESULTS

Four dietary patterns were identified. Economic status was positively associated with both the high fat, low carbohydrate [βHighVsLow = 0.22; 95% CI: 0.16, 0.28] and high protein patterns [βHighVsLow = 0.07; 95% CI: 0.03, 0.11], and negatively associated with both the high saturated fat [βHighVsLow = -0.06; 95% CI: -0.08, -0.03] and the low alcohol patterns [βHighVsLow = -0.08; 95% CI; -0.10, -0.06]. The high saturated fat pattern was positively associated with waist circumference [βQ5VsQ1 = 1.71; 95% CI: 0.97, 2.44] and CRP [βQ5VsQ1 = 0.37; 95% CI: 0.26, 0.47].

CONCLUSION

Macronutrient dietary patterns, which varied by economic status and were associated with metabolic health markers, may explain associations between economic status and health.

Sitting Time, Physical Activity and Mortality: A Cohort Study In Low-Income Older Americans

INTRODUCTION

Physical inactivity and sedentary behavior are recognized as independent risk factors for many diseases. However, studies investigating their associations with total and cause-specific mortality in low-income and Black populations are limited, particularly among older adults.

METHODS

A prospective cohort study was conducted among 8,337 predominantly low-income and Black Americans aged ≥65 years residing in the southern United States. Participants reported their daily sitting time and leisure-time physical activity (LTPA) at baseline (2002-2009), and mortality data were collected through 2019. Analysis was conducted from September 2022 to October 2023.

RESULTS

During a median follow-up of 12.25 years, nearly 50% (n=4,111) were deceased. A prolonged sitting time (>10 hours/day versus <4 hours/day) was associated with elevated all-cause mortality (hazard ratios [HR], 1.15; 95% confidence intervals [CI], 1.04-1.27) after adjusting for LTPA and other potential confounders. LTPA was associated with a reduced risk of all-cause mortality, with an adjusted HR of 0.75 (95% CI 0.64, 0.88) associated with 150-300 minutes per week of moderate-intensity physical activity. Individuals who were physically inactive and had a sitting time of >10 hours/day had the highest mortality risk (HR, 1.48; 95% CI, 1.23-1.78), compared with those who were physically active and had low sitting time. These associations were more pronounced for mortality due to cardiovascular diseases.

CONCLUSIONS

High sitting time is an independent risk factor for all-cause and cardiovascular disease mortality, and LTPA could partially attenuate the adverse association of prolonged sitting time with mortality.

Higher neighborhood disadvantage is associated with weaker interactions among cardiometabolic drivers

Background

Adiposity, dysglycemia, and hypertension are metabolic drivers that have causal interactions with each other. However, the effect of neighborhood-level disadvantage on the intensity of interactions among these metabolic drivers has not been studied. The objective of this study is to determine whether the strength of the interplay between these drivers is affected by neighborhood-level disadvantage.

Methods

This cross-sectional study analyzed patients presenting to a multidisciplinary preventive cardiology center in New York City, from March 2017 to February 2021. Patients' home addresses were mapped to the Area Deprivation Index to determine neighborhood disadvantage. The outcomes of interest were correlation coefficients (range from -1 to +1) among the various stages (0 - normal, 1 - risk, 2 - predisease, 3 - disease, and 4 - complications) of abnormal adiposity, dysglycemia, and hypertension at presentation, stratified by neighborhood disadvantage.

Results

The cohort consisted of 963 patients (age, median [IQR] 63.8 [49.7-72.5] years; 624 [65.1 %] female). The correlation among the various stages of adiposity, dysglycemia, and hypertension was weaker with increasing neighborhood disadvantage (P for trend <0.001). Specifically, the correlation describing adiposity, dysglycemia, and hypertension interaction was weaker in the high neighborhood disadvantage group compared to the intermediate neighborhood disadvantage group (median [IQR]: 0.34 [0.27, 0.44] vs. median [IQR]: 0.39 [0.34, 0.45]; P < 0.001) and compared to the low neighborhood disadvantage group (median [IQR]: 0.34 [0.27, 0.44] vs. median [IQR]: 0.54 [0.52, 0.57]; P < 0.001), as well as weaker in the intermediate neighborhood disadvantage group compared to the low neighborhood disadvantage group (median [IQR]: 0.39 [0.34, 0.45] vs. 0.54 median [IQR]: 0.54 [0.52, 0.57]; P < 0.001).

Conclusions

Interactions among the various stages of abnormal adiposity, dysglycemia, and hypertension with each other are weaker with increasing neighborhood disadvantage. Factors related to neighborhood-level disadvantage, other than abnormal adiposity, might play a crucial role in the development of dysglycemia and hypertension.

Income-Related Disparities in Mortality Among Young Adults With Type 2 Diabetes

Importance

Previous studies have indicated an inverse association between income and mortality. However, differences in health outcomes according to the income level of young adults with type 2 diabetes (T2D) compared with older adults with T2D have not been elucidated.

Objective

To estimate the overall and cause-specific mortality risks among patients with T2D according to income and age.

Design, Setting, and Participants

This retrospective nationwide cohort study in South Korea included adults aged 20 to 79 years who were diagnosed with T2D between January 1, 2008, and December 31, 2013, and followed up until December 31, 2019, and age- and sex-matched controls without diabetes. Data were analyzed between January 1, 2023, and August 27, 2024.

Main Outcomes and Measures

Risks of all-cause, cardiovascular, and cancer mortality were estimated according to participants' income, which was categorized into 3 levels (low, middle, and high) based on the health insurance premium. Logistic regression analyses and Cox proportional hazard regression analyses were performed according to age groups (20-39, 40-59, and 60-79 years).

Results

A total of 1 240 780 adults (604 975 patients with T2D and 635 805 age- and sex-matched controls without diabetes) were included in the analyses. Their mean (SD) age was 56.9 (11.8) years, and 626 176 (50.5%) were men. Overall, the risk of mortality increased with lower income among patients with T2D, as well as in comparison with controls without diabetes. There was an inverse association between income and mortality risk in younger individuals (adjusted hazard ratios of all-cause mortality in the low income vs high income subgroups with T2D were 2.88 [95% CI, 2.25-3.69] in those aged 20 to 39 years, 1.90 [95% CI, 1.81-2.00] in those aged 40 to 59 years, and 1.26 [95% CI, 1.23-1.29] in those aged 60 to 79 years; P < .001 for comparing risk ratios between age groups). The pattern of income-related disparities in younger individuals was observed in cardiovascular mortality but less in cancer mortality.

Conclusions and Relevance

In this cohort study of 1 240 780 individuals aged 20 to 79 years, the risk of mortality with low income was most prominent among individuals with T2D aged 20 to 39 years. These findings highlight the need for socioeconomic support to reduce income-related health disparities in younger individuals.

Prevalence of Cardiovascular-Kidney-Metabolic Syndrome Stages by Social Determinants of Health

Importance

Cardiovascular-kidney-metabolic (CKM) syndrome-a novel, multistage, multisystem disorder as defined by the American Heart Association-is highly prevalent in the US. However, the prevalence of CKM stages by social determinants of health (SDOH) remains unclear.

Objective

To investigate whether the prevalence of CKM stages varies by SDOH in US adults.

Design, Setting, and Participants

This cross-sectional study used data from the National Health and Nutrition Examination Survey (1999-2018) and included a nationally representative sample of adults aged 30 to 79 years through complex, multistage probability sampling. Data were analyzed from April 1 to June 15, 2024.

Exposures

The exposures included 5 CKM stages (ie, stages 0-4) reflecting progressive pathophysiology, with advanced (stages 3 or 4) and nonadvanced (stages 0, 1, or 2) disease. CKM stages were defined based on risk factors for metabolic syndrome, cardiovascular disease, and chronic kidney disease.

Main Outcome and Measures

The main outcome was the age-standardized prevalence of CKM stages and advanced CKM stages across SDOH, including education, marital status, family income, food security, health insurance, employment, home ownership, and health care access.

Results

Among 29 722 participants (weighted mean [SE] age, 50.8 [0.1] years; weighted 50.7% male), the age-standardized prevalence of CKM stages 0 to 4 was 13.6% (95% CI, 13.0%-14.3%), 29.9% (95% CI, 29.1%-30.7%), 43.7% (95% CI, 42.9%-44.5%), 4.7% (95% CI, 4.4%-5.0%), and 8.1% (95% CI, 7.6%-8.5%), respectively. Significant differences were observed in the prevalence of CKM stages across all unfavorable SDOH of interest compared with their favorable counterparts, with unemployment (18.8% [95% CI, 17.7%-20.1%] vs 11.4% [95% CI, 11.0%-11.9%]), low family income (16.1% [95% CI, 15.4%-16.8%] vs 10.1% [95% CI, 9.5%-10.7%]), and food insecurity (18.3% [95% CI, 17.1%-19.6%] vs 11.7% [95% CI, 11.2%-12.2%]) associated with an increased likelihood of advanced CKM stages. Participants with 2 or more unfavorable SDOH were more likely to have advanced CKM stages (age-standardized prevalence, 15.8% [95% CI, 15.2%-16.5%] vs 10.5% [95% CI, 9.9%-11.1%] with <2 unfavorable SDOH). Living in a rented home (15.9% [95% CI, 14.7%-17.0%] vs 9.3% [95% CI, 8.7%-9.9%] owning the home) or not living with a partner (13.2% [95% CI, 12.3%-14.3%] vs 9.2% [95% CI, 8.5%-9.8%] living with a partner) increased the likelihood of advanced CKM stages in female but not male participants.

Conclusions and Relevance

In this cross-sectional study, disparities in the prevalence of CKM stages by SDOH, particularly family income, food security, and employment, with notable sex differences, were observed in US adults. These findings highlight the need to address inequities in CKM syndrome through targeted interventions.

Heterogeneity in disparities by income in cardiovascular risk factors across 209 US metropolitan areas

Objective

The United States has a lower life expectancy and wider income inequality than its similarly developed counterparts, and disparities continue to widen. The objective of our study is to examine the heterogeneity of disparities by income in cardiovascular disease (CVD) risk factors among U.S. metropolitan areas.

Methods

Data was obtained from the Behavioral Risk Factor Surveillance System for 2012-2019. We used self-reported data for respondent characteristics and for CVD risk factors/prevalence, and on metropolitan-level demographic and socioeconomic characteristics. We computed the relative index of inequality (RII) for each outcome using a multilevel Poisson model, sequentially adjusted for age, sex, and race/ethnicity with a random slope for income. We also included interactions between income and the metropolitan-level variables.

Results

Our sample included 1.4 million participants from 209 metropolitan areas. All CVD risk factors and CVD demonstrated income-related disparities. There were no clear regional patterns for risk factors, though seven of the top 10 large metropolitan areas with the widest disparities in CVD prevalence were in the South. Improved socioeconomic conditions were associated with wider disparities in the five risk factors, and contextual variables explained almost half of the variability in income disparities in smoking, sedentarism, and obesity, even after adjusting for age, sex, and race/ethnicity.

Conclusions

This study found that CVD risk factors and prevalence in U.S. metropolitan areas have heterogeneous income disparities, especially in advantaged metropolitan areas. Further studies with improved data collection may shed more light into potential drivers of income-based disparities in cardiovascular risk.

Association Between Family Income, Subclinical Myocardial Injury, and Cardiovascular Mortality in the General Population

INTRODUCTION

Both low family income and subclinical myocardial injury (SCMI) are risk factors for cardiovascular disease (CVD) mortality. However, the impact of their joint association on CVD mortality is unclear.

METHODS

This analysis from the third National Health and Nutrition Examination Survey included 6805 participants (age 59.1 ± 13.4 years, 52.3% women, and 49.8% White) free of CVD at baseline. Family income was assessed using the poverty-income ratio (PIR) and categorized into low (PIR < 1), middle (PIR = 1-4), and high (PIR > 4) income. A validated ECG-based cardiac infarction injury score (CIIS) ≥ 10 was considered positive for SCMI. CVD mortality was determined using the National Death Index. Cox-proportional hazard analysis was used to evaluate the associations of family income and SCMI, separately and jointly, with CVD mortality.

RESULTS

A total of 1782 (26.2%) participants had SCMI at baseline. During a median follow-up of 18.2 years, 856 (12.6%) events of CVD mortality occurred. In separate multivariable Cox models, SCMI (vs. no SCMI) and middle- and low-income (vs. high-income) were each associated with a higher risk of CVD mortality (HR [95% CI]: 1.34 [1.16-1.54], 1.44 [1.16-1.78], and 1.59 [1.22-2.07], respectively). Compared to high-income participants without SCMI, those with low-income and SCMI had an increased risk of CVD mortality (HR [95% CI]: 2.17 [1.53-3.08]). The multiplicative interaction between PIR and SCMI was not significant (p = 0.054).

CONCLUSION

Lower family income and SCMI are associated with CVD mortality, and their concomitant presence is associated with the highest risk. Family income and SCMI may help in the individualized assessment of CVD risk.

Socioeconomic Status and Obesity

Obesity is a pervasive public health problem that causes debilitating complications across the life course. One opportunity for preventing the onset of obesity is to focus on its social determinants. Socioeconomic status (SES), which includes factors such as income, educational attainment, occupational prestige, and access to resources, is a key determinant of obesity. In this scoping mini-review, we summarized review articles and meta-analyses of the SES-obesity association. From the 1980s to the present, cross-sectional studies have demonstrated a persistent socioeconomic gradient in obesity in which the association is negative in developed countries and positive in developing countries. Longitudinal studies have revealed the bidirectionality of the SES-obesity association; some studies demonstrate that socioeconomic adversity precedes the onset of obesity, while others provide evidence of reverse causality. While earlier studies relied on anthropometric assessments of weight and height to define obesity, the use of modern technologies like dual-energy x-ray absorptiometry and bioelectrical impedance have demonstrated that the socioeconomic gradient in obesity is robust across multiple indicators of body composition, including direct measures of lean and fat mass. More recently, examination of mediators and moderators of the SES-obesity association have highlighted causal pathways and potential intervention targets, with a focus on health behaviors, environmental conditions, psychological factors, and biological processes. We describe current gaps in knowledge and propose opportunities for future innovation to reduce the burden of obesity and related socioeconomic disparities.

Cardiovascular health and cancer mortality: evidence from US NHANES and UK Biobank cohort studies

BACKGROUND

The American Heart Association recently introduced a novel cardiovascular health (CVH) metric, Life's Essential 8 (LE8), for health promotion. However, the relationship between LE8 and cancer mortality risk remains uncertain.

METHODS

We investigated 17,076 participants from US National Health and Nutrition Examination Survey (US NHANES) and 272,727 participants from UK Biobank, all free of cancer at baseline. The CVH score, based on LE8 metrics, incorporates four health behaviors (diet, physical activity, smoking, and sleep) and four health factors (body mass index, lipid, blood glucose, and blood pressure). Self-reported questionnaires assessed health behaviors. Primary outcomes were mortality rates for total cancer and its subtypes. The association between CVH score (continuous and categorical variable) and outcomes was examined using Cox model with adjustments. Cancer subtypes-related polygenic risk score (PRS) was constructed to evaluate its interactions with CVH on cancer death risk.

RESULTS

Over 141,526 person-years in US NHANES, 424 cancer-related deaths occurred, and in UK Biobank, 8,872 cancer deaths were documented during 3,690,893 person-years. High CVH was associated with reduced overall cancer mortality compared to low CVH (HR 0.58, 95% CI 0.37-0.91 in US NHANES; 0.51, 0.46-0.57 in UK Biobank). Each one-standard deviation increase in CVH score was linked to a 19% decrease in cancer mortality (HR: 0.81; 95% CI: 0.73-0.91) in US NHANES and a 19% decrease (HR: 0.81; 95% CI: 0.79-0.83) in UK Biobank. Adhering to ideal CVH was linearly associated with decreased risks of death from lung, bladder, liver, kidney, esophageal, breast, colorectal, pancreatic, and gastric cancers in UK Biobank. Furthermore, integrating genetic data revealed individuals with low PRS and high CVH exhibited the lowest mortality from eight cancers (HRs ranged from 0.36 to 0.57) compared to those with high PRS and low CVH. No significant modification of the association between CVH and mortality risk for eight cancers by genetic predisposition was observed. Subgroup analyses showed a more pronounced protective association for overall cancer mortality among younger participants and those with lower socio-economic status.

CONCLUSIONS

Maintaining optimal CVH is associated with a substantial reduction in the risk of overall cancer mortality. Adherence to ideal CVH correlates linearly with decreased mortality risk across multiple cancer subtypes. Individuals with both ideal CVH and high genetic predisposition demonstrated significant health benefits. These findings support adopting ideal CVH as an intervention strategy to mitigate cancer mortality risk and promote healthy aging.

Assessment of EMR ML Mining Methods for Measuring Association between Metal Mixture and Mortality for Hypertension

INTRODUCTION

There are limited data available regarding the connection between heavy metal exposure and mortality among hypertension patients.

AIM

We intend to establish an interpretable machine learning (ML) model with high efficiency and robustness that monitors mortality based on heavy metal exposure among hypertension patients.

METHODS

Our datasets were obtained from the US National Health and Nutrition Examination Survey (NHANES, 2013-2018). We developed 5 ML models for mortality prediction among hypertension patients by heavy metal exposure, and tested them by 10 discrimination characteristics. Further, we chose the optimally performing model after parameter adjustment by genetic algorithm (GA) for prediction. Finally, in order to visualize the model's ability to make decisions, we used SHapley Additive exPlanation (SHAP) and Local Interpretable Model-Agnostic Explanations (LIME) algorithm to illustrate the features. The study included 2347 participants in total.

RESULTS

A best-performing eXtreme Gradient Boosting (XGB) with GA for mortality prediction among hypertension patients by 13 heavy metals was selected (AUC 0.959; 95% CI 0.953-0.965; accuracy 96.8%). According to sum of SHAP values, cadmium (0.094), cobalt (2.048), lead (1.12), tungsten (0.129) in urine, and lead (2.026), mercury (1.703) in blood positively influenced the model, while barium (- 0.001), molybdenum (- 2.066), antimony (- 0.398), tin (- 0.498), thallium (- 2.297) in urine, and selenium (- 0.842), manganese (- 1.193) in blood negatively influenced the model.

CONCLUSIONS

Hypertension patients' mortality associated with heavy metal exposure was predicted by an efficient, robust, and interpretable GA-XGB model with SHAP and LIME. Cadmium, cobalt, lead, tungsten in urine, and mercury in blood are positively correlated with mortality, while barium, molybdenum, antimony, tin, thallium in urine, and lead, selenium, manganese in blood is negatively correlated with mortality.

Implementing Self-Measured Blood Pressure Monitoring With Clinical Support: A Qualitative Study of Federally Qualified Health Centers

CONTEXT

Self-measured blood pressure monitoring (SMBP) with clinical support is effective at reducing blood pressure for people with hypertension. Although strengths and challenges around SMBP are well-documented, few studies describe the complexities of real-world implementation of SMBP with clinical support in the Federally Qualified Health Center (FQHC) setting.

PROGRAM

Between 2019 and 2023, the Ohio Department of Health funded the Ohio Association of Community Health Centers to manage a multiyear quality improvement (QI) project with 21 FQHCs. The project aimed to improve the identification and management of patients with hypertension, diabetes, and prediabetes. This study focuses on the activities implemented to provide SMBP support to patients with hypertension.

IMPLEMENTATION

FQHCs implemented clinical SMBP support using multiple roles, approaches, and resources. FQHCs established a process to identify patients eligible for SMBP support, provide blood pressure monitors, train patients on SMBP, track blood pressure readings, follow up with patients, and connect patients to resources.

EVALUATION

External evaluators interviewed 13 staff members within seven FQHCs from the QI project. Interviewed FQHCs were located across Ohio and represented urban, rural, suburban, and Appalachian areas. Clinical activities to support SMBP, facilitators, and barriers were identified with thematic analysis. The National Association of Community Health Centers SMBP Implementation Toolkit was used as a framework to assess SMBP activities. Facilitators included team-based care, health information technology capacity, funding for blood pressure monitors and staff time, leadership and staff support, and external support. Barriers included technology challenges, staffing shortages, low patient engagement, sustainability, and the COVID-19 pandemic.

DISCUSSION

This study demonstrates how FQHCs can use a variety of staff, processes, and resources to implement clinical SMBP support across a range of geographic regions. To facilitate this, FQHCs and patients may need more comprehensive insurance coverage of blood pressure monitors, reimbursement for staff time, and technology support.

Twelve-year (2008-2019) trends in socioeconomic inequalities in cardiovascular risk factors in a Swiss representative survey of the general population

Objective

We assessed trends in socioeconomic inequalities in cardiovascular risk factors prevalence among Swiss adults from 2008 to 2019.

Methods

Using data from the Bus Santé study, an annual survey of adults living in Geneva, Switzerland, we calculated the prevalence per period and by demographic and socioeconomic indicators, assessing inequality trends using the relative index of inequality (RII) and the slope index of inequality (SII).

Results

Among 10,739 participants, most CVD risk factors decreased over time, while diabetes, obesity, and smoking prevalence remained steady. In 2017-2019, prevalence of most CVD risk factors was higher in socioeconomically disadvantaged groups. Relative and absolute inequalities decreased over time, but mostly remained, for hypertension [in 2017-2019, education-RII (95 % CI) = 1.27 (1.12-1.46), income-RII = 1.27 (1.10-1.47)], hypercholesterolemia [education-RII = 1.15 (1.00-1.32)], and sedentarity [education-RII = 1.95 (1.52-2.51), income-RII = 1.69 (1.28-2.23)], and appeared to have reversed for hazardous alcohol use [income-RII = 0.75 (0.60-0.93)]. Substantial and persistent relative and absolute inequalities in diabetes prevalence were observed [education-RII = 2.39 (1.75-3.27), income-RII = 3.18 (2.25-4.48), and subsidy-RII = 2.77 (1.89-4.05)]. Inequalities were also marked across all socioeconomic indicators for obesity prevalence [education-RII = 3.32 (2.63-4.19), income-RII = 2.37 (1.85-3.04), subsidy-RII = 1.98 (1.48-2.66)] and for smoking [education-RII = 2.42 (2.06-2.84), income-RII = 2.37 (1.99-2.84), subsidy-RII = 1.91 (1.56-2.35)].

Conclusions

Over 12 years in Geneva, Switzerland, socioeconomic inequalities in hypertension, hypercholesterolemia, hazardous alcohol use, and sedentarity decreased but persist, while substantial inequalities in diabetes, obesity, and smoking remained unchanged.

Alcohol drinking triggered decrease of oxidative balance score is associated with high all-cause and cardiovascular mortality in hypertensive individuals: findings from NHANES 1999-2014

BACKGROUND

Oxidative stress is closely associated with hypertensive outcomes. The oxidative balance score (OBS) measures oxidative stress exposure from dietary and lifestyle elements. The objective of this study was to investigate the association between OBS and mortality in hypertensive patients.

METHODS

This study included 7823 hypertensive patients from the National Health and Nutrition Examination Survey (NHANES) 1999-2014. Several models, including Cox regression, restricted cubic splines (RCS), Kaplan‒Meier survival analysis, subgroup, and sensitivity analyses, were exploited to investigate the relationship between OBS and the risk of mortality.

RESULTS

Controlling for all potential confounders, a significantly inverse association was observed between elevated OBS and all-cause [hazard ratio (HR) = 0.90, 95% CI: 0.85-0.95] and cardiovascular mortality (HR = 0.85, 95% CI: 0.75-0.95). With adjustment for covariates, significant associations between lifestyle OBS and mortality risks diminished, whereas associations between dietary OBS and these mortality risks remained robust (all-cause mortality: HR = 0.91, 95% CI: 0.86-0.96; cardiovascular mortality: HR = 0.85, 95% CI: 0.76-0.96). RCS demonstrated a linear relationship between OBS and all-cause and cardiovascular mortality risk (P nonlinear = 0.088 and P nonlinear = 0.447, respectively). Kaplan‒Meier curves demonstrated that the mortality rate was lower with a high OBS (P < 0.001). The consistency of the association was demonstrated in subgroup and sensitivity analyses. RCS after stratification showed that among current drinkers, those with higher OBS had a lower risk of mortality compared with former or never drinkers.

CONCLUSIONS

In hypertensive individuals, there was a negative association between OBS and all-cause and cardiovascular mortality. Encouraging hypertensive individuals, especially those currently drinking, to maintain high levels of OBS may be beneficial in improving their prognosis.

A meta-synthesis of the cycle of financial strain, coping behaviors and health outcomes across the life course

Background

The lived experience and impact of financial strain on broad physical and mental health outcomes is important and yet underexplored. Improving our depth of understanding of the relationship between financial strain and health may offer important insights to address this complex phenomenon.

Objective

The primary objective of this study was to conduct a meta-synthesis of existing qualitative literature that investigated or described the relationship between financial strain and health outcomes.

Methods

A search using Web of Science, PsycINFO, and PubMed identified 18,624 peer-reviewed manuscripts from 2009 to 2021 that examined the impact of financial strain on health outcomes. Selection for inclusion was limited to qualitative studies that included a research question or thematic finding related to financial strain. Literature reviews and non-U.S. based manuscripts were excluded. Selected studies (n = 25) underwent evaluation and thematic analysis using meta-synthesis methods.

Results

Twenty-five qualitative studies with a combined total of 1385 participants examined financial strain in relation to health. We identified three themes: 1) Financial strain: An intersection of threats to meeting basic needs; 2) Financial strain across the life course and intergenerational stress; and 3) The cycle of financial strain, coping behaviors and health outcomes. Our conceptual framework proposes that financial strain cyclically influences health outcomes, with threats to meeting basic needs resulting in decision making and coping that lead to disparities in health outcomes. We propose this model for further hypothesis generation and qualitative inquiry.

Conclusion

This meta-synthesis emphasizes the importance of considering the intersectionality of insecurities that affect safety and health and the need for adopting a life course perspective when researching the lived experience of financial strain. The complexity of the relationship between financial strain, coping behaviors, and health outcomes merits innovative approaches and further study.

Comparison of Cardiovascular Health Between Parents and Non-Parents in NHANES 2011-2018

BACKGROUND AND OBJECTIVES

We compared cardiovascular health for parents and non-parents using the American Heart Association's Life's Essential 8 (LE8).

METHODS

This cross-sectional cohort analyzed 2011-2018 NHANES participants aged 20 to 54. The exposure was parenting, defined as living with a child. Logistic regression assessed whether parenting was associated with odds of ideal LE8 total or sub-scores. Regression adjusted for age, sex, race and ethnicity, educational attainment, marital status, and income. Subgroups included female sex, male sex, income <150% federal poverty levels, and parents of younger children.

RESULTS

6847 participants represented a weighted population of 79 120 285 (57% parents). Parenting was not associated with adjusted odds of ideal total LE8 (OR 0.91, 95% CI 0.76-1.09). Parenting was associated with decreased odds of ideal body mass index (BMI) (OR 0.81, 95% CI 0.72-0.91) and increased odds of smoking avoidance (OR 1.22, 95% CI 1.09-1.38). Associations varied by subgroup. Only the subgroup with lower incomes demonstrated reduced odds of ideal total LE8 for parents (OR 0.58, 95% CI 0.41-0.82).

CONCLUSIONS

Parents and non-parents differed in smoking and BMI, though not in LE8 total. Families with low incomes may particularly benefit from dual generation cardiovascular risk reduction.

Prevalence and Risk Factors of Fatigue in Adults with Stage 3 and 4 CKD: Findings from the National Health and Nutrition Examination Survey, 2007-2012

Key Points

Fatigue is a common symptom experienced by adults with CKD. Physiological, sociodemographic, psychological, and behavioral factors are associated with fatigue.

Background

Fatigue is a devastating symptom experienced by adults with CKD, but less is known about the prevalence of fatigue and factors associated with fatigue in a general population of adults with CKD. Therefore, we examined the prevalence of fatigue and identified factors associated with fatigue among a national cohort of US adults with CKD.

Methods

We utilized cross-sectional data from 1079 adults from the National Health and Nutrition Examination Survey 2007–2012 and included participants aged 18 years and older with stage 3 and 4 CKD (eGFR between 15 and 60 ml/min per 1.73 m2) who had available data evaluating fatigue. Unadjusted and adjusted logistic regression models were used to evaluate the odds of having fatigue in the context of physiological, sociodemographic, psychological, and behavioral factors.

Results

We estimated that 48% of those with CKD had fatigue. Among the risk factors examined, those with the strongest evidence of association in multivariable analyses were female sex (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.02 to 2.17), pain (OR, 2.49; 95% CI, 1.57 to 3.93), poor mental health (OR, 1.97; 95% CI, 1.05 to 3.72), anxiety (OR, 1.95; 95% CI, 1.14 to 3.34), and depressive symptoms (OR, 2.58; 95% CI, 1.17 to 5.66).

Conclusions

Fatigue is a common symptom experienced by adults with CKD in the United States. Physiological, sociodemographic, psychological, and behavioral factors are associated with fatigue, with psychological factors being most strongly associated with fatigue. Future work is needed to identify interventions to mitigate fatigue and risk factors of fatigue in adults with CKD.

Association between body roundness index and overactive bladder: results from the NHANES 2005-2018

BACKGROUND AND AIM

An increasing amount of research has indicated obesity greatly affects individuals with overactive bladder (OAB). However, traditional anthropometric methods present challenges in accurately assessing the likelihood of OAB. Hence, this study's objective was to identify the correlation between the body roundness index (BRI) and OAB.

METHODS

The research included 12,401 individuals who participated in the National Health and Nutrition Examination Survey spanning 2005-2018. The correlation between BRI and OAB was explored by using weighted multiple logistic regression and weighted restricted cubic spline (RCS). Subgroup analyses showed the associations based on different population types. The study also analyzed the predictive capability of various anthropometric indices, including BRI, body mass index, waist circumference, and weight, in assessing the likelihood of OAB through Receiver-operating characteristic (ROC) curves.

RESULTS

An independent positive correlation between OAB and BRI was identified after adjusting for potential confounders in weighted multivariate logistic models[odds ratio (OR) = 1.15, 95% confidence interval (CI), 1.12-1.17]. Weighted RCS analysis found a positive dose-response correlation between OAB and BRI. The effect size of BRI on OAB remained stable across all prespecified subgroups (all P for interactions > 0.05). In ROC analysis, BRI showed better discriminatory ability for OAB compared with other anthropometric measures for both genders (all P < 0.01). The best BRI cutoff for predicting OAB was lower for men (5.151) than for women (5.383), suggesting that men were more susceptible to changes in BRI than women.

CONCLUSIONS

This study demonstrated that a raised BRI is correlated with a higher likelihood of OAB. Due to the effectiveness and non-invasiveness of BRI in predicting OAB, it is expected to become the preferred method for early detection and management strategies.

Challenges in Promoting Health Equity and Reducing Disparities in Access Across New and Established Technologies

Medical innovations and novel technologies stand to improve the return on high levels of health spending in developed countries, particularly in cardiovascular care. However, cardiac innovations also disrupt the landscape of accessing care, potentially creating disparities in who has access to novel and extant technologies. These disparities might disproportionately harm vulnerable groups, including those whose nonmedical conditions-including social determinants of health-inhibit timely access to diagnoses, referrals, and interventions. We first document the barriers to access novel and existing technologies in isolation, then proceed to document their interaction. Novel cardiac technologies might affect existing available services, and change the landscape of care for vulnerable patient groups who seek access to cardiology services. There is a clear need to identify and heed lessons learned from the dissemination of past innovations in the development, funding, and dissemination of future medical technologies to promote equitable access to cardiovascular care. We conclude by highlighting and synthesizing several policy implications from recent literature.

Nonlinear associations between the ratio of family income to poverty and all-cause mortality among adults in NHANES study

Socioeconomic status (SES) has been linked to mortality rates, with family income being a quantifiable marker of SES. However, the precise association between the family income-to-poverty ratio (PIR) and all-cause mortality in adults aged 40 and older remains unclear. A cross-sectional study was conducted using data from NHANES III, including 20,497 individuals. The PIR was used to assess financial status, and various demographic, lifestyle, and clinical factors were considered. Mortality data were collected from the NHANES III linked mortality file. The study revealed a non-linear association between PIR and all-cause mortality. The piecewise Cox proportional hazards regression model showed an inflection point at PIR 3.5. Below this threshold, the hazard ratio (HR) for all-cause mortality was 0.85 (95% CI 0.79-0.91), while above 3.5, the HR decreased to 0.66 (95% CI 0.57-0.76). Participants with lower income had a higher probability of all-cause mortality, with middle-income and high-income groups showing lower multivariate-adjusted HRs compared to the low-income group. This study provides evidence of a non-linear association between PIR and all-cause mortality in adults aged 40 and older, with an inflection point at PIR 3.5. These findings emphasize the importance of considering the non-linear relationship between family income and mortality when addressing socioeconomic health disparities.

Social Disadvantage and Multimorbidity Including Oral Conditions in the United States

Existing studies on multimorbidity have largely excluded oral diseases in multimorbidity prevalence estimates. The reason behind this is somewhat unclear, as chronic oral conditions are highly prevalent, affecting over half the global population. To address this gap, we examined the relationship between social disadvantage and multimorbidity, stratifying by the inclusion and exclusion of oral conditions. For participants aged 30 y and over (n = 3,693), cross-sectional analysis was carried out using the US National Health and Nutrition Survey (2013-2014). Multimorbidity was defined as having 2 or more chronic conditions. Five medical conditions were examined: diabetes, asthma, arthritis, cardiovascular disease, and depression, as well as 4 oral health conditions: caries, periodontal disease, number of teeth, and edentulousness. Education and income poverty ratio were selected as measures of social disadvantage. Multimorbidity prevalence estimates according to social disadvantage were analyzed on an absolute and relative scale using inverse probability treatment weighting (IPTW), adjusting for age, sex, and ethnicity. The inclusion of oral health conditions in the assessment of multimorbidity increased the overall prevalence of multimorbidity from 20.8% to 53.4%. Findings from IPTW analysis demonstrated clear social gradients for multimorbidity estimates stratified by the exclusion of oral conditions. Upon inclusion of oral conditions, the prevalence of multimorbidity was higher across all social groups for both education and income. Stratifying by the inclusion of oral conditions, the mean probability of multimorbidity was 27% (95% confidence interval [CI], 23%-30%) higher in the low-education group compared to the high-education group. Similarly, the mean probability of multimorbidity was 44% (95% CI, 40%-48%) higher in the low-income group. On a relative scale, low education was associated with a 1.52 times (95% CI, 1.44-1.61) higher prevalence of multimorbidity compared to high education. Low income was associated with a 2.18 (95% CI, 1.99-2.39) higher prevalence of multimorbidity. This novel study strongly supports the impact of chronic oral conditions on multimorbidity prevalence estimates.

Trends in Income Inequities in Cardiovascular Health Among US Adults, 1988-2018

BACKGROUND

Mean cardiovascular health has improved over the past several decades in the United States, but it is unclear whether the benefit is shared equitably. This study examined 30-year trends in cardiovascular health using a suite of income equity metrics to provide a comprehensive picture of cardiovascular income equity.

METHODS

The study evaluated data from the 1988-2018 National Health and Nutrition Examination Survey. Survey groupings were stratified by poverty-to-income ratio (PIR) category, and the mean predicted 10-year risk of a major cardiovascular event or death based on the pooled cohort equations (PCE) was calculated (10-year PCE risk). Equity metrics including the relative and absolute concentration indices and the achievement index-metrics that assess both the prevalence and the distribution of a health measure across different socioeconomic categories-were calculated.

RESULTS

A total of 26 633 participants aged 40 to 75 years were included (mean age, 53.0-55.5 years; women, 51.9%-53.0%). From 1988-1994 to 2015-2018, the mean 10-year PCE risk improved from 7.8% to 6.4% (P<0.05). The improvement was limited to the 2 highest income categories (10-year PCE risk for PIR 5: 7.7%-5.1%, P<0.05; PIR 3-4.99: 7.6%-6.1%, P<0.05). The 10-year PCE risk for the lowest income category (PIR <1) did not significantly change (8.1%-8.7%). In 1988-1994, the 10-year PCE risk for PIR <1 was 6% higher than PIR 5; by 2015-2018, this relative inequity increased to 70% (P<0.05). When using metrics that account for all income categories, the achievement index improved (8.0%-7.1%, P<0.05); however, the achievement index was consistently higher than the mean 10-year PCE risk, indicating the poor persistently had a greater share of adverse health.

CONCLUSIONS

In this serial cross-sectional survey of US adults spanning 30 years, the population's mean 10-year PCE risk improved, but the improvement was not felt equally across the income spectrum.

The neutrophil-to-lymphocyte ratio is associated with all-cause and cardiovascular mortality among individuals with hypertension

BACKGROUND

Identifying reliable prognostic markers is crucial for the effective management of hypertension. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a potential inflammatory marker linked to cardiovascular outcomes. This study aims to investigate the association of NLR with all-cause and cardiovascular mortality among patients with hypertension.

METHODS

This study analyzed data from 3067 hypertensive adults in the National Health and Nutritional Examination Surveys (NHANES) from 2009 to 2014. Mortality details were obtained from the National Death Index (NDI). Restricted cubic spline (RCS) was deployed to visualize the association of the NLR with mortality risk. Weighted Cox proportional hazards models were employed to assess the independent association of NLR with mortality risk. Time-dependent receiver operating characteristic curve (ROC) analysis was conducted to access the predictive ability of NLR for survival. Mediation analysis was used to explore the indirect impact of NLR on mortality mediated through eGFR.

RESULTS

Over a median 92.0-months follow-up, 538 deaths occurred, including 114 cardiovascular deaths. RCS analysis revealed a positive association between NLR and both all-cause and cardiovascular mortality. Participants were stratified into higher (> 3.5) and lower (≤ 3.5) NLR groups. Weighted Cox proportional hazards models demonstrated that individuals with higher NLR had a significantly increased risk of all-cause (HR 1.96, 95% confidence interval (CI) 1.52-2.52, p < 0.0001) and cardiovascular mortality (HR 2.33, 95% CI 1.54-3.51, p < 0.0001). Stratified and interaction analysis confirmed the stability of the core results. Notably, eGFR partially mediated the association between NLR and both all-cause and cardiovascular mortality by a 5.4% and 4.7% proportion, respectively. Additionally, the areas under the curve (AUC) of the 3-, 5- and 10- year survival was 0.68, 0.65 and 0.64 for all-cause mortality and 0.68, 0.70 and 0.69 for cardiovascular mortality, respectively.

CONCLUSION

Elevated NLR independently confers an increased risk for both all-cause and cardiovascular mortality in individuals with hypertension.

Sociodemographic Factors, Leisure-Time Physical Activity and Mortality

INTRODUCTION

Exploring sociodemographic effect modification is important to provide evidence for developing targeted recommendations and reducing health inequalities. This study evaluated how sociodemographic factors including age, sex, race/ethnicity and socioeconomic status (SES) modify the association between leisure-time physical activity (LTPA) and all-cause and major cause-specific mortality.

METHODS

The study sample included 471,992 people from the 1997-2018 National Health Interview Survey (NHIS) and 41,830 people from the 1999-2018 National Health and Nutrition Examination Survey (NHANES). Data were analyzed in December 2022. Mortality data from the National Death Index were available to December 31, 2019. Sufficient LTPA was defined as at least 150 minutes of moderate and/or vigorous intensity per week.

RESULTS

There were 46,289 deaths in NHIS participants and 4,617 deaths in NHANES participants during a mean follow-up of 10 years. Individuals with sufficient LTPA had lower risk of all-cause (NHIS: hazard ratio, 0.74, 95% CI: [0.74-0.74]; NHANES: 0.73 [0.68-0.79]) and cardiovascular mortality (NHIS: 0.75 [0.75-0.75]; NHANES: 0.80 [0.69-0.93]) compared with inactive participants. The subgroup analysis showed significant interactions between LTPA and all sociodemographic factors. Associations between LTPA and mortality were weaker among younger individuals, males, Hispanic adults or those of low SES, respectively.

CONCLUSIONS

Sociodemographic factors significantly modified the associations between LTPA and mortality. The health benefits of sufficient LTPA were smaller in younger individuals, males, Hispanic adults or those of low SES. These findings can help identify target populations for promotion of physical activity to reduce health inequalities and the development of physical activity guidelines.

Community Socioeconomic Status, Acute Cardiovascular Hospitalizations, and Mortality in Medicare, 2003 to 2019

BACKGROUND

Socioeconomically disadvantaged communities in the United States disproportionately experience poor cardiovascular outcomes. Little is known about how hospitalizations and mortality for acute cardiovascular conditions have changed among Medicare beneficiaries in socioeconomically disadvantaged and nondisadvantaged communities over the past 2 decades.

METHODS

Medicare files were linked with the Centers for Disease Control and Prevention's social vulnerability index to examine age-sex standardized hospitalizations for myocardial infarction, heart failure, ischemic stroke, and pulmonary embolism among Medicare fee-for-service beneficiaries ≥65 years of age residing in socioeconomically disadvantaged communities (highest social vulnerability index quintile nationally) and nondisadvantaged communities (all other quintiles) from 2003 to 2019, as well as risk-adjusted 30-day mortality among hospitalized beneficiaries.

RESULTS

A total of 10 942 483 Medicare beneficiaries ≥65 years of age were hospitalized for myocardial infarction, heart failure, stroke, or pulmonary embolism (mean age, 79.2 [SD, 8.7] years; 53.9% female). Although age-sex standardized myocardial infarction hospitalizations declined in socioeconomically disadvantaged (990-650 per 100 000) and nondisadvantaged communities (950-570 per 100 000) from 2003 to 2019, the gap in hospitalizations between these groups significantly widened (adjusted odds ratio 2003, 1.03 [95% CI, 1.02-1.04]; adjusted odds ratio 2019, 1.14 [95% CI, 1.13-1.16]). There was a similar decline in hospitalizations for heart failure in socioeconomically disadvantaged (2063-1559 per 100 000) and nondisadvantaged communities (1767-1385 per 100 000), as well as for ischemic stroke, but the relative gap did not change for both conditions. In contrast, pulmonary embolism hospitalizations increased in both disadvantaged (146-184 per 100 000) and nondisadvantaged communities (153-184 per 100 000). By 2019, risk-adjusted 30-day mortality was similar between hospitalized beneficiaries from socioeconomically disadvantaged and nondisadvantaged communities for myocardial infarction, heart failure, and ischemic stroke but was higher for pulmonary embolism (odds ratio, 1.10 [95% CI, 1.01-1.20]).

CONCLUSIONS

Over the past 2 decades, hospitalizations for most acute cardiovascular conditions decreased in both socioeconomically disadvantaged and nondisadvantaged communities, although significant disparities remain, while 30-day mortality is now similar across most conditions.

Effect of Household Income on Cardiovascular Diseases, Cardiovascular Biomarkers, and Socioeconomic Factors

PURPOSE

To examine whether household income is causally related to cardiovascular diseases and investigate the potential reasons.

METHODS

Using 2-sample Mendelian randomization analyses, we obtained summary statistics from genome-wide association studies of household income and a range of cardiovascular diseases, biomarkers, and socioeconomic factors.

FINDINGS

Higher household income was causally associated with lower risks of coronary heart disease (odd ratio [OR] = 0.63; 95% CI: 0.49-0.79; P = 0.0001), myocardial infarction (OR = 0.64; 95% CI: 0.50-0.82; P = 0.0003), and hypertension (OR = 0.71; 95% CI: 0.58-0.88; P = 0.0015). With increasing household income, the cardiovascular biomarkers including triglycerides, C-reactive protein, body mass index, fasting glucose were decreased whereas telomere length and high-density lipoprotein cholesterol were increased. Besides, individuals with higher household income were less likely to smoke (β = -0.34; 95% CI: -0.47 to -0.21; P = 1.91×10-07), intake salt (β = -0.14; 95% CI: -0.21 to -0.07; P = 0.0001), or be exposed to air pollution (β = -0.10; 95% CI: -0.15 to -0.06; P = 8.81×10-06) or depression state (β = -0.03; 95% CI: -0.04 to -0.02; P = 5.16×10-07). They were more likely to take physical activity (β = 0.06; 95% CI: 0.02 to 010; P = 0.0016) and have long years of schooling (β = 0.70; 95% CI: 0.62 to 0.78; P = 5.32×10-67).

IMPLICATIONS

Higher household income is causally associated with better socioeconomic factors and improved cardiovascular biomarkers, which translates into a reduced prevalence of cardiovascular diseases. Policies to improve income equality may result in a reduced burden of cardiovascular diseases.

Association of aerobic and muscle-strengthening physical activity with all-cause and cardiovascular disease mortality among adults with type 2 diabetes: A prospective cohort of US adults

OBJECTIVE

To investigate the relationship of moderate physical activity (MPA), vigorous physical activity (VPA), and muscle strengthening activity (MSA), independently and jointly, with all-cause, cardiovascular disease (CVD), and non-CVD mortality in individuals with type 2 diabetes (T2D).

MATERIAL AND METHODS

This cohort study included 47,538 adults with T2D and 561,963 adults without T2D from the National Health Interview Survey 1997-2018 who provided data on self-reported physical activity (PA). Mortality data were obtained from the National Death Index through 2019. Cox regression was used to estimate hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

In analyses mutually adjusted, versus no MPA adults with T2D, performing the recommendations of MPA (150-299 min/week) associated with lower all-cause mortality (HR, 0.72; 95% CI, 0.66-0.78), CVD mortality (HR, 0.68; 95% CI, 0.58-0.79), and non-CVD mortality (HR, 0.72; 95% CI, 0.65-0.79). Similar benefits were observed in those meeting recommendations for VPA and MSA. Higher levels of PA beyond current recommendations may provide a few additional benefits without adverse effects on mortality risk, regardless of diabetes onset age, duration of diabetes, and medication status. The joint analysis indicates that combining MSA with aerobic PA could further lower mortality risk, and lowest all-cause mortality was observed among individuals engaging in either 75-150 min/week of VPA and 1 time/week of MSA (HR, 0.30; 95% CI, 0.13-0.70) or 150-299 min/week of MPA and 1 time/week of MSA (HR, 0.33; 95% CI, 0.20-0.55).

CONCLUSION

Our study supports the current PA guidelines and suggests that there may be limited benefits gained from exercising beyond recommended levels in adults with T2D, combining recommended levels of aerobic and resistance exercises could yield the greatest benefits.

Gender differences in all-cause and cardiovascular mortality among US adults: from NHANES 2005-2018

Background

Gender disparities in mortality have drawn great interest, with previous studies identifying various biological, social, and behavioral factors contributing to the observed gender differences. This study aims to identify the sources of gender disparities in mortality rates and quantify the extent to which these factors mediate the gender differences in all-cause mortality.

Methods

Data from the National Health and Nutrition Examination Survey (NHANES) conducted between 2005 and 2018 were analyzed. A total of 38,924 participants were included in the study. Gender information, socioeconomic status, lifestyle factors, and baseline disease status were obtained through questionnaires. Blood samples were collected to assess serological indicators. All-cause and cardiovascular mortality were considered as primary and secondary outcomes, respectively.

Results

The study with an average age of 50.1 ± 17.9 years. Among the participants, 50.7% were women, and 41.8% were non-Hispanic White. The median follow-up length was 87 months [Inter-Quartile Range (IQR): 47-128]. Men showed higher rates of all-cause and cardiovascular mortality compared to women in both the general population and the population with cardiovascular disease. After adjustment for potential confounders (age, race, marital status, socioeconomic status, lifestyle level, smoking status, cardiovascular disease, hypertension, diabetes and cancer), the men: women hazard ratios (HRs) for all-cause and cardiovascular mortality were 1.58 [95% Confidence Interval (CI): 1.48-1.68] and 1.60 (95%CI:1.43-1.80) in the general population. Among individuals with cardiovascular disease, the fully adjusted HR for all-cause mortality was 1.34 (95% CI: 1.20 to 1.51), and for cardiovascular mortality, the fully adjusted HRs was 1.52 (95% CI: 1.26 to 1.83). Mediation analysis revealed that uric acid levels significantly mediated the association between gender and all-cause mortality, accounting for 17.53% (95% CI: 11.0% to 23.7%) in the general population and 27.47% (95% CI: 9.0% to 13.6%) in the population with cardiovascular disease.

Conclusions

The study highlights the complex interplay of biological and social factors contributing to gender disparities in mortality. Uric acid was identified as key mediators of the gender-mortality association. These findings can inform targeted interventions aimed at reducing gender disparities in mortality and promoting better public health outcomes.

Risk factors for uncontrolled blood pressure among individuals with hypertension on treatment: the CONSTANCES population-based study

BACKGROUND

We aimed to assess factors associated with uncontrolled blood pressure (BP) among individuals with hypertension on treatment, by sex.

METHODS

We conducted a nested cross-sectional analysis using data from the population-based cohort study CONSTANCES, designed as a randomly selected sample of French adults aged 18-69 years at study inception. We included 11 760 participants previously diagnosed with hypertension and taking antihypertensive medications. Uncontrolled BP was defined as mean systolic BP ≥140 mmHg and/or mean diastolic BP ≥90 mmHg. Sex-specific age-adjusted multivariable analyses were performed using logistic regression models stratified by stages of uncontrolled hypertension.

RESULTS

The mean age of participants was 59.4 years. The prevalence of uncontrolled BP was 51.4%, and it was higher in men than in women [adjusted odds ratio (aOR), 1.80; 95% CI, 1.67-1.94]. In both sexes, the lower the age, the lower the prevalence of uncontrolled hypertension. Low level of education and history of cardiovascular events had, respectively, higher and lower odds of uncontrolled BP. In men, additional risk factors included overweight and obesity (aOR, 1.15; 95% CI, 1.00-1.32; and aOR, 1.45; 95% CI, 1.23-1.70, respectively), lack of physical activity (aOR, 1.20; 95% CI, 1.04-1.40), low adherence to a Dietary Approach to Stop Hypertension diet (aOR, 1.21; 95% CI, 1.05-1.40) and heavy alcohol consumption (aOR, 1.33; 95% CI, 1.08-1.63), with the last two factors persisting across different stages of uncontrolled BP.

CONCLUSIONS

From a population-based perspective, socio-economic and behavioural characteristics were risk factors for uncontrolled hypertension, but they differed by sex and by stage of uncontrolled hypertension. Modifiable risk factors, such as weight, diet, physical activity and alcohol consumption, have an important role in the control of hypertension.

The interpretable machine learning model associated with metal mixtures to identify hypertension via EMR mining method

There are limited data available regarding the connection between hypertension and heavy metal exposure. The authors intend to establish an interpretable machine learning (ML) model with high efficiency and robustness that identifies hypertension based on heavy metal exposure. Our datasets were obtained from the US National Health and Nutrition Examination Survey (NHANES, 2013-2020.3). The authors developed 5 ML models for hypertension identification by heavy metal exposure, and tested them by 10 discrimination characteristics. Further, the authors chose the optimally performing model after parameter adjustment by Genetic Algorithm (GA) for identification. Finally, in order to visualize the model's ability to make decisions, the authors used SHapley Additive exPlanation (SHAP) and Local Interpretable Model-Agnostic Explanations (LIME) algorithm to illustrate the features. The study included 19 368 participants in total. A best-performing eXtreme Gradient Boosting (XGB) with GA for hypertension identification by 16 heavy metals was selected (AUC: 0.774; 95% CI: 0.772-0.776; accuracy: 87.7%). According to SHAP values, Barium (0.02), Cadmium (0.017), Lead (0.017), Antimony (0.008), Tin (0.007), Manganese (0.006), Thallium (0.004), Tungsten (0.004) in urine, and Lead (0.048), Mercury (0.035), Selenium (0.05), Manganese (0.007) in blood positively influenced the model, while Cadmium (-0.001) in urine negatively influenced the model. Study participants' hypertension associated with heavy metal exposure was identified by an efficient, robust, and interpretable GA-XGB model with SHAP and LIME. Barium, Cadmium, Lead, Antimony, Tin, Manganese, Thallium, Tungsten in urine, and Lead, Mercury, Selenium, Manganese in blood are positively correlated with hypertension, while Cadmium in blood is negatively correlated with hypertension.

Prospective cohort study of broccoli consumption frequency and all-cause and cause-specific mortality risks

Background

Broccoli is rich in vitamins, minerals, and antioxidants with broad health benefits, but its intake frequency and dose-response relationship with mortality risk remain unclear.

Methods

Using data from the U.S. National Health and Nutrition Examination Survey 2003-2006, 12,486 adults were included. Broccoli intake frequency was evaluated by a food frequency questionnaire, and all-cause and cause-specific mortality risks were followed up. The relationship between broccoli intake and mortality risk was analyzed using Cox models.

Results

Compared with never consumption of broccoli, different frequencies of broccoli consumption were associated with significantly decreased risks of all-cause mortality (p for trend <0.001). Consuming broccoli 1-2 times per week was associated with a 32-43% lower mortality risk. More frequent broccoli consumption was negatively correlated with cardiovascular and cancer mortality risks (p < 0.05). Consuming broccoli 1-2 times per week for males and ≥ 3 times per week for females could significantly reduce all-cause mortality risk.

Conclusion

Moderate and frequent consumption of broccoli may reduce the risks of all-cause and cause-specific mortality. Optimal intake frequencies may differ by gender.

Early Home Visits and Health Outcomes in Low-Income Mothers and Offspring: 18-Year Follow-Up of a Randomized Clinical Trial

Importance

Individuals with low income may have heightened rates of obesity and hypertension.

Objective

To determine whether prenatal and infancy home visitation by nurses reduces maternal and offspring obesity and hypertension.

Design, Setting, and Participants

This randomized clinical trial of prenatal and infancy nurse home visitation in a public health care system in Memphis, Tennessee, enrolled 742 women with no previous live births and at least 2 sociodemographic risk factors (unmarried, <12 years of education, unemployed) from June 1, 1990, through August 31, 1991. At registration during pregnancy, 727 mothers (98%) were unmarried, and 631 (85%) lived below the federal poverty level. At offspring ages 12 and 18 years, maternal and offspring obesity and hypertension were assessed by staff masked to treatment. The data analysis was performed from July 1, 2021, to October 31, 2023.

Interventions

Women assigned to the control group received free transportation for prenatal care and child developmental screening and referral at child ages 6, 12, and 24 months. Women assigned to nurse visitation received transportation and screening plus prenatal and infant and toddler nurse home visits.

Main Outcomes and Measures

Obesity and hypertension among mothers and their offspring at child ages 12 and 18 years, although not hypothesized in the original trial design, were analyzed using post-double selection lasso method.

Results

Of the 742 participants randomized (mean [SD] age, 18.1 [3.2] years), interviews were completed with 594 mothers and 578 offspring at child age 12 years and 618 mothers and 629 offspring at child age 18 years. Obesity was assessed for 576 offspring at age 12 years and 605 at age 18 years and for 563 and 598 mothers at child ages 12 and 18 years, respectively. Blood pressure was assessed for 568 offspring aged 12 years and 596 aged 18 years and 507 and 592 mothers at child ages 12 and 18 years, respectively. There were no overall treatment-control differences in offspring obesity or hypertension at ages 12 and 18 years combined, although nurse-visited female offspring, compared with controls, had a lower prevalence of obesity (adjusted relative risk [ARR], 0.449; 95% CI, 0.234-0.858; P = .003) and severe obesity (ARR, 0.185; 95% CI, 0.046-0.748; P < .001). There were reductions at ages 12 and 18 years combined for stage 1 and stage 2 hypertension for nurse-visited vs control group mothers, with differences limited to mothers of females (stage 1: ARR, 0.613 [95% CI, 0.440-0.855; P = .001]; stage 2: ARR, 0.217 [95% CI, 0.081-0.582; P < .001]). For both obesity and hypertension outcomes, there was no intervention effect among male offspring or the mothers of males. Self-reported maternal health aligned with program effects on hypertension.

Conclusions and Relevance

In this clinical trial follow-up at offspring ages 12 and 18, nurse-visited female offspring had lower rates of obesity and mothers of females had lower rates of hypertension than control-group counterparts. These findings suggest that risks for chronic disease among mothers of females and their female offspring who live in extreme poverty may be prevented with prenatal and infant and toddler home visitations by nurses.

Trial Registration

ClinicalTrials.gov Identifier: NCT00708695.

Age affects the association between socioeconomic status and infertility: a cross-sectional study

BACKGROUND

Previous studies have shown the interaction between age and socioeconomic status (SES) on the risk of infertility in the UK, but the association is still unclear in the United States. Therefore, the present study investigated the effect of age on the relationship between SES and the risk of infertility in American women.

METHODS

The study included adults who participated in the National Health and Nutrition Examination Survey (NHANES) from 2013 to 2018. The poverty income ratio (PIR) was used to represent the SES of the population. With participants stratified according to age category (< 35 years; ≥ 35 years), we further assessed differences in the relationship between PIR and infertility risk among participants of different age groups using multivariate logistic regression and interaction tests.

RESULTS

Approximately 3,273 participants were enrolled in the study. There were 399 cases of infertility and 2,874 cases without infertility. In women ≥ 35 years of age, PIR levels were significantly higher in infertile participants than in non-infertile participants, but no such difference was found in those < 35 years of age. The association of PIR with the risk of infertility appeared to differ between age < 35 years and age ≥ 35 years (OR: 0.99, 95%Cl: 0.86-1.13 vs. OR: 1.24, 95%Cl: 1.12-1.39) in a fully adjusted model. Furthermore, an interaction between age and PIR increased the risk of infertility (p-value for interaction < 0.001).

CONCLUSION

Our study found that age may influence the association between PIR and infertility. It is imperative to perform further studies to provide more evidence.

Investigating the Associations of Sexual Minority Stressors and Incident Hypertension in a Community Sample of Sexual Minority Adults

BACKGROUND

Sexual minority adults are at higher risk of hypertension than their heterosexual counterparts. Sexual minority stressors (i.e., unique stressors attributed to sexual minority identity) are associated with a variety of poor mental and physical health outcomes. Previous research has not tested associations between sexual minority stressors and incident hypertension among sexual minority adults.

PURPOSE

To examine the associations between sexual minority stressors and incident hypertension among sexual minority adults assigned female sex at birth.

METHODS

Using data from a longitudinal study, we examined associations between three sexual minority stressors and self-reported hypertension. We ran multiple logistic regression models to estimate the associations between sexual minority stressors and hypertension. We conducted exploratory analyses to determine whether these associations differed by race/ethnicity and sexual identity (e.g., lesbian/gay vs. bisexual).

RESULTS

The sample included 380 adults, mean age 38.4 (± 12.81) years. Approximately 54.5% were people of color and 93.9% were female-identified. Mean follow-up was 7.0 (± 0.6) years; during which 12.4% were diagnosed with hypertension. We found that a 1-standard deviation increase in internalized homophobia was associated with higher odds of developing hypertension (AOR 1.48, 95% Cl: 1.06-2.07). Stigma consciousness (AOR 0.85, 95% CI: 0.56-1.26) and experiences of discrimination (AOR 1.07, 95% CI: 0.72-1.52) were not associated with hypertension. The associations of sexual minority stressors with hypertension did not differ by race/ethnicity or sexual identity.

CONCLUSIONS

This is the first study to examine the associations between sexual minority stressors and incident hypertension in sexual minority adults. Implications for future studies are highlighted.

Associations of family income and healthy lifestyle with all-cause mortality

Background

There is a lack of evidence on whether combined lifestyle factors mediate the association between family income and all-cause mortality, as well as the joint relations between family income and lifestyle factors with mortality.

Methods

Using data on family income and lifestyle factors of participants in the US National Health Interview Survey 2016-2018, we performed multivariable logistic regression models to estimate the odds ratios (ORs) and 95% confidence intervals (CI) for the association of all-cause mortality with said data.

Results

We included 73 729 participants with a mean age of 47.1 years (standard deviation (SD) = 18.0), 51% of whom were women and 65% of whom were non-Hispanic Whites. There were 2284 deaths documented. After multivariable adjustment, middle-income participants had an OR of 0.73 (95% CI = 0.61-0.88) for mortality, while high-income participants had an OR of 0.47 (95% CI = 0.37-0.60) compared with low-income participants. We found that lower all-cause mortality was related to higher lifestyle scores. Adults from high-income families with lifestyle scores of 3 and 4 had an OR for mortality of 0.44 (95% CI = 0.30-0.65) compared to those from low-income families and lifestyle scores of 0 or 1. When comparing those in highest vs lowest income groups in the mediation analysis, 9.8% (95% CI = 7.4-13.0) of the relation for all-cause mortality was mediated by lifestyles. Adults from high-income families with lifestyle scores of 3 or 4 had an OR of 0.23 (95% CI = 0.17-0.33) for mortality compared with those from low-income families and lifestyle scores of 0 or 1.

Conclusions

A lower risk of all-cause mortality was linked to higher family income and healthier lifestyles. Furthermore, lifestyle factors mediated a small proportion of the association between family income and mortality among US adults. Economic disparity in health may not be eliminated by changing only one's lifestyle. Therefore, besides promoting a healthy lifestyle, we should stress how family income inequality affects health outcomes.

Association Between Lack of Access to a Neighborhood Park and High Blood Pressure in the Philadelphia Metropolitan Area

INTRODUCTION

Studies have shown a lower risk of high blood pressure (HBP) among people who live near parks; however, little information exists on how feeling safe and comfortable visiting the park affects blood pressure. We identified associations between neighborhood park access, comfort visiting a park, and HBP to understand how these factors may contribute to disparities in HBP prevalence.

METHODS

The 2018 Southeastern Pennsylvania Household Health Survey of 3,600 residents in the Philadelphia metropolitan area asked if respondents had ever been told they had HBP and whether they had a neighborhood park or outdoor space that they were comfortable visiting during the day. To assess the association between park access and HBP, we built multilevel logistic models to account for variation in HBP by zip code. We examined the effect modification of perceptions of park access (having a neighborhood park, not having a neighborhood park, or having a neighborhood park but not comfortable visiting it) and HBP by race, education, and poverty status.

RESULTS

Both not having a neighborhood park and having a park but not feeling comfortable visiting it were associated with higher unadjusted odds of HBP, 70% and 90%, respectively, compared with having a neighborhood park. Adjusted odds ratios for the lack-of-park responses remained significant (no neighborhood park, adjusted odds ratio [aOR] = 1.4; 95% CI, 1.1-1.7; neighborhood park but not comfortable visiting, aOR = 1.4; 95% CI, 1.03-2.0). A significant gradient was observed for Black respondents compared with White respondents with odds of HBP increasing by perceptions of park access (aOR = 1.95 for people with a park; aOR = 2.69 for those with no park; aOR = 3.5 for people with a park that they are not comfortable visiting).

CONCLUSION

Even accounting for other risk factors for HBP, not having a neighborhood park or not feeling comfortable visiting one may influence individual HBP. Neighborhood factors that deter park access may contribute to racial disparities in HBP.

Linking Sepsis with chronic arterial hypertension, diabetes mellitus, and socioeconomic factors in the United States: A scoping review

RATIONALE

Sepsis is a syndrome of life-threatening organ dysfunction caused by a dysregulated host immune response to infection. Social risk factors including location and poverty are associated with sepsis-related disparities. Understanding the social and biological phenotypes linked with the incidence of sepsis is warranted to identify the most at-risk populations. We aim to examine how factors in disadvantage influence health disparities related to sepsis.

METHODS

A scoping review was performed for English-language articles published in the United States from 1990 to 2022 on PubMed, Web of Science, and Scopus. Of the 2064 articles found, 139 met eligibility criteria and were included for review.

RESULTS

There is consistency across the literature of disproportionately higher rates of sepsis incidence, mortality, readmissions, and associated complications, in neighborhoods with socioeconomic disadvantage and significant poverty. Chronic arterial hypertension and diabetes mellitus also occur more frequently in the same geographic distribution as sepsis, suggesting a potential shared pathophysiology.

CONCLUSIONS

The distribution of chronic arterial hypertension, diabetes mellitus, social risk factors associated with socioeconomic disadvantage, and sepsis incidence, are clustered in specific geographical areas and linked by endothelial dysfunction. Such population factors can be utilized to create equitable interventions aimed at mitigating sepsis incidence and sepsis-related disparities.

Body mass index mediates the direct association of subjective social status and hypertension in a fulani west African immigrant sample

The inverse association between social status and hypertension (HTN) often observed in native-born populations may not hold among immigrants from regions where larger bodies are markers of success. Qualitative evidence suggests that many African immigrant groups view larger body size as a marker of social status. The present study examined the relationships between subjective social status, body mass index (BMI), and HTN in a cross-sectional, community snowball sample of 218 West African Fulani immigrants living in New York City. Over a third of the sample met criteria for HTN. Higher subjective social status within the Fulani community was directly associated with higher likelihood of HTN. BMI fully mediated this association. Member checking revealed a community narrative in which being heavy indicated higher status. These findings provide the first quantitative evidence that aesthetic markers of status within African immigrant communities may comprise risks to cardiovascular health. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Association of Serum Vitamin B12 and Circulating Methylmalonic Acid Levels with All-Cause and Cardiovascular Disease Mortality among Individuals with Chronic Kidney Disease

(1) Background: it is unclear whether serum vitamin B₁₂ and circulating methylmalonic acid (MMA) are related with a poor prognosis among individuals with chronic kidney disease (CKD); (2) Methods: this prospective cohort study included 2589 individuals with CKD who participated in the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2004, and from 2011 to 2014, respectively. Hazard ratios (HRs) and 95% Cis for the associations of MMA and vitamin B₁₂ levels with the risk of all-cause and cardiovascular disease (CVD) mortality were calculated using multivariable Cox proportional hazards regression models. Restricted cubic spline analyses were used to examine the non-linear association of MMA levels with all-cause and CVD mortality. (3) Results: among the 2589 participants, we identified 1192 all-cause deaths and 446 CVD deaths, respectively, with a median follow-up of 7.7 years. Compared with participants with MMA < 123 nmol/L, those with MMA ≥ 240 nmol/L had an increased all-cause and CVD mortality in the multivariable-adjusted model [HR (95% CI), 2.01 (1.54-2.62) and 1.76 (1.18-2.63), respectively]; (4) Conclusions: higher circulating MMA levels were found to be strongly associated with an elevated all-cause and CVD mortality among individuals with CKD, while serum vitamin B₁₂ levels were not associated.

The role of hypertension in bone mineral density among males older than 50 years and postmenopausal females: evidence from the US National Health and Nutrition Examination Survey, 2005-2010

Background

Hypertension is a significant chronic disease that has been linked with bone mineral density (BMD) in various studies. However, the conclusions are contradictory. The purpose of our study was to identify the bone mineral density (BMD) of postmenopausal females and males older than 50 years with hypertension.

Methods

This cross-sectional study of 4,306 participants from the 2005-2010 US National Health and Nutrition Examination Survey explored the relationship between BMD and hypertension. Participants who had a mean systolic blood pressure (SBP) ≥140 mmHg, or a mean diastolic blood pressure (DBP) ≥90 mmHg, or were taking any prescribed medicine for high blood pressure were defined as having hypertension. BMD values were measured at the femoral neck and lumbar vertebrae as the primary outcome. Weight general linear model was used to describe the status of BMD in patients with hypertension. Weighted multivariate regression analysis was conducted to demonstrate the association between hypertension and BMD. Weighted restricted cubic spline (RCS) was used to assess the relationship between BMD and SBP and DBP.

Results

Our study found that there was a positive association between hypertension and lumbar BMD and the lumbar BMD was significantly higher in the presence of hypertension than in the control group in both males (1.072 vs. 1.047 g/cm²) and females (0.967 vs. 0.938 g/cm²; both p < 0.05), but a similar pattern was not found in the femoral neck. Meanwhile, lumbar BMD was positively associated with SBP and negatively associated with DBP both in males and females. The prevalence of low bone mass and osteoporosis at the lumbar vertebrae was lower in male patients with hypertension than in the control group. However, no difference was observed among postmenopausal females between the hypertension and control groups.

Conclusions

Hypertension was associated with higher BMD at the lumbar vertebrae in both males older than 50 years and postmenopausal females.

Disparities in absolute cardiovascular risk, metabolic syndrome, hypertension, and other risk factors by income within racial/ethnic groups among middle-aged and older US people

This cross-sectional study determined income disparities in age-adjusted prevalence and trends of 10-year high absolute cardiovascular disease (CVD) risk, metabolic syndrome, hypertension, diabetes, obesity, chronic kidney disease (CKD), leisure-time physical activity (LTPA), and current tobacco smoking within racial/ethnic groups in the US. National Health and Nutrition Examination Survey 2001-2016 data of 40-79-year-old people were analyzed. Survey periods were grouped as 2001-2006, 2007-2012, and 2013-2016. Race/ethnicity was grouped as non-Hispanic whites, non-Hispanic blacks, and other races/ethnicities. Three equal-sized strata (low-, middle-, and high income) were made from the family income-to-poverty ratio. Of the 25,777 participants (mean age: 55.6 years, 48% males), a majority of the studied prevalence was higher in most survey years among non-Hispanic blacks compared to non-Hispanic whites. Most studied prevalence was also higher among low-income people than middle-/high-income people. Within racial/ethnic groups, the prevalence also differed by income for high CVD risk, metabolic syndrome, hypertension, diabetes, obesity, CKD, LTPA, and tobacco smoking (P < 0.05) in most survey periods. After stratifying by race/ethnicity, the prevalence of many conditions remained disproportionately higher among low- and middle-income people, compared to those with high income during most survey periods in all racial/ethnic groups. These results reveal income in addition to race/ethnicity to be an important correlate of cardiovascular health and underscore the need to consider each when controlling for risk factors.

Associations of healthy lifestyle and socioeconomic status with cognitive function in U.S. older adults

We investigated the complex relations of socioeconomic status (SES) and healthy lifestyles with cognitive functions among older adults in 1313 participants, aged 60 years and older, from the National Health and Nutrition Examination Survey 2011-2014. Cognitive function was measured using an average of the standardized z-scores of the Consortium to Establish a Registry for Alzheimer's Disease Word Learning and delayed recall tests, the Animal Fluency Test, and the Digit Symbol Substitution Test. Latent class analysis of family income, education, occupation, health insurance, and food security was used to define composite SES (low, medium, high). A healthy lifestyle score was calculated based on smoking, alcohol consumption, physical activity, and the Healthy-Eating-Index-2015. In survey-weighted multivariable linear regressions, participants with 3 or 4 healthy behaviors had 0.07 (95% CI 0.005, 0.14) standard deviation higher composite cognitive z-score, relative to those with one or no healthy behavior. Participants with high SES had 0.37 (95% CI 0.29, 0.46) standard deviation higher composite cognitive z-score than those with low SES. No statistically significant interaction was observed between healthy lifestyle score and SES. Our findings suggested that higher healthy lifestyle scores and higher SES were associated with better cognitive function among older adults in the United States.