All-cause, cardiovascular, and cancer mortality rates in postmenopausal white, black, Hispanic, and Asian women with and without diabetes in the United States: the Women's Health Initiative, 1993-2009

Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long?

Menopausal hormone therapy (HT) was widely used in the past, but with the publication of seminal primary and secondary prevention trials that reported an excess cardiovascular risk with combined estrogen-progestin, HT use declined significantly. However, over the past 20 years, much has been learned about the relationship between the timing of HT use with respect to age and time since menopause, HT route of administration, and cardiovascular disease risk. Four leading medical societies recommend HT for the treatment of menopausal women with bothersome menopausal symptoms. In this context, this review, led by the American College of Cardiology Cardiolovascular Disease in Women Committee, along with leading gynecologists, women's health internists, and endocrinologists, aims to provide guidance on HT use, including the selection of patients and HT formulation with a focus on caring for symptomatic women with cardiovascular disease risk.

Added Sugar, Sugar-Sweetened Beverages, and Artificially Sweetened Beverages and Risk of Cardiovascular Disease: Findings from the Women's Health Initiative and a Network Meta-Analysis of Prospective Studies

Much remains unknown about the role of added sugar in relation to cardiovascular disease (CVD) and the relative contributions of sugar-sweetened beverages (SSB) or artificially sweetened beverages (ASB) to CVD risk. Among the 109,034 women who participated in Women's Health Initiative, we assessed average intakes of added sugar, SSB and ASB, and conducted Cox regression to estimate the hazard ratios (HRs) and their 95% confidence intervals for CVD risk. The consistency of findings was compared to a network meta-analysis of all available cohorts. During an average of 17.4 years of follow-up, 11,597 cases of total CVD (nonfatal myocardial infarction, coronary heart disease (CHD) death, stroke, coronary revascularization, and/or incident heart failure) were confirmed. Added sugar as % energy intake daily (%EAS) at ≥15.0% was positively associated with total CVD (HR = 1.08 [1.01, 1.15]) and CHD (HR = 1.20 [1.09, 1.32]). There was also a higher risk of total CVD associated with ≥1 serving of SSB intake per day (HR = 1.29 [1.17, 1.42]), CHD (1.35 [1.16, 1.57]), and total stroke (1.30 [1.10, 1.53]). Similarly, ASB intake was associated with an increased risk of CVD (1.14 [1.03, 1.26]) and stroke (1.24 [1.04, 1.48]). According to the network meta-analysis, there was a large amount of heterogeneity across studies, showing no consistent pattern implicating added sugar, ASB, or SSB in CVD outcomes. A diet containing %EAS ≥15.0% and consuming ≥1 serving of SSB or ASB may be associated with a higher CVD incidence. The relative contribution of added sugar, SSB, and ASB to CVD risk warrants further investigation.

The interplay between diabetes mellitus and menopause: clinical implications

The menopausal transition is an impactful period in women's lives, when the risk of cardiovascular disease is accelerated. Similarly, diabetes mellitus profoundly impacts cardiovascular risk. However, the interplay between menopause and diabetes mellitus has not been adequately studied. The menopausal transition is accompanied by metabolic changes that predispose to diabetes mellitus, particularly type 2 diabetes mellitus (T2DM), as menopause results in increased risk of upper body adipose tissue accumulation and increased incidence of insulin resistance. Equally, diabetes mellitus can affect ovarian ageing, potentially causing women with type 1 diabetes mellitus and early-onset T2DM to experience menopause earlier than women without diabetes mellitus. Earlier age at menopause has been associated with a higher risk of T2DM later in life. Menopausal hormone therapy can reduce the risk of T2DM and improve glycaemic control in women with pre-existing diabetes mellitus; however, there is not enough evidence to support the administration of menopausal hormone therapy for diabetes mellitus prevention or control. This Review critically appraises studies published within the past few years on the interaction between diabetes mellitus and menopause and addresses all clinically relevant issues, such as the effect of menopause on the development of T2DM, and the management of both menopause and diabetes mellitus.

Sedentary Behavior and Prevalent Diabetes in 6,166 Older Women: The Objective Physical Activity and Cardiovascular Health Study

BACKGROUND

We examined associations of sedentary time and sedentary accumulation patterns (ie, how sedentary time is accumulated) with prevalent diabetes in an ethnically diverse cohort of older women.

METHODS

Community-dwelling women aged 63-99 (n = 6,116; median age = 79) wore ActiGraph GT3X+ accelerometers 24 h/day for up to 7 days from which we derived average daily sedentary time and three measures of sedentary accumulation patterns: breaks in sedentary time, usual sedentary bout duration, and alpha. Odds ratios (ORs) and 95% confidence intervals (CIs) for prevalent diabetes were estimated using multivariable logistic regression.

RESULTS

Twenty-one percent (n = 1,282) of participants had diabetes. Women in the highest quartile of sedentary time (≥10.3 h/day) had higher odds of diabetes (OR = 2.18; 95% CI = 1.77-2.70) than women in the lowest quartile (≤8.3 h/day). Prolonged accumulation patterns (ie, accumulating sedentary time in longer sedentary bouts) was associated with higher odds of diabetes than regularly interrupted patterns (comparing quartiles with the most vs least prolonged patterns: usual bout duration OR = 1.57, 95% CI = 1.28-1.92; alpha OR = 1.61, 95% CI = 1.32-1.97); however, there was no significant association for breaks in sedentary time (OR = 1.00, 95% CI = 0.82-1.20).

CONCLUSIONS

High levels of sedentary time and accumulating it in prolonged patterns were associated with increased odds of diabetes among older women.

Gynecological cancer and metabolic screening of 1001 elderly Brazilian women

OBJECTIVE

The aim of this study was to evaluate gynecological cancer and metabolic screening of Brazilian women aged 65 years or older.

METHODS

This retrospective descriptive study was conducted by including 1,001 Brazilian patients of the gynecological geriatric outpatient office of our institution to evaluate the influence of age on gynecological cancer and metabolic screening parameters at the first clinical visit. All patients were divided into three groups: a) 65 to 69 years; b) 70 to 74 years; c) ≥ 75 years. We considered clinical, laboratorial, and image data as variables of this study. The Chi-square test was used to assess the proportion of differences among the age groups, and Kruskal-Wallis was used for quantitative variables.

RESULTS

The values of BMI and height in the group over 75 years was lower than that of the 65 to 69 years (p = 0.001). Regardless of the age group, high arterial blood pressure levels were found in 85.45% of participants. Also, many patients had glucose intolerance in the blood. The pelvic ultrasonography showed abnormal endometrial echo thickness (> 5 mm) in 6.14% of patients, but with no significant statistical difference between the age groups. A total of 4.04% of patients had ovaries with high volume values ( > 6.1 mL). Abnormal mammography (BI-RADS 3 or 4) was observed in 12.21%.

CONCLUSIONS

our data suggest that a great reduction in BMI and stature is more frequent in the group over 75 years. Also, systemic arterial hypertension and carbohydrate disturbance are frequent morbidities in women over 65 years.

Differences in cancer survival among white and black cancer patients by presence of diabetes mellitus: Estimations based on SEER-Medicare-linked data resource

Diabetes prevalence and racial health disparities in the diabetic population are increasing in the US. Population‐based cancer‐specific survival estimates for cancer patients with diabetes have not been assessed. The Surveillance, Epidemiology, and End Results (SEER)‐Medicare linkage provided data on cancer‐specific deaths and diabetes prevalence among 14 separate cohorts representing 1 068 098 cancer patients ages 66 +  years diagnosed between 2000 and 2011 in 17 SEER areas. Cancer‐specific survival estimates were calculated by diabetes status adjusted by age, stage, comorbidities, and cancer treatment, and stratified by cancer site and sex with whites without diabetes as the reference group. Black patients had the highest diabetes prevalence particularly among women. Risks of cancer deaths were increased across most cancer sites for patients with diabetes regardless of race. Among men the largest effect of having diabetes on cancer‐specific deaths were observed for black men diagnosed with Non‐Hodgkin lymphoma (NHL) (HR = 1.53, 95%CI = 1.33‐1.76) and prostate cancer (HR = 1.37, 95%CI = 1.32‐1.42). Diabetes prevalence was higher for black females compared to white females across all 14 cancer sites and higher for most sites when compared to white and black males. Among women the largest effect of having diabetes on cancer‐specific deaths were observed for black women diagnosed with corpus/uterus cancer (HR = 1.66, 95%CI = 1.54‐1.79), Hodgkin lymphoma (HR = 1.62, 95%CI = 1.02‐2.56) and breast ER+ (HR = 1.39, 95%CI = 1.32‐1.47). The co‐occurrence of diabetes and cancer significantly increases the risk of cancer death. Our study suggests that these risks may vary by cancer site, and indicates the need for future research to address racial and sex disparities and enhance understanding how prevalent diabetes may affect cancer deaths.

Estrogen alone and health outcomes in black women by African ancestry: a secondary analyses of a randomized controlled trial

OBJECTIVE

In postmenopausal black women in the Women's Health Initiative randomized trial, estrogen alone reduced breast cancers but its comprehensive influence on health outcomes in black women is unknown. Therefore, we examined this issue in the Women's Health Initiative overall and by African ancestry.

METHODS

A total of 1,616 black women with prior hysterectomy, including 1,061 with percent African ancestry determination, at 40 US centers were randomly assigned to conjugated equine estrogen (0.625 mg/d) or placebo for 7.2 years' (median) intervention with 13 years' cumulative follow-up. Coronary heart disease (CHD) and breast cancer were primary efficacy and safety outcomes, respectively. A global index also included stroke, colorectal cancer, hip fracture, pulmonary embolism, and death.

RESULTS

Black women in the estrogen-alone group compared with black women in the placebo group had fewer breast cancers (17 vs 40, hazard ratio [HR] 0.47, 95% CI 0.26-0.82). In women with more than 80% African ancestry, breast cancer HR was lower (0.32, 95% CI 0.12-0.86, trend P = 0.04 for ancestry effect). Most other outcomes including CHD, stroke, hip fracture, and the global index were null with estrogen use in black women; a global index effect was more favorable in younger black women (HR 0.65, 95% CI 0.43-0.98).

CONCLUSIONS

In black postmenopausal women with prior hysterectomy, estrogen alone significantly reduced breast cancer incidence with no adverse influence on CHD, venous thromboembolism, or all-cause mortality. Favorable estrogen-alone global index effects in younger black women warrant further study.

Determinants of Successful Weight Loss in Low-Income African American Women: A Positive Deviance Analysis

OBJECTIVE

We set out to investigate the behaviors of low-income African American women who successfully lost weight.

METHODS

From an urban, academic, family medicine practice, we used a mixed methods positive deviance approach to evaluate 35 low-income African American women who were obese and lost at least 10% of their maximum weight, and maintained this loss for 6 months, comparing them with 36 demographically similar control participants who had not lost weight. Survey outcomes included demographics and behaviors that were hypothesized to be related to successful weight loss. Interviews focused on motivations, barriers, and what made weight loss successful. Survey data were analyzed using t tests and linear regression for continuous outcomes and chi-square tests and logistic regression for categorical outcomes. Interviews were analyzed using a modified approach to grounded theory.

RESULTS

In adjusted analyses, women in the positive deviant group were more likely to be making diet changes compared with those women who did not lose at least 10% of their initial body weight. Major themes from qualitative analyses included ( a) motivations (of health, appearance, quality of life, family, and epiphanies), ( b) opportunity (including time and support), ( c) adaptability.

CONCLUSIONS

The findings of this study may be useful in developing motivational interviewing strategies for primary care providers working with similar high-risk populations.

Iron reduction response and demographic differences between diabetics and non-diabetics with cardiovascular disease entered into a controlled clinical trial

Filings of elemental iron separated magnetically from a homogenate of breakfast cereal implicated in the risk of cardiovascular disease and diabetes.

Comparison of Dietary Quality Assessment Using Food Frequency Questionnaire and 24-hour-recalls in Older Men and Women

OBJECTIVES

To examine the agreement in nutrient intake and alternative healthy eating indices (AHEI) between a self-administered Food Frequency Questionnaire (FFQ) and 24-hour recall (24HR) measurements of diet by gender, among older adults.

MATERIAL AND METHODS

This is a cross-sectional observational study of 105 men and 99 women aged 65 and older living in urban and rural neighborhoods in Worcester County, Massachusetts, USA. Participants were queried on diet using both FFQ and 24HR. The healthy eating classification was compared between the two instruments by gender.

RESULTS

For men, the mean ± SD of AHEI total score was 48.2 ± 12.3 based on FFQ versus 34.7 ± 10.2 based on 24HR. For women, the mean ± SD was 47.9 ± 10.1 based on FFQ versus 36.1 ± 10.0 based on 24HR. Using 32 as the cutoff (40% of maximum AHEI score), 9% of men and 7% of women were classified as eating unhealthy based on the FFQ, versus 47% of men and 38% of women based on 24HR. Compared to women, men had larger 24HR to FFQ discrepancies in the nuts and vegetable protein subscore and white/red meat ratio, and smaller discrepancy in alcohol beverages subscore.

CONCLUSION

Agreements between FFQ and 24HR-based measures of diet quality were roughly comparable between men and women, though slightly better for women than men. Compared to 24HR, the FFQ tended to underestimate the proportions of older men and women classified as eating unhealthy and misclassified more men than women. Such limitations should be considered when the FFQ is used to study healthy eating in older age.

Menopause, hormone therapy and diabetes

Over the past three decades, the prevalence of diabetes has increased four-fold. Coupled with the global obesity epidemic and aging of the world's population, a perfect metabolic storm is brewing. The influence of menopause and exogenous estrogen and progestogens must be included in this equation. In this review, criteria for diagnosing diabetes and recommendations for screening are described. The reported effects of menopause on diabetes risk in healthy women are reviewed as well as the relationship between established diabetes and the timing of menopause. The effects of menopausal hormone therapies (MHT) on glucose control in women with diabetes and the effect of MHT on diabetes risk in menopausal women without diabetes are described. Evidence-based strategies to prevent diabetes in midlife women are highlighted. The augmenting effect of diabetes on chronic health concerns of aging women, such as cardiovascular disease, osteoporosis, and cancer, along with current recommendations for screening and prevention are presented. Given the current demographics of today's world, the content of this review may apply to as many as one-third of the average practitioner's postmenopausal patient population.

Racial Differences in Misclassification of Healthy Eating Based on Food Frequency Questionnaire and 24-Hour Dietary Recalls

OBJECTIVES

To examine the agreement in nutrient intake and alternate healthy eating indices (AHEI) between a self-administered Food Frequency Questionnaire (FFQ) and 24-hour recall (24HR) measurements of diet by race, among urban older women.

DESIGN

Cross-sectional observational study.

SETTING

Urban neighborhoods in Washington, DC, USA.

PARTICIPANTS

Community-dwelling White and Black women aged 65 and older.

MEASUREMENTS

In 2014 and 2015, 49 White and 44 Black older women were queried on diet using both FFQ and 24-hour recalls. The correlation coefficients of 55 nutrient intake measures and agreements on healthy eating classification between the two instruments were compared overall and by race.

RESULTS

The mean correlation coefficient (rho) was 0.46 for Whites and 0.23 for Blacks. For 47 measures, rho was lower for Blacks. Whites had a strong correlation of ≥0.5 for 28 items, while Blacks had strong correlations for only 3 items. Based on FFQ, the mean (SD) of AHEI were 54.0 (10.3) for Whites and 45.9 (8.8) for Blacks (p<0.001). Based on 24HR, the mean (SD) were 43.9 (10.8) for Whites and 33.2 (9.6) for Blacks (p<0.001). Using 32 as the cutoff (40% of maximum AHEI score), 50% of Blacks and 14% of Whites were classified as eating unhealthy based on the 24HR, versus 2.6% and 0% based on the FFQ.

CONCLUSION

The FFQ has limited ability to accurately assess nutrient intake among older Black women, and tends to underestimate racial differences in healthy eating. The FFQ should be further improved for use in racial disparities research of healthy eating in older age, using a larger sample of older women with racial and geographic diversities.

Racial Differences in Eating Patterns and Food Purchasing Behaviors among Urban Older Women

OBJECTIVE

To examine differences in diet and food purchasing behaviors between Black and White older women living in urban neighborhoods.

DESIGN

Cross-sectional observational study.

SETTING

Urban neighborhoods in Washington, DC, USA.

PARTICIPANTS

Community-dwelling White and Black women of age 65 and older.

MEASUREMENTS

Participants were queried on diet via 24-hour recalls, food purchasing habits, their use of neighborhood resources and local travel patterns. Frequency and location of self-reported food purchasing and consumption were compared by race.

RESULTS

In 2014 and 2015, 49 White and 44 Black older women were enrolled in the study. Compared to Whites, Blacks reported lower daily caloric intake (mean (SD) 1314 (404) vs. 1529 (448), p=0.02), with a higher percent of calories from protein and fat 1.8 (7.0), p=0.03), and a slightly higher polyunsaturated to saturated fat ratio (p=0.05). Blacks had substantially lower alternate healthy eating index (AHEI) (33.5 (10.2) vs. 43.9 (10.8) of 80 possible points, p<0.001), daily intake (grams) of total fiber (15.3 (8.1) vs. 22.9 (8.5), p<0.001), insoluble fiber (10.8 (6.9) vs. 15.9 (6.5), p<0.001), and soluble fiber (4.5 (2.0) vs. 6.9 (2.8), p<0.001). Blacks had lower intake of micronutrients, alcohol and caffeine. Blacks shopped for groceries less often (4.4 (3.0) vs. 6.2 (3.0) monthly; p=0.006) and spent a longer time traveling to stores (15.8 (9.1) vs. 11.5 (7.2) minutes per trip, p=0.02). A lower percent of Blacks walked to stores (14% vs. 40%, p=0.003) and a higher percent of Blacks rode in a car with someone else (33% vs. 6%, p<0.001).

CONCLUSIONS

In an urban setting, food consumption and purchasing behaviors differed substantially between older Black and White women, which should be further investigated and considered to promote healthy eating in older populations.

Duration of reproductive lifespan and age at menarche in relation to metabolic syndrome in postmenopausal Chinese women

AIM

This study aimed to assess the associations between menstrual characteristics and the prevalence of metabolic syndrome (MetS) and non-alcoholic fatty liver disease.

METHODS

A cross-sectional study was conducted with a sample of 1625 postmenopausal women in China. Subjects were classified into three groups according to the tertiles of some variables related to the reproductive life. We assessed associations in multivariable-adjusted analyses, using logistic regressions.

RESULTS

After adjustments for confounding factors, the odds ratios (OR) for predicting the presence of MetS increased gradually: as the years of menstruation increased (18-34 years vs 35-37 years vs 38-46 years: OR [95% confidence interval (CI)] = 1 vs 1.231 [0.942-1.610] vs 1.309 [0.985-1.740], respectively); as age at menopause increased (31-48 years vs 49-51 years vs 52-59 years: OR [95%CI] = 1 vs 1.115 [0.846-1.469] vs 1.315 [0.986-1.753], respectively); and as age at menarche decrease (11-13 years vs 14-15 years vs 16-20 years: OR [95%CI] = 1 vs 0.950 [0.728-1.240] vs 0.862 [0.610-1.119], respectively). Among the components of MetS, the highest tertile of years of menstruation was significantly associated with elevated waist circumference (OR =1.401 [95%CI = 1.092-1.798]), and elevated triglyceride (OR =1.220 [95%CI = 0.934-1.593]). Nevertheless, the association between these reproductive factors and non-alcoholic fatty liver disease was not significant.

CONCLUSION

Longer duration of menstruation and earlier age at menarche were significantly associated with a higher risk of central obesity and MetS in postmenopausal Chinese women.

Impact of incident diabetes on atherosclerotic cardiovascular disease according to statin use history among postmenopausal women

To compare impact of incident diabetes on atherosclerotic cardiovascular disease (ASCVD) risk among postmenopausal women according to statin use. Prospective data from 120,499 postmenopausal women without prevalent diabetes or cardiovascular disease at baseline from the Women's Health Initiative were used. Incident diabetes was self-reported annually and defined as treatment with pills or injectable medication for diabetes. Current statin use was determined at enrollment and years 1, 3, 6, 9 and 13.5 in the three clinical trial arms, and at baseline, year 3, and 13.5 for the observational study. The primary outcome was incident ASCVD events, self-reported annually and adjudicated by blinded local and central physicians. Incident diabetes and statin use status were fitted as time-varying covariates in Cox regression models to assess ASCVD risk during an average follow-up of 13.6 years. For those not on statins at the time of diabetes diagnosis, there was a 42 % increased risk of ASCVD [hazard ratio (HR) 1.42, 95 % CI 1.28-1.58] among women with incident diabetes versus those without diabetes. Among women on statins, there was a 39 % increased risk of ASCVD (HR 1.39, 95 % CI 1.12-1.74) in women with incident diabetes versus those without diabetes. The increased ASCVD risk due to diabetes was similar between women before or after initiating statins (P = 0.89). Whether diabetes was diagnosed before or after statin use did not alter the increased risk of ASCVD associated with diabetes. Mitigating the increased incidence of diabetes in statin users could increase the ASCVD benefit-to-risk ratio of statins.

Conjugated estrogens and bazedoxifene in minority populations: pooled analysis of four phase 3 trials

OBJECTIVE

The aim of the study was to compare efficacy of conjugated estrogens (CE)/bazedoxifene (BZA) for treatment of menopausal symptoms and prevention of postmenopausal osteoporosis in minorities (black/Hispanic) versus whites.

METHODS

In a post hoc analysis, data were pooled from 3,424 white or minority nonhysterectomized postmenopausal women randomized to CE 0.45 or 0.625 mg/BZA 20 mg or placebo in four double-blind, phase 3 Selective Estrogens, Menopause, and Response to Therapy (SMART) trials. Outcomes included hot flush frequency/severity (daily diary) in women with at least seven moderate-to-severe hot flushes per day (SMART-1, -2), vaginal cytology in women with at most 5% superficial cells (SMART-1, -3), lumbar spine and total hip bone mineral density (BMD) (SMART-1, -5), and the Menopause-Specific Quality of Life (MENQOL) questionnaire (SMART-1, -2, -3, -5).

RESULTS

The analysis included 2,907 white (84.9%), 315 black (9.2%), and 202 Hispanic (5.9%) women. The reduction in hot flush frequency/severity versus placebo (P < 0.05; week 12) was similar in white and minority women. In both populations, both doses significantly (P < 0.05 vs placebo) improved MENQOL vasomotor function, sexual function, and total scores at 3 months; decreased the percentage of parabasal cells at 2 years; and increased the percentage of BMD responders at 12 and 24 months. Significant differential treatment effects by race/ethnicity were observed only for effects on vaginal superficial cells at month 24 and vaginal pH at month 3.

CONCLUSIONS

Notwithstanding a limited sample size, CE/BZA had a similar and beneficial impact on hot flushes, MENQOL, and BMD in minorities and whites.

Kidney Function and Cardiovascular Events in Postmenopausal Women: The Impact of Race and Ethnicity in the Women's Health Initiative

BACKGROUND

Kidney disease disproportionately affects minority populations, including African Americans and Hispanics; therefore, understanding the relationship of kidney function to cardiovascular (CV) outcomes within different racial/ethnic groups is of considerable interest. We investigated the relationship between kidney function and CV events and assessed effect modification by race/ethnicity in the Women's Health Initiative.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

Baseline serum creatinine concentrations (assay traceable to isotope-dilution mass spectrometry standard) of 19,411 postmenopausal women aged 50 to 79 years who self-identified as either non-Hispanic white (n=8,921), African American (n=7,436), or Hispanic (n=3,054) were used to calculate estimated glomerular filtration rates (eGFRs).

PREDICTORS

Categories of eGFR (exposure); race/ethnicity (effect modifier).

OUTCOMES

The primary outcome was the composite of 3 physician-adjudicated CV events: myocardial infarction, stroke, or CV-related death.

MEASUREMENTS

We evaluated the multivariable-adjusted associations between categories of eGFR and CV events using proportional hazards regression and formally tested for effect modification by race/ethnicity.

RESULTS

During a mean follow-up of 7.6 years, 1,424 CV events (653 myocardial infarctions, 627 strokes, and 297 CV-related deaths) were observed. The association between eGFR and CV events was curvilinear; however, the association of eGFR with CV outcomes differed by race (P=0.006). In stratified analyses, we observed that the U-shaped association was present in non-Hispanic whites, whereas African American participants had a rather curvilinear relationship, with lower eGFR being associated with higher CV risk, and higher eGFR, with reduced CV risk. Analyses among Hispanic women were inconclusive owing to few Hispanic women having very low or high eGFRs and very few events occurring in these categories.

LIMITATIONS

Lack of urinary albumin measurements; residual confounding by unmeasured or imprecisely measured characteristics.

CONCLUSIONS

In postmenopausal women, the patterns of association between eGFR and CV risk differed between non-Hispanic whites and African American women.

Military Generation and Its Relationship to Mortality in Women Veterans in the Women's Health Initiative

PURPOSE OF THE STUDY

Women's military roles, exposures, and associated health outcomes have changed over time. However, mortality risk-within military generations or compared with non-Veteran women-has not been assessed. Using data from the Women's Health Initiative (WHI), we examined all-cause and cause-specific mortality by Veteran status and military generation among older women.

DESIGN AND METHODS

WHI participants (3,719 Veterans; 141,802 non-Veterans), followed for a mean of 15.2 years, were categorized into pre-Vietnam or Vietnam/after generations based on their birth cohort. We used cox proportional hazards models to examine the association between Veteran status and mortality by generation.

RESULTS

After adjusting for sociodemographic characteristics and WHI study arm, all-cause mortality hazard rate ratios (HRs) for Veterans relative to non-Veterans were 1.16 (95% CI: 1.09-1.23) for pre-Vietnam and 1.16 (95% CI: 0.99-1.36) for Vietnam/after generations. With additional adjustment for health behaviors and risk factors, this excess mortality rate persisted for pre-Vietnam but attenuated for Vietnam/after generations. After further adjustment for medical morbidities, across both generations, Veterans and non-Veterans had similar all-cause mortality rates. Relative to non-Veterans, adjusting for sociodemographics and WHI study arm, pre-Vietnam generation Veterans had higher cancer, cardiovascular, and trauma-related morality rates; Vietnam/after generation Veterans had the highest trauma-related mortality rates (HR = 2.93, 1.64-5.23).

IMPLICATIONS

Veterans' higher all-cause mortality rates were limited to the pre-Vietnam generation, consistent with diminution of the healthy soldier effect over the life course. Mechanisms underlying Vietnam/after generation Veteran trauma-related mortality should be elucidated. Efforts to modify salient health risk behaviors specific to each military generation are needed.

Time to and factors associated with insulin initiation in patients with type 2 diabetes mellitus

AIMS

Determine the time between the start of oral antidiabetic therapy (OAD) and the initiation of insulin therapy and to establish factors associated with insulin prescription among patients with type 2 diabetes mellitus (T2DM) in Colombia.

METHODS

Cohort, retrospective, population-based study. We identify patients with T2DM who started OAD therapy between 1 January 2007 and 31 December 2008, and a 5-year follow-up was performed. Kaplan-Meier survival analysis for time to start insulin therapy was generated and factors associated with insulin initiation were determined using logistic regression.

RESULTS

A total of 1042 patients (52.4% women), mean age 63.4 years at the start of pharmacological treatment. After 5 years, 272 patients (26.1%) initiated insulin therapy. Using combination therapy of metformin and glibenclamide was associated with greater risk of insulin initiation (OR: 1.64, 95% CI: 1.12-2.40, p=0.010), while being a male over 45 years of age (OR: 0.59, 95% CI: 0.37-0.96, p=0.034) and initiating OAD therapy with metformin (OR: 0.30, 95% CI: 0.20-0.46, p<0.001) reduced the risk of insulin use.

CONCLUSIONS

After 5 years of OAD treatment, 26.1% of people with T2DM started insulin therapy. Age, sex and type of initial OAD affected the probability of switching to insulin in these patients in Colombia.

Metabolic disorder and obesity in 5027 Brazilian postmenopausal women

OBJECTIVES

To evaluate the frequency of obesity in postmenopausal women and assess the potential effects of increased body mass index (BMI) on lipoprotein profile and on risk factors for arterial hypertension and diabetes.

DESIGN

A cross-sectional study was conducted with 5027 postmenopausal Brazilian women. Analyses were performed of BMI and cardiovascular factors (systemic blood pressure [BP], total cholesterol, low-density lipoprotein, high-density lipoprotein [HDL-C], triglyceride, and fast glucose). The statistical analysis included the chi-square and Mann-Whitney tests. The significance level was set at 5%.

RESULTS

Obesity (BMI >30) in our study characterized approximately 30% of the 5027 postmenopausal women. The comparison of patients with normal BMI and those with high BMI showed that high BMI had a significant negative effect on BP, as evidenced by the increased frequency of hypertension in overweight and obese patients (>25) (p < 0.001), that it also negatively and significantly affected triglyceride (p < 0.001) and fast glucose levels (p < 0.001), and that it was linked significantly to low levels of HDL-C.

CONCLUSION

Our data showed the high frequency of obesity in our population and of the cardiovascular risks (glucose, systemic arterial hypertension, and low HDL-C) associated with high BMI.

Menopausal hormone treatment cardiovascular disease: another look at an unresolved conundrum

Cardiovascular disease (CVD) is the most common cause of death in women. Before the Women's Health Initiative (WHI) hormone trials, evidence favored the concept that menopausal hormone treatment (MHT) protects against CVD. WHI studies failed to demonstrate CVD benefit, with worse net outcomes for MHT versus placebo in the population studied. We review evidence regarding the relationship between MHT and CVD with consideration of mechanisms and risk factors for atherogenesis and cardiac events, results of observational case-control and cohort studies, and outcomes of randomized trials. Estrogen effects on CVD risk factors favor delay or amelioration of atherosclerotic plaque development but may increase risk of acute events when at-risk plaque is present. Long-term observational studies have shown ∼40% reductions in risk of myocardial infarction and all-cause mortality. Analyses of data from randomized control trials other than the WHI show a ∼30% cardioprotective effect in recently menopausal women. Review of the literature as well as WHI data suggests that younger and/or more recently menopausal women may have a better risk-benefit ratio than older or remotely menopausal women and that CVD protection may only occur after >5 years; WHI women averaged 63 years of age (12 years postmenopausal) and few were studied for >6 years. Thus, a beneficial effect of long-term MHT on CVD and mortality is still an open question and is likely to remain controversial for the foreseeable future.

Diabetes-related mortality among American Indians and Alaska Natives, 1990-2009

OBJECTIVES

We assessed diabetes-related mortality for American Indians and Alaska Natives (AI/ANs) and Whites.

METHODS

Study populations were non-Hispanic AI/AN and White persons in Indian Health Service (IHS) Contract Health Service Delivery Area counties; Hispanics were excluded. We used 1990 to 2009 death certificate data linked to IHS patient registration records to identify AI/AN decedents aged 20 years or older. We examined disparities and trends in mortality related to diabetes as an underlying cause of death (COD) and as a multiple COD.

RESULTS

After increasing between 1990 and 1999, rates of diabetes as an underlying COD and a multiple COD subsequently decreased in both groups. However, between 2000 and 2009, age-adjusted rates of diabetes as an underlying COD and a multiple COD remained 2.5 to 3.5 times higher among AI/AN persons than among Whites for all age groups (20-44, 45-54, 55-64, 65-74, and ≥ 75 years), both sexes, and every IHS region except Alaska.

CONCLUSIONS

Declining trends in diabetes-related mortality in both AI/AN and White populations are consistent with recent improvements in their health status. Reducing persistent disparities in diabetes mortality will require developing effective approaches to not only control but also prevent diabetes among AI/AN populations.