Relation of glycohemoglobin and adiposity to atherosclerosis in youth. Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group

Body mass index and characteristics of coronary plaque in younger patients with type 2 diabetes

BACKGROUND AND AIMS

The association between the body mass index (BMI) and the characteristics of coronary plaque in younger type 2 diabetes (T2D) patients with coronary artery disease (CAD) remains to be elucidated.

METHODS AND RESULTS

A total of 138 consecutive younger (<65 years) T2D patients with CAD, who underwent optical coherence tomography imaging of the culprit lesion were included. The patients were classified into either the higher BMI group (n = 68) or the lower BMI group (n = 70) according to the median of BMI (25.9 kg/m2). The prevalence of thin-cap fibroatheroma (TCFA) (35.3 vs. 17.1 %, p = 0.015) was significantly higher in the higher BMI group than in the lower BMI group. The prevalence of TCFA was significantly higher in patients with higher BMI than in those with lower BMI among patients with hemoglobin A1c (HbA1c) ≥7.0 % (odds ratio [OR] 5.40, 95 % confidence interval [CI] 1.72-17.0, p = 0.003) although the significant difference was not observed among patients with HbA1c <7.0 % (OR 0.89, 95 % CI 0.25-3.13, p = 0.851).

CONCLUSION

Higher BMI was associated with a higher prevalence of TCFA in younger T2D patients with CAD, particularly in patients with HbA1c ≥ 7.0 %.

The Role of Obstructive Sleep Apnea in Vision-Threatening Diabetic Retinopathy-A National Register-Based Study

INTRODUCTION

we investigated the association between OSA and vision-threatening diabetic retinopathy (VTDR).

METHODS

we used three nationwide registers to identify subjects with and without OSA and patients with type 1 (T1DM) or type 2 diabetes mellitus (T2DM). The Danish Civil Registration System was used to link OSA with diabetes diagnosis. The primary outcome was the occurrence of VTDR in diabetic patients with and without OSA. The secondary outcome was the prevalence of diabetes mellitus in patients with and without OSA.

RESULTS

we included 532,828 diabetic subjects comprising 13,279 patients with OSA (2.5%) and 519,549 without OSA (97.5%). Diabetic patients with OSA had a 57% lower risk of VTDR compared to diabetic patients without OSA (OR 0.43, 95% CI 0.38-0.50, p < 0.0001).

CONCLUSIONS

our findings indicate that OSA is associated with a lower risk of VTDR. Since we did not adjust our outcomes for diabetes duration, hypertension control and hemoglobin A1c, future studies are needed to confirm our findings.

Atherosclerosis from Newborn to Adult-Epidemiology, Pathological Aspects, and Risk Factors

Cardiovascular disease is the leading cause of mortality and morbidity throughout the world, accounting for 16.7 million deaths each year. The underlying pathological process for the majority of cardiovascular diseases is atherosclerosis, a slowly progressing, multifocal, chronic, immune-inflammatory disease that involves the intima of large and medium-sized arteries. The process of atherosclerosis begins in childhood as fatty streaks-an accumulation of lipids, inflammatory cells, and smooth muscle cells in the arterial wall. Over time, a more complex lesion develops into an atheroma and characteristic fibrous plaques. Atherosclerosis alone is rarely fatal; it is the further changes that render fibrous plaques vulnerable to rupture; plaque rupture represents the most common cause of coronary thrombosis. The prevalence of atherosclerosis is increasing worldwide and more than 50% of people with circulatory disease die of it, mostly in modern societies. Epidemiological studies have revealed several environmental and genetic risk factors that are associated with the early formation of a pathogenic foundation for atherosclerosis, such as dyslipidemia, hypertension, diabetes mellitus, obesity, and smoking. The purpose of this review is to bring together the current information concerning the origin and progression of atherosclerosis in childhood as well as the identification of known risk factors for atherosclerotic cardiovascular disease in children.

Impact of puberty, sex determinants and chronic inflammation on cardiovascular risk in young people

Worrying trends of increased cardiovascular disease (CVD) risk in children, adolescents and young people in the Modern Era have channelled research and public health strategies to tackle this growing epidemic. However, there are still controversies related to the dynamic of the impact of sex, age and puberty on this risk and on cardiovascular health outcomes later in life. In this comprehensive review of current literature, we examine the relationship between puberty, sex determinants and various traditional CVD-risk factors, as well as subclinical atherosclerosis in young people in general population. In addition, we evaluate the role of chronic inflammation, sex hormone therapy and health-risk behaviours on augmenting traditional CVD-risk factors and health outcomes, ultimately aiming to determine whether tailored management strategies for this age group are justified.

Evolocumab attenuate pericoronary adipose tissue density via reduction of lipoprotein(a) in type 2 diabetes mellitus: a serial follow-up CCTA study

BACKGROUND

Pericoronary adipose tissue (PCAT) density is a biomarker of vessel inflammation, which is supposed to be increased in patients with type 2 diabetes mellitus (T2DM). However, whether the coronary inflammation revealed by this novel index could be alleviated after evolocumab treatment in T2DM remains unknown.

METHODS

From January 2020 to December 2022, consecutive T2DM patients with low-density lipoprotein cholesterol ≥ 70 mg/dL on maximally tolerated statin and taking evolocumab were prospectively included. In addition, patients with T2DM who were taking statin alone were recruited as control group. The eligible patients underwent baseline and follow-up coronary CT angiography with an interval of 48-week. To render patients with evolocumab as comparable to those controls, a propensity-score matching design was used to select the matched pairs with a 1:1 ratio. Obstructive lesion was defined as the extent of coronary artery stenosis ≥ 50%; the numbers inside the brackets were interquartile ranges.

RESULTS

A total of 170 T2DM patients with stable chest pain were included [(mean age 64 ± 10.6 [range 40-85] years; 131 men). Among those patients, 85 were in evolocumab group and 85 were in control group. During follow-up, low-density lipoprotein cholesterol (LDL-C) level (2.02 [1.26, 2.78] vs. 3.34 [2.53, 4.14], p < 0.001), and lipoprotein(a) (12.1 [5.6, 21.8] vs. 18.9 [13.2, 27.2], p = 0.002) were reduced after evolocumab treatment. The prevalence of obstructive lesions and high-risk plaque features were significantly decreased (p < 0.05 for all). Furthermore, the calcified plaque volume were significantly increased (188.3 [115.7, 361.0] vs. 129.3 [59.5, 238.3], p = 0.015), while the noncalcified plaque volume and necrotic volume were diminished (107.5 [40.6, 180.6] vs. 125.0 [65.3, 269.7], p = 0.038; 0 [0, 4.7] vs. 0 [0, 13.4], p < 0.001, respectively). In addition, PCAT density of right coronary artery was significantly attenuated in evolocumab group (- 85.0 [- 89.0, - 82.0] vs. - 79.0 [- 83.5, - 74.0], p < 0.001). The change in the calcified plaque volume inversely correlated with achieved LDL-C level (r =  - 0.31, p < 0.001) and lipoprotein(a) level (r =  - 0.33, p < 0.001). Both the changes of noncalcified plaque volume and necrotic volume were positively correlated with achieved LDL-C level and Lp(a) (p < 0.001 for all). However, the change of PCAT_RCA density only positively correlated with achieved lipoprotein(a) level (r = 0.51, p < 0.001). Causal mediation analysis revealed Lp(a) level mediated 69.8% (p < 0.001) for the relationship between evolocumab and changes of PCAT_RCA.

CONCLUSIONS

In patients with T2DM, evolocumab is an effective therapy to decrease noncalcified plaque volume necrotic volume, and increase calcified plaque volume. Furthermore, evolocumab could attenuate PCAT density, at least in part, via the reduction of lipoprotein(a).

Ambulatory blood pressure monitoring in children: A retrospective single-center study

OBJECTIVES

(1) Compare 24-hour ambulatory blood pressure monitoring (ABPM) diagnoses in a pediatric population with the new 2022 guidelines to the original diagnoses with the 2014 guidelines. (2) Determine whether findings of hypertension from ABPM could be predicted from prior patient data. (3) Determine whether ABPM readings could predict left ventricular mass index (LVMI) in patients who obtained an echocardiogram (ECHO).

STUDY DESIGN

Single-center retrospective study on patients referred to Pediatric Nephrology Clinic for evaluation of elevated blood pressure who underwent ABPM from 2015 to 2018. Predictions of hypertension were obtained using a logistic regression model, and predictions of LVMI were performed using regression models including (a) the wake systolic and diastolic BP indices, or (b) additionally including the standard deviation (SD) of wake SBP and DBP.

RESULTS

With the change in 2022 to new ABPM guidelines from the AHA, comparing the old and new guidelines led to 70% of previous pre-hypertensive diagnoses now meeting criteria for diagnosis of hypertension, and a rise from 21% of the ABPMs meeting criteria for hypertension to 51% now meeting criteria. In a logistic regression model, prior patient data were not predictive of a diagnosis of hypertension from ABPM (Nagelkerke's R ² = 0.04). Among the individual variables studied, none were statistically significant. For prediction of LVMI, the SD of wake SBP and DBP were significantly associated with increased LVMI, but the wake SBP and DBP indices were not.

CONCLUSIONS

In our patient population, the new ABPM guidelines led to a significant increase in diagnoses of hypertension. Prior patient data was not sufficient to predict a diagnosis of hypertension by ABPM, supporting the need for evaluation by ABPM as the gold standard. Our analysis of the relationship between ABPM readings and LVMI supports the hypothesis that BP variability contributes to increased LVMI. These data are consistent with growing evidence in the adult literature that BP variability detected by ABPM is associated with left-ventricular hypertrophy.

Typ-1-Diabetes und kardiovaskuläre Risikofaktoren bei Kindern und Jugendlichen

Die langfristigen kardiovaskulären Folgen des Typ-1-Diabetes determinieren die Lebenserwartung betroffener Kinder und Jugendlicher. Risikofaktoren für deren Entwicklung sind eine längere Diabetesdauer bzw. Diabetesmanifestation im frühen Lebensalter, Hypertonie, Rauchen, hoher BMI sowie Fettstoffwechselstörungen. Das Management der kardiovaskulären Risikofaktoren bei Kindern und Jugendlichen mit Typ-1-Diabetes beinhaltet zum einen Screeningsmaßnahmen zur frühzeitigen Aufdeckung der pathologischen Veränderungen und zum anderen eine Lebensstilanpassung im Sinne einer ausgewogenen, normokalorischen Ernährung, regelmäßiger Bewegung sowie ggf. einer medikamentösen lipid- bzw. blutdrucksenkenden Therapie.

Die Leitlinien und Empfehlungen zur standardisierten Erkennung und Behandlung kardiovaskulärer Risikofaktoren bei jungen Menschen mit Typ-1-Diabetes sind bisher uneinheitlich formuliert und werden deshalb nicht immer im klinischen Alltag angewendet bzw. umgesetzt. Dies führt zu einer relevanten Unterversorgung dieser Patientengruppe. Dem gilt es mit mehr Forschungsansätzen und der Entwicklung eines universellen Prozederes zur Diagnostik und Therapie der kardiovaskulären Risikofaktoren entgegenzuwirken.

Glycemic control is associated with dyslipidemia over time in youth with type 2 diabetes: The SEARCH for diabetes in youth study

BACKGROUND

Dyslipidemia has been documented in youth with type 2 diabetes. There is a paucity of studies examining dyslipidemia over time in youth with type 2 diabetes and associated risk factors.

OBJECTIVE

To evaluate lipids at baseline and follow-up and associated risk factors in youth with type 2 diabetes.

METHODS

We studied 212 youth with type 2 diabetes at baseline and after an average of 7 years of follow-up in the SEARCH for Diabetes in Youth Study. Abnormal lipids were defined as high-density lipoprotein cholesterol (HDL-C) < 35, low-density lipoprotein cholesterol (LDL-C) > 100, or triglycerides >150 (all mg/dl). We evaluated participants for progression to abnormal lipids (normal lipids at baseline and abnormal at follow-up), regression (abnormal lipids at baseline and normal at follow-up), stable normal, and stable abnormal lipids over time for HDL-C, LDL-C, and triglycerides. Associations between hemoglobin A1c (HbA1c) and adiposity over time (area under the curve [AUC]) with progression and stable abnormal lipids were evaluated.

RESULTS

HDL-C progressed, regressed, was stable normal, and stable abnormal in 12.3%, 11.3%, 62.3%, and 14.2% of participants, respectively. Corresponding LDL-C percentages were 15.6%, 12.7%, 42.9%, and 28.8% and triglycerides were 17.5%, 10.8%, 55.7%, and 16.0%. Each 1% increase in HbA1c AUC was associated with a 13% higher risk of progression and stable abnormal triglycerides and a 20% higher risk of progression and stable abnormal LDL-C. Higher adiposity AUC was marginally (p = 0.049) associated with abnormal HDL-C.

CONCLUSIONS

Progression and stable abnormal LDL-C and triglycerides occur in youth with type 2 diabetes and are associated with higher HbA1c.

Novel insights on the role of spexin as a biomarker of obesity and related cardiometabolic disease

Spexin (SPX) is a 14-amino acid neuropeptide, discovered recently using bioinformatic techniques. It is encoded by the Ch12:orf39 gene that is widely expressed in different body tissues/organs across species, and secreted into systemic circulation. Recent reports have highlighted a potentially important regulatory role of SPX in obesity and related comorbidities. SPX is also ubiquitously expressed in human tissues, including white adipose tissue. The circulating concentration of SPX is significantly lower in individuals with obesity compared to normal weight counterparts. SPX's role in obesity appears to be related to various factors, such as the regulation of energy expenditure, appetite, and eating behaviors, increasing locomotion, and inhibiting long-chain fatty acid uptake into adipocytes. Recent reports have also suggested SPX's relationship with novel biomarkers of cardiovascular disease (CVD) and glucose metabolism and evoked the potential role of SPX as a key biomarker/player in the early loss of cardiometabolic health and development of CVD and diabetes later in life. Data on age-related changes in SPX and SPX's response to various interventions are also emerging. The current review focuses on the role of SPX in obesity and related comorbidities across the life span, and its response to interventions in these conditions. It is expected that this article will provide new ideas for future research on SPX and its metabolic regulation, particularly related to cardiometabolic diseases.

Obesity and Cardiovascular Disease: A Scientific Statement From the American Heart Association

The global obesity epidemic is well established, with increases in obesity prevalence for most countries since the 1980s. Obesity contributes directly to incident cardiovascular risk factors, including dyslipidemia, type 2 diabetes, hypertension, and sleep disorders. Obesity also leads to the development of cardiovascular disease and cardiovascular disease mortality independently of other cardiovascular risk factors. More recent data highlight abdominal obesity, as determined by waist circumference, as a cardiovascular disease risk marker that is independent of body mass index. There have also been significant advances in imaging modalities for characterizing body composition, including visceral adiposity. Studies that quantify fat depots, including ectopic fat, support excess visceral adiposity as an independent indicator of poor cardiovascular outcomes. Lifestyle modification and subsequent weight loss improve both metabolic syndrome and associated systemic inflammation and endothelial dysfunction. However, clinical trials of medical weight loss have not demonstrated a reduction in coronary artery disease rates. In contrast, prospective studies comparing patients undergoing bariatric surgery with nonsurgical patients with obesity have shown reduced coronary artery disease risk with surgery. In this statement, we summarize the impact of obesity on the diagnosis, clinical management, and outcomes of atherosclerotic cardiovascular disease, heart failure, and arrhythmias, especially sudden cardiac death and atrial fibrillation. In particular, we examine the influence of obesity on noninvasive and invasive diagnostic procedures for coronary artery disease. Moreover, we review the impact of obesity on cardiac function and outcomes related to heart failure with reduced and preserved ejection fraction. Finally, we describe the effects of lifestyle and surgical weight loss interventions on outcomes related to coronary artery disease, heart failure, and atrial fibrillation.

A Nephrologist Perspective on Obesity: From Kidney Injury to Clinical Management

Obesity is one of the epidemics of our era. Its prevalence is higher than 30% in the U.S. and it is estimated to increase by 50% in 2030. Obesity is associated with a higher risk of all-cause mortality and it is known to be a cause of chronic kidney disease (CKD). Typically, obesity-related glomerulopathy (ORG) is ascribed to renal hemodynamic changes that lead to hyperfiltration, albuminuria and, finally, impairment in glomerular filtration rate due to glomerulosclerosis. Though not only hemodynamics are responsible for ORG: adipokines could cause local effects on mesangial and tubular cells and podocytes promoting maladaptive responses to hyperfiltration. Furthermore, hypertension and type 2 diabetes mellitus, two conditions generally associated with obesity, are both amplifiers of obesity injury in the renal parenchyma, as well as complications of overweight. As in the native kidney, obesity is also related to worse outcomes in kidney transplantation. Despite its impact in CKD and cardiovascular morbility and mortality, therapeutic strategies to fight against obesity-related CKD were limited for decades to renin-angiotensin blockade and bariatric surgery for patients who accomplished very restrictive criteria. Last years, different drugs have been approved or are under study for the treatment of obesity. Glucagon-like peptide-1 receptor agonists are promising in obesity-related CKD since they have shown benefits in terms of losing weight in obese patients, as well as preventing the onset of macroalbuminuria and slowing the decline of eGFR in type 2 diabetes. These new families of glucose-lowering drugs are a new frontier to be crossed by nephrologists to stop obesity-related CKD progression.

Obesity and Coronary Heart Disease: Epidemiology, Pathology, and Coronary Artery Imaging

Overweight and obesity contribute to the development of cardiovascular disease (CVD) in general and coronary heart disease (CHD) in particular in part by their association with traditional and nontraditional CVD risk factors. Obesity is also considered to be an independent risk factor for CVD. The metabolic syndrome, of which central obesity is an important component, is strongly associated with CVD including CHD. There is abundant epidemiologic evidence of an association between both overweight and obesity and CHD. Evidence from postmortem studies and studies involving coronary artery imaging is less persuasive. Recent studies suggest the presence of an obesity paradox with respect to mortality in persons with established CHD. Physical activity and preserved cardiorespiratory fitness attenuate the adverse effects of obesity on CVD events. Information concerning the effect of intentional weight loss on CVD outcomes in overweight and obese persons is limited.

A Brief Review of Cardiovascular Diseases, Associated Risk Factors and Current Treatment Regimes

Cardiovascular diseases (CVDs) are the leading cause of premature death and disability in humans and their incidence is on the rise globally. Given their substantial contribution towards the escalating costs of health care, CVDs also generate a high socio-economic burden in the general population. The underlying pathogenesis and progression associated with nearly all CVDs are predominantly of atherosclerotic origin that leads to the development of coronary artery disease, cerebrovascular disease, venous thromboembolism and, peripheral vascular disease, subsequently causing myocardial infarction, cardiac arrhythmias or stroke. The aetiological risk factors leading to the onset of CVDs are well recognized and include hyperlipidaemia, hypertension, diabetes, obesity, smoking and, lack of physical activity. They collectively represent more than 90% of the CVD risks in all epidemiological studies. Despite high fatality rate of CVDs, the identification and careful prevention of the underlying risk factors can significantly reduce the global epidemic of CVDs. Beside making favorable lifestyle modifications, primary regimes for the prevention and treatment of CVDs include lipid-lowering drugs, antihypertensives, antiplatelet and anticoagulation therapies. Despite their effectiveness, significant gaps in the treatment of CVDs remain. In this review, we discuss the epidemiology and pathology of the major CVDs that are prevalent globally. We also determine the contribution of well-recognized risk factors towards the development of CVDs and the prevention strategies. In the end, therapies for the control and treatment of CVDs are discussed.

Nitric Oxide Gene Polymorphism is a Risk Factor for Diabetic Nephropathy and Atherosclerosis in Type 1 Diabetic Patients

AIM:

To assess the risk factor for diabetic atherosclerosis nephropathy and diabetic nephropathy in type 1 diabetic patients.

PATIENTS AND METHODS:

Thirty healthy volunteers age and sex-matched and Sixty-five type 1 diabetic patient were in rolled in the study. The mean age of patients was 17.99 ± 2.59 years, mean age of onset of diabetes was 7.00 ± 3.28 years, mean duration of diabetes was 10.91 ± 3.54 years. Glycosylated sex-matched (HbA1c) was assessed in blood samples, serum lipid profile was determined, and serum level of oxidised low-density lipoprotein (OxLDL), and nitric oxide was evaluated by enzyme-linked immunosorbent assay (ELISA) technique. Nitric oxide 894G > T genotype was analysed by (PCR-RFLP) method and confirmed by Sequencing. Assessment of the albumin / creatinine ratio was done in urine samples. Renal Doppler and Carotid intima-media thickness (cIMT) via ultrasound was also performed.

RESULTS:

OxLDL, lipid profile, albumin/creatinine ratio, cIMT and resistivity index were significantly higher in diabetic patients while nitric oxide was significantly lower. Nitric oxide genotype shows no significant difference between diabetic’s patients and controls. Diabetic patients with homozygous NO had a significantly lower serum level of Nitric oxide, a significantly higher OxLDL, albumin / creatinine ratio and lipid profile.

CONCLUSION:

diabetic patients are liable for the occurrence of early diabetic nephropathy and atherosclerosis as a result of the presence of low level of nitric oxide. Nitric oxide gene polymorphism 894G > T in diabetic patients is a risk factor for diabetic nephropathy and atherosclerosis.

Vascular health determinants in children

Background

The epidemic of cardiovascular disease (CVD) in the twentieth century generated numerous population-based surveys. These results clearly demonstrate that many factors are causally related to the development of atherosclerosis. Eighty percent of the CVD can be explained by smoking, high blood pressure, deterioration of lipid and glucose metabolism and physical inactivity. CVD is a disease that becomes clinically apparent in adults. However, it is undisputed that this disease develops over a long period of time due to progressive, subclinical changes in the cardiovascular system. The early manifestation of arteriosclerosis correlates with traditional risk factors.

Methods

This brief report focusses on determinates of vascular health. It describes non-invasive diagnostic methods such as oscillometric analysis of pulse wave velocity (PWV), ultrasound measurement of carotid structure and function as well as brachial endothelial function. Special attention is paid to possible correlations with physical activity, fitness and exercise.

Results

Non-invasive diagnostic methods to determine vascular health are applicable in children. The influence of physical activity and the relationship between aerobic fitness and arterial compliance (AC) remain controversial. First results in young athletes demonstrated an increased carotid intima-media thickness (cIMT), by revealing arterial elasticity. The mechanism and determinants explaining these adaptations have not been fully explained in young healthy athletes.

Conclusions

Traditional cardiovascular risk factors act early in life and have a major impact on the development of atherosclerosis. The results underline that the prevention strategies and risk factor control should begin in childhood. The emphasis in the present report lied on the determination of vascular health, analyzing arterial structure and function, using non-invasive diagnostic methods. Vascular health and its relation to obesity, hypertension, physical activity and exercise were emphasized. The harmonization of knowledge and methods would greatly increase the comparability of existing results. To further elucidate the clinical relevance, the mechanisms linking arterial structure and compliance function with physical activity, fitness and exercise need further clinical investigation to enhance early preventive intervention strategies.

Obesity and cardiovascular disease: revisiting an old relationship

A wealth of clinical and epidemiological evidence has linked obesity to a broad spectrum of cardiovascular diseases (CVD) including coronary heart disease, heart failure, hypertension, stroke, atrial fibrillation and sudden cardiac death. Obesity can increase CVD morbidity and mortality directly and indirectly. Direct effects are mediated by obesity-induced structural and functional adaptations of the cardiovascular system to accommodate excess body weight, as well as by adipokine effects on inflammation and vascular homeostasis. Indirect effects are mediated by co-existing CVD risk factors such as insulin resistance, hyperglycemia, hypertension and dyslipidemia. Adipose tissue (AT) quality and functionality are more relevant aspects for cardiometabolic risk than its total amount. The consequences of maladaptive AT expansion in obesity are local and systemic: the local include inflammation, hypoxia, dysregulated adipokine secretion and impaired mitochondrial function; the systemic comprise insulin resistance, abnormal glucose/lipid metabolism, hypertension, a pro-inflammatory and pro-thrombotic state and endothelial dysfunction, all of which provide linking mechanisms for the association between obesity and CVD. The present narrative review summarizes the major pathophysiological links between obesity and CVD (traditional and novel concepts), analyses the heterogeneity of obesity-related cardiometabolic consequences, and provides an overview of the cardiovascular impact of weight loss interventions.

Specialized Pro-resolving Lipid Mediators: Modulation of Diabetes-Associated Cardio-, Reno-, and Retino-Vascular Complications

Diabetes and its associated chronic complications present a healthcare challenge on a global scale. Despite improvements in the management of chronic complications of the micro-/macro-vasculature, their growing prevalence and incidence highlights the scale of the problem. It is currently estimated that diabetes affects 425 million people globally and it is anticipated that this figure will rise by 2025 to 700 million people. The vascular complications of diabetes including diabetes-associated atherosclerosis and kidney disease present a particular challenge. Diabetes is the leading cause of end stage renal disease, reflecting fibrosis leading to organ failure. Moreover, diabetes associated states of inflammation, neo-vascularization, apoptosis and hypercoagulability contribute to also exacerbate atherosclerosis, from the metabolic syndrome to advanced disease, plaque rupture and coronary thrombosis. Current therapeutic interventions focus on regulating blood glucose, glomerular and peripheral hypertension and can at best slow the progression of diabetes complications. Recently advanced knowledge of the pathogenesis underlying diabetes and associated complications revealed common mechanisms, including the inflammatory response, insulin resistance and hyperglycemia. The major role that inflammation plays in many chronic diseases has led to the development of new strategies aiming to promote the restoration of homeostasis through the "resolution of inflammation." These strategies aim to mimic the spontaneous activities of the 'specialized pro-resolving mediators' (SPMs), including endogenous molecules and their synthetic mimetics. This review aims to discuss the effect of SPMs [with particular attention to lipoxins (LXs) and resolvins (Rvs)] on inflammatory responses in a series of experimental models, as well as evidence from human studies, in the context of cardio- and reno-vascular diabetic complications, with a brief mention to diabetic retinopathy (DR). These data collectively support the hypothesis that endogenously generated SPMs or synthetic mimetics of their activities may represent lead molecules in a new discipline, namely the 'resolution pharmacology,' offering hope for new therapeutic strategies to prevent and treat, specifically, diabetes-associated atherosclerosis, nephropathy and retinopathy.

Manifestations and mechanisms of myocardial lipotoxicity in obesity

Environmental and socioeconomic changes over the past thirty years have contributed to a dramatic rise in the worldwide prevalence of obesity. Heart disease is amongst the most serious health risks of obesity, with increases in both atherosclerotic coronary heart disease and heart failure among obese individuals. In this review, we focus on primary myocardial alterations in obesity that include hypertrophic remodelling and diastolic dysfunction. Obesity-associated perturbations in myocardial and systemic lipid metabolism are important contributors to cardiovascular complications of obesity. Accumulation of excess lipid in nonadipose cells of the cardiovascular system can cause cell dysfunction and cell death, a process known as lipotoxicity. Lipotoxicity has been modelled in mice using high-fat diet feeding, inbred lines with mutations in leptin receptor signalling, and in genetically engineered mice with enhanced myocardial fatty acid uptake, altered lipid droplet homoeostasis or decreased cardiac fatty acid oxidation. These studies, along with findings in cell culture model systems, indicate that the molecular pathophysiology of lipid overload involves endoplasmic reticulum stress, alterations in autophagy, de novo ceramide synthesis, oxidative stress, inflammation and changes in gene expression. We highlight recent advances that extend our understanding of the impact of obesity and altered lipid metabolism on cardiac function.

Clinical features and therapeutic perspectives on hypertension in diabetics

Over 50% of patients with diabetes mellitus, either type 1 or 2, ultimately develop hypertension as a complication. In diabetics, this further increases the incidence of cardiovascular disease (CVD) by 2- to 3-fold and accelerates the progression of diabetic nephropathy. Arteriosclerosis, a clinical feature of hypertension in diabetics, develops and advances from a young age. Therefore, in providing treatment, it is necessary to evaluate the degree of arteriosclerosis. Diabetic patients are encouraged to strictly control their blood glucose levels. Recently developed drugs, such as GLP-1 receptor agonists, DPP-4 inhibitors and SGLT2 inhibitors, also have hypotensive actions, making them ideal for use in diabetics with hypertension. SGLT2 inhibitors and GLP-1 receptor agonists reportedly suppress the onset and progression of CVD, as well as diabetic nephropathy. The possibility of hypoglycemia triggering blood pressure elevation and arrhythmia has been noted, so a key point here is not to cause hypoglycemia. In selecting hypotensive agents, we must choose types that do not aggravate insulin resistance and engage in hypotensive treatment that also considers both nocturnal and morning hypertension. In addition, facing the onset of an aging society, there is a growing need for treatments that do not cause excessive blood pressure reduction or hypoglycemia. Favorable lifelong blood pressure and glucose control are increasingly important for the treatment of diabetes accompanied by hypertension.

Modeling anthropometric indices in relation to 10-year (2002-2012) incidence of cardiovascular disease, among apparently healthy individuals: The ATTICA study

AIMS

Body fat accumulation is implicated in the development of cardiovascular disease (CVD). Our objective was to explore potential associations between anthropometric indices and the 10-year CVD incidence in Greek adults without previous CVD.

METHODS

During 2001-2, we enrolled 3042 adults without CVD from the general population of Attica, Greece. In 2011-2, the 10-year study follow-up was performed, recording the CVD incidence in 1958 participants with baseline body mass index (BMI) ≥18.5kg/m².

RESULTS

The study 10-year CVD incidence was 15.8%, exhibiting a gradual increase according to the baseline body mass index (BMI) category. Baseline BMI ≥30kg/m² was related with significantly higher 10-year CVD risk compared to BMI <25kg/m², even after adjustment for age and other known CVD risk factors. Baseline BMI, waist circumference, waist-to-hip ratio, waist-to-height ratio and waist-to-hip-to-height ratio were independently associated with the 10-year CVD risk in multi-adjusted models. Gender-specific analyses showed that these associations were more evident in men compared to women, with baseline BMI exhibiting an independent association with the 10-year CVD incidence in men.

CONCLUSIONS

Our results indicate that even simple anthropometric indices exhibit independent associations with CVD risk in a representative sample of the Greek general population without previous CVD.

Physical Activity and Sedentary Time Associations with Metabolic Health Across Weight Statuses in Children and Adolescents

OBJECTIVE

The aim of this study was to examine the prevalence of metabolic health across weight statuses and the associations of physical activity and sedentary time within and across metabolic health-weight status groups.

METHODS

Six studies (n = 4,581) from the International Children's Accelerometry Database were used. Sedentary time, light physical activity, and moderate to vigorous physical activity (MVPA) were accelerometer derived. Individuals were classified with normal weight (NW), overweight, or obesity. Strict and lenient composite definitions of metabolic health were created. Binomial and multinomial logistic regressions controlling for age, sex, study, and accelerometer wear time were conducted.

RESULTS

The metabolically unhealthy (MU) prevalence was 26.4% and 45.6% based on two definitions. Across definitions, more sedentary time was associated with higher odds of MU classification compared with metabolically healthy (MH) classification for the NW group. More MVPA was associated with lower odds of MU classification than MH classification for NW and overweight groups. For multinomial logistic regressions, more MVPA was associated with lower odds of MH-obesity classification, as well as MU-NW, -overweight, and -obesity classifications, compared with the MH-NW group. Furthermore, more sedentary time was associated with higher odds of MU-NW classification compared with the MH-NW group.

CONCLUSIONS

More MVPA was beneficial for metabolic health and weight status, whereas lower sedentary time was beneficial for metabolic health alone, although associations were weak.

Pediatric Markers of Adult Cardiovascular Disease

BACKGROUND

Cardiovascular diseases are the leading cause of death worldwide. While cardiovascular disease typically does not occur until adulthood, the pathogenesis of atherosclerotic cardiovascular disease starts in early childhood.

OBJECTIVE

The purpose of this review is to describe the evidence that the process of atherosclerosis begins in childhood, as well as identify the risk factors present in childhood that are associated with the presence of atherosclerotic cardiovascular disease in childhood as well as future cardiovascular events in adulthood.

RESULTS AND CONCLUSION

There is much accumulating evidence linking modifiable risk factors that are already present in childhood and that strongly predict future cardiovascular disease. The selective targeting of modifiable risk factors in childhood, including body mass index, holds promise in reducing the burden of adult cardiovascular disease. Future research studies should focus on elucidating the mechanisms which drive the pathogenesis of atherosclerosis in childhood and young adulthood, as well as identifying which interventions are most effective at limiting the progression of atherosclerosis and thus reducing future cardiovascular disease.

Carotid Intima-Media Thickness and Incident ESRD: The Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND AND OBJECTIVES

Carotid intima-media thickness has been reported to predict kidney function decline. However, whether carotid intima-media thickness is associated with a hard kidney end point, ESRD, has not been investigated.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We studied 13,197 Atherosclerosis Risk in Communities participants at visit 1 (1987-1989) without history of cardiovascular disease, including coronary heart disease, stroke, and heart failure, at baseline and assessed whether carotid intima-media thickness measured by B-mode ultrasound is associated with ESRD risk using Cox proportional hazards models. Regarding carotid intima-media thickness parameters, we investigated the mean and maximum values of overall and segment-specific (common, bifurcation, and internal carotid arteries) measurements.

RESULTS

Mean age was 54.0 (SD=5.7) years old, and there were 3373 (25.6%) blacks and 7370 (55.8%) women. During a median follow-up of 22.7 years, 433 participants developed ESRD (1.4/1000 person-years). After adjusting for shared risk factors for atherosclerosis and kidney disease, including baseline kidney function, carotid intima-media thickness was significantly associated with ESRD risk (hazard ratio [HR] between quartiles 4 and 1, 1.46; 95% confidence interval [95% CI], 1.02 to 2.08 for overall mean intima-media thickness and HR between quartiles 4 and 1, 1.75; 95% CI, 1.24 to 2.48 for overall maximum intima-media thickness). The associations were largely consistent in demographic and clinical subgroups. When we explored segment-specific intima-media thicknesses, the associations with ESRD were most robust for bifurcation carotid (e.g., adjusted HR between quartiles 4 and 1 of mean intima-media thickness, 1.49; 95% CI, 1.04 to 2.13 for bifurcation; adjusted HR between quartiles 4 and 1 of mean intima-media thickness, 1.36; 95% CI, 0.94 to 1.97 for common; and adjusted HR between quartiles 4 and 1 of mean intima-media thickness, 0.93; 95% CI, 0.67 to 1.29 for internal).

CONCLUSIONS

Carotid intima-media thickness was independently associated with incident ESRD in the general population, suggesting the shared etiology of atherosclerosis and ESRD.

Statin therapy across the lifespan: evidence in major age groups

This review provides needed perspective on statin efficacy and safety in individuals under 40, 40-75, and > 75 years of age. Starting with the 2013 ACC-AHA cholesterol guidelines extensive evidence base on randomized controlled trials (RCTs) we added references in the past 5 years that discussed statin efficacy and safety over the life span. In those under 40, statins are primarily used for treatment of severe hypercholesterolemia, often familial, and they are well tolerated. In middle-aged adults, statins have strong evidence for benefit in primary and secondary prevention trials; however, in primary prevention, a clinician-patient risk discussion should precede statin prescription in order to determine appropriate treatment. In those over 75, issues of statin intensity and net benefit loom large as associated comorbidity, polypharmacy, and potential for adverse effects impact the decision to use statins with RCT data strongest in support of use in secondary prevention. Statin drugs have been studied by RCTs in a large number of individuals. In those groups shown to benefit, statins have reduced the risk of atherosclerotic cardiovascular disease with few side effects as compared to controls. This review has detailed considerations that should occur when statins are given to individuals in different age groups.

Is serum Klotho protective against atherosclerosis in patients with type 1 diabetes mellitus?

OBJECTIVE

Klotho deficiency is associated with several metabolic disorders. Two dimensional (2D) longitudinal strain (LS) of left ventricle (LV), carotid artery intima-media thickness (CIMT), flow-mediated dilation (FMD) of brachial artery and epicardial fat thickness (EFT) have been reported to be early predictors of atherosclerosis. We aimed to investigate the relationship between serum Klotho levels and these early predictors of atherosclerosis in patients with type 1 diabetes mellitus (DM).

METHODS

The study included 45 type 1 diabetic patients and 35 controls. Serum Klotho levels were determined by ELISA method. The patient group was also divided into two subgroups according to serum Klotho levels: high (HK) and low Klotho (LK) groups. EFT, CIMT and FMD were measured according to appropriate recommendations. Speckle tracking analysis was performed using the Echopac software.

RESULTS

The patient group had significantly lower serum Klotho (p=0.001), FMD (p<0.001) and LS of LV (p<0.001) values, but larger EFT (p<0.001) and CIMT (p<0.001) values than controls. LK subgroup had also significantly lower FMD (p<0.001) and LS of LV (p<0.001) but larger EFT (p=0.002) and CIMT (p<0.001) values than HK subgroup.

CONCLUSION

Serum Klotho may have a protective effect against atherosclerosis and endothelial dysfunction in type 1 DM.

Carotid intimal medial thickness and its relation to endothelial dysfunction and echocardiographic changes in adolescents with type 1 diabetes

AIM

To assess carotid intimal medial thickness (cIMT) in adolescent type 1 diabetic patients and to detect its relation with echocardiographic changes and flow mediated dilatation (FMD) in the brachial artery.

METHODS

The study included 62 type 1 diabetic patients and 30 healthy volunteer of the same age and sex. A blood sample was taken for analysis of glycosylated hemoglobin and lipid profile and a urine sample was taken for analysis of albumin/creatinine ratio. cIMT, echocardiography, and FMD via ultrasound were also done; t-test or Mann-Whitney U-test (for non-symmetrically distributed data) for independent variables and Pearson's or Spearman correlation were used.

RESULTS

The mean age of patients was 16.3 ± 1.5 years and mean duration of diabetes was 9.4 ± 2.9 years. cIMT (Rt, Lt, and both Rt and Lt) were significantly higher, while FMD and FMD/nitrate mediated dilatation (NMD) ratio was significantly lower in diabetics. Rt cIMT had a significant negative correlation with FMD and FMD/NMD. cIMT had a significant positive correlation with left ventricular end diastolic dimension, inter ventricular septum thickness, peak mitral flow velocity during early diastole/peak mitral flow velocity during late diastole, left ventricular mass, and left ventricular mass index (p<0.05). In addition, cIMT had a significant correlation with waist circumference, waist/height ratio, albumin/ creatinine ratio, total cholesterol, and triglyceride.

CONCLUSION

We conclude that alteration in myocardial function and vascular endothelial dysfunction induced by diabetes mellitus may begin early with the association of early atherosclerotic changes.

Accumulating exercise and postprandial health in adolescents

PURPOSE

To examine the influence of exercise intensity on postprandial health outcomes in adolescents when exercise is accumulated throughout the day.

METHODS

19 adolescents (9 male, 13.7±0.4 years old) completed three 1-day trials in a randomised order: (1) rest (CON); or four bouts of (2) 2×1 min cycling at 90% peak power with 75 s recovery (high-intensity interval exercise; HIIE); or (3) cycling at 90% of the gas exchange threshold (moderate-intensity exercise; MIE), which was work-matched to HIIE. Each bout was separated by 2 hours. Participants consumed a high fat milkshake for breakfast and lunch. Postprandial triacylglycerol (TAG), glucose, systolic blood pressure (SBP) and fat oxidation were assessed throughout the day.

RESULTS

There was no effect of trial on total area under the curve (TAUC) for TAG (P=0.87). TAUC-glucose was lower in HIIE compared to CON (P=0.03, ES=0.42) and MIE (P=0.04, ES=0.41), with no difference between MIE and CON (P=0.89, ES=0.04). Postprandial SBP was lower in HIIE compared to CON (P=0.04, ES=0.50) and MIE (P=0.04, ES=0.40), but not different between MIE and CON (P=0.52, ES=0.11). Resting fat oxidation was increased in HIIE compared to CON (P=0.01, ES=0.74) and MIE (P=0.05, ES=0.51), with no difference between MIE and CON (P=0.37, ES=0.24).

CONCLUSION

Neither exercise trial attenuated postprandial lipaemia. However, accumulating brief bouts of HIIE, but not MIE, reduced postprandial plasma glucose and SBP, and increased resting fat oxidation in adolescent boys and girls. The intensity of accumulated exercise may therefore have important implications for health outcomes in youth.

DIABETES AND PREDIABETES ARE SIGNIFICANTLY HIGHER IN MORBIDLY OBESE CHILDREN COMPARED WITH OBESE CHILDREN

OBJECTIVE

The objective of this study was to examine the prevalence and characteristics of comorbidities in obese and morbidly obese children with a comparison between the 2 sets of children.

METHODS

This was a retrospective electronic chart review of obese and morbidly obese children and adolescents as defined by body mass index. We evaluated medical history of comorbid conditions, medication use, and cardiovascular risk markers, including blood pressure, lipid profile, and glycosylated hemoglobin.

RESULTS

There were 1,111 subjects (African American = 635; non-Hispanic white = 364; Hispanic = 36; others = 86), of which 274 were obese and 837 were morbidly obese children with a mean age of 12.7 ± 3.37 years. Morbidly obese children had a higher prevalence of prediabetes (19.5% of obese versus 27.3% of morbidly obese; P<.0001) and type 2 diabetes (39.8% of obese versus 52.4% of morbidly obese; P<.0001). Use of medications for treatment of asthma was significantly higher in the morbidly obese group compared with the obese group (21% versus 14%; P = .01).

CONCLUSION

Morbidly obese children have a higher prevalence of diabetes, prediabetes, and use of asthma medications compared with obese children.

Risk of all-cause mortality and vascular events in women versus men with type 1 diabetes: a systematic review and meta-analysis

BACKGROUND

Studies have suggested sex differences in the mortality rate associated with type 1 diabetes. We did a meta-analysis to provide reliable estimates of any sex differences in the effect of type 1 diabetes on risk of all-cause mortality and cause-specific outcomes.

METHODS

We systematically searched PubMed for studies published between Jan 1, 1966, and Nov 26, 2014. Selected studies reported sex-specific estimates of the standardised mortality ratio (SMR) or hazard ratios associated with type 1 diabetes, either for all-cause mortality or cause-specific outcomes. We used random effects meta-analyses with inverse variance weighting to obtain sex-specific SMRs and their pooled ratio (women to men) for all-cause mortality, for mortality from cardiovascular disease, renal disease, cancer, the combined outcome of accident and suicide, and from incident coronary heart disease and stroke associated with type 1 diabetes.

FINDINGS

Data from 26 studies including 214 114 individuals and 15 273 events were included. The pooled women-to-men ratio of the SMR for all-cause mortality was 1·37 (95% CI 1·21-1·56), for incident stroke 1·37 (1·03-1·81), for fatal renal disease 1·44 (1·02-2·05), and for fatal cardiovascular diseases 1·86 (1·62-2·15). For incident coronary heart disease the sex difference was more extreme; the pooled women-to-men ratio of the SMR was 2·54 (95% CI 1·80-3·60). No evidence suggested a sex difference for mortality associated with type 1 diabetes from cancer, or accident and suicide.

INTERPRETATION

Women with type 1 diabetes have a roughly 40% greater excess risk of all-cause mortality, and twice the excess risk of fatal and nonfatal vascular events, compared with men with type 1 diabetes.

FUNDING

None.

Serum paraoxonase/arylesterase activity and oxidative stress status in children with metabolic syndrome

OBJECTIVE

This study aimed to measure paraoxonase/arylesterase activities and to evaluate the total oxidant and antioxidant capacities in obese children and in children with metabolic syndrome (MetS).

METHODS

A total of 151 children of comparable ages (13.23±1.96 years, 13.45±1.85 years and 13.95±1.31 years) were enrolled in the study. Forty of these were children with MetS, 55 were obese and 56 were healthy controls. Diagnosis of the MetS was made according to International Diabetes Federation criteria. Paraoxonase/arylesterase activities were evaluated by using paraoxon and phenylacetate substrates. Total oxidant status (TOS) and total antioxidant status (TAS) were measured and oxidative stress index (OSI) was estimated by calculation.

RESULTS

High levels of paraoxonase were detected in the obese group, whereas high levels of arylesterase were detected in both MetS and obese groups. Higher values for TOS, TAS and OSI were found in the MetS group (p<0.05).

CONCLUSION

Higher values of mean TOS and OSI in the MetS group than those in the control groups indicate that these parameters may be indicators of future risks such as atherosclerosis in patients with MetS.

2013 Russell Ross memorial lecture in vascular biology: cellular and molecular mechanisms of diabetes mellitus-accelerated atherosclerosis

Adults with diabetes mellitus are much more likely to have cardiovascular disease than those without diabetes mellitus. Genetically engineered mouse models have started to provide important insight into the mechanisms whereby diabetes mellitus promotes atherosclerosis. Such models have demonstrated that diabetes mellitus promotes formation of atherosclerotic lesions, progression of lesions into advanced hemorrhaged lesions, and that it prevents lesion regression. The proatherosclerotic effects of diabetes mellitus are driven in part by the altered function of myeloid cells. The protein S100A9 and the receptor for advanced glycation end-products are important modulators of the effect of diabetes mellitus on myelopoiesis, which might promote monocyte accumulation in lesions. Furthermore, myeloid cell expression of the enzyme acyl-CoA synthetase 1 (ACSL1), which converts long-chain fatty acids into their acyl-CoA derivatives, has emerged as causal to diabetes mellitus-induced lesion initiation. The protective effects of myeloid ACSL1-deficiency in diabetic mice, but not in nondiabetic mice, indicate that myeloid cells are activated by diabetes mellitus through mechanisms that play minor roles in the absence of diabetes mellitus. The roles of reactive oxygen species and insulin resistance in diabetes mellitus-accelerated atherosclerosis are also discussed, primarily in relation to endothelial cells. Translational studies addressing whether the mechanisms identified in mouse models are equally important in humans with diabetes mellitus will be paramount.

Identification of obesity and cardiovascular risk factors in childhood and adolescence

Obesity in the child and adolescent population is a growing problem. This article discusses the identification of obesity and overweight youth using body mass index and anthropometry and reviews literature to show the relationship between obesity and premature cardiovascular disease.

Association of diet and anthropometric measures as cardiovascular modifiable risk factors in young adults

Abstract Background: Cardiovascular accidents are the major cause of death in the developing world, accounting for nearly 40% of deaths in adult men and women. Developed countries have already brought this under control, whereas India has to take a giant leap. Diet plays a pivotal role among the various modifiable cardiovascular risk factors. The sole objective of this study is to point at nutrition as being the main modulator of different anthropometric parameters and directly or indirectly has a tremendous impact on the blood pressure levels even during young age. Methods: In a cross-sectional study involving 223 young adults, the pattern of food habits and level of physical activity were determined from self-reported questionnaires, while blood pressure, weight, height, waist circumference (WC), and hip circumference were measured, and body mass index (BMI) and waist-to-hip ratio (WHR) were computed. The subjects were grouped as normotensives and prehypertensives and also were compared according to their BMI and other parameters. Results: Statistically significant, greater association of weight followed by WC with the prehypertensive levels of blood pressure compared to other parameters was seen. The subjects detected as prehypertensives had predilection for salty, fried, oily, sweet, and fast food; BMI >25 kg/m2; and WC and WHR in high risk-categories per World Health Organization standards. More than 69% of subjects had high WHR, whereas only 9% of total subjects exercised regularly. Conclusions: Central obesity is associated with sedentary life and high intake of calories, leading to hypertension with advancing age. Early detection, awareness, and primary prevention would help reduce morbidity and mortality associated with cardiovascular diseases.

Overview of epidemiology and contribution of obesity to cardiovascular disease

The prevalence of obesity has increased worldwide and is a source of concern since the negative consequences of obesity start as early as in childhood. The most commonly used anthropometric tool to assess relative weight and classify obesity is the body mass index (BMI); BMI alone shows a U- or a J-shaped association with clinical outcomes and mortality. Such an inverse relationship fuels a controversy in the literature, named the 'obesity paradox', which associates better survival and fewer cardiovascular (CV) events in patients with elevated BMI afflicted with chronic diseases compared to non-obese patients. However, BMI cannot make the distinction between an elevated body weight due to high levels of lean vs. fat body mass. Generally, an excess of body fat (BF) is more frequently associated with metabolic abnormalities than a high level of lean body mass. Another explanation for the paradox is the absence of control for major individual differences in regional BF distribution. Adipose tissue is now considered as a key organ regarding the fate of excess dietary lipids, which may determine whether or not body homeostasis will be maintained (metabolically healthy obesity) or a state of inflammation/insulin resistance will be produced, with deleterious CV consequences. Obesity, particularly visceral obesity, also induces a variety of structural adaptations/alterations in CV structure/function. Adipose tissue can now be considered as an endocrine organ orchestrating crucial interactions with vital organs and tissues such as the brain, the liver, the skeletal muscle, the heart and blood vessels themselves. Thus, the evidence reviewed in this paper suggests that adipose tissue quality/function is as important, if not more so, than its amount in determining the overall health and CV risks of overweight/obesity.

Growing Right Onto Wellness (GROW): a family-centered, community-based obesity prevention randomized controlled trial for preschool child-parent pairs

Growing Right Onto Wellness (GROW) is a randomized controlled trial that tests the efficacy of a family-centered, community-based, behavioral intervention to prevent childhood obesity among preschool-aged children. Focusing on parent-child pairs, GROW utilizes a multi-level framework, which accounts for macro (i.e., built-environment) and micro (i.e., genetics) level systems that contribute to the childhood obesity epidemic. Six hundred parent-child pairs will be randomized to a 3-year healthy lifestyle intervention or a 3-year school readiness program. Eligible children are enrolled between ages 3 and 5, are from minority communities, and are not obese. The principal site for the GROW intervention is local community recreation centers and libraries. The primary outcome is childhood body mass index (BMI) trajectory at the end of the three-year study period. In addition to other anthropometric measurements, mediators and moderators of growth are considered, including genetics, accelerometry, and diet recall. GROW is a staged intensity intervention, consisting of intensive, maintenance, and sustainability phases. Throughout the study, parents build skills in nutrition, physical activity, and parenting, concurrently forming new social networks. Participants are taught goal-setting, self-monitoring, and problem solving techniques to facilitate sustainable behavior change. The GROW curriculum uses low health literacy communication and social media to communicate key health messages. The control arm is administered to both control and intervention participants. By conducting this trial in public community centers, and by implementing a family-centered approach to sustainable healthy childhood growth, we aim to develop an exportable community-based intervention to address the expanding public health crisis of pediatric obesity.

IMPACT: a multi-level family and school intervention targeting obesity in urban youth

IMPACT (Ideas Moving Parents and Adolescents to Change Together) is a 3-group randomized, multi-level trial comparing the efficacy of two distinct behavioral interventions and a control condition on body mass index (BMI) in middle school urban youth who are overweight/obese. Interventions include: (1) SystemCHANGE (SC), a promising new behavior change approach that focuses on system redesign of the family environment and daily routines; (2) HealthyCHANGE (HC), a cognitive-behavioral and Motivational Interviewing (MI)-consistent approach to behavior change that focuses on increasing intrinsic motivation, self-monitoring, goal setting, and problem solving; and (3) diet and physical education counseling (attention control). In addition, about half of the participants are enrolled in a K-8 public school that offers an innovative community-sponsored fitness program, augmented by study-supported navigators. In addition to the primary interventions effects, the study assesses the moderating effect of the school environment on BMI, blood pressure, cardiovascular risk factors, and quality of life. The sample consists of 360 children entering 6th grade from a large urban school district in the Midwest, identified through an existing BMI screening program. The intervention period is 36 months, and measures are obtained at baseline, 12, 24, and 36 months. Using intent-to-treat analyses across the 36-month intervention window, we hypothesize that both SC and HC will have a greater impact on BMI and other health outcomes compared to health education alone, and that the enriched school environment will enhance these effects. This manuscript describes IMPACT's study design and methods.

Prognostic value of multidetector computed tomography coronary angiography in diabetes: excellent long-term prognosis in patients with normal coronary arteries

OBJECTIVE

To assess the prognostic role of multidetector computed tomography coronary angiography (MDCT-CA) in patients with diabetes with suspected coronary artery disease (CAD). Use of MDCT-CA is increasing in patients with suspected CAD. However, data supporting its prognostic value in patients with diabetes are limited.

RESEARCH DESIGN AND METHODS

Between January 2006 and September 2007, 429 consecutive diabetic patients were prospectively studied with MDCT-CA for detecting the presence and assessing the extent of CAD (disease extension and coronary plaque scores). Patients were classified according to the presence of normal coronary arteries and nonobstructive (<50%) and obstructive (≥50%) coronary lesions. The composite rates of hard cardiac events (cardiac death, nonfatal myocardial infarction, unstable angina) and all cardiac events (including revascularization) were the end points of the study.

RESULTS

Twenty-four patients were excluded because MDCT-CA data were not able to be interpreted. Of the remaining 405 patients, clinical follow-up (mean 62 ± 9 months) was obtained in 390 (98%). Multivariate analysis showed that predictors of hard and all events were obstructive CAD, three-vessel CAD, and left main coronary artery (LMCA) disease. Cumulative event-free survival was 100% for hard and all events in patients with normal coronary arteries, 78% for hard events and 56% for all events in patients with nonobstructive CAD, and 60% for hard events and 16% for all events in patients with obstructive CAD. Three-vessel CAD and LMCA disease were associated with a higher rate of hard cardiac events.

CONCLUSIONS

MDCT-CA provides long-term prognostic information for patients with diabetes with suspected CAD, showing excellent prognosis when there is no evidence of atherosclerosis and allowing risk stratification when CAD is present.

Abdominal aortic atherosclerosis at MR imaging is associated with cardiovascular events: the Dallas heart study

PURPOSE

To determine the value of two abdominal aortic atherosclerosis measurements at magnetic resonance (MR) imaging for predicting future cardiovascular events.

MATERIALS AND METHODS

This study was approved by the institutional review board and complied with HIPAA regulations. The study consisted of 2122 participants from the multiethnic, population-based Dallas Heart Study who underwent abdominal aortic MR imaging at 1.5 T. Aortic atherosclerosis was measured by quantifying mean aortic wall thickness (MAWT) and aortic plaque burden. Participants were monitored for cardiovascular death, nonfatal cardiac events, and nonfatal extracardiac vascular events over a mean period of 7.8 years ± 1.5 (standard deviation [SD]). Cox proportional hazards regression was used to assess independent associations of aortic atherosclerosis and cardiovascular events.

RESULTS

Increasing MAWT was positively associated with male sex (odds ratio, 3.66; P < .0001), current smoking (odds ratio, 2.53; P < .0001), 10-year increase in age (odds ratio, 2.24; P < .0001), and hypertension (odds ratio, 1.66; P = .0001). A total of 143 participants (6.7%) experienced a cardiovascular event. MAWT conferred an increased risk for composite events (hazard ratio, 1.28 per 1 SD; P = .001). Aortic plaque was not associated with increased risk for composite events. Increasing MAWT and aortic plaque burden both conferred an increased risk for nonfatal extracardiac events (hazard ratio of 1.52 per 1 SD [P < .001] and hazard ratio of 1.46 per 1 SD [P = .03], respectively).

CONCLUSION

MR imaging measures of aortic atherosclerosis are predictive of future adverse cardiovascular events.

Lipid and inflammatory cardiovascular risk worsens over 3 years in youth with type 2 diabetes: the TODAY clinical trial

OBJECTIVE

Type 2 diabetes increases cardiovascular risk. We examined lipid profiles and inflammatory markers in 699 youth with recent-onset type 2 diabetes in the TODAY clinical trial and compared changes across treatment groups: metformin alone (M), metformin plus rosiglitazone (M+R), and metformin plus intensive lifestyle program (M+L).

RESEARCH DESIGN AND METHODS

Multiethnic youth with type 2 diabetes received M, M+R, or M+L. Statin drugs were begun for LDL cholesterol (LDL) ≥ 130 mg/dL or triglycerides ≥ 300 mg/dL. Lipids, apolipoprotein B (apoB), LDL particle size, high-sensitivity c-reactive protein (hsCRP), homocysteine, plasminogen activator inhibitor-1 (PAI-1), and HbA1c were measured over 36 months or until loss of glycemic control.

RESULTS

LDL, apoB, triglycerides, and non-HDL cholesterol (HDL) rose over 12 months and then stabilized over the next 24 months. Participants with LDL ≥ 130 mg/dL or using LDL-lowering therapy increased from 4.5 to 10.7% over 36 months, while 55.9% remained at LDL goal (<100 mg/dL) over that time. Treatment group did not impact LDL, apoB, or non-HDL. Small dense LDL (particle size, ≤ 0.263 relative flotation rate) was most common in M. Triglycerides were lower in M+L than M, and M+L attenuated the negative effect of hyperglycemia on triglycerides and HDL in females. hsCRP, PAI-1, and homocysteine increased over time. However, hsCRP was lower in M+R compared with M or M+L.

CONCLUSIONS

Dyslipidemia and chronic inflammation were common in youth with type 2 diabetes and worsened over time. Diabetes treatment, despite some treatment group differences in lipid and inflammatory marker change over time, is generally inadequate to control this worsening risk.

Prevalence of coronary atherosclerosis in asymptomatic healthy subjects: an intravascular ultrasound study of donor hearts

AIM

At present, limited in vivo information is available on the prevalence and severity of coronary atherosclerosis in asymptomatic healthy subjects. The aim of this study was to examine the prevalence, extent and severity of coronary atherosclerosis in healthy individuals.

METHODS

We performed an intravascular ultrasound (IVUS) examination on 198 heart transplant recipients 4 weeks after transplantation. The donor population consisted of 147 men and 51 women (31.4±11.0 years). The left anterior descending coronary artery was imaged in all patients, and 3 vessel images were obtained for 99 patients.

RESULTS

Angiographic appearance was completely normal in 177 of the 198 subjects (89.4%), while atherosclerotic luminal irregularities were observed in the remaining individuals. IVUS revealed that atherosclerotic lesions (defined as intimal thickness ≥0.5 mm at any site) were present in 96 patients (48.5%). The prevalence of coronary atherosclerosis rapidly increased with age (10-19 years, 5.9%; 20-29 years, 31.1%; 30-39 years, 59.0%; 40-49 years, 78.4%). In the diseased subgroup, atherosclerotic lesions were mostly eccentric (92.7%), with maximal intimal thickness of 0.99±0.42 mm (area stenosis, 32.2±11.7%). All coronary arteries were predominantly located in the proximal third of each vessel. Donor age, male sex, and hypertension were the determinants of coronary atherosclerosis measured by IVUS examination. As more risk factors were present, the risk of atherosclerosis increased.

CONCLUSION

Coronary atherosclerosis is common in asymptomatic young healthy adults, supporting the need for preventive cardiology in the early stages of life.

Atherogenic risk factors among preschool children in Crete, Greece

OBJECTIVE

To investigate the presence of atherogenic factors among preschool children of Crete, Greece.

MATERIALS AND METHODS

This was a cross-sectional study. The study population included 1189 children, aged four to seven years, examined from January to May 2005, in public kindergartens. Biochemical, anthropometric, and blood pressure measurements were performed.

RESULTS

Of the boys 27.4% were classified as overweight or obese (obese 10.8%). The respective percentage for girls was 28.5% (obese 9%); 7.4% percent of the boys and 7.9% of the girls had blood pressure above the ninety-fifth percentile. TC of > 200 mg / dl was found in 14.4% and LDL-C of > 130 mg / dl in 13.8% of the children. Children with serum TG of > 100 mg / dl had a significantly higher mean WC and BMI than those with triglyceride levels of ≤ 80 mg / dl (59.7 vs. 55.9 cm and 17.9 vs. 16.6 kg / m(2); P < 0.05). Similarly, children with HDL-C < 45 mg / dl had significantly higher WC and BMI than children with HDL-C ≥ 60 mg / dl (57.7 vs. 53.5 cm and 17.1 vs. 16.5 kg / m(2); P < 0.05). Obese children had an Odds Ratio of 2.87 (95% confidence interval, 1.05 - 7.85, P = 0.041) for hypertriglyceridemia, as compared to non-obese children.

CONCLUSION

Levels of obesity and especially central obesity were strongly related to other atherogenic risk factors in Cretan preschool children indicating the presence of this major public health problem in early ages.

The distinctive nature of atherosclerotic vascular disease in diabetes: pathophysiological and morphological insights

As the incidence of diabetes mellitus continues to rise, parallel increases in the rates of diabetic atherosclerotic vascular disease are projected to impart major health and socioeconomic challenges for authorities worldwide. Diabetes results in a proatherogenic phenotype, manifesting in an accelerated, diffuse, polyvascular fashion. In this review, we highlight the pathophysiological and morphological hallmarks of diabetic atherosclerosis.

A life course approach to cardiovascular disease prevention

During the past 2 decades, life-course social-ecological frameworks have emerged across health, developmental, social, behavioral, and public health disciplines as useful models for explaining how health trajectories develop over an individual's lifetime and how this knowledge can guide and inform new approaches to clinical and public health practice, multilevel policies, and research. Viewed from this perspective, and with emphasis on global cardiovascular health promotion and prevention of cardiovascular disease (CVD), this article summarizes evidence on the early origins and progression of CVD processes across the life course of individuals and diverse populations. Current evidence-based guidelines for CVD prevention are summarized, and recommendations for future research are suggested.

Cardiovascular disease in diabetes: where does glucose fit in?

CONTEXT

Recent prospective clinical trials have failed to confirm a unique benefit from normalization of glycemia on cardiovascular disease outcomes, despite evidence from basic vascular biology, epidemiological, and cohort studies.

EVIDENCE ACQUISITION

The literature was searched using the http://www.ncbi.nlm.nih.gov search engine including over 20 million citations on MEDLINE (1970 to present). Keyword searches included: atherosclerosis, cardiovascular, and glucose. Epidemiological, cohort, and interventional data on cardiovascular disease outcomes and glycemic control were reviewed along with analysis of recent reviews on this topic.

EVIDENCE SYNTHESIS

High glucose activates a proatherogenic phenotype in all cell types in the vessel wall including endothelial cells, vascular smooth muscle cells, inflammatory cells, fibroblasts, and platelets, leading to a feedforward atherogenic response. EPIDEMIOLOGICAL AND COHORT STUDIES: Epidemiological and cohort evidence indicates a clear and consistent correlation of glycemia with cardiovascular disease. A recent report of over 25,000 subjects with diabetes in the Swedish National Diabetes Registry verifies this relationship in contemporary practice. Interventional Studies: Prospective randomized interventions targeting a hemoglobin A1c of 6-6.5% for cardiovascular disease prevention failed to consistently decrease cardiovascular events or all-cause mortality.

CONCLUSIONS

Basic vascular biology data plus epidemiological and cohort evidence would predict that glucose control should impact cardiovascular events. Prospective clinical trials demonstrate that current strategies that improve blood glucose do not achieve this goal but suggest that a period of optimal control may confer long-term cardiovascular disease benefit. Clinicians should target a hemoglobin A1c of 7% for the prevention of microvascular complications, individualized to avoid hypoglycemia.

Histological changes and risk factor associations in type 2 atherosclerotic lesions (fatty streaks) in young adults

OBJECTIVES

The purpose of this study was to investigate which histological changes associated with risk factors could contribute to the progression from the initial atherosclerotic lesions including fatty streaks to the advanced lesions.

METHODS

We examined the associations of histomorphometric findings in the determined anatomical sites of mid-thoracic aortas (TAs) and left anterior descending coronary arteries (LADs) with major risk factors for atherosclerosis, using a young autopsied series from the the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study. The histological classification by the American Heart Association was graded for 1013 TAs and 1009 LADs. Histometric study, including immunohistochemistry, was performed in type 2 lesions (fatty streaks) of TAs from 59 subjects and LADs from 45 ones.

RESULTS

For the progression from the initial lesions into the advanced atherosclerotic lesions, the most effective lipid profiles were low plasma HDL-C in TA and elevated serum non-HDL-C in LAD. This lipid profile of each artery correlated with number or density of intimal smooth muscle cell-derived foam cells, respectively. The serum concentration of non-HDL-C correlated with macrophage foam cells in TAs. Hypertension and hyperglycemia were associated with increase of intimal area and/or collagen content in both arteries, but not with either types of foam cell proliferation. Smoking correlated with increased collagen content in TAs.

CONCLUSION

There were histologically different ways of progressing from fatty streaks to advanced atherosclerotic lesions depending on the risk factors. For the atherosclerosis progression from type 2 lesions to advanced lesions, increase in number of smooth muscle cell-derived foam cells could be an important indicator.