Twenty-Five Year Secular Trends in Lipids and Modifiable Risk Factors in a Population-Based Biracial Cohort: The Coronary Artery Risk Development in Young Adults (CARDIA) Study, 1985-2011

Trends in Prevalence of Hypertriglyceridemia and Related Factors in Korean Adults: A Serial Cross-Sectional Study

Objective

We aimed to investigate the longitudinal trends in prevalence of hypertriglyceridemia in Korean adults and hypertriglyceridemia-associated lifestyle habits, socioeconomic factors and comorbidities.

Methods

Data from the 2007-2020 Korea National Health and Nutrition Examination Survey (KNHANES) were used in this study. Two cutoff values (≥150 mg/dL and ≥200 mg/dL) for fasting serum triglyceride levels were used to estimate the age- and sex-specific prevalence of hypertriglyceridemia. Use of lipid-lowering medications, lifestyle factors such as smoking, alcohol consumption, and regular exercise, socioeconomic variables such as educational attainment and household income, and comorbidities such as obesity, abdominal obesity, hypertension, and diabetes mellitus were also investigated.

Results

The prevalence of hypertriglyceridemia among Koreans based on KNHANES 2007-2020 was 29.6% at ≥150 mg/dL and 16.1% at ≥200 mg/dL. While the rate of using lipid-lowering medications increased steadily from 2007 to 2020, changes in annual prevalence of hypertriglyceridemia were subtle. The prevalence of hypertriglyceridemia in men peaked in middle age (47.7% and 30.0% for ≥150 mg/dL and ≥200 mg/dL, respectively, in their 40s), but its prevalence in women increased throughout their lifetime (32.6% and 14.7% for ≥150 mg/dL and ≥200 mg/dL, respectively, in their 70s). Smoking and high-risk drinking exacerbated peak prevalence in both sexes. Young adults with any comorbidities had prominently increased prevalence of hypertriglyceridemia. The lowest levels of education and income were both associated with the higher prevalence of hypertriglyceridemia in both sexes.

Conclusion

It is important to understand the age- and sex-specific epidemiology of hypertriglyceridemia to establish its appropriate management plans.

Association Between Triglycerides and Incident Cognitive Impairment in Black and White Adults in the Reasons for Geographic and Racial Differences in Stroke Study

Background Elevated nonfasting triglycerides were associated with non-Alzheimer dementia in a recent study. However, this study neither evaluated the association of fasting triglycerides with incident cognitive impairment (ICI) nor adjusted for high-density lipoprotein cholesterol or hs-CRP (high-sensitivity C-reactive protein), known risk markers for ICI and dementia. Methods and Results We examined the association between fasting triglycerides and ICI among 16 170 participants in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study without cognitive impairment or a history of stroke at baseline in 2003 to 2007 and who had no stroke events during follow-up through September 2018. Overall, 1151 participants developed ICI during the median follow-up of 9.6 years. The relative risk for ICI associated with fasting triglycerides of ≥150 mg/dL versus <100 mg/dL including adjustment for age and geographic region of residence was 1.59 (95% CI, 1.20-2.11) among White women and 1.27 (95% CI, 1.00-1.62) among Black women. After multivariable adjustment, including adjustment for high-density lipoprotein cholesterol and hs-CRP, the relative risk for ICI associated with fasting triglycerides ≥150 mg/dL versus <100 mg/dL was 1.50 (95% CI, 1.09-2.06) among White women and 1.21 (95% CI, 0.93-1.57) among Black women. There was no evidence of an association between triglycerides and ICI among White or Black men. Conclusions Elevated fasting triglycerides were associated with ICI in White women after full adjustment including high-density lipoprotein cholesterol and hs-CRP. The current results suggest that the association between triglycerides and ICI is stronger in women than men.

Distribution of lipid levels and prevalence of hyperlipidemia: data from the NHANES 2007-2018

Background

Lipid-lowering therapy is important, and the distribution of lipid levels and the incidence of hyperlipidemia may vary in different subgroups of the population. We aimed to explore the distribution of lipid levels and the prevalence of hyperlipidemia in subpopulations with subgroup factors, including age, sex, race, and smoking status.

Methods

Our study used data from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2018, ultimately enrolling and analyzing 15,499 participants. A cross-sectional analysis was performed to assess the distribution of lipids and prevalence of hyperlipidemia in subpopulations, and multifactorial logistic regression analyses were performed for the prevalence of hyperlipidemia, adjusted for age, sex, race and smoking status.

Results

Blacks had significantly lower mean serum total cholesterol and triglycerides and higher serum high-density lipoprotein cholesterol (HDL-C) than whites (P < 0.001). In contrast, Mexican Americans had markedly higher mean serum triglycerides and lower serum HDL-C than whites (P < 0.001). Furthermore, the prevalence of hypercholesterolemia and hypertriglyceridemia was lower in blacks than in whites (P = 0.003 and P < 0.001, respectively), while the prevalence of hypertriglyceridemia was significantly higher in Mexican Americans than in whites (P = 0.002). In addition, total cholesterol and triglyceride levels were significantly higher in women aged 65 years or older and markedly higher than in men in the same age group (P < 0.001). In addition, overall mean total cholesterol, triglyceride, and low-density lipoprotein cholesterol (LDL-C) levels were higher in smokers than in nonsmokers (P = 0.01, P < 0.001, and P = 0.005, respectively).

Conclusion

Based on NHANES data, the mean lipid levels and prevalence of hyperlipidemia differed by sex, age, race, and smoking status.

Plasma lipid profiles in early adulthood are associated with epigenetic aging in the Coronary Artery Risk Development in Young Adults (CARDIA) Study

Background

GrimAge acceleration (GAA), an epigenetic marker that represents physiologic aging, is associated with atherosclerotic cardiovascular disease. However, the associations between early adulthood lipid levels and GAA in midlife are unknown. Also, it is unknown whether GAA mediates the associations between lipid levels in young adults and subclinical atherosclerosis in midlife.

Results

We estimated measures of epigenetic age acceleration in 1118 White and Black participants from the Coronary Artery Risk Development in Young Adults (CARDIA) Study at examination years (Y) 15 and 20. We used multivariable regression models to examine associations of Y15 and Y20 GAA estimates with plasma lipid levels measured at prior examination years (Y0, Y5, and Y10) and concurrently: triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) levels. Mediation analysis was used to assess the extent to which GAA may mediate associations between plasma lipids and coronary artery calcification (CAC). In our study each 1-SD higher cumulative TG level was associated with an average 0.73 ± 0.12 years older GAA. Each 1-SD higher cumulative HDL-C level was associated with an average 0.57 ± 0.17 years younger GAA. Stratified analyses showed that the associations between TG and GAA were stronger among female and Black participants and the associations between HDL-C and GAA were stronger among female and White participants. GAA statistically mediated 17.4% of the association of cumulative TG with CAC.

Conclusions

High TG and low HDL-C in early adulthood are associated with accelerated epigenetic aging by midlife. Increased epigenetic age acceleration may partially mediate the associations between high TG levels and the presence of subclinical atherosclerosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13148-021-01222-2.

Trends in Nutritional Biomarkers by Demographic Characteristics Across 14 Years Among US Adults

Background: Understanding trend in nutritional status is crucial to inform national health priorities to improve diets and reduce related diseases. The present study aimed to analyze trends in the concentrations of all measured nutritional biomarkers and their status among US adults across 14 years.

Methods: Trends on the concentrations of nutritional biomarkers and nutritional status evaluated by the prevalence of deficiency, inadequacy, excess, and dyslipidemia were analyzed among US adults in 7 cross-sectional National Health and Nutrition Examination Surveys (NHANES 2003–2016) and by age, sex, race/ethnicity, and socioeconomic status.

Results: A total of 38,505 participants (weighted mean age of 47.2 years, 51.4% women) were included in the present study. Across 14 years, increased trends were found in red blood cell (RBC) folate, serum vitamin B₁₂, vitamin D and albumin, the prevalence of iodine deficiency, vitamin B₆ inadequacy, and hypophosphatemia, whereas decreased trends were observed in serum vitamin E, phosphorus, total calcium, total protein, apolipoprotein B (Apo B), low-density-lipoprotein cholesterol (LDL-C), triglyceride (TG), total cholesterol (TC), blood lead, cadmium, mercury, and the prevalence of vitamin C deficiency, vitamin D inadequacy, iodine excess, and dyslipidemia with elevated LDL-C, TC, TG, and lowered HDL/LDL. Non-Hispanic blacks (NHB) and participants with low socioeconomic status were accounted for the poor nutritional status of most biomarkers compared to their comparts.

Conclusion: Most nutritional biomarkers and their status were improved among US adults from 2003 to 2016, but some specific populations should be paid much attention to improve their nutritional status, especially for NHB and participants with low socioeconomic status.

Magnesium intake is inversely associated with risk of non-alcoholic fatty liver disease among American adults

PURPOSE

Human data are limited linking magnesium (Mg) intake to the risk of non-alcoholic fatty liver disease (NAFLD). We aimed to examine the association between Mg intake and the risk of NAFLD among young adults in the US with a 25-year follow-up.

METHODS

This study included 2685 participants from the Coronary Artery Risk Development in Young Adult (CARDIA) study. Diet and dietary supplements were assessed at baseline (1985-1986) and exam years 7 and 20 using an interview-based dietary history. NAFLD, defined as liver attenuation ≤ 51 Hounsfield Units excluding secondary causes of liver fat accumulation, was identified by non-contrast-computed tomography scanning at exam year 25. Multivariable-adjusted logistic regression model was used to examine the associations between cumulative average total intake of Mg (dietary plus supplemental) and NAFLD odds.

RESULTS

A total of 629 NAFLD cases were documented. After adjustment for potential confounders, an inverse association between total Mg intake and NAFLD odds was observed. Compared to participants in the lowest quintile of total Mg intake, the odds of NAFLD was 55% lower among individuals in the highest quintile [multivariable-adjusted odds ratio (OR) = 0.45, 95% confidence interval (CI) (0.23, 0.85), p for trend = 0.03]. Consistently, whole-grain consumption, a major dietary source of Mg, was inversely associated with NAFLD odds (p for trend = 0.02).

CONCLUSIONS

This study suggests that higher cumulative intake of Mg throughout adulthood is associated with lower odds of NAFLD in midlife. Future studies are needed to establish a possible causal relationship.

Secular changes in mid-adulthood body mass index, waist circumference, and low HDL cholesterol between 1990, 2003, and 2018 in Great Britain

Objective

To investigate the extent to which 1) secular changes in mid-adulthood WC are independent of BMI and 2) secular changes in low HDL-C are dependent on WC in each sex.

Methods

The sample comprised 19,406 adults (aged 43-47 years) from three birth cohort studies with BMI and WC measured in 1990, 2003, or 2018; 13,239 participants additionally had HDL-C measured in 2003 or 2018. Quantile regression was used to model differences between 1990-2003 and 2003-2018 in 1) BMI and WC internal Z-scores and 2) WC in cm before and after adjustment for BMI. Binary logistic regression was used to model differences between 2003-2018 in low HDL-C, before and after adjustment for BMI or WC.

Results

Secular increases in BMI and WC were larger between 1990-2003 than 2003-2018 and at the upper ends of the distributions. At the 85^th quantile, effect sizes were larger for WC than BMI Z-scores in females but not males. Adjustment for BMI attenuated estimates of secular increases in WC in cm more in males than females. Odds ratios for low HDL-C in 2018 compared to 2003 were 1.73 (95% CI 1.32, 2.28) in males and 1.34 (1.01, 1.78) in females. Adjustment for WC did not substantially change the estimate in males but attenuated the estimate for females to 1.09 (0.81, 1.47).

Conclusions

In women much more so than in men, secular increases in mid-adulthood WC appear to have occurred independently of BMI and largely explain the observed rise in low HDL-C prevalence between 2003-2018.

Associations of Accelerometer-Measured Sedentary Time and Physical Activity With Prospectively Assessed Cardiometabolic Risk Factors: The CARDIA Study

Background

Isotemporal substitution examines the effect on health outcomes of replacing sedentary time with light‐intensity physical activity or moderate‐to‐vigorous intensity physical activity; however, existing studies are limited by cross‐sectional study designs.

Methods and Results

Participants were 1922 adults from the CARDIA (Coronary Artery Risk Development in Young Adults) study. Linear regression examined the associations of sedentary, light‐intensity physical activity, and moderate‐to‐vigorous intensity physical activity at year 20 (2005–2006) with waist circumference, blood pressure, glucose, insulin, triglycerides, high‐density lipoprotein cholesterol, and a composite risk score at year 30 (2015–2016). Models then examined change in activity with change in cardiometabolic risk over the same 10‐year period. Replacing 30 min/day of sedentary time with 30 min/day of light‐intensity physical activity at year 20 was associated with a lower composite risk score (−0.01 SD [95% CI, −0.02, −0.00]) at year 30, characterized by lower waist circumference (0.15 cm [95% CI, −0.27, 0.02]), insulin (0.20 μU/mL [95% CI, −0.35, −0.04]), and higher high‐density lipoprotein cholesterol (0.20 mg/dL [95% CI, 0.00, 0.40]; all P<0.05). An increase of 30 min/day in MVPA from year 20 to year 30, when replacing an equivalent increase in sedentary time, was associated with a decrease in the composite risk score (−0.08 [95% CI, −0.13, −0.04]) over the same 10 years, characterized by a decrease in waist circumference (1.52 cm [95% CI, −2.21, −0.84]), insulin (−1.13 μU/mL [95% CI, −1.95, −0.31]), triglycerides (−6.92 mg/dL [95% CI, −11.69, −2.15]), and an increase in high‐density lipoprotein cholesterol (1.59 mg/dL [95% CI, 0.45, 2.73]; all P<0.05).

Conclusions

Replacement of sedentary time with light‐intensity physical activity or moderate‐to‐vigorous intensity physical activity is associated with improved cardiometabolic health 10 years later.

Atherosclerosis

Atherosclerosis, the formation of fibrofatty lesions in the artery wall, causes much morbidity and mortality worldwide, including most myocardial infarctions and many strokes, as well as disabling peripheral artery disease. Development of atherosclerotic lesions probably requires low-density lipoprotein, a particle that carries cholesterol through the blood. Other risk factors for atherosclerosis and its thrombotic complications include hypertension, cigarette smoking and diabetes mellitus. Increasing evidence also points to a role of the immune system, as emerging risk factors include inflammation and clonal haematopoiesis. Studies of the cell and molecular biology of atherogenesis have provided considerable insight into the mechanisms that link all these risk factors to atheroma development and the clinical manifestations of this disease. An array of diagnostic techniques, both invasive (such as selective coronary arteriography) and noninvasive (such as blood biomarkers, stress testing, CT and nuclear scanning), permit assessment of cardiovascular disease risk and targeting of therapies. An expanding armamentarium of therapies that can modify risk factors and confer clinical benefit is available; however, we face considerable challenge in providing equitable access to these treatments and in maximizing adherence. Yet, the clinical application of the fruits of research has advanced preventive strategies, enhanced clinical outcomes in affected individuals, and improved their quality of life. Rapidly accelerating knowledge and continued research promise to provide further progress in combating this common chronic disease.

Trend of lipid and thyroid function tests in adults without overt thyroid diseases: A cohort from Tehran thyroid study

CONTEXT

While the role of overt hypothyroidism in lipid disorders is clear, the association between dyslipidemia and subclinical thyroid diseases remains unclarified.

OBJECTIVE

To examine lipid trends based on thyroid function over a 10-year period.

DESIGN

This is a prospective population based cohort study.

SETTING

General community.

PARTICIPANTS

2383 euthyroid participants, as well as those with subclinical thyroid diseases, in all residents of district 13 of Tehran were examined. Subjects who were on levothyroxine, anti-hyperthyroid drugs, and glucocorticoids, those with a history of thyroid surgery or RAI and pregnant women were excluded.

MAIN OUTCOME MEASURES

Lipid trends in Model 1 were adjusted for age and follow up duration, and in Model 2 gender-specific multivariate adjustments were performed for thyroid status, diabetes mellitus, smoking status, education, BMI, lipid lowering medications, age and follow up duration by using generalized estimating equations.

RESULTS

In every four years of assessments, there were significant decreases in levels of all lipid parameters (all Ps <0.001) except for HDL-C, in which a decrescendo-crescendo trend was observed. The results did not change after adjusting for thyroid status, consumption of lipid lowering drugs during the follow-up period, or other variables. There were significant decreases in the prevalence of hypercholesterolemia and hypertriglyceridemia (all Ps <0.001) during the follow-up period.

CONCLUSION

During a 10 year follow-up, decrescendo trends were observed in levels of total cholesterol, triglycerides, which were not be accounted for by the consumption of lipid lowering drugs and thyroid status.

Racial and sex differences in biological and chronological heart age in the Coronary Artery Risk Development in Young Adults study

PURPOSE

Calculation of a biological heart age offers an alternative to absolute risk for characterizing cardiovascular risk by describing risk relative to an individual with normal health. We examined risk factors contributing to differences between biological and chronological heart age in young adults.

METHODS

The Coronary Artery Risk Development in Young Adults study included 2264 Black and White men and women who attended examination years 10 through 25. We estimated biological heart age using the nonlaboratory-based Framingham 10-year cardiovascular disease risk calculator. Trends in risk factors were examined cross-sectionally and longitudinally.

RESULTS

Biological heart ages for Black participants were 5.6 years older than their chronological ages over 15 years (P < .001). In longitudinal analyses, urinary albumin-creatinine ratio and alcohol intake were statistically significantly related to higher biological compared with chronological heart age, whereas physical activity and education were statistically significantly related to negative heart age differences (P < .001). Trends were similar in cross-sectional analyses at all time points.

CONCLUSIONS

Most risk factors driving biological heart age, including race, education, physical activity, and urinary albumin-creatinine ratio, contributed to heart age differences cross-sectionally and longitudinally suggesting that risk factors related to adverse biological aging are important at younger and older ages.

Novel Antiatherosclerotic Therapies

Many measures can control lipid risk factors for atherosclerosis. Yet, even with excellent control of dyslipidemia, other sources of risk remain. Hence, we must look beyond lipids to address residual risk. Lifestyle measures should form the foundation of cardiovascular risk control. Many pharmacological interventions targeting oxidation have proven disappointing. A large program tested inhibition of a LpPLA2 (lipoprotein-associated phospholipase A2), culminating in 2 large-scale clinical trials that did not meet their primary end points. A variety of antioxidants have not shown benefit in clinical trials. Numerous laboratory and clinical studies have inculpated inflammatory pathways in the pathogenesis of atherosclerotic events. The p38 MAPK (mitogen-activated protein kinase) inhibitor losmapimod and an inhibitor of a leukocyte adhesion molecule, P-selectin, did not alter adverse events in trials. Low-dose methotrexate, despite the promising observational studies, did not lower biomarkers of inflammation or alter cardiovascular outcomes in the CIRT (cardiovascular inflammation reduction trial). Four large-scale investigations underway will determine colchicine's ability to reduce recurrent events in secondary prevention. The CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcomes Study) showed that an antibody that neutralizes IL (interleukin)-1β can reduce recurrent cardiovascular events in secondary prevention. The success of CANTOS points to the pathway that leads from the NLRP3 (NOD-like receptor family, pyrin domain-containing protein 3) inflammasome through IL-1β to IL-6 as an attractive target for further study and clinical development beyond lipid therapies to address the unacceptable burden of risk that remains despite our best current care in secondary prevention.

Reassessing the Mechanisms of Acute Coronary Syndromes

The mechanisms that underlie superficial erosion, a cause of coronary thrombosis distinct from plaque rupture, have garnered recent interest. In an era of improved control of traditional risk factors, such as LDL (low-density lipoprotein), plaque erosion may assume greater clinical importance. Plaques complicated by erosion tend to be matrix-rich, lipid-poor, and usually lack prominent macrophage collections, unlike plaques that rupture, which characteristically have thin fibrous caps, large lipid pools, and abundant foam cells. Thrombi that complicate superficial erosion seem more platelet-rich than the fibrinous clots precipitated by plaque rupture. The pathogenesis of plaque rupture probably does not pertain to superficial erosion, a process heretofore little understood mechanistically. We review here data that support a substantial shift in the mechanisms of the thrombotic complications of atherosclerosis. We further consider pathophysiologic processes recently implicated in the mechanisms of erosion. Multiple processes likely predispose plaques to superficial erosion, including experiencing disturbed flow, basement membrane breakdown, endothelial cell death, and detachment potentiated by innate immune activation mediated through pattern-recognition receptors and endothelial-to-mesenchymal transition. Monocytes/macrophages predominate in the pathogenesis of plaque rupture and consequent thrombosis, but polymorphonuclear leukocytes likely promote endothelial damage during superficial erosion. The formation of neutrophil extracellular traps probably perpetuates and propagates intimal injury and potentiates thrombosis due to superficial erosion. These considerations have profound clinical implications. Acute coronary syndromes because of erosion may not require immediate invasive therapy. Understanding the biological bases of erosion points to novel therapies for acute coronary syndrome caused by erosion. Future research should probe further the mechanisms of superficial erosion, and develop point-of-care tests to distinguish acute coronary syndromes provoked by erosion versus rupture that may direct more precision management. Future clinical investigations should evaluate intervening on the targets that have emerged from experimental studies and the management strategies that they inform.