Cumulative Exposure to Ideal Cardiovascular Health and Incident Diabetes in a Chinese Population: The Kailuan Study

Association between ideal cardiovascular health and abnormal glucose metabolism in the elderly: evidence based on real-world data

BACKGROUND

Limited information is available on the effect of ideal cardiovascular health (CVH) and abnormal glucose metabolism in elderly people. We aimed to analyze the prevalence of CVH behaviors, abnormal glucose metabolism, and their correlation in 65 and older people.

METHODS

In this study, randomized cluster sampling, multivariate logistic regression, and mediating effects analysis were used. Recruiting was carried out between January 2020 and December 2020, and 1984 participants aged 65 years or older completed the study.

RESULTS

The prevalence of abnormal glucose metabolism in this group was 26.7% (n = 529), among which the prevalence of impaired fasting glucose (IFG) was 9.5% (male vs. female: 8.7% vs 10.1%, P = 0.338), and the prevalence of type 2 diabetes mellitus (T2DM) was 19.0% (male vs. female: 17.8 vs. 19.8%, P = 0.256). The ideal CVH rate (number of ideal CVH metrics ≥ 5) was only 21.0%. The risk of IFG and T2DM decreased by 23% and 20% with each increase in one ideal CVH metrics, with OR (95%CI) of 0.77(0.65-0.92) and 0.80(0.71-0.90), respectively (P -trend < 0.001). TyG fully mediated the ideal CVH and the incidence of T2DM, and its mediating effect OR (95%CI) was 0.88(0.84-0.91).

CONCLUSIONS

Each increase in an ideal CVH measure may effectively reduce the risk of abnormal glucose metabolism by more than 20%.

Changes in Life's Essential 8 and risk of cardiovascular disease in Chinese people

BACKGROUND

The American Heart Association recently released an updated algorithm for evaluating cardiovascular health-Life's Essential 8 (LE8). However, the associations between changes in LE8 score over time and risk of cardiovascular disease (CVD) remain unclear.

METHODS

We investigated associations between 6-year changes (2006-12) in LE8 score and risk of subsequent CVD events (2012-20) among 53 363 Chinese men and women from the Kailuan Study, who were free from CVD in 2012. The LE8 score was calculated based on eight components: diet quality, physical activity, smoking status, sleep health, body mass index, blood lipids, blood glucose and blood pressure. Multivariable-adjusted Cox proportional-hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

We documented 4281 incident CVD cases during a median of 7.7 years of follow-up. Compared with participants whose LE8 scores remained stable in a 6-year period, those with the large increases of LE8 score over the 6-year period had a lower risk of CVD, heart disease and stroke in the subsequent 8 years [HRs and 95% CIs: 0.67 (0.64, 0.70) for CVD, 0.65 (0.61, 0.69) for heart disease, 0.71 (0.67, 0.76) for stroke, all Ptrend < 0.001]. Conversely, those with the large decreases of LE8 score had 47%, 51% and 41% higher risk for CVD, heart disease and stroke, respectively. These associations were consistent across the subgroups stratified by risk factors.

CONCLUSIONS

Improving LE8 score in a short- and moderate-term was associated with a lower CVD risk, whereas decreased LE8 score over time was associated with a higher risk.

Association of Cumulative Exposure to Cardiovascular Health Behaviors and Factors with the Onset and Progression of Arterial Stiffness

AIM

This study aims to explore the association of cumulative exposure to cardiovascular health behaviors and factors with the onset and progression of arterial stiffness.

METHODS

In this study, 24,110 participants were examined from the Kailuan cohort, of which 11,527 had undergone at least two brachial-ankle pulse wave velocity (baPWV) measurements. The cumulative exposure to cardiovascular health behaviors and factors (cumCVH) was calculated as the sum of the cumCVH scores between two consecutive physical examinations, multiplied by the time interval between the two. A logistic regression model was constructed to evaluate the association of cumCVH with arterial stiffness. Generalized linear regression models were used to analyze how cumCVH affects baPWV progression. Moreover, a Cox proportional hazards regression model was used to analyze the effect of cumCVH on the risk of arterial stiffness.

RESULTS

In this study, participants were divided into four groups, according to quartiles of cumCVH exposure levels, namely, quartile 1 (Q1), quartile 2 (Q2), quartile 3 (Q3), and quartile 4 (Q4). Logistic regression analysis showed that compared with the Q1 group, the incidence of arterial stiffness in terms of cumCVH among Q2, Q3, and Q4 groups decreased by 16%, 30%, and 39%, respectively. The results of generalized linear regression showed that compared with the Q1 group, the incidence of arterial stiffness in the Q3 and Q4 groups increased by -25.54 and -29.83, respectively. The results of Cox proportional hazards regression showed that compared with the Q1 group, the incidence of arterial stiffness in cumCVH among Q2, Q3, and Q4 groups decreased by 11%, 19%, and 22%, respectively. Sensitivity analyses showed consistency with the main results.

CONCLUSIONS

High cumCVH can delay the progression of arterial stiffness and reduce the risk of developing arterial stiffness.

Longitudinal cardiovascular health measured by life's essential 8 metrics with incident diabetes: A 13-year prospective cohort study

AIMS

To investigate the associations of baseline and longitudinal cardiovascular health (CVH) measured by 'Life's Essential 8' (LE8) metrics with the risk of diabetes in Chinese people with normoglycaemia or prediabetes.

MATERIALS AND METHODS

A total 86,149 participants without diabetes were enroled from the Kailuan study and were stratified by baseline glycaemic status (normoglycaemia or prediabetes). Cardiovascular health score ranged from 0 to 100 points was categorised into low (0-49), middle (50-79), and high (80-100) CVH status. Cox regressions were used to assess the associations of baseline and time-updated CVH status with incident diabetes in the overall cohort and across baseline glycaemic statuses.

RESULTS

During a median follow-up of 12.94 (interquartile rage: 12.48-13.16) years, we identified 13,097 (15.20%) cases of incident diabetes. Baseline and time-updated high CVH status was associated with a lower risk of diabetes, the corresponding hazard ratio (HR) versus low CVH status was 0.27 (95% confidence interval [CI], 0.23-0.31) and 0.26 (95% CI, 0.23-0.30) in the overall cohort, respectively. Additionally, the effect of high CVH on diabetes was more prominent in participants with normoglycaemia than those with prediabetes (P < 0.0001), with an HR of 0.26 (95% CI, 0.22-0.31) versus 0.50 (95% CI, 0.41-0.62) for baseline CVH, and 0.25 (95% CI, 0.21-0.30) versus 0.39 (95% CI, 0.32-0.48) for time-updated CVH.

CONCLUSIONS

Elevated baseline and longitudinal CVH score assessed by LE8 metrics is associated with a lower risk of subsequent diabetes, especially in normoglycaemic adults.

Association of ideal cardiovascular health metrics with incident low estimated glomerular filtration rate: More than a decade follow-up in the Tehran Lipid and Glucose Study (TLGS)

AIMS

To evaluate the association between ideal cardiovascular health metrics (ICVHM) and incident low estimated glomerular filtration rate (eGFR) among the Iranian population.

METHODS

The study population included 6927 Iranian adults aged 20-65 years (2942 male) without prevalent low eGFR [i.e., eGFR < 60 ml/min/1.73 m2] and free of cardiovascular disease. The ICVHM was defined according to the 2010 American Heart Association. The multivariable Cox proportional hazards regression analysis was used to calculate the hazard ratios (HRs) of ICVHM both as continuous and categorical variables.

RESULTS

Over the median of 12.1 years of follow-up, we found 1259 incident cases of low eGFR among the study population. In this population, ideal and intermediate categories of body mass index (BMI) and blood pressure (BP) and only the ideal category of fasting plasma glucose (FPG) significantly decreased the risk of developing low eGFR; the corresponding HRs and (95% confidence intervals) were (0.87, 0.77-0.99), (0.84, 0.76-0.99), (0.79, 0.68-0.93), (0.70, 0.60-0.83) and (0.76, 0.64-0.91). Also, one additional ICVHM was associated with a reduced risk of low eGFR for the global (0.92, 0.88-0.97) and biological cardiovascular health (0.88, 0.82-0.93) in these participants. A sensitivity analysis using the interval-censoring approach demonstrated that our method is robust, and results remained essentially unchanged. In a subgroup population with dietary data (n = 2285), we did not find the beneficial impact of having intermediate/ideal categories of nutrition status compared to its poor one on incident low eGFR.

CONCLUSION

We found a strong inverse association between having higher global ICVHM with incident low eGFR among the non-elderly Iranian population; the issue is mainly attributable to normal BP, BMI, and FPG levels.

Not only baseline but cumulative exposure of remnant cholesterol predicts the development of nonalcoholic fatty liver disease: a cohort study

BACKGROUND AND AIM

Remnant cholesterol (remnant-C) mediates the progression of major adverse cardiovascular events. It is unclear whether remnant-C, and particularly cumulative exposure to remnant-C, is associated with nonalcoholic fatty liver disease (NAFLD). This study aimed to explore whether remnant-C, not only baseline but cumulative exposure, can be used to independently evaluate the risk of NAFLD.

METHODS

This study included 1 cohort totaling 21,958 subjects without NAFLD at baseline who underwent at least 2 repeated health checkups and 1 sub-cohort totaling 2,649 subjects restricted to those individuals with at least 4 examinations and no history of NAFLD until Exam 3. Cumulative remnant-C was calculated as a timeweighted model for each examination multiplied by the time between the 2 examinations divided the whole duration. Cox regression models were performed to estimate the association between baseline and cumulative exposure to remnant-C and incident NAFLD.

RESULTS

After multivariable adjustment, compared with the quintile 1 of baseline remnant-C, individuals with higher quintiles demonstrated significantly higher risks for NAFLD (hazard ratio [HR] 1.48, 95%CI 1.31-1.67 for quintile 2; HR 2.07, 95%CI 1.85-2.33 for quintile 3; HR 2.55, 95%CI 2.27-2.88 for quintile 4). Similarly, high cumulative remnant-C quintiles were significantly associated with higher risks for NAFLD (HR 3.43, 95%CI 1.95-6.05 for quintile 2; HR 4.25, 95%CI 2.44-7.40 for quintile 3; HR 6.29, 95%CI 3.59-10.99 for quintile 4), compared with the quintile 1.

CONCLUSION

Elevated levels of baseline and cumulative remnant-C were independently associated with incident NAFLD. Monitoring immediate levels and longitudinal trends of remnant-C may need to be emphasized in adults as part of NAFLD prevention strategy.

Relationship between ideal cardiovascular health score and perioperative acute kidney injury: A case-control study

BACKGROUND

Maintaining ideal cardiovascular health scores (CHS) may indirectly contribute to reducing the risk of perioperative acute kidney injury (AKI), which has never been explored previously. In this study, we aimed to explore the relationship between CHS and AKI and provide new ideas for AKI prevention and treatment.

METHODS

We examined the effects of CHS on the occurrence of AKI among 2783 participants from the Kailuan study, who received general anesthesia during noncardiac surgery from 2016 to 2020. The odds ratios (ORs) and 95% confidence intervals (95% CIs) for AKI were calculated by using the logistic regression.

RESULTS

Among 2783 participants 187 were diagnosed with perioperative AKI. We found an inverse relationship between the CHS scores and the risk of AKI. Participants with CHS score ≥ 10 had 57% decreased risk of AKI (OR = 0.43, 95% CI = 0.23, 0.79), compared with participants with CHS score ≤ 7, especially in men (OR = 0.39, 95% CI: 0.20, 0.76). In addition, participants who never smoked, exercised frequently, and had normal blood pressure had decreased risk of AKI, with corresponding ORs (95% CIs) of 0.66 (0.47, 0.91), 0.73 (0.60, 0.92), and 0.46 (0.28, 0.75), respectively.

CONCLUSIONS

CHS was strongly associated with the risk of perioperative AKI, and higher CHS scores were associated with a lower risk of AKI. Further research is needed to explore the long-term effects of achieving and maintaining an ideal CHS on AKI risk.

Baseline and longitudinal cardiovascular health using Life's Essential 8 metrics with the risk of incident hypertension

OBJECTIVE

The quantification of cardiovascular health (CVH) was updated by the American Heart Association recently by using the "Life's Essential 8" (LE8) score. We aimed to investigate the associations of baseline and longitudinal CVH status measured by the new LE8 score (except for blood pressure) with the risk of hypertension.

METHODS

A total of 52 990 participants with complete data on LE8 metrics and without hypertension were enrolled from the Kailuan study, Tangshan, China. The associations of incident hypertension with the overall baseline, time-updated, and time-varying CVH score (ranging 0 [lowest] to 100 [highest]), and each component of LE8, were assessed by Cox regressions.

RESULTS

During a median follow-up of 10.73 years 28 380 cases of incident hypertension were identified. The risk of hypertension attenuated with increased CVH score (Ptrend < 0.0001), the hazard ratios (HRs) in high CVH versus low CVH group was 0.54 (95% confidence interval [CI], 0.51-0.57) for baseline CVH, 0.47 (95% CI, 0.45-0.50) for time-updated CVH, and 0.59 (95% CI, 0.55-0.63) for time-varying CVH. The predictive value of CVH in predicting hypertension improved by using LE8 than using Life's Simple 7 metrics. Among LE8 components, body mass index score was the strongest risk factor for hypertension. Subgroup analyses showed that the benefit of a higher CVH score on hypertension was more prominent in young adults and in women (Pinteraction < 0.05).

CONCLUSIONS

A higher CVH score assessed by new LE8 is associated with a lower risk of subsequent hypertension, especially young adults and women.

Ideal cardiovascular health metrics and risk of type 2 diabetes: A systematic review and dose-response meta-analysis of prospective cohort studies

BACKGROUND AND AIMS

Studies suggest a potential link between ideal cardiovascular health (CVH) and the risk of type 2 diabetes (T2D). However, systematic reviews are lacking to pool these data and present a balanced review about this association.

METHODS AND RESULTS

We performed a systematic search of PubMed/Medline, Web of Sciences, and Scopus from inception until November 2022 to search for prospective observational studies assessing the link between ideal CVH metrics, as introduced by the American Heart Association, and the risk of T2D in adults. Nine cohort studies with 78,912 participants and 6242 cases of T2D were included. The pooled relative risk of T2D for the highest versus the lowest category of ideal CVH metrics was 0.36 (95% confidence interval [CI]: 0.25, 0.47; risk difference: 5 fewer per 100 patients, 95% CI: 6 fewer, 4 fewer; Grading of Recommendations Assessment, Development and Evaluation certainty = high). Each unit increase in the components of the ideal CVH metrics was associated with a 20% lower risk of T2D. Dose-response meta-analysis indicated a monotonic inverse association between ideal CVH metrics and the risk of T2D. Results from analysis of individual components showed that having a normal weight, adopting a healthy diet, and having normal blood pressure levels were associated with a reduced risk of T2D.

CONCLUSIONS

Having an ideal CVH profile and a unit increase in any CVH metric are inversely associated with the risk of T2D.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022376934.

Better Life's Essential 8 Is Associated With Lower Risk of Diabetic Kidney Disease: A Community-Based Study

Background Diabetic kidney disease (DKD) is a common diabetic complication and increases the complexity of diabetes management. No prospective study has focused on the association between DKD and Life's Essential 8 (LE8). Our study aims to examine the association between LE8 and DKD risk. Methods and Results A total of 7605 participants, aged 54.32±9.77 years, and 4688 participants, aged 56.11±10.38 years, were included in the longitudinal and trajectory analyses, respectively, from 2006 to 2020. The DKD was confirmed using data collected during each follow-up. LE8 was based on 4 health behaviors and 4 health factors. The range of each metric was 0 to 100, and the overall LE8 score was calculated as the unweighted average of all 8 component metric scores. The trajectories of LE8 during 2006 to 2010 were classified using latent mixture models. Cox models and restricted cubic splines were applied. After a median follow-up of 12.41 and 6.71 years in longitudinal and trajectory analyses, respectively, the DKD incidence decreased, with the LE8 level increasing (P-trend<0.05), and the linearity assumption for this relationship (P-nonlinear=0.685) had been satisfied. Adjusted hazard ratios (HRs) for the highest tertile were 0.77 (95% CI, 0.69-0.87) and 0.70 (95% CI, 0.62-0.78) in baseline and time-updated LE8 scores, respectively, compared with the lowest tertile. Adjusted HR was 0.53 (95% CI, 0.41-0.69) for the stable-high pattern compared with the stable-low pattern. Conclusions Although LE8 is an indicator of cardiovascular health, the beneficial impact of a high LE8 score is also evident in the protection of renal health among patients with diabetes.

Time spent in a better cardiovascular health and risk of cardiovascular diseases and mortality: a prospective cohort study

BACKGROUND

The protective effect of a higher ideal cardiovascular health (CVH) score on cardiovascular diseases (CVDs) and mortality is well recognized. However, little is known regarding the length of favorable CVH status associated with CVDs and mortality. This study aimed to examined whether the duration of better (ideal or intermediate) CVH is associated with risk of developing CVDs and mortality.

METHODS

This prospective cohort study used data from 83,536 individuals from 2006 to 2020 who were enrolled in the Kailuan Study. The CVH scores of individuals were assessed at visits 1, 2, 3, and 4, respectively. The years spent in better CVH were estimated for each individual as the number of examination cycles (0-4) in which the participant was in that CVH score ≥ 8 multiplied by 2 (the mean year interval of each visit). The primary outcomes are CVD events and all-cause mortality.

RESULTS

After a median follow-up period of 7.48 years, 5486 (7.07%) cases of incident CVD events and 7669 (9.18%) deaths occurred. Compared with participants in " ≤ 4 years" group, those who maintained for > 4 years had less likely to develop adverse outcomes (CVD events: hazard ratio (HR): 0.60, 95% confidence interval (CI 0.56-0.63; all-cause mortality: HR: 0.77, 95% CI 0.74-0.81). The number of years spent in better CVH was nonlinearly correlated with CVD events or mortality (all Ps for nonlinear < 0.05). The results indicated that maintaining more than 6 years in a better CVH status was associated with a decreased risk of CVD events or mortality.

CONCLUSION

Our study indicates that individuals maintaining more than 6 years in better CVH could increase cardiometabolic benefits and a lower risk of all-cause mortality.

Dynamic Status of SII and SIRI Alters the Risk of Cardiovascular Diseases: Evidence from Kailuan Cohort Study

Background

Two novel systemic inflammation indices, SII and SIRI, are associated with increased risk of cardiovascular diseases (CVD). However, SII and SIRI are prone to change over time and the association between changeable status and long-term outcome risk remains to be uncovered. This study aims to examine the association between the dynamic status of SII and SIRI and risk of CVD.

Methods

This prospective study included a total of 45,809 subjects without MI, stroke and cancer prior to or in 2010 (baseline of this study). The dynamic status of SII and SIRI during 2006, 2008, and 2010 was assessed by dynamic trajectories (primary exposure), annual increase, and average value. The outcome was CVD incidence during 8.6 years' follow-up. Multiple Cox regression models were used to calculate the adjusted hazard ratios (HRs) and confidence intervals (95% CIs).

Results

Four dynamic trajectories of SII and SIRI were identified as follows: low stable pattern, moderate stable pattern, increase pattern, and decrease pattern. For SII, compared with "low stable pattern", after controlling confounders and level of SII in 2006, adjusted HRs were 1.24 (95% CI = 1.02-1.51) for "increase pattern" and 1.11 (95% CI = 1.00-1.23) for "moderate-stable pattern" while the association was not significant for "decrease pattern". Additionally, the highest group of annual SII increase and average SII had respective HR of 1.20 (95% CI = 1.05-1.37) and 1.32 (95% CI = 1.13-1.55). The results were consistent for SIRI. "Increase pattern" and "moderate stable pattern" increased the risk of CVD by 38% (HR = 1.38, 95% CI = 1.17-1.63) and 12% (HR = 1.12, 95% CI = 1.01-1.25), while no significant association was found for "decrease pattern". The highest group of annual SIRI increase and average SIRI had respective HR of 1.25 (95% CI = 1.09-1.44) and 1.39 (95% CI = 1.19-1.63).

Conclusion

Dynamic status of SII and SIRI was significantly associated with risk of CVD, which highlighted that we should focus on the dynamic change of SII and SIRI.

Association between cardiovascular health metrics and risk of incident type 2 diabetes mellitus: the Rural Chinese Cohort Study

AIMS

The evidence for association between cardiovascular health (CVH) metrics and type 2 diabetes mellitus (T2DM) in Chinese population is limited. We explored the association between the number of ideal CVH metrics and risk of incident T2DM in a rural Chinese population.

MATERIALS AND METHODS

A total of 12,150 rural Chinese participants (median age 51 years) were enrolled. A Cox proportional-hazards model was used to assess the association between the number of ideal CVH metrics and risk of incident T2DM by using hazard ratios (HRs) and 95% confidence intervals (CIs). We another conducted multiplicative and additive interaction effect between the number of ideal CVH metrics and sex or age on incident T2DM, and subgroup analyses of the association were also conducted by sex and age.

RESULTS

During a median of 6.01 years of follow-up, 840 incident cases of T2DM occurred. The number of ideal CVH metrics was negatively associated with risk of incident T2DM (per unit increase: HR = 0.76, 95% CI 0.70-0.82). We also observed both multiplicative and additive interaction effect between lower number of ideal CVH metrics and sex on incident T2DM, and multiplicative interaction effect between lower number of ideal CVH metrics and age on incident T2DM was observed. The association remained statistically significant for both men and women, or participants with age < 65 years.

CONCLUSIONS

Increasing number of ideal CVH metrics was associated with reduced risk of incident T2DM, which presented age- and sex-related differential associations.

The Association of Ideal Cardiovascular Health Metrics and Incident Type 2 Diabetes Mellitus Among an urban population of Iran: a decade follow-up in Tehran Lipid and Glucose Study

AIMS

To evaluate the association between ideal cardiovascular health metrics (ICVHM) and incident type diabetes (T2DM) among Iranian men and women.

METHODS

The study population included 7,488 Iranian adults aged ≥20 years (4236 women) free from diabetes at baseline. The ICVHM was defined according to the 2020-American Heart Association. The multivariable Cox proportional hazards regression analysis was used to calculate the hazard ratios (HRs) for ICVHM both as continuous and categorical variables.

RESULTS

Over the median of 9.1 years of follow-up, we identified 922 new cases of T2DM (526 women). Body mass index <30 kg/m² , untreated systolic/diastolic blood pressure <120/80 mmHg in both genders, and physical activity ≥1500 MET mins/wk (only among men) were significantly associated with a lower risk of T2DM. Each additional unit in the ICVHM was associated with a 21% and 15% lower risk of T2DM in men and women, respectively (p-values<0.05). Compared with participants having poor cardiovascular health (CVH), the HR (95% confidence interval) for T2DM risk was 0.69 (0.56-0.85) and 0.35 (0.21-0.59) for men with intermediate and ideal CVHM, respectively. The corresponding values for women were 0.79 (0.65-0.97) and 0.30 (0.15-0.60), respectively. in a subpopulation with nutritional data (n=2236), ideal and intermediate nutritional status was associated with 83% and 77% lower risk of T2DM only among women (p-values<0.05).

CONCLUSION

We found a strong inverse association between having higher global ICVHM with incident T2DM; the issue is mainly attributable to normal blood pressure, normal body weight, and intensive physical activity (only for men).

Dynamic Changes of Metabolic Syndrome Alter the Risks of Cardiovascular Diseases and All-Cause Mortality: Evidence From a Prospective Cohort Study

Background: Metabolic syndrome (MetS) at baseline increases the risks of cardiovascular diseases (CVD) and all-cause mortality. However, MetS status is changeable during follow-up. The associations of dynamic changes of MetS with CVD and all-cause mortality remain unclear.

Methods: Thirty-one thousand four hundred eighty-one eligible subjects were included from the Kailuan cohort. Dynamic changes of MetS were divided into four patterns as MetS-free, MetS-developed, MetS-recovery and MetS-stable. The outcomes were CVD, all-cause mortality, and the subtypes of CVD as myocardial infarction (MI), stroke and heart failure. Multiple Cox regression models were used to calculate the adjusted hazard ratios (HRs) and confidence intervals (95% CIs).

Results: Altered risks of CVD, the subtypes of CVD, and all-cause mortality were observed among different dynamic patterns of MetS. Compared with the MetS-free group, MetS-developed group increased the risks of CVD (HR = 1.78, 95% CI = 1.51–2.11), MI (HR = 1.54, 95% CI = 1.01–2.34), stroke (HR = 1.78, 95% CI = 1.45–2.18), and heart failure (HR = 1.63, 95% CI = 1.11–2.39). MetS-recovery group decreased these risks with the HRs of 0.59 (95% CI = 0.48–0.72) for CVD, 0.62 (95% CI = 0.41–0.96) for MI, 0.59 (95% CI = 0.46–0.75) for stroke, and 0.56 (95% CI = 0.34–0.91) for heart failure compared with the MetS-stable group. However, the increased risk in the MetS-developed group and the decreased risk in the MetS-recovery group were not significant for all-cause mortality. When stratified by the onset age of MetS status change, early development of MetS (<50 years) had higher risks of CVD (HR = 2.20, 95% CI = 1.58–3.05), MI (HR = 2.35, 95% CI = 1.00–5.50), stroke (HR = 2.05, 95% CI = 1.38–3.05), heart failure (HR = 2.63, 95% CI = 1.15–6.04), and all-cause mortality (HR = 1.61, 95% CI = 1.13–2.30) than late development (≥50 years). Early recovery of MetS had lower risks with the HRs of 0.38 (95% CI = 0.24–0.59) for CVD, 0.43 (95% CI = 0.18–1.06) for MI, 0.37 (95% CI = 0.21–0.64) for stroke, 0.30 (95% CI = 0.09–1.04) for heart failure, and 0.68 (95% CI = 0.43–1.06) for all-cause mortality than late recovery.

Conclusion: Dynamic changes of MetS altered the risks of CVD and all-cause mortality, especially in individuals with an early onset age. These findings highlight the importance of dynamic changes of MetS and onset age on the prevention and control for CVD.

Combined lifestyle factors and risk of incident type 2 diabetes and prognosis among individuals with type 2 diabetes: a systematic review and meta-analysis of prospective cohort studies

AIMS/HYPOTHESIS

A healthy lifestyle has been widely recommended for the prevention and management of type 2 diabetes. However, no systematic review has summarised the relationship between combined lifestyle factors (including, but not limited to, smoking, alcohol drinking, physical activity, diet and being overweight or obese) and incident type 2 diabetes and risk of health outcomes among diabetic individuals.

METHODS

EMBASE and PubMed were searched up to April 2019 without language restrictions. References included in articles in relevant publications were also screened. Cohort studies investigating the combined associations of at least three lifestyle factors with incident type 2 diabetes and health outcomes among diabetic individuals were included. Reviewers were paired and independently screened studies, extracted data and evaluated study quality. Random-effects models were used to calculate summary HRs. Heterogeneity and publication bias tests were also conducted.

RESULTS

Compared with participants considered to have the least-healthy lifestyle, those with the healthiest lifestyle had a 75% lower risk of incident diabetes (HR 0.25 [95% CI 0.18, 0.35]; 14 studies with approximately 1 million participants). The associations were largely consistent and significant among individuals from different socioeconomic backgrounds and baseline characteristics. Among individuals with type 2 diabetes (10 studies with 34,385 participants), the HRs (95% CIs) were 0.44 (0.33, 0.60) for all-cause death, 0.51 (0.30, 0.86) for cardiovascular death, 0.69 (0.47, 1.00) for cancer death and 0.48 (0.37, 0.63) for incident cardiovascular disease when comparing the healthiest lifestyle with the least-healthy lifestyle.

CONCLUSIONS/INTERPRETATION

Adoption of a healthy lifestyle is associated with substantial risk reduction in type 2 diabetes and long-term adverse outcomes among diabetic individuals. Tackling multiple risk factors, instead of concentrating on one certain lifestyle factor, should be the cornerstone for reducing the global burden of type 2 diabetes.

Association between cumulative serum urate and development of diabetes type II: the Kailuan Study

OBJECTIVE

To explore whether cumulative serum urate (cumSU) is correlated with diabetes type II mellitus incidence.

METHODS

In this study, we recruited individuals participating in all Kailuan health examinations from 2006 to 2013 without stroke, cancer, gestation, myocardial infarction, and diabetes type II diagnosis in the first three examinations. CumSU was calculated by multiplying the average serum urate concentration and the time between the two examinations (umol/L × year). CumSU levels were categorized into five groups: Q₁-Q₅. The effect of cumSU on diabetes type II incidence was estimated by logistic regression.

RESULTS

A total of 36,277 individuals (27,077 men and 9200 women) participated in the final analysis. The multivariate logistic regression model showed the odds ratios (95% confidence intervals) of diabetes type II from Q₁ to Q₅ were 1.00 (reference), 1.25 (1.00 to 1.56), 1.43 (1.15 to 1.79), 1.49 (1.18 to 1.87), and 1.80 (1.40 to 2.32), respectively. Multivariable odds ratios per 1-standard deviation increase in cumSU were 1.26 (1.17 to 1.37) in all populations, 1.20 (1.10 to 1.32) for men, and 1.52 (1.27 to 1.81) for women, respectively.

CONCLUSIONS

CumSU is a significant risk factor for diabetes type II. Individuals with higher cumSU, especially women, are at a higher risk of diabetes type II independent of other known risk factors.Key Points• Cumulative exposure to serum urate is a significant risk factor for diabetes type II.• Individuals with higher cumSU, especially women, are at a higher risk of diabetes type II.

Relationship of ideal cardiovascular health metrics with retinal vessel calibers and retinal nerve fiber layer thickness: a cross-sectional study

BACKGROUND

Ideal cardiovascular health (CVH) metrics have been found to be associated with subclinical vascular abnormalities. However, the relationship between ideal CVH metrics and retinal vessel calibers and retinal nerve fiber layer (RNFL) thickness in a Chinese population is unknown.

METHODS

We collected information on the seven ideal CVH metrics among 3376 participants aged 40 years or older from the Asymptomatic Polyvascular Abnormalities Community Study in 2012. Retinal vessel calibers and RNFL thickness were assessed by retinal photography and spectral-domain optical coherence tomography. Multivariable linear models were used to analyze the relationship between ideal CVH metrics and retinal parameters.

RESULTS

With the decreased number of ideal CVH metrics, central retinal arteriolar equivalents (CRAE) was significantly narrowed and arterio- venous ratio (AVR) significantly decreased (p < 0.0001). While the RNFL thickness and central retinal venous equivalents (CRVE) showed no significant changes with the decreased ideal CVH metrics. Linear regression showed that both CRAE and AVR was positively related with the number of ideal CVH metrics (regression coefficient beta: 0.806, 95% confidence interval (CI): 0.266-1.346 for CRAE (micron); and regression coefficient beta: 0.005, 95% CI: 0.002-0.009 for AVR) after adjusting for age (year), sex = male (n), education (n), average monthly income (¥) and other related risk factors.

CONCLUSIONS

These findings suggested a clear positive relationship between the number of ideal CVH metrics and CRAE and AVR in Chinese population, supporting the importance of ideal health behaviors and factors in subclinical vascular abnormalities prevention.

Relationship between the exposure to cumulative cardiovascular health behaviors and factors and chronic kidney disease-The Kailuan study

It is unclear whether ideal cardiovascular health (CVH) behaviors and factors, particularly cumulative exposure to ideal CVH (cumCVH), is associated with chronic kidney disease (CKD). The aim of the study was to examine the effect of cumCVH on CKD using the data from the Kailuan study. The study included the 27,970 (21,199 males) of the Kailuan community (China). The participants were 19 to 98 years of age. They were followed in 2008-2009, 2010-2011, and 2012-2013 by the same medical staff that did the initial physical examinations in 2006-2007. Participants were censored on the visit reporting CKD. A CVH score was created based on the seven AHA health metrics. The cumCVH score was CVH1×timev1-v2+CVH2×timev2-v3+CVH3×timev3-v4. In the fully adjusted model, compared with the lowest quintile of cumCVH, individuals in the highest quintile had a 75% lower risk of CKD (95% confidence interval (CI): 66-82%). Every additional year lived with a 1-unit increase in ideal CVH was associated with an 11% (95% CI: 9-13%) reduction in the incidence of CKD. Furthermore, when we excluded each of the six metrics from the cumCVH score in turn, the association was unaffected after the exclusion of individual risk factors. Ideal CVH is associated with a reduced incidence of CKD. Measurements of cumCVH are more likely to reflect the lifetime risk of CKD and possibly of other health outcomes.

Dietary Cholesterol and the Lack of Evidence in Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of death in the United States. For years, dietary cholesterol was implicated in increasing blood cholesterol levels leading to the elevated risk of CVD. To date, extensive research did not show evidence to support a role of dietary cholesterol in the development of CVD. As a result, the 2015–2020 Dietary Guidelines for Americans removed the recommendations of restricting dietary cholesterol to 300 mg/day. This review summarizes the current literature regarding dietary cholesterol intake and CVD. It is worth noting that most foods that are rich in cholesterol are also high in saturated fatty acids and thus may increase the risk of CVD due to the saturated fatty acid content. The exceptions are eggs and shrimp. Considering that eggs are affordable and nutrient-dense food items, containing high-quality protein with minimal saturated fatty acids (1.56 gm/egg) and are rich in several micronutrients including vitamins and minerals, it would be worthwhile to include eggs in moderation as a part of a healthy eating pattern. This recommendation is particularly relevant when individual’s intakes of nutrients are suboptimal, or with limited income and food access, and to help ensure dietary intake of sufficient nutrients in growing children and older adults.

Proteinuria and risk of stroke in patients with hypertension: The Kailuan cohort study

Proteinuria is associated with stroke, but the effects of changes in proteinuria on stroke risk are not well understood in the hypertensive population. This study examined whether proteinuria changes across 2-year assessments were associated with incident stroke in individuals with hypertension. We used visit data from 24 300 participants with hypertension of the Kailuan study who were stroke free at baseline. Based on the baseline and 2-year dipstick screening results, participants were classified as having no, remittent, incident, or persistent proteinuria. The relationship between proteinuria and stroke was analyzed using Cox proportional-hazards models after adjusting for potential variables. During a median of 6.89-year follow-up, we identified 1197 people with stroke. Compared to those with no proteinuria, stroke risk was significantly increased in participants with incident (hazard ratio [HR] 1.41, 95% CI, 1.05-1.77) and persistent proteinuria (HR 1.49, 95% CI, 1.25-1.89) after adjustment for other factors, which was consistent in ischemic stroke and intracerebral hemorrhage. No interaction was found between changes of proteinuria and diabetes mellitus in the hypertensive population. Changes in proteinuria exposure, particularly persistent proteinuria, play a role in reflecting the risk of stroke in patients with hypertension.

Association of visit-to-visit blood pressure variability with the risk of all-cause mortality and cardiovascular events in general population

The association between blood pressure variability (BPV) and the risk of all-cause mortality and cardiovascular diseases (CVD) is not well understood. The Kailuan study is a prospective longitudinal cohort study on cerebrovascular events and cardiovascular factors. In this study, resting blood pressure was measured at baseline and every 2 years from 2006 to 2007. BPV is mainly defined as the coefficient of variation (CV). Hazard ratio (HR), with 95% confidence intervals (CI) was calculated using Cox regression model. Among 52 387 participants, we identified 1817 who ended up with all-cause death and 1198 with CVD. Each 4.68% increase in BPV was associated with a 13% increase in the risk of mortality (HR = 1.13, 95% CI = 1.09-1.18) and a 7% increase in CVD (HR = 1.07, 95% CI = 1.02-1.13), respectively. After adjustment of confounding factors, the HR of comparing participants in the highest versus lowest quartile of CV of systolic blood pressure (SBP) was 1.37 (1.19, 1.57) for all-cause death, 1.18 (1.01, 1.39) for CVD. Similar results were also observed when BPV was measured by different parameters. We concluded that visit-to-visit BPV was associated with all-cause death and cardiovascular and cerebrovascular events in Chinese general population.

Adherence to a healthy lifestyle and the risk of type 2 diabetes in Chinese adults

Background

Simultaneously adhering to multiple healthy lifestyle factors has been related to up to 90% reduction in type 2 diabetes (T2DM) incidence in White populations; however, little is known about whether such protective effects persist in other non-White populations.

Methods

We examined the associations of six lifestyle factors with T2DM in the China Kadoorie Biobank of 461 211 participants aged 30-79 years without diabetes, cardiovascular diseases or cancer at baseline. We defined low-risk lifestyle factors as non-smoking or having stopped for reasons other than illness; alcohol consumption of <30 g/day; upper quarter of the physical activity level; diet rich in vegetables and fruits, low in red meat and with some degree of replacement of rice with wheat; body mass index (BMI) of 18.5-23.9 kg/m2; and waist-to-hip ratio (WHR) <0.90 (men)/<0.85 (women).

Results

During a median of 7.2 years of follow-up, we identified 8784 incident T2DM. In multivariable-adjusted analyses, two important risk factors for developing T2DM were higher BMI and WHR. Compared with participants without any low-risk factors, the hazard ratio [95% confidence interval (CI)] for those with at least three low-risk factors was 0.20 (0.19, 0.22). Approximately 72.6% (64.2%, 79.3%) of the incident diabetes were attributable to the combination of BMI, WHR, diet and physical activity. The population attributable risk percentage (PAR%) of diabetes appeared to be similar for men and women, and higher among urban, older and obese participants.

Conclusions

Our findings indicate that adherence to a healthy lifestyle may substantially lower the burden of T2DM in the Chinese population.

Relation of Ideal Cardiovascular Health Metrics to Asymptomatic Polyvascular Disease in a Chinese Population

Atherosclerosis is a systemic disease with manifestations in multiple vascular beds. Ideal cardiovascular health (CVH) metrics relate to cardiovascular and cerebrovascular disease. However, the relation between ideal CVH metrics and asymptomatic polyvascular disease (polyVD) is unknown. We collected information on the 7 CVH metrics among 5,224 participants aged ≥40 years from 2010 to 2011. Intracranial artery stenosis, extracranial artery stenosis, and lower extremity artery disease were detected by transcranial Doppler, duplex sonography, and by calculating ankle-brachial index. Ordinal logistic regression and linear models were used to analyze the relation between ideal CVH metrics and polyVD. PolyVD was identified in 158 (3%) participants. We observed a significant inverse gradient relation between the number of ideal CVH metrics and prevalence of polyVD after adjustment for potential confounders. The adjusted odds ratios and 95% confidence intervals were 0.824 (0.657 to 1.032), 0.641 (0.511 to 0.804), 0.538 (0.423 to 0.684), 0.583 (0.442 to 0.769), and 0.530 (0.348 to 0.808) for those having 2, 3, 4, 5, and 6 or 7 ideal CVH metrics, respectively, compared with those having 0 or 1 ideal CVH metric (p-trend <0.0001). Similarly, a larger number of ideal CVH metrics was associated with a lower prevalence of polyVD in the linear models (adjusted β coefficient -0.030, 95% confidence interval -0.041 to -0.020). Stratification for gender and age yielded consistent results in all subgroups except for women subgroup. In conclusion, we observed a significant inverse gradient association between the number of ideal CVH metrics and prevalence of asymptomatic polyVD.

Long Sleep Duration Is an Independent Risk Factor for Incident Atrial Fibrillation in a Chinese Population: A Prospective Cohort Study

There is limited information on the relation between sleep duration and incident atrial fibrillation. We aimed to investigate this association in a Chinese population using cohort data from a study in Kailuan. The analysis included 87,693 participants (age range, 18–98 years) free of atrial fibrillation at the baseline survey. Participants were divided into three categories according to self-reported sleep duration: ≤6.0 hours, 7 hours (ref), ≥8.0 hours. Atrial fibrillation diagnosis was made on a standard 12-lead electrocardiogram and via self-reported history. Cox proportional hazards models were used to calculate hazard ratio (HR) and confidence interval (CI) for atrial fibrillation, according to sleep duration. During median follow-up of 7.89 (range, 6.36–8.57) years, 322 cases of atrial fibrillation had occurred. Using 7 hours of sleep as the reference group, multivariable adjusted HRs (95% CI) for atrial fibrillation were 1.07 (0.75–1.53), 1.0 (ref), and 1.50 (1.07–2.10), from lowest to highest category of sleep duration. Secondary analysis showed no evidence of interactions between sleep duration and sex and snoring on the risk of incident atrial fibrillation (p = 0.75/0.25). We conclude long sleep duration may be a potential predictor/marker for incident atrial fibrillation.

Chronic Fluid Overload and Mortality in ESRD

Sustained fluid overload (FO) is considered a major cause of hypertension, heart failure, and mortality in patients with ESRD on maintenance hemodialysis. However, there has not been a cohort study investigating the relationship between chronic exposure to FO and mortality in this population. We studied the relationship of baseline and cumulative FO exposure over 1 year with mortality in 39,566 patients with incident ESRD in a large dialysis network in 26 countries using whole-body bioimpedance spectroscopy to assess fluid status. Analyses were applied across three discrete systolic BP (syst-BP) categories (<130, 130-160, and >160 mmHg), with nonoverhydrated patients with syst-BP=130-160 mmHg as the reference category; >200,000 FO measurements were performed over follow-up. Baseline FO value predicted excess risk of mortality across syst-BP categories (<130 mmHg: hazard ratio [HR], 1.51; 95% confidence interval [95% CI], 1.38 to 1.65; 130-160 mmHg: HR, 1.25; 95% CI, 1.16 to 1.36; >160 mmHg: HR, 1.30; 95% CI, 1.19 to 1.42; all P<0.001). However, cumulative 1-year FO exposure predicted a higher death risk (P<0.001) across all syst-BP categories (<130 mmHg: HR, 1.94; 95% CI, 1.68 to 2.23; 130-160 mmHg: HR, 1.51; 95% CI, 1.35 to 1.69; >160 mmHg: HR, 1.62; 95% CI, 1.39 to 1.90). In conclusion, chronic exposure to FO in ESRD is a strong risk factor for death across discrete BP categories. Whether treatment policies that account for fluid status monitoring are preferable to policies that account solely for predialysis BP measurements remains to be tested in a clinical trial.

Vitamin D and hypertension: Prospective study and meta-analysis

OBJECTIVES

The study sought to determine the link between vitamin D concentrations and incident hypertension in prospective study and meta-analysis.

METHODS

The study was embedded in the Kailuan Study, a population-based cohort of adults that contains underground miners. In 2012, we studied 2,456 men and women free of prevalent hypertension, age 21 to 67 at baseline. Serum 25-hydroxyvitamin D was measured from previously frozen baseline samples using ELISA (Enzyme-Linked ImmunoadSorbent Assay). We use the logistic regression analysis to estimate the odd radio (ORs) 95% confidence intervals (CIs) for 25-hydroxyvitamin D [25(OH)D] concentrations with incident hypertension. To help place our new data in context, we conducted a systemic review and meta-analysis of previous prospective reports of vitamin D and hypertension.

RESULTS

During a median follow-up of 2 years, 42.6% of the cohort (n = 1047) developed hypertension. Compared with the 25-hydroxyvitamin D >30ng/ml, 25-hydroxyvitamin D <20 ng/ml was associated with a greater hypertension risk (OR: 1.225 [95% CI: 1.010 to 1.485] p = 0.04), although the association was attenuated and not statistically significant after adjusting for potential confounders (OR: 1.092 [95% CI: 0.866 to 1.377] p = 0.456). This meta-analysis included seven prospective studies for 53,375 participants using adjusted HR founded a significant association between vitamin D deficiencies and incident hypertension (HRs = 1.235 (95% CI: 1.083 to 1.409, p = 0.002)).

CONCLUSION

Lower serum 25-hydroxyvitamin D concentrations were not associated with a greater risk of incident hypertension. More research is needed to further determine the role of 25-hydroxyvitamin D in hypertension prevention and therapy.