Antenatal depressive symptoms and adverse birth outcomes in healthy start participants: The modifying role of utilization of mental health services

OBJECTIVE

We examined the association between antenatal depressive symptoms and adverse birth outcomes in Midland Healthy Start (MHS) participants and determined whether receiving mental health services reduced the odds of adverse outcomes among those with elevated antenatal depressive symptoms.

METHOD

Data from a retrospective cohort of participants (N = 1,733) served by the MHS in South Carolina (2010-2019) were linked with their birth certificates. A score of ≥16 on the Center for Epidemiologic Studies Depression Scale was defined as elevated antenatal depressive symptoms. Services provided by MHS were categorized into: (1) receiving mental health services, (2) receiving other services, and (3) not receiving any services. Adverse birth outcomes included preterm birth, low birth weight, and small for gestational age.

RESULTS

Around 31 % had elevated antenatal depressive symptoms. The prevalences of preterm birth, low birthweight, and small for gestational age were 9.5 %, 9.1 %, and 14.6 %, respectively. No significant associations were observed between elevated depressive symptoms and adverse outcomes. Among women with elevated antenatal depressive symptoms, the odds for small for gestational age were lower in those who received mental health services (AOR 0.33, 95 % CI 0.15-0.72) or other services (AOR 0.34, 95 % CI 0.16-0.74) compared to those who did not receive any services. The odds for low birth weight (AOR 0.34, 95 % CI 0.13-0.93) were also lower in those who received mental health services.

CONCLUSIONS

Receiving screening and referral services for antenatal depression reduced the risks of having small for gestational age or low birth weight babies among MHS participants.

Identifying a group of factors predicting cognitive impairment among older adults

BACKGROUND

Cognitive impairment has multiple risk factors spanning several domains, but few studies have evaluated risk factor clusters. We aimed to identify naturally occurring clusters of risk factors of poor cognition among middle-aged and older adults and evaluate associations between measures of cognition and these risk factor clusters.

METHODS

We used data from the National Health and Nutrition Examination Survey (NHANES) III (training dataset, n = 4074) and the NHANES 2011-2014 (validation dataset, n = 2510). Risk factors were selected based on the literature. We used both traditional logistic models and support vector machine methods to construct a composite score of risk factor clusters. We evaluated associations between the risk score and cognitive performance using the logistic model by estimating odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Using the training dataset, we developed a composite risk score that predicted undiagnosed cognitive decline based on ten selected predictive risk factors including age, waist circumference, healthy eating index, race, education, income, physical activity, diabetes, hypercholesterolemia, and annual visit to dentist. The risk score was significantly associated with poor cognitive performance both in the training dataset (OR Tertile 3 verse tertile 1 = 8.15, 95% CI: 5.36-12.4) and validation dataset (OR Tertile 3 verse tertile 1 = 4.31, 95% CI: 2.62-7.08). The area under the receiver operating characteristics curve for the predictive model was 0.74 and 0.77 for crude model and model adjusted for age, sex, and race.

CONCLUSION

The model based on selected risk factors may be used to identify high risk individuals with cognitive impairment.

Longitudinal Associations of Diet, Food Insecurity, and Supplemental Nutrition Assistance Program Use with Global Cognitive Performance in Middle-Aged and Older Adults

BACKGROUND

Diet quality, food access, and food assistance policies may be key modifiable factors related to cognitive decline.

OBJECTIVE

We aimed to evaluate whether diet quality, food insecurity, and Supplemental Nutrition Assistance Program (SNAP) use are associated with longitudinal changes in cognition among older adults in the United States.

METHODS

Food intake data from the Health Care and Nutrition Study were linked with longitudinal health information from 5 waves of the Health and Retirement Study (2012-2020). The analytic sample (n = 6968) included community-dwelling United States adults aged ≥51 y without cognitive impairment. Global cognition was measured using a telephone-based cognitive status interview (range: 0-27). Diet quality was measured with the Healthy Eating Index, using participants' average intake of 13 dietary components. Questions regarding food access and affordability were used to determine food insecurity and use of SNAP benefits. Linear mixed-effects regression models were used to estimate longitudinal associations between diet-related factors and cognitive score changes.

RESULTS

Poorer diets [β: -0.24; 95% confidence interval (CI): -0.33, -0.15], food insecurity (β: -1.08; 95% CI: -1.31, -0.85), and SNAP use (β: -0.57; 95% CI: -0.82, -0.32) were associated with lower baseline cognitive scores. Poorer diets (β: -0.17; 95% CI: -0.29, -0.05) and food insecurity (β: -0.23; 95% CI: -0.47, -0.01) were associated with significantly steeper declines in cognitive scores over time, after 8 and 2 y of follow-up, respectively; however, SNAP use was not significantly associated with the rate of cognitive decline over time. Estimates were qualitatively similar when restricting the sample to participants aged ≥65 y.

CONCLUSIONS

Results suggest that food access and adherence to healthy diet recommendations may be important elements to maintain cognitive health in aging. SNAP benefits may be insufficient to prevent negative cognitive effects of poor diet and limited access to nutritious foods.

Association Between Physical Activity During Pregnancy and Perinatal Depressive Symptoms in Pregnant Individuals With Overweight and Obesity

INTRODUCTION

Current research on the association between physical activity and perinatal depression is inconclusive. This study examined the association between objectively measured physical activity during pregnancy and perinatal depressive symptoms among individuals with overweight and obesity.

METHODS

Data came from the Health in Pregnancy and Postpartum study (N = 205). Physical activity was measured using the SenseWear Armband at 16 weeks' or fewer and 32 weeks' gestation and categorized into 1) never meeting 2018 physical activity guidelines, 2) meeting the guidelines at one time point, or 3) meeting the guidelines at both time points. Antenatal depressive symptoms were assessed at 32 weeks' gestation, and postpartum depressive symptoms were assessed at 6 and 12 months postpartum using the Edinburgh Postnatal Depression Scale. A score of 10 or higher was defined as probable at least minor depression (hereafter, probable depression).

RESULTS

Nearly one-half of the participants (45.4%) met physical activity guidelines both in early and late pregnancy. Pregnant individuals who met physical activity guidelines at one (adjusted odds ratio, 0.07; 95% confidence interval, 0.01-0.76) or both time points (adjusted odds ratio, 0.08; 95% confidence interval, 0.01-0.69) during pregnancy had lower odds of probable depression at 6 months postpartum than individuals who never met physical activity guidelines during pregnancy. No significant associations were found between prenatal physical activity and probable antenatal or postpartum depression at 12 months.

CONCLUSIONS

Antenatal physical activity was associated with lower odds of probable depression at 6 months after childbirth. Physicians should use evidence-based strategies to encourage pregnant people, especially those who are at risk for postpartum depression, to meet physical activity guidelines.

Household Food Insecurity Is Associated With Physical Activity in Youth and Young Adults With Diabetes: A Cross-Sectional Study

BACKGROUND

Physical activity (PA) is essential for optimal diabetes management. Household food insecurity (HFI) may negatively affect diabetes management behaviors. The purpose of this study was to cross-sectionally examine the association between HFI and PA in youth and young adults (YYA) with type 1 (N = 1998) and type 2 (N = 391) diabetes from the SEARCH for Diabetes in Youth Study.

METHODS

HFI was measured with the US Household Food Security Survey Module. PA was measured with the International Physical Activity Questionnaire Short Form. Walking, moderate-intensity PA (excluding walking), vigorous-intensity PA, moderate- to vigorous-intensity PA, and total PA were estimated as minutes per week, while time spent sitting was assessed in minutes per day. All were modeled with median regression. Meeting PA guidelines or not was modeled using logistic regression.

RESULTS

YYA with type 1 diabetes who experienced HFI spent more time walking than those who were food secure. YYA with type 2 diabetes who experienced HFI spent more time sitting than those who were food secure.

CONCLUSIONS

Future research should examine walking for leisure versus other domains of walking in relation to HFI and use objective PA measures to corroborate associations between HFI and PA in YYA with diabetes.

Association between clusters of antibodies against periodontal microorganisms and Alzheimer disease mortality: Evidence from a nationally representative survey in the USA

BACKGROUND

Alzheimer disease (AD) has been linked with periodontal microorganisms such as Porphyromonas gingivalis in observational and mechanistic studies. IgG antibodies against periodontal microorganisms which are markers of past and current periodontal infection have been correlated with cognitive impairment. We examined associations between empirically derived groups of 19 IgG antibodies against periodontal microorganisms and AD mortality.

METHODS

Individuals participating in the Third National Health and Nutrition Examination Survey (NHANES III) with complete data on IgG titers were followed up between 1988 and December 31, 2019. The outcome was AD mortality, and the main exposures were IgG antibodies against periodontal microorganisms classified into four mutually exclusive groups using cluster analysis. Survey-weighted Cox proportional hazard models were used to evaluate adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for the relationship between clusters and AD mortality.

RESULTS

With up to 21 years of follow-up, 160 AD-related deaths were documented. In the multivariable-adjusted model, AD mortality overall was not associated with the Red-Green (aHR 1.18; 95% CI, 0.46-3.07), Yellow-Orange (aHR 1.36; 95% CI, 0.58-3.19), Orange-Blue (aHR 0.63; 95%, CI, 0.33-1.21), and the Orange-Red (aHR 0.79; 95% CI, 0.37-1.70) when the upper tertiles were compared to the bottom tertiles. However, the subgroup of middle-aged individuals in the highest tertile of the Red-Green cluster, but not older individuals, had a 13% higher risk of AD mortality (aHR 1.13; 95% CI, 1.02-1.26) compared with those in the bottom tertile.

CONCLUSION

Clusters of IgG antibodies against periodontal microorganisms did not predict AD mortality in this study.

Dietary patterns, socioeconomic disparities, and risk of type 2 diabetes in the Sister Study

AIMS

We investigated the role of socioeconomic disparities in the association between diet and risk of type 2 diabetes (T2D).

METHODS

We used prospective data from 40,243 Sister Study participants aged 35 to 74 years who were enrolled in 2003-2009. Scores for healthy eating indices (alternate Mediterranean diet, Dietary Approaches to Stop Hypertension, alternative Healthy Eating Index, and Healthy Eating Index 2015 (HEI-2015)) were calculated using data from a 110-item food frequency questionnaire completed at enrollment. Incident T2D was defined based on self-reported physician's diagnosis or use of anti-diabetic medications. Multivariable-adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models.

RESULTS

We observed inverse associations between all four dietary indices and incident T2D after multivariable adjustment. These associations were most pronounced among women with higher educational attainment, higher income, and lower area deprivation index (ADI) (e.g., for the HEI-2015: low ADI, aHRQ4vsQ1: 0.44, 95% CI: 0.35, 0.56 vs high ADI, aHRQ4vsQ1: 0.75, 95% CI: 0.63, 0.90; pinteraction: 0.0007).

CONCLUSIONS

Weaker associations among women with lower socioeconomic status and higher neighborhood deprivation suggests that other factors play a larger role in T2D incidence than diet quality among individuals with low SES.

Periodontal Disease Treatment After Stroke or Transient Ischemic Attack: The PREMIERS Study, a Randomized Clinical Trial

BACKGROUND

Patients with stroke/transient ischemic attack and periodontal disease (PD) are at increased risk for cardiovascular events. PD treatments that can improve stroke risk factors were tested if they might assist patients with cerebrovascular disease.

METHODS

In this multicenter phase II trial, patients with stroke/transient ischemic attack and moderately severe PD were randomly assigned to intensive or standard PD treatment arms. The primary outcome measure was a composite of death, myocardial infarction, and recurrent stroke, as well as adverse events. Secondary outcome included changes in stroke risk factors.

RESULTS

A total of 1209 patients with stroke/transient ischemic attack were screened, of whom 481 met the PD eligibility criteria; 280 patients were randomized to intensive arm (n=140) and standard arm (n=140). In 12-month period, primary outcome occurred in 11 (8%) in the intensive arm and 17 (12%) in the standard arm. The intensive arm was nonsuperior to the standard arm (hazard ratio, 0.65 [95% CI, 0.30-1.38]) with similar rates of adverse events (sepsis 2.1% versus 0.7%; dental bleeding 1.4% versus 0%; and infective endocarditis 0.7% versus 0%). Secondary-outcome improvements were noted in both arms with diastolic blood pressure and high-density lipoprotein cholesterol (P<0.05).

CONCLUSIONS

In patients with recent stroke/transient ischemic attack and PD, intensive PD treatment was not superior to standard PD treatment in prevention of stroke/myocardial infarction/death. Fewer events were noted in the intensive arm and the 2 arms were comparable in the safety outcomes. Secondary-outcome measures showed a trend toward improvement, with significant changes noted in diastolic blood pressure and high-density lipoprotein in both the treatment arms.

Ten-Year Cardiovascular Disease Risk Score and Cognitive Function Among Older Adults: The National Health and Nutrition Examination Survey 2011 to 2014

Background The Framingham 10-year cardiovascular disease risk score, which is based on age, sex, smoking, total cholesterol, high-density lipoprotein-cholesterol, blood pressure, and diabetes, has been found to be associated with cognitive health, but these findings have not been validated in a representative sample in the United States. We aimed to examine the associations of Framingham risk score with cognitive function among older adults in a nationally representative sample, as well as by race or ethnicity, education, and family income. Methods and Results A total of 2254 older adults ≥60 years (57% female, 79% non-Hispanic White) in the National Health and Nutrition Examination Survey 2011 to 2014 were included in the final sample for analysis. All components of the Framingham risk score were obtained with questionnaire or measured in the laboratory. Cognitive function was examined using the Consortium to Establish a Registry for Alzheimer's Disease Word List Memory Task (immediate and delayed memory), Digit Symbol Substitution Test, and Animal Fluency Test. Multivariable linear regression models were used to assess the associations between Framingham risk score and test-specific and global cognition Z scores. Each incremental 5% in Framingham 10-year cardiovascular disease risk was associated with lower Z scores for Digit Symbol Substitution Test (β=-0.06 [95% CI, -0.09 to -0.03]), delayed memory (β=-0.05 [95% CI, -0.08 to -0.01]), immediate memory (β=-0.07 [95% CI, -0.10 to -0.03]), and global cognition (β=-0.05 [95% CI, -0.09 to -0.02]). Socioeconomic status, particularly race or ethnicity and monthly income levels, were strong effect measure modifiers of the associations. Conclusions Lower cardiovascular risk factors are associated with better cognitive function.

Antibodies against Periodontal Microorganisms and Cognition in Older Adults

INTRODUCTION

Markers of poor oral health are associated with impaired cognition and higher risk of Alzheimer disease (AD) and thus may help predict AD.

OBJECTIVES

The aim of this study was to evaluate the cross-sectional association between empirically derived groups of 19 IgG antibodies against periodontal microorganisms and cognition in middle-aged and older adults.

METHODS

The study population consisted of participants of the third National Health and Nutrition Examination Survey (NHANES III) (1988 to 1994), who were 60 y and older, among whom cognition and IgG antibodies against 19 periodontal microorganisms were measured (N = 5,162).

RESULTS

In multivariable quantile regression analyses, the Orange-Red (Prevotella melaninogenica, Prevotella intermedia, Prevotella nigrescens, Porphyromonas gingivalis) and Yellow-Orange (Staphylococcus intermedius, Streptococcus oralis, Streptococcus mutans, Fusobacterium nucleatum, Peptostreptococcus micros, Capnocytophaga ochracea) cluster scores were negatively associated with cognition. A 1-unit higher cluster score for the Orange-Red cluster was associated on average with a lower cognitive score (β for 30th quantile = -0.2640; 95% confidence interval [CI], -0.3431 to -0.1848). Similarly, a 1-unit higher score for the Yellow-Orange cluster was associated with a lower cognitive score (β for 30th quantile = -0.2445; 95% CI, -0.3517 to -0.1372).

CONCLUSION

Groups of IgG antibodies against periodontal microorganisms were associated with lower cognition among free living adults 60 years and older, who were previously undiagnosed with cognitive impairment. Though poor oral health precedes the development of dementia and AD, oral health information is currently not used, to our knowledge, to predict dementia or AD risk. Combining our findings with current algorithms may improve risk prediction for dementia and AD.

KNOWLEDGE TRANSLATION STATEMENT

IgG antibodies against periodontal microorganisms were associated with lower cognition among adults 60 years and older previously undiagnosed with cognitive impairment. Periodontal disease may predict cognition among older adults.

Impact of a Large Healthy Start Program on Perinatal Outcomes, South Carolina, 2009-2019

Using linked birth and death certificates for participants served by a Healthy Start program in South Carolina and community controls, we found that the Healthy Start program contributed to significant improvements in prenatal care, breastfeeding initiation, and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children and significant reductions in inadequate weight gain and large-for-gestational-age births. However, Healthy Start participants were more likely to gain excessive weight during pregnancy, and there were no significant differences in perinatal outcomes. (Am J Public Health. Published online ahead of print March 9, 2023:e1-e5. https://doi.org/10.2105/AJPH.2023.307232).

Relationship of Nonsteroidal Anti-Inflammatory Drug Use During Pregnancy with Autism Spectrum Disorder and Intellectual Disability Among Offspring

Objective: This study aimed to examine the association of nonsteroidal anti-inflammatory drug (NSAID) use by pregnant women during pregnancy with autism spectrum disorder (ASD) and intellectual disability (ID) in their children among Medicaid-insured mother-child dyads. Materials and Methods: We conducted a retrospective cohort study linking multiple datasets of South Carolina for the years between 2010 and 2017, in which the main exposure variable was NSAID use during pregnancy and outcome variables were ASD only, ID only, and ASD with ID. We conducted a multinomial logistic regression analysis, controlling for identified risk factors for ASD (mother's age, race, body-mass index, preeclampsia, and gestational diabetes). Results: NSAID use during pregnancy was found to be associated with ID only in both unadjusted and adjusted analyses. Children with mothers who had NSAID prescriptions were 26% more likely to have ID in comparison with children whose mothers did not have NSAID prescriptions (odds ratio: 1.26 [1.10-1.46]). The other risk factors identified for ASD were maternal age, race, preeclampsia, smoking, low birth weight, and obesity. For ID, the risk factors were maternal age, race, smoking, birth weight, overweight, and obesity, all of which were also associated with ASD with ID, except for overweight. Conclusions: NSAID usage during pregnancy was found to be associated with ID only and not with ASD. However, more research is needed to validate the effect of NSAIDs during pregnancy on ASD and ID among children.

Abstract 54: Newly Initiation of Antihypertensive Medication on Reduction of Incident Dementia: Emulation of Target Trials Based on the Health and Retirement Study

Background: Although antihypertensive medication use is associated with a lower risk of dementia in observational studies, such an effect is rarely found in randomized controlled trials (RCTs). As midlife high blood pressure is more predictive of incident dementia than hypertension in late life, so midlife hypertension may be the target for intervention. However, no such an RCT has been conducted to prevent incident dementia through reducing high blood pressure from midlife. Therefore, we aimed to emulate a target trial with an observational study design to estimate the effect of initiating antihypertensive medication from midlife on reducing incident dementia.

Hypothesis: We assessed the hypothesis that newly initiating antihypertensive medication among midlife adults with hypertension reduces incident dementia.

Methods: New-user design was used to emulate a target trial using data from the Health and Retirement Study from 1996 to 2018 with non-institutional dementia-free participants aged 45 to 65 years without taking antihypertensive medication in past two years. Participants with information of self-reported hypertension diagnosis and new use of antihypertensive medication, as well as no dementia based on algorithm were included in the analysis and represented group with/without initiating antihypertensive medication. An intention-to-treat approach was applied for analysis, and sequential emulation was used to increase the efficiency of intention-to-treat analysis. Proportional hazards models were applied to estimate the effect of initiating antihypertensive medication on incident dementia. Inverse probability of treatment and censoring weights were created to adjust for confounding and selection bias due to loss to follow-up, and death was considered as a competing event. Another emulated target trial with the same specifications was conducted among late-life adults aged 66 years or older for comparison.

Results: A total of 3,151 non-unique participants (baseline mean age: 59.0 ± 4.0 years, 54.6% (n=1,719) women, 78.3% (n=2468) Whites, 71.4% (n=2,249) initiating antihypertensive medication) were included in the analysis. Initiating antihypertensive medication showed benefit in reducing incident dementia over a total of 22-year follow-up, with a reduction of risk by 19% (hazards ratio=0.81, 95% confidence interval: 0.66, 0.99). No significant reduction was observed for initiators of antihypertensive medication from late life.

Conclusions: Initiating antihypertensive medication from midlife, but not from late life may reduce incident dementia. Future studies are warranted to estimate the effect of blood pressure lowering in midlife through other means of intervention in reducing incident dementia.

Inflammatory potential of diet and risk of mortality in normal-weight adults with central obesity

BACKGROUND & AIMS

Inflammatory potential of diet may contribute to poor health outcomes in individuals with metabolic disorders. In a representative sample of the U.S. population, we investigated the association between consuming a pro-inflammatory diet and mortality risk in adults with normal range of body mass index (BMI) but with central obesity.

METHODS

This prospective cohort study included 3521 adults 20-90 years of age with normal BMI who participated in the National Health and Nutrition Examination Survey III, 1988-1994 and did not have a history of cardiovascular disease (CVD) or cancer and did not change their dietary intake in the year preceding baseline measurements. Mortality from all causes, CVD, and cancer was ascertained from the National Death Index. Normal-weight central obesity (NWCO, n = 1777) was defined as those with BMI 18.5 to <25 kg/m2 and waist-to-hip ratio (WHR) ≥0.85 in women and ≥0.90 in men. Severe central obesity was defined as WHR ≥0.92 in women and ≥1.00 in men. The dietary inflammatory index (DII®) was computed based on baseline dietary intake using 24-h dietary recalls, and associations with mortality were estimated using multivariable Cox proportional hazards regression.

RESULTS

In individuals with NWCO, DII score (i.e., more pro-inflammatory diet) was associated with increased risk of CVD mortality (HRT3 vs T1, 1.89 [95% CI, 1.01-3.53], P trend = 0.04; HR 1 SD increase 1.29 [95% CI, 1.06-1.57]). This association was stronger with more severe central obesity (HRT3 vs T1, 2.79 [95% CI, 1.10-7.03], P trend = 0.03; HR 1 SD increase 1.52 [95% CI, 1.05-2.21]). DII score was not associated with increased risk of mortality in normal-weight individuals without central obesity or with risk of cancer mortality in either group.

CONCLUSION

Among individuals in the normal-weight range of BMI, a pro-inflammatory diet assessed by high DII scores was associated with increased risk of CVD mortality in those with central obesity.

Social networks, perceived social support, and HbA1c in individuals with type 2 diabetes mellitus in urban Ghana

OBJECTIVES

Although links between social relationships and health are well established, few studies have concurrently examined the effects of compositional, structural, and functional dimensions of social networks on glycemic (HbA1c) control in low- and middle-income countries such as Ghana. In these settings where informal social relationships are critical for access to resources, evaluating the links between social network characteristics, social support, and glycemic control may provide clarity about important relationships that facilitate the well-being of individuals with type 2 diabetes mellitus (T2DM).

DESIGN

In 2018, we conducted a hospital-based, cross-sectional survey of noninstitutionalized adults with T2DM in Ghana. Using data from 247 study participants, multivariable linear regression models were used to estimate associations between: 1) HbA1c and three social network characteristics (kin composition, household composition, and network density); 2) social support and the three social network characteristics; and 3) HbA1c and social support. We also examined gender differences in these associations and applied mediation techniques to determine if network characteristics operated through social support to affect HbA1c.

RESULTS

Findings indicated that higher kin composition and higher household composition were each significantly associated with increased social support. Neither social support nor social network characteristics were significantly related to HbA1c, and there were no gender differences in any of these associations.

CONCLUSION

Although family and household members were identified as important sources of social support for diabetes management, the ways in which they influence HbA1c control among Ghanaians require further investigation. Future studies can examine whether changes in social support over time, social support satisfaction, or other dimensions of social relationships improve T2DM outcomes in countries like Ghana.

Social Mediators of the Association Between Depression and Falls Among Older Adults

OBJECTIVES

To investigate the role of social factors in the association between depression and falls among older adults.

METHODS

The sample included data from 3443 older adults from three waves of the Health and Retirement Study (2010-2014). A Lifestyle Questionnaire was used to measure social engagement, social network contact, and neighborhood social context. Mediating effects of social factors were estimated through causal mediation analysis. Results: Poorer social engagement and network contact were associated with greater likelihood of falls, while poorer neighborhood context was associated with greater likelihood of fall injuries. Social engagement mediated a significant portion of the effect of depression on falls (OR: 1.03, 95% CI: 1.00, 1.06), and neighborhood context mediated a portion of the effect of depression on fall injuries (OR: 1.03, 95% CI: 1.00, 1.07). Discussion: The direct and indirect impacts of social factors suggest that considering them may help improve existing fall prevention approaches.

Depressive Symptoms Partially Mediate the Association of Frailty Phenotype Symptoms and Cognition for Females but Not Males

OBJECTIVES

We aimed to evaluate whether depressive symptoms mediated the relationship between frailty phenotype and cognitive function by sex.

METHODS

Data came from the Health and Retirement Study from 2012-2016. The outcome was measured by Fried's frailty criteria, our outcome was continuous global cognition, and mediator was depressive symptoms. We used mediation analysis, stratified by sex, to estimate the direct and indirect effects of frailty symptoms on cognition mediated by depressive symptoms.

RESULTS

Males had a larger total effect (β= -0.43; 95% CI: -0.66, -0.02) for lower cognitive score for each increase in frailty symptom compared to females (β= -0.28; 95% CI: -0.47, -0.08). A significant indirect effect from frailty phenotype to cognition was found through depressive symptoms for females but not males.

CONCLUSION

These results highlight the importance of identifying individuals with frailty and depressive symptoms to monitor and provide interventions to preserve cognitive function.

Initiation of Antihypertensive Medication from Midlife on Incident Dementia: The Health and Retirement Study

BACKGROUND

Hypertension has been identified as a risk factor of dementia, but most randomized trials did not show efficacy in reducing the risk of dementia. Midlife hypertension may be a target for intervention, but it is infeasible to conduct a trial initiating antihypertensive medication from midlife till dementia occurs late life.

OBJECTIVE

We aimed to emulate a target trial to estimate the effectiveness of initiating antihypertensive medication from midlife on reducing incident dementia using observational data.

METHODS

The Health and Retirement Study from 1996 to 2018 was used to emulate a target trial among non-institutional dementia-free subjects aged 45 to 65 years. Dementia status was determined using algorithm based on cognitive tests. Individuals were assigned to initiating antihypertensive medication or not, based on the self-reported use of antihypertensive medication at baseline in 1996. Observational analog of intention-to-treat and per-protocol effects were conducted. Pooled logistic regression models with inverse-probability of treatment and censoring weighting using logistic regression models were applied, and risk ratios (RRs) were calculated, with 200 bootstrapping conducted for the 95% confidence intervals (CIs).

RESULTS

A total of 2,375 subjects were included in the analysis. After 22 years of follow-up, initiating antihypertensive medication reduced incident dementia by 22% (RR = 0.78, 95% CI: 0.63, 0.99). No significant reduction of incident dementia was observed with sustained use of antihypertensive medication.

CONCLUSION

Initiating antihypertensive medication from midlife may be beneficial for reducing incident dementia in late life. Future studies are warranted to estimate the effectiveness using large samples with improved clinical measurements.

Association of Chlorhexidine Use and Scaling and Root Planing With Birth Outcomes in Pregnant Individuals With Periodontitis: A Systematic Review and Meta-analysis

IMPORTANCE

Chlorhexidine mouthwash enhances treatment effects of conventional periodontal treatment, but data on chlorhexidine as a source of heterogeneity in meta-analyses assessing the treatment of maternal periodontitis in association with birth outcomes are lacking.

OBJECTIVE

To assess possible heterogeneity by chlorhexidine use in randomized clinical trials (RCTs) evaluating the effect of periodontal treatment (ie, scaling and root planing [SRP]) vs no treatment on birth outcomes.

DATA SOURCES

Cochrane Oral Health's Trials Register, Cochrane Pregnancy and Childbirth's Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database), US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov), and the WHO International Clinical Trials Registry Platform were searched through March 2022.

STUDY SELECTION

RCTs were included if they were conducted among pregnant individuals with periodontitis, used interventions consisting of SRP vs no periodontal treatment, and assessed birth outcomes.

DATA EXTRACTION AND SYNTHESIS

Data were abstracted with consensus of 2 reviewers using Rayyan and assessed for bias with the Cochrane Risk of Bias 2 tool before random effects subgroup meta-analyses. Analyses were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline.

MAIN OUTCOMES AND MEASURES

Outcomes of interest were preterm birth (ie, <37 weeks' gestation) and low birth weight (ie, <2500 g).

RESULTS

There were 12 studies with a total of 5735 participants evaluating preterm birth. Control group participants did not receive any treatment or use chlorhexidine during pregnancy. All intervention group participants received SRP; in 5 of these studies (with 2570 participants), pregnant participants in the treatment group either received chlorhexidine mouthwash or advice to use it, but participants in the remaining 7 studies (with 3183 participants) did not. There were 8 studies with a total of 3510 participants evaluating low birth weight, including 3 studies with SRP plus chlorhexidine (with 594 participants) and 6 studies with SRP only (with 2916 participants). The SRP plus chlorhexidine groups had lower risk of preterm birth (relative risk [RR], 0.56; 95% CI, 0.34-0.93) and low birth weight (RR, 0.47; 95% CI, 0.32-0.68) but not the SRP-only groups (preterm birth: RR, 1.03; 95% CI, 0.82-1.29; low birth weight: RR, 0.82; 95% CI, 0.62-1.08).

CONCLUSIONS AND RELEVANCE

These findings suggest that treating maternal periodontitis with chlorhexidine mouthwash plus SRP was associated with reduced risk of preterm and low birth weight. Well-conducted RCTs are needed to test this hypothesis.

Household food insecurity is associated with diabetic ketoacidosis but not severe hypoglycemia or glycemic control in youth and young adults with youth-onset type 2 diabetes

OBJECTIVE

To examine the association between household food insecurity (HFI), glycemic control, severe hypoglycemia and diabetic ketoacidosis (DKA) among youth and young adults (YYA) with youth-onset type 2 diabetes.

RESEARCH DESIGN AND METHODS

This cross-sectional study included 395 YYA with type 2 diabetes from the SEARCH for Diabetes in Youth Study (2015-2019). HFI was reported by young adult participants or parents of minor participants via the US Household Food Security Survey Module. Glycemic control was assessed by HbA_1c and analyzed as a continuous and categorical variable (optimal: <7.0%, suboptimal: ≥7.0%-9.0%, poor: >9.0%). Acute complications included self-reported severe hypoglycemia or DKA in the last 12 months. Adjusted logistic and linear regression were used for binary and continuous outcomes, respectively.

RESULTS

Approximately 31% reported HFI in the past 12 months. Mean HbA_1c among those with HFI was 9.2% compared to 9.5% without HFI. Of those with HFI, 56% had an HbA_1c  >9.0% compared to 55% without HFI. Adjusted models showed no associations between HFI and glycemic control. Of those with HFI, 14.4% reported experiencing DKA and 4.7% reported severe hypoglycemia. YYA with HFI had 3.08 times (95% CI: 1.18-8.06) the odds of experiencing DKA as those without HFI. There was no association between HFI and severe hypoglycemia.

CONCLUSIONS

HFI was associated with markedly increased odds of DKA but not with glycemic control or severe hypoglycemia. Future research among YYA with type 2 diabetes should evaluate longitudinally whether alleviating HFI reduces DKA.

Association of U.S. birth, duration of residence in the U.S., and atherosclerotic cardiovascular disease risk factors among Asian adults

Introduction

Prior studies have shown a direct association between U.S. birth and duration of residence with atherosclerotic cardiovascular disease (ASCVD) though, few have specifically focused on Asian Americans.

Methods

We utilized cross-sectional data from the 2006 to 2015 National Health Interview Survey. We compared prevalent cardiovascular risk factors and ASCVD among Asian American individuals by U.S. birth and duration of time spent in the U.S.

Results

The study sample consisted of 18,150 Asian individuals of whom 20.5 % were Asian Indian, 20.5 % were Chinese, 23.4 % were Filipino, and 35.6 % were of other Asian ethnic groups. The mean (standard error) age was 43.8 (0.21) years and 53 % were women. In multivariable-adjusted logistic regression models, U.S. birth was associated with a higher prevalence odds ratio (95 % confidence interval) of current smoking 1.31 (1.07,1.60), physical inactivity 0.62 (0.54,0.72), obesity 2.26 (1.91,2.69), hypertension 1.33 (1.12,1.58), and CAD 1.96 (1.24,3.11), but lower prevalence of stroke 0.28 (0.11,0.71). Spending greater than 15 years in the U.S. was associated with a higher prevalence of current smoking 1.65 (1.24,2.21), obesity 2.33 (1.57,3.47), diabetes 2.68 (1.17,6.15), and hyperlipidemia 1.72 (1.09,2.71).

Conclusion

Heterogeneity exists in cardiovascular risk factor burden among Asian Americans according to Asian ethnicity, U.S. birth, and duration of time living in the U.S.

Heterogeneity in the prevalence of premature hypertension among Asian American populations compared with white individuals: A National Health Interview Survey study

Background

Differences in prevalence of risk factors such as hypertension may explain heterogeneity in cardiovascular risk across Asian American populations.

Methods

We used National Health Interview Survey (NHIS) data from 2006 to 2018 among White, Chinese, Asian Indian, Filipino, and ‘other Asians’ (Japanese, Korean, and Vietnamese). Unadjusted and adjusted odds ratios (aOR) with 95% confidence intervals were reported using logistic regression models for the association between race and self-reported premature hypertension (age <50 years old). Models were adjusted for sex, education, body mass index, smoking status, diabetes, and coronary heart disease.

Results

We studied 99,864 participants with history of hypertension (mean age, 59.3 ± 0.1; 50% women, 90% US born). Asian Indians had higher prevalence of premature hypertension (37%) compared with Filipinos (27%), ‘other Asians’ (26%), Whites (25%), and Chinese (21%). Compared with Whites, Chinese individuals had lower odds of premature hypertension (aOR = 0.79, 0.63–0.98), but Asian Indians had higher odds (aOR = 1.85, 1.48–2.31). Compared with Chinese, odds of premature hypertension was higher for Asian Indians (aOR = 2.39, 1.74–3.27), Filipinos (aOR = 1.53, 1.16–2.04), and ‘other Asians’ (OR = 1.32, 1.03–1.70; aOR = 1.59, 1.20–2.10). Overall prevalence of hypertension was lower among Asian Indians (aOR = 0.52, 0.46–0.58) and ‘other Asians’ (aOR = 0.74, 0.68–0.79) compared with Whites.

Conclusions

There is heterogeneity in the risk of hypertension across Asian Americans by age. Asian Indians and ‘other Asians’ had higher prevalence of premature hypertension and lower prevalence of overall hypertension, which may call for earlier screening for risk factors among these populations.

•

There is heterogeneity in the risk of hypertension across Asian Americans by age.

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Asian Indians and ‘other Asians’, defined as Japanese, Korean, and Vietnams, have higher prevalence of premature hypertension.

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Asian Americans with higher prevalence of premature hypertension may benefit from early screening to prevent cardiovascular disease.

The role of frailty in the association between depression and fall risk among older adults

OBJECTIVES

Although there is a recognized association between depression and greater fall risk among older adults, the mechanisms explaining this association are unclear. This study evaluated the role of frailty, a common geriatric syndrome, in determining greater risk of falls among older adults with depression.

METHOD

We used longitudinal data from three biennial waves of the Health and Retirement Study (HRS; 2010-2014). The sample included community-dwelling survey respondents age ≥ 65 who participated in objective physiological measures. Major Depression (MD) was measured using Composite International Diagnostic Interview for depression short form. Frailty was measured using criteria outlined in the frailty phenotype model. Causal mediation analysis was used to differentiate the direct effect of depression and indirect effect mediated by frailty on falls, fall injuries, and multiple falls.

RESULTS

Major depression was associated with significantly greater odds of experiencing a fall (OR: 1.91; 95% CI: 1.31, 2.77), fall injury (OR: 1.86; 95% CI: 1.17, 2.95), and multiple falls (OR: 2.26; 95% CI: 1.52, 3.37) over a two-year period. Frailty was a significant mediator of the effects of depression on falls and multiple falls, accounting for approximately 18.9% and 21.3% of the total effects, respectively. We found no evidence of depression-frailty interaction. Sensitivity analyses showed that results were robust to unmeasured confounding and alternative operationalizations of depression.

CONCLUSION

Frailty explains a significant proportion of increased likelihood of falls among older adults with depression. Treatment and management of frailty symptoms may be an important components of fall prevention among older adults with depression.

The Influence of Religious Participation and Use of Traditional Medicine on Type 2 Diabetes Control in Urban Ghana

This study examined whether the frequency of participation in religious activities and seeking care from spiritual and other traditional medicine (TM) practitioners were associated with blood glucose (HbA1c) control among urban Ghanaians with type 2 diabetes mellitus (T2DM). Findings revealed that increased frequency of participation in religious activities was significantly associated with decreased HbA1c levels, whereas increased use of TM practitioners was significantly associated with increased HbA1c levels. These findings suggest that strategically integrating religious activities into disease management plans for Ghanaians with T2DM who identify as being religious may be a viable intervention mechanism.

Association between groups of immunoglobulin G antibodies against periodontal microorganisms and diabetes related mortality

BACKGROUND

Immunoglobulin G (IgG) antibodies against periodontal microorganisms can be markers of periodontal infection because their levels rise following infection and remain elevated several years later.

METHODS

We evaluated the relation between groups of IgG antibodies against 19 periodontal microorganisms and diabetes related mortality over 27 years among participants of the National Health and Nutrition Examination Survey III (1988 to 1992) 40 years and older at the time of examination (N = 8153).

RESULTS

Individuals in the highest versus lowest antibody tertiles were at 86% higher risk of dying due to diabetes related causes in the Red-Green antibody cluster (T. forsythia, T. denticola, A. actinomycetemcomitans, E. corrodens, S. noxia, V. parvula, C. rectus) (HR = 1.86, 95% CI 1.09 to 3.20) and 55% lower in the Orange-Blue antibody cluster (E. nodatum, A. naeslundii) (HR = 0.45, 95% CI 0.32 to 0.63) in multivariable models. In these models, individuals with diabetes at the time of examination had a 16-fold higher risk of dying due to diabetes related causes (HR = 16.4, 95% CI 11.0 to 24.7).

CONCLUSION

As a subset of periodontal microorganisms are associated with adverse systemic outcomes, antibody profiles may help in prediction of diabetes related mortality and identify sub-groups of individuals among whom periodontal treatment may impact diabetes related outcomes. This article is protected by copyright. All rights reserved.

Residential Segregation and Emergency Department Utilization Among an Underserved Urban Emergency Department Sample in North Carolina

BACKGROUND Residential segregation is a spatial manifestation of structural racism. Racial disparities in emergency department (ED) utilization mirror social inequity in the larger community. We evaluated associations between residential segregation and ED utilization in a community with known disparities and geographically concentrated social and health risk.METHODS Cross-sectional data were collected from electronic medical records of 101 060 adult ED patients living in Mecklenburg County, North Carolina in 2017. Community context was measured as residential segregation using the dissimilarity index, categorized into quintiles (Q1-Q5) using 2013-2017 American Community Survey estimates, and residency in a public health priority area (PHPA). The outcome was measured as total ED visits during the study period. Associations between community context and ED utilization were modeled using Anderson's behavioral model of health service utilization, and estimated using negative binomial regression, including interaction terms by race.RESULTS Compared to areas with the lowest proportions of Black residents (Q1), living in Q4 was associated with higher rates of ED utilization among Black/Other (AME = 0.11) and White (AME = 0.23) patients, while associations with living in Q5 were approximately equivalent (AME = 0.12). PHPA residency was associated with higher rates of ED utilization among Black/Other (AME = 0.10) and White patients (AME = 0.22).LIMITATIONS Associations should not be interpreted as causal, or be generalized to the larger community without ED utilization. Health system leakage is possible but limited.CONCLUSIONS Residential segregation is associated with higher rates of ED utilization, as are PHPA residency and other individual-level determinants.

Dietary Advanced Glycation End-Products and Mortality after Breast Cancer in the Women's Health Initiative

BACKGROUND

Advanced glycation end-products (AGE) are formed through nonenzymatic glycation of free amino groups in proteins or lipid. They are associated with inflammation and oxidative stress, and their accumulation in the body is implicated in chronic disease morbidity and mortality. We examined the association between postdiagnosis dietary Nε-carboxymethyl-lysine (CML)-AGE intake and mortality among women diagnosed with breast cancer.

METHODS

Postmenopausal women aged 50 to 79 years were enrolled in the Women's Health Initiative (WHI) between 1993 and 1998 and followed up until death or censoring through March 2018. We included 2,023 women diagnosed with first primary invasive breast cancer during follow-up who completed a food frequency questionnaire (FFQ) after diagnosis. Cox proportional hazards (PH) regression models estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) of association between tertiles of postdiagnosis CML-AGE intake and mortality risk from all causes, breast cancer, and cardiovascular disease.

RESULTS

After a median 15.1 years of follow-up, 630 deaths from all causes were reported (193 were breast cancer-related, and 129 were cardiovascular disease-related). Postdiagnosis CML-AGE intake was associated with all-cause (HRT3vsT1, 1.37; 95% CI, 1.09-1.74), breast cancer (HRT3vsT1, 1.49; 95% CI, 0.98-2.24), and cardiovascular disease (HRT3vsT1, 1.91; 95% CI, 1.09-3.32) mortality.

CONCLUSIONS

Higher intake of AGEs was associated with higher risk of major causes of mortality among postmenopausal women diagnosed with breast cancer.

IMPACT

Our findings suggest that dietary AGEs may contribute to the risk of mortality after breast cancer diagnosis. Further prospective studies examining dietary AGEs in breast cancer outcomes and intervention studies targeting dietary AGE reduction are needed to confirm our findings.

Social and demographic characteristics of frequent or high-charge emergency department users: A quantile regression application

OBJECTIVE

Heavy users of the emergency department (ED) are a heterogeneous population. Few studies have captured the social and demographic complexity of patients with the largest burden of ED use. Our objective was to model associations between social and demographic patient characteristics and quantiles of the distributions of ED use, defined as frequent and high-charge.

METHODS

We conducted a cross-sectional analysis of electronic health and billing records of 99 637 adults residing in an urban North Carolina county who visited an ED within Atrium Health, a large integrated health care system, in 2017. Mid-quantile and standard quantile regression models were used for count and continuous responses, respectively. Frequent and high-charge use outcomes were defined as the median (0.50) and upper quantiles (0.75, 0.95, 0.99) of the outcome distributions for total billed ED visits and associated charges during the study period. Patient characteristic predictors were: insurance coverage (Medicaid, Medicare, private, uninsured), total visits to ambulatory care during the study period (0, 1, >1), and patient demographics: age, gender, race, ethnicity, and living in an underprivileged community called a public health priority area (PHPA).

RESULTS

Results showed heterogeneous relationships that were stronger at higher quantiles. Having Medicaid or Medicare insurance was positively associated with ED visits and ED charges at most quantiles. Racial and geographic disparities were observed. Black patients had more ED visits and lower ED charges than their White counterparts at most quantiles of the outcome distributions. Patients living in PHPAs, had lower charges than their counterparts at the median but higher charges at the 0.95 and 0.99 quantiles.

CONCLUSIONS

The relationships between patient characteristics and frequent and high-charge use of the ED vary based on the level of use. These findings can be used to inform targeted interventions, tailored policy, and population health management initiatives.

Antidepressant Use Partially Mediates the Association Between Depression and Risk of Falls and Fall Injuries Among Older Adults

BACKGROUND

The association between depression and fall risk in older adults is recognized, yet the mechanisms underlying this association are unclear. This study estimated the mediating role of antidepressant use in the association between depression and falls and fall injuries.

METHODS

Longitudinal data from the Health and Retirement Study (2004-2006) were linked with medication data from the Prescription Drug Study (2005). The sample included community-dwelling adults aged ≥65 with data on depression and medication use (n = 3565). Depression was measured using 2 independent survey tools: Composite International Diagnostic Interview for depression short form and an 8-item version of the Center for Epidemiological Studies-Depression scale. We used causal mediation analysis to estimate and compare the direct and indirect (mediated by antidepressant use) effects of depression on falls and fall injuries.

RESULTS

Individuals with major depressive disorder were significantly more likely to experience a fall (OR: 1.92; 95% CI: 1.41, 2.62) and a fall injury (OR: 1.67; 95% CI: 1.09, 2.55) over 2 years. Indirect effect estimates showed that antidepressant medication use accounted for approximately 19% and 18% of the association between major depressive disorder and falls and fall injuries, respectively. Results were similar when using an alternative depression measure and when considering only selective serotonin reuptake inhibitor antidepressants.

CONCLUSIONS

Antidepressant use explains a significant proportion, but not a majority, of the association between depression and greater fall risk. Treatment benefits of antidepressants should be considered with, and may outweigh, concerns about increased risk of falls associated with antidepressant use.

Diabetes-Related Stigma and its Influence on Social Networks, Social Support, and HbA1c in Ghana

Objective

We applied a social network approach to examine if three types of diabetes-related stigma (self-stigma, perceived stigma and enacted stigma) moderated associations between social network characteristics (network size, kin composition, household composition, and network density), social support, and blood glucose among Ghanaians with type 2 diabetes mellitus (T2DM).

Methods

Data were obtained through a cross-sectional survey of 254 adults at a diabetes clinic in Ghana that assessed participants' social networks, social support, and frequency of experiencing three types of diabetes-related stigma.

Results

Self-stigma moderated associations between kin composition and social support when controlling for network size β=-.97, P=.004). Among study participants reporting low self-stigma, kin composition was positively associated with social support (β=1.29, P<.0001), but this association was not found among those reporting high self-stigma. Network size was positively associated with social support among participants reporting both low and high self-stigma. None of the types of diabetes-related stigma moderated other associations between social networks, social support, and blood glucose.

Conclusions

Individuals with T2DM who report high self-stigma may have lower social support, which can reduce their capacity for disease management. Additionally, larger social networks may be beneficial for individuals with T2DM in countries like Ghana, and interventions that expand network resources may facilitate diabetes control.

Association of Smokeless Tobacco Use With the Use of Other Illicit Drugs in the United States

BACKGROUND

There has been an increase in the use of smokeless tobacco recently. Whether smokeless tobacco use may predispose individuals to use other addictive substances is unknown. The use of multiple addictive substances may compound an individual's adverse health effects.

METHODS

In a cross-sectional analysis, we used the 2016-2017 Behavioral Risk Factor Surveillance System (BRFSS) survey database to identify all individuals who reported the use of smokeless tobacco and extracted data regarding baseline and demographic patterns, as well as information regarding the use of other addictive substances. Weighted multivariable logistic regression models adjusting for age, gender, race/ethnicity, poverty level, education, employment status, and marital status were used to determine the odds ratios (ORs) for use of alcohol, cigarettes, e-cigarettes, and marijuana among smokeless tobacco users.

RESULTS

We identified 30,395 (3.38%) individuals in our study population who reported smokeless tobacco use. Compared with non-users, smokeless tobacco users were more likely to be unmarried, male, Caucasian, belonging to the lower socioeconomic strata, and did not have a formal college education (P <0.01). In multivariable analyses, smokeless tobacco use was associated with a higher likelihood of cigarettes use (OR: 1.76 [95% confidence interval {CI}: 1.66-1.86, P <0.01]), e-cigarette use (OR: 1.61 [95% CI: 1.52-1.71, P <0.01]), and heavy alcohol consumption (OR:2.36 [95% CI: 2.17-2.56, P <0.01]) but not marijuana use (OR: 1.11 [95% CI: 0.90-1.38, P = 0.33]).

CONCLUSION

In a large, nationally representative sample, smokeless tobacco use was associated with the increased use of cigarettes, e-cigarettes, and alcohol. Simultaneous use of these substances may compound the adverse health effects of smokeless tobacco use. Public health interventions addressing this concerning trend are warranted.

Untreated Dental Caries May be Associated with Subsequent Mortality among Working-Age Adults: Evidence from NHANES III

OBJECTIVES

Poor oral health has been shown to be associated with selected adverse health outcomes. This study assessed the association between untreated dental caries and mortality and examined whether having dental insurance mitigates the risk of mortality among working-age US adults with dental caries.

METHODS

Analysis used the publicly available linked mortality file for NHANES III, an observational study conducted in 1988-1994, with follow-up through December 2015. Propensity score matching was conducted to create similar populations of insured and uninsured adults, resulting in a sample of 4420 matched observations. The Cox proportional hazard model was used to investigate the effect of untreated dental caries and that of dental insurance on risk of all-cause mortality. The descriptive and final outcome statistical analyses were adjusted for complex sampling technique using weights, strata and cluster variables.

RESULTS

Adults with untreated dental caries had a higher risk of mortality (HR: 1.33; 95% CI: 1.06-1.68) than those with no dental caries. Having dental insurance was associated with a lower risk of mortality (HR: 0.73; 95% CI: 0.59-0.92). An interaction between caries treatment status and dental insurance was not statistically significant.

CONCLUSIONS

Adults with untreated dental caries have a higher risk of mortality, even in the presence of dental insurance. Untreated caries may be an indicator for multiple risk factors, including personal attitudes regarding health and healthcare-seeking behaviour.

E-cigarette Use and Risk Behaviors among Lesbian, Gay, Bisexual, and Transgender Adults: The Behavioral Risk Factor Surveillance System (BRFSS) Survey

Introduction

The prevalence of e-cigarette use among lesbian, gay, bisexual, and transgender (LGBT) individuals and its association with risk behaviors was studied.

Methods

Using data from the Behavioral Risk Factor Surveillance System (BRFSS) survey, self-reported sexual orientation, e-cigarette use, cigarettes, marijuana, smokeless tobacco, and high-risk behavior (using non-prescribed drugs, treatment for sexually transmitted disease, or receiving monetary or drug compensation in exchange for sex in the previous year) were assessed. Multivariable-adjusted logistic regression models were used to study the association between LGBT and risk behaviors.

Results

The prevalence of e-cigarette use among LGBT adults was 13%, nearly twice that of heterosexual adults. LGBT adults were more likely [Odds Ratio (95% Confidence Interval)] to report current use of e-cigarettes 1.84 (1.64, 2.06), cigarettes 1.61 (1.49, 1.73), marijuana 2.37 (1.99, 2.82), and high-risk behavior 3.69 (3.40, 4.01) compared to heterosexual adults. Results for smokeless tobacco were not significant.

Conclusion

There are disparities in e-cigarette and other risk behaviors among LGBT adults, which may increase risk of adverse health effects in this vulnerable population.

Quantile regression to estimate the survivor average causal effect of periodontal treatment effects on birthweight and gestational age

BACKGROUND

Survival average causal effect (SACE) can give valid estimates of the periodontal treatment effect on birth outcomes in randomized controlled trials when fetal losses are unequal across the treatment arms. A regression-based method to estimate SACE using ordinary least squares (OLS) regression can be biased if the treatment effect varies across the outcome distribution. In this case quantile regression may be a suitable alternative.

METHODS

We compared OLS and quantile regression models estimating SACE to calculate the effect of periodontal treatment on birthweight and gestational age in secondary analyses of publicly available Obstetrics and Periodontal Therapy (OPT) trial data.

RESULTS

Periodontal treatment tended to increase birthweight and gestational age at the lowest quantiles, remained flat in the middle quantiles, and trended to decrease both birthweight and gestational age in the highest quantiles. In quantile regression models estimating SACE the β-coefficients: 95% confidence intervals (CI) for the 5th, 50th, and 95th percentiles were 277.5:  -141.0 to 696.0 g, 1.4: -107 to 110.3 g, and -84: -344 to 175.3 g for birthweight, and 0.6: -1.0 to 2.2 weeks, -0.1: -0.5 to 0.2 weeks, and -0.6: -1.0 to -0.1 weeks for gestational age. Estimates from OLS models estimating SACE were close to the null, β: 95% CI -4.7: 132.3 to 123.0 g for birthweight, and 0.03: -0.72 to 0.78 weeks for gestational age.

CONCLUSIONS

OLS models to evaluate SACE for periodontal treatment effects on birthweight and gestational age may be biased towards the null. Quantile regression may be a preferable alternative.

The role of dental insurance in mitigating mortality among working-age U.S. adults with periodontitis

AIM

To assess the relationship of dental insurance with all-cause mortality and mortality due to cardiovascular diseases (CVD), diabetes mellitus (DM), and cerebrovascular diseases (CBD) among those with periodontitis.

MATERIALS AND METHODS

NHANES III and its associated mortality data set were used in this study. The outcome variables were "all-cause mortality" and "combined mortality" due to CVD, DM, and CBD. The independent variable was dental insurance stratified over periodontitis status. Unweighted frequencies with weighted column percentages were used for descriptive statistics, and chi-square test was applied for significance. Cox proportional hazard models were used for stratified multivariable analyses. All analyses were performed in SAS v9.4 accounting for survey data complexities. Significance level was kept at 5%.

RESULTS

The mortality was 14.58% for all-cause mortality and 4.06% for combined mortality among those with periodontitis in this study. Dental insurance significantly reduced the hazard of all-cause mortality among those with periodontitis (HR: 0.75; 95% CI: 0.61 - 0.93), adjusted for covariates. However, no association of dental insurance with combined mortality was observed among periodontitis group.

CONCLUSIONS

Dental insurance reduces hazard of all-cause mortality among those with periodontitis. Dental insurance ensures access to dentists and improves oral and dental health. Longitudinal study is needed to establish causality.

Ambulatory care, insurance, and avoidable emergency department utilization in North Carolina

OBJECTIVE

To examine whether and how avoidable emergency department (ED) utilization is associated with ambulatory or primary care (APC) utilization, insurance, and interaction effects.

DESIGN AND SAMPLE

A cross-sectional analysis of electronic health records from 70,870 adults residing in Mecklenburg County, North Carolina, who visited an ED within a large integrated healthcare system in 2017.

METHODS

APC utilization was measured as total visits, categorized as: 0, 1, and > 1. Insurance was defined as the method of payment for the ED visit as: Medicaid, Medicare, private, or uninsured. Avoidable ED utilization was quantified as a score (aED), calculated as the sum of New York University Algorithm probabilities multiplied by 100. Quantile regression models were used to predict the 25th, 50th, 75th, 95th, and 99th percentiles of avoidable ED scores with APC visits and insurance as predictors (Model 1) and with an interaction term (Model 2).

RESULTS

Having >1 APC visit was negatively associated with aED at the lower percentiles and positively associated at higher percentiles. A higher aED was associated with having Medicaid insurance and a lower aED was associated with having private insurance, compared to being uninsured. In stratified models, having >1 APC visit was negatively associated with aED at the 25th percentile for the uninsured and privately insured, but positively associated with aED at higher percentiles among the uninsured, Medicaid-insured, and privately insured.

CONCLUSIONS

The association between APC utilization and avoidable ED utilization varied based on segments of the distribution of ED score and differed significantly by insurance type.

Temporal Trends in E-Cigarette Use Among U.S. Adults: Behavioral Risk Factor Surveillance System, 2016 to 2018

BACKGROUND

It is important to study the trends of e-cigarette use among various subgroups to understand which populations may be more susceptible to increased use and, therefore, are at risk for potential long-term health effects.

METHODS

We used cross-sectional data from the 2016-2017 Behavioral Risk Factor Surveillance System, a nationally representative U.S. telephone-based survey of adults aged 18 years or older. The 2017 dataset also includes data from participant interviews that had been conducted in the year 2018. Current e-cigarette use was defined as use of e-cigarettes every day or on some days. We analyzed data using survey weights to ensure representativeness of the data to the US population.

RESULTS

The study population consisted of 936,319 individuals, of whom 28,917 were current e-cigarette users, and corresponded to 10.8 million U.S. adults. Thirty percent were aged between 18 and 34 years. Forty-nine percent were men; 63% were white, 12% black, and 17% Hispanic. The overall prevalence of current e-cigarette use increased from 4.3% in 2016 to 4.8% in 2018. E-cigarette use significantly increased among middle-aged adults (from 3.9% to 5.2%; P = .004), women (from 3.3% to 4.3%; P <.001), and former smokers (from 5.2% to 7.9%; P = .02), but decreased among current smokers (from 14.5% to 13.8%; P = .02).

CONCLUSIONS

In a nationally representative sample, we found important trends in e-cigarette use in a relatively short time frame. A significantly increasing prevalence of e-cigarette use was noted among middle-age adults, women, and former smokers. Our study provides important information about e-cigarette trends that can be used by clinicians when counselling patients and by regulatory agencies to develop public policies.

The Association Between Periodontitis and Cardiovascular Disease: an Update

PURPOSE OF THE REVIEW

The purpose of this review is to provide an update on the data regarding periodontitis and its association with cardiovascular disease (CVD), as well as a closer look at the connection between periodontitis and valvular heart disease.

RECENT FINDINGS

The body of literature that demonstrates an association between periodontitis and CVD is growing, and there is increasing evidence that periodontal disease (PD) can have negative cardiovascular effects. Far less data is available for the management of periodontitis specifically in those with valvular heart disease. However, recent studies suggest that routine preoperative dental evaluation practices may not be necessary in all patients and, similar to changes in antibiotic prophylaxis, may only be indicated for a select group of individuals. There is a strong association between PD and CVD, although a causal relationship is yet to be elucidated. Further data is needed in this regard, as well as in determining the appropriate management of PD in those with valvular heart disease.

Abstract A43: Dietary advanced glycation end-products (AGEs) and breast cancer in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO)

Introduction: Advanced glycation end-products (AGEs) are implicated in chronic diseases and cancer. AGEs are produced endogenously but can also be consumed in foods. AGE formation in food is accelerated during cooking at high temperatures. The objective of the study is to assign and quantify dietary AGE (dAGE) content in food and investigate the association between dAGE intake and breast cancer risk in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO).

Methods: The PLCO enrolled women aged 55 to 74 years into a randomized controlled trial examining various cancer screening modalities. In this prospective analysis, the study sample included only women enrolled in the intervention arm who were cancer-free at baseline and completed a baseline questionnaire and food frequency questionnaire (DQX) (n=28,127). dAGE values were assigned and quantified to foods in the DQX using a published AGE database. Descriptive analysis was used to obtain means and percentages while Pearson correlation was used to obtain correlation coefficient of dAGE intake with dietary factors linked to AGEs.

Results: After a median 11.6 years of follow-up, 1,642 women were diagnosed with breast cancer. The average dAGE consumption among all the women was 11,355 KU/day (SD: 6614 KU/day) and ranged between 715 and 87,129 KU/day. A higher proportion of overweight and obese women, African American women, and women who were diagnosed with breast cancer during follow-up were in the higher quintile of dAGE intake as compared to the lowest quintile. Significant positive correlations were observed between dAGE intake and dietary sources of animal protein (0.74), monounsaturated fatty acids (MUFA) (0.83), polyunsaturated fatty acid (PUFA) (0.70), and saturated fatty acids (SF) (0.83), while the correlations between dAGE and fructose (0.12), carbohydrates (0.39), and plant protein (0.40) were weaker.

Conclusion: A higher proportion of women who were diagnosed with breast cancer during follow-up were in the highest quintile of dAGE intake at baseline compared to the lowest quintile. The strong positive correlation observed between dAGE and fat and protein intake reflects the high AGE levels found in meats, especially those cooked at high temperatures. Further analyses using Cox proportional hazards will be conducted examining the association between dAGE intake and breast cancer risk.

Citation Format: Omonefe O. Omofuma, David P. Turner, Lindsay L. Peterson, Anwar T. Merchant, Jiajia Zhang, Susan E. Steck. Dietary advanced glycation end-products (AGEs) and breast cancer in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO) [abstract]. In: Proceedings of the AACR Special Conference on Environmental Carcinogenesis: Potential Pathway to Cancer Prevention; 2019 Jun 22-24; Charlotte, NC. Philadelphia (PA): AACR; Can Prev Res 2020;13(7 Suppl): Abstract nr A43.

Dietary Advanced Glycation End-products (AGE) and Risk of Breast Cancer in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO)

Advanced glycation end-products (AGEs) are implicated in the pathogenesis of several chronic diseases including cancer. AGEs are produced endogenously but can also be consumed from foods. AGE formation in food is accelerated during cooking at high temperatures. Certain high fat or highly processed foods have high AGE values. The objective of the study was to assign and quantify N^ϵ-carboxymethyl-lysine (CML)-AGE content in food and investigate the association between dietary AGE intake and breast cancer risk in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. The study included women enrolled in the intervention arm who were cancer-free at baseline and completed a baseline questionnaire and food frequency questionnaire (DQX). CML-AGE values were assigned and quantified to foods in the DQX using a published AGE database. Cox proportional hazards models were used to estimate the hazard ratios (HR) and 95% confidence intervals (CI) of breast cancer among all women, and stratified by race/ethnicity, invasiveness of disease, and hormone receptor status. After a median 11.5 years of follow-up, 1,592 women were diagnosed with breast cancer. Higher CML-AGE intake was associated with increased risk of breast cancer among all women (HR_Q5VSQ1, 1.30; 95% CI, 1.04-1.62; P _trend = 0.04) and in non-Hispanic white women (HR_T3VST1, 1.21; 95% CI, 1.02-1.44). Increased CML-AGE intake was associated with increased risk of in situ (HR_T3VST1, 1.49; 95% CI, 1.11-2.01) and hormone receptor-positive (HR_T3VST1, 1.24; 95% CI, 1.01-1.53) breast cancers. In conclusion, high intake of dietary AGE may contribute to increased breast cancer.

Periodontal Antibodies and All-Cause and Cardiovascular Disease Mortality

Periodontitis is positively linked to cardiovascular disease (CVD), diabetes, cancer, and increased mortality. Empirically derived clusters of IgG antibodies against 19 selected periodontal microorganisms have been associated with hyperglycemia. We further investigated associations between these serum IgG antibody clusters and all-cause and CVD mortality in a representative US population. Participants free of CVD and cancer and aged ≥40 y at baseline (N = 6,491) from the Third National Health and Nutrition Examination Survey (1988 to 1994) were followed up until December 31, 2011. Antibodies were categorized into 4 clusters: red-green, orange-red, yellow-orange, and orange-blue. Over a 23-y follow-up, 2,702 deaths occurred, including 810 CVD-related deaths. In fully adjusted Cox proportional hazard models, the red-green cluster was positively associated with all-cause mortality (tertile 3 vs. tertile 1: hazard ratio [HR] = 1.43, 95% CI = 1.08 to 1.90, P = 0.015). The yellow-orange cluster was inversely associated with all-cause mortality (tertile 3 vs. tertile 1: HR = 0.78, 95% CI = 0.63 to 0.97, P = 0.028) and CVD mortality (tertile 2 vs. tertile 1: HR = 0.57, 95% CI = 0.42 to 0.77, P = 0.005). The orange-blue cluster (composed of antibodies against Eubacterium nodatum and Actinomyces naeslundii) was inversely associated with all-cause mortality (tertile 3 vs. tertile 1: HR = 0.65, 95% CI = 0.55 to 0.78, P < 0.0001) and CVD mortality (tertile 3 vs. tertile 1: HR = 0.65, 95% CI = 0.47 to 0.88, P = 0.007). These antibodies could predict prognosis or be potential intervention targets to prevent systemic effects of periodontal disease if further studies establish a causal relationship.

Association of dietary patterns and dietary diversity with cardiometabolic disease risk factors among adults in South Asia: The CARRS study

BACKGROUND AND OBJECTIVES

To investigate the association of dietary patterns and dietary diversity with cardiometabolic disease risk factors among South Asians.

METHODS AND STUDY DESIGN

In a population based study conducted in 2010-11, we recruited 16,287 adults aged >20 years residing in Delhi, Chennai, and Karachi. Diet was assessed using an interviewer-administered 26-item food frequency questionnaire. Principal component analysis identified three dietary patterns: Prudent, Indian, and Non-Vegetarian. We also computed a dietary diversity score. Multinomial and binary logistic regressions were used to calculate adjusted prevalence (95% confidence intervals) of cardio-metabolic disease risk factors across quartiles of dietary pattern and dietary diversity scores.

RESULTS

The adjusted prevalence of diagnosed diabetes was lower among participants in the highest versus lowest quartile of the Prudent Pattern (4.7% [3.8-5.6] versus 10.3% [8.5-12.0]), and the Indian Pattern (4.8% [3.7-5.9] versus 8.7% [6.7-10.6] in highest versus lowest quartile, respectively). Participants following the Indian Pattern also had lower adjusted prevalence of diagnosed hypertension (7.0% [5.4-8.5] versus 10.6% [8.6-12.5] in highest versus lowest quartile, respectively). Participants in the highest versus lowest quartile of the dietary diversity score had a lower adjusted prevalence of diagnosed diabetes (4.1% [3.0-5.2] versus 8.2% [7.1-9.3]), diagnosed hypertension (6.7% [5.3-8.1] versus 10.3% [9.1-11.5]), and undiagnosed hypertension (14.2% [12.0-16.4] versus 18.5% [16.9-20.1]).

CONCLUSIONS

High dietary diversity appears to be protective against cardio-metabolic disease risk factors in this urban cohort of South Asian adults. Further investigation to understand the underlying mechanism of this observation is warranted.

Serum IgG Antibodies against Periodontal Microbes and Cancer Mortality

INTRODUCTION

Periodontitis is a chronic inflammatory condition initiated by microorganisms and is positively linked to systemic conditions such as cancer, cardiovascular disease, and diabetes mellitus.

OBJECTIVES

To prospectively investigate associations between empirically derived clusters of IgG antibodies against 19 selected periodontal microorganisms and cancer mortality in a representative sample of the US population.

METHODS

We evaluated 6,491 participants aged ≥40 y from the Third National Health and Nutrition Examination Survey (1988 to 1994), who had complete data on IgG antibody titers against 19 selected periodontal microorganisms and were free of cardiovascular disease and cancer. In a prior study, antibodies were categorized into 4 mutually exclusive groups via cluster analysis: red-green, orange-red, yellow-orange, and orange-blue. Cluster scores were estimated by summing z scores of the antibody titers making up each cluster. Participants were followed up to death until December 31, 2011. Cox proportional hazard models were applied to estimate hazard ratios (HRs) and 95% CIs for all-cancer mortality by tertiles of cluster scores.

RESULTS

During follow-up for a median of 15.9 y, there were 2,702 deaths (31.3%), including 631 cancer-related deaths (8.1%). After adjusting for multiple confounders, the orange-blue cluster was inversely associated with cancer mortality (tertile 2 vs. tertile 1: HR = 0.67, 95% CI = 0.54 to 0.84; tertile 3 vs tertile 1: HR = 0.62, 95% CI = 0.46 to 0.84). The association between the yellow-orange cluster and all-cancer mortality was also inverse but not significant, and the orange-red cluster and the red-green cluster were not associated with all-cancer mortality.

CONCLUSIONS

Antibodies against Eubacterium nodatum and Actinomyces naeslundii may be novel predictors of cancer mortality. If further studies establish a causal relationship between these antibodies and cancer mortality, they could be targets to prevent possible systemic effects of periodontal disease with potential interventions to raise their levels.

KNOWLEDGE TRANSFER STATEMENT

Periodontal antibodies against Eubacterium nodatum and Actinomyces naeslundii were inversely associated with cancer mortality among adults followed up for an average of 16 y. Periodontal antibodies may predict cancer mortality.

Burden of Cardiovascular Risk Factors Over Time and Arterial Stiffness in Youth With Type 1 Diabetes Mellitus: The SEARCH for Diabetes in Youth Study

Background The incidence of type 1 diabetes mellitus (T1DM) in children is increasing, resulting in higher burden of cardiovascular diseases due to diabetes mellitus-related vascular dysfunction. Methods and Results We examined cardiovascular risk factors ( CVRF s) and arterial parameters in 1809 youth with T1DM. Demographics, anthropometrics, blood pressure, and laboratory data were collected at T1DM onset and 5 years later. Pulse wave velocity and augmentation index were collected with tonometry. ANOVA or chi-square tests were used to test for differences in measures of arterial parameters by CVRF . Area under the curve of CVRF s was entered in general linear models to explore determinants of accelerate vascular aging. Participants at the time of arterial measurement were 17.6±4.5 years old, 50% female, 76% non-Hispanic white, and duration of T1DM was 7.8±1.9 years. Glycemic control was poor (glycated hemoglobin, 9.1±1.8%). All arterial parameters were higher in participants with glycated hemoglobin ≥9% and pulse wave velocity was higher with lower insulin sensitivity or longer duration of diabetes mellitus. Differences in arterial parameters were found by sex, age, and presence of obesity, hypertension, or dyslipidemia. In multivariable models, higher glycated hemoglobin, lower insulin sensitivity, body mass index, blood pressure, and lipid areas under the curve were associated with accelerated vascular aging. Conclusions In young people with T1DM, persistent poor glycemic control and higher levels of traditional CVRF s are independently associated with arterial aging. Improving glycemic control and interventions to lower CVRF s may prevent future cardiovascular events in young individuals with T1DM.

Inflammatory Potential of Diet, Inflammation-Related Lifestyle Factors, and Risk of Pancreatic Cancer: Results from the NIH-AARP Diet and Health Study

BACKGROUND

Chronic inflammation is implicated in pancreatic cancer, and can be modulated by diet and other lifestyle factors. We examined the association between Dietary Inflammatory Index (DII) scores and pancreatic cancer risk in the NIH-AARP Diet and Health Study, and examined effect modification by inflammation-related lifestyle factors, including body mass index, cigarette smoking, diabetes, alcohol drinking, and use of non-steroidal anti-inflammatory drugs.

METHODS

Energy-adjusted DII scores (E-DII) were computed on the basis of food frequency questionnaire responses for foods and dietary supplements. Cox proportional hazards models were fitted and effect modification was examined by adding a cross-product of each effect modifier with E-DII quintile in the multivariable-adjusted model.

RESULTS

There were 2,824 primary incident pancreatic cancers diagnosed during a median of 13.4 years follow-up, and there was no association between E-DII scores and pancreatic cancer risk among either men [HR_Q5vsQ1, 1.00; 95% confidence interval (CI), 0.86-1.16] or women (HR_Q5vsQ1, 1.00; 95% CI, 0.82-1.21) in the multivariable-adjusted model, and no association was detected by any cancer stage. The E-DII and pancreatic cancer association was not modified by any of the inflammation-related lifestyle factors examined.

CONCLUSIONS

Results from this large prospective study did not support an association between inflammatory potential of diet and pancreatic cancer, or effect modification by other inflammation-related lifestyle factors.

IMPACT

Inflammatory potential of diet may not be related to pancreatic cancer risk. Future cohort studies with more frequent dietary measures could be useful in determining the appropriate timing of dietary intake in relation to pancreatic cancer etiology.