Parks, Trails, and Greenways for Physical Activity: A Community Guide Systematic Economic Review

INTRODUCTION

This systematic economic review examined the cost-benefit and cost-effectiveness of park, trail, and greenway infrastructure interventions to increase physical activity or infrastructure use.

METHODS

The search period covered the date of inception of publications databases through February 2022. Inclusion was limited to studies that reported cost-benefit or cost-effectiveness outcomes and were based in the U.S. and other high-income countries. Analyses were conducted from March 2022 through December 2022. All monetary values reported are in 2021 U.S. dollars.

RESULTS

The search yielded 1 study based in the U.S. and 7 based in other high-income countries, with 1 reporting cost-effectiveness and 7 reporting cost-benefit outcomes. The cost-effectiveness study based in the United Kingdom reported $23,254 per disability-adjusted life year averted. The median benefit-to-cost ratio was 3.1 (interquartile interval=2.9-3.9) on the basis of 7 studies.

DISCUSSION

The evidence shows that economic benefits exceed the intervention cost of park, trail, and greenway infrastructure. Given large differences in the size of infrastructure, intervention costs and economic benefits varied substantially across studies. There was insufficient number of studies to determine the cost-effectiveness of these interventions.

Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Enhancing grant-writing expertise in BUILD institutions: Building infrastructure leading to diversity

BACKGROUND

The lack of race/ethnic and gender diversity in grants funded by the National Institutes of Health (NIH) is a persistent challenge related to career advancement and the quality and relevance of health research. We describe pilot programs at nine institutions supported by the NIH-sponsored Building Infrastructure Leading to Diversity (BUILD) program aimed at increasing diversity in biomedical research.

METHODS

We collected data from the 2016-2017 Higher Education Research Institute survey of faculty and NIH progress reports for the first four years of the program (2015-2018). We then conducted descriptive analyses of data from the nine BUILD institutions that had collected data and evaluated which activities were associated with research productivity. We used Poisson regression and rate ratios of the numbers of BUILD pilots funded, students included, abstracts, presentations, publications, and submitted and funded grant proposals.

RESULTS

Teaching workshops were associated with more abstracts (RR 4.04, 95% CI 2.21-8.09). Workshops on grant writing were associated with more publications (RR 2.64, 95% CI 1.64-4.34) and marginally with marginally more presentations. Incentives to develop courses were associated with more abstracts published (RR 4.33, 95% CI 2.56-7.75). Workshops on research skills and other incentives were not associated with any positive effects.

CONCLUSIONS

Pilot interventions show promise in supporting diversity in NIH-level research. Longitudinal modeling that considers time lags in career development in moving from project development to grants submissions can provide more direction for future diversity pilot interventions.

Exercise/Physical Activity in Individuals with Type 2 Diabetes: A Consensus Statement from the American College of Sports Medicine

ABSTRACT

This consensus statement is an update of the 2010 American College of Sports Medicine position stand on exercise and type 2 diabetes. Since then, a substantial amount of research on select topics in exercise in individuals of various ages with type 2 diabetes has been published while diabetes prevalence has continued to expand worldwide. This consensus statement provides a brief summary of the current evidence and extends and updates the prior recommendations. The document has been expanded to include physical activity, a broader, more comprehensive definition of human movement than planned exercise, and reducing sedentary time. Various types of physical activity enhance health and glycemic management in people with type 2 diabetes, including flexibility and balance exercise, and the importance of each recommended type or mode are discussed. In general, the 2018 Physical Activity Guidelines for Americans apply to all individuals with type 2 diabetes, with a few exceptions and modifications. People with type 2 diabetes should engage in physical activity regularly and be encouraged to reduce sedentary time and break up sitting time with frequent activity breaks. Any activities undertaken with acute and chronic health complications related to diabetes may require accommodations to ensure safe and effective participation. Other topics addressed are exercise timing to maximize its glucose-lowering effects and barriers to and inequities in physical activity adoption and maintenance.

Supporting Biomedical Research Training for Historically Underrepresented Undergraduates Using Interprofessional, Nonformal Education Structures

Research experience provides critical training for new biomedical research scientists. Students from underrepresented populations studying science, technology, engineering, and mathematics (STEM) are increasingly recruited into research pathways to diversify STEM fields. However, support structures outside of research settings designed to help these students navigate biomedical research pathways are not always available; nor are program support components outside the context of laboratory technical skills training and formal mentorship well understood. This study leveraged a multi-institutional research training program, Enhancing Cross-Disciplinary Infrastructure and Training at Oregon (EXITO), to explore how nine institutions designed a new curricular structure (Enrichment) to meet a common goal of enhancing undergraduate research training and student success. EXITO undergraduates participated in a comprehensive, 3-year research training program with the Enrichment component offered across nine sites: three universities and six community colleges, highly diverse in size, demographics, and location. Sites' approaches to supporting students in the training program were studied over a 30-month period. All sites independently created their own nonformal curricular structures, implemented interprofessionally via facilitated peer groups. Site data describing design and implementation were thematically coded to identify essential programmatic components across sites, with student feedback used to triangulate findings. Enrichment offered students time to critically reflect on their interests, experiences, and identities in research; network with peers and professionals; and support negotiation of hidden and implicit curricula. Students reported the low-pressure setting and student-centered curriculum balanced the high demands associated with academics and research. Core curricular themes described Enrichment as fostering a sense of community among students, exposing students to career paths and skills, and supporting development of students' professional identities. The non-formal, interprofessional curricula enabled students to model diverse biomedical identities and pathways for each other while informing institutional structures to improve diverse undergraduate students' success in academia and research.

Men and Oral Health: A Review of Sex and Gender Differences

Sex and gender related health disparities in oral health remain an underappreciated and often over looked aspect of well-being. The goal of this narrative review is to identify sex and gender related oral health disparities by summarizing the current literature related to differences in oral health between men and women. The review identified that men are more likely to: ignore their oral health, have poorer oral hygiene habits, and experience higher rates of periodontal disease, oral cancer, and dental trauma. Men also visit dentists less frequently and compared to women seek oral treatment more often for an acute problem and less often for disease prevention. Women exhibit more positive attitudes about dental visits, greater oral health literacy, and demonstrate better oral health behaviors than men. Men disproportionately develop periodontal diseases due to a combination of biological and gender related reasons including immune system factors, hormone differences, poorer oral hygiene behaviors, and greater tobacco use. There is a male to female ratio of 2:1 for oral cancer, largely attributable to more tobacco use, heavier use of alcohol, and longer sun exposure. Minority men experience a disproportionate burden of oral health disparities because of both their gender and race/ethnic identities. In conclusion, this review identifies several differences between men and women related to oral health and highlights the need for further research to better understand these disparities and how to incorporate them into developing prevention, education and treatment strategies to improve oral health in men.

New research directions on disparities in obesity and type 2 diabetes

Obesity and type 2 diabetes disproportionately impact U.S. racial and ethnic minority communities and low-income populations. Improvements in implementing efficacious interventions to reduce the incidence of type 2 diabetes are underway (i.e., the National Diabetes Prevention Program), but challenges in effectively scaling-up successful interventions and reaching at-risk populations remain. In October 2017, the National Institutes of Health convened a workshop to understand how to (1) address socioeconomic and other environmental conditions that perpetuate disparities in the burden of obesity and type 2 diabetes; (2) design effective prevention and treatment strategies that are accessible, feasible, culturally relevant, and acceptable to diverse population groups; and (3) achieve sustainable health improvement approaches in communities with the greatest burden of these diseases. Common features of guiding frameworks to understand and address disparities and promote health equity were described. Promising research directions were identified in numerous areas, including study design, methodology, and core metrics; program implementation and scalability; the integration of medical care and social services; strategies to enhance patient empowerment; and understanding and addressing the impact of psychosocial stress on disease onset and progression in addition to factors that support resiliency and health.

World Health Organization cardiovascular disease risk charts: revised models to estimate risk in 21 global regions

BACKGROUND

To help adapt cardiovascular disease risk prediction approaches to low-income and middle-income countries, WHO has convened an effort to develop, evaluate, and illustrate revised risk models. Here, we report the derivation, validation, and illustration of the revised WHO cardiovascular disease risk prediction charts that have been adapted to the circumstances of 21 global regions.

METHODS

In this model revision initiative, we derived 10-year risk prediction models for fatal and non-fatal cardiovascular disease (ie, myocardial infarction and stroke) using individual participant data from the Emerging Risk Factors Collaboration. Models included information on age, smoking status, systolic blood pressure, history of diabetes, and total cholesterol. For derivation, we included participants aged 40-80 years without a known baseline history of cardiovascular disease, who were followed up until the first myocardial infarction, fatal coronary heart disease, or stroke event. We recalibrated models using age-specific and sex-specific incidences and risk factor values available from 21 global regions. For external validation, we analysed individual participant data from studies distinct from those used in model derivation. We illustrated models by analysing data on a further 123 743 individuals from surveys in 79 countries collected with the WHO STEPwise Approach to Surveillance.

FINDINGS

Our risk model derivation involved 376 177 individuals from 85 cohorts, and 19 333 incident cardiovascular events recorded during 10 years of follow-up. The derived risk prediction models discriminated well in external validation cohorts (19 cohorts, 1 096 061 individuals, 25 950 cardiovascular disease events), with Harrell's C indices ranging from 0·685 (95% CI 0·629-0·741) to 0·833 (0·783-0·882). For a given risk factor profile, we found substantial variation across global regions in the estimated 10-year predicted risk. For example, estimated cardiovascular disease risk for a 60-year-old male smoker without diabetes and with systolic blood pressure of 140 mm Hg and total cholesterol of 5 mmol/L ranged from 11% in Andean Latin America to 30% in central Asia. When applied to data from 79 countries (mostly low-income and middle-income countries), the proportion of individuals aged 40-64 years estimated to be at greater than 20% risk ranged from less than 1% in Uganda to more than 16% in Egypt.

INTERPRETATION

We have derived, calibrated, and validated new WHO risk prediction models to estimate cardiovascular disease risk in 21 Global Burden of Disease regions. The widespread use of these models could enhance the accuracy, practicability, and sustainability of efforts to reduce the burden of cardiovascular disease worldwide.

FUNDING

World Health Organization, British Heart Foundation (BHF), BHF Cambridge Centre for Research Excellence, UK Medical Research Council, and National Institute for Health Research.

Equalization of four cardiovascular risk algorithms after systematic recalibration: individual-participant meta-analysis of 86 prospective studies

AIMS

There is debate about the optimum algorithm for cardiovascular disease (CVD) risk estimation. We conducted head-to-head comparisons of four algorithms recommended by primary prevention guidelines, before and after 'recalibration', a method that adapts risk algorithms to take account of differences in the risk characteristics of the populations being studied.

METHODS AND RESULTS

Using individual-participant data on 360 737 participants without CVD at baseline in 86 prospective studies from 22 countries, we compared the Framingham risk score (FRS), Systematic COronary Risk Evaluation (SCORE), pooled cohort equations (PCE), and Reynolds risk score (RRS). We calculated measures of risk discrimination and calibration, and modelled clinical implications of initiating statin therapy in people judged to be at 'high' 10 year CVD risk. Original risk algorithms were recalibrated using the risk factor profile and CVD incidence of target populations. The four algorithms had similar risk discrimination. Before recalibration, FRS, SCORE, and PCE over-predicted CVD risk on average by 10%, 52%, and 41%, respectively, whereas RRS under-predicted by 10%. Original versions of algorithms classified 29-39% of individuals aged ≥40 years as high risk. By contrast, recalibration reduced this proportion to 22-24% for every algorithm. We estimated that to prevent one CVD event, it would be necessary to initiate statin therapy in 44-51 such individuals using original algorithms, in contrast to 37-39 individuals with recalibrated algorithms.

CONCLUSION

Before recalibration, the clinical performance of four widely used CVD risk algorithms varied substantially. By contrast, simple recalibration nearly equalized their performance and improved modelled targeting of preventive action to clinical need.

Cardiovascular Risk Factors Associated With Venous Thromboembolism

Importance

It is uncertain to what extent established cardiovascular risk factors are associated with venous thromboembolism (VTE).

Objective

To estimate the associations of major cardiovascular risk factors with VTE, ie, deep vein thrombosis and pulmonary embolism.

Design, Setting, and Participants

This study included individual participant data mostly from essentially population-based cohort studies from the Emerging Risk Factors Collaboration (ERFC; 731 728 participants; 75 cohorts; years of baseline surveys, February 1960 to June 2008; latest date of follow-up, December 2015) and the UK Biobank (421 537 participants; years of baseline surveys, March 2006 to September 2010; latest date of follow-up, February 2016). Participants without cardiovascular disease at baseline were included. Data were analyzed from June 2017 to September 2018.

Exposures

A panel of several established cardiovascular risk factors.

Main Outcomes and Measures

Hazard ratios (HRs) per 1-SD higher usual risk factor levels (or presence/absence). Incident fatal outcomes in ERFC (VTE, 1041; coronary heart disease [CHD], 25 131) and incident fatal/nonfatal outcomes in UK Biobank (VTE, 2321; CHD, 3385). Hazard ratios were adjusted for age, sex, smoking status, diabetes, and body mass index (BMI).

Results

Of the 731 728 participants from the ERFC, 403 396 (55.1%) were female, and the mean (SD) age at the time of the survey was 51.9 (9.0) years; of the 421 537 participants from the UK Biobank, 233 699 (55.4%) were female, and the mean (SD) age at the time of the survey was 56.4 (8.1) years. Risk factors for VTE included older age (ERFC: HR per decade, 2.67; 95% CI, 2.45-2.91; UK Biobank: HR, 1.81; 95% CI, 1.71-1.92), current smoking (ERFC: HR, 1.38; 95% CI, 1.20-1.58; UK Biobank: HR, 1.23; 95% CI, 1.08-1.40), and BMI (ERFC: HR per 1-SD higher BMI, 1.43; 95% CI, 1.35-1.50; UK Biobank: HR, 1.37; 95% CI, 1.32-1.41). For these factors, there were similar HRs for pulmonary embolism and deep vein thrombosis in UK Biobank (except adiposity was more strongly associated with pulmonary embolism) and similar HRs for unprovoked vs provoked VTE. Apart from adiposity, these risk factors were less strongly associated with VTE than CHD. There were inconsistent associations of VTEs with diabetes and blood pressure across ERFC and UK Biobank, and there was limited ability to study lipid and inflammation markers.

Conclusions and Relevance

Older age, smoking, and adiposity were consistently associated with higher VTE risk.

Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies

BACKGROUND

Low-risk limits recommended for alcohol consumption vary substantially across different national guidelines. To define thresholds associated with lowest risk for all-cause mortality and cardiovascular disease, we studied individual-participant data from 599 912 current drinkers without previous cardiovascular disease.

METHODS

We did a combined analysis of individual-participant data from three large-scale data sources in 19 high-income countries (the Emerging Risk Factors Collaboration, EPIC-CVD, and the UK Biobank). We characterised dose-response associations and calculated hazard ratios (HRs) per 100 g per week of alcohol (12·5 units per week) across 83 prospective studies, adjusting at least for study or centre, age, sex, smoking, and diabetes. To be eligible for the analysis, participants had to have information recorded about their alcohol consumption amount and status (ie, non-drinker vs current drinker), plus age, sex, history of diabetes and smoking status, at least 1 year of follow-up after baseline, and no baseline history of cardiovascular disease. The main analyses focused on current drinkers, whose baseline alcohol consumption was categorised into eight predefined groups according to the amount in grams consumed per week. We assessed alcohol consumption in relation to all-cause mortality, total cardiovascular disease, and several cardiovascular disease subtypes. We corrected HRs for estimated long-term variability in alcohol consumption using 152 640 serial alcohol assessments obtained some years apart (median interval 5·6 years [5th-95th percentile 1·04-13·5]) from 71 011 participants from 37 studies.

FINDINGS

In the 599 912 current drinkers included in the analysis, we recorded 40 310 deaths and 39 018 incident cardiovascular disease events during 5·4 million person-years of follow-up. For all-cause mortality, we recorded a positive and curvilinear association with the level of alcohol consumption, with the minimum mortality risk around or below 100 g per week. Alcohol consumption was roughly linearly associated with a higher risk of stroke (HR per 100 g per week higher consumption 1·14, 95% CI, 1·10-1·17), coronary disease excluding myocardial infarction (1·06, 1·00-1·11), heart failure (1·09, 1·03-1·15), fatal hypertensive disease (1·24, 1·15-1·33); and fatal aortic aneurysm (1·15, 1·03-1·28). By contrast, increased alcohol consumption was log-linearly associated with a lower risk of myocardial infarction (HR 0·94, 0·91-0·97). In comparison to those who reported drinking >0-≤100 g per week, those who reported drinking >100-≤200 g per week, >200-≤350 g per week, or >350 g per week had lower life expectancy at age 40 years of approximately 6 months, 1-2 years, or 4-5 years, respectively.

INTERPRETATION

In current drinkers of alcohol in high-income countries, the threshold for lowest risk of all-cause mortality was about 100 g/week. For cardiovascular disease subtypes other than myocardial infarction, there were no clear risk thresholds below which lower alcohol consumption stopped being associated with lower disease risk. These data support limits for alcohol consumption that are lower than those recommended in most current guidelines.

FUNDING

UK Medical Research Council, British Heart Foundation, National Institute for Health Research, European Union Framework 7, and European Research Council.

Enhancing Institutional Research Capacity: Results and Lessons from a Pilot Project Program

The National Institutes of Health (NIH) established the Building University Infrastructure Leading to Diversity (BUILD) initiative to increase engagement and retention of undergraduates from diverse backgrounds in biomedical research. Portland State University, in partnership with ten other academic institutions, received a BUILD award and developed the BUILD EXITO (Enhancing Cross-Disciplinary Infrastructure and Training at Oregon) project. The EXITO program offers a three-year research and mentorship experience for undergraduates in biomedical, behavioral, social science, clinical, and bioengineering disciplines. The BUILD initiative also emphasizes enhancing research capacity and infrastructure through institutional change and faculty development. A key piece of EXITO's program to enhance research capacity is offering faculty an opportunity to apply for up to $50,000 of funding to carry out a one-year pilot study. We conducted two separate RFAs for this purpose, closely modeled on NIH's Small Grant Program (R03), over two years. Principal Investigators of pilot projects were encouraged to include EXITO students, or other undergraduate students, on their research teams. Students then worked on these research projects as part of EXITO's intensive mentored research program. This paper reports on methods to conduct and implement a pilot project program intended to train primarily junior faculty members to write and submit an NIH proposal and fund successful applicants to gather pilot project data to aid in applying for future proposals. We provided a step-by-step rigorous submission and review process. We provided proposal writing and revising workshops, technical support, and helped pilot project Principal Investigators (PIs) with biosketches, IRB applications, IUCUC documents, budgets, and other proposal sections. We secured at least three external (not at any BUILD EXITO institution) reviewers for each proposal. PIs revised proposals before resubmitting and receiving their final scores. Across two RFAs, we provided funds twenty PIs to conduct pilot projects; these projects included at least 21 students working on them who received mentoring in research methods and in disseminating results. This paper describes important lessons learned, including the importance of: allotting sufficient time to recruit reviewers; recruiting reviewers through a variety of sources and methods; and assisting PIs in engaging with research administration staff at Portland State University and partner institutions. Challenges included: finding an optimal timeline that was neither too compressed nor too stretched out; encouraging applicants from distant partner institutions to apply and keeping them engaged and retained through the entire process; and assisting PIs from partner institutions to efficiently utilize Portland State University's sponsored projects department if similar resources were not available at their home institutions. Our goal is to provide guidance and insights to faculty and research-administration staff at other institutions interested in replicating or adapting EXITO's program to enhance institutional research capacity.

BUILD EXITO: a multi-level intervention to support diversity in health-focused research

Background and purpose

As part of the NIH BUILD initiative to diversify the scientific workforce, the EXITO project is a large multi-institutional effort to provide comprehensive support and training for undergraduates from traditionally underrepresented student populations who aspire to health-related research careers. Portland State University, a major public urban university that prioritizes student access and opportunity, and Oregon Health & Science University, a research-intensive academic health center, lead the EXITO network comprised of eleven 2-year and 4-year institutions of higher education spanning Oregon, Washington, Alaska, Hawaii, Guam, American Samoa, and the Northern Mariana Islands. The EXITO project aims for impact in biomedical research by training diverse scholars from indigenous and underserved communities affected by adverse health disparities.

Project approach

Guided by socio-ecological theory, the EXITO project is a multi-level intervention offering a three-year research training pathway for scholars in the biomedical, behavioral, health, and social sciences. Fundamental components of the model include student outreach and engagement, integrated curricular enhancements, intensive research experiences, multi-faceted developmental mentoring, supportive community and services, and rigorous evaluation and quality improvement. EXITO also advances faculty and institutional development in these domains by holding curriculum development conferences, creating research learning communities, awarding pilot project research funding, providing mentor training and ongoing support, collaborating with other research equity programs, and developing campus infrastructure and services to support scholars with diverse backgrounds and needs.

Highlights

The large and geographically broad network of EXITO institutions engages a range of diverse students, including indigenous populations and students beginning post-secondary education at community colleges. The EXITO model specifically accommodates many students transferring from 2-year partner institutions and facilitates seamless transfer to the 4-year institution. EXITO features several approaches to research training, including supported summer entry into research placements, the incorporation of responsible conduct of research content into general education curriculum, and the intentional matching of scholars with three types of mentors (e.g., peer, career, research).

Implications

EXITO provides an example of a comprehensive research training initiative for traditionally underrepresented students that can be implemented across a diverse range of 2-year and 4-year institutions.

Association of Cardiometabolic Multimorbidity With Mortality

IMPORTANCE

The prevalence of cardiometabolic multimorbidity is increasing.

OBJECTIVE

To estimate reductions in life expectancy associated with cardiometabolic multimorbidity.

DESIGN, SETTING, AND PARTICIPANTS

Age- and sex-adjusted mortality rates and hazard ratios (HRs) were calculated using individual participant data from the Emerging Risk Factors Collaboration (689,300 participants; 91 cohorts; years of baseline surveys: 1960-2007; latest mortality follow-up: April 2013; 128,843 deaths). The HRs from the Emerging Risk Factors Collaboration were compared with those from the UK Biobank (499,808 participants; years of baseline surveys: 2006-2010; latest mortality follow-up: November 2013; 7995 deaths). Cumulative survival was estimated by applying calculated age-specific HRs for mortality to contemporary US age-specific death rates.

EXPOSURES

A history of 2 or more of the following: diabetes mellitus, stroke, myocardial infarction (MI).

MAIN OUTCOMES AND MEASURES

All-cause mortality and estimated reductions in life expectancy.

RESULTS

In participants in the Emerging Risk Factors Collaboration without a history of diabetes, stroke, or MI at baseline (reference group), the all-cause mortality rate adjusted to the age of 60 years was 6.8 per 1000 person-years. Mortality rates per 1000 person-years were 15.6 in participants with a history of diabetes, 16.1 in those with stroke, 16.8 in those with MI, 32.0 in those with both diabetes and MI, 32.5 in those with both diabetes and stroke, 32.8 in those with both stroke and MI, and 59.5 in those with diabetes, stroke, and MI. Compared with the reference group, the HRs for all-cause mortality were 1.9 (95% CI, 1.8-2.0) in participants with a history of diabetes, 2.1 (95% CI, 2.0-2.2) in those with stroke, 2.0 (95% CI, 1.9-2.2) in those with MI, 3.7 (95% CI, 3.3-4.1) in those with both diabetes and MI, 3.8 (95% CI, 3.5-4.2) in those with both diabetes and stroke, 3.5 (95% CI, 3.1-4.0) in those with both stroke and MI, and 6.9 (95% CI, 5.7-8.3) in those with diabetes, stroke, and MI. The HRs from the Emerging Risk Factors Collaboration were similar to those from the more recently recruited UK Biobank. The HRs were little changed after further adjustment for markers of established intermediate pathways (eg, levels of lipids and blood pressure) and lifestyle factors (eg, smoking, diet). At the age of 60 years, a history of any 2 of these conditions was associated with 12 years of reduced life expectancy and a history of all 3 of these conditions was associated with 15 years of reduced life expectancy.

CONCLUSIONS AND RELEVANCE

Mortality associated with a history of diabetes, stroke, or MI was similar for each condition. Because any combination of these conditions was associated with multiplicative mortality risk, life expectancy was substantially lower in people with multimorbidity.

Association of body mass index with cardiovascular disease biomarkers

BACKGROUND

Few studies have examined the underweight-morbidity relationship, and those that have were conducted in non-U.S. populations and limited in their evaluation of cardiovascular disease (CVD) risk factors.

PURPOSE

To examine the associations among underweight (along with overweight and obese) and various CVD risk factors in a national sample of U.S. adults (aged ≥20 years).

METHODS

Ten years of data (1999-2010) from the National Health and Nutrition Examination Survey were used (analyzed in 2014). Underweight (tertiles); overweight (25-29.9); and obesity (three classes: 30-34.9, 35-39.9, and ≥40) were assessed from measured BMI. The evaluated biological and anthropometric markers included waist circumference; mean arterial pressure; C-reactive protein (CRP); fasting low-density lipoprotein (LDL) cholesterol; total cholesterol; fasting triglycerides; and fasting glucose.

RESULTS

After adjustments, underweight adults had significantly (p<0.005) lower levels of CRP (β=-0.12, Tertile 2); total cholesterol (β=-17.7 and -12.2, Tertiles 1 and 3); total cholesterol to high-density lipoprotein cholesterol ratio (β=-0.39 and -0.46, Tertiles 2 and 3); LDL cholesterol (β=-20.7, Tertile 1); and triglycerides (β=-37.1 and -18.0, Tertiles 1 and 3) compared to normal-weight individuals. The severely underweight and obese were less likely to be physically active than normal-weight adults (p<0.001). Adults in each of the overweight and obese groups had higher levels for each biomarker compared to normal-weight individuals.

CONCLUSIONS

Underweight adults have lower (i.e., more favorable) levels of various CVD biomarkers.

Association of Concurrent Healthy Eating and Regular Physical Activity With Cardiovascular Disease Risk Factors in U.S. Youth

PURPOSE

Examine whether concurrently consuming a healthy diet and regularly being physically active among U.S. youth is more favorably associated with cardiovascular disease (CVD) biomarkers than other physical activity and dietary patterns.

DESIGN

Cross-sectional.

SETTING

United States (National Health and Nutrition Examination Survey) 2003-2006.

SUBJECTS

Two thousand six hundred twenty-nine youth (6-17 years).

MEASURES

Healthy Eating Index (HEI), accelerometer-determined physical activity, biomarkers, and anthropometry. Four categories were created: consuming a healthy diet (top 40% of HEI) and active (sufficient to meet guidelines); unhealthy diet and active; healthy diet and inactive; and unhealthy diet and inactive.

ANALYSIS

Multivariable regression.

RESULTS

Children consuming a healthy diet and who were active had significantly lower waist circumference (β = -5.5, p < .006), C-reactive protein (CRP) (β = -.2, p < .006), and triglycerides (β = -27.9, p < .006) than children consuming an unhealthy diet and who were inactive. Children engaging in both healthy behaviors had significantly lower CRP (β = -.11, p < .001) and total cholesterol levels (β = -7.8, p = .004) than those only engaging in sufficient activity; there were no significant differences in biomarker levels among children engaging in both healthy behaviors and those only consuming a healthy diet. No associations were significant for adolescents.

CONCLUSION

Concurrent healthy eating and regular physical activity among children is favorably associated with CVD biomarkers when compared with unhealthy diet and inactivity.

Assessing arsenic exposure from consumption of seafood from Vieques-Puerto Rico: a pilot biomonitoring study using different biomarkers

The various toxic effects associated with inorganic arsenic (iAs) warrants that exposure sources be identified. This pilot study evaluated if greater seafood consumption from Vieques-Puerto Rico is associated with increased exposure to iAs. Nail, hair, and urine samples were used as biomarkers of iAs exposure in adult women and men from Vieques classified as high (n = 31) and low (n = 21) seafood consumers, who reported eating fish and/or shellfish ≥1 time per week and once per month or less, respectively. The sum of urinary iAs (As III + As V), monomethylarsonic acid (MA[V]), and dimethylarsinic acid (DMA[V]), denoted as SumAs, fluctuated from 3.3 µg/g Cr (1.2 μg/L) to 42.7 μg/g Cr (42 μg/L) (n = 52). Levels of As in nail samples (n = 49) varied from 0.04 to 0.82 μg/g dry weight (dw), whereas in hair (n = 49) As was only detected in 49 % of the samples with a maximum value of 0.95 μg/g dw. None of the biomarkers of exposure to As exceeded exposure reference values for urine (50 μg/g Cr or 50 μg/L), nails (1 μg/g), or hair (1 μg/g). However, median (10.0 μg/g Cr; 10.6 μg/L) and 95th percentile (31.9 μg/g Cr; 40.4 μg/L) of urinary SumAs were higher in Vieques samples than in the those from the general population of other countries. Among the three biomarkers of exposure, nail samples reflected better the exposure to iAs from seafood consumption with significantly higher average As concentrations in high (0.24 μg/g) than low (0.12 μg/g) seafood consumers. Multivariate results for As in nail samples (R(2) = 0.55, p < 0.0001) showed a positive association with fish consumption, particularly for men, with levels increasing with years of residency in Vieques.

Does obesity associate with mortality among Hispanic persons? Results from the National Health Interview Survey

OBJECTIVE

To evaluate the association between BMI: kg/m(2) and mortality among Hispanic adults.

DESIGN AND METHODS

Eight years (1997-2004) of National Health Interview Survey data linked to public-use mortality follow-up data through 2006 were acquired. Using Cox proportional hazards regression, separate models for two attained age strata (18 to <60 years, ≥60 years) adjusting for sex, smoking, and physical activity with over 38,000 analyzable respondents were fit.

RESULTS

Among those aged ≥60 years, underweight (BMI ≤ 18.5) associated with elevated mortality (hazard ratio [HR] = 2.19; 95% confidence interval [CI], 1.38-3.46), whereas overweight (BMI of 25 to <30) and obesity grade 1 (BMI of 30 to <35) associated with reduced mortality (HRs = 0.79; 95% CI, 0.65-0.95 and 0.71; 95% CI, 0.56-0.91), respectively. There were no significant associations between BMI and mortality among the 18 to <60 years attained age strata or among never smokers for either age strata.

CONCLUSIONS

Overweight and obesity are not obviously associated with elevated mortality among Hispanic adults.

Differences in demographic, behavioral, and biological variables between those with valid and invalid accelerometry data: implications for generalizability

BACKGROUND

The exclusion of participants with invalid accelerometry data (IAD) may lead to biased results and/or lack of generalizability in large population studies. The purpose of this study was to investigate whether demographic, behavioral, and biological differences occur between those with IAD and valid accelerometry data (VAD) among adults using a representative sample of the civilian noninstitutionalized U.S. population.

METHODS

Ambulatory participants from NHANES (2003-2004) who were 20-85 years of age were included in the current study and wore an ActiGraph 7164 accelerometer for 7 days. A "valid person" was defined as those with 4 or more days of at least 10+ hrs of monitoring per day. Among adults (20-85 yrs), 3088 participants provided VAD and 987 provided IAD. Demographic, behavioral, and biological information were obtained from the household interview or from data obtained in a mobile examination center.

RESULTS

Differences were observed in age, BMI, ethnicity, education, smoking status, marital status, use of street drugs, current health status, HDL-cholesterol, C-reactive protein, self-reported vigorous physical activity, and plasma glucose levels between those with VAD and IAD.

CONCLUSIONS

Investigators should take into consideration the potential cut-off bias in interpreting results based on data that excludes IAD participants.

Relationship between Body Weight Gain and Significant Knee, Hip, and Back Pain in Older Americans

OBJECTIVE

To examine the association between BMI (kilograms per meter squared) and reports of significant knee, hip, and back pain using data from a nationally representative sample of U.S. adults 60 years or older.

RESEARCH METHODS AND PROCEDURES

Population-based survey data from the Third National Health and Nutrition Examination Survey, involving 5724 adults 60 years or older, were used. BMI, calculated from measured weight (kilograms) and height (meters squared), was used to categorize participants into six BMI-defined groups: underweight (<18.5), desirable weight (18.5 to 24.9), overweight (25 to 29.9), obese class I (30 to 34.9), obese class II (35 to 39.9), and obese class III (>/=40). The presence of significant knee, hip, and back pain in the groups was studied.

RESULTS

The overall prevalences of knee, hip, and back pain were 21%, 14%, and 22%, respectively. Prevalence estimates for knee (underweight 12.1% to obesity class III 55.7%), hip (underweight 10.4% to obesity class III 23.3%), and back (underweight 20.2% to obesity class III 26.1%) pain increased with increased BMI. Sex-, race-, and age-specific pain prevalence estimates also generally increased at increased levels of BMI.

DISCUSSION

Among U.S. adults 60 years or older, the prevalence of significant knee, hip, and back pain increases with increased levels of BMI.

The relationship of actigraph accelerometer cut-points for estimating physical activity with selected health outcomes: results from NHANES 2003-06

The purpose of this study was to examine the influence of child and adult cut-points on physical activity (PA) intensity, the prevalence of meeting PA guidelines, and association with selected health outcomes. Participants (6,578 adults > or = 18 years, and 3,174 children and adolescents < or = 17 years) from the National Health and Nutrition Examination Survey 2003-06 (Centers for Disease Control and Prevention, 2006) wore an accelerometer for 7 days. PA intensity was estimated with 5 child-derived and 12 adult-derived cut-points. For all, the cut-point influenced PA intensity and the prevalence of meeting PA guidelines. Similarly, cut-point selection influenced the relationship between physical activity and various health outcomes. Future research should further enhance meaningful cut-points relevant to populations with diverse health and age profiles.

Risk of cancer among Hispanics with AIDS compared with the general population in Puerto Rico: 1987-2003

BACKGROUND

The risk of cancer among Hispanics with Acquired Immune Deficiency Syndrome (AIDS) in the United States and Puerto Rico (PR) has not been well described. The purpose of this study was to determine the risk of AIDS related and non-AIDS related cancers among Hispanics with AIDS in PR.

METHODS

A probabilistic record linkage of the PR AIDS Surveillance Program and PR Central Cancer Registry databases was conducted. AIDS cases were grouped according to year of AIDS onset and antiretroviral therapy availability: 1987-1989 (limited availability), 1990-1995 (mono and dual therapy), and 1996-2003 (highly active antiretroviral therapy: HAART). Cancer risk was described using the standardized incidence ratios (SIR).

RESULTS

A total of 612 cancers were identified after 3 months of AIDS diagnosis: 409 (66.7%) AIDS related and 203 (33.1%) non-AIDS related. Although a decreasing trend in the risk of AIDS and non-AIDS related cancers was observed, the risk for both remained higher in the AIDS group compared to the general population in PR. Non-AIDS related cancers with higher risk during the HAART availability were: oropharyngeal, anal, liver, larynx, eye and orbit, Hodgkin lymphoma, and vaginal.

CONCLUSION

Hispanics with AIDS in PR consistently showed a greater risk of AIDS and non-AIDS related cancers compared to the general population in PR and that has not changed over time.

Building community research capacity: process evaluation of community training and education in a community-based participatory research program serving a predominantly Puerto Rican community

BACKGROUND

Education and training build community research capacity and have impact on improvements of health outcomes.

OBJECTIVES

This manuscript describes the training and educational approaches to building research capacity that were utilized in a community-based participatory research program serving a Puerto Rican population and identifies barriers and strategies for overcoming them.

METHODS

A process evaluation identified a multitiered approach to training and education that was critical to reaching the broad community.

RESULTS

This approach included four major categories providing a continuum of education and training opportunities: networking, methods training, on-the-job experience, and community education. Participation in these opportunities supported the development of a registry, the implementation of a survey, and two published manuscripts. Barriers included the lack of a formal evaluation of the education and training components, language challenges that limited involvement of ethnic groups other than Puerto Ricans, and potential biases associated with the familiarity of the data collector and the participant. The CBPR process facilitated relationship development between the university and the community and incorporated the richness of the community experience into research design. Strategies for improvement include incorporating evaluation into every training and educational opportunity and developing measures to quantify research capacity at the individual and community levels.

CONCLUSIONS

Evaluating training and education in the community allows researchers to quantify the impact of CBPR on building community research capacity.

Recommendations for advancing opportunities to increase physical activity in racial/ethnic minority communities

We provide suggestions for advancing opportunities for effective and sustainable strategies for increasing physical activity in racial/ethnic minority populations.

Association of cigarette smoking, alcohol consumption, and physical activity with sex steroid hormone levels in US men

BACKGROUND

We evaluated the associations of smoking, alcohol consumption, and physical activity with sex steroid hormone concentrations among 1,275 men > or =20 years old who participated in the Third National Health and Nutrition Examination Survey (NHANES III).

METHODS

Serum concentrations of testosterone, estradiol, and sex hormone-binding globulin (SHBG) were measured. We compared geometric mean concentrations across levels of smoking, alcohol, and physical activity using multiple linear regression.

RESULTS

Current smokers had higher total testosterone (5.42, 5.10, and 5.26 ng/ml in current, former, and never smokers), free testosterone (0.110, 0.102, and 0.104 ng/ml), total estradiol (40.0, 34.5, and 33.5 pg/ml), and free estradiol (1.05, 0.88, and 0.84 pg/ml) compared with former and never smokers (all p < or = 0.05). Men who consumed > or =1 drink/day had lower SHBG than men who drank less frequently (31.5 vs. 34.8 nmol/l, p = 0.01); total (p-trend = 0.08) and free testosterone (p-trend = 0.06) increased with number of drinks per day. Physical activity was positively associated with total (p-trend = 0.01) and free testosterone (p-trend = 0.05).

CONCLUSIONS

In this nationally representative sample of men, smoking, alcohol, and physical activity were associated with hormones and SHBG, thus these factors should be considered as possible confounders or upstream variables in studies of hormones and men's health, including prostate cancer.

Protein and Legume Intake and Prostate Cancer Mortality in Puerto Rican Men

Prostate cancer is the number 1 cancer killer among Puerto Rican (PR) men. Plant foods have been inversely associated with prostate cancer. Legumes play a significant role in the PR diet; consumption of legumes in PR (14 lb/capita) was double that of the United States (7 lb/capita). We examined dietary protein consumption (from baseline 24-h dietary recalls) and prostate cancer mortality in the PR Heart Health Program, a cohort study of 9,824 men aged 35-79 years at baseline (1964) with follow-up until 2005. Total protein intake in the cohort was 85 g/day, and sources of protein were 30% vegetable, 30% dairy, 31% animal, and 8% seafood protein. Legume intake was 2.3 servings/day (1/4 cup each). Legume intake was not associated with prostate cancer mortality [comparing highest quartile to lowest quartile-odds ratio (OR) 1.40 [95% confidence interval (CI) 0.91-2.18], P trend 0.17]-nor were total protein, animal, seafood, dairy, or vegetable protein intakes. Consuming 1-2 servings of fruit was inversely associated (OR 0.50, 95% CI 0.32-0.77), whereas consuming more than 2 servings of fruit was not associated with prostate cancer mortality. Thus, we find no association between legumes or protein intake and prostate cancer mortality in this longitudinal cohort study of PR men.

Skin color and mortality risk among men: the Puerto Rico Heart Health Program

PURPOSE

To examine the association between skin color and all-cause and cardiovascular disease (CVD)-related mortality risk before and after adjusting for selected characteristics and risk factors, we used data on 5,304 men with information on skin color at Exam 3 of the Puerto Rico Heart Health program (PRHHP), a longitudinal study of the incidence of coronary heart disease in Puerto Rican men.

METHODS

Mortality was ascertained using hospital and physician records, postmortem records, death certificates, and information from the next of kin.

RESULTS

Dark-skinned men exhibited higher age-adjusted mortality rates than light skinned men (10.1 vs. 8.8/10,000 population). There was no association between skin color and all-cause and CVD-related mortality. However, the association between skin color and all-cause mortality varied with area of residence (p for interaction = 0.05). Among men living in urban areas, the risk of all-cause mortality was 28% (95% confidence interval, 1.02-1.61) greater among dark-skinned men than their light-skinned counterparts after adjusting for age, education, BMI, physical activity, and the presence of diabetes. There was no association between skin color and CVD mortality in urban men. Neither all-cause nor CVD mortality was associated with skin color among rural men.

CONCLUSION

Our results suggest that skin color may be capturing environmental dynamics that may influence mortality risk among Puerto Rican men.

Physical activity in a cohort of HIV-positive and HIV-negative injection drug users

Physical activity is beneficial for persons with HIV infection but little is known about the relationships between physical activity, HIV treatment and injection drug use (IDU). This study compared physical activity levels between HIV-negative and HIV-positive injection drug users (IDUs) and between HIV-positive participants not on any treatment and participants on highly active antiretroviral therapy (HAART). Anthropometric measurements were obtained and an interviewer-administered modified Paffenbarger physical activity questionnaire was administered to 324 participants in a sub-study of the AIDS Linked to Intravenous Experiences (ALIVE) cohort, an ongoing study of HIV-negative and HIV-positive IDUs. Generalized linear models were used to obtain univariate means and to adjust for confounding (age, gender, employment and recent IDU). Vigorous activity was lower among HAART participants than HIV-positive participants not on treatment (p=0.0025) and somewhat lower than HIV-negative participants (p=0.11). Injection drug use and viral load were not associated with vigorous activity. Energy expenditure in vigorous activity was also lower among HAART participants than both HIV-negative and HIV-positive participants not on treatment. Thus, HIV-positive participants on HAART spend less time on vigorous activity independent of recent IDU. More research is needed into the reasons and mechanism for the lack of vigorous activities, including behavioral, psychological and physiological reasons.

Detecting overweight children in primary care: do national data reflect the typical urban practice?

Primary care physicians can easily identify overweight in children aged < 2 years using body-mass index. There is no consensus on the appropriate way of identifying overweight before age 2 years. However, the primary care physician should be alert if the body-mass index of a child < 2 years of age is significantly higher then those published (as a guideline) in this paper. Overweight is occurring early. Thus it is essential that primary care physicians focus on identifying overweight as early as preschool age. Primary care physicians have to pay particular attention to identifying overweight in non-Hispanic black children aged 2 to 11 years, who may have a higher prevalence of being at risk for overweight compared with 1999-2002 national data. Children seen for a sick-child visit may be at higher risk for overweight; thus, we recommend that height and weight measurements be obtained during these visits.

Effects of a culturally sensitive sign on the use of stairs in African American commuters

OBJECTIVES

To examine the effectiveness of a culturally sensitive sign to encourage stair use among African American commuters.

METHODS

16,035 commuters were observed in their using either stairs or an adjacent escalator in a subway station. After baseline observation, a culturally sensitive sign to promote stair use was displayed beside the escalator/stairs. Demographic information and use of escalators/stairs were recorded.

RESULTS

Stair use increased from 15.8% to 21.5% with the sign. Caucasian commuters used the stairs 23.1% of the time at baseline, and increased to 28.3% with the sign. Among African Americans, stair use increased from 10.3% to 16.4% with the sign. African American women showed the greatest increases in stair use. Stair use remained elevated the week after the sign was removed in all commuters. Among African Americans, stair use returned to baseline within three weeks. Stair use increased significantly among both overweight and non-overweight Caucasians and African Americans.

CONCLUSION

Culturally sensitive interventions can promote physical activity among African Americans in an urban setting.

The relationship between blood lead levels and neurobehavioral test performance in NHANES III and related occupational studies

OBJECTIVES

The goals of this study were two-fold: (1) to assess the relationship between blood lead levels and neurobehavioral test performance in a nationally sample of adults from the third National Health and Nutrition Evaluation Survey and (2) to analyze the results from previously published studies of occupational lead exposure that used the same neurobehavioral tests as those included in the survey.

METHODS

Regression models were used to test and estimate the relationships between measurements of blood lead and performance on a simple reaction time, a symbol-digit substitution, and a serial digit learning test in adults aged 20-59 years who participated the survey. Mixed models were used to analyze the data from the occupational studies.

RESULTS

The blood lead levels of those participating in the survey ranged from 0.7 to 41.8 microg/dl. The estimated geometric mean was 2.51 microg/dl, and the estimated arithmetic mean was 3.30 microg/dl. In the survey, no statistically significant relationships were found between blood lead concentration and performance on the three neurobehavioral tests when adjusted for covariates. In the occupational studies, the groups exposed to lead consistently performed worse than control groups on the simple reaction time and digit-symbol substitution tests.

CONCLUSIONS

The results from the survey and the occupational studies do not provide evidence for impairment of neurobehavioral test performance at levels below 25 microg/dl, the concentration that the Centers for Disease Control and Prevention define as elevated in adults. The average blood lead level of the exposed groups in the occupational studies was 41.07 microg/dl, less than 50 microg/dl, the minimum concentration that the Occupational Safety and Health Administration requires for medical removal from the workplace. Given the evidence of impaired neurobehavioral performance in these groups, the 50 microg/dl limit should be reevaluated.

Association of cigarette smoking, alcohol consumption and physical activity with lower urinary tract symptoms in older American men: findings from the third National Health And Nutrition Examination Survey

OBJECTIVES

To examine the association of cigarette smoking, alcohol consumption and physical activity with lower urinary tract symptoms (LUTS) in older men.

SUBJECTS AND METHODS

The study included 2797 men participating in the Third National Health and Nutrition Examination Survey (NHANES III), who were aged > or = 60 years. During an interview, LUTS, smoking history, alcohol consumption and physical activity were assessed. Cases comprised men with at least three of the symptoms of nocturia, hesitancy, weak stream and incomplete emptying. Men who had had prostate surgery unrelated to cancer were not included as cases. Controls were men with no symptoms or surgery. We adjusted for age and race in logistic regression models and used sampling weights to account for selection probability.

RESULTS

Current cigarette smokers had no higher odds of LUTS than 'never' smokers, but former heavy smokers (> or = 50 pack-years) had a higher odds of LUTS than never smokers (odds ratio 2.01; 95% confidence interval 1.04-3.89). Men who drank alcohol daily had a lower chance of LUTS than non-drinkers (0.59; 0.37-0.95; P trend, 0.07). All levels of moderate and vigorous activity were statistically significantly inversely associated with LUTS (P trend, 0.06), whereas men who reported no leisure-time physical activity had a greater odds of LUTS (2.06; 1.26-3.39).

CONCLUSIONS

Moderate alcohol consumption and physical activity may be protective against LUTS. Current cigarette smoking was not consistently associated with the condition. The possible association in former smokers warrants further investigation.