P6233The association between ideal cardiovascular health behavior and long-term risk profile and outcomes

Background

Health behaviors are important contributors to cardiovascular health (CVH) across populations. Little data exist regarding the association between attaining health behavior goals and long-term health outcomes.

Methods

Ideal CVH behaviors (no tobacco smoking, normal body mass index, engagement in leisure physical activity and healthy dietary habits) based on the American Heart Association definition, were evaluated in a random Israeli population sample (N=1079) stratified by sex, ethnicity (Arabs and Jews) and age (range: 25–74 years). Negative binomial models were used for testing associations with health service utilization counts and the Cox proportional hazard models for the associations with major adverse cardiovascular events (MACE) and mortality. Median follow-up was 15.6 years (interquartile [IQ] rage: 12.9–16.1) for mortality and 9.7 (IQ range: 7.7–10.2) otherwise.

Results

None of the participants had all four ideal health behaviors at baseline, 68 (6%) had three, 308 (28%) had two, 547 (51%) had one, and 156 (14%) had none. Mean [standard deviation; SD] participant age was 49 [12], 51 [14], 52 [15] and 47 [15] for participants with 0, 1, 2 and 3 ideal health behaviors, respectively. With each additional ideal health behavior, the prevalence of male (range: 83% of subjects with no ideal behaviors to 40% of subjects with three), Arab (61% to 21%) and married (92% to 65%) participants decreased, and the prevalence of participants with higher socioeconomic determinants increased. A higher number of ideal health behavior was associated with lower baseline diastolic blood pressure (mean [SD]: 82 [9] mmHg for none, to 76 [9] mmHg for three ideal behaviors), and a more favorable baseline lipid profile. Adjusting for age, sex, ethnicity, marital status, education years, professional prestige and comorbidities (Charlson index), each additional ideal health behavior was associated with reduced risk of developing diabetes (Hazard Ratio [HR]: 0.73, 95% confidence interval [CI]: 0.58–0.91), hypertension (HR: 0.86, 95% CI: 0.71–1.03) and dyslipidemia (HR: 0.85, 95% CI: 0.74–0.98). Controlling for the same variables, the addition of one ideal health behavior was associated with fewer hospitalizations (rate ratio [RR]: 0.80; 95% CI: 0.69–0.93), and cardiology clinic visits (RR: 0.88; 95% CI: 0.75–1.03). The hazard ratio was 0.84 (95% CI: 0.62–1.14) for MACE and 0.82 (95% CI: 0.66–1.03) for all-cause mortality.

Conclusion

Attainment of all four cardiovascular health behaviors goals is rare across the population. A higher number of ideal health behaviors is associated with a lower risk of long-term diabetes, hypertension and dyslipidemia, fewer health service utilizations and a lower MACE and mortality risk.

Adult-onset diabetes among Arabs and Jews in Israel: a population-based study

AIMS

To study the age at presentation and factors associated with adult-onset diabetes (≥ 20 years) among Arabs and Jews in Israel.

METHODS

Participants (n = 1100) were randomly selected from the urban population of the Hadera District in Israel. The study sample was stratified into equal groups according to sex, ethnicity (Arabs and Jews) and age. Information on age at diabetes presentation, family history of diabetes, history of gestational diabetes, socio-demographic and lifestyle characteristics was obtained through personal interviews. Self reports of diabetes were compared with medical records and were found reliable (κ = 0.87). The risk for diabetes was calculated using Kaplan-Meier survival analysis. Factors associated with diabetes in both ethnic groups were studied using Cox proportional hazard model.

RESULTS

The prevalence of adult-onset diabetes was 21% among Arabs and 12% among Jews. Arab participants were younger than Jews at diabetes presentation. By the age of 57 years, 25% of Arabs had diagnosed diabetes; the corresponding age among Jews was 68 years, a difference of 11 years (P < 0.001). The greater risk for diabetes among Arabs was independent of lifestyle factors, family history of diabetes and, among women, history of gestational diabetes; adjusted hazard ratio 1.70; 95% confidence interval 1.19-2.43.

CONCLUSIONS

Arabs in Israel are at greater risk for adult-onset diabetes than Jews and are younger at diabetes presentation. Culturally sensitive interventions aimed at maintaining normal body weight and active lifestyle should be targeted at this population. Possible genetic factors and gene-environmental interactions underlying the high risk for diabetes among Arabs should be investigated.

The relative importance of traditional and "modern" foods for Israeli Negev Bedouins. A population in transition

The impact of urbanization on the health and nutritional status of developing populations is an issue of concern worldwide. The Bedouin Arabs in Southern Israel are a traditionally semi-nomadic/nomadic population undergoing a rapid process of urbanization which is accompanied by rising chronic disease rates. We examined the diet of urban and rural (more traditional) Bedouins to determine the relative importance of modern foods and drinks in their daily diet. We found that for main meals both populations rely heavily on traditional foods (available before 1948) but for snacks and drinks many manufactured products are used. These products rich in calories may contribute to the changing disease patterns. Rural areas rely more on traditional milk products which are made non-perishable, while urban populations use more meat products and pre-prepared meals because of the availability of electricity and refrigeration. Traditional foods and drink and the traditional way of eating (eating from a common plate) is still a very important part of the Bedouin way of life. This pattern of eating requires the development of culture-specific dietary assessment methodology to allow quantitative assessment of both traditional and more modern foods consumption and handle the eating practices of the Bedouin society today.

Evaluating the process of tailoring the global HIV/AIDS practice guidelines for use in developing countries

OBJECTIVE

To describe a systematic procedure for adapting, or 'tailoring' the World Health Organisation's 'global guidelines for the management of HIV/AIDS in adults and children' for use in two developing countries: Malawi and Barbados.

DESIGN

In order for these guidelines to achieve reproducibility, clinical flexibility, and clinical applicability, a systematic procedure is needed to tailor the guidelines to the local practice conditions of specific settings.

METHODS

A group of local experts in each country used a nominal group process to modify the global program on AIDS (GPA) guidelines for local use. Semantic analysis techniques, known as clinical algorithm nosology (CAN), were used to compare the two modified guidelines with the global ones to determine the extent and type of differences between sets of guidelines.

RESULTS

Standard, locally-tailored algorithm map guidelines (AMG) were developed within 4 months. CAN semantic analysis showed that guideline structure was maintained; 572/858 (66.6%) decision nodes were found to be the same in the GPA/Malawi, GPA/Barbados and Malawi/Barbados comparisons. However, different guideline versions managed patients quite differently, as evidenced by clinical algorithm patient abstraction (CAPA) scores of between 0 and 8.46 (0 = different; 8 = similar; 10 = identical). Analysis of the 197 specific differences found in these abstractions showed that 83% were in approaches to diagnosis and therapy, while the remaining 17% related to disease prevalence.

CONCLUSIONS

Standard techniques involving consensus used to develop clinical guidelines can also be employed to tailor these guidelines to local settings. Semantic analysis shows that the tailoring preserves structure but may involve significant modification to the processes of clinical care that could in turn affect care outcomes.

Undernutrition among Bedouin Arab children: a follow-up of the Bedouin Infant Feeding Study

After 10 y of urban settlement, 680 Bedouin Arab children, who had had anthropometric assessment from birth (1981-1982) through early childhood, were reassessed in 1991-1992 to compare the rates of stunting in early and later childhood as well as to describe the factors influencing current height-for-age. Stunting had dropped from 32.7% at 18 mo to 7.2% at 10 y in the 1981 birth cohort and dropped from 17.5% at 9 mo to 8.2% at 9 y in the 1982 birth cohort. Based on a multiple-linear-regression analysis, height in early childhood and maternal height were statistically significantly and positively associated with current mean height-for-age in both cohorts. In the 1982 cohort socioeconomic status in early childhood was positively and current family size was negatively and significantly associated with current mean height-for-age. Thus, conditions that were present in early childhood had the largest influence on current height. In 1992, 10% and 6% of the infant siblings of the 1981 and 1982 cohorts, respectively, were stunted compared with 17% and 1% of the siblings aged 1-2 y of the respective cohorts. Therefore, the high rates of early childhood stunting in 1981-1982 appeared to be a birth cohort-specific phenomenon.