Low sodium intake and cardiovascular disease mortality among adults with hypertension

Background

Though high sodium intake is linked to an increased risk of hypertension and cardiovascular diseases, the relationship between sodium intake and mortality remains controversial. Given that medications used to treat hypertension can potentially lower blood sodium levels and alter electrolyte balance, it begs the question whether a further reduction in dietary sodium below the recommended daily intake of 2300 mg is beneficial among adults with hypertension.

Objective

To evaluate the effect of low sodium intake on cardiovascular disease (CVD) mortality and all-cause mortality among adults with hypertension.

Design

A retrospective cohort study was conducted using data from the Continuous NHANES (1999-2010) linked to mortality files from the National Death Index. Using sodium intake categorized as low <2300 mg/day and high ≥2300 mg/day, the baseline demographic and health characteristics of participants were determined. Hazard ratios (HR) for CVD and all-cause mortality were determined through cox proportional hazard regression analysis adjusted for age, sex, race, total dietary calories, body mass index, physical activity, smoking, diabetes, alcohol consumption, and total serum cholesterol while considering the complex survey design.

Results

Of the 8542 adults with hypertension, 71.01% consumed sodium higher than the recommended daily intake of 2300 mg. The mean age was 54 years, 52.3% were female and 73.1% were white. Over 12.7 years of follow-up, there were 971 deaths, with 232 deaths from CVD. The low sodium intake group had a nonsignificant 5% higher risk of CVD mortality, [Adjusted HR 1.05,95% CI (0.7-1.6), p-value 0.82]. Similarly, there was a nonsignificant 17% higher risk for all-cause mortality for the low sodium intake group, [Adjusted HR 1.17,95% CI (1.0-1.4), p-value 0.10]. There was no effect modification by age, race, or sex.

Conclusion

The findings of an inverse association between sodium intake and mortality among adults with hypertension seen here, though not statistically significant warrant further investigation.

Assessing state level variation in signature authority and cause of death accuracy, 2005-2017

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In 2005–2017, US states liberalized statutes on cause of death signature authority.

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State variation in signature authority contributes to cause of death inaccuracies.

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Logistic regressions suggest certifier type influences death certificate accuracy.

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Death certificate training is needed across the array of professional certifiers.

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Cause of Death Signature Authority database allows for more robust analysis of certification errors.

This study utilized a convergent mixed-methods design to examine whether variation in death certificate certifier type predicts the accuracy of cause of death reporting in the US. We analyzed the content of state statutes, amendments, and policies concerning cause of death signature authority in 2005–2017 to create the Cause of Death Signature Authority (CoDSA) database. After merging the CoDSA data with 2005–2017 National Vital Statistics System Multiple Cause of Death Mortality files for adults with cerebral palsy (CP) (N = 29,996), we employed logistic regression models to determine the likelihood that different certifier groups made one particular type of death certification error – inaccurately reporting CP as the underlying cause of death (UCOD). The content analysis provided evidence of significant liberalization of cause of death signature authority, with 23 states expanding signature authority to include physician extenders. Logistic regression analysis revealed differences in UCOD accuracy based on certifier type. Compared to medical examiners, the likelihood of CP being reported as the UCOD, was: 41% higher (CI 1.12, 1.78) for coroners; 25% higher (1.05, 1.49) for mixed-system death investigators; 24% higher (1.08, 1.42) for physicians; and 16% higher (1.00, 1.34) for physician extenders. Inaccuracies limit public health efforts aimed at improving the health and longevity for disadvantaged populations, such as people with CP. Poor performance among cause of death certifiers may indicate systemic problems with death certification that should be addressed with more robust training for all professional groups with signature authority.

Associations of smoking indicators and cotinine levels with telomere length: National Health and Nutrition Examination Survey

The influence of smoking exposure on telomere length with a focus on the impact of race has rarely been discussed. We performed a cross sectional analysis into the associations of smoking indicators with leukocyte telomere length (LTL) by race among 5864 nationally representative sample of US adults (≥20 years). Data from 1999 to 2002 National Health and Nutrition Examination Survey was used for the analysis. Smoking indicators were assessed by interviews and serum cotinine levels. LTL was quantified by polymerase chain reaction. Multiple linear regressions were used to assess the association with adjustment for covariates, sample weights and design effects separately for Whites, Blacks and Mexican Americans. The intensity of smoking, measured by the average number of cigarettes consumed per day, was negatively associated with LTL among Whites (β: −3.87, 95% CI: −5.98 to −1.21) and among Blacks (β: −15.46, 95% CI: −29.79 to −2.12) participants. Compared with cotinine level < 0.05 ng/ml, cotinine level ≥3 ng/ml was associated with shorter LTL (β: −77.92, 95% CI = −143.05 to −11.70) among Whites, but not among Blacks. We found increased number of cigarette consumption to be associated with shorter LTL in both Blacks and Whites, indicating that the impact of smoking on life-shortening diseases could partly be explained by telomere biology. Increased cotinine concentration however, was associated with shorter LTL only among Whites, not among Blacks. This differential relationship that we observed may have implications in interpreting cotinine as an objective biomarker of smoking exposure across races and warrant additional prospective investigation.

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Higher cigarette consumption was related to shorter telomere in Blacks and Whites.

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The impact of smoking on diseases could partly be explained by telomere biology.

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Cotinine concentration was associated with reduced telomere length only among Whites.

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We observed a differential impact of biomarker cotinine on telomere length by race.

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This questions cotinine's role as an objective biomarker of smoking exposure across races.

Changing rate orders of race-gender heart disease death rates: An exploration of county-level race-gender disparities

A holistic view of racial and gender disparities that simultaneously compares multiple groups can suggest associated underlying contextual factors. Therefore, to more comprehensively understand temporal changes in combined racial and gender disparities, we examine variations in the orders of county-level race-gender specific heart disease death rates by age group from 1973-2015. We estimated county-level heart disease death rates by race, gender, and age group (35-44, 45-54, 55-64, 65-74, 75-84, ≥ 85, and ≥ 35) from the National Vital Statistics System of the National Center for Health Statistics from 1973-2015. We then ordered these rates from lowest to highest for each county and year. The predominant national rate order (i.e., white women (WW) < black women (BW) < white men (WM) < black men (BM)) was most common in younger age groups. Inverted rates for black women and white men (WW Collapse

Key Words

• BM, black men
• BW, black women
• CDC, Centers for Disease Control and Prevention
• County-level
• Gender
• Heart disease mortality
• ICD, International Classification of Diseases
• MCMC, Markov chain Monte Carlo
• NCHS, National Center for Health Statistics
• Race
• Spatiotemporal
• Temporal trends
• WM, white men
• WW, white women

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MESH Headings Collapse

Grants

• K01 HD074726 NICHD NIH HHS

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Affiliation(s)

Adam S. Vaughan Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, United States
Harrison Quick Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Nesbitt Hall, 3215 Market St., Philadelphia, PA 19104, United States
Linda Schieb Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, United States
Michael R. Kramer Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, United States
Herman A. Taylor Cardiovascular Research Institute, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, United States
Michele Casper Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, United States

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Outpatient, combined use of opioid and benzodiazepine medications in the United States, 1993-2014

The combined use of opioid and benzodiazepine medications increases the risk of hazardous effects, such as respiratory depression. Although recent increases in outpatient use of opioid prescriptions have been documented, there are limited data regarding rates and correlates of combined opioid and benzodiazepines among adults in outpatient settings. Our objective was to examine annual trends in outpatient visits including opioids, benzodiazepines, and their combination among adults as well as clinical and demographic correlates. We used data from the 1993–2014 National Ambulatory Medical Care Survey (NAMCS) among non-elderly (i.e., ages 18–64 years) adults to examine the probability of a visit including an opioid, benzodiazepine, or their combination, in addition to clinical and demographic correlates. From 1993 to 2014, benzodiazepines-with-opioids visits increased from 9.8 to 62.5 (OR = 9.23, 95% CI = 5.45–15.65) per 10,000 visits. Highest-represented groups among benzodiazepines-with-opioids visits were older (50–64 years) (49.1%), white (88.8%), commercially insured (58.0%) patients during their first visit (87.6%) to a primary-care physician (41.9%). We identified a significant increase in the outpatient co-prescription of opioids and benzodiazepines, notably among adults aged 50–64 years during primary-care visits. Educational and policy changes to provide alternatives to benzodiazepine-with-opioid co-prescription and limiting opioid prescription to pain specialists may reduce rates of this potentially hazardous combination.

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Current guidelines for prescribing opioids recommend against co-administration with benzodiazepines

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Concurrent use of opioids and benzodiazepines increases the risk of overdose, respiratory depression, and death.

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We examined 22 years of outpatient prescribing patterns of opioids and benzodiazepines using a survey of US physicians.

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Over this period, visits with both opioids and benzodiazepines increased from roughly 9.8 to 62.5 per 10,000 visits.

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These visits were more likely among older (50–64 years), white, privately insured patients with a low-back pain diagnosis.

The association between social participation and lower extremity muscle strength, balance, and gait speed in US adults

Social participation is associated with healthy aging, and although associations have been reported between social participation and demographics, no published studies have examined a relationship between social participation and measures amenable to intervention. The purpose was to explore the association between self-reported social participation and lower extremity strength, balance, and gait speed. A cross-sectional analysis of US adults (n = 2291; n = 1,031 males; mean ± standard deviation age 63.5 ± 0.3 years) from the 2001–2 National Health and Nutrition Examination Survey was conducted. Two questions about self-reported difficulty with social participation were categorized into limited (yes/no). The independent variables included knee extension strength (n = 1537; classified as tertiles of weak, normal, and strong), balance (n = 1813; 3 tests scored as pass/fail), and gait speed (n = 2025; dichotomized as slow [less than 1.0 m/s] and fast [greater than or equal to 1.0 m/s]). Logistic regression, accounting for the complex survey design and adjusting for age, sex, physical activity, and medical conditions, was used to estimate the odds of limitation in social participation with each independent variable. Alpha was decreased to 0.01 due to multiple tests. Slower gait speed was significantly associated with social participation limitation (odds ratio = 3.1; 99% confidence interval: 1.5–6.2). No significant association was found with social participation and lower extremity strength or balance. The odds of having limitation in social participation were 3 times greater in those with slow gait speed. Prospective studies should examine the effect of improved gait speed on levels of social participation.

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Social participation is a component of healthy aging.

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Population-based studies can explore associations amenable to intervention.

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Walking speed and social participation were significantly associated.

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Strength and balance were not associated with social participation.

Utilization of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) in patients diagnosed with diabetes: Analysis from the National Ambulatory Medical Care Survey

Objective

The objective of this study was to determine if a difference exists in the proportion of visits for the prescribing of angiotensin converting enzyme inhibitors (ACEI), or angiotensin receptor blockers (ARBs) in diabetic patients during 2007–2010.

Methods

This retrospective, cross-sectional, observational study included adults diagnosed with diabetes mellitus from the National Ambulatory Medical Care Survey (NAMCS) during 2007–2010. Weighted chi-square tests and a multivariable logistic regression model were used to analyze associations between ACEI/ARB prescriptions and predictors of interest. Odds ratios and 95% confidence intervals were reported.

Results

An unweighted total of 13,590 outpatient ambulatory care visits were identified for adult patients with diabetes without contraindications to ACEIs or ARBs in the NAMCS for the years studied. No statistically significant increase in the proportion of visits with an ACEI/ARB prescription was identified for years 2007–2010 (28.1% in 2007 to 32.2% in 2010). Females (OR 0.78, 95% CI 0.69- 0.89), patients 18–39 years old (OR 0.56, 95% CI 0.43- 0.75), and Medicare users (OR 0.81, 95% CI 0.70- 0.94) were significantly less likely to receive an ACEI/ARB prescription. Patients with hypertension (OR 2.80, 95% CI 2.39-3.29), hyperlipidemia (OR 1.42, 95% CI 1.22-1.65), and ischemic heart disease (OR 1.36, 95% CI 1.10-1.70) were significantly more likely to receive an ACEI/ARB prescription.

Conclusions

Despite extensive evidence showing the benefits of ACEI/ARB medications in diabetic patients, disparities of treatment remain evident.

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Assessed ACEI/ARB prescriptions in diabetic patients for ADA guideline adherence

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A low percentage of patients prescribed an ACEI/ARB (28.1% in 2007–32.2% in 2010)

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Females, age 18–39, and Medicare users less likely to receive ACEI/ARB prescription

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Hypertension, hyperlipidemia and IHD: more likely to receive ACEI/ARB prescription

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Disparities in ACEI/ARB prescriptions remain evident

Trends in varicella mortality in the United States: Data from vital statistics and the national surveillance system

This manuscript describes trends in US varicella mortality using national vital statistics system data for 2008-2011, the first years of the routine 2-dose varicella vaccination program, and characteristics of varicella deaths reported to CDC during 1996-2013. We obtained data on deaths with varicella as underlying or contributing cause from the 2008-2011 Mortality Multiple Cause-of Death records and calculated rates to compare with the prevaccine and mature 1-dose varicella vaccination program eras. We also reviewed available records of varicella deaths reported to CDC through the national varicella death surveillance. The annual average age-adjusted mortality rate for varicella as the underlying cause was 0.05 per million population during 2008-2011, an 87% reduction from the prevaccine years. Varicella deaths among persons aged <20 y declined by 99% in 2008-2011 compared with prevaccine years. There was a 70% decline in varicella mortality rates among those <20 y in 2008-2011 compared to 2005-2007. Among the 83 deaths reported to CDC during 1996-2013 classified as likely due to varicella, 24 (29%) were among immunocompromised individuals. Five were among persons previously vaccinated with 1 dose of varicella vaccine. In conclusion, although the US varicella vaccination program has significantly reduced varicella disease burden, there are still opportunities to prevent varicella and its associated morbidity and mortality through routine varicella vaccination, catch-up vaccination, and ensuring that household contacts of immunocompromised persons have evidence of immunity.