Association between human papillomaviruses, metabolic syndrome, and all-cause death; analysis of the U.S. NHANES 2003-2004 to 2015-2016

INTRODUCTION

Human papillomavirus (HPV) is the most common sexually transmitted infection, attributed to 4.5% of all cancers worldwide. Co-infection with the metabolic syndrome (MetS), a common cluster of cardiometabolic risk factors, has been shown to increase the persistence of HPV. The purpose of this study was to estimate the association between HPV and MetS on mortality risk.

METHODS

Data for the current study was drawn from seven consecutive cycles (2003-2004 to 2015-2016) of the U.S. NHANES. The final analytic sample consisted of 5,101 individuals aged 18-65y with HPV and MetS information with follow-up to Dec. 31st, 2019. Baseline HPV status was assessed by either vaginal swab, penile swab or oral rinse and used to classify participants as: no HPV (n = 1,619), low (n = 1,138), probable (n = 672), and high-risk (n = 1,672; 22% type 16, and 10% type 18) HPV using IARC criteria. MetS was assessed by the Harmonized criteria.

RESULTS

The average follow-up was 9.4 y with 240 all-cause deaths (no HPV: n = 46 deaths; low-risk: n = 60 deaths; probable: n = 37 deaths, and; high-risk: n = 97 deaths). HPV status alone revealed no associations with mortality in fully adjusted models. Cross-classification into discrete MetS/HPV strata yielded an increased risk of mortality in females with high-risk HPV/MetS relative to the no MetS/no HPV group.

CONCLUSIONS

In this study, low, probable, and high-risk HPV and MetS were differentially related to mortality risk in men and women. Further work is necessary to separate the temporal, age, vaccination, and sex effects of HPV diagnosis in these relationships using prospective studies with detailed histories of HPV infection and persistence.

Changes in the prevalence of U.S. adults using diet, exercise, pharmaceuticals and diet products for weight loss over time: Analysis of NHANES 1999-2018

To examine changes in the use of diet, exercise, and pharmacological/diet product weight loss (WL) practices over time, and differences in these trends by sex and obesity status, data from the National Health and Examination Survey (NHANES Continuous 1999-2018) was used. The prevalence of diet, exercise and use of WL drugs and products over time were examined in men and women with and without obesity in a series of cross-sectional nationally representative samples (n = 43,020). Women and those with obesity were more likely to engage in WL practices over the past year, with an increased prevalence of WL efforts over time (38.4 to 43.2%). Amongst those who engaged in WL attempts, diet-related WL was most common (87-93%), followed by exercise-related WL (47-68%), whereas use of WL drugs and products was the least common (5-21%). There were modest differences in the prevalence of diet or exercise WL over time, with some differences by sex and obesity status. Most notable was the increase in the prevalence of exercise WL practices in women with obesity, with no differences among men or women without obesity. When examining specific types of diets, there were more clear differences in the adoption of diets over time, with the use of more traditional calorie/portion/fat restriction diets becoming less prevalent, and sugar/carbohydrate restriction becoming more prevalent over time (P<0.005). Changes over time in the use of diets were, were however, similar in men and women with and without obesity. Use of pharmacotherapy/diet products tended to decline in prevalence over time but was consistently highest in women with obesity. Thus, there are differences in the types of WL strategies individuals have employed over time, with variations in their popularity of use by sex and obesity status. However, the pattern of changes over time were quite similar in men and women with and without obesity.

The relationships between acetylcholine-induced chest pain, objective measures of coronary vascular function and symptom status

Background

Acetylcholine-induced chest pain is routinely measured during the assessment of microvascular function.

Aims

The aim was to determine the relationships between acetylcholine-induced chest pain and both symptom burden and objective measures of vascular function.

Methods

In patients with angina but no obstructive coronary artery disease, invasive studies determined the presence or absence of chest pain during both acetylcholine and adenosine infusion. Thermodilution-derived coronary blood flow (CBF) and index of microvascular resistance (IMR) was determined at rest and during both acetylcholine and adenosine infusion. Patients with epicardial spasm (>90%) were excluded; vasoconstriction between 20% and 90% was considered endothelial dysfunction.

Results

Eighty-seven patients met the inclusion criteria. Of these 52 patients (60%) experienced chest pain during acetylcholine while 35 (40%) did not. Those with acetylcholine-induced chest pain demonstrated: (1) Increased CBF at rest (1.6 ± 0.7 vs. 1.2 ± 0.4, p = 0.004) (2) Decreased IMR with acetylcholine (acetylcholine-IMR = 29.7 ± 16.3 vs. 40.4 ± 17.1, p = 0.004), (3) Equivalent IMR following adenosine (Adenosine-IMR: 21.1 ± 10.7 vs. 21.8 ± 8.2, p = 0.76), (4) Increased adenosine-induced chest pain (40/52 = 77% vs. 7/35 = 20%, p < 0.0001), (5) Increased chest pain during exercise testing (30/46 = 63% vs. 4/29 = 12%, p < 0.00001) with no differences in exercise duration or electrocardiographic changes, and (6) Increased prevalence of epicardial endothelial dysfunction (33/52 = 63% vs. 14/35 = 40%, p = 0.03).

Conclusions

After excluding epicardial spasm, acetylcholine-induced chest pain is associated with increased pain during exercise and adenosine infusion, increased coronary blood flow at rest, decreased microvascular resistance in response to acetylcholine and increased prevalence of epicardial endothelial dysfunction. These findings raise questions about the mechanisms underlying acetylcholine-induced chest pain.

Is anyone truly healthy? Trends in health risk factors prevalence and changes in their associations with all-cause mortality

OBJECTIVE

The purpose of the study was to determine trends in the prevalence of individual health risk factors across time and to examine if their associations with mortality have changed over time.

METHODS

Data from the National Health and Nutrition Examination Surveys (NHANES III- 1988-1994 and NHANES 1999-2014; age ≥20 years) was used to examine differences in the odds ratio (OR) of 5-year mortality risk associated with various common health risk factors over the two survey periods using weighted logistic regression analysis adjusting for age, sex, obesity category and white ethnicity (n = 28,279).

RESULTS

Over 97% of individuals had at least one of the 19 risk factors examined with no difference in the prevalence over time (P>0.34). The prevalence of lifestyle, social/mental and physical risk factors (2.2 to 19.1%) increased over time (P<0.0002), while the prevalence of having physiological risk factors decreased by ~6.5% (P<0.0001). Having any lifestyle or social/mental risk factor was significantly associated with a higher 5-year OR for mortality risk in 1999-2014, than 1988-94. In particular, having low education or use of mental health medication were not associated with mortality risk in 1988-94 (P>0.1), but were significantly associated with a higher 5-year OR for mortality in 1999-2014 (P<0.0001). Conversely, physiological risk factors were more weakly related with mortality risk in 1988-1994, than 1999-2014. Having any physical risk factor, and poor self-rated health were similarly related with 5-year mortality risk at both timepoints.

CONCLUSION

Health risk factors have both increased and decreased in prevalence over time, along with changes in the association between many of the risk factors and mortality risk. Taken together, these changes complicate interpretation of temporal trends and warrant cautious interpretation of population health patterns based on surveillance data.

Neighborhood greenness, but not walkability, is associated with self-rated measures of health in older adults: An analysis of the Canadian Longitudinal Study on Aging

The purpose of this analysis was to determine whether older Canadians residing in neighborhoods characterized by denser greenness or higher walkability have better self-reported health outcomes at 3-year follow-up. Data on self-reported chronic diseases (composite score of 10 conditions) and self-rated measures of health (general health, mental health, and healthy aging) from the Canadian Longitudinal Study on Aging (CLSA) were used as outcomes. The CLSA database was linked with the Canadian Active Living Environments (Can-ALE), a measure of walkability, and Normalized Difference Vegetation Index (NDVI), a measure of greenness. The analytic sample consisted of adults aged 65 and older (n = 15339, age 72.9 ± 5.6, 50 % female). Crude and adjusted associations were assessed using Poisson regression and proportional odds regression modelling. The 4th quartile of greenness was associated with the chronic disease index and all three measures of self-rated health (general health, mental health, and healthy aging); living in a neighborhood with the highest greenness was associated with better health three years later when compared to those in the lowest quartile of greenness. After adjustment for covariates of age, sex, income, education, and physical activity levels, only the association for the 3rd quartile of greenness was significantly associated with general health (OR: 0.90, 95 %CI: 0.81–0.99) and mental health (OR: 0.88, 95 %CI: 0.79-0.97). Can-ALE was not associated with any of the outcomes assessed. Future research assessing perceived environmental walkability and geriatric relevant health outcomes rather than chronic disease may provide greater insight into our understanding of age-friendly environments.

Inflammation, Oxidative Stress, and Antioxidant Micronutrients as Mediators of the Relationship Between Sleep, Insulin Sensitivity, and Glycosylated Hemoglobin

Background

Sleep deprivation and poor sleep quality contribute to increases in oxidative stress, antioxidant imbalance, and a pro-inflammatory state which may predispose to a higher risk of diabetes. Our objective was to estimate the contributions of C-reactive protein (CRP), gamma glutamyl transferase (GGT), and micronutrient antioxidants (bilirubin, carotenoids, uric acid, vitamins A, C-E?) to the relationships between sleep-fasting insulin concentration and -glycosylated hemoglobin (HbA1c).

Methods

Data from the 2005/06 US National Health and Nutritional Examination Survey were used (N = 1,946; 20 y+). Sleep quality and quantity was assessed by the Sleep Disorders Questionnaire, and fasting blood was collected to quantify CRP, GGT, antioxidant micronutrients, insulin concentration, and HbA1c. The bootstrap method was used to estimate the amount of mediation or contribution of these mediators to the sleep-insulin concentration and -HbA1c relationships, which were quantified as large (≥0.25) or moderate (≥0.09).

Results

The sleep duration-fasting insulin relationship was mediated by GGT, carotenoids, uric acid, and vitamins C and D, whereas CRP and bilirubin were non-significant mediators of a moderate effect size. Similarly, the sleep quality-fasting insulin relationship was mediated by CRP, bilirubin and vitamin C, whereas GGT, carotenoids, uric acid, and vitamin D were non-significant large-to-moderate mediators. To a lesser degree, these micronutrients mediated for the relationship between sleep-HbA1c levels.

Conclusion

Several factors related to inflammation, oxidative stress, and antioxidant status were found to lie on the pathway of the sleep-insulin and -glycemic control relationships. Sleep hygiene, reduced systemic inflammation/oxidative stress, and optimal antioxidants intake are potentially beneficial targets for managing diabetes risk.

Associations between weight discrimination and metabolic health: A cross sectional analysis of middle aged adults

BACKGROUND

Concurrent with the recent rise in overweight and obesity, concerns with weight discrimination have arisen. Individuals who have experienced weight discrimination report a host of deteriorations related to physical and psychological health, which may co-exist with behaviours such as increased food consumption and decreases in physical activity that make weight management difficult. What remains less clear, however, is the extent to which metabolic health may be specifically affected, and how this may vary by setting and perceived intensity of the lifetime history of weight discrimination.

METHOD

To address this, a secondary data analysis was performed on 1365 participants from year 25 of the Coronary Artery Disease in Young Adults (CARDIA) study who were living with overweight and obesity. Descriptive statistics and logistic regression analyses were performed on the presence of metabolic syndrome, diabetes, and abdominal obesity, as well as their experience of the weight discrimination.

RESULTS

Prevalence of the metabolic syndrome, diabetes, and abdominal obesity was higher among those reporting low and high stress weight discrimination compared to those with no history of weight discrimination. In the adjusted analyses, weight discrimination was associated with a 65% greater likelihood for having metabolic syndrome, 85% greater likelihood of diabetes, and between a 2.5- and 3.9-times greater likelihood of abdominal obesity for low and high stress experiences, respectively.

CONCLUSION

Exposure to weight discrimination may worsen metabolic health, as characterized by higher rates of metabolic syndrome and abdominal obesity. These associations may be greater with levels of stress experienced from weight discrimination. Further longitudinal work is necessary to understand the temporal sequence, time lag, and any possible critical periods for weight discrimination on metabolic health.

Concurrently Low Coronary Flow Reserve and Low Index of Microvascular Resistance Are Associated With Elevated Resting Coronary Flow in Patients With Chest Pain and Nonobstructive Coronary Arteries

BACKGROUND

Coronary microvascular function can be distinctly quantified using the coronary flow reserve (CFR) and index of microvascular resistance (IMR). Patients with low CFR can present with low or high IMR, although the prevalence and clinical characteristics of these patient groups remain unclear.

METHODS

One hundred ninety-nine patients underwent coronary microvascular assessments using coronary thermodilution techniques. A pressure-temperature sensor-tipped guidewire measured proximal and distal coronary pressure, whereas the inverse of the mean transit time to room temperature saline was used to measure coronary blood flow. The CFR and IMR were quantified during adenosine and acetylcholine hyperemia.

RESULTS

Low adenosine and acetylcholine CFR was observed in 70 and 49 patients, respectively, whereas low CFR/low IMR to adenosine and acetylcholine was observed in 39(56%) and 19(39%) patients, respectively. Despite similar adenosine CFR, patients with low CFR/low IMR had increased resting (2.8±1.2 versus 1.3±0.4s^-1) and hyperemic coronary blood flow (4.8±1.5 versus 2.1±0.5s^-1) compared with patients with low CFR/high IMR (both P<0.01). The same pattern was observed in response to acetylcholine. Patients with low CFR/low IMR to adenosine were younger (56±12 versus 63±10 years), women (84% versus 66%), had fewer coronary risk factors (1.1±1.0 versus 1.6±1.1), lower hemoglobin A1c (5.8±0.7 versus 6.1±0.9 mmol/L), and thinner septal thickness (8.5±2.5 versus 9.9±1.6 mm) compared with patients with low CFR/high IMR to adenosine (all P<0.05).

CONCLUSIONS

Low CFR/low IMR to adenosine and acetylcholine are associated with elevated resting coronary blood flow and preserved hyperemic coronary blood flow. These patients present with distinct phenotypic characteristics. Simultaneous CFR and IMR measures appear necessary to differentiate these endotypes.

A systematic review and meta-analysis of the effect of treadmill desks on energy expenditure, sitting time and cardiometabolic health in adults

Background

As the health risks of sedentary working environments become more clear, greater emphasis on the implementation of walking interventions to reduce sitting time is needed. In this systematic review and meta-analysis, we investigate the role of treadmill-desk interventions on energy expenditure, sitting time, and cardiometabolic health in adults with sedentary occupations.

Methods

Relevant studies published in English were identified using CINAHL, EMBASE, MEDLINE, Web of Science, Scopus, and PubMed databases up to December 2020. Random effects meta-analysis models were used to pool study results.

Results

Thirteen relevant studies (six workplaces and seven laboratories) were found with a total of 351 participants. Pooled analysis of laboratory studies showed a significant increase in energy expenditure (105.23 kcal per hour, 95% confidence interval [CI]: 90.41 to 120.4), as well as metabolic rate (5.0 mL/kg/min, 95% CI: 3.35 to 6.64), among treadmill desk users compared to sitting conditions. No evidence of significant differences in blood pressure were found. In workplace studies, we observed a significant reduction in sitting time over a 24-h period (− 1.73 min per hour, 95% CI: − 3.3 to − 0.17) among users of treadmill desks, compared to a conventional desk. However, there were no evidence of statistically significant changes in other metabolic outcomes.

Conclusions

Treadmill desks offer a feasible and effective intervention to increase energy expenditure and metabolic rate and reduce sitting time while performing work-related tasks. Future studies are needed to increase generalizability to different workplace settings and further evaluate their impact on cardiometabolic health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12094-9.

Trends in Serum AST-to-ALT Ratio Among U.S. Adults: Analysis of the U.S. National Health and Nutrition Examination Survey

Background: Using nationally representative data, we examined the age-, sex-, and ethnic-specific variation in the ratio of serum aspartate aminotransferase and alanine aminotransferase (AST-to-ALT ratio or AAR) of U.S. adults (20+ years). Understanding these subgroup differences in AAR will provide insight into population patterns of these ratios, which provide a basis for normative comparisons for the application of personalized diagnostic information to patients in the clinical setting. Methods: Data for this analysis are based on continuous cycles (1999-2016) of the National Health and Nutrition Examination Survey (NHANES). Results: Within the complete sample (n = 13,731), mean AST and ALT values were similar (∼25 U/L), with higher absolute values, but lower AAR, in males compared with females. From 1999-2000 to 2015-2016 there were consistent sex, age, and ethnic differences in the AAR. Specifically, the AAR for individuals 65+ years was markedly higher in all survey years, with subtle ethnic variation [Mexican Americans (0.95-1.04) Other Hispanic (1.0-1.09), Non-Hispanic White (1.05-1.11), Non-Hispanic Black (1.12-1.22), and Other Ethnicity (1.01-1.17)]. Sex-specific analysis reveals that the lower AAR observed among Mexican Americans is almost entirely accounted for by the markedly lower AAR in men. Conclusion: Future work is necessary to understand these subgroup variations in longer term studies with incident disease.

Associations between elevated kidney and liver biomarker ratios, metabolic syndrome and all-cause and coronary heart disease (CHD) mortality: analysis of the U.S. National Health and Nutrition Examination Survey (NHANES)

BACKGROUND

We examined the relationship between ratios of select biomarkers of kidney and liver function on all-cause and coronary heart disease (CHD) mortality, both in isolation, and in combination with metabolic syndrome (MetS), among adults (20 + years, n = 10,604).

METHODS

Data was derived from the U.S. National Health and Nutrition Examination Survey (1999-2016) including public-use linked mortality follow-up files through December 31, 2015.

RESULTS

Select biomarker ratios of kidney (UACR or albuminuria and BUN-CR) and liver (AST-ALT and GGT-ALP) function in isolation and in combination with MetS were associated with all-cause and CHD mortality. Compared to individuals with neither elevated biomarker ratios nor MetS (HR = 1.00, referent), increased risk of all-cause mortality was observed in the following groups: MetS with elevated UACR (HR, 95% CI = 2.57, 1.99-3.33), MetS with elevated AST-ALT (HR = 2.22, 1.61-3.07), elevated UACR without MetS (HR = 2.12, 1.65-2.72), and elevated AST-ALT without MetS (HR = 1.71, 1.35-2.18); no other biomarker ratios were associated with all-cause mortality. For cause-specific deaths, elevated risk of CHD mortality was associated with MetS with elevated UACR (HR = 1.67, 1.05-2.67), MetS with elevated AST-ALT (HR = 2.80, 1.62-4.86), and elevated BUN-CR without MetS (HR = 2.12, 1.12-4.04); no other biomarker ratios were associated with CHD mortality.

CONCLUSION

Future longitudinal studies are necessary to examine the utility of these biomarker ratios in risk stratification for chronic disease management.

Abstract P207: Association Between Rehabilitation and Functional Outcomes of Stroke Survivors: A Population-Based Study

Background: The increasing rate of stroke and its consequent disabilities has contributed to a growing proportion of stroke survivors requiring rehabilitation. Further research is needed to understand the provision of rehabilitation in the community settings and relationship between variance in stroke care and patient outcomes.

Hypothesis: To investigate the association between rehabilitation and functional outcomes of stroke survivors.

Method: Data for this analysis was derived from the Canadian Community Health Survey (CCHS) (merged cycles 2013-2016: 237,121 participants). Participants reporting complications from stroke were selected to assess the effect of physiotherapy (PT) and other allied health (AH) utilization. Primary endpoints included need for assistance in activity of daily living (ADL) and injury due to fall in the past 12 months (Inj-Fall). All statistical analyses were performed using R (V.4.0.2) and survey design.

Results: Overall, 3,773 (1.1%) patients with stroke (47% females, 71.1% older than 60 years) were studied. Total of 0.2% and 1.6% of stroke survivors in 2013-14 had consulted PT and AH compared to 9.1% and 21% in 2015-16, respectively. Consequently, the rate of need for ADL and Inj-Fall were significantly greater in 2013-14. In general, age was a significant predictor of low accessibility to PT (OR=0.66(0.51-0.85)) or AH (OR=0.79(0.66-0.93)) whereas no significant association between sex and access to PT or AH (P=0.1). As expected, higher income was associated with greater PT utilization (OR=2.11(1.1-4.2)). Finally, PT or AH consultations were significantly associated with less need for assistance in ADL and lower Inj-Fall (Table1).

Conclusion: Results of this study reinforce the beneficial effect of rehabilitation on ADL and injury in stroke survivors. Future longitudinal work is necessary to understand directionality of the relationship, and the impact of healthcare access, within varied healthcare systems and models of health .

Changes in the prevalence of chronic conditions associated with abdominal obesity between 1999 and 2014

To examine the trends in chronic conditions after accounting for temporal differences in body mass index (BMI) and waist circumference (WC). Pooled cycles (1999-2014) of the U.S. National Health and Nutrition Examination Survey (NHANES) were analysed (n = 36 959). The models were adjusted for caloric intake, smoking, medications use and physical activity. The prevalence of diabetes increased in women with general or abdominal obesity (BMI*time; WC*time, P < .05), but there were no differences in men. For hypertension, independent of BMI, the prevalence was not different over time in both sexes (P > .05), whereas for a given WC, there was a decrease in the prevalence over time in women (WC*time, P = .05). For dyslipidemia, independent of BMI, the prevalence decreased in men, whereas for a given WC, there was a decrease in the prevalence in both sexes (P < .05). Over the same time frame, blood pressure, low-density lipoprotein and triglycerides decreased, while plasma glucose increased independent of general and abdominal obesity (P < .001). The relationship between obesity and chronic conditions has changed over time. There may be other changes that have altered how obesity is related with metabolic health markers over time. Further investigation is needed to better understand the current causes of chronic conditions.

Noninvasive Microvascular Indices Reveal Peripheral Vascular Abnormalities in Patients With Suspected Coronary Microvascular Dysfunction

BACKGROUND

Reactive hyperemia peripheral arterial tonometry and flow-mediated dilation are common noninvasive measures of peripheral vascular function. However, their relationship with the coronary circulation, particularly in coronary microvascular dysfunction (CMD), is unclear. Therefore, the purpose of this study is to compare these noninvasive measurements with coronary microvascular function after endothelial-independent, endothelial-dependent, and sympathetically mediated pharmacologic hyperemia.

METHODS

Forty-seven patients with suspected CMD completed peripheral and coronary assessments. The reactive hyperemia index was collected using the EndoPAT2000 device, whereas a subset of patients (n = 28) completed brachial artery flow-mediated dilation using duplex ultrasound. Coronary microvascular function was quantified using the resistance and flow responses to intravenous adenosine (140 μg/kg/min), dobutamine (40 μg/kg/min), and intracoronary acetylcholine (100 μg). Abnormal coronary microvascular responses to adenosine and/or acetylcholine were used to define CMD.

RESULTS

The reactive hyperemia index (No CMD: 0.85 ± 0.23 vs CMD: 0.61 ± 0.26, P < 0.05) and flow-mediated dilation (No CMD: 7.2 ± 2.3 vs CMD: 4.8 ± 3.1; P < 0.05) were attenuated in patients with CMD. Whereas the reactive hyperemia index was correlated with the resistance and flow responses to dobutamine (ρ = -0.44 and ρ = 0.39, respectively; P < 0.05), flow-mediated dilation was correlated with the resistance responses to both adenosine (ρ = -0.48; P < 0.05) and acetylcholine (ρ = -0.66; P < 0.05). Lastly, the reactive hyperemia index and flow-mediated dilation had sensitivities of 80% and 69% and specificities of 71% and 93%, respectively, for identifying patients with CMD.

CONCLUSIONS

Peripheral vascular function is attenuated in CMD, and noninvasive measurements are associated with coronary responses to pharmaceutical stimulation.

Lifetime risk of cardiometabolic mortality according to vitamin D status of middle and older-aged adults: NHANES III mortality follow-up

The predictive value of total 25-hydroxyvitamin D (25(OH)D, a biomarker of vitamin D status) in relation to lifetime risk of cardiometabolic mortality is not known. The purpose of this study was to determine the association between standardized and annualized total 25(OH)D levels and lifetime risk for cardiometabolic mortality in middle- to older-aged adults. In this study, we followed up 7958 participants in the Third National Health and Nutrition Examination Survey from 1988 to 1994 (NHANES III) until the occurrence of cardiometabolic death or attainment of 95 years of age (median follow-up 17.9 years, 1371 cardiometabolic-deaths). Lifetime risks were estimated according to recommended total 25(OH)D cutoffs by national guidelines, and a combination of total 25(OH)D status and traditional risk factor burden. We also explored variation in lifetime risk estimates by levels of body mass index (BMI). The results of this study showed that annualized total 25(OH)D <30 nmol/L was associated with high lifetime risk of cardiometabolic mortality (40%). Lifetime risks of cardiometabolic mortality were similar for annualized levels between 30-< 50 nmol/L, 50-< 75 nmol/L and ≥75 nmol/L (31-33%). Lifetime risk was highest among participants with annualized total 25(OH)D <30 nmol/L and ≥2 major traditional risk factors (45%), whereas lifetime risk was lowest among participants with annualized 25(OH)D ≥30 nmol/L and low-intermediate risk factors (28%). Lifetime risk estimates were similar across BMI categories. In conclusion, a single measurement of vitamin D deficiency (annualized levels <30 nmol/L) in middle- to older-aged adults is a strong predictor of high lifetime risk for cardiometabolic mortality, particularly among those with high burden of traditional risk factors.

Cross-associations between physical activity and sedentary time on metabolic health: a comparative assessment using self-reported and objectively measured activity

Purpose

Physical activity and sedentary time have distinct physiologic and metabolic effects, but little is known about their joint associations.

Methods

The Canadian Health Measures Survey (n = 5950) was used to (i) examine the joint relationship between active/non-sedentary (referent group), active/sedentary, inactive/non-sedentary and inactive/sedentary phenotypes on obesity and metabolic health; and (ii) compare these relationships when using objective (accelerometer) total activity or subjective (self-report) leisure-time measures. Weighted associations for the metabolic syndrome (MetS), individual MetS components, 1+ disease (1 or more of diabetes, myocardial infarction, stroke, cardiovascular disease) and obesity were estimated using logistic regression.

Results

After adjustments, the odds (OR, 95% CI) of 1+ disease (OR = 3.05, 1.47-6.34) and abdominal obesity (OR = 2.75, 1.16-6.55) were higher in the inactive/sedentary group versus the referent group (OR = 1.00) when measured objectively. Within self-report leisure-time groups, elevated odds were observed for the inactive/sedentary group for MetS, obesity, abdominal obesity and elevated triglycerides. Inactive/non-sedentary and active/sedentary groups were similarly protective when measured by accelerometer.

Conclusion

Using accelerometer data, the inactive/sedentary group was at higher risk for 1+ disease and abdominal obesity only, whereas the active/sedentary and inactive/non-sedentary groups were not at higher risk for any health outcome.

The Association Between Metabolic Syndrome and Serum Concentrations of Micronutrients, Inflammation, and Oxidative Stress Outside of the Clinical Reference Ranges: A Cross-Sectional Study

BACKGROUND

Clinical reference ranges are often used to assess nutritional status, but whether having lower or higher than the current clinical reference range for micronutrients, inflammation, and oxidative stress is related to metabolic syndrome (MetS) is not known. Our objectives are to estimate the odds of having MetS outside of established clinical references, and to identify any effect modifications by sex have for these relationships.

METHODS

Data from the 2005 to 2006 National Health and Nutrition Examination Survey were used (≥20 years; N = 2049) with MetS defined utilizing the harmonized criteria from the Joint Interim Statement. The odds of having MetS in individuals with lower or higher than the clinical reference range for the serum concentrations of micronutrient antioxidants, inflammation, and oxidative stress were estimated following adjustments for age, sex, ethnicity, education, income, smoking, alcohol intake, recreational physical activity, and BMI.

RESULTS

Having lower than the clinical reference range for carotenoids and vitamin C [odds ratios (95% confidence interval): 1.37 (1.05-1.78) and 1.39 (1.01-1.90), respectively] was associated with significantly greater odds of MetS. By contrast, having higher than the clinical reference range for vitamins A and E, uric acid, and γ-glutamyl transferase (GGT) [2.10 (1.50-2.92), 2.36 (1.78-3.13), 2.65 (1.54-4.57), and 2.08 (1.61-2.69), respectively] was associated with higher odds of MetS, whereas higher levels of vitamins B12 were protective [0.64 (0.42-0.98]. Sex moderated these relationships for carotenoids, vitamin A, C, E, uric acid, C-reactive protein, and GGT.

CONCLUSIONS

Lower carotenoids and vitamin C and higher vitamins A and E, uric acid, and oxidative stress were associated with a greater likelihood of MetS, whereas higher vitamin B12 was protective. Further research is necessary to replicate these findings in a prospective setting to confirm the importance of the overall and sex-specific findings.

Metabolically healthy obesity, vitamin D, and all-cause and cardiometabolic mortality risk in NHANES III

BACKGROUND & AIMS

Previous studies assessing the prognosis of metabolically healthy obesity (MHO) have been limited by a lack of a harmonized definition of MHO phenotype. Furthermore, obesity is a risk factor for vitamin D deficiency and low vitamin D status has been associated with a higher risk of mortality; however, few studies have evaluated the joint association between vitamin D, metabolic health phenotype, and mortality risk. Using a harmonized definition, we investigated whether MHO is associated with subsequent all-cause and cardiometabolic mortality, and whether serum 25-hydroxyvitamin D [25(OH)D] modifies these associations.

METHODS

This study included participants aged ≥20 years from the Third National Health and Nutrition Examination Survey (NHANES III). MHO phenotype was defined as a combination of obesity (≥30 kg/m²) and zero component of metabolic syndrome. Multivariable Cox regression was used to assess the risk of mortality across metabolic phenotypes, and the joint association between metabolic phenotype and 25(OH)D. Fine and Gray regression was performed to account for competing risk events.

RESULTS

Among 11,333 participants, a total of 2980 deaths (937 cardiometabolic death outcomes) occurred during a median follow-up of 19.1 years. In the absence of any metabolic abnormality, obesity (MHO) was not associated with a higher risk of all-cause (hazard ratio [HR], 0.89 [95% CI, 0.52-1.51]) or cardiometabolic mortality (cause-specific HR, 1.21 [95% CI 0.33-4.46]). Similar results were obtained from competing risk analysis. No significant differences in average 25(OH)D levels were observed between MHO and non-MHO participants; however, there was a significant interaction between metabolic health phenotype and serum 25(OH)D in relation to cardiometabolic mortality such that levels of serum 25(OH)D < 50 nmol/L were associated with increased risk of cardiometabolic mortality, particularly in participants within the normal-weight and obese BMI ranges.

CONCLUSIONS

Our results support the hypothesis that MHO phenotype is a benign health condition. Vitamin D deficiency may exacerbate the risk of cardiometabolic death outcomes associated with metabolic dysfunction in normal weight and obese individuals. Further research is warranted to validate our findings.

Association between cardiorespiratory fitness and metabolic risk factors in a population with mild to severe obesity

Background

Previous literature suggests the beneficial effects of fitness on abdominal obesity may be attenuated in obesity and abolished in severe obesity. It is unclear whether the beneficial association between fitness and health is similarly present in those with mild and severe obesity.

Methods

Patients from the Wharton Medical Clinic (n = 853) completed a clinical examination and maximal treadmill test. Patients were categorized into fit and unfit based on age- and sex-categories and body mass index (BMI) class (mild: ≤ 34.9 kg/m², moderate: 35–39.9 kg/m² or severe obesity: ≥ 40 kg/m²).

Results

Within the sample, 41% of participants with mild obesity had high fitness whereas only 25% and 11% of the participants with moderate and severe obesity, respectively, had high fitness. BMI category was independently associated with most of the metabolic risk factors, while fitness was only independently associated with systolic blood pressure and triglycerides (P < 0.05). The prevalent relative risk for pre-clinical hypertension, hypertriglyceridemia and hypoalphalipoproteinemia and pre-diabetes was only elevated in the unfit moderate and severe obesity groups (P < 0.05), and fitness groups were only significantly different in their relative risk for prevalent pre-clinical hypertension within the severe obesity group (p = 0.03). High fitness was associated with smaller waist circumferences, with differences between high and low fitness being larger in those with severe obesity than mild obesity (Men: P = 0.06, Women: P = 0.0005).

Conclusions

Thus, in contrast to previous observations, the favourable associations of having high fitness and health may be similar if not augmented in individuals with severe compared to mild obesity.

Emergency Room Visits by Uninsured Child and Adult Residents in Ontario, Canada: What Diagnoses, Severity and Visit Disposition Reveal About the Impact of Being Uninsured

Canadian immigrants can be without health insurance for many reasons but limited data exists regarding uninsured health outcomes. Uninsured Canadian residents were identified in the National Ambulatory Care Reporting System for all visits to emergency departments in Ontario, Canada between 2002/3 and 2010/11 (N = 44,489,750). Frequencies for main diagnoses, severity (triage), and visit disposition were compared. Ambulatory care sensitive conditions were identified in a 10 % subsample. The uninsured (N = 140,730; 0.32 %) were more likely to be diagnosed with mental health (insured: 3.48 %; uninsured: 10.47 %) or obstetric problems (insured: 2.69 %; uninsured: 5.56 %), be triaged into the two most severe categories (insured: 11.2 %; uninsured 15.6 %), leave untreated (insured: 3.1 %; uninsured: 5.4 %), or die (insured: 2.8 %; uninsured: 3.7 %). More ACSC visits were made by uninsured children and youth. Insurance status is associated with more serious health status on arrival to emergency departments and more negative visit outcomes.

Clinical utility of serum 25-hydroxyvitamin D in the diagnosis of insulin resistance and estimation of optimal 25-hydroxyvitamin D in U.S. adults

AIMS

To assess the clinical utility of measuring serum 25-hydroxyvitamin-D [25(OH)D] along with traditional risk factors in the diagnosis of insulin resistance (IR) and to estimate the optimal 25(OH)D level associated with normal glucose and insulin homeostasis.

METHODS

A cross-sectional analysis of 6868 adults aged≥20years without diagnosed diabetes in the National Health and Nutrition Examination Survey, with available standardized 25(OH)D data (2001-2010). IR was defined by the homeostatic-model-assessment of insulin resistance (HOMA-IR; ≥75th percentile, sex-specific: 3.9 in men or 3.6 in women). Using logistic regression, two risk models were developed to estimate the risk of IR: Model 1 included established risk factors, and Model 2 additionally included serum 25(OH)D. Predictiveness curves and decision-curve analysis were used to assess differences in IR detection among models. Receiver-operating-characteristic curves were used to estimate the lower threshold for 25(OH)D. Results were validated in a testing sample.

RESULTS

Model 2 marginally improved detection of IR: at a risk threshold of 0.2, adding 25(OH)D would identify an additional 2 to 4 cases per 1000 people. Overall, the lower 25(OH)D threshold was estimated at 60nmol/L, however, the threshold differed by ethnicity (Mexican-Americans: 54nmo/L, non-Hispanic whites: 68nmol/L, and non-Hispanic blacks: 41nmol/L).

CONCLUSION

Addition of serum 25(OH)D to traditional risk factors provided small incremental improvement in detection of IR in asymptomatic adults. The optimal 25(OH)D threshold was estimated to be at least 60nmol/L, however, the threshold may differ by ethnic-background. Further research is needed to validate these results in other populations.

Physical activity mediates the relationship between fruit and vegetable consumption and cognitive functioning: a cross-sectional analysis

Background

Excess adiposity is associated with impairments in cognitive functioning, whereas physical activity (PA) and fruit and vegetable consumption (FVC) may be protective against cognitive decline. Therefore, this study investigated the interrelationships between FVC, body mass index (BMI), PA and cognitive functioning in younger and older adults.

Methods

Cross-sectional data of 45 522 participants (≥30 years) were examined from the 2012 annual component of the Canadian Community Health Survey. Cognitive function was assessed using a single six-level question of the Health Utilities Index. PA was classified according to the Physical Activity Index kilocalories per kilogram per day  as active, moderately active and inactive; BMI was measured in kg/m2 and FVC (servings/day) was classified as low, moderate or high. To assess the interrelationship between FVC, BMI, PA, age and cognitive functioning, general linear models and mediation analyses were used.

Results

Higher BMIs, lower PA and FVC were associated with poorer cognitive functioning. Additionally, PA statistically mediated the relationship between FVC and cognitive function (Sobel test: t = -3.15; P < 0.002); and higher education levels and daily FVC were associated with better cognitive function (P < 0.001).

Conclusion

Higher PA levels were associated with better cognitive functioning in younger and older adults. Also, higher daily FVC and education levels were associated with better cognitive scores.

Inter-relationships between physical activity, body mass index, sedentary time, and cognitive functioning in younger and older adults: cross-sectional analysis of the Canadian Community Health Survey

OBJECTIVES

Engagement in leisure-time physical activity (LTPA) is protective against cognitive decline whereas obesity and sedentary behaviors are associated with impairments in perceived cognitive function. Currently, little is known about how these relationships vary across the lifespan. This study investigated the inter-relationships between LTPA, leisure-time sedentary time (LTST), body mass index (BMI), and perceived cognitive functioning in younger and older Canadian adults.

STUDY DESIGN

This is a cross-sectional study.

METHODS

Data from the 2012 annual component of the Canadian Community Health Survey (n = 45,522; ≥30 y) were used to capture LTPA, BMI, LTST, and perceived cognitive function. The inter-relationships were assessed using both mediation analyses and general linear models.

RESULTS

Lower LTPA and higher BMI and LTST were related to poorer perceived cognitive functioning (P < 0.0001) and LTPA mediated the BMI-perceived cognitive functioning (Sobel's test: t = 3.24; P < 0.002) and LTST-perceived cognitive functioning (Sobel test: t = 3.35; P < 0.002) relationships.

CONCLUSION

Higher LTPA levels contribute to better perceived cognitive functioning scores both independently and by way of offsetting the impact of elevated BMI and LTST on cognitive function.

Factors associated with complementary and alternative medicine use among women at midlife

Hormone replacement therapy (HRT) has been established as the first-line treatment for women experiencing menopausal symptoms. The use of complementary and alternative medicine (CAM), however, is becoming increasingly popular among women at midlife for management of such symptoms. Despite the equivocal evidence of CAM's efficacy in the reduction and alleviation of menopausal symptoms in placebo-controlled, randomized trials, 50% of women at midlife use CAM. To date, several large, population-based studies have focused upon CAM use amongst menopausal women and the factors associated with the adoption of such therapies. By identifying women in the menopausal transition who tend to use CAM, this narrative review highlights evidence that aids women at this stage of life make better and individualized treatment choices to relieve these symptoms. The available evidence suggests that the prevalence of CAM use among menopausal women is high world-wide, but there is a paucity of high-quality studies that adequately assess the factors associated with its use. Further studies are needed to confirm the characteristics of women who employ CAM to manage their night sweats and hot flushes. Results of this study might enable the development of policies catering to the needs of those women and provide a resource to support their decision-making regarding treatment options.

Associations Between Sleep Habits and Dysglycemia in Adults in the United States: A Cross-Sectional Analysis

OBJECTIVES

To examine the independent and joint associations between sleep duration and quality with glycated hemoglobin (A1C) levels and dysglycemia in non-institutionalized adults living in the United States.

METHODS

Data from the United States National Health and Nutrition Examination Survey (2005-2008) were used (N=9478; ≥20 years). Information on sleep quantity and quality were derived from the Sleep Disorders Questionnaire and used to classify sleep quality as good, fair, poor, or very poor.

RESULTS

Overall, sleep quantity and quality were related to A1C levels in our unadjusted models. In general, a U-shaped relationship between sleep quantity and A1C levels was observed. Compared to those who slept for 7 to 8 hours per night, sleeping for 4 hours or fewer was associated with higher A1C levels (mean, 95% CI; 5.49%, 5.45 to 5.53 vs. 5.69%, 5.60 to 5.77; p<0.05), whereas only those reporting good and very poor sleep quality had higher A1C levels than poor sleepers (mean, 95% CI: 5.63%, 5.57 to 5.69; 5.56%, 5.52 to 5.60 vs. 5.46%, 5.42 to 5.50; p<0.05). The relationships among sleep duration and quality and the joint effects of sleep quality and quantity and dysglycemia were not significant after multivariable adjustment.

CONCLUSIONS

Between 7 and 8 hours of sleep and fair/poor sleep quality were associated with optimal A1C levels, while sleeping for fewer or more hours appeared to increase dysglycemia, without adjustment for covariates. These relationships were attenuated following multivariable adjustment. Future research is necessary to refine our understanding of the sleep/glycemic-control relationship to provide a context for the clinical significance of these findings for longer-term A1C control in adults with diabetes.

Standardized serum 25-hydroxyvitamin D concentrations are inversely associated with cardiometabolic disease in U.S. adults: a cross-sectional analysis of NHANES, 2001-2010

BACKGROUND

Previously reported associations between vitamin D status, as measured by serum 25-hydroxyvitamin D [25(OH)D] concentrations, and cardiometabolic risk factors were largely limited by variability in 25(OH)D assay performance. In accordance with the Vitamin D Standardization Program, serum 25(OH)D measurement was recently standardized in the National Health and Nutrition Examination Survey (NHANES) to reduce laboratory and method related differences in serum 25(OH)D results. We evaluated the overall and ethnic-specific associations between the newly standardized serum 25(OH)D concentrations and cardiometabolic risk in U.S. adults.

METHODS

This study examined standardized 25(OH)D data from five cycles of the NHANES (2001-2010). The total sample included 7674 participants (1794 Mexican-Americans, 4289 non-Hispanic whites, and 1591 non-Hispanic blacks) aged ≥ 20 years who were examined in the morning after overnight fasting. Serum 25(OH)D was directly measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in 2007-2010, and was predicted from LC-MS/MS equivalents for 2001-2006. Serum 25(OH)D levels were categorized into quartiles (<43.4, 43.4-58.6, 58.7-74.2, ≥74.3 nmol/L). Cardiometabolic risk was defined by the homeostatic model assessment of insulin resistance (HOMA-IR), metabolic syndrome (MetS), and Framingham cardiovascular disease (CVD) risk. Prevalence ratios and 95% confidence intervals were calculated using modified Poisson regression.

RESULTS

After full adjustment for confounders, serum 25(OH)D ≥74.3 nmol/L was associated with lower cardiometabolic risk compared to 25(OH)D <43.4 nmol/L in the overall sample [HOMA-IR: 0.70 (0.59, 0.84); MetS: 0.82 (0.74, 0.91); CVD risk: 0.78 (0.66, 0.91)]. These associations remained significant in Mexican-Americans [HOMA-IR: 0.54 (0.35, 0.82); MetS: 0.73 (0.55, 0.96)], non-Hispanic whites [HOMA-IR: 0.81 (0.68, 0.96); MetS: 0.84 (0.73, 0.95); CVD risk: 0.78 (0.64, 0.93)]; and in non-Hispanic blacks [HOMA-IR: 0.67 (0.45, 0.99); MetS: 0.75 (0.56, 0.97); CVD risk: 0.58 (0.41, 0.81)].

CONCLUSIONS

Low vitamin D status is a significant risk factor for cardiometabolic disease in U.S. adults based on standardized serum 25(OH)D results, irrespective of ethnic background. Future studies using standardized 25(OH)D data are needed to confirm these results, particularly amongst U.S. blacks with 25(OH)D concentrations above 75 nmol/L.

Formulation of evidence-based messages to promote the use of physical activity to prevent and manage Alzheimer's disease

Background

The impending public health impact of Alzheimer’s disease is tremendous. Physical activity is a promising intervention for preventing and managing Alzheimer’s disease. However, there is a lack of evidence-based public health messaging to support this position. This paper describes the application of the Appraisal of Guidelines Research and Evaluation II (AGREE-II) principles to formulate an evidence-based message to promote physical activity for the purposes of preventing and managing Alzheimer’s disease.

Methods

A messaging statement was developed using the AGREE-II instrument as guidance. Methods included (a) conducting a systematic review of reviews summarizing research on physical activity to prevent and manage Alzheimer’s disease, and (b) engaging stakeholders to deliberate the evidence and formulate the messaging statement.

Results

The evidence base consisted of seven systematic reviews focused on Alzheimer’s disease prevention and 20 reviews focused on symptom management. Virtually all of the reviews of symptom management conflated patients with Alzheimer’s disease and patients with other dementias, and this limitation was reflected in the second part of the messaging statement. After deliberating the evidence base, an expert panel achieved consensus on the following statement: “Regular participation in physical activity is associated with a reduced risk of developing Alzheimer’s disease. Among older adults with Alzheimer’s disease and other dementias, regular physical activity can improve performance of activities of daily living and mobility, and may improve general cognition and balance.” The statement was rated favourably by a sample of older adults and physicians who treat Alzheimer’s disease patients in terms of its appropriateness, utility, and clarity.

Conclusion

Public health and other organizations that promote physical activity, health and well-being to older adults are encouraged to use the evidence-based statement in their programs and resources. Researchers, clinicians, people with Alzheimer’s disease and caregivers are encouraged to adopt the messaging statement and the recommendations in the companion informational resource.

Association between Sleep Habits and Metabolically Healthy Obesity in Adults: A Cross-Sectional Study

Higher body mass index (BMI) increases the risk of cardiometabolic diseases, but nearly a third of the people living with obesity (BMI: ≥30 kg/m²) are metabolically healthy (MHO). Extreme sleep durations and poor sleep quality are associated with higher bodyweight and cardiometabolic dysfunction, but the full extent to which sleep habits may help differentiate those with MHO versus metabolically abnormal obesity (MAO) is not yet known. Data from the U.S. National Health and Nutritional Examination Survey 2005-08 was used (BMI: ≥30 kg/m²; ≥20 y; N = 1,777). The absence of metabolic syndrome was used to define MHO. Those with MHO tended to be younger, female, Non-Hispanic Black, never smokers, more physically active, and with less physician diagnosed sleep disorders than MAO. Neither sleep duration nor overall sleep quality was related to MHO in crude or multivariable adjusted analyses; however, reporting "almost always" to having trouble falling asleep (OR (95% CI): 0.40 (0.20-0.78)), waking up during the night (0.38 (0.17-0.85)), feeling unrested during the day (0.35 (0.18-0.70)), and feeling overly sleepy during the day (0.35 (0.17-0.75)) was related to lower odds of MHO. Selected sleep quality factors, but not sleep quantity or overall sleep quality, are associated with the MHO phenotype.

Physical Activity Contributes to Several Sleep-Cardiometabolic Health Relationships

PURPOSE

To estimate the contribution of accelerometer-derived physical activity to the relationship between sleep and cardiometabolic health.

METHODS

Data from the 2005 to 2006 US National Health and Nutritional Examination Survey were used (N = 1226; 20 years+). Metabolic syndrome (MetS) was defined by the Joint Interim Statement, and sleep quality and quantity by the Sleep Disorders Questionnaire. Physical activity intensities were defined by activity thresholds (counts per minute) as sedentary activity (0-99), light intensity (100-759), lifestyle activity (760-2019), moderate intensity (2020-5996), and vigorous intensity (≥5999). Outcomes were MetS, number of MetS components, waist circumference (WC), systolic and diastolic blood pressure (BP), triglycerides, HDL-cholesterol, fasting plasma glucose, and fasting insulin concentration. The bootstrap method was used to estimate the amount of mediation or contribution of activity intensities (ab) to the sleep-cardiometabolic health relationships, which were quantified as large (≥0.25) or moderate (≥0.09).

RESULTS

Lifestyle activity level contributes to several sleep duration and cardiometabolic health relationships, most notably for WC (ab: 0.28), systolic BP (0.39), and fasting insulin concentration (0.85). While moderate intensity and lifestyle activity intensities were large contributors to the sleep quality-fasting insulin concentration relationship (0.47 and 0.48, respectively), light intensity activity only moderately contributed to the relationship between sleep duration and quality with abdominal obesity (0.15).

CONCLUSION

Lifestyle and moderate intensity physical activity have a large effect on the relationship between sleep and cardiometabolic health, including WC, BP, and fasting insulin concentration. Appropriate sleep hygiene, in combination with regular physical activity should be considered mutually beneficial targets for cardiometabolic health.

Does Early Career Achievement Lead to Earlier Death? Assessment of the Precocity-Longevity Effect in Professional Basketball Players

Objectives

To examine the precocity-longevity (P-L) effect in North American professional basketball players who debuted between 1946 and 1979, and to determine whether playing position and decade of play influenced the relationship between age of career achievements and life span.

Methods

A total of 1852 players were evaluated from a recognized sports archive (i.e., http://sports-reference.com), which provided information on date of birth, death, and career debut, playing position, and indicators of achievement (i.e., All-Star team and/or All-League team selection). Athletes were categorized as above or below the median age of professional debut and median age of selection to first All-Star team and/or All-League team. Analyses of deceased players (n = 598) were comprised of bivariate correlations between age of achievement (age of debut, age of first All-Star game, and age of first All-League team selection) and age of death, and t-tests to compare the average age of death of early and late achievers (p < 0.05). Survival analyses, using the entire sample (living and deceased players), compared the life spans between those who debuted above and below the median age of achievement for each indicator of achievement.

Results

Only the correlation between age of professional debut and age of death (r = 0.33, p < 0.001), age of first All-Star game and age of death (r = 0.29, p < 0.05), and the t-test comparing the average death age of early (66.4 years) and later (69.3 years) debut age groups (p = 0.01) reached statistical significance. However, survival analyses demonstrated a trend for lower risk of death for early achievers, with one exception (i.e., age of debut); this trend was not statistically significant.

Conclusion

Results did not support the P-L hypothesis, suggesting that sample characteristics (i.e., physical fitness of high performance athletes), and measurement methodologies, may influence support for the proposed hypothesis in sport. However, future research would benefit form larger sample sizes and cause of death data.

Predictors of early attrition and successful weight loss in patients attending an obesity management program

Background

Our objective was to identify factors that are independently associated with early attrition and successful weight loss (WL) in an obesity-management program.

Methods

Participants were 9,498 patients enrolled in treatment at the Wharton Weight Management Clinic for at least 6 months. Predictors of early attrition (<6 months) and successful WL (≥5 %) were analyzed using relative risk (RR) in men and women separately. Pearson’s correlation was used to determine the relationship between WL and treatment time Weight loss and attrition analysis was restricted to patients who had more than two visits (n = 5415).

Results

Older individuals had lower early attrition (RR Range:0.74–0.92, P < 0.05) and greater WL success (RR Range:1.40–1.65, P < 0.05) than younger individuals. Males with hypertension and females with depression had greater early attrition (RR Range:1.09–1.20, P < 0.05) and lower WL success (RR Range:0.48–0.57, P < 0.05) than those without these health conditions. Males with lower education had greater early attrition (RR = 1.11[1.03–1.19]) than males with higher education, but did not differ in WL. Females who smoked had greater early attrition (RR = 1.06[1.01–1.11]) than females who did not smoke, but did not differ in WL. Ethnicity was not related to early attrition, however, females of Black and Other ethnicities had lower WL success compared to White females (RR Range:0.58–0.74, P < 0.05). After adjusting for treatment time, all above associations were no longer significant and treatment time remained as the only independent predictor of WL success (P < 0.0001).

Conclusion

As WL is positively and independently related with treatment time, individuals at risk for early attrition may need alternative treatment options, in order to improve patient retention and improve WL success.

Contribution of Inflammation, Oxidative Stress, and Antioxidants to the Relationship between Sleep Duration and Cardiometabolic Health

OBJECTIVES

To explore the interrelationship and mediating effect of factors that are beneficial (i.e., antioxidants) and harmful (i.e., inflammation and oxidative stress) to the relationship between sleep and cardiometabolic health.

DESIGN

Cross-sectional data from the 2005-2006 National Health and Nutrition Examination Survey.

SETTING

Nationally representative population sample from the US.

PARTICIPANTS

Age ≥ 20 y with sleep data; final analytical sample of n = 2,079.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Metabolic syndrome was classified according to the Joint Interim Statement, and sleep duration was categorized as very short, short, adequate, and long sleepers (≤ 4, 5-6, 7-8, and ≥ 9 h per night, respectively). The indirect mediation effect was quantified as large (≥ 0.25), moderate (≥ 0.09), modest (≥ 0.01), and weak (< 0.01). In general, inflammation was above the current clinical reference range across all sleep duration categories, whereas oxidative stress was elevated among short and very short sleepers. Select sleep duration- cardiometabolic health relationships were mediated by C-reactive protein (CRP), γ-glutamyl transferase (GGT), carotenoids, uric acid, and vitamins C and D, and were moderated by sex. Specifically, moderate-to-large indirect mediation by GGT, carotenoids, uric acid, and vitamin D were found for sleep duration-waist circumference and -systolic blood pressure relationships, whereas vitamin C was a moderate mediator of the sleep duration-diastolic blood pressure relationship.

CONCLUSIONS

Several factors related to inflammation, oxidative stress, and antioxidant status were found to lie on the casual pathway of the sleep duration-cardiometabolic health relationship. Further longitudinal studies are needed to confirm our results.

Urinary Biomarkers of Polycyclic Aromatic Hydrocarbons Are Associated with Cardiometabolic Health Risk

BACKGROUND

Polycyclic aromatic hydrocarbons (PAH) are both man-made and naturally occurring environmental pollutants that may be related to cardiometabolic health risk.

OBJECTIVE

To determine whether PAH is associated with obesity in the adult population and to examine whether urinary concentrations of PAH metabolites are associated with differences in how obesity relates to 3 or more risk factors for the metabolic syndrome (3RFMetS), type 2 diabetes (T2D), hypertension, and dyslipidemia.

METHODS

A total of 4765 adult participants from the 2001-2008 National Health and Nutrition Examination Survey were examined. The association between 8 urinary hydroxylated PAH metabolites, obesity, and health were examined using weighted logistic regressions adjusting for age, sex, ethnicity, PIR, smoking status, and urinary creatinine.

RESULTS

There was a positive dose-dependent association between obesity and 2-phenanthrene quintiles (P trend <0.0001). Contrarily, higher quintiles of 1-naphthalene were associated with lower risk of obesity (P trend = 0.0004). For a given BMI, those in the highest quintile of 2-naphthalene, 2-fluorene, 3-fluorene and 2-phenanthrene had a 66-80% greater likelihood of 3RFMetS (P≤0.05) compared to low levels. Higher quintiles of 1-naphthalene, 2-naphthalene, 2-phenanthrene and 1-pyrene were associated with a 78-124% greater likelihood of T2D (P≤0.05) compared to low levels while high 1-naphthalene, 2-naphthalene, 2-fluorene, 3-fluorene and 2-phenanthrene were associated with a 38-68% greater likelihood of dyslipidemia (P≤0.05) compared to lower levels. Finally, 2-naphthalene and 2-phenanthrene were positively associated with hypertension (P trend = 0.008 and P trend = 0.02 respectively).

CONCLUSIONS

PAH is related to obesity and the expression of a number of obesity-related cardiometabolic health risk factors. Future research is needed to bring to light the mechanistic pathways related to these findings.

Lifestyle and weight predictors of a healthy overweight profile over a 20-year follow-up

OBJECTIVE

To examine whether changes in modifiable risk factors [physical activity, cardiorespiratory fitness (CRF), body weight, and diet composition] are associated with the transition to metabolically healthy overweight/obese (MHOW) versus metabolically abnormal overweight/obese.

METHODS

Analysis included 1,358 adults [aged 25.0 (3.5) years] from the CARDIA study who were healthy at baseline and had overweight/obesity at follow-up. Participants with zero or one of the following six risk factors were classified as MHOW: elevated triglycerides, LDL, blood pressure, fasting glucose, and HOMA-insulin resistance and low HDL.

RESULTS

Over the 20-year follow-up, the sample gained weight (BMI 24.5 to 31.1 kg/m(2) ), and the prevalence of MHOW was 47% at follow-up. After adjusting for changes in CRF, diet, and weight change, physical activity and macronutrient intake were not independently associated with MHOW (P > 0.05), while changes in CRF [fit-unfit: RR (95%) = 0.58, 0.52-0.66; unfit-unfit: RR = 0.67, 0.58-0.76, versus fit-fit] and weight [gain: RR (95%) = 0.54, 0.43-0.67; cycle: RR = 0.74, 0.57-0.94, versus stable] were independently associated with MHOW.

CONCLUSIONS

Focusing on high CRF and strategies to limit weight gain may be important for individuals with overweight and obesity in early to mid-adulthood to maintain a metabolically healthy profile.

Differences in physical activity domains, guideline adherence, and weight history between metabolically healthy and metabolically abnormal obese adults: a cross-sectional study

BACKGROUND

Despite the accepted health consequences of obesity, emerging research suggests that a significant segment of adults with obesity are metabolically healthy (MHO). To date, MHO individuals have been shown to have higher levels of physical activity (PA), but little is known about the importance of PA domains or the influence of weight history compared to their metabolically abnormal (MAO) counterpart.

OBJECTIVE

To evaluate the relationship between PA domains, PA guideline adherence, and weight history on MHO.

METHODS

Pooled cycles of the National Health and Nutritional Examination Survey (NHANES) 1999-2006 (≥20 y; BMI ≥ 30 kg/m(2); N = 2,753) and harmonized criteria for metabolic syndrome (MetS) were used. Participants were categorized as "inactive" (no reported PA), "somewhat active" (>0 to < 500 metabolic equivalent (MET) min/week), and "active" (PA guideline adherence, ≥ 500 MET min/week) according to each domain of PA (total, recreational, transportation and household). Logistic and multinomial regressions were modelled for MHO and analyses were adjusted for age, sex, education, ethnicity, income, smoking and alcohol intake.

RESULTS

Compared to MAO, MHO participants were younger, had lower BMI, and were more likely to be classified as active according to their total and recreational PA level. Based on total PA levels, individuals who were active had a 70% greater likelihood of having the MHO phenotype (OR = 1.70, 95% CI: 1.19-2.43); however, once stratified by age (20-44 y; 45-59 y; and; ≥60 y), the association remained significant only amongst those aged 45-59 y. Although moderate and vigorous PA were inconsistently related to MHO following adjustment for covariates, losing ≥30 kg in the last 10 y and not gaining ≥10 kg since age 25 y were significant predictors of MHO phenotype for all PA domains, even if adherence to the PA guidelines were not met.

CONCLUSION

Although PA is associated with MHO, the beneficial effects of PA may be moderated by longer-term changes in weight. Longitudinal analysis of physical activity and weight change trajectories are necessary to isolate the contribution of duration of obesity, PA behaviours, and longer-term outcomes amongst MHO individuals.

The relationship between changes in sitting time and mortality in post-menopausal US women

BACKGROUND

Prolonged sitting is linked to various deleterious health outcomes. The alterability of the sitting time (ST)-health relationship is not fully established however and warrants study within populations susceptible to high ST.

METHODS

We assessed the mortality rates of post-menopausal women from the Women's Health Initiative (WHI) observational study, a 15-year prospective study of post-menopausal women aged 50-79 years, according to their change in ST between baseline and year six. A total of 77 801 participants had information at both times on which to be cross-classified into the following: (i) high ST at baseline and follow-up; (ii) low ST at baseline and follow-up; (iii) increased ST and (iv) decreased ST. Cox regression was used to assess the relationship between all-cause, CVD and cancer mortality with change in ST.

RESULTS

At the end of follow-up, there were 1855 deaths. Compared with high ST maintainers, low ST maintainers had a 51 and 48% lower risk of all-cause and cancer mortality, respectively. Reducing sitting also resulted in a protective rate of 29% for all-cause and 27% for cancer mortality.

CONCLUSIONS

These results highlight not only the benefit of maintaining minimal ST, but also the utility of decreasing ST in older women, if current levels are high.

The Influence of Urinary Concentrations of Organophosphate Metabolites on the Relationship between BMI and Cardiometabolic Health Risk

The objective was to determine whether detectable levels of OP metabolites influence the relationship between BMI and cardiometabolic health. This cross-sectional study was conducted using 2227 adults from the 1999-2008 NHANES datasets. Urinary concentrations of six dialkyl phosphate metabolites were dichotomized to above and below the detection limit. Weighted multiple regression analysis was performed adjusting for confounding variables. Independent of BMI, individuals with detectable metabolites had higher diastolic blood pressure (for dimethylphosphate, diethylphosphate, and diethyldithiophosphate; P < 0.05), lower HDL (for diethyldithiophosphate; P = 0.02), and higher triglyceride (for dimethyldithiophosphate; P = 0.05) than those below detection. Contrarily, those with detectable dimethylthiophosphate had better LDL, HDL, and total cholesterol, independent of BMI. Individuals at a higher BMI range who had detectable diethylphosphate (interaction: P = 0.03) and diethylthiophosphate (interaction: P = 0.02) exhibited lower HDL, while little difference existed between OP metabolite detection statuses at lower BMIs. Similarly, individuals with high BMIs and detectable diethylphosphate had higher triglyceride than those without detectable levels, while minimal differences between diethylphosphate detection statuses were observed at lower BMIs (interaction: P = 0.02). Thus, cardiometabolic health outcome differs depending on the specific OP metabolite being examined, with higher BMIs amplifying health risk.

Tricyclic and SSRI usage influences the association between BMI and health risk factors

To determine if selective-serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) influence the association between obesity and cardiovascular disease risk, participants from the Third National Health and Nutrition Examination Survey (NHANES III; 1988-1992) and continuous NHANES (1999-2009, n = 18 274) were used. For a given body mass index (BMI), individuals taking SSRIs (n = 219) tended to have significantly better health risk profiles with lower systolic blood pressure (P = 0.002) and higher high-density lipoprotein (P = 0.003) compared with non-users. Conversely, those who used TCAs (n = 116) had significantly worse health risk profiles with higher diastolic blood pressure (P ≤ 0.0001) and triglycerides (P = 0.023) as compared with non-users for a given BMI. Insulin resistance (HOMA-IR) was higher in TCA users and those with larger BMIs, whereby the differences in insulin resistance between TCA users and non-users was greater with higher BMIs (interaction effect: P = 0.013). Furthermore, individuals taking SSRIs were less likely to have cardiovascular disease than non-users (odds ratio, 95% confidence interval = 0.50, 0.33-0.75) for a given BMI, with no differences by TCA use (odds ratio = 0.74, 0.44-1.24). SSRI and TCA use may alter how body weight relates with cardiovascular risk. When prescribing antidepressant medications, it may be necessary to monitor and consider body weight and cardiovascular risk profile of individual patients.

Trajectories of metabolic syndrome development in young adults

Background

Metabolic syndrome (MetS) is a constellation of metabolic aberrations that collectively increase the risk for cardiovascular disease and type 2 diabetes. Greater understanding of MetS developments may provide insight into targeted prevention strategies for individuals at greatest risk. The purpose of this study was to i) identify distinct patterns of longitudinal MetS development and; ii) develop a character profile that differentiates groups by level of MetS risk.

Methods and Results

Data from the Coronary Artery Risk Development in Young Adults (CARDIA) study (n = 3 804; 18–30 y) was obtained by limited access application from the National Heart, Lung, and Blood Institute and used for this analysis. MetS, as defined by the Harmonized criteria, was assessed over a 20 year follow-up period. Group-level trajectory analysis identified 4 distinct groups with varying rates of component development [No (23.8% of sample); Low (33.5%); Moderate (35.3%); and High MetS (7.4%)]. After adjusting for covariates, individuals in the At-Risk groups (Low, Moderate and High MetS) were more likely to be of black ethnicity (1.37, 1.14–1.66), have a family history of cardiovascular disease (1.61, 1.31–1.97) and history of dieting (1.69, 1.20–2.39) when compared to the No Risk trajectory group (No MetS). Conversely, increasing baseline education (0.76, 0.65–0.89) and aerobic fitness (0.55, 0.47–0.64) was inversely associated with At-Risk group membership.

Conclusions

Results suggest distinct profiles of MetS development that can be identified by baseline risk factors. Further research is necessary to understand the clinical implication of intermediate MetS development groups with respect to overall cardiometabolic risk.

Association between obesity and cardiometabolic health risk in Asian-Canadian sub-groups

Objectives

To quantify and compare the association between the World Health Organizations’ Asian-specific trigger points for public health action [‘increased risk’: body mass index (BMI) ≥23 kg/m², and; ‘high risk’: BMI ≥27.5 kg/m²] with self-reported cardiovascular-related conditions in Asian-Canadian sub-groups.

Methods

Six cycles of the Canadian Community Health Survey (2001–2009) were pooled to examine BMI and health in Asian sub-groups (South Asians, Chinese, Filipino, Southeast Asians, Arabs, West Asians, Japanese and Korean; N = 18 794 participants, ages 18–64 y). Multivariable logistic regression, adjusting for demographic, lifestyle characteristics and acculturation measures, was used to estimate the odds of cardiovascular-related health (high blood pressure, heart disease, diabetes, ‘at least one cardiometabolic condition’) outcomes across all eight Asian sub-groups.

Results

Compared to South Asians (OR = 1.00), Filipinos had higher odds of having ‘at least one cardiometabolic condition’ (OR = 1.29, 95% CI: 1.04–1.62), whereas Chinese (0.63, 0.474–0.9) and Arab-Canadians had lower odds (0.38, 0.28–0.51). In ethnic-specific analyses (with ‘acceptable’ risk weight as the referent), ‘increased’ and ‘high’ risk weight categories were the most highly associated with ‘at least one cardiometabolic condition’ in Chinese (‘increased’: 3.6, 2.34–5.63; ‘high’: 8.9, 3.6–22.01). Compared to normal weight South Asians, being in the ‘high’ risk weight category in all but the Southeast Asian, Arab, and Japanese ethnic groups was associated with approximately 3-times the likelihood of having ‘at least one cardiometabolic condition’.

Conclusion

Differences in the association between obesity and cardiometabolic health risks were seen among Asian sub-groups in Canada. The use of WHO’s lowered Asian-specific BMI cut-offs identified obesity-related risks in South Asian, Filipino and Chinese sub-groups that would have been masked by traditional BMI categories. These findings have implications for public health messaging, especially for ethnic groups at higher odds of obesity-related health risks.

Associations between the built environment, total, recreational, and transit-related physical activity

Background

Many aspects of the built, physical environment have been shown to be associated with physical activity, but little research has focused on the unique circumstances and urban form of the suburban environment. The following analyses explore the associations between features of the built environment and components of overall physical activity, after accounting for neighborhood variability using hierarchical linear modeling.

Methods

These analyses utilized regionally-specific Geographic Information Systems data along with health measures collected from the 2007–8 Canadian Community Health Survey. Linear and logistic regression models explored the associations between measures of the built environment with leisure-time and transport-related physical activity.

Results

Respondents living with the highest number of intersections were more likely to engage in walking or cycling for leisure (OR: 1.85 CI 95%: 1.23-2.78), and in general, those living in areas with higher residential density were more likely to engage in active modes of transportation (OR: 2.67, CI 95%: 1.34-5.34).

Conclusions

Further analyses are necessary to clarify the extent to which modifications to such features of the built environment may improve physical activity participation in similar suburban communities.