BACKGROUND:During the 2010 Deepwater Horizon (DWH) disaster, in-situ burning and flaring were conducted to remove oil from the water. Workers near combustion sites were potentially exposed to burning-related fine particulate matter (PM2.5). Exposure to PM2.5 has been linked to increased risk of coronary heart disease (CHD), but no study has examined the relationship among oil spill workers. OBJECTIVES:To investigate the association between estimated PM2.5 from burning/flaring of oil/gas and CHD risk among the DWH oil spill workers. METHODS:We included workers who participated in response and cleanup activities on the water during the DWH disaster (N = 9091). PM2.5 exposures were estimated using a job-exposure matrix that linked modelled PM2.5 concentrations to detailed DWH spill work histories provided by participants. We ascertained CHD events as the first self-reported physician-diagnosed CHD or a fatal CHD event that occurred after each worker's last day of burning exposure. We estimated hazard ratios (HR) and 95% confidence intervals (95%CI) for the associations between categories of average or cumulative daily maximum PM2.5 exposure (versus a referent category of water workers not near controlled burning) and subsequent CHD. We assessed exposure-response trends by examining continuous exposure parameters in models. RESULTS:We observed increased CHD hazard among workers with higher levels of average daily maximum exposure (low vs. referent: HR = 1.26, 95% CI: 0.93, 1.70; high vs. referent: HR = 2.11, 95% CI: 1.08, 4.12; per 10 μg/m3 increase: HR = 1.10, 95% CI: 1.02, 1.19). We also observed suggestively elevated HRs among workers with higher cumulative daily maximum exposure (low vs. referent: HR = 1.19, 95% CI: 0.68, 2.08; medium vs. referent: HR = 1.38, 95% CI: 0.88, 2.16; high vs. referent: HR = 1.44, 95% CI: 0.96, 2.14; per 100 μg/m3-d increase: HR = 1.03, 95% CI: 1.00, 1.05). CONCLUSIONS:Among oil spill workers, exposure to PM2.5 from flaring/burning of oil/gas was associated with increased risk of CHD.

Introduction: Research examining the influence of neighborhood healthy food environment on diet has been mostly cross-sectional and has lacked robust characterization of the food environment. We examined longitudinal associations between features of the local food environment and healthy diet, and whether associations were modified by race/ethnicity. Methods: Data on 3634 adults aged 45-84 followed for 10 years were obtained from the Multi-Ethnic Study of Atherosclerosis. Diet quality was assessed using the Alternative Healthy Eating Index at Exam 1 (2000-2002) and Exam 5 (2010-2012). We assessed four measures of the local food environment using survey-based measures (e. g. perceptions of healthier food availability) and geographic information system (GIS)-based measures (e.g. distance to and density of healthier food stores) at Exam 1 and Exam 5. Random effects models adjusted for age, sex, education, moving status, per capita adjusted income, and neighborhood socioeconomic status, and used interaction terms to assess effect measure modification by race/ethnicity. Results: Net of confounders, one standard z-score higher average composite local food environment was associated with higher average AHEI diet score (beta=1.39, 95% CI: 1.05, 1.73) over the follow-up period from Exam 1 to 5. This pattern of association was consistent across both GIS-based and survey-based measures of local food environment and was more pronounced among minoritized racial/ethnic groups. There was no association between changes in neighborhood environment and change in AHEI score, or effect measure modification by race/ ethnicity. Conclusion: Our findings suggest that neighborhood-level food environment is associated with better diet quality, especially among racially/ethnically minoritized populations.

BACKGROUND:Experimental and observational research has suggested the potential for increased type 2 diabetes (T2D) risk among populations taking statins for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, few studies have directly compared statin-associated benefits and harms or examined heterogeneity by population subgroups or assumed treatment effect. Thus, we compared ASCVD risk reduction and T2D incidence increases across 3 statin treatment guidelines or recommendations among adults without a history of ASCVD or T2D who were eligible for statin treatment initiation.METHODS AND FINDINGS:Simulations were conducted using Markov models that integrated data from contemporary population-based studies of non-Hispanic African American and white adults aged 40-75 years with published meta-analyses. Statin treatment eligibility was determined by predicted 10-year ASCVD risk (5%, 7.5%, or 10%). We calculated the number needed to treat (NNT) to prevent one ASCVD event and the number needed to harm (NNH) to incur one incident case of T2D. The likelihood to be helped or harmed (LHH) was calculated as ratio of NNH to NNT. Heterogeneity in statin-associated benefit was examined by sex, age, and statin-associated T2D relative risk (RR) (range: 1.11-1.55). A total of 61,125,042 U.S. adults (58.5% female; 89.4% white; mean age = 54.7 years) composed our primary prevention population, among whom 13-28 million adults were eligible for statin initiation. Overall, the number of ASCVD events prevented was at least twice as large as the number of incident cases of T2D incurred (LHH range: 2.26-2.90). However, the number of T2D cases incurred surpassed the number of ASCVD events prevented when higher statin-associated T2D RRs were assumed (LHH range: 0.72-0.94). In addition, females (LHH range: 1.74-2.40) and adults aged 40-50 years (LHH range: 1.00-1.14) received lower absolute benefits of statin treatment compared with males (LHH range: 2.55-3.00) and adults aged 70-75 years (LHH range: 3.95-3.96). Projected differences in LHH by age and sex became more pronounced as statin-associated T2D RR increased, with a majority of scenarios projecting LHHs < 1 for females and adults aged 40-50 years. This study's primary limitation was uncertainty in estimates of statin-associated T2D risk, highlighting areas in which additional clinical and public health research is needed.CONCLUSIONS:Our projections suggest that females and younger adult populations shoulder the highest relative burden of statin-associated T2D risk.

AIMS:To conduct a meta-analysis of statin-associated type 2 diabetes mellitus (T2D) risk among randomized controlled trials (RCTs) and observational studies (OBSs), excluding studies conducted among secondary prevention populations. METHODS:Studies were identified by searching PubMed (1994-present) and EMBASE (1994-present). Articles had to meet the following criteria: (1) follow-up >one year; (2) >50% of participants free of clinically diagnosed ASCVD; (3) adult participants ≥30 years old; (4) reported statin-associated T2D effect estimates; and (5) quantified precision using 95% confidence interval. Data were pooled using random-effects model. RESULTS:We identified 23 studies (35% RCTs) of n = 4,012,555 participants. OBS participants were on average younger (mean difference = 6.2 years) and had lower mean low-density lipoprotein cholesterol (LDL-C, mean difference = 20.6 mg/dL) and mean fasting plasma glucose (mean difference = 5.2 mg/dL) compared to RCT participants. There was little evidence for publication bias (P > 0.1). However, evidence of heterogeneity was observed overall and among OBSs and RCTs (PCochran = <0.05). OBS designs, younger baseline mean ages, lower LDL-C concentrations, and high proportions of never or former smokers were significantly associated with increased statin-associated T2D risk. CONCLUSIONS:Potentially elevated statin-associated T2D risk in younger populations with lower LDL-C merits further investigation in light of evolving statin guidelines targeting primary prevention populations.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has not been fixed in the paper

PURPOSE: A significant proportion of cardiac rehabilitation (CR) patients decline or cease regular exercise following the structured CR program. The purpose of this qualitative study was to identify barriers, enablers, and intervention strategies to maintain exercise post CR. METHODS: We conducted five focus groups (3 to 5 participants in each group) in three North Carolina locations in 2017 with 22 current CR participants. Participants also completed a brief survey. Focus groups were transcribed verbatim and double coded, analyzed, and reconstructed to identify overarching themes using ATLAS.ti software. RESULTS: Focus group participants were referred to CR after experiencing a myocardial infarction (36%), coronary artery bypass grafting surgery (36%), stents (9%), angina (5%), and heart failure (5%). Over half of participants were male (55%), the mean age was 72 years (standard deviation=7 years), and 82% were retired. Potential barriers to continuing exercise post CR included lack of motivation to exercise, lack of financial resources to stay active, health conditions, loss of group social support, and not enjoying exercise. Potential enablers to continuing exercise post CR included continued contact with CR staff after finishing the CR program, extending the number of weeks of CR, returning for a check-in CR session after discharge, having an exercise plan after finishing CR, and receiving social support from family and friends. The focus group discussion asked participants about their interest in using an activity tracker during and following CR. Most participants were positive about using activity trackers; however, some expressed concern about the complexity of using the tracker. In questions about specific activity tracker features, most participants expressed favorable views about tracking step counts, but had mixed views about sharing their tracking information with peers. Participants were asked about introducing peer support from CR alumni and this feature received positive feedback. CONCLUSION: These findings can be used to design interventions that help CR participants maintain exercise following CR.\

Importance Many studies have assessed racial/ethnic and sex disparities in the prevalence of elevated blood pressure (BP) from childhood to adulthood, yet few have examined differences in age-specific transitions between categories of BP over the life course in contemporary, multiracial/multiethnic populations. Objective To estimate age, racial/ethnic, and sex–specific annual net transition probabilities between categories of BP using Markov modeling of cross-sectional data from the National Health and Nutrition Examination Survey. Design, Setting, and Participants National probability sample (National Health and Nutrition Examination Survey in 2007-2008, 2009-2010, and 2011-2012) of 17 747 African American, white American, and Mexican American participants aged 8 to 80 years. The data were analyzed from September 2014 to November 2015. Main Outcomes and Measures Age-specific American Heart Association–defined BP categories. Results Three National Health and Nutrition Examination Survey cross-sectional samples were used to characterize the ages at which self-reported African American (n = 4973), white American (n = 8886), and Mexican American (n = 3888) populations transitioned between ideal BP, prehypertension, and hypertension across the life course. At age 8 years, disparities in the prevalence of ideal BP were observed, with the prevalence being lower among boys (86.6%-88.8%) compared with girls (93.0%-96.3%). From ages 8 to 30 years, annual net transition probabilities from ideal to prehypertension among male individuals were more than 2 times the net transition probabilities of their female counterparts. The largest net transition probabilities for ages 8 to 30 years occurred in African American young men, among whom a net 2.9% (95% CI, 2.3%-3.4%) of those with ideal BP transitioned to prehypertension 1 year later. Mexican American young women aged 8 to 30 years experienced the lowest ideal to prehypertension net transition probabilities (0.6%; 95% CI, 0.3%-0.8%). After age 40 years, ideal to prehypertension net transition probabilities stabilized or decreased (range, 3.0%-4.5%) for men, whereas net transition probabilities for women increased rapidly (range, 2.6%-13.0%). Mexican American women exhibited the largest ideal to prehypertension net transition probabilities after age 60 years. The largest prehypertension to hypertension net transition probabilities occurred at young ages in boys of white race/ethnicity and African Americans, approximately age 8 years and age 25 years, respectively, while net transition probabilities for white women and Mexican Americans increased over the life course. Conclusions and Relevance Heterogeneity in net transition probabilities from ideal BP emerge during childhood, with associated rapid declines in ideal BP observed in boys and African Americans, thus introducing disparities. Primordial prevention beginning in childhood and into early adulthood is necessary to preempt the development of prehypertension and hypertension, as well as associated racial/ethnic and sex disparities.

Importance Many studies have assessed racial/ethnic and sex disparities in the prevalence of elevated blood pressure (BP) from childhood to adulthood, yet few have examined differences in age-specific transitions between categories of BP over the life course in contemporary, multiracial/multiethnic populations. Objective To estimate age, racial/ethnic, and sex–specific annual net transition probabilities between categories of BP using Markov modeling of cross-sectional data from the National Health and Nutrition Examination Survey. Design, Setting, and Participants National probability sample (National Health and Nutrition Examination Survey in 2007-2008, 2009-2010, and 2011-2012) of 17 747 African American, white American, and Mexican American participants aged 8 to 80 years. The data were analyzed from September 2014 to November 2015. Main Outcomes and Measures Age-specific American Heart Association–defined BP categories. Results Three National Health and Nutrition Examination Survey cross-sectional samples were used to characterize the ages at which self-reported African American (n = 4973), white American (n = 8886), and Mexican American (n = 3888) populations transitioned between ideal BP, prehypertension, and hypertension across the life course. At age 8 years, disparities in the prevalence of ideal BP were observed, with the prevalence being lower among boys (86.6%-88.8%) compared with girls (93.0%-96.3%). From ages 8 to 30 years, annual net transition probabilities from ideal to prehypertension among male individuals were more than 2 times the net transition probabilities of their female counterparts. The largest net transition probabilities for ages 8 to 30 years occurred in African American young men, among whom a net 2.9% (95% CI, 2.3%-3.4%) of those with ideal BP transitioned to prehypertension 1 year later. Mexican American young women aged 8 to 30 years experienced the lowest ideal to prehypertension net transition probabilities (0.6%; 95% CI, 0.3%-0.8%). After age 40 years, ideal to prehypertension net transition probabilities stabilized or decreased (range, 3.0%-4.5%) for men, whereas net transition probabilities for women increased rapidly (range, 2.6%-13.0%). Mexican American women exhibited the largest ideal to prehypertension net transition probabilities after age 60 years. The largest prehypertension to hypertension net transition probabilities occurred at young ages in boys of white race/ethnicity and African Americans, approximately age 8 years and age 25 years, respectively, while net transition probabilities for white women and Mexican Americans increased over the life course. Conclusions and Relevance Heterogeneity in net transition probabilities from ideal BP emerge during childhood, with associated rapid declines in ideal BP observed in boys and African Americans, thus introducing disparities. Primordial prevention beginning in childhood and into early adulthood is necessary to preempt the development of prehypertension and hypertension, as well as associated racial/ethnic and sex disparities.

BACKGROUND:Few studies have examined weight transitions in contemporary multi-ethnic populations spanning early childhood through adulthood despite the ability of such research to inform obesity prevention, control, and disparities reduction.METHODS AND RESULTS:We characterized the ages at which African American, Caucasian, and Mexican American populations transitioned to overweight and obesity using contemporary and nationally representative cross-sectional National Health and Nutrition Examination Survey data (n = 21,220; aged 2-80 years). Age-, sex-, and race/ethnic-specific one-year net transition probabilities between body mass index-classified normal weight, overweight, and obesity were estimated using calibrated and validated Markov-type models that accommodated complex sampling. At age two, the obesity prevalence ranged from 7.3% in Caucasian males to 16.1% in Mexican American males. For all populations, estimated one-year overweight to obesity net transition probabilities peaked at age two and were highest for Mexican American males and African American females, for whom a net 12.3% (95% CI: 7.6%-17.0%) and 11.9% (95% CI: 8.5%-15.3%) of the overweight populations transitioned to obesity by age three, respectively. However, extrapolation to the 2010 U.S. population demonstrated that Mexican American males were the only population for whom net increases in obesity peaked during early childhood; age-specific net increases in obesity were approximately constant through the second decade of life for African Americans and Mexican American females and peaked at age 20 for Caucasians.CONCLUSIONS:African American and Mexican American populations shoulder elevated rates of many obesity-associated chronic diseases and disparities in early transitions to obesity could further increase these inequalities if left unaddressed.

Introduction: Ideal low density lipoprotein (LDL) levels are associated with lower cardiovascular disease morbidity and mortality and the National Cholesterol Education Program has identified LDL as the primary target for cholesterol lowering treatment. The prevalence of poor LDL has decreased since the 1970’s, however 27% of U.S. adults still have poor LDL levels. Few studies have characterized the transitions from ideal to intermediate to poor LDL levels in different life epochs and in minorities using contemporary data. Methods: Cross-sectional 2007-2012 National Health and Nutrition Examination Survey (NHANES) data (N = 11,140) and 2008-2011 Hispanic Community Health Study/Study of Latinos (HCHS/SOL) data (N = 15,262) were used to estimate the age-, race-, and sex- specific prevalence of ideal (<100 mg/dL untreated), intermediate (100-140 mg/dL or treated to goal), or poor (>140 mg/dL) among European American (EA), African American (AA) and Hispanic/Latino (HL) adults ≥20 years of age. We then used these data and novel Markov-type models to estimate race/ethnic- and sex-specific net transition probabilities between ideal, intermediate, and poor LDL. Results: At age 20 the prevalence of ideal LDL ranged from 44% (HL men) to 64% (EA women).Variation in the loss of ideal LDL was also observed by race/ethnicity and gender. For example, among EA men aged 20, a net 4.6% (95% CI: 3.9%-5.3%) transitioned from ideal to intermediate LDL levels by age 21, net transitions that were 30% higher than net transitions estimated for EA women aged 20, for whom a net 3.3% (95% CI: 2.3%-4.3%) transitioned from ideal to intermediate LDL levels by age 21. Movement from ideal to intermediate LDL levels in adulthood also peaked at earlier ages among men (EA=27, AA=28, and HL= 31) than among women (EA=36, AA=35, and HL=45), with the largest transitions occurring among EA men [net transition probability of 5.6% (95% CI: 4.6%-6.6%)]. In addition, net transition patterns favored movement from intermediate to poor LDL levels across the life course, with adult net transitions peaking at age 20 among EA and AA men and approximately 10 years later among EA women, AA women, and HL men. Net transitions peaked at the latest ages among HL women [age 36, net transition probability = 2.7% (95% CI: 2.4%-3.1%)]. Conclusions: Loss of ideal LDL begins early in life and shows divergent patterns by gender and race. Difficulties re-attaining ideal LDL once classified as intermediate or poor support interventions that promote ideal LDL levels in younger ages, especially in men.

Introduction: Gender and race/ethnic disparities in the burden of adverse blood pressure (BP) levels in adulthood have origins in childhood. Proper timing of primordial prevention efforts could narrow inequalities in BP trajectories across the life course. Few studies have characterized the ages at which children transition from ideal BP by gender and race/ethnicity, using contemporary multiethnic populations. Methods: We utilized the prevalence of ideal (<90th percentile for SBP and/or DBP), intermediate (90th-95th percentile or SBP ≥120 or DBP ≥80 mm Hg) and poor (>95th percentile for SBP and/or DBP) BP levels among African American (AA), European American (EA), and Mexican American (MA) NHANES participants (2007-2012, n=4,566) to estimate race/ethnic, age (8-19 years), and sex-specific net probabilities of transitioning between levels of BP using novel Markov-type modeling. Results: At age 8, the prevalence of ideal BP differed more by gender than by race/ethnicity, with the prevalence of ideal BP among boys (AA: 87%; EA and MA: 89%) being lower than the prevalence of ideal BP in girls (AA: 92%, EA 94%, MA 96%). From age 8, the magnitude of net declines in ideal BP also varied by gender and race/ethnicity. For example, between ages 8-11, the population of AA boys with ideal BP declined a net 1.6% [95% confidence interval (CI): 1.3-1.8%] annually, net declines that were approximately 25% greater than net declines estimated in EA and MA boys. For all race/ethnic groups, annual net declines in ideal BP among girls were less than half the decline of their male counterparts. Between 12-15 years of age, the largest declines for both genders occurred in AAs (AA boys: 2.1%, 95% CI: 1.7-2.5%; AA girls: 0.9%, 95% CI: 0.7-1.1%). By age 19, the annual net declines in ideal BP increased to approximately 2.9% (95% CI: 2.3-3.5%) and 1.4% (95% CI: 1.1-1.7%) per year for AA boys and AA girls, respectively. These declines, together with earlier net transition patterns widened ideal BP disparities in both boys (AA 68%, EA 73%, MA 75%) and girls (AA 84%, EA 89% MA 93%) at age 19. Conclusions: Disparities in transitions from ideal BP emerge during childhood and early adolescence, with disparate, rapid declines in ideal BP observed in boys and AAs, thus introducing BP disparities. Research emphasizing safe and effective primordial prevention efforts in childhood is necessary to preempt disparities and their maintenance.

Introduction: Blood pressure (BP) levels in early life have been shown to predict development of hypertension and cardiovascular disease in later life. Many studies have assessed differences in trajectories of elevated BP from childhood to adulthood, but few have examined gender and racial disparities in the age-specific transition from ideal BP over the life course. Methods: Following AHA’s Ideal Cardiovascular Health (CVH) criteria for BP, we used the prevalence of ideal (age ≥20, 95th percentile) resting BP levels among EA, and AA NHANES participants (2007-2012, n=11,663) to estimate the race, age, and sex-specific probabilities and patterns of transitioning between levels using novel Markov-type transition models. These net transition models were specifically design...

Introduction: Ideal total blood cholesterol (TC) levels are associated with lower cardiovascular disease (CVD) morbidity and mortality. In the U.S. TC increases up to middle age, but declines at older ages. Few studies have characterized the transition from ideal to intermediate and poor TC levels in different life epochs and in minorities. Methods: Cross-sectional 2007-2012 NHANES data (N = 11,140) were used to estimate the age-, race-, and sex- specific prevalence of ideal (≥20 years: <200 mg/dL untreated, 16-19 years: <170 mg/dL), intermediate (≥20 years: 200-239 mg/dL or treated to goal, 16-19 years: 170-199 mg/dL), and poor (≥20 years: ≥240 mg/dL, 16-19 years: ≥200 mg/dL) TC, defined per American Heart Association criteria. We then used these data and novel Markov-type models to estimate net transition probabilities between ideal, intermediate and poor TC. Results: Between the ages of 16 and 18, the prevalence of ideal TC among European American (EA) and African American (AA) men was approximately 68%, notably higher than the prevalence in EA women (63%) and AA women (61%). Variation in the loss of ideal TC was also observed by race and sex. Between 16-50 years of age, the proportion of AA men, EA men and EA women with ideal levels of TC declined approximately 2.0% (95% CI: 1.8%, 2.2%) per year. In AA women by contrast, the age-specific decline in ideal TC was not uniform between 16-50 years of age. The proportion of AA women with ideal levels of TC declined 0.7% (95% CI: 0.2%, 1.2%) per year from 16-20 years of age but increased to 2.8% (95% CI: 2.4%, 3.3%) per year by age 50. Among populations with intermediate TC levels, estimated 1-year net transitions to poor TC peaked at age 16, the earliest age under investigation, for EA men, EA women, and AA men but remained stable for AA women through 70 years of age, where a net 0.6% (95% CI: 0.1%, 1.3%) of the population with intermediate TC levels transitioned to poor TC levels one year later. In all demographic groups and life epochs, greater proportions of the population transitioned from intermediate to poor TC than from poor to intermediate TC. Conclusions: Loss of ideal TC begins early in life and shows divergent patters by gender and race. Difficulties re-attaining ideal TC once classified as intermediate or poor support interventions that promote ideal TC levels in younger ages, especially among AA women.

Background: Multiple studies of heart failure patients demonstrated significant improvement in exercise capacity, quality of life, cardiac left ventricular function, and survival from cardiac resynchronization therapy (CRT), but the underenrollment of women in these studies is notable. Etiological and pathophysiological differences may result in different outcomes in response to this treatment by sex. The observed disproportionate representation of women suggests that many women with heart failure either do not meet current clinical criteria to receive CRT in trials or are not properly recruited and maintained in these studies. Methods: We performed a systematic literature review through May 2014 of clinical trials and registries of CRT use that stratified outcomes by sex or reported percent women included. One-hundred eighty-three studies contained sex-specific information. Results: Ninety percent of the studies evaluated included ≤35% women. Fifty-six articles included effectiveness data that reported response with regard to specific outcome parameters. When compared with men, women exhibited more dramatic improvement in specific parameters. In the studies reporting hazard ratios for hospitalization or death, women generally had greater benefit from CRT. Conclusions: Our review confirms women are markedly underrepresented in CRT trials, and when a CRT device is implanted, women have a therapeutic response that is equivalent to or better than in men, while there is no difference in adverse events reported by sex.