Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report.

Cardiovascular disparities remain pervasive in the United States. Unequal disease burden is evident among population groups based on sex, race, ethnicity, socioeconomic status, educational attainment, nativity, or geography. Despite the significant declines in cardiovascular disease mortality rates in all demographic groups during the last 50 years, large disparities remain by sex, race, ethnicity, and geography. Recent data from modeling studies, linked micromap plots, and small-area analyses also demonstrate prominent variation in cardiovascular disease mortality rates across states and counties, with an especially high disease burden in the southeastern United States and Appalachia. Despite these continued disparities, few large-scale intervention studies have been conducted in these high-burden populations to examine the feasibility of reducing or eliminating cardiovascular disparities. To address this challenge, on June 22 and 23, 2017, the National Heart, Lung, and Blood Institute convened experts from a broad range of biomedical, behavioral, environmental, implementation, and social science backgrounds to summarize the current state of knowledge of cardiovascular disease disparities and propose intervention strategies aligned with the National Heart, Lung, and Blood Institute mission. This report presents the themes, challenges, opportunities, available resources, and recommended actions discussed at the workshop.

Cumulative psychosocial factors are associated with cardiovascular disease risk factors and management among African Americans in the Jackson Heart Study.

BACKGROUND: Racial disparities in cardiovascular disease (CVD) have been attributed in part to negative psychosocial factors. Prior studies have demonstrated associations between individual psychosocial factors and CVD risk factors, but little is known about their cumulative effects. METHODS: Using the Jackson Heart Study, we examined the cross-sectional associations of cumulative psychosocial factors with CVD risk factors among 5306 African Americans. We utilized multivariable Poisson regression to estimate sex-stratified prevalence ratios (PR 95% confidence interval-CI) of obesity, hypertension and diabetes prevalence and hypertension and diabetes control with negative affect (cynicism, anger-in, anger-out, depressive symptoms and cumulative negative affect) and stress (global stress, weekly stress, major life events-MLEs and cumulative stress), adjusting for demographics, socioeconomic status, and behaviors. RESULTS: After full adjustment, high (vs. low) cumulative negative affect was associated with prevalent obesity among men (PR 1.36 95% CI 1.16-1.60), while high (vs. low) cumulative stress was similarly associated with obesity among men and women (PR 1.24 95% CI 1.01-1.52 and PR 1.13 95% CI 1.03-1.23, respectively). Psychosocial factors were more strongly associated with prevalent hypertension and diabetes among men than women. For example, men who reported high cynicism had a 12% increased prevalence of hypertension (PR 1.12, 95% CI 1.03-1.23). Psychosocial factors were more strongly associated with lower hypertension and diabetes control for women than men. Women who reported high (vs. low) cynicism had a 38% lower prevalence of hypertension control (PR 0.62, 95% CI 0.46-0.84). CONCLUSIONS: Cumulative psychosocial factors were associated with CVD risk factors and disease management among African Americans. The joint accumulation of psychosocial factors was more associated with risk factors for men than women.

Circadian CLOCK gene polymorphisms in relation to sleep patterns and obesity in African Americans: findings from the Jackson heart study.

BACKGROUND: Circadian rhythms regulate key biological processes and the dysregulation of the intrinsic clock mechanism affects sleep patterns and obesity onset. The CLOCK (circadian locomotor output cycles protein kaput) gene encodes a core transcription factor of the molecular circadian clock influencing diverse metabolic pathways, including glucose and lipid homeostasis. The primary objective of this study was to evaluate the associations between CLOCK single nucleotide polymorphisms (SNPs) and body mass index (BMI). We also evaluated the association of SNPs with BMI related factors such as sleep duration and quality, adiponectin and leptin, in 2962 participants (1116 men and 1810 women) from the Jackson Heart Study. Genotype data for the selected 23 CLOCK gene SNPS was obtained by imputation with IMPUTE2 software and reference phase data from the 1000 genome project. Genetic analyses were conducted with PLINK RESULTS: We found a significant association between the CLOCK SNP rs2070062 and sleep duration, participants carriers of the T allele showed significantly shorter sleep duration compared to non-carriers after the adjustment for individual proportions of European ancestry (PEA), socio economic status (SES), body mass index (BMI), alcohol consumption and smoking status that reach the significance threshold after multiple testing correction. In addition, we found nominal associations of the CLOCK SNP rs6853192 with longer sleep duration and the rs6820823, rs3792603 and rs11726609 with BMI. However, these associations did not reach the significance threshold after correction for multiple testing. CONCLUSIONS: In this work, CLOCK gene variants were associated with sleep duration and BMI suggesting that the effects of these polymorphisms on circadian rhythmicity may affect sleep duration and body weight regulation in Africans Americans.

Race-specific associations between health-related quality of life and cellular aging among adults in the United States: evidence from the National Health and Nutrition Examination Survey.

PURPOSE: Poor health-related quality of life (HRQOL) could lead to higher morbidity and mortality through telomere attrition or accelerated cellular aging. We conducted a cross-sectional analysis to examine the relationship between four dimensions of HRQOL and leukocyte telomere length (LTL) among a nationally representative sample of 3547 US adults (≥20 years) using the data from the 2001-2002 National Health and Nutrition Examination Survey. METHOD: We used HRQOL survey information collected on individuals' self-rated general health, recent physical health, recent mental health, and recent activity limitation. Telomere length was assessed using quantitative polymerase chain reaction. Multiple linear regressions were used to estimate the relationship between each dimension of HRQOL and log-transformed values of LTL with adjustment for sample weights and design effects. RESULTS: HRQOL-race interactions were significant, and the results were stratified by race. After controlling for demographic factors, disease conditions, and lifestyle variables, worse general health was significantly associated with shorter LTL for Blacks (coefficient, ß: -0.022, 95% Confidence Interval, 95% CI: -0.03 to -0.01), but not for Whites or Mexican Americans. Unwell physical health was associated with shorter telomere length for Whites (ß: -0.005, 95% CI: -0.01 to -0.001) only. Unwell mental health showed no significant association with LTL in any race. CONCLUSIONS: Although longitudinal studies are needed to prove causality, our findings suggest that HRQOL could be associated with LTL shortening. We also found a possible racial difference in this association and recommend additional multiethnic studies to confirm this and to understand the reasons and consequences of this difference.

Obstructive sleep apnea risk and leukocyte telomere length in African Americans from the MH-GRID study.

PURPOSE: Shorter telomere length and obstructive sleep apnea are associated with increased oxidative stress and chronic inflammation, which are both considered leading causes of age-related diseases. Different forms of sleep disordered breathing have been linked to telomere length although their relationship remains uncertain. The purpose of this study was to explore the associations between the risk of obstructive sleep apnea and telomere length in African Americans. METHODS: The analysis included 184 women and 122 men aged 30-55 years from the Morehouse School of Medicine Study. Relative TL (T/S ratio) was measured from peripheral blood leukocytes using quantitative real-time polymerase chain reaction. The Berlin questionnaire was used for OSA risk assessments. Multivariable linear regression models were used to examine the associations between OSA risk and LTL. RESULTS: We observed that LTL varied by OSA risk in women (0.532 ± 0.006 vs. 0.569 ± 0.008) (p = 0.04). Multiple linear regression analysis confirmed that women at higher risk for OSA presented shorter LTL compared to those at lower risk, independent of age, income, education, obesity, smoking, alcohol consumption, and hypertension. These differences were not observed in men. CONCLUSIONS: Our findings suggest that OSA risk may contribute to the acceleration of cellular aging processes through telomere shortening.

Vitamin D Receptor Gene Polymorphisms Are Associated with Abdominal Visceral Adipose Tissue Volume and Serum Adipokine Concentrations but Not with Body Mass Index or Waist Circumference in African Americans: The Jackson Heart Study.

BACKGROUND: The biological actions of vitamin D are mediated through the vitamin D receptor (VDR). Single-nucleotide polymorphisms (SNPs) in the VDR gene have been previously associated with adiposity traits. However, to our knowledge, few studies have included direct measures of adiposity and adipokine concentrations. OBJECTIVE: We examined the association of tagging SNPs in the VDR gene with multiple adiposity measures, including waist circumference (WC), body mass index (BMI), body fat percentage, subcutaneous and visceral adipose tissue (VAT) volume, and serum adipokine (adiponectin and leptin) concentrations in adult African Americans (AAs). METHODS: Data from 3020 participants (61.9% women; mean age, 54.6 y) from the Jackson Heart Study were used for this analysis. Forty-five tag SNPs were chosen with the use of genotype data from the International HapMap project. We used linear regression to test the associations of imputed VDR SNPs with each of the traits, adjusted for age, sex, educational status, physical activity, smoking, alcohol intake, serum vitamin D concentration, European ancestry, and multiple testing. RESULTS: The G allele of the SNP rs4328262 remained associated with increased VAT volume after multiple testing correction (ß = 45.7; P < 0.001). The A allele of another SNP (rs11574070) was nominally associated with body fat percentage (ß = 0.96; P = 0.002). None of the VDR SNPs analyzed showed any link with WC or BMI. The A allele of rs2228570 (ß = 0.08; P = 0.001) for men and the T allele of rs2853563 (ß = 0.04; P < 0.001) for women remained positively associated with serum adiponectin concentrations after multiple testing correction. CONCLUSION: Although we did not find any association for anthropometric measures, we did observe associations of VDR variants with serum adipokines and with the more metabolically active fat, VAT. Therefore, our findings demonstrate a possible role of VDR variants in regulating adipose tissue activity and adiposity among AAs.

Associations between Vitamin D and Cardiovascular Disease Risk Factors in African Americans Are Partly Explained by Circulating Adipokines and C-Reactive Protein: The Jackson Heart Study.

BACKGROUND: Although it is recognized that vitamin D deficiency is associated with cardiovascular disease (CVD) risk factors, and is more common in African Americans (AAs), the pathologic mechanisms by which vitamin D may influence these risk factors are poorly understood. OBJECTIVES: We explored the association between vitamin D status, as reflected by serum 25-hydroxyvitamin D [25(OH)D] concentrations, and CVD risk factors including mean arterial pressure (MAP), fasting plasma glucose (FPG), plasma HDL cholesterol, and waist circumference (WC) in adult AAs. We also tested whether plasma C-reactive protein (CRP), adipokines (adiponectin and leptin), and aldosterone mediated the associations between 25(OH)D and these risk factors. METHODS: Data on 4010 (63.8% women; mean age: 54.0 y) individuals from the Jackson Heart Study were analyzed. Multivariable linear regression models were used to examine the associations of 25(OH)D with CVD risk factors. We used path analysis and bootstrapping methods to quantify and test the share of these associations that was statistically explained by each of the mediators by decomposing the associations into direct and indirect effects. RESULTS: Serum 25(OH)D concentrations were inversely associated with WC, FPG, and MAP and were positively associated with HDL cholesterol in multivariable analysis. A nearly 20% effect of 25(OH)D on MAP was masked by aldosterone (total indirect effect: ß = 0.01, P < 0.05). Approximately 23% of the effect of 25(OH)D on WC (ß = -0.03, P < 0.05) and ∼9% of the effect of 25(OH)D on FPG (ß = -0.02, P < 0.05) were mediated through CRP, adiponectin, and leptin together. A 23% share of the association between 25(OH)D and HDL cholesterol was mediated by adiponectin alone (ß = 0.03, P < 0.05). CONCLUSIONS: Our findings suggest that the associations between vitamin D status and CVD risk factors in AAs are partially mediated through circulating adipokines and CRP. More evidence, however, is required from longitudinal and randomized controlled studies to validate our findings.

Genetic ancestry is associated with measures of subclinical atherosclerosis in African Americans: the Jackson Heart Study.

OBJECTIVE: To determine whether genetic ancestry was associated with subclinical atherosclerosis measures after adjustment for traditional cardiovascular disease risk factors, inflammatory marker, socioeconomic status, and psychosocial factors in a large admixed African American population. APPROACH AND RESULTS: Participants were drawn from the Jackson Heart Study. Participant's percent of European ancestry (PEA) was estimated based on 1747 genetic markers using HAPMIX. Association of PEA with peripheral arterial disease and common carotid intima-media thickness were investigated among 2168 participants and with coronary artery calcification >0 and abdominal aortic calcification >0 among 1139 participants. The associations were evaluated using multivariable regression models. Our results showed that a 1 SD increase in PEA was associated with a lower peripheral arterial disease prevalence after adjusting for age and sex (prevalence ratio=0.90 [95% CI, 0.82-0.99]; P=0.036). Adjustments for traditional cardiovascular disease risk factors, socioeconomic status, and psychosocial factors attenuated this association (prevalence ratio=0.91 [0.82-1.00]; P=0.046). There was also a nonlinear association between PEA and coronary artery calcification and abdominal aortic calcification. The lowest PEA was associated with a lower coronary artery calcification (prevalence ratio=0.75 [0.58-0.96]; P=0.022) and a lower abdominal aortic calcification [prevalence ratio=0.80 [0.67-0.96]; P=0.016) compared with the reference group (10th-90th percentile) after adjusting for traditional cardiovascular disease risk factors, inflammatory marker, socioeconomic status, and psychosocial factors. However, we found no significant association between PEA and common carotid intima-media thickness. CONCLUSIONS: Overall, our findings indicate that genetic ancestry was associated with subclinical atherosclerosis, suggesting unmeasured risk factors and interactions with genetic factors might contribute to the distribution of subclinical atherosclerosis among African Americans.

Association of adiponectin and socioeconomic status in African American men and women: the Jackson heart study.

BACKGROUND: Recent emphasis has been placed on elucidating the biologic mechanism linking socioeconomic status (SES) to cardiovascular disease (CVD). Positive associations of inflammatory biomarkers provide evidence suggestive of a biologic pathway by which SES may predispose to CVD. African Americans have disproportionately lower SES and have a higher prevalence of CVD risk factors compared to most ethnic/racial groups. Adiponectin (an anti-inflammatory marker) is also lower. The objective of this study was to assess the association of adiponectin with SES among African American men and women using the Jackson Heart Study. METHODS: Study sample included 4340 participants. Linear regression was performed separately by SES and stratified by sex. Annual household income and level of education was used as proxies for SES. Crude, age, health behavior and health status adjusted models were analyzed. The main outcome was log-transformed adiponectin. RESULTS: Men in the lowest income group had significantly higher adiponectin than those in the highest income group in the fully adjusted model (ß/standard error [se], p value = .16/.08, p = .0008. Men with < high school level of education had significantly higher adiponectin in the crude and age adjusted models than those with ≥ college degree (.25/.05, p < .0001; .14/.05/ p = .005, respectively). Women with some college or vocational training in the crude and age adjusted models had lower adiponectin compared to women with ≥ college degree (-.09/.03, p = .004; -.06/.03, p = .04, respectively). CONCLUSION: Findings suggest a potential inverse biologic pathway between annual household income and adiponectin among African American men. There was no such finding among women. Findings suggest interventions should be targeted for higher SES African American men to improve adiponectin levels.

Gender-specific associations between ADIPOQ gene polymorphisms and adiponectin levels and obesity in the Jackson Heart Study cohort.

BACKGROUND: Despite the important role of adiponectin in regulating general metabolic homeostasis, analysis of genetic determinants of adiponectin and the related cardio-metabolic traits in African American population has been limited and inconsistent. Considering the high genetic admixture of African Americans and thus the important population stratification that may confound the genetic-trait associations, the objective of this work was to perform a comprehensive analysis of the associations between ADIPOQ variants and adiponectin levels and obesity phenotypes in a large African American population from the Jackson Heart Study (JHS) cohort. METHODS: Genotype data was available for 2968 JHS participants (1131men; 1837women). Single Nucleotide Polymorphisms (SNPs) were selected by a Tag-SNP Approach and literature review. The genotype imputation was performed using IMPUTE2 software and reference phased data from the 1000G project. PLINK software was used for the genetic analysis. Plasma specimens were analyzed by ELISA for adiponectin levels. All analyses were controlled for population stratification assessed by Individual Proportions of European Ancestry (PEA) estimates calculated in HAPMIX using ancestry informative markers (AIMs). RESULTS: We found a gender-dependent association of some ADIPOQ variants and adiponectin levels. In women four of the studied polymorphisms (rs6444174, rs16861205, rs1403697, rs7641507) were associated with adiponectin levels after Bonferroni correction and controlling for the percentage of PEA, age, annual household income and smoking. These results were consistent with the haplotype analysis. The association between the rs12495941 variant and obesity is modulated by the PEA, so that the relationship between the G allele and a higher incidence of obesity was present in those individuals within the lower PEA group. In addition we found an effect modification of obesity on the association between the ADIPOQ rs6444174 SNP and BMI so that the presence of the T allele was negatively and significantly associated with BMI only in participants with a normal weight. CONCLUSIONS: In this large African American cohort, ADIPOQ variants were associated with adiponectin levels in a gender-dependent manner and the relationship of some of these variants with obesity and BMI was modulated by the PEA and obesity status respectively. This suggests that the effects of these polymorphisms on adiponectin and obesity phenotypes are subject to a strong interaction with genetic and environmental factors in African American population.

Association of ADIPOQ gene with type 2 diabetes and related phenotypes in African American men and women: the Jackson Heart Study.

BACKGROUND: African Americans experience disproportionately higher prevalence of type 2 diabetes and related risk factors. Little research has been done on the association of ADIPOQ gene on type 2 diabetes, plasma adiponectin, blood glucose, HOMA-IR and body mass index (BMI) in African Americans. The objective of our research was to assess such associations with selected SNPs. The study included a sample of 3,020 men and women from the Jackson Heart Study who had ADIPOQ genotyping information. Unadjusted and adjusted regression models with covariates were used with type 2 diabetes and related phenotypes as the outcome stratified by sex. RESULTS: There was no association between selected ADIPOQ SNPs with type 2 diabetes, blood glucose, or BMI in men or women. There was a significant association between variant rs16861205 and lower adiponectin in women with minor allele A in the fully adjusted model (ß(SE) p = -.13(0.05), 0.003). There was also a significant association with variant rs7627128 and lower HOMA-IR among men with minor allele A in the fully adjusted model (ß(SE) p = -0.74(0.20), 0.0002). CONCLUSIONS: These findings represent new insights regarding the association of ADIPOQ gene and type 2 diabetes and related phenotypes in African American men and women.

Association of adiponectin with type 2 diabetes and hypertension in African American men and women: the Jackson Heart Study.

BACKGROUND: Adiponectin is a biomarker that is associated with type 2 diabetes and hypertension. Lower circulating level is a risk factor. Higher levels are protective. African Americans have a higher prevalence of type 2 diabetes and hypertension and lower levels of adiponectin when compared to other racial/ethnic groups. Little is known about the association of adiponectin on these health outcomes among African Americans. The purpose of the study was to assess the association of adiponectin on type 2 diabetes and hypertension likelihood among African American men and women in the Jackson Heart Study. METHODS: Separate multivariate logistic regressions were conducted stratified by sex based on cross-sectional data with type 2 diabetes and hypertension as the outcomes. Adiponectin was divided into four quartiles with the highest quartile as the reference. Data was collected from 2000-2004 on 3,663 participants. Data analysis was conducted in calendar year 2014. Two- tailed P < .05 was established as level of significance. RESULTS: In the adjusted multivariate models, adiponectin level was inversely associated with type 2 diabetes among women (odds ratio [OR], 95% confidence interval [CI] = 1.47, [1.02, 2.11], P = .04). There was no association among men. Women with the lowest level of adiponectin were less likely to be hypertensive (OR, 95% CI = 0.66, [0.46, 0.95], p = .02). There was no association among men. CONCLUSION: Findings reveal differential associations between levels of adiponectin with type 2 diabetes and hypertension likelihood among African American women. More research is needed to elucidate this differential association.

Relation of obesity to circulating B-type natriuretic peptide concentrations in blacks: the Jackson Heart Study.

BACKGROUND: Lower plasma B-type natriuretic peptide (BNP) concentrations in obese individuals ("natriuretic handicap") may play a role in the pathogenesis of obesity-related hypertension. Whether this phenomenon may contribute to hypertension in blacks is unknown. We tested the hypothesis that body mass index is inversely related to BNP concentrations in blacks. METHODS AND RESULTS: We examined the relation of plasma BNP to body mass index in 3742 Jackson Heart Study participants (mean age, 55 ± 13; 62% women) without heart failure using multivariable linear and logistic regression, adjusting for clinical and echocardiographic covariates. The multivariable-adjusted mean BNP was higher for lean participants compared with obese participants in both normotensive (P<0.0001) and hypertensive (P<0.0012) groups. In sex-specific analyses, the adjusted mean BNP was higher in lean hypertensive individuals compared with obese hypertensive individuals for both men (20.5 versus 10.9 pg/mL, respectively; P=0.0009) and women (20.0 versus 13.8 pg/mL; P=0.011). The differences between lean and obese participants were more pronounced in normotensive participants (men, 9.0 versus 4.4 pg/mL; P<0.0001; women, 12.8 versus 8.4 pg/mL; P=0.0005). For both hypertensive and normotensive individuals in the pooled sample, multivariable-adjusted BNP was significantly related to both continuous body mass index (P<0.05 and P<0.0001, respectively) and categorical body mass index (P for trend <0.006 and <0.0001, respectively). CONCLUSION: Our cross-sectional study of a large community-based sample of blacks demonstrates that higher body mass index is associated with lower circulating BNP concentrations, thereby extending the concept of a natriuretic handicap in obese individuals observed in non-Hispanic whites to this high-risk population.

A review of spatial methods in epidemiology, 2000-2010.

Understanding the impact of place on health is a key element of epidemiologic investigation, and numerous tools are being employed for analysis of spatial health-related data. This review documents the huge growth in spatial epidemiology, summarizes the tools that have been employed, and provides in-depth discussion of several methods. Relevant research articles for 2000-2010 from seven epidemiology journals were included if the study utilized a spatial analysis method in primary analysis (n = 207). Results summarized frequency of spatial methods and substantive focus; graphs explored trends over time. The most common spatial methods were distance calculations, spatial aggregation, clustering, spatial smoothing and interpolation, and spatial regression. Proximity measures were predominant and were applied primarily to air quality and climate science and resource access studies. The review concludes by noting emerging areas that are likely to be important to future spatial analysis in public health.

Social patterning of cumulative biological risk by education and income among African Americans.

OBJECTIVES: We examined the social patterning of cumulative dysregulation of multiple systems, or allostatic load, among African Americans adults. METHODS: We examined the cross-sectional associations of socioeconomic status (SES) with summary indices of allostatic load and neuroendocrine, metabolic, autonomic, and immune function components in 4048 Jackson Heart Study participants. RESULTS: Lower education and income were associated with higher allostatic load scores in African American adults. Patterns were most consistent for the metabolic and immune dimensions, less consistent for the autonomic dimension, and absent for the neuroendocrine dimension among African American women. Associations of SES with the global allostatic load score and the metabolic and immune domains persisted after adjustment for behavioral factors and were stronger for income than for education. There was some evidence that the neuroendocrine dimension was inversely associated with SES after behavioral adjustment in men, but the immune and autonomic components did not show clear dose-response trends, and we observed no associations for the metabolic component. CONCLUSIONS: Findings support our hypothesis that allostatic load is socially patterned in African American women, but this pattern is less consistent in African American men.

Geographic representation of the jackson heart study cohort to the African-American population in Jackson, Mississippi.

Recent advances in geographic information systems software and multilevel methodology provide opportunities for more extensive characterization of "at-risk" populations in epidemiologic studies. The authors used age-restricted, geocoded data from the all-African-American Jackson Heart Study (JHS), 2000-2004, to demonstrate a novel use of the Lorenz curve and Gini coefficient to determine the representativeness of the JHS cohort to the African-American population in a geographic setting. The authors also used a spatial binomial model to assess the geographic variability in participant recruitment across the Jackson, Mississippi, Metropolitan Statistical Area. The overall Gini coefficient, an equality measure that ranges from 0 (perfect equality) to 1 (perfect inequality), was 0.37 (95% confidence interval (CI): 0.30, 0.45), indicating moderate representation. The population of sampled women (Gini coefficient = 0.34, 95% CI: 0.30, 0.39) tended to be more representative of the underlying population than did the population of sampled men (Gini coefficient = 0.49, 95% CI: 0.35, 0.61). Representative recruitment of JHS participants was observed in predominantly African-American and mixed-race census tracts and in the center of the study area, the area nearest the examination clinic. This is of critical importance as the authors continue to explore novel approaches to investigate the geographic variation in disease etiology.

Life Course Socioeconomic Status and Hypertension in African American Adults: The Jackson Heart Study.

BACKGROUND: Limited research has examined the association of life-course socioeconomic status (SES) with hypertension prevalence and incidence in a large cohort of African Americans. METHODS: Among 4,761 participants from the Jackson Heart Study (JHS), we examined the association of SES indicators with prevalent and incident hypertension. We used multivariable Poisson regression to estimate prevalence ratios (PR, 95% confidence interval-CI) of baseline (2000-2004) hypertension by adult (education, income, occupation, wealth) and childhood (mother's education) SES. Cox proportional hazards regression was used to estimate hazard ratios (HR, 95% CI) of incident hypertension by adult and childhood SES (2005-2013; 7.21 median years of follow-up). We also examined the association of childhood-to-adult SES mobility (parent-to-adult education) with prevalent and incident hypertension. Model 1 adjusted for age and sex. Model 2 added waist circumference, behaviors (smoking, alcohol, physical activity, diet), and diabetes prevalence. RESULTS: High (vs. low) adult SES measures were associated with a lower prevalence of hypertension, with the exception of having a college degree and upper-middle income (PR: 1.04, 95% CI: 1.01, 1.07; PR: 1.05, 95% CI: 1.01, 1.09, respectively). Higher childhood SES was associated with a lower prevalence and risk of hypertension (PR: 0.83, 95%: CI 0.75, 0.91; HR: 0.76, 95% CI: 0.65, 0.89, respectively). Upward mobility and consistent high SES (vs. consistent low SES) from childhood to adulthood was associated with a greater prevalence, but lower incidence of hypertension. CONCLUSION: Efforts to prevent hypertension among African Americans should consider childhood and current SES status.

The relationship between neighborhood socioeconomic deprivation and telomere length: The 1999-2002 National Health and Nutrition Examination Survey.

Socioeconomically disadvantaged neighborhoods have been associated with poor health outcomes. Little is known about the biological mechanism by which deprived neighborhood conditions exert negative influences on health. Data from the 1999-2002 National Health and Nutrition Examination Surveys (NHANES) were used to assess the relationship between neighborhood deprivation index (NDI) and log-transformed leukocyte telomere length (LTL) via multilevel modeling to control for census tract level clustering. Models were constructed using tertiles of NDI (ref = low NDI). NDI was calculated using census tract level socioeconomic indicators from the 2000 U.S. Census. The sample (n = 5,106 adults) was 49.8% female and consisted of 82.9% non-Hispanic whites, 9.4% non-Hispanic blacks, and 7.6% Mexican Americans. Mean age was 45.8 years. Residents of neighborhoods with high NDI were younger, non-white, had lower educational attainment, and had a lower poverty to income ratio (all p < 0.0001). Neighborhood deprivation was inversely associated with LTL among individuals living in neighborhoods with medium NDI (ß = -0.043, SE = 0.012, p = 0.0005) and high NDI (ß = -0.039, SE = 0.013, p = 0.003). Among men, both medium (ß = -0.042, SE = 0.015, p = 0.006) and high (ß = -0.047, SE = 0.015, p = 0.001) NDI were associated with shorter LTL. Among women, only medium NDI (ß = -0.020, SE = 0.016, p = 0.009) was associated with shorter LTL. After controlling for individual characteristics, including individual-level socioeconomic status, increasing neighborhood socioeconomic deprivation is associated with shorter LTL among a nationally representative sample of US adults. This suggests that telomere shortening may be a mechanism through which neighborhood deprivation results in poor health outcomes.

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

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

Visualization and interpretation of birth defects data using linked micromap plots.

BACKGROUND: Many states have implemented birth defects surveillance systems to monitor and disseminate information regarding birth defects. However, many of these states rely on tabular methods to disseminate statistical birth defects summaries. An innovative presentation technique for birth defect data that portrays the information in a joint geographical and statistical context is the linked micromap (LM) plot. METHODS: LM plots were generated for oral cleft data at two geographical resolutions-USA states and counties of Utah. The LM plots also included demographic and behavioral risk data. RESULTS: A LM plot for the USA reveals spatial patterns indicating higher oral cleft occurrence in the southwest and the midwest and lower occurrence in the east. The LM plot also indicates relationships between oral cleft occurrence and maternal smoking rates and the proportion of American Indians and Alaskan Natives. In particular, the five states with the highest oral cleft occurrence had a higher proportion of American Indians and Alaskan Natives. Among the 15 states with the highest oral cleft occurrence, nine had a smoking rate of 16% or higher while among the 15 states with the lowest oral cleft occurrence only one state had a smoking rate greater than 16%. The LM plot for the state of Utah shows no clear geographic pattern, due perhaps to a relatively small number of cases in a limited geographic area. CONCLUSIONS: LM plots are effective in representing complex and large volume birth defects data. Integration to birth defects surveillance systems will improve both presentation and interpretation.