Fine particulate matter and incident coronary heart disease events up to 10 years of follow-up among Deepwater Horizon oil spill workers.

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.

Projections of incident atherosclerotic cardiovascular disease and incident type 2 diabetes across evolving statin treatment guidelines and recommendations: A modelling study.

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.

Resident racial and ethnic composition, neighborhood-level socioeconomic status, and COVID-19 infections in California SNFs.

BACKGROUND: In California, >29,000 residents in skilled nursing facility (SNFs) were diagnosed with novel coronavirus disease 2019 (COVID-19) between March 2020 and November 2020. Prior research suggests that SNFs serving racially and ethnically minoritized residents often have fewer resources and lower quality of care. We performed a cross-sectional analysis of COVID-19 incidence among residents in California SNFs, assessing the association of SNF-level racial and ethnic compositions and facility- and neighborhood-level (census tract- and county-level) indicators of socioeconomic status (SES). METHODS: SNFs were grouped based on racial and ethnic composition using data from the Centers for Medicare and Medicaid Services; categories included SNFs with ≥88% White residents, SNFs with ≥32% Black or Latinx residents, SNFs with ≥32% Asian residents, or SNFs not serving a high proportion of any racial and ethnic composition (mixed). SNF resident-level COVID-19 infection data were obtained from the National Healthcare Safety Network from May 25, 2020 to August 16, 2020. Multilevel mixed-effects negative binomial regressions were used to estimate incidence rate ratios (IRR) for confirmed COVID-19 infections among residents. RESULTS: Among 971 SNFs included in our sample, 119 (12.3%) had ≥88% White residents; 215 (22.1%) had ≥32% Black or Latinx residents; 78 (8.0%) had ≥32% Asian residents; and 559 (57.6%) were racially and ethnically mixed. After adjusting for confounders, SNFs with ≥32% Black or Latinx residents (IRR = 2.40 [95% CI = 1.56, 3.68]) and SNFs with mixed racial and ethnic composition (IRR = 2.12 [95% CI = 1.49, 3.03]) both had higher COVID-19 incidence rates than SNFs with ≥88% White residents. COVID-19 incidence rates were also found to be higher in SNFs with low SES neighborhoods compared to those in high SES neighborhoods. CONCLUSION: Public health personnel should consider SNF- and neighborhood-level factors when identifying facilities to prioritize for COVID-19 outbreak prevention and control.

Longitudinal associations between objective and perceived healthy food environment and diet: The Multi-Ethnic Study of Atherosclerosis.

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 (ß=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.

Evidence of heterogeneity in statin-associated type 2 diabetes mellitus risk: A meta-analysis of randomized controlled trials and observational studies.

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.

Transitions from Ideal to Intermediate Cholesterol Levels may vary by Cholesterol Metric.

To examine the ability of total cholesterol (TC), a low-density lipoprotein cholesterol (LDL-C) proxy widely used in public health initiatives, to capture important population-level shifts away from ideal and intermediate LDL-C throughout adulthood. We estimated age (≥20 years)-, race/ethnic (Caucasian, African American, and Hispanic/Latino)-, and sex- specific net transition probabilities between ideal, intermediate, and poor TC and LDL-C using National Health and Nutrition Examination Survey (2007-2014; N = 13,584) and Hispanic Community Health Study/Study of Latinos (2008-2011; N = 15,612) data in 2016 and validated and calibrated novel Markov-type models designed for cross-sectional data. At age 20, >80% of participants had ideal TC, whereas the race/ethnic- and sex-specific prevalence of ideal LDL-C ranged from 39.2%-59.6%. Net transition estimates suggested that the largest one-year net shifts away from ideal and intermediate LDL-C occurred approximately two decades earlier than peak net population shifts away from ideal and intermediate TC. Public health and clinical initiatives focused on monitoring TC in middle-adulthood may miss important shifts away from ideal and intermediate LDL-C, potentially increasing the duration, perhaps by decades, that large segments of the population are exposed to suboptimal LDL-C.

Author Correction: Transitions from Ideal to Intermediate Cholesterol Levels may vary by Cholesterol Metric.

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.

Heterogeneity in Blood Pressure Transitions Over the Life Course: Age-Specific Emergence of Racial/Ethnic and Sex Disparities in the United States.

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.

Disparities in Early Transitions to Obesity in Contemporary Multi-Ethnic U.S. Populations.

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.

Sex differences in device therapy for heart failure: utilization, outcomes, and adverse events.

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.