Prevalence of Perceived Food and Housing Security - 15 States, 2013.

Recent global (1) and national (2,3) health equity initiatives conclude that the elimination of health disparities requires improved understanding of social context (4,5) and ability to measure social determinants of health, including food and housing security (3). Food and housing security reflect the availability of and access to essential resources needed to lead a healthy life. The 2013 Behavioral Risk Factor Surveillance System (BRFSS) included two questions to assess perceived food and housing security in 15 states.* Among 95,665 respondents, the proportion who answered "never or rarely" to the question "how often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals?" ranged from 68.5% to 82.4% by state. Among 90,291 respondents living in housing they either owned or rented, the proportion who answered "never or rarely" to the question, "how often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage?" ranged from 59.9% to 72.8% by state. Food security was reported less often among non-Hispanic blacks (blacks) (68.5%) and Hispanics (64.6%) than non-Hispanic whites (whites) (81.8%). These racial/ethnic disparities were present across all levels of education; housing security followed a similar pattern. These results highlight racial/ethnic disparities in two important social determinants of health, food and housing security, as well as a substantial prevalence of worry or stress about food or housing among all subgroups in the United States. The concise nature of the BRFSS Social Context Module's single-question format for food and housing security makes it possible to incorporate these questions into large health surveys so that social determinants can be monitored at the state and national levels and populations at risk can be identified.

Reduced Prevalence of Obesity in 14 Disadvantaged Black Communities in the United States: A Successful 4-Year Place-Based Participatory Intervention.

OBJECTIVES: To assess the impact of a large-scale place-based intervention on obesity prevalence in Black communities. METHODS: The Racial and Ethnic Approaches to Community Health across the United States (REACH US) project was conducted in 14 predominantly Black communities in California, Illinois, Massachusetts, New York, Ohio, Pennsylvania, South Carolina, Virginia, Washington, and West Virginia. We measured trends from 2009 to 2012 in the prevalence of obesity. We used Behavioral Risk Factor Surveillance System data to compare these trends with trends among non-Hispanic Whites and non-Hispanic Blacks in the United States and in the 10 states where REACH communities were located, and with a propensity score-matched national sample of non-Hispanic Blacks. RESULTS: The age-standardized prevalence of obesity decreased in REACH US communities (P = .045), but not in the comparison populations (P = .435 to P = .996). The relative change was -5.3% in REACH US communities versus +2.4% in propensity score-matched controls (P value for the difference = .031). The net effect on the reduction of obesity prevalence was about 1 percentage point per year for REACH. CONCLUSIONS: Obesity prevalence was reduced in 14 disadvantaged Black communities that participated in the REACH project.

Improving actions to control high blood pressure in Hispanic communities - Racial and Ethnic Approaches to Community Health Across the U.S. Project, 2009-2012.

BACKGROUND: Compared with the general population in the United States (U.S.), Hispanics with hypertension are less likely to be aware of their condition, to take antihypertensive medication, and to adopt healthy lifestyles to control high blood pressure. We examined whether a multi-community intervention successfully increased the prevalence of actions to control hypertension among Hispanics. METHODS: Annual survey from 2009-2012 was conducted in six Hispanic communities in the Racial and Ethnic Approaches to Community Health (REACH) Across the U.S. PROJECT: The survey used address based sampling design that matched the geographies of intervention program. RESULTS: Age- and sex-standardized prevalences of taking hypertensive medication, changing eating habits, cutting down on salt, and reducing alcohol use significantly increased among Hispanics with self-reported hypertension in REACH communities. The 3-year relative percent increases were 5.8, 6.8, 7.9, and 35.2% for the four indicators, respectively. These favorable (healthier) trends occurred in both foreign-born and U.S.-born Hispanics. CONCLUSION: This large community-based participatory intervention resulted in more Hispanic residents in the communities taking actions to control high blood pressure.

Summarizing health-related quality of life (HRQOL): development and testing of a one-factor model.

BACKGROUND: Health-related quality of life (HRQOL) is a multi-dimensional concept commonly used to examine the impact of health status on quality of life. HRQOL is often measured by four core questions that asked about general health status and number of unhealthy days in the Behavioral Risk Factor Surveillance System (BRFSS). Use of these measures individually, however, may not provide a cohesive picture of overall HRQOL. To address this concern, this study developed and tested a method for combining these four measures into a summary score. METHODS: Exploratory and confirmatory factor analyses were performed using BRFSS 2013 data to determine potential numerical relationships among the four HRQOL items. We also examined the stability of our proposed one-factor model over time by using BRFSS 2001-2010 and BRFSS 2011-2013 data sets. RESULTS: Both exploratory factor analysis and goodness of fit tests supported the notion that one summary factor could capture overall HRQOL. Confirmatory factor analysis indicated acceptable goodness of fit of this model. The predicted factor score showed good validity with all of the four HRQOL items. In addition, use of the one-factor model showed stability, with no changes being detected from 2001 to 2013. CONCLUSION: Instead of using four individual items to measure HRQOL, it is feasible to study overall HRQOL via factor analysis with one underlying construct. The resulting summary score of HRQOL may be used for health evaluation, subgroup comparison, trend monitoring, and risk factor identification.

Does perceived neighborhood walkability and safety mediate the association between education and meeting physical activity guidelines?

The role of neighborhood walkability and safety in mediating the association between education and physical activity has not been quantified. We used data from the 2010 and 2012 Communities Putting Prevention to Work Behavioral Risk Factor Surveillance System and structural equation modeling to estimate how much of the effect of education level on physical activity was mediated by perceived neighborhood walkability and safety. Neighborhood walkability accounts for 11.3% and neighborhood safety accounts for 6.8% of the effect. A modest proportion of the important association between education and physical activity is mediated by perceived neighborhood walkability and safety, suggesting that interventions focused on enhancing walkability and safety could reduce the disparity in physical activity associated with education level.

Hepatitis B testing and access to care among racial and ethnic minorities in selected communities across the United States, 2009-2010.

UNLABELLED: Hepatitis B virus (HBV) infection is widely prevalent among racial and ethnic minorities in the United States; however, few data have been available regarding HBV testing and referral to care for these populations. Using survey data collected in 2009-2010 from the Racial and Ethnic Approaches to Community Health (REACH) across the U.S., we assessed rates and determinants of hepatitis B testing and access to care in 28 minority communities in the U.S. Of 53,896 respondents, 21,129 (39.2%) reported having been tested for hepatitis B. Of the 1,235 who reported testing positive, 411 (33.3%) reported currently receiving specialty care. After controlling for demographic and socioeconomic characteristics, the likelihood of having been tested for hepatitis B and receiving care if infected was higher among males, non-English speaking persons, and those having health insurance compared to their counterparts. Compared to college graduates, respondents without a college education were less likely to get tested for hepatitis B. CONCLUSION: These data indicate that more than half of racial/ethnic minority persons in these communities had not been tested for hepatitis B, and only about one-half of those who tested positive had ever received treatment. More state and federal efforts are needed to screen racial/ethnic minorities, especially foreign-born persons, for HBV and link those with infection to care.

Models for count data with an application to Healthy Days measures: are you driving in screws with a hammer?

INTRODUCTION: Count data are often collected in chronic disease research, and sometimes these data have a skewed distribution. The number of unhealthy days reported in the Behavioral Risk Factor Surveillance System (BRFSS) is an example of such data: most respondents report zero days. Studies have either categorized the Healthy Days measure or used linear regression models. We used alternative regression models for these count data and examined the effect on statistical inference. METHODS: Using responses from participants aged 35 years or older from 12 states that included a homeownership question in their 2009 BRFSS, we compared 5 multivariate regression models--logistic, linear, Poisson, negative binomial, and zero-inflated negative binomial--with respect to 1) how well the modeled data fit the observed data and 2) how model selections affect inferences. RESULTS: Most respondents (66.8%) reported zero mentally unhealthy days. The distribution was highly skewed (variance = 58.7, mean = 3.3 d). Zero-inflated negative binomial regression provided the best-fitting model, followed by negative binomial regression. A significant independent association between homeownership and number of mentally unhealthy days was not found in the logistic, linear, or Poisson regression model but was found in the negative binomial model. The zero-inflated negative binomial model showed that homeowners were 24% more likely than nonowners to have excess zero mentally unhealthy days (adjusted odds ratio, 1.24; 95% confidence interval, 1.08-1.43), but it did not show an association between homeownership and the number of unhealthy days. CONCLUSION: Our comparison of regression models indicates the importance of examining data distribution and selecting models with appropriate assumptions. Otherwise, statistical inferences might be misleading.

Hepatitis C testing, infection, and linkage to care among racial and ethnic minorities in the United States, 2009-2010.

OBJECTIVES: We estimated rates and determinants of hepatitis C virus (HCV) testing, infection, and linkage to care among US racial/ethnic minorities. METHODS: We analyzed the Racial and Ethnic Approaches to Community Health Across the US Risk Factor Survey conducted in 2009-2010 (n = 53,896 minority adults). RESULTS: Overall, 19% of respondents were tested for HCV. Only 60% of those reporting a risk factor were tested, with much lower rates among Asians reporting injection drug use (40%). Odds of HCV testing decreased with age and increased with higher education. Of those tested, 8.3% reported HCV infection. Respondents with income of $75,000 or more were less likely to report HCV infection than those with income less than $25,000. College-educated non-Hispanic Blacks and Asians had lower odds of HCV infection than those who did not finish high school. Of those infected, 44.4% were currently being followed by a physician, and 41.9% had taken HCV medications. CONCLUSIONS: HCV testing and linkage to care among racial/ethnic minorities are suboptimal, particularly among those reporting HCV risk factors. Socioeconomic factors were significant determinants of HCV testing, infection, and access to care. Future HCV testing and prevention activities should be directed toward racial/ethnic minorities, particularly those of low socioeconomic status.

Misclassification of survey responses and black-white disparity in mammography use, Behavioral Risk Factor Surveillance System, 1995-2006.

INTRODUCTION: The validity of self-reported data for mammography differ by race. We assessed the effect of racial differences in the validity of age-adjusted, self-reported mammography use estimates from the Behavioral Risk Factor Surveillance System (BRFSS) from 1995 through 2006 to determine whether misclassification (inaccurate survey question response) may have obscured actual racial disparities. METHODS: We adjusted BRFSS mammography use data for age by using 2000 census estimates and for misclassification by using the following formula: (estimated prevalence - 1 + specificity) / (sensitivity + specificity - 1). We used values reported in the literature for the formula (sensitivity = 0.97 for both black and white women, specificity = 0.49 and 0.62, respectively, for black and white women). RESULTS: After adjustment for misclassification, the percentage of women aged 40 years or older in 1995 who reported receiving a mammogram during the previous 2 years was 54% among white women and 41% among black women, compared with 70% among both white and black women after adjustment for age only. In 2006, the percentage after adjustment for misclassification was 65% among white women and 59% among black women compared with 77% among white women and 78% among black women after adjustment for age only. CONCLUSION: Self-reported data overestimate mammography use - more so for black women than for white women. After adjustment for respondent misclassification, neither white women nor black women had attained the Healthy People 2010 objective (≥ 70%) by 2006, and a disparity between white and black women emerged.

Decreases in smoking prevalence in Asian communities served by the Racial and Ethnic Approaches to Community Health (REACH) project.

OBJECTIVES: We examined trends in smoking prevalence from 2002 through 2006 in 4 Asian communities served by the Racial and Ethnic Approaches to Community Health (REACH) intervention. METHODS: Annual survey data from 2002 through 2006 were gathered in 4 REACH Asian communities. Trends in the age-standardized prevalence of current smoking for men in 2 Vietnamese communities, 1 Cambodian community, and 1 Asian American/Pacific Islander (API) community were examined and compared with nationwide US and state-specific data from the Behavioral Risk Factor Surveillance System. RESULTS: Prevalence of current smoking decreased dramatically among men in REACH communities. The reduction rate was significantly greater than that observed in the general US or API male population, and it was greater than reduction rates observed in the states in which REACH communities were located. There was little change in the quit ratio of men at the state and national levels, but there was a significant increase in quit ratios in the REACH communities, indicating increases in the proportions of smokers who had quit smoking. CONCLUSIONS: Smoking prevalence decreased in Asian communities served by the REACH project, and these decreases were larger than nationwide decreases in smoking prevalence observed for the same period. However, disparities in smoking prevalence remain a concern among Cambodian men and non-English-speaking Vietnamese men; these subgroups continue to smoke at a higher rate than do men nationwide.

Asian American/Pacific Islander paradox in diabetic retinopathy: findings from the Behavioral Risk Factor Surveillance System, 2006-2008.

OBJECTIVES: To compare the self-reported prevalence of diabetic retinopathy (DR) between Asian Americans/Pacific Islanders (AAPIs) and Whites in the United States. METHODS: We analyzed data from 70,209 adults aged > or =18 years with diabetes derived from the 2006-2008 Behavioral Risk Factor Surveillance System (BRFSS), including 1,499 AAPIs and 68,710 White individuals. RESULTS: Compared with Whites with diabetes, AAPIs with diabetes had higher socioeconomic status, fewer risk factors (eg, smoking) and coexisting chronic diseases (eg, cardiovascular disease [CVD]). Diabetes duration and percentage of persons using insulin were similar between the 2 populations. However, AAPIs had a much higher prevalence of DR (27.6%) than Whites (18.2%) (P<.001). Comparing AAPIs to Whites, the age- and gender-adjusted odds ratio of DR was 1.97 (1.48-2.62). The adjusted odds ratio was 2.21 (1.63-3.00) after adjustment for sociodemographic (education and marital status), chronic conditions (CVD and smoking), severity of diabetes and diabetes care (age of diabetes onset, frequency of self-checking blood sugar, and frequency of dilated eye exam). CONCLUSIONS: Despite their favorable socio- and health-related profiles, AAPIs had significantly higher prevalence of DR compared with Whites.

Factors explaining excess stroke prevalence in the US Stroke Belt.

BACKGROUND AND PURPOSE: Higher risk and burden of stroke have been observed within the southeastern states (the Stroke Belt) compared with elsewhere in the United States. We examined reasons for these disparities using a large data set from a nationwide cross-sectional study. METHODS: Self-reported data from the 2005 and 2007 Behavioral Risk Factor Surveillance System were used (n=765,368). The potential contributors for self-reported stroke prevalence (n=27 962) were demographics (age, sex, geography, and race/ethnicity), socioeconomic status (education and income), common risk factors (smoking and obesity), and chronic diseases (hypertension, diabetes, and coronary heart disease). Multivariate logistic regression was used in the analysis. RESULTS: The age- and sex-adjusted OR comparing self-reported stroke prevalence in the 11-state Stroke Belt versus non-Stroke Belt region was 1.25 (95% CI, 1.19 to 1.31). Unequal black/white distribution by region accounted for 20% of the excess prevalence in the Stroke Belt (OR reduced to 1.20; 1.15 to 1.26). Approximately one third (32%) of the excess prevalence was accounted either by socioeconomic status alone or by risk factors and chronic disease alone (OR, 1.12). The OR was further reduced to 1.07 (1.02 to 1.13) in the fully adjusted logistic model, a 72% reduction. CONCLUSIONS: Differences in socioeconomic status, risk factors, and prevalence of common chronic diseases account for most of the regional differences in stroke prevalence.

Cardiovascular risk factors and knowledge of symptoms among Vietnamese Americans.

BACKGROUND: There are few population-based studies of cardiovascular risk factors, knowledge, and related behaviors among Vietnamese Americans. OBJECTIVE: To describe cardiovascular risk factors, knowledge, and related behaviors among Vietnamese Americans and compare the results to non-Hispanic whites. DESIGN: Comparison of data from two population-based, cross-sectional telephone surveys. PARTICIPANTS: Vietnamese Americans in Santa Clara County, California, and non-Hispanic whites in California, aged 18 and older. MEASUREMENTS: Survey measures included sociodemographics, diagnoses, body mass index, fruit and vegetable intake, exercise, and tobacco use. Knowledge of symptoms of heart attack and stroke was collected for Vietnamese Americans. MAIN RESULTS: Compared to non-Hispanic whites (n = 19,324), Vietnamese Americans (n = 4,254) reported lower prevalences of obesity, diabetes mellitus, coronary heart disease, and hypertension, and similar prevalences of stroke and hypercholesterolemia. Fewer Vietnamese Americans consumed fruits and vegetables five or more times daily (27.8% vs 16.3%, p < 0.05), and more reported no moderate or vigorous physical activity (12.1% vs 40.1%, p < 0.05). More Vietnamese men than non-Hispanic White men were current smokers (29.8% vs 19.0%, p < 0.05). Vietnamese Americans who spoke Vietnamese were more likely than those who spoke English to eat fruits and vegetables less frequently, engage in no moderate or vigorous physical activity, and, among men, be current smokers. Only 59% of Vietnamese Americans knew that chest pain was a symptom of heart attack. CONCLUSIONS: There are significant disparities in risk factors and knowledge of symptoms of cardiovascular diseases among Vietnamese Americans. Culturally appropriate studies and interventions are needed to understand and to reduce these disparities.

Hepatitis B testing and vaccination among Vietnamese- and Cambodian-Americans.

We determined hepatitis B virus (HBV) testing and vaccination levels and factors associated with testing and vaccination among Vietnamese- and Cambodian-Americans. We also examined factors associated with healthcare professional (HCP)-patient discussions about HBV. We analyzed 2006 Racial and Ethnic Approaches to Community Health (REACH) 2010 Risk Factor Survey data from four US communities. We used logistic regression to identify variables associated with HBV vaccination, testing, and HCP-patient discussions about HBV. Of the 2,049 Vietnamese- and Cambodian-American respondents, 60% reported being tested for HBV, 35% reported being vaccinated against hepatitis B, and 36% indicated that they had discussed HBV with a HCP. Cambodian-Americans were less likely than Vietnamese-Americans to have been tested for HBV, while respondents with at least a high school diploma were more likely to have been tested for HBV. Respondents born in the US, younger individuals, and respondents with at least some college education were more likely to have been vaccinated against hepatitis B. HBV testing and vaccination remain suboptimal among members of these populations. Culturally sensitive efforts that target Vietnamese- and Cambodian-Americans for HBV testing and vaccination are needed to identify chronic carriers of HBV, prevent new infections, and provide appropriate medical management. HCPs that serve these populations should be encouraged to discuss HBV with their patients.

Patterns of alcohol consumption and the metabolic syndrome.

CONTEXT AND OBJECTIVE: Protective and detrimental associations have been reported between alcohol consumption and the metabolic syndrome. This may be due to variations in drinking patterns and different alcohol effects on the metabolic syndrome components. This study is designed to examine the relationship between alcohol consumption patterns and the metabolic syndrome. DESIGN, SETTING, PARTICIPANTS, AND MEASURES: The 1999-2002 National Health and Nutrition Examination Survey is a population-based survey of noninstitutionalized U.S. adults. Current drinkers aged 20-84 yr without cardiovascular disease who had complete data on the metabolic syndrome and drinking patterns were included in the analysis (n = 1529). The metabolic abnormalities comprising the metabolic syndrome included having three of the following: impaired fasting glucose/diabetes mellitus, high triglycerides, abdominal obesity, high blood pressure, and low high-density-lipoprotein cholesterol. Measures of alcohol consumption included usual quantity consumed, drinking frequency, and frequency of binge drinking. RESULTS: In multinomial logistic regression models controlling for demographics, family history of cardiovascular disease and diabetes, and lifestyle factors, increased risk of the metabolic syndrome was associated with daily consumption that exceeded U.S. dietary guideline recommendations (more than one drink per drinking day for women and more than two drinks per drinking day for men (odds ratio 1.60, 95% confidence interval 1.22-2.11) and binge drinking once per week or more [odds ratio (95% confidence interval) 1.51 (1.01-2.29]. By individual metabolic abnormality, drinking in excess of the dietary guidelines was associated with an increased risk of impaired fasting glucose/diabetes mellitus, hypertriglyceridemia, abdominal obesity, and high blood pressure. CONCLUSION: Public health messages should emphasize the potential cardiometabolic risk associated with drinking in excess of national guidelines and binge drinking.

Sex differences in the effect of diabetes duration on coronary heart disease mortality.

BACKGROUND: It is not known whether the coronary heart disease (CHD) mortality risk associated with recent (RDM; <10 years) or long-standing diabetes mellitus (LDM; > or =10 years) varies by sex. METHODS: The relationship between diabetes duration and CHD mortality was evaluated among 10 871 adults (aged 35-74 years at baseline) using the 1971-1992 National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. RESULTS: The CHD mortality rates per 1000 person-years in men with no myocardial infarction (MI) or diabetes, MI only, RDM only, LDM only, MI and RDM, and MI and LDM were 5.5 (95% confidence interval, 4.8-6.2), 15.2 (11.6-20.0), 13.2 (7.9-22.1), 11.4 (6.4-20.3), 36.0 (16.7-77.7), and 35.4 (14.0-89.7), respectively. The corresponding rates in women were 2.9 (2.5-3.3), 7.3 (5.0-10.8), 5.2 (3.5-7.7), 10.7 (7.5-15.5), 9.3 (4.3-19.9), and 21.6 (6.1-76.0), respectively. Compared with MI, the multivariate hazard ratios and their 95% confidence intervals (adjusted for age, race, smoking, hypertension, total cholesterol level, and body mass index) for fatal CHD in men with RDM, LDM, MI and RDM, and MI and LDM were 0.7 (0.3-1.3), 0.8 (0.4-1.4), 3.2 (1.4-7.4), and 2.4 (0.8-6.7), respectively. The corresponding ratios in women were 0.9 (0.6-1.3), 1.8 (1.1-3.2), 1.3 (0.5-3.5), and 1.6 (0.2-10.9), respectively. CONCLUSIONS: In men, RDM and LDM were associated with as high a risk for CHD death as MI. In women, although RDM had a CHD mortality risk similar to MI, LDM had an even greater risk. Because women with LDM are at very high risk for CHD mortality, current guidelines may need to be further refined to match intensity of treatment to risk in these women.

The REACH 2010 logic model: an illustration of expected performance.

The Centers for Disease Control and Prevention (CDC) supports 40 Racial and Ethnic Approaches to Community Health (REACH 2010) community coalitions in designing, implementing, and evaluating community-driven strategies to eliminate health disparities in racial and ethnic groups. The REACH 2010 logic model was developed to assist grantees in identifying, documenting, and evaluating local attributes of the coalition and its partners to reduce and eliminate local health disparities. The model emphasizes the program's theory of change for addressing health disparities; it displays five distinct stages of evaluation for which qualitative and quantitative measurement data are collected. The CDC is relying on REACH 2010 grantees to provide credible evidence that explains how community contributions have changed conditions and behaviors, thus leading to the reduction and elimination of health disparities.

Midlife body mass index and hospitalization and mortality in older age.

CONTEXT: Abundant evidence links overweight and obesity with impaired health. However, controversies persist as to whether overweight and obesity have additional impact on cardiovascular outcomes independent of their strong associations with established coronary risk factors, eg, high blood pressure and high cholesterol level. OBJECTIVE: To assess the relation of midlife body mass index with morbidity and mortality outcomes in older age among individuals without and with other major risk factors at baseline. DESIGN: Chicago Heart Association Detection Project in Industry study, a prospective study with baseline (1967-1973) cardiovascular risk classified as low risk (blood pressure < or =120/< or =80 mm Hg, serum total cholesterol level <200 mg/dL [5.2 mmol/L], and not currently smoking); moderate risk (nonsmoking and systolic blood pressure 121-139 mm Hg, diastolic blood pressure 81-89 mm Hg, and/or total cholesterol level 200-239 mg/dL [5.2-6.2 mmol/L]); or having any 1, any 2, or all 3 of the following risk factors: blood pressure > or =140/90 mm Hg, total cholesterol level > or =240 mg/dL (6.2 mmol/L), and current cigarette smoking. Body mass index was classified as normal weight (18.5-24.9), overweight (25.0-29.9), or obese (> or =30). Mean follow-up was 32 years. SETTING AND PARTICIPANTS: Participants were 17,643 men and women aged 31 through 64 years, recruited from Chicago-area companies or organizations and free of coronary heart disease (CHD), diabetes, or major electrocardiographic abnormalities at baseline. MAIN OUTCOME MEASURES: Hospitalization and mortality from CHD, cardiovascular disease, or diabetes, beginning at age 65 years. RESULTS: In multivariable analyses that included adjustment for systolic blood pressure and total cholesterol level, the odds ratio (95% confidence interval) for CHD death for obese participants compared with those of normal weight in the same risk category was 1.43 (0.33-6.25) for low risk and 2.07 (1.29-3.31) for moderate risk; for CHD hospitalization, the corresponding results were 4.25 (1.57-11.5) for low risk and 2.04 (1.29-3.24) for moderate risk. Results were similar for other risk groups and for cardiovascular disease, but stronger for diabetes (eg, low risk: 11.0 [2.21-54.5] for mortality and 7.84 [3.95-15.6] for hospitalization). CONCLUSION: For individuals with no cardiovascular risk factors as well as for those with 1 or more risk factors, those who are obese in middle age have a higher risk of hospitalization and mortality from CHD, cardiovascular disease, and diabetes in older age than those who are normal weight.

Effects of insulin resistance and type 2 diabetes on lipoprotein subclass particle size and concentration determined by nuclear magnetic resonance.

The insulin resistance syndrome (IRS) is associated with dyslipidemia and increased cardiovascular disease risk. A novel method for detailed analyses of lipoprotein subclass sizes and particle concentrations that uses nuclear magnetic resonance (NMR) of whole sera has become available. To define the effects of insulin resistance, we measured dyslipidemia using both NMR lipoprotein subclass analysis and conventional lipid panel, and insulin sensitivity as the maximal glucose disposal rate (GDR) during hyperinsulinemic clamps in 56 insulin sensitive (IS; mean +/- SD: GDR 15.8 +/- 2.0 mg. kg(-1). min(-1), fasting blood glucose [FBG] 4.7 +/- 0.3 mmol/l, BMI 26 +/- 5), 46 insulin resistant (IR; GDR 10.2 +/- 1.9, FBG 4.9 +/- 0.5, BMI 29 +/- 5), and 46 untreated subjects with type 2 diabetes (GDR 7.4 +/- 2.8, FBG 10.8 +/- 3.7, BMI 30 +/- 5). In the group as a whole, regression analyses with GDR showed that progressive insulin resistance was associated with an increase in VLDL size (r = -0.40) and an increase in large VLDL particle concentrations (r = -0.42), a decrease in LDL size (r = 0.42) as a result of a marked increase in small LDL particles (r = -0.34) and reduced large LDL (r = 0.34), an overall increase in the number of LDL particles (r = -0.44), and a decrease in HDL size (r = 0.41) as a result of depletion of large HDL particles (r = 0.38) and a modest increase in small HDL (r = -0.21; all P < 0.01). These correlations were also evident when only normoglycemic individuals were included in the analyses (i.e., IS + IR but no diabetes), and persisted in multiple regression analyses adjusting for age, BMI, sex, and race. Discontinuous analyses were also performed. When compared with IS, the IR and diabetes subgroups exhibited a two- to threefold increase in large VLDL particle concentrations (no change in medium or small VLDL), which produced an increase in serum triglycerides; a decrease in LDL size as a result of an increase in small and a reduction in large LDL subclasses, plus an increase in overall LDL particle concentration, which together led to no difference (IS versus IR) or a minimal difference (IS versus diabetes) in LDL cholesterol; and a decrease in large cardioprotective HDL combined with an increase in the small HDL subclass such that there was no net significant difference in HDL cholesterol. We conclude that 1) insulin resistance had profound effects on lipoprotein size and subclass particle concentrations for VLDL, LDL, and HDL when measured by NMR; 2) in type 2 diabetes, the lipoprotein subclass alterations are moderately exacerbated but can be attributed primarily to the underlying insulin resistance; and 3) these insulin resistance-induced changes in the NMR lipoprotein subclass profile predictably increase risk of cardiovascular disease but were not fully apparent in the conventional lipid panel. It will be important to study whether NMR lipoprotein subclass parameters can be used to manage risk more effectively and prevent cardiovascular disease in patients with the IRS.