Plasma trans-Fatty Acid Concentrations Continue to Be Associated with Serum Lipid and Lipoprotein Concentrations among US Adults after Reductions in trans-Fatty Acid Intake.

Background: High intakes of trans-fatty acids (TFAs), especially industrially produced TFAs, can lead to unfavorable lipid and lipoprotein concentrations and an increased risk of cardiovascular disease. It is unknown how this relation might change in a population after significant reductions in TFA intake.Objective: This study, which used a new analytical method for measuring plasma TFA concentrations, clarified the association between plasma TFA and serum lipid and lipoprotein concentrations before and after the US FDA enacted TFA food-labeling regulations in 2006.Methods: Data were selected from the NHANES of 1999-2000 and 2009-2010. Findings on 1383 and 2155 adults, respectively, aged ≥20 y, were evaluated. Multivariable linear regressions were used to examine the associations between plasma TFA concentration and lipid and lipoprotein concentrations. The outcome measures were serum concentrations of total cholesterol (TC), LDL cholesterol, HDL cholesterol, and triglycerides and the ratio of TC to HDL cholesterol.Results: The median plasma TFA concentration decreased from 80.6 µmol/L in 1999-2000 to 37.0 µmol/L in 2009-2010. Plasma TFA concentration continued to be associated with serum lipid and lipoprotein concentrations after significant reductions in TFA intake in the population. For example, by comparing the lowest with the highest quintiles of TFA concentration in 1999-2000, adjusted mean (95% CI) LDL-cholesterol concentrations increased from 118 mg/dL (112, 123 mg/dL) to 135 mg/dL (130, 141 mg/dL) (P-trend < 0.001). The corresponding values for 2009-2010 were 102 mg/dL (97.4, 107 mg/dL) and 129 mg/dL (125, 133 mg/dL) for LDL cholesterol (P-trend < 0.001). Differences between the highest and lowest quintiles were consistent across age groups, sexes, races/ethnicities, and other covariates.Conclusions: Despite a 54% reduction in plasma TFA concentrations in US adults from 1999-2000 to 2009-2010, concentrations remained significantly associated with serum lipid and lipoprotein concentrations. There does not appear to be a threshold under which the association between plasma TFA concentration and lipid profiles might become undetectable.

Use of Urine Biomarkers to Assess Sodium Intake: Challenges and Opportunities.

This article summarizes current data and approaches to assess sodium intake in individuals and populations. A review of the literature on sodium excretion and intake estimation supports the continued use of 24-h urine collections for assessing population and individual sodium intake. Since 2000, 29 studies used urine biomarkers to estimate population sodium intake, primarily among adults. More than half used 24-h urine; the rest used a spot/casual, overnight, or 12-h specimen. Associations between individual sodium intake and health outcomes were investigated in 13 prospective cohort studies published since 2000. Only three included an indicator of long-term individual sodium intake, i.e., multiple 24-h urine specimens collected several days apart. Although not insurmountable, logistic challenges of 24-h urine collection remain a barrier for research on the relationship of sodium intake and chronic disease. Newer approaches, including modeling based on shorter collections, offer promise for estimating population sodium intake in some groups.

Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA.

With non-communicable conditions accounting for nearly two-thirds of deaths worldwide, the emergence of chronic diseases as the predominant challenge to global health is undisputed. In the USA, chronic diseases are the main causes of poor health, disability, and death, and account for most of health-care expenditures. The chronic disease burden in the USA largely results from a short list of risk factors--including tobacco use, poor diet and physical inactivity (both strongly associated with obesity), excessive alcohol consumption, uncontrolled high blood pressure, and hyperlipidaemia--that can be effectively addressed for individuals and populations. Increases in the burden of chronic diseases are attributable to incidence and prevalence of leading chronic conditions and risk factors (which occur individually and in combination), and population demographics, including ageing and health disparities. To effectively and equitably address the chronic disease burden, public health and health-care systems need to deploy integrated approaches that bundle strategies and interventions, address many risk factors and conditions simultaneously, create population-wide changes, help the population subgroups most affected, and rely on implementation by many sectors, including public-private partnerships and involvement from all stakeholders. To help to meet the chronic disease burden, the US Centers for Disease Control and Prevention (CDC) uses four cross-cutting strategies: (1) epidemiology and surveillance to monitor trends and inform programmes; (2) environmental approaches that promote health and support healthy behaviours; (3) health system interventions to improve the effective use of clinical and other preventive services; and (4) community resources linked to clinical services that sustain improved management of chronic conditions. Establishment of community conditions to support healthy behaviours and promote effective management of chronic conditions will deliver healthier students to schools, healthier workers to employers and businesses, and a healthier population to the health-care system. Collectively, these four strategies will prevent the occurrence of chronic diseases, foster early detection and slow disease progression in people with chronic conditions, reduce complications, support an improved quality of life, and reduce demand on the health-care system. Of crucial importance, with strengthened collaboration between the public health and health-care sectors, the health-care system better uses prevention and early detection services, and population health is improved and sustained by solidifying collaborations between communities and health-care providers. This collaborative approach will improve health equity by building communities that promote health rather than disease, have more accessible and direct care, and focus the health-care system on improving population health.

Vital Signs: Predicted Heart Age and Racial Disparities in Heart Age Among U.S. Adults at the State Level.

INTRODUCTION: Cardiovascular disease is a leading cause of morbidity and mortality in the United States. Heart age (the predicted age of a person's vascular system based on their cardiovascular risk factor profile) and its comparison with chronological age represent a new way to express risk for developing cardiovascular disease. This study estimates heart age and differences between heart age and chronological age (excess heart age) and examines racial, sociodemographic, and regional disparities in heart age among U.S. adults aged 30-74 years. METHODS: Weighted 2011 and 2013 Behavioral Risk Factor Surveillance System data were applied to the sex-specific non-laboratory-based Framingham risk score models, stratifying the results by age and race/ethnic group, educational and income level, and state. These results were then translated into age-standardized heart age values, mean excess heart age was calculated, and the findings were compared across groups. RESULTS: Overall, average predicted heart age for adult men and women was 7.8 and 5.4 years older than their chronological age, respectively. Statistically significant (p<0.05) racial/ethnic, sociodemographic, and regional differences in heart age were observed: heart age among non-Hispanic black men (58.7 years) and women (58.9 years) was greater than other racial/ethnic groups, including non-Hispanic white men (55.3 years) and women (52.5 years). Excess heart age was lowest for men and women in Utah (5.8 and 2.8 years, respectively) and highest in Mississippi (10.1 and 9.1 years, respectively). CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: The predicted heart age among U.S. adults aged 30-74 years was significantly higher than their chronological age. Use of predicted heart age might 1) simplify risk communication and motivate more persons to live heart-healthy lifestyles and better comply with recommended therapeutic interventions, and 2) motivate communities to implement programs and policies that support cardiovascular health.

Vital signs: sodium intake among U.S. school-aged children - 2009-2010.

BACKGROUND: A national health objective is to reduce average U.S. sodium intake to 2,300 mg daily to help prevent high blood pressure, a major cause of heart disease and stroke. Identifying common contributors to sodium intake among children can help reduction efforts. METHODS: Average sodium intake, sodium consumed per calorie, and proportions of sodium from food categories, place obtained, and eating occasion were estimated among 2,266 school-aged (6­18 years) participants in What We Eat in America, the dietary intake component of the National Health and Nutrition Examination Survey, 2009­2010. RESULTS: U.S. school-aged children consumed an estimated 3,279 mg of sodium daily with the highest total intake (3,672 mg/d) and intake per 1,000 kcal (1,681 mg) among high school­aged children. Forty-three percent of sodium came from 10 food categories: pizza, bread and rolls, cold cuts/cured meats, savory snacks, sandwiches, cheese, chicken patties/nuggets/tenders, pasta mixed dishes, Mexican mixed dishes, and soups. Sixty-five percent of sodium intake came from store foods, 13% from fast food/pizza restaurants, 5% from other restaurants, and 9% from school cafeteria foods. Among children aged 14­18 years, 16% of total sodium intake came from fast food/pizza restaurants versus 11% among those aged 6­10 years or 11­13 years (p<0.05). Among children who consumed a school meal on the day assessed, 26% of sodium intake came from school cafeteria foods. Thirty-nine percent of sodium was consumed at dinner, followed by lunch (29%), snacks (16%), and breakfast (15%). IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Sodium intake among school-aged children is much higher than recommended. Multiple food categories, venues, meals, and snacks contribute to sodium intake among school-aged children supporting the importance of populationwide strategies to reduce sodium intake. New national nutrition standards are projected to reduce the sodium content of school meals by approximately 25%­50% by 2022. Based on this analysis, if there is no replacement from other sources, sodium intake among U.S. school-aged children will be reduced by an average of about 75­150 mg per day and about 220­440 mg on days children consume school meals.

Recent economic evaluations of interventions to prevent cardiovascular disease by reducing sodium intake.

Excess intake of sodium, a common problem worldwide, is associated with hypertension and cardiovascular disease (CVD), and hypertension is a major risk factor for CVD. Population-wide efforts to reduce sodium intake have been identified as a promising strategy for preventing hypertension and CVD, and such initiatives are currently recommended by a variety of scientific and public health organizations. By reviewing the literature published from January 2011 to March 2013, we summarized recent economic analyses of interventions to reduce sodium intake. The evidence, derived from estimates of resultant blood pressure decreases and thus decreases in the incidence of CVD events, supports population-wide interventions for reducing sodium intake. Both lowering the salt content in manufactured foods and conducting mass media campaigns at the national level are estimated to be cost-effective in preventing CVD. Although better data on the cost of interventions are needed for rigorous economic evaluations, population-wide sodium intake reduction can be a promising approach for containing the growing health and economic burden associated with hypertension and its sequelae.

Suicide among lawyers: Role of job problems.

INTRODUCTION: Suicide research has neglected the legal profession. The present investigation determines what risk factors distinguish lawyers' suicides from those of the general population. Given the substantial investment in their careers, client dependency, and ongoing stress of work, job problems are seen as key potential drivers of lawyers' suicides. METHODOLOGY: Data are from the National Violent Death Reporting System (NVDRS). They refer to 30,570 suicides. Fifteen predictors, including social strains, psychiatric morbidity, and demographics, are assessed as possible drivers of lawyers' suicides. The dependent variable is a dichotomy where lawyers' suicides = 1 and other suicides = 0. RESULTS: The results of a multivariate logistic regression analysis showed that after adjusting for the other 14 risk factors, lawyers' suicides were 91% more apt (Odds ratio = 1.91, CI: 1.17, 3.14) than other suicides to have job problems that contributed to their suicide. Other constructs differentiating lawyers' suicides from other suicides included presence of a known mental health problem, age, presence of a known substance abuse problem, and marital status. The full model correctly classified 99.57% of the suicides. CONCLUSION: Job problems can serve as a key warning sign for lawyers' suicides. This is the first investigation of the drivers of lawyers' suicides.

Prevalence of Cardiovascular Risk Factors and Strokes in Younger Adults.

Importance: While stroke mortality rates have decreased substantially in the past 2 decades, this trend has been primarily limited to older adults. Increasing trends in stroke incidence and hospitalizations have been noted among younger adults, but there has been concern that this reflected improved diagnosis through an increased use of imaging rather than representing a real increase. Objectives: To determine whether stroke hospitalization rates have continued to increase and to identify the prevalence of associated stroke risk factors among younger adults. Design, Setting, and Participants: Hospitalization data from the National Inpatient Sample from 1995 through 2012 were used to analyze acute stroke hospitalization rates among adults aged 18 to 64 years. Hospitalization data from 2003 to 2012 were used to identify the prevalence of associated risk factors for acute stroke. Acute stroke hospitalizations were identified by the principal International Classification of Diseases, Ninth Revision, Clinical Modification code and associated risk factors were identified by secondary International Classification of Diseases, Ninth Revision, Clinical Modification codes for each hospitalization. Main Outcomes and Measures: Trends in acute stroke hospitalization rates by stroke type, age, sex, and race/ethnicity, as well as the prevalence of associated risk factors by stroke type, age, and sex. Results: The 2003-2004 set included 362 339 hospitalizations and the 2011-2012 set included 421 815 hospitalizations. The major findings in this study are as follows: first, acute ischemic stroke hospitalization rates increased significantly for both men and women and for certain race/ethnic groups among younger adults aged 18 to 54 years; they have almost doubled for men aged 18 to 34 and 35 to 44 years since 1995-1996, with a 41.5% increase among men aged 35 to 44 years from 2003-2004 to 2011-2012. Second, the prevalence of stroke risk factors among those hospitalized for acute ischemic stroke continued to increase from 2003-2004 through 2011-2012 for both men and women aged 18 to 64 years (range of absolute increase: hypertension, 4%-11%; lipid disorders, 12%-21%; diabetes, 4%-7%; tobacco use, 5%-16%; and obesity, 4%-9%). Third, the prevalence of having 3 to 5 risk factors increased from 2003-2004 through 2011-2012 (men: from 9% to 16% at 18-34 years, 19% to 35% at 35-44 years, 24% to 44% at 45-54 years, and 26% to 46% at 55-64 years; women: 6% to 13% at 18-34 years, 15% to 32% at 35-44 years, 25% to 44% at 45-54 years, and 27% to 48% at 55-65 years; P for trend < .001). Finally, hospitalization rates for intracerebral hemorrhage and subarachnoid hemorrhage remained stable, with the exception of declines among men and non-Hispanic black patients aged 45 to 54 with subarachnoid hemorrhage (13.2/10 000 to 10.3/10 000 hospitalizations and 15.8/10 000 to 11.5/10 000 hospitalizations, respectively). Conclusions and Relevance: The identification of increasing hospitalization rates for acute ischemic stroke in young adults coexistent with increasing prevalence of traditional stroke risk factors confirms the importance of focusing on prevention in younger adults.

Evidence of Dietary Improvement and Preventable Costs of Cardiovascular Disease.

We conducted a review to summarize preventable medical costs of cardiovascular disease (CVD) associated with improved diet, as defined by the 2020 Strategic Impact Goal of the American Heart Association. We searched databases of PubMed, Embase, CINAHL and ABI/INFORM to identify population-based studies published from January 1995 to December 2015 on CVD medical costs related to excess intake of salt/sodium or sugar-sweetened beverages, and inadequate intake of fruits and vegetables, fish/fish oils/omega-3 fatty acids, or whole grains/fiber/dietary fiber. Based on the American Heart Association's secondary dietary metrics, we also searched the literature on inadequate intake of nuts and excess intake of processed meat and saturated fat. For each component, we evaluated the CVD cost savings if consumption levels were changed. The cost savings were adjusted into 2013 US dollars. Among 330 studies focusing on diet and economic consequences, 16 studies evaluated CVD costs associated with 1 or more dietary components: salt/sodium (n = 13), fruits and vegetables (n = 1), meat (n = 1), and saturated fat (n = 3). In the United States, reducing individual sodium intake to 2,300 mg/day from the current level could potentially save $1,990.9/person per year for hypertension treatment, based on a simulation study. Increasing consumption of fruits and vegetables from <0.5 cup/day to >1.5 cups/day could save $1,568.0/person per year in treatment costs for CVD, based on a cohort study. Potential CVD cost savings associated with diet improvement are substantial. Interventions for reducing sodium intake and increasing fruit and vegetable consumption could be viable means to alleviate the increasing national medical expenditures.

Feasibility of collecting 24-h urine to monitor sodium intake in the National Health and Nutrition Examination Survey.

BACKGROUND: Twenty-four-hour urine sodium excretion is recommended for monitoring population sodium intake. Because of concerns about participation and completion, sodium excretion has not been collected previously in US nationally representative surveys. OBJECTIVE: We assessed the feasibility of implementing 24-h urine collections as part of a nationally representative survey. DESIGN: We selected a random half sample of nonpregnant US adults aged 20-69 y in 3 geographic locations of the 2013 NHANES. Participants received explicit instructions, started and ended the urine collection in a urine study mobile examination center, and answered questions about their collection. Among those with a complete 24-h urine collection, a random one-half were asked to collect a second 24-h urine sample. Sodium, potassium, chloride, and creatinine excretion were analyzed. RESULTS: The final NHANES examination response rate for adults aged 20-69 y in these 3 study locations was 71%. Of those examined (n = 476), 282 (59%) were randomly selected to participate in the 24-h urine collection. Of these, 212 persons [75% of those selected for 24-h urine collection; 53% (equal to 71% × 75% of those selected for the NHANES)] collected a complete initial 24-h specimen and 92 persons (85% of 108 selected) collected a second complete 24-h urine sample. More men than women completed an initial collection (P = 0.04); otherwise, completion did not vary by sociodemographic characteristics, body mass index, education, or employment status for either collection. Mean 24-h urine volume and sodium excretion were 1964 ± 1228 mL and 3657 ± 2003 mg, respectively, for the first 24-h urine sample, and 2048 ± 1288 mL and 3773 ± 1891 mg, respectively, for the second collection. CONCLUSION: Given the 53% final component response rate and 75% completion rate, 24-h urine collections were deemed feasible and implemented in the NHANES 2014 on a subsample of adults aged 20-69 y to assess population sodium intake. This study was registered at clinicaltrials.gov as NCT02723682.

Vitamin or supplement use among adults, behavioral risk factor surveillance system, 13 states, 2001.

OBJECTIVE: The authors examined vitamin/supplement (V/S) use and its relationship to sociodemographics, health behaviors, and health conditions among adults in 13 states. METHODS: This investigation used 2001 data from a cross-sectional study of non-institutionalized adults aged > or = 18 years, the Behavioral Risk Factor Surveillance System. RESULTS: Of 45,415 respondents with complete data (18,723 males and 26,692 females), 56.5% (n=5,652) reported current V/S use. After adjusting for age, sex, race/ethnicity, and education, the authors found a statistically significant association between V/S use and positive health risk behavior (adjusted odds ratio [OR]=1.46; p<0.001). Also, WS use was found to increase with age (p<0.001). No association was found between V/S use and the absence of specific chronic disease conditions (adjusted OR=0.93; p=0.052). CONCLUSIONS: People who used V/S in the states surveyed were more likely to demonstrate positive health risk behaviors than those who did not report V/S use. Thus it appears that individuals who are most likely to use V/S are least likely to need V/S. It is crucial that individuals report quantity and frequency of V/S use when providing medical or diet histories to health care providers.

Primary prevention of type 2 diabetes mellitus by lifestyle intervention: implications for health policy.

More than 18 million Americans currently have diabetes mellitus. The economic and human cost of the disease is devastating. In the United States, diabetes is the most common cause of blindness among working-age adults, the most common cause of nontraumatic amputations and end-stage renal disease, and the sixth most common cause of death. For the cohort of Americans born in 2000, the estimated lifetime risk for diabetes is more than 1 in 3. In the next 50 years, the number of diagnosed cases of diabetes is predicted to increase by 165% in the United States, with the largest relative increases seen among African Americans, American Indians, Alaska Natives, Asian and Pacific Islanders, and Hispanic/Latino persons. Compelling scientific evidence indicates that lifestyle change prevents or delays the occurrence of type 2 diabetes in high-risk groups. This body of evidence from randomized, controlled trials conducted in 3 countries has definitively established that maintenance of modest weight loss through diet and physical activity reduces the incidence of type 2 diabetes in high-risk persons by about 40% to 60% over 3 to 4 years. The number of persons at high risk for type 2 diabetes is similar to the number of persons who have diabetes. This paper summarizes scientific evidence supporting lifestyle intervention to prevent type 2 diabetes and discusses major policy challenges to broad implementation of lifestyle intervention in the health system.

Community-based lifestyle interventions to prevent type 2 diabetes.

OBJECTIVE: To conduct a literature review of community-based interventions intended to prevent or delay type 2 diabetes. RESEARCH DESIGN AND METHODS: Recently published findings about the potential to prevent or delay type 2 diabetes with intensive lifestyle interventions prompted a literature search for community-based diabetes prevention interventions. The literature review design was a search of databases for publications in 1990-2001 that identified reports on community-based interventions designed to prevent or modify risk factors for type 2 diabetes. RESULTS: The search revealed 16 published interventions, 8 of which were conducted in the U.S. and involved populations disproportionately burdened by diabetes (e.g., American Indians, Native Hawaiians, Mexican Americans, and African Americans). Of the studies reporting results among youth, there were posttest improvements in intervention groups in knowledge, preventive behaviors, and self-esteem. Among studies reporting results among adults, most reported improvements in intervention groups in knowledge or adoption of regular physical activity. Several investigators offered important reflections about the process of engaging communities and sharing decision making in participatory research approaches, as well as insights about the expectations and limitations of community-based diabetes prevention research. Many of the studies reported limitations in their design, including the lack of control or comparison groups, low response rates or lack of information on nonresponders, or brief intervention periods. CONCLUSIONS: There is a critical need to conduct and publish reports on well-designed community-based diabetes prevention research and share information on the process, results, and lessons learned. Armed with recent positive findings about diabetes prevention and literature documenting community-based efforts, advocates at local, state, and national levels can collaborate to stem the rising tide of diabetes in communities.

Predicted 10-year risk of developing cardiovascular disease at the state level in the U.S.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in the U.S. State-specific predicted 10-year risk of developing CVD could provide useful information for state health planning and policy. PURPOSE: To estimate state-specific 10-year risk of developing CVD. METHODS: Using the updated non-laboratory-based Framingham CVD Risk Score (RS), this study estimated 10-year risk of developing CVD; coronary heart disease (CHD); and stroke, stratified by demographic factors and by state among 2009 Behavioral Risk Factors Surveillance System participants aged 30-74 years. Data analysis was completed in June 2014. RESULTS: The age-standardized mean CVD, CHD, and stroke RSs for adults aged 30-74 years were 14.6%, 10.4%, and 2.3% among men, respectively, and 7.5%, 4.5%, and 1.8% among women. RSs increased significantly with age and were highest among non-Hispanic blacks, those with less than high school education, and households with incomes <$35,000. State-specific age-standardized CVD, CHD, and stroke RS ranged, among men, from lows in Utah (13.2%, 9.6%, and 2.1%, respectively) to highs in Louisiana (16.2%, 11.7%, and 2.6%), and among women, from lows in Minnesota (6.3%, 3.8%, and 1.5%) to highs in Mississippi (8.7%, 5.3%, and 2.1%). CONCLUSIONS: The predicted 10-year risk of developing CVD varies significantly by age, gender, race/ethnicity, educational attainment, household income, and state of residence. These results support the development and implementation of targeted prevention programs by states to address the risk of developing CVD, CHD, and stroke among their populations.

Differences in the relation of obesity to serum triacylglycerol and VLDL subclass concentrations between black and white children: the Bogalusa Heart Study.

BACKGROUND: Obese children and adults, particularly those with abdominal obesity, have an elevated serum triacylglycerol concentration. Furthermore, triacylglycerol concentrations are generally higher in whites than in blacks, and the relation of obesity to triacylglycerol concentrations may be stronger in whites. However, there is little information on the relation of obesity to the metabolically distinct subclasses of VLDL in children. OBJECTIVE: The objective was to examine possible differences between blacks (n = 367) and whites (n = 549) in mean concentrations of triacylglycerols, in mean concentrations of small and large VLDL, and in the relation of waist circumference to concentrations of triacylglycerol and VLDL subclasses. DESIGN: We measured VLDL subclass concentrations and assessed the relation of various obesity indexes to triacylglycerols in a cross-sectional study of 10- to 17-y-olds. RESULTS: The mean triacylglycerol concentration was 0.3 mmol/L (25 mg/dL) higher in white than in black children, primarily because of a 0.2-mmol/L (140%) difference in mean concentrations of large VLDL. In contrast, the mean concentrations of small VLDL differed by only 0.05 mmol/L (29%). In addition, the relations of waist girth to concentrations of triacylglycerol and large VLDL were 2- to 6-fold stronger among white children than among black children. Although white children had higher concentrations of large VLDL than did black children, this difference increased from 0.1 to 0.4 mmol/L across quintiles of waist circumference. Waist circumference was not significantly related to concentrations of small VLDL. CONCLUSION: These contrasting associations with obesity, which differ between white and black children, suggest that information on VLDL subclasses could provide additional information on the risk of obesity-related ischemic heart disease.