Cardiometabolic disease costs associated with suboptimal diet in the United States: A cost analysis based on a microsimulation model.

BACKGROUND: Poor diet is a leading risk factor for cardiometabolic disease (CMD) in the United States, but its economic costs are unknown. We sought to estimate the cost associated with suboptimal diet in the US. METHODS AND FINDINGS: A validated microsimulation model (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends [CVD PREDICT]) was used to estimate annual cardiovascular disease (fatal and nonfatal myocardial infarction, angina, and stroke) and type 2 diabetes costs associated with suboptimal intake of 10 food groups (fruits, vegetables, nuts/seeds, whole grains, unprocessed red meats, processed meats, sugar-sweetened beverages, polyunsaturated fats, seafood omega-3 fats, sodium). A representative US population sample of individuals aged 35-85 years was created using weighted sampling from National Health And Nutrition Examination Surveys (NHANES) 2009-2012 cycles. Estimates were stratified by cost type (acute, chronic, drug), sex, age, race, education, BMI, and health insurance. Annual diet-related CMD costs were $301/person (95% CI $287-$316). This translates to $50.4 billion in CMD costs (18.2% of total) for the whole population, of which 84.3% are attributed to acute care ($42.6 billion). The largest annual per capita costs are attributed to low consumption of nuts/seeds ($81; 95% CI $74-$86) and seafood omega-3 fats ($76; 95% CI $70-$83), and the lowest are attributed to high consumption of red meat ($3; 95% CI $2.8-$3.5) and polyunsaturated fats ($20; 95% CI $19-$22). Individual costs are highest for men ($380), those aged ≥65 years ($408), blacks ($320), the less educated ($392), and those with Medicare ($481) or dual-eligible ($536) insurance coverage. A limitation of our study is that dietary intake data were assessed from 24-hour dietary recall, which may not fully capture a diet over a person's life span and is subject to measurement errors. CONCLUSIONS: Suboptimal diet of 10 dietary factors accounts for 18.2% of all ischemic heart disease, stroke, and type 2 diabetes costs in the US, highlighting that timely implementation of diet policies could address these health and economic burdens.

Modeling the cost effectiveness and budgetary impact of Polypills for secondary prevention of cardiovascular disease in the United States.

BACKGROUND: There is underutilization of appropriate medications for secondary prevention of cardiovascular disease (CVD). METHODS: Usual care (UC) was compared to polypill-based care with 3 versions using a validated micro-simulation model in the NHANES population with prior CVD. UC included individual prescription of up to 4 drug classes (antiplatelet agents, beta-blockers, renin-angiotensin-aldosterone inhibitors and statins). The polypills modeled were aspirin 81 mg, atenolol 50 mg, ramipril 5 mg, and either simvastatin 40 mg (Polypill I), atorvastatin 80 mg (Polypill II), or rosuvastatin 40 mg (Polypill III). Baseline medication use and adherence came from United Healthcare claims data. RESULTS: When compared to UC, there were annual reductions of 130,000 to 178,000 myocardial infarctions and 54,000 to 74,000 strokes using Polypill I and II, respectively. From a health sector perspective, in incremental analysis the ICERs for Polypill I and II were $20,073/QALY and $21,818/QALY respectively; Polypill III was dominated but had a similar cost-effectiveness ratio to Polypill II when compared directly to usual care. From a societal perspective, Polypill II was cost-saving and dominated all strategies. Over a 5-year period, those taking Polypill I and II compared to UC saved approximately $12 and $6 per-patient-per-year alive, respectively. Polypill II was the preferred strategy in 98% of runs at a willingness to pay of $50,000 in the probability sensitivity analysis. CONCLUSIONS: Use of a polypill has a favorable cost profile for secondary CVD prevention in the United States. Reductions in CVD-related healthcare costs outweighed medication cost increases on a per-patient-per-year basis, suggesting that a polypill would be economically advantageous to both patients and payers.

Cost-Effectiveness of a US National Sugar-Sweetened Beverage Tax With a Multistakeholder Approach: Who Pays and Who Benefits.

OBJECTIVES: To estimate the health impact and cost-effectiveness of a national penny-per-ounce sugar-sweetened beverage (SSB) tax, overall and with stratified costs and benefits for 9 distinct stakeholder groups. METHODS: We used a validated microsimulation model (CVD PREDICT) to estimate cardiovascular disease reductions, quality-adjusted life years gained, and cost-effectiveness for US adults aged 35 to 85 years, evaluating full and partial consumer price pass-through. RESULTS: From health care and societal perspectives, the SSB tax was highly cost-saving. When we evaluated health gains, taxes paid, and out-of-pocket health care savings for 6 distinct consumer categories, incremental cost-effectiveness ratios ranged from $20 247 to $42 662 per quality-adjusted life year for 100% price pass-through (incremental cost-effectiveness ratios similar with 50% pass-through). For the beverage industry, net costs were $0.92 billion with 100% pass-through (largely tax-implementation costs) and $49.75 billion with 50% pass-through (largely because of partial industry coverage of the tax). For government, the SSB tax positively affected both tax revenues and health care cost savings. CONCLUSIONS: This stratified analysis improves on unitary approaches, illuminating distinct costs and benefits for stakeholders with political influence over SSB tax decisions.

Predictors of overweight/obesity in a Brazilian cohort after 13 years of follow-up.

BACKGROUND: Obesity is a chronic complex disease with an increasing prevalence around the world. Prospective studies in adult cohorts are needed to provide information about predictors of new-onset overweight/obesity on population-based levels. The aim of this study was to identify factors associated with the risk of an adult individual become overweight/obese after 13 years of follow-up. METHODS: Second phase of an observational population-based prospective cohort study in a small town in the Midwest region of Brazil. A representative sample of the adult population (≥18 years) was assessed in 2002 (phase 1). Anthropometric, sociodemographic, dietary intake and lifestyle data were collected. After 13 years of follow-up (2015), the same variables were re-evaluated (phase 2). New-onset overweight/obesity was the outcome variable. RESULTS: A total of 685 subjects were included with a mean age in phase 1 of 42.7 ± 13.8 years and 56.1 ± 13.8 years in phase 2, the mean follow-up time was 13.2 years and female sex counted for 66.3% of the sample. Total weight gain was 5.9 ± 10.2 Kg, body mass index increased 2.6 ± 3.8 Kg/m2 and waist circumference (WC) values increased 8.0 ± 10.5 cm. The prevalence of overweight/obesity went from 49.1% in phase 1 to 69.8% in phase 2 (p < 0.001). The factors associated with a decreased risk of new-onset overweight/obesity were ages between 50 and 64 (RR 0.40; CI 0.24-0.67 - p = 0.001) and ≥65 years (RR 0.15; CI 0.06-0.35 - p < 0.001), being part of the second quartile of fat consumption (RR 0.59; CI 0.35-0.97 - p = 0.041), no alcohol consumption (RR 0.59; CI 0.37-0.93 - p = 0.024) and smoking (RR 0.58; CI 0.39-0.86 - p = 0,007) in phase 1. CONCLUSIONS: We identified in thirteen years of follow-up that older ages, a moderate fat consumption compared to low consumption, no alcohol consumption and smoking habit were related to a decreased risk of new-onset overweight/obesity. Obesity prevention actions must focus on subjects at younger ages and include policies to reduce alcohol consumption.

Is waist-to-height ratio the best predictive indicator of hypertension incidence? A cohort study.

BACKGROUND: The best anthropometric indicator to verify the association between obesity and hypertension (HTN) has not been established. We conducted this study to evaluate and compare the discriminatory power of waist-to-height ratio (WHtR) in relation to body mass index (BMI) and waist circumference (WC) in predicting HTN after 13 years of follow-up. METHODS: This study was an observational prospective cohort study performed in the city of Firminópolis, in Brazilian's midwest. The cohort baseline (phase 1) was initiated in 2002 with the evaluation of a representative sample of the normotensive population (≥ 18 years of age). The incidence of HTN was evaluated as the outcome (phase 2). Sociodemographic, dietary and lifestyle variables were used to adjust proportional hazards models and evaluate risk of HTN according to anthropometric indices. The areas under the receiver operating characteristic (ROC) curves were used to compare the predictive capacity of these indices. The best HTN predictor cut-offs were obtained based on sensitivity and specificity. RESULTS: A total of 471 patients with a mean age of 38.9 ± 12.3 years were included in phase 1. The mean follow-up was 13.2 years, and 207 subjects developed HTN. BMI, WC and WHtR were associated with risk of HTN incidence and had similar power in predicting the disease. However, the associations were only significant for women. The cut-off points with a better HTN predictive capacity were in agreement with current recommendations, except for the WC in men. CONCLUSIONS: The results suggest that both overall obesity (BMI) and central obesity (WC and WHtR) anthropometric indicators can be used in this population to evaluate the risk of developing hypertension.

White-coat, masked and sustained hypertension detected by home blood pressure monitoring in adolescents: prevalence and associated factors.

PURPOSE: Population-based studies estimating prevalence's of white-coat, masked and sustained hypertension in non-European adolescents are needed, particularly in developing countries. Aiming to determine these estimates and, additionally identify factors associated to these conditions this study was conducted. MATERIALS AND METHODS: Cross-sectional study with a representative sample of secondary school students from a Brazilian state capital. Office measurements were performed with validated semi-automatic devices. Home BP (blood pressure) monitoring protocol included two day-time and two evening-time measurements over 6 days. Adolescents' were classified as: normotensives (office and home BP <95th percentile); sustained hypertensives (office and home BP ≥95th percentile); white-coat hypertensives (office BP ≥95th percentile and home BP <95th percentile) and masked hypertensives (office BP <95th percentile and home BP ≥95th percentile). Logistic regression models were built to identify if sex, age, BMI and family history of HTN were independently associated with white-coat, masked and sustained hypertension. RESULTS: In a sample of 1024 adolescents, prevalence of white-coat, masked and sustained hypertension was 7.5%, 2.2% and 1.7%, respectively. Male sex was positively associated with white-coat hypertension (OR 2.68; 95%CI 1.58-4.54; p < 0.001). BMI was positively associated with both white-coat (OR 1.23; 95%CI 1.16-1.30; p < 0.001) and sustained hypertension (OR 1.19; 95%CI 1.11-1.29; p < 0.001). None of the independent variables were associated with masked hypertension in this population. CONCLUSION: The estimated prevalence of white-coat hypertension, masked and sustained hypertension in a population of non-European adolescents assessed by home BP monitoring was 7.5%, 2.2% and 1.7% respectively. Male sex was positively associated with white-coat hypertension in these adolescents while BMI was positively associated with both white-coat and sustained hypertension.

Office blood pressure measurements with oscillometric devices in adolescents: a comparison with home blood pressure.

PURPOSE: Compare multiple in office BP measurements in adolescents using an oscillometric device with out-of-office blood pressure measurements (home blood pressure monitoring - HBPM). MATERIALS AND METHODS: Office measurements were performed with validated semi-automatic devices twice (3 minutes interval) in two different moments (1 week apart), with a total of four readings. These BP readings were named R1, R2, R3 and R4 (following the sequence they were performed), FDM (mean of two readings on first day) and SDM (mean of two readings on second day) and SRM (R2-R4 means). The HBPM protocol included two day-time and two evening-time measurements over 6 days. RESULTS: A total of 1024 students between 12 and 17 years were included (mean age 14.68 years; 52.4% females). The mean systolic blood pressure (SBP) values of R2, SDM and SRM were similar to HBPM values. Regarding diastolic blood pressure (DBP) HBPM value was different than R4. High SBP and DBP correlation coefficients with HBPM values were found for R2, SDM and SRM values. CONCLUSION: The second office BP measurement performed with an oscilometric device in adolescents was comparable to HBPM values, suggesting that two office readings might be suitable to rule out hypertension in this age group.

Sedentary lifestyle and its associated factors among adolescents from public and private schools of a Brazilian state capital.

BACKGROUND: Adolescence is a transition stage between childhood and adulthood and is an important phase for the acquisition of future lifestyles, including the practice of physical activity (PA). The prevalence of sedentary lifestyle in adolescents is often high, creating the need for studies addressing the practice of PA and its associated factors for a better understanding of the phenomenon and possible interventions that would encourage positive changes. METHODS: Cross-sectional study of a representative sample of students aged 14-18 years enrolled in both public and private schools of a large Brazilian city to determine the level of physical activity (PA) and its associated factors. Sedentary lifestyle was measured by applying the International Physical Activity Questionnaire. The independent variables were gender, age, race, tobacco use and alcohol consumption in the past 30 days, socioeconomic status, body mass index, waist circumference and blood pressure. The crude prevalence ratio was used as a measure of association and was estimated from a Poisson regression. RESULTS: The sample consisted of 862 adolescents with a mean age of 15.4 ± 1.1 years. Females were predominant (52.8%), and the age between 14 and 15 years was the most frequent (52.2%). The majority of the group reported themselves as Caucasians (51.2%), belonging to socioeconomic class C (52.5%) and were attending to public schools (69.1%). The prevalence of sedentary lifestyle was 66.8% (95% confidence interval [CI]: 63.5-69.9), where values of 65.4% and 69.9% were observed among students from public and private schools, respectively (p = 0.196). Sedentary lifestyle was more frequent in females (78.0% vs 54.3%; p < 0.001). The factor directly associated with sedentary lifestyle was female gender both in public and private schools and the only independent variable related to sedentarism was also female gender. CONCLUSION: The prevalence of sedentary lifestyle was extremely high in the population of adolescents studied both in public and private schools. Female sex was directly associated with sedentary lifestyle.

The natural history of cardiovascular risk factors in health professionals: 20-year follow-up.

BACKGROUND: The knowledge of the presence and evolution of cardiovascular risk factors in young people may significantly contribute to actions to modify the natural history of these risks and prevent the onset of cardiovascular disease. OBJECTIVES: To assess the presence and evolution of cardiovascular risk factors in health professionals over a 20-year period. METHODS: A group of individuals was evaluated when they first started graduate programs in medicine, nursing, nutrition, dentistry, and pharmacy, and 20 years later. Data obtained in the two phases were compared. Questionnaires about hypertension, diabetes, hypercholesterolemia, family history of early-onset cardiovascular disease, smoking, alcohol consumption, and sedentary lifestyle were administered. Cholesterol, blood glucose, blood pressure, weight, height, and body mass index (BMI) were measured. RESULTS: Of the 281 individuals (62.9 % women; mean age 19.7 years) initially analyzed, 215 (59.07 % women; mean age 39.8 years) were analyzed 20 years later. An increase in mean values of systolic (111.6 vs 118.7 mmHg- p < 0.001) and diastolic blood pressure (71 vs 77.1 mmHg - p < 0.001), cholesterol (150.1 vs 182.4 mg/dL - p < 0.001), blood glucose (74.3 vs 81.4 mg/dL - p < 0.001) and BMI (20.7 vs 23.7 kg/m(2) - p = 0.017) was observed. Despite the decrease of sedentarism (50.2 vs 38.1 % - p = 0.015), the prevalence of hypertension (4.6 vs 18.6 % - p < 0.001), excessive weight (8.2 vs 32.1 % - p < 0.001), hypercholesterolemia (7.8 vs 24.2 % - p < 0.001), and alcohol consumption (32.7 vs 34.9 % - p = 0.037) increased. There was no change in the prevalence of smoking. CONCLUSION: Health professionals presented an increase in systolic and diastolic blood pressure, blood glucose, body mass index, and cholesterol over the 20-year study period. Regarding the prevalence of cardiovascular risk factors, increased blood pressure, overweight, hypercholesterolemia and alcohol consumption, and a decrease in sedentary lifestyle were observed.

Acute effects of high-intensity resistance training on central blood pressure parameters of elderly hypertensive women: a crossover clinical trial.

OBJECTIVE: Assess the acute effects of a high-intensity resistance training session on central blood pressure (CBP) parameters of elderly hypertensive women. METHODS: Forty physically active hypertensive women were included in resistance training and control protocols. Resistance training exercises were bench press, leg press and lat pull-down. The resistance training protocol consisted of three sets of 10 repetitions to volitional failure with 90 s of rest between sets. No exercise was performed in the control protocol. CBP parameters were measured in four moments: before (PRE), immediately after (T0), 30 min (T30) and 60 min (T60) following both protocols. RESULTS: Resistance training significantly increased central SBP (cSBP) 107.4 ±â€Š16.3 vs. 117.5 ±â€Š16.7), augmentation index ((24.9 ±â€Š12.7 vs. 33.1 ±â€Š12.0), pulse wave velocity (PWV 9.7 ±â€Š1.0 vs. 10.3 ±â€Š1.1), peripheral pulse pressure (pPP 48.5 ±â€Š11.7 vs. 58.9 ±â€Š13.1), central pulse pressure (cPP 38.3 ±â€Š11.6 vs. 46.5 ±â€Š13.1) and amplified pulse pressure (ampPP 10.2 ±â€Š4.2 vs. 12.4 ±â€Š5.6) immediately after exercises. The comparison between groups showed higher values of cSBP (117.5 ±â€Š16.7 vs. 106.3 ±â€Š14.6), augmentation index (20.9 ±â€Š11.0 vs. 33.1 ±â€Š12.0), pPP (46.6 ±â€Š11.0 vs. 58.9 ±â€Š13.1) and cPP (36 ±â€Š10.2 vs. 46.5 ±â€Š13.1) at T0. After 30 min, all variables returned to the baseline values. CONCLUSION: High-intensity resistance training session increased CBP parameters immediately after exercises, but those changes were not sustained after 30 min.

Comparison between the Effects of Hymalaian Salt and Common Salt Intake on Urinary Sodium and Blood Pressure in Hypertensive Individuals. / Comparação entre os Efeitos da Ingestão de Sal do Himalaia e de Sal Comum sobre os Valores de Sódio Urinário e Pressão Arterial em Indivíduos Hipertensos.

BACKGROUND: The Himalayan salt (HS) has become a popular alternative for the traditional table salt (TS) due to its health benefit claims, particularly for individuals with arterial hypertension. However, despite the increase in HS consumption, there is still a lack of clinical evidence to support a recommendation for its consumption by health professionals. OBJECTIVE: This cross-over study aimed to compare the impact of HS and TS intake on systolic blood pressure (SBP) and diastolic blood pressure (DBP), and urinary sodium concentration in individuals with arterial hypertension. METHODS: This study recruited 17 female patients with arterial hypertension who ate out no more than once a week. Participants were randomized into two groups, to receive and consume either HS or TS. Before and after each intervention, participants had their blood pressure measured and urine collected for mineral analysis. A p-value < 0.05 was considered statistically significant. RESULTS: There were no statistically significant differences before and after the HS intervention for DBP (70mmHg vs. 68.5mmHg; p=0.977), SBP (118.5 mmHg vs. 117.5 mmHg; p= 0.932) and sodium urinary concentration (151 mEq/24h vs. 159 mEq/24; p=0.875). Moreover, the between-group analysis showed no significant differences after the intervention regarding SBP (117mmHg vs 119 mmHg; p=0.908), DBP (68.5 mmHg vs. 71mmHg; p= 0,645) or sodium urinary concentration (159 mEq/24h vs. 155 mEq/24h; p=0.734). CONCLUSION: This study suggests that there are no significant differences on the impact of HS consumption compared to TS on blood pressure and sodium urinary concentration in individuals with arterial hypertension.

FUNDAMENTO: O sal do Himalaia (SH) tornou-se uma alternativa popular para o sal de mesa (SM) devido às suas alegações de benefícios à saúde, principalmente para indivíduos com hipertensão arterial. Porém, apesar do aumento do consumo de SH, ainda faltam evidências clínicas que sustentem a recomendação de seu consumo por profissionais de saúde. OBJETIVO: Este estudo teve como objetivo comparar o impacto da ingestão de SH e SM sobre a pressão arterial sistólica (PAS), pressão arterial diastólica (PAD) e concentração de sódio urinário em indivíduos com PA. MÉTODOS: Este estudo recrutou 17 pacientes do sexo feminino com hipertensão arterial que comiam fora de casa no máximo uma vez por semana. Os participantes foram divididos aleatoriamente em dois grupos, para receber e consumir SH ou SM. Antes e depois de cada intervenção, os participantes tiveram sua pressão arterial medida e urina coletada para análise mineral. Um valor de p <0,05 foi considerado estatisticamente significativo. RESULTADOS: Não houve diferenças estatisticamente significativas antes e depois da intervenção SH para PAD (70 mmHg vs. 68,5 mmHg; p = 0,977), PAS (118,5 mmHg vs. 117,5 mmHg; p = 0,932) e concentração urinária de sódio (151 mEq / 24h vs. 159 mEq / 24; p = 0,875). Além disso, a análise entre os grupos não mostrou diferenças significativas após a intervenção em relação a PAS (117 mmHg vs 119 mmHg; p = 0,908), PAD (68,5 mmHg vs 71 mmHg; p = 0,645) ou concentração urinária de sódio (159 mEq / 24h vs 155 mEq / 24h; p = 0,734). CONCLUSÃO: Este estudo sugere que não há diferenças significativas no impacto do consumo de SH em relação ao SM na PA e concentração urinária de sódio em indivíduos com hipertensão arterial.

Antihypertensive effect of Equisetum arvense L.: a double-blind, randomized efficacy and safety clinical trial.

BACKGROUND: Equisetum arvense L. (EA) is a traditional phytomedicine used as a diuretic agent worldwide and regulated strictly by European Medicine Agency (EMA) and Brazilian National Health Surveillance Agency (ANVISA). However, few studies evaluating its efficacy and safety have been published and no clinical trial assessing its antihypertensive effect has been reported to date. PURPOSE: To assess antihypertensive effect, safety and tolerability of EA compared to hydrochlorothiazide (HCTZ). METHODS: This is a double-blind randomized clinical trial, allocating 58 systemic arterial hypertension (SAH) stage I patients (both sexes, 25-65 years old) into two groups (EA and HCTZ). All patients underwent biochemical and cardiologic checkup prior to and during interventions. The EA standardized dry extract (900 mg/day) or HCTZ (25 mg/day) were administered for 3 months and follow-up visits were conducted every 30 days. Efficacy established goals were systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) decreases ≥ 10.0 mmHg and/or casual blood pressure (CBP) < 140/90 mmHg. RESULTS: EA treatment demonstrated a significant antihypertensive effect, promoting a mean decrease of SBP and DBP by 12.6 and 8.1 mmHg, respectively, and resulting a CBP mean of 134.0/84.5 mmHg at the end of intervention on the SAH stage I patients (CBP mean of 148.5/95.7 mmHg). There were no significant statistical differences between EA and HCTZ interventions on blood pressure decrease, and before-after treatments regarding to biochemical tests and signs of acute toxicity, renal, hepatic and hematologic alterations. A slight trend but no significant difference were observed between adverse events from EA (3.58%) and HCTZ (4.68%) groups. CONCLUSION: EA standardized dry extract was successfully applied to the SAH stage I patient treatment, decreasing effectively SBP ad DBP values to the reference normal ranges, and demonstrating a well-tolerability profile similar to HCTZ intervention.

Echocardiographic and Electrocardiographic Abnormalities Among Elderly Adults With Cardiovascular Disease in Rural South Africa.

BACKGROUND: Sub-Saharan Africa is undergoing an epidemiological transition fueled by the interaction between infectious and cardiovascular diseases. Our cross-sectional study aimed to characterize the spectrum of abnormalities suggesting end-organ damage on ECG and transthoracic echocardiograms (TTE) among older adults with cardiovascular diseases in rural South Africa. METHODS: The prevalence of ECG and TTE abnormalities was estimated; χ2 analyses and multivariable logistic regressions were performed to test their association with sex, hypertension, and other selected comorbidities. RESULTS: Overall, 729 ECGs and 155 TTEs were completed, with 74 participants completing both. ECG evaluation showed high rates of left ventricular hypertrophy (LVH, 36.5%) and T wave abnormalities (13.6%). TTE evaluation showed high rates of concentric LVH (31.6%), with moderate-severe (56.8%) diastolic dysfunction. Participants with hypertension showed more cardiac remodeling on ECG by LVH (45.4% versus 22.1%, P<0.01), and TTE by concentric LVH (42.5% versus 8.2%, P<0.01) and increased left ventricular mass (58.5% versus 20.4%, P<0.0001). In multivariable logistic regression, systolic blood pressure remained significantly associated with LVH on ECG (adjusted odds ratio, 1.03 per mm Hg [95% CI, 1.03-1.04], P<0.0001) and increased left ventricular mass on TTE (adjusted odds ratio, 1.04 per mm Hg [95% CI, 1.01-1.06], P=0.001). Male participants (n=326, 40.2%) were more likely than females (n=484, 59.8%) to show ECG abnormalities like LVH (45% versus 30.8%, P<0.01), whereas females were more likely to show TTE abnormalities like concentric LVH (40.8% versus 13.5%, P<0.01) and increased left ventricular mass (58.4% versus 23.1%, P<0.0001). Similar results were confirmed in multivariable models. CONCLUSIONS: Our findings suggest that cardiovascular diseases are widespread in rural South Africa, with a larger burden of hypertensive heart disease than previously appreciated, and define the severity of end-organ damage that is already underway. Local health systems must adapt to face the growing burden of hypertension, as suboptimal rates of hypertension diagnosis and treatment may dramatically increase the heart failure burden.

Blood Pressure Control and Associated Factors in a Real-World Team-Based Care Center. / Controle da Pressão Arterial e Fatores Associados em um Serviço Multidisciplinar de Tratamento da Hipertensão.

BACKGROUND: Although team-based care is recommended for patients with hypertension, results of this intervention in a real-world setting are missing in the literature. OBJECTIVE: To report the results of a real-world long-term team-based care for hypertensive patients we conducted this study. METHODS: Data of hypertensive patients attending a multidisciplinary treatment center located in the Midwest region of Brazil in June 2017 with at least two follow-up visits were retrospectively assessed. Anthropometric, blood pressure (BP), follow-up time, pharmacological treatment, diabetes and lifestyle data were collected from the last visit to the service. BP values < 140 x 90 mmHg in non-diabetics and < 130 x 80 mmHg in diabetics were considered controlled. A logistic regression model was built to identify variables independently associated to BP control. Significance level adopted p < 0.05. RESULTS: A total of 1,548 patients were included, with a mean follow-up time of 7.6 ± 7.1 years. Most patients were female (73.6%; n=1,139) with a mean age of 61.8 ±12.8 years. BP control rates in all the sample, and in non-diabetics and diabetics were 68%, 79%, and 37.9%, respectively. Diabetes was inversely associated with BP control (OR 0.16; 95%CI 0.12-0.20; p<0.001) while age ≥ 60 years (OR 1.48; 95%CI 1.15-1.91; p=0.003) and female sex (OR 1.38; 95%CI 1.05-1.82; p=0.020) were directly associated. CONCLUSIONS: A BP control rate around 70% was found in patients attending a multidisciplinary team care center for hypertension. Focus on patients with diabetes, younger than 60 years and males should be given to further improve these results. (Arq Bras Cardiol. 2020; 115(2):174-181).

FUNDAMENTO: Apesar de se recomendar a intervenção em equipe no tratamento da hipertensão, resultados dessa abordagem em ambientes do mundo real são escassos na literatura. OBJETIVOS: Apresentar os resultados de uma estratégia terapêutica baseada em equipe, de longo prazo, de pacientes hipertensos em um serviço de saúde. MÉTODOS: Dados de pacientes hipertensos acompanhados em um centro de tratamento multidisciplinar localizado na região centro-oeste do Brasil em junho de 2017 com pelo menos duas visitas de acompanhamento foram avaliados retrospectivamente. Dados antropométricos, pressão arterial (PA), tempo de acompanhamento, tratamento farmacológico, diabetes, estilo de vida foram coletados da última consulta. Valores de PA < 140 x 90 mmHg em não diabéticos e < 130 x 80 mmHg em diabéticos foram considerados PA controlada. Um modelo de regressão logística foi construído para identificar variáveis independentemente associadas com o controle da PA. O nível de significância adotado foi de p<0.05. RESULTADOS: Foram incluídos 1548 pacientes, com média de acompanhamento de 7,6 ± 7,1 anos. A maioria dos pacientes eram mulheres (73,6%; n=1139), com idade média de 61,8 anos. As taxas de controle da PA na amostra total, em não diabéticos e nos diabéticos foram 68%, 79%, e 37,9%, respectivamente. Diabetes associou-se inversamente com controle da PA (OR 0,16; IC95% 0,12-0,20; p<0,001), enquanto idade ≥ 60 anos (OR 1,48; IC95% 1,15-1,91; p=0,003) e sexo feminino (OR 1,38; IC95% 1,05-1,82; p=0,020) apresentaram associação direta. CONCLUSÕES: Uma taxa de controle de cerca de 70% foi encontrada em pacientes atendidos em um serviço multidisciplinar de tratamento da hipertensão. A fim de melhorar esses resultados, atenção deve ser dada a pacientes diabéticos, com idade menor que 60 anos e do sexo masculino. (Arq Bras Cardiol. 2020; 115(2):174-181).

Physical inactivity during leisure and school time is associated with the presence of common mental disorders in adolescence.

OBJECTIVE: To investigate the association of physical inactivity in leisure and school time with common mental disorders during adolescence. METHODS: The sample consisted of 73,399 adolescents (12-17 years old), participants in the Estudo de Riscos Cardiovasculares em Adolescentes (Erica - Study of Cardiovascular Risks in Adolescents). This cross-sectional, national and school-based study was conducted in 2013 and 2014 in Brazilian municipalities with more than 100,000 inhabitants. Leisure time physical activity was categorized according to weekly practice volume, and adolescents were classified as active (≥ 300 minutes/week), inactive (0 minute/week) and insufficiently active (1-299 minutes/week). Sports practice and participation in physical education classes at school were also analyzed. The presence of common mental disorders was assessed based on the general health questionnaire, with a cutoff point greater than or equal to 3. Odds ratios (OR) were estimated using multiple logistic regression. RESULTS: The chance of common mental disorders was 16% higher in the group that reported being inactive (0 minute/week) at leisure time (OR = 1.16; 95%CI 1.06 (1.27). The prevalence of common mental disorders was higher among young people who did not practice sports (37.2% vs. 25.9%; OR = 1.14; 95%CI 1.04-1.25) and did not participate in physical education classes at school (39.5% vs. 29.6%; OR = 1.25; 95%CI 1.15-1.36). Insufficient physical activity (1-299 minutes/week) did not increase the OR of common mental disorders. Practicing physical activity during leisure time, regardless of duration and weekly frequency, reduced the chances of common mental disorders in this population by 26%. CONCLUSIONS: Physical inactivity during leisure and school time is associated with the presence of common mental disorders in adolescence. The results suggest that sports practice, school physical education and physical activity during leisure time, even without reaching the current recommendation, are related to the mental health of young people.

Blood pressure reference values for Brazilian adolescents: data from the Study of Cardiovascular Risk in Adolescents (ERICA Study).

OBJECTIVE: Blood pressure (BP) references for Brazilian adolescents are lacking in the literature. This study aims to investigate the normal range of office BP in a healthy, non-overweight Brazilian population of adolescents. METHOD: The Brazilian Study of Cardiovascular Risks in Adolescents (Portuguese acronym "ERICA") is a national school-based study that included adolescents (aged 12 through 17 years), enrolled in public and private schools, in cities with over 100,000 inhabitants, from all five Brazilian macro-regions. Adolescents' height and body mass index (BMI) were classified in percentiles according to age and gender, and reference curves from the World Health Organization were adopted. Three consecutive office BP measurements were taken with a validated oscillometric device using the appropriate cuff size. The mean values of the last two readings were used for analysis. Polynomial regression models relating BP, age, and height were applied. RESULTS: Among 73,999 adolescents, non-overweight individuals represented 74.5% (95% CI: 73.3-75.6) of the total, with similar distribution across ages. The majority of the non-overweight sample was from public schools 84.2% (95% CI: 79.9-87.7) and sedentary 54.8% (95% CI: 53.7-55.8). Adolescents reporting their skin color as brown (48.8% [95% CI: 47.4-50.1]) or white (37.8% [95% CI: 36.1-39.5]) were most frequently represented. BP increased by both age and height percentile. Systolic BP growth patterns were more marked in males when compared to females, along all height percentiles. The same pattern was not observed for diastolic BP. CONCLUSIONS: Blood pressure references by sex, age, and height percentiles for Brazilian adolescents are provided.

Smoking, alcohol consumption and mental health: Data from the Brazilian study of Cardiovascular Risks in Adolescents (ERICA).

INTRODUCTION: Previous researches have indicated a strong association of alcohol and tobacco use with psychiatric disorders, but the relationship with depression and anxiety symptoms is still uncertain. We investigated the association of psychological distress and alcohol consumption, tobacco use and exposure to secondhand smoke (SHS) among adolescents in a developing country. METHODS: The authors evaluated 73,399 individuals (12-17 years) who participated in the Cardiovascular Risks Study in Adolescents (ERICA), a cross-sectional, national and school-based study, carried out in 124 Brazilian municipalities. The variables considered were alcoholic beverages (experimentation, consumption in the previous month and frequency of use) and smoking (experimentation, current smoking habits, frequent smoking and SHS exposure). Psychological distress was defined as a score ≥ 3 points in GHQ-12. Analyses included multiple logistic regression modeling. RESULTS: The frequency of individuals with psychological distress was higher in the group who smoked for at least 7 consecutive days (53.3% vs 31.2%; OR: 2.17; 95%CI: 1.65-2.86), were exposed to SHS indoors (37.8% vs 29.8%; OR:1.30; 95%CI: 1.14-1.48), and outdoors (37.7% vs 26.6%; OR: 1.49; 95%CI: 1.28-1.74), and among young people who consumed at least 1 drink of alcohol in the previous 30 days (42.4% vs 28.6%; OR: 1.70; 95%CI: 1.46-1.97), when compared to adolescents not exposed. CONCLUSIONS: Smoking (passively and actively) and the consumption of alcoholic beverages are associated to psychological distress in the adolescent population. Avoiding smoking and the use of alcohol may have beneficial effects on the mental health. Our data reinforce the urgent necessity to prevent effectively underage access to legal drugs in Brazil.

Hormonal assessment of participants in a long distance walk.

BACKGROUND: Exercise can disrupt homeostasis and trigger many adaptive responses in different hormonal axes. The study of hormonal interactions with physical activity is highly complex due to the number of variables, such as exercise duration, exercise intensity, individual level of training, circadian rhythm, nutritional status, and environmental conditions. METHODS: This study was performed to assess daily variations of thyroid hormones, cortisol, testosterone, insulin and glucose during moderate to high intensity aerobic physical activity for 5 consecutive days. Sample collection was performed at baseline in the morning and in the evening, immediately after finishing the activity, on the 4 initial days of the activity. Statistical analysis was performed using software STATA V14. Continuous variables are presented as means and standard deviations, while categorical variables are presented as absolute and percentage values. We used Shapiro-Wilk, Wilcoxon Sign, Mann-Whitney and Student's T test, according the needs. RESULTS: The adrenocorticotropic axis showed an initial increase in the evening cortisol level compared to the baseline level in the morning (17.46 µg/dL and 15.97 µg/dL, respectively) and then exhibited a significant reduction between the 1st and 4th day of activity (17.46 µg/dL and 8.39 µg/dL, respectively; P = 0.001). The same pattern was observed for free thyroxine (T4) between the 1st and 4th day (1.31 and 1.14, respectively; P < 0.001). CONCLUSIONS: Moderate to intense long duration physical activity resulted in little variation in the hormones assessed, with a trend toward reduced levels of cortisol and free T4. These findings highlight an adaptive hormonal mechanism in response to stress that is repeated daily, as shown by cortisol and thyroid function in our study.

Cardiovascular Disease Profile of the Oldest Adults in Rural South Africa: Data from the HAALSI Study (Health and Aging in Africa: Longitudinal Studies of INDEPTH Communities).

OBJECTIVES: To characterize the cardiovascular disease (CVD) profile of individuals aged 80 and older in rural South Africa. DESIGN: First wave of population-based longitudinal cohort. SETTING: Agincourt subdistrict (Mpumalanga Province) in rural South Africa. PARTICIPANTS: Adults residents (N = 5,059). MEASUREMENTS: In-person interviews were conducted to obtain social, behavioral, economic, and clinical data. Prevalence of hypertension, diabetes, dyslipidemia, high waist-to-hip ratio, overweight and obesity, high-risk high-sensitivity C-reactive protein, smoking, stroke, myocardial infarction, angina pectoris, and heart failure in individuals younger than 65, aged 65 to 79, and aged 80 and older were compared. Associations between self-reported treatments and determinants of hypertension treatment in those aged 80 and older were assessed using multivariable regression. RESULTS: Of 5,059 individuals included, 549 (10.8%) were aged 80 and older, and their CVD prevalence was 17.9% (stroke 3.8%, myocardial infarction 0.5%, angina pectoris 13.5%, heart failure 0.7%). Hypertension prevalence in this group was 73.8%, and along with angina pectoris, it increased with age (p<.001), whereas overweight and obesity (46.4%), dyslipidemia (39.1%), and smoking prevalences (3.1%) decreased (p<.001). Hypertension treatment was significantly associated with being aged 80 and older (odds ratio (OR)=1.48; 95% confidence interval (CI)=1.14-1.92, p=.003). Male sex (OR=0.73, 95% CI=0.66-0.88, p=.001), being an immigrant (OR=0.80, 95% CI=0.65-0.98; p=.03), higher socioeconomic status (OR=1.28, 95% CI=1.06-1.53, p=.009), and higher depression score (OR=1.12, 95% CI=1.05-1.19, p<.001) were associated with hypertension treatment in those aged 80 and older. CONCLUSION: This is the first study to characterize the CVD profile of individuals aged 80 and older in sub-Saharan Africa and provides baseline data for comparison with future studies in this rapidly growing age group. J Am Geriatr Soc 66:2151-2157, 2018.

Birth weight and its association with blood pressure and nutritional status in adolescents.

OBJECTIVE: The management of children with low birth weight is not the same in countries with different resources. The authors assessed the association of birth weight with blood pressure and nutritional status in a representative sample of adolescents from a Brazilian state, aiming to identify possible consequences of these differences. METHODS: A cross-sectional school-based study was conducted with adolescents (12-18 years) enrolled in public and private schools. Birth weight, office blood pressure, home blood pressure measurements, and nutritional status (body mass index, height z-score for the age, and waist circumference) were assessed. The association of birth weight with the outcomes (blood pressure, height, body mass index, and waist circumference) was studied through univariate and multivariable linear regression models. RESULTS: A total of 829 adolescents with a mean age of 14.6±1.62 years were included; 43.3% were male, and 37.0% from private schools. The prevalence of low birth weight was 8.7%. Mild low height prevalence was higher among those adolescents with low/insufficient birth weight when compared to those with normal/high birth weight (11.7 vs. 4.2%; p<0.001). In the multiple linear regression analysis, for each increase of 100g in birth weight, height increased by 0.28cm (95% CI: 0.18-0.37; p<0.01). Birth weight did not influence office blood pressure and home blood pressure, body mass index, or waist circumference of adolescents. CONCLUSIONS: Birth weight was directly associated to height, but not associated to blood pressure, body mass index, and waist circumference in adolescents from an urban area of a developing country.