Process, pitfalls and profits: lessons from interviewing New Zealand policy-makers.

Little has been written about interviewing policy-makers in health promotion and public health research. This article explores the process, pitfalls and profits of semi-structured interviews with policy-makers in 10 research projects conducted in New Zealand. Key members of each research team were surveyed about their research and findings verified against research publications. Key aspects of the process of policy-maker interviews include gaining ethical approval, navigating gatekeepers, using personal contacts and multiple research dissemination methods. Pitfalls of interviewing policy-makers include interviewers not having enough knowledge of the topic so efforts were made to use knowledgeable researchers or up-skill others. Interviews provide access to specialist knowledge of the policy process which cannot be obtained by other methods. While this study was conducted in one jurisdiction, it has implications for other countries. Effective policy-maker interviews in health promotion policy research could contribute to improvements in the quality of data collected and uptake of research by policy-makers.

A difference in larval mosquito size allows a biocontrol agent to target the invasive species.

As the global temperature rises in the coming decades, Aedes albopictus is expected to invade and establish in South East England, where Culex pipiens is currently the most common native mosquito species. Biocontrol measures that use local cyclopoid copepods against Ae. albopictus may be compromised if the copepods prefer alternate Cx. pipiens prey. In this study, I assessed the predation efficiency of Megacyclops viridis copepods against Ae. albopictus larvae from France and larvae that hatched from egg rafts of Cx. pipiens collected in South East England. The experiments were conducted at 15 and 25°C, which are representative of present and future summer temperatures in South East England. Ae. albopictus larvae that survived the course of the experiment in the predator-absent controls were significantly smaller than Cx. pipiens larvae that survived in the absence of predation. The background mortality of Cx. pipiens larvae increased with the 10-degree increase in temperature, and the smaller size of surviving Cx. pipiens larvae at 25°C, relative to survivors at 15°C, suggests that larger Cx. pipiens larvae were more likely to die at the higher temperature setting. Across all experimental treatments, the ratio of copepod body length to mean prey length, based on larval lengths of survivors from the corresponding predator-absent controls, was a significant predictor of the copepod's predation efficiency. Adding temperature setting to the predation efficiency model as a predictor did not improve model fit. Within the mixed prey treatments, the predation efficiency of M. viridis was 34.5 percentage points higher against Ae. albopictus prey than against Cx. pipiens prey. The higher predation efficiency that M. viridis exhibited against invasive Ae. albopictus prey, likely due to the smaller size of these larvae, supports the future use of M. viridis as a biocontrol agent in the United Kingdom.

Qualitative exploration of public and smoker understanding of, and reactions to, an endgame solution to the tobacco epidemic.

BACKGROUND: There is increasing interest in ending the tobacco epidemic and in applying 'endgame' solutions to achieve that goal at national levels. We explored the understanding of, and reactions to, a tobacco-free vision and an endgame approach to tobacco control among New Zealand smokers and non-smokers. METHODS: We recruited participants in four focus groups held in June 2009: Maori (indigenous people) smokers (n=7); non-Maori smokers (n=6); Maori non-smokers (n=7); and non-Maori non-smokers (n=4). Participants were from the city of Whanganui, New Zealand. We introduced to them the vision of a tobacco-free New Zealand and the concept of a semi-autonomous agency (Tobacco-Free Commission [TFC]) that would control the tobacco market as part of an endgame approach. RESULTS: There was mostly strong support for the tobacco-free New Zealand vision among all groups of participants. The reason most commonly given for supporting the vision was to protect children from tobacco. Most participants stated that they understood the TFC concept and reacted positively to it. Nevertheless, rather than focusing on organisational or structural arrangements, participants tended to focus on supporting the specific measures which a future TFC might facilitate such as plain packaging of tobacco products. Various concerns were also raised around the TFC, particularly around the feasibility of its establishment. CONCLUSIONS: We were able to successfully communicate a complex and novel supply-side focused tobacco control policy intervention to smokers and non-smokers. The findings add to the evidence from national surveys that there is public support, including from smokers, for achieving a tobacco-free vision and using regulatory and policy measures to achieve it. Support for such measures may be enhanced if they are clearly communicated and explained with a rationale which stresses protecting children and future generations from tobacco smoking.

No Impact of Biocontrol Agent's Predation Cues on Development Time or Size of Surviving Aedes albopictus under Optimal Nutritional Availability.

Cyclopoid copepods have been applied successfully to limit populations of highly invasive Aedes albopictus mosquitoes that can transmit diseases of public health importance. However, there is concern that changes in certain mosquito traits, induced by exposure to copepod predation, might increase the risk of disease transmission. In this study, third instar Ae. albopictus larvae (focal individuals) were exposed to Megacyclops viridis predator cues associated with both the consumption of newly hatched mosquito larvae and attacks on focal individuals. The number of newly hatched larvae surrounding each focal larva was held constant to control for density effects on size, and the focal individual's day of pupation and wing length were recorded for each replicate. Exposing late instar Ae. albopictus to predation decreased their chances of surviving to adulthood, and three focal larvae that died in the predator treatment showed signs of melanisation, indicative of wounding. Among surviving focal Ae. albopictus, no significant difference in either pupation day or wing length was observed due to copepod predation. The absence of significant sublethal impacts from M. viridis copepod predation on surviving later stage larvae in this analysis supports the use of M. viridis as a biocontrol agent against Ae. albopictus.

Relative Influence of Land Use, Mosquito Abundance, and Bird Communities in Defining West Nile Virus Infection Rates in Culex Mosquito Populations.

Since its introduction to North America in 1999, the West Nile virus (WNV) has resulted in over 50,000 human cases and 2400 deaths. WNV transmission is maintained via mosquito vectors and avian reservoir hosts, yet mosquito and avian infections are not uniform across ecological landscapes. As a result, it remains unclear whether the ecological communities of the vectors or reservoir hosts are more predictive of zoonotic risk at the microhabitat level. We examined this question in central Iowa, representative of the midwestern United States, across a land use gradient consisting of suburban interfaces with natural and agricultural habitats. At eight sites, we captured mosquito abundance data using New Jersey light traps and monitored bird communities using visual and auditory point count surveys. We found that the mosquito minimum infection rate (MIR) was better predicted by metrics of the mosquito community than metrics of the bird community, where sites with higher proportions of Culex pipiens group mosquitoes during late summer (after late July) showed higher MIRs. Bird community metrics did not significantly influence mosquito MIRs across sites. Together, these data suggest that the microhabitat suitability of Culex vector species is of greater importance than avian community composition in driving WNV infection dynamics at the urban and agricultural interface.

Both consumptive and non-consumptive effects of predators impact mosquito populations and have implications for disease transmission.

Predator-prey interactions influence prey traits through both consumptive and non-consumptive effects, and variation in these traits can shape vector-borne disease dynamics. Meta-analysis methods were employed to generate predation effect sizes by different categories of predators and mosquito prey. This analysis showed that multiple families of aquatic predators are effective in consumptively reducing mosquito survival, and that the survival of Aedes, Anopheles, and Culex mosquitoes is negatively impacted by consumptive effects of predators. Mosquito larval size was found to play a more important role in explaining the heterogeneity of consumptive effects from predators than mosquito genus. Mosquito survival and body size were reduced by non-consumptive effects of predators, but development time was not significantly impacted. In addition, Culex vectors demonstrated predator avoidance behavior during oviposition. The results of this meta-analysis suggest that predators limit disease transmission by reducing both vector survival and vector size, and that associations between drought and human West Nile virus cases could be driven by the vector behavior of predator avoidance during oviposition. These findings are likely to be useful to infectious disease modelers who rely on vector traits as predictors of transmission.

Mosquitoes are often referred to as the deadliest animals on earth because some species spread malaria, West Nile virus or other dangerous diseases when they bite humans and other animals. Adult mosquitoes fly to streams, ponds and other freshwater environments to lay their eggs. When the eggs hatch, the young mosquitoes live in the water until they are ready to grow wings and transform into adults. In the water, the young mosquitoes are particularly vulnerable to being eaten by dragonfly larvae, fish and other predators. When adult females are choosing where to lay their eggs, they can use their sense of smell to detect these predators and attempt to avoid them. Along with eating the mosquitoes, the predators may also reduce mosquito populations in other ways. For example, predators can disrupt feeding among young mosquitoes, which may affect the time that it takes for them to grow into adults or the size of their bodies once they reach the adult stage. Although the impacts of different predators have been tested separately in multiple settings, the overall effects of predators on the ability of mosquitoes to spread diseases to humans remain unclear. To address this question, Russell, Herzog et al. used an approach called meta-analysis on data from previous studies. The analysis found that along with increasing the death rates of mosquitoes, the presence of predators also leads to a reduction in the body size of those mosquitoes that survive, causing them to have shorter lifespans and fewer offspring. Russell, Herzog et al. found that one type of mosquito known as Culex ­ which carries West Nile virus ­ avoided laying its eggs near predators. During droughts, increased predation in streams, ponds and other aquatic environments may lead adult female Culex mosquitoes to lay their eggs closer to residential areas with fewer predators. Russell, Herzog et al. propose that this may be one reason why outbreaks of West Nile virus in humans are more likely to occur during droughts. In the future, these findings may help researchers to predict outbreaks of West Nile virus, malaria and other diseases carried by mosquitoes more accurately. Furthermore, the work of Russell, Herzog et al. provides examples of mosquito predators that could be used as biocontrol agents to decrease numbers of mosquitoes in certain regions.

Identifying opportunities for chlamydia screening among American Indian women.

Medical record review was used to identify missed opportunities for chlamydia screening among 103 American Indian/Alaska Native women. Of these, 69% had received a pregnancy test and 74% had received a urine test in the previous 12 months. Chlamydia screening may increase if linked to the other routine clinical testing.

Daring to dream: reactions to tobacco endgame ideas among policy-makers, media and public health practitioners.

BACKGROUND: Tobacco control strategies have mainly targeted reducing demand. Supply-side focused measures, though less familiar, deserve consideration, particularly to achieve 'endgame' tobacco control aims (e.g. achieving close to zero smoking prevalence). We explored attitudes towards supply-side focused 'endgame' tobacco control approaches and how they can be best communicated with senior policymakers, journalists, and public health practitioners. METHODS: We identified five supply-side focused approaches which could potentially lead to the tobacco endgame: two structural models and three discrete actions. The structural models were: (i) a Nicotine Authority to coordinate tobacco control activities and regulate the nicotine/tobacco market for public health aims; and (ii) a Tobacco Supply Agency acting as a monopoly purchaser of tobacco products and controlling the tobacco supply for public health aims. The actions were: (a) allocating progressively reducing tobacco product import quotas (the 'sinking lid') until importation and commercial sale of tobacco products ceased; (b) making tobacco companies responsible for reducing smoking prevalence with stringent financial penalties if targets were missed; and (c) new laws to facilitate litigation against tobacco companies. These approaches were presented as means to achieve a tobacco free New Zealand by 2020 to 19 senior policymakers, journalists, and public health physicians in two focus groups and eight interviews, and their reactions sought. RESULTS: The tobacco-free vision was widely supported. Participants engaged fully with the proposed tobacco control approaches, which were viewed as interesting or even intriguing. Most supported increasing the focus on supply-side measures. Views differed greatly about the desirability, feasibility and likely effectiveness of each approach. Participants identified a range of potential barriers to implementation and challenges to successfully advocating and communicating these approaches. The current framing of tobacco as a risky but legal commodity was noted as an important potential barrier to implementing endgame approaches. CONCLUSIONS: Endgame tobacco control approaches were considered to be viable policy options. Further policy analysis, research and public discussion are needed to develop endgame approaches. A significant change in the public framing of tobacco may be a prerequisite for implementing endgame solutions.

An assessment of persistent organic pollutants in Scottish coastal and offshore marine environments.

Concentrations of persistent organic pollutants (POPs), including polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs) and polybrominated diphenyl ethers (PBDEs) were determined in sediment and biota (fish liver) from around Scotland. The concentrations were investigated using assessment criteria developed by OSPAR and ICES. Organic contaminant concentrations, PAHs, PCBs and PBDEs in sediment, and PCBs and PBDEs in fish liver, were significantly higher in the Clyde compared to all other sea areas. This is mainly due to historic industrial inputs. Highest PCB and PAH concentrations were found in the strata furthest up the Clyde estuary, with concentrations of POPs in these strata being at levels such that there is an unacceptable risk of chronic effects occurring in marine species. Furthermore, for PAHs in Clyde sediment there was a significant negative gradient going from north to south towards the open sea. PAH and PCB concentrations in sediment and biota in all other Scottish sea areas (except for PCBs in sediment from East Scotland) were unlikely to give rise to pollution effects, being below relevant assessment criteria. Although no assessment criteria are available for PBDEs, the concentrations observed in Scottish sediments were low with all congeners below the limit of detection (LoD; 0.03 µg kg(-1) dry weight) in 140 out of a total of 307 samples analysed. Where PBDEs were detected, the dominant congeners were BDE47 and BDE99. PBDEs were detected in fish livers, although concentrations were less than 150 µg kg(-1) lipid weight in all sea areas except the Clyde where concentrations ranged between 8.9 and 2202 µg kg(-1) lipid weight. Few trends were detected in contaminant concentrations in biota or sediment at any Scottish site with more than five years data. Downward trends were detected in PAHs in sediment from the Clyde, Irish Sea and Minches and Malin Sea and PCBs in fish liver from the Moray Firth. Rules were developed for the aggregation of the contaminant data across a sea area. An overall assessment for each sea area was then assigned, looking at the frequency of sites or strata within each sea area that were above or below the relevant assessment criteria. Overall the status of the various sea areas, with respect to the assessed POPs, can be considered to be acceptable in that they were below concentrations likely to result in chronic effects for all sea areas except the Clyde.

Microplastics in sea surface waters around Scotland.

This is the first regional, multi-annual assessment of floating microplastics in Scotland's seas. Sea surface samples were collected from 2014 to 2020, using a catamaran swimmer body/neuston net trawl and evaluated for the presence of microplastics. Microplastics were present in the surface waters of all Scottish Marine Regions (SMR) and Offshore Marine Regions (OMR) though almost 35% of sample sites contained no microplastics. Concentrations ranged from 0 to 91,128 microplastics km-2 sea surface. Potential hotspots were identified in the Clyde (0-77,168 microplastics km-2), Forth & Tay (0-83,729 microplastics km-2) and the Solway (607-91,128 microplastics km-2). Fragmented plastics accounted for almost 50% of the microplastics recovered and this may suggest that the microplastics in Scotland's seas are predominantly from the breakdown of larger items. Due to the variable geographic and temporal extents of the data it was not possible to carry out a trend assessment.

Nile Red staining for detecting microplastics in biota: Preliminary evidence.

Nile Red is a lipophilic, metachromatic and solvatochromic dye used as an alternative or complementary method to aid identification of microplastics in routine analysis of biological samples. It was rarely used in biota since organic residues after the digestion step can be co-stained with possible overestimation of microplastics. The limits of using Nile Red in biota were investigated in marine mussels experimentally contaminated with low-density polyethylene (LDPE) microplastics. Stained particles were detected through magnified images obtained by stitching together thirty photographs of the filter surface of each sample. LDPE particles appeared yellowish and fluorescent and could be confused with certain organic residues. The smaller the fragments, the greater the difficulty in recognizing them. In particular, it was difficult to recognize LDPE particles based on their fluorescence if <180 µm in size. Regardless of the size, fluorescence of the items aids the operator in LDPE particles identification also in biota.

Size, not temperature, drives cyclopoid copepod predation of invasive mosquito larvae.

During range expansion, invasive species can experience new thermal regimes. Differences between the thermal performance of local and invasive species can alter species interactions, including predator-prey interactions. The Asian tiger mosquito, Aedes albopictus, is a known vector of several viral diseases of public health importance. It has successfully invaded many regions across the globe and currently threatens to invade regions of the UK where conditions would support seasonal activity. We assessed the functional response and predation efficiency (percentage of prey consumed) of the cyclopoid copepods Macrocyclops albidus and Megacyclops viridis from South East England, UK against newly-hatched French Ae. albopictus larvae across a relevant temperature range (15, 20, and 25°C). Predator-absent controls were included in all experiments to account for background prey mortality. We found that both M. albidus and M. viridis display type II functional response curves, and that both would therefore be suitable biocontrol agents in the event of an Ae. albopictus invasion in the UK. No significant effect of temperature on the predation interaction was detected by either type of analysis. However, the predation efficiency analysis did show differences due to predator species. The results suggest that M. viridis would be a superior predator against invasive Ae. albopictus larvae due to the larger size of this copepod species, relative to M. albidus. Our work highlights the importance of size relationships in predicting interactions between invading prey and local predators.

Physical activity and incident diabetes in American Indians: the Strong Heart Study.

The authors examined the association between total physical activity (leisure-time plus occupational) and incident diabetes among 1,651 American Indians who participated in the Strong Heart Study, a longitudinal study of cardiovascular disease and its risk factors among 13 American Indian communities in 4 states (North Dakota, South Dakota, Oklahoma, and Arizona). Discrete Cox models were used to examine the association between physical activity level (in tertiles), compared with no physical activity, and incident diabetes, after adjustment for potential confounders. During 10 years of follow-up (f1989-1999), 454 incident cases of diabetes were identified. Compared with participants who reported no physical activity, those who reported any physical activity had a lower risk of diabetes: Odds ratios were 0.67 (95% confidence interval (CI): 0.46, 0.99), 0.67 (95% CI: 0.45, 0.99), and 0.67 (95% CI: 0.45, 0.99) for increasing tertile of physical activity, after adjustment for age, sex, study site, education, smoking, alcohol use, and family history of diabetes. Further adjustment for body mass index and other potential mediators attenuated the risk estimates. These data suggest that physical activity is associated with a lower risk of incident diabetes in American Indians. This study identifies physical activity as an important determinant of diabetes among American Indians and suggests the need for physical activity outreach programs that target inactive American Indians.

Smoker interest in lower harm alternatives to cigarettes: national survey data.

INTRODUCTION: The aim of this study was to examine knowledge and attitudes to lower harm alternatives to cigarettes among New Zealand (NZ) smokers. METHODS: The NZ arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) utilizes the NZ Health Survey (a national sample). From this sample, we surveyed adult smokers (N = 1,376). RESULTS: Knowledge about smokeless tobacco was poor, with only 16% regarding such products as less harmful than ordinary cigarettes. Only 7% considered such products to be "a lot less" harmful. When participants were asked to assume that these products were much less harmful than cigarettes, 34% of smokers stated that they would be interested in trying smokeless tobacco products, with another 11% saying "maybe" or "don't know." In the multivariate analysis, Maori smokers were significantly more interested in trying smokeless products than Europeans in all 3 models considered (e.g., Model 1: adjusted odds ratio [AOR] = 1.71, 95% CI = 1.23-2.37). There was also significantly increased interest for those concerned about the impact of smoking on health and quality of life in the future (AOR = 1.44, 95% CI = 1.17-1.78). But interest did not vary significantly by 2 measures of socioeconomic status and varied inconsistently by 2 measures of financial stress. DISCUSSION: The finding that one third of smokers said that they would be interested in trying smokeless products suggests that these products could have a role as part of a tobacco epidemic endgame that phases out smoked tobacco. Differences in interest level by ethnic group may be relevant to stimulating further work in this area (e.g., among those health workers concerned for smokers with the highest need to quit).

Halogenated persistent organic pollutants in Scottish deep water fish.

Halogenated persistent organic pollutants (chlorobiphenyls (CBs), polybrominated diphenyl ethers (PBDEs), hexabromocyclododecane (HBCD) and tetrabromobisphenol-A (TBBP-A)) and total lipid content were measured in the liver and muscle of three species of deep water fish (black scabbard, roundnose grenadier and black dogfish) collected from the Rockall Trough, to the west of Scotland, in 2006. CB concentrations (SigmaICES (International Council for the Exploration of the Seas)7 CBs) >500 microg kg(-1) lipid weight) were found in 9 of the 31 deep water fish liver samples. Non-ortho CBs were measured in samples with the highest ortho CB concentrations. Non-ortho CBs (CB81, 77, 126 and 169) were not detected in any of the fish muscle samples. In liver, CB81 was not detected in any of the samples while CB169 was detected in all but one sample. The total 'dioxin-like' CB concentration was calculated based on the 5 mono-ortho and 4 non-ortho CBs measured. The non-ortho CB concentration made a very small contribution to the total 'dioxin-like' CB concentrations (<1%). Concentrations for the individual ICES7 CBs in fish liver were above OSPAR Background Assessment Concentrations (BACs) in all three species, except for CB28 and 101 in black dogfish. Toxic Equivalent (TEQs) concentrations calculated for the five mono-ortho and four non-ortho CBs measured, and estimated TEQs calculated using published models in the fish muscle indicated that consumption of deep water fish muscle is unlikely to represent a risk to human health. However, dioxins and furans were not measured and the contribution to the calculated TEQs from these compounds was not taken into account. Calculated and estimated TEQs for some roundnose grenadier liver samples exceeded the 25 pg g(-1) wet weight limit for fish liver and, therefore, there may be a health risk if consumed. PBDEs were detected in both the liver and muscle of the deep water fish, whilst HBCD and TBBP-A were not detected in any of the deep water fish.

Per- and polyfluoroalkyl substances in two different populations of northern cardinals.

The northern cardinal (Cardinalis cardinalis) is a good indicator species for environmental contaminants because it does not migrate and its range covers a diversity of habitats, including metropolitan Atlanta, GA and the geographically isolated Hawaiian Islands. In addition, the cardinal is often found near people's homes, making it likely to be exposed to the same outdoor elements, including soil, groundwater, and air, that surrounding humans experience. In this study, blood serum concentrations of 12 per- and polyfluoroalkyl substances (PFASs) were measured in 40 cardinals from Atlanta and 17 cardinals from the Big Island (Hawaii), HI. We observed significantly higher median concentrations of four PFASs and significantly higher detection frequencies of seven PFASs in the cardinals from Atlanta, relative to the PFAS median concentrations and detection frequencies observed in the cardinals from Hawaii (α = 0.05). Among the PFASs measured, perfluorooctane sulfonate (PFOS) was observed in the highest concentrations. A linear regression model controlling for sex, age, and airport distance did not explain PFOS variation within the Atlanta samples, but a similar model explained 90% of PFOS variation within the Hawaii samples. To our knowledge, these are the first measurements of PFASs in northern cardinals.

Cardiac and systemic hemodynamic characteristics of hypertension and prehypertension in adolescents and young adults: the Strong Heart Study.

BACKGROUND: The epidemic of overweight is increasing the prevalence of both prehypertension and early-onset hypertension, but few population-based data exist on their impact on cardiac structure and function in adolescents and young adults. METHODS AND RESULTS: We analyzed clinical characteristics, hemodynamic parameters, and left ventricular structure and function in 1940 participants, 14 to 39 years of age, in the Strong Heart Study. Hypertension occurred in 294 participants (15%), who were more often men (70% versus 30%), older (age, 31+/-7 versus 25+/-8 years), and more commonly diabetic (23% versus 4.5%; all P<0.001) than their normotensive counterparts. Prehypertension occurred in 675 (35%) of participants with similar trends in gender, age, and diabetes status. After adjustment for covariates, both hypertensive and prehypertensive participants had higher left ventricular wall thickness (0.83 and 0.78 versus 0.72 cm), left ventricular mass (182 and 161 versus 137 g), and relative wall thickness (0.30 and 0.29 versus 0.28 cm) and 3- and 2-fold-higher prevalences of left ventricular hypertrophy than their normotensive counterparts (all P<0.001). Hypertension and prehypertension also were associated with higher mean pulse pressure/stroke volume index (1.24 and 1.15 versus 1.02 mm Hg/mL x m2) and total peripheral resistance index (3027 and 2805 versus 2566 dynes x s x cm(-5) x m2; all P<0.001). CONCLUSIONS: In a population with high prevalences of obesity and diabetes, hypertension and prehypertension are associated with increases in both cardiac output and peripheral resistance index. Despite the young age of participants with hypertension and prehypertension, they had prognostically adverse preclinical cardiovascular disease, including left ventricular hypertrophy and evidence of increased arterial stiffness.

Metabolic syndrome and the development of CKD in American Indians: the Strong Heart Study.

BACKGROUND: Metabolic impairments that precede type 2 diabetes, such as metabolic syndrome, may contribute to the development of chronic kidney disease (CKD). This study documents the prevalence and incidence of CKD and the prospective association between metabolic syndrome and CKD in American Indians without diabetes in the Strong Heart Study. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: American Indians aged 45 to 74 years from 3 geographic regions were recruited by using tribal records and were assessed every 3 years from 1989 to 1999 as part of the Strong Heart Study. Participants with type 2 diabetes, on dialysis therapy, or who received a kidney transplant at baseline examination were excluded. PREDICTOR: Metabolic syndrome, defined using Adult Treatment Panel III criteria. OUTCOMES & MEASUREMENTS: CKD was measured by using estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (ACR) dichotomized at conventional cutoff values. The association between metabolic syndrome and incident CKD was evaluated by using multivariable Cox proportional hazards models and binomial regression, with statistical adjustment for confounders (age, sex, study center, education, and smoking). RESULTS: Metabolic syndrome was present in 896 (37.7%) and absent in 1,484 participants (62.3%) at baseline. The prevalence of ACR of 30 mg/g or greater at baseline examination was 12.1%, with 290 new cases and an incidence of 233/10,000 person-years. The prevalence of eGFR less than 60 mL/min/1.73 m(2) was 7.8%, with 189 new cases and an incidence of 138/10,000 person-years. The prevalence of CKD was 17.8%, with 388 new cases and an incidence of 342/10,000 person-years. The adjusted hazard ratio for CKD associated with metabolic syndrome was 1.3 (95% confidence interval [CI], 1.1 to 1.6). Equivalent hazard ratios for ACR greater than 30 mg/g and eGFR less than 60 mL/min/1.73 m(2) were 1.4 (95% CI, 1.0 to 1.9) and 1.3 (95% CI, 1.0 to 1.6), respectively. The relationship between metabolic syndrome and kidney outcomes was stronger in those who developed diabetes during follow-up. LIMITATIONS: Intraindividual variability in serum creatinine and ACR measures may have resulted in some misclassification of participants by outcome status. CONCLUSIONS: Metabolic syndrome is associated with an increased risk of developing CKD in American Indians without diabetes. The mechanism through which metabolic syndrome may cause CKD in this population likely is the development of diabetes.

Effect of lower targets for blood pressure and LDL cholesterol on atherosclerosis in diabetes: the SANDS randomized trial.

CONTEXT: Individuals with diabetes are at increased risk for cardiovascular disease (CVD), but more aggressive targets for risk factor control have not been tested. OBJECTIVE: To compare progression of subclinical atherosclerosis in adults with type 2 diabetes treated to reach aggressive targets of low-density lipoprotein cholesterol (LDL-C) of 70 mg/dL or lower and systolic blood pressure (SBP) of 115 mm Hg or lower vs standard targets of LDL-C of 100 mg/dL or lower and SBP of 130 mm Hg or lower. DESIGN, SETTING, AND PARTICIPANTS: A randomized, open-label, blinded-to-end point, 3-year trial from April 2003-July 2007 at 4 clinical centers in Oklahoma, Arizona, and South Dakota. Participants were 499 American Indian men and women aged 40 years or older with type 2 diabetes and no prior CVD events. INTERVENTIONS: Participants were randomized to aggressive (n=252) vs standard (n=247) treatment groups with stepped treatment algorithms defined for both. MAIN OUTCOME MEASURES: Primary end point was progression of atherosclerosis measured by common carotid artery intimal medial thickness (IMT). Secondary end points were other carotid and cardiac ultrasonographic measures and clinical events. RESULTS: Mean target LDL-C and SBP levels for both groups were reached and maintained. Mean (95% confidence interval) levels for LDL-C in the last 12 months were 72 (69-75) and 104 (101-106) mg/dL and SBP levels were 117 (115-118) and 129 (128-130) mm Hg in the aggressive vs standard groups, respectively. Compared with baseline, IMT regressed in the aggressive group and progressed in the standard group (-0.012 mm vs 0.038 mm; P < .001); carotid arterial cross-sectional area also regressed (-0.02 mm(2) vs 1.05 mm(2); P < .001); and there was greater decrease in left ventricular mass index (-2.4 g/m(2.7) vs -1.2 g/m(2.7); P = .03) in the aggressive group. Rates of adverse events (38.5% and 26.7%; P = .005) and serious adverse events (n = 4 vs 1; P = .18) related to blood pressure medications were higher in the aggressive group. Clinical CVD events (1.6/100 and 1.5/100 person-years; P = .87) did not differ significantly between groups. CONCLUSIONS: Reducing LDL-C and SBP to lower targets resulted in regression of carotid IMT and greater decrease in left ventricular mass in individuals with type 2 diabetes. Clinical events were lower than expected and did not differ significantly between groups. Further follow-up is needed to determine whether these improvements will result in lower long-term CVD event rates and costs and favorable risk-benefit outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00047424.