Project Joy: faith based cardiovascular health promotion for African American women.

OBJECTIVE: The authors tested the impact on cardiovascular risk profiles of African American women ages 40 years and older after one year of participation in one of three church-based nutrition and physical activity strategies: a standard behavioral group intervention, the standard intervention supplemented with spiritual strategies, or self-help strategies. METHODS: Women were screened at baseline and after one year of participation. The authors analyzed intention-to-treat within group and between groups using a generalized estimating equations adjustment for intra-church clustering. Because spiritual strategies were added to the standard intervention by participants themselves, the results from both active groups were similar and, thus, combined for comparisons with the self-help group. RESULTS: A total of 529 women from 16 churches enrolled. Intervention participants exhibited significant improvements in body weight (-1.1 lbs), waist circumference (-0.66 inches), systolic blood pressure (-1.6 mmHg), dietary energy (-117 kcal), dietary total fat (-8 g), and sodium intake (-145 mg). The self-help group did not. In the active intervention group, women in the top decile for weight loss at one year had even larger, clinically meaningful changes in risk outcomes (-19.8 lbs). CONCLUSIONS: Intervention participants achieved clinically important improvements in cardiovascular disease risk profiles one year after program initiation, which did not occur in the self-help group. Church-based interventions can significantly benefit the cardiovascular health of African American women.

Dietary Counseling for High Blood Cholesterol in Families at Risk of Coronary Disease.

A positive family history of coronary heart disease alone confers an increased risk, which may be affected by untreated hypercholesterolemia. Dietary counseling is a first-line treatment approach. To determine whether nurse counseling can provide additional benefits over usual physician efforts to lower dietary fat in high-risk persons, 117 apparently healthy adult siblings of persons with premature coronary heart disease were counseled by a registered nurse using adapted national guidelines. Reductions in total fat, saturated fat, and cholesterol were significantly greater in the nurse group compared to those in the usual care group. Total fat intake decreased by 14 g in the nurse group, compared with an increase of 5 g in the usual care group (p=0.0001). Assignment to the nurse group was also a significant predictor of a greater reduction in the percentage of total fat calories (p=0.008). The authors conclude that a registered nurse may serve as a complement to usual care in efforts to lower dietary fat and cholesterol in high-risk families. (c)2001 CHF, Inc.

Comparison of the effectiveness of a telephone 24-hour dietary recall method vs an in-person method among urban African-American women.

OBJECTIVE: To examine the comparative accuracy of telephone and in-person 24-hour dietary recall methods. SUBJECTS: One hundred eighty-five African-American females, aged 40 years and older, recruited from Sunday church services in Baltimore City, Md. METHODS: Participants were trained to estimate portion size with plastic food models and a 2-dimensional food recall booklet. Dietary intake was then assessed with 2 in-person 24-hour dietary recalls and 1 telephone 24-hour dietary recall, all using a computer-assisted, multiple pass approach. Results from the 2 in-person recalls were averaged and compared with the results from the telephone recall. STATISTICAL ANALYSES: Cross-tabulation, paired t test, Pearson's correlation, chance-corrected agreement, and stepwise linear regression analyses were performed. RESULTS: There were no significant differences between the telephone and in-person methods for any nutrient. Agreement between methods was moderate for all major dietary components, with corrected correlations between methods ranging from 0.26 to 0.97 (P<.001), and kappas ranging from 0.155 to 0.372 (P<.01). Levels of low-energy reporting were high (88% telephone, 91% in-person), though there were no significant differences between methods. CONCLUSIONS: The telephone 24-hour dietary recall method appears to be comparable to the standard in-person method among older African-American women. Portion-size training in person may make subsequent telephone dietary recalls acceptable in this population.

Higher prevalence of GPIIIa PlA2 polymorphism in siblings of patients with premature coronary heart disease.

BACKGROUND: The Pl(A2) polymorphism of GPIIIa has been associated with unstable coronary syndromes in some studies, but the association has remained debated. None of the previous studies have focused on families at high risk. Risk factors tend to cluster within kindreds with high prevalence of premature coronary heart disease (CHD). Therefore, a heightened prevalence of the Pl(A2) polymorphism among siblings of patients with CHD would support the hypothesis that Pl(A2) is linked, directly or indirectly, to CHD. OBJECTIVES: To measure the prevalence of the Pl(A2) polymorphism among siblings of patients with CHD before the age of 60 years and to seek an association between the Pl(A2) polymorphism and established atherosclerotic and thrombogenic risk factors. METHODS: From January 1994 to April 1996, we genotyped 116 asymptomatic siblings (60 Caucasians, 56 Afro-Caribbeans) of patients with CHD manifestations before the age of 60 years for the Pl(A) polymorphism (also called HPA-1). A control cohort was used for comparison, consisting of individuals that were matched for race and geographic area but were free of CHD (n = 268, 168 Caucasians and 100 Afro-Caribbeans). In addition, we have characterized the sibling cohort for other atherogenic and thrombogenic risk factors. RESULTS: The prevalence of Pl(A2)-positive individuals (Pl(A2)[+], Pl(A1/A2) heterozygotes plus Pl(A2/A2) homozygotes) in the sibling cohort was high: 41.4%. When analyzed separately, the prevalence of Pl(A2)(+) siblings was 53.3% among Caucasians and 28.6% among Afro-Caribbeans. There was no association between Pl(A2) and other established atherogenic or thrombogenic risk factors. Interestingly, the clustering of other risk factors was lesser among Pl(A2)(+) siblings than their Pl(A1) counterparts. CONCLUSIONS: This study supports the hypothesis that the prevalence of Pl(A2)(+) individuals is high in kindreds with premature CHD. Hence, like the established risk factors that tend to cluster in families with premature CHD and contribute strongly to the accelerated atherosclerotic process affecting these individuals, the Pl(A2) polymorphism of GPIIIa may represent an inherited risk that promotes the thromboembolic complications of CHD. That these asymptomatic Pl(A2)(+) siblings had overall less established risk factors than their Pl(A1) counterparts might represent an explanation for why they remained asymptomatic despite their Pl(A2) positivity.

Markedly high prevalence of coronary risk factors in apparently healthy African-American and white siblings of persons with premature coronary heart disease.

Among persons with a family history of premature coronary heart disease (CHD), siblings bear an excess risk of CHD that is as high as 12 times that of the general population. Aggressive, new, national guidelines for CHD risk reduction have focused on high-risk families, yet little is known about actual remediable risk factors in siblings of persons with premature CHD. To determine the magnitude of the problem relative to the general population, we screened 846 unaffected siblings (ages 30 to 59 years) of persons with documented CHD before age 60 years and compared their risk factor values with population reference norms obtained in the Third National Health and Nutrition Examination Survey (NHANES III) and the National Health Interview Survey (NHIS). Mean levels of low-density lipoprotein cholesterol were 0.52 mmol/L (20 mg/dl) higher in siblings; the prevalence of low-density lipoprotein cholesterol > or =4.14 mmol/L (160 mg/dl) was nearly twice that of race, sex, and age-specific values from NHANES III. Levels of high-density lipoprotein cholesterol <0.91 mmol/L (35 mg/dl) were similar between siblings and NHANES III (11% and 12%, respectively). Only 4% of all siblings had triglyceride levels > or =4.52 mmol/L (400 mg/dl). Hypertension prevalence was twice as high among siblings as among the NHANES III. Current smoking was 33.9% in white siblings and 25.5% in the NHIS, whereas smoking in African-Americans was similar to that in the NHIS (31.1% vs 29.2%). A mere 13% to 29% of siblings were without any major remediable risk factors. The overwhelming need for risk factor modification in this easily identifiable high-risk population supports aggressive national guidelines and demonstrates the lack of adequate treatment of apparently healthy siblings of persons with premature CHD.

Dietary fat patterns in urban African American women.

The purpose of this study was to describe the scope of fatty food preferences of urban African American women and to examine factors associated with the selection of high fat foods. A volunteer sample of urban African American women church-goers were invited for dietary and risk factor screening at health fairs held following Sunday services. A standardized instrument, the Fat Intake Scale (FIS), was administered primarily by dietitians to estimate dietary fat intake and usual food choices. A sum score of 25 or more is thought to be associated with higher fat and cholesterol intake. As a validation of the FIS, a 24-hour recall was administered to a subsample. Sociodemographics, smoking status and comorbidity were assessed by self-report. Body weight, height, and total blood serum cholesterol were assessed using standardized measurement techniques. In the 521 participating women, 61% were classified as obese based on national reference norms for body mass index (BMI). More than 81% had an FIS of 25 or greater. On multiple logistic regression analysis, significant predictors of a higher fat diet (FIS > or = 25) included age greater than 45 years, obesity, and the absence of comorbidity. These findings suggest that there are independent predictors of selection of a diet high in fat. This has implications for planning and targeting community-based nutrition interventions for African American women who exhibit among the highest rates of obesity in the U.S. and who suffer an excess burden of obesity-related diseases.

Nurse-mediated cholesterol management compared with enhanced primary care in siblings of individuals with premature coronary disease.

BACKGROUND: Siblings of individuals with premature coronary heart disease have a high prevalence of low-density lipoprotein cholesterol (LDL-C) levels requiring treatment. OBJECTIVE: To evaluate management strategies for high LDL-C levels in apparently healthy 30- to 59-year-old siblings of individuals with documented coronary heart disease prior to age 60 years. METHODS: In a 2-year trial of care provided by either a nurse trained in lipid management (NURS) or enhanced primary care (EPC), in which physicians received recommendations based on national guidelines, 156 siblings with LDL-C levels of 4.14 mmol/L (160 mg/dL) were randomized by family. The LDL-C goal levels below 3.36 mmol/L (130 mg/dL) were compared between and within intervention groups. Multiple logistic regression analyses were applied to predict 2-year achievement of the goal. RESULTS: The NURS group achieved a significantly greater percentage of goal LDL-C levels than the EPC group (26% vs 10%; P=.008). The NURS LDL-C levels decreased an average of 0.91 mmol/L (35 mg/dL) while EPC levels decreased by 0.52 mmol/L (24 mg/dL) (P=.09). In the final multivariate model, siblings taking lipid-lowering drug treatment were 6.02 times more likely (95% confidence interval, 2.24-16.18) than those not receiving pharmacotherapy to achieve LDL-C goals; nurse management (P=.09) was marginally significant. Pharmacotherapy was instituted in 45.2% of NURS and 16.7% of EPC siblings (P=.001). CONCLUSIONS: High LDL-C levels in siblings were more effectively treated by a trained nurse, probably related to greater adherence to the application of national guidelines. Nonetheless, the majority of siblings with high LDL-C levels did not meet goal levels 2 years after an index case coronary heart disease event.

Hypertension among siblings of persons with premature coronary heart disease.

To determine the extent to which the Fifth Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC-V) guidelines were implemented in high-risk families with premature coronary heart disease, we examined the prevalence of hypertension and associated coronary risk factors in asymptomatic siblings of persons with documented premature coronary disease (<60 years of age). A total of 859 apparently healthy siblings (51% male, 19% African American) were screened for coronary risk factors. Siblings were classified as normotensive or hypertensive (BP > or = 140/90 and/or current antihypertensive pharmacotherapy). The prevalence of hypertension, awareness, treatment, and control among siblings was compared with published national estimates from the third National Health and Nutrition Examination Survey. The prevalence of hypertension in siblings was 44%. Among all hypertensives, only 60% were aware of being hypertensive, 45% were being treated, and 16% were under control. A high prevalence of other coronary risk factors was found among hypertensive siblings: 72% were hypercholesterolemic; 61% were obese; 29% were current smokers; 82% were consuming >30% of calories from fat; and only 14% were participating in vigorous physical activity three or more times per week. Comparisons with the national reference population revealed siblings to have a significantly higher prevalence of hypertension, along with significantly lower levels of awareness, treatment, and control. These findings demonstrate the intersection of multiple risk factors among hypertensive siblings and emphasize the need for more aggressive screening and treatment in this easily identifiable high-risk population.

Lipoprotein(A) and coronary heart disease risk factors in a racially mixed population: the Johns Hopkins Sibling Study.

OBJECTIVES: To determine if heart disease risk factors differentially affect lipoprotein(a) concentration by race, we assessed the association of lipoprotein(a) with heart disease risk factors in healthy Caucasians and African Americans with family histories of premature heart disease. METHODS: Participants (403 Caucasian and 148 African American), all less than 60 years old and free of heart disease, were recruited through a brother or sister diagnosed with coronary heart disease before age 60. Risk factor information was elicited through an interview and medical examination. RESULTS: As expected, lipoprotein(a) was significantly higher among African Americans than among Caucasians. Mean lipoprotein(a) concentrations were positively associated with smoking status and age, and negatively associated with hypertension in African Americans. Smokers had lipoprotein(a) levels 38% higher than nonsmokers. Conversely, lipoprotein(a) concentrations were unrelated to heart disease risk factors among Caucasians. CONCLUSION: While this study confirms that lipoprotein(a) concentration is independent of CHD risk factors in Caucasians, lipoprotein(a) appears to be related to several CHD risk factors in African Americans at high risk for premature heart disease. Given the high levels of lipoprotein(a) in people of African descent and lipoprotein(a)'s link to cardiovascular diseases, more research is needed to understand the relationship of lipoprotein(a) to heart disease risk factors and the subsequent disease in African-American populations.

Prevalence of hypercholesterolemia among siblings of persons with premature coronary heart disease. Application of the Second Adult Treatment Panel guidelines.

BACKGROUND: Increased blood cholesterol, specifically high low-density lipoprotein cholesterol, increases risk for coronary heart disease (CHD). Persons with a positive family history of premature CHD also are at markedly increased risk. OBJECTIVE: To examine the prevalence of hypercholesterolemia based on the second report of the National Cholesterol Educational Program Adult Treatment Panel (ATP II) guidelines in the asymptomatic healthy siblings of people with premature CHD. METHODS: A total of 668 asymptomatic healthy siblings (354 men and 314 women) underwent screening for risk factors for CHD. Siblings were categorized into treatment categories for primary prevention defined by ATP II. The percentage who were candidates for intervention were compared with the published national estimates for those without CHD from the third National Health and Nutrition Examination Survey (NHANES III). RESULTS: Based on ATP II guidelines, 65% of the asymptomatic adult siblings required fasting lipoprotein analysis compared with 33% of adults without CHD in the national reference population. Of the siblings who met the criteria for fasting lipoprotein analysis, most (56%) were candidates for dietary therapy, more than twice the proportion of adults from NHANES III. The percentage of the siblings who qualified for drug intervention and dietary therapy was 3 times greater than the national sample, 33% vs 11%, respectively. Assuming a 10% hypothetical reduction in low-density lipoprotein cholesterol levels as the result of dietary modification, the proportion of the sibling sample who were possible candidates for drug therapy was 20%, still 4 times that predicted for the national sample. CONCLUSIONS: These results underscore the need for aggressive detection and treatment of hypercholesterolemia in this easily identifiable high-risk population of siblings of people with premature CHD.

Exercise thallium tomography predicts future clinically manifest coronary heart disease in a high-risk asymptomatic population.

BACKGROUND: Exercise testing, even when combined with radionuclide perfusion imaging, does not accurately predict future clinical coronary heart disease (CHD) in low-risk asymptomatic populations. We hypothesized that these tests would perform better in a higher-risk population with a high prevalence of occult CHD. Siblings of persons with premature CHD represent such a group in whom it would be advantageous to identify affected individuals before the occurrence of clinically manifest CHD. METHODS AND RESULTS: Exercise thallium scintigraphy was performed in 264 asymptomatic individuals less than 60 years of age who had a sibling with documented CHD before age 60. Despite an average age of only 46 years at the time of screening, 19 of 264 siblings developed clinical CHD (sudden death in 1, myocardial infarction in 10, coronary revascularization in 8) over a mean of 6.2 years (range, 1 to 9 years) of follow-up. Abnormal thallium scans were observed in 29% of men and 9% of women, while abnormal exercise ECGs occurred in 12% and 5% respectively. Of men >/= 45 years of age, 45% had an abnormal exercise ECG, thallium scan, or both. In contrast, only 3% of women < 45 years of age had an abnormal test result. Although abnormal exercise ECGs and thallium scans were both predictive of future clinical CHD, the thallium scan was associated with a higher relative risk. After adjustment for age, sex, and exercise ECG results, the relative risk of developing clinical CHD was 4.7 for an abnormal scan. Siblings with a concordant abnormal exercise ECG and thallium scan had a relative risk of 14.5. These siblings were all men > 45 years of age at the time of screening and had a strikingly high incidence of CHD (6 of 12, 50%). CONCLUSIONS: Exercise thallium scintigraphy appears to be useful in the risk assessment of asymptomatic siblings of patients with premature CHD, particularly in male siblings who are 45 years of age or older.

The effect of fasting status on the determination of low-density and high-density lipoprotein cholesterol.

PURPOSE: To determine the effect of a self-selected meal on concentrations of low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) in a screening setting and to determine the effect of using nonfasting values to classify individuals according to National Cholesterol Education Program guidelines. SUBJECTS AND METHODS: Study subjects were 115 employees who had previously participated in worksite total cholesterol screening, selected by stratified random sampling for sex and total cholesterol levels. Total cholesterol, triglycerides, HDL-C, and estimated LDL-C were determined before subjects ate a self-selected breakfast and 3 and 5 hours after eating it. RESULTS: LDL-C values determined 3 and 5 hours following breakfast were approximately 7% and 2.5% lower, respectively, than fasting values. Use of 3-hour and 5-hour LDL-C determinations to classify individuals with elevated fasting levels (> or = 3.36 mmol/L) resulted in false-negative rates of 20% and 14%, respectively. Three- and 5-hour HDL-C values were approximately 4% and 1.5% lower, respectively, than fasting levels. Use of 3-hour HDL-C values to classify individuals with low fasting levels (< 0.91 mmol/L) resulted in no false-negatives, whereas 1 of 7 individuals with low fasting HDL-C was misclassified when 5-hour values were used. CONCLUSIONS: These results support the 1993 National Cholesterol Education Program guidelines that LDL-C levels should be determined only in fasting persons, and that nonfasting HDL-C values may be acceptable for screening purposes.

The effect of filtered-coffee consumption on plasma lipid levels. Results of a randomized clinical trial.

OBJECTIVE: --To determine the effect of filtered-coffee consumption on plasma lipoprotein cholesterol levels in healthy men. DESIGN: --Randomized controlled trial with an 8-week washout period followed by an 8-week intervention period during which men were randomly assigned to drink 720 mL/d of caffeinated coffee, 360 mL/d of caffeinated coffee, 720 mL/d of decaffeinated coffee, or no coffee. SETTING: --Outpatient clinical research center in a university medical center. PARTICIPANTS: --One hundred healthy male volunteers. OUTCOME MEASURE: --Changes in plasma lipoprotein cholesterol levels during the intervention period. RESULTS: --Men who consumed 720 mL of caffeinated coffee daily had mean increases in plasma levels of total cholesterol (0.24 mmol/L, P = .001), low-density lipoprotein cholesterol (0.17 mmol/L, P = .04), and high-density lipoprotein cholesterol (0.08 mmol/L, P = .03). No significant changes in these plasma lipoprotein levels occurred in the other groups. Compared with the group who drank no coffee the group who drank 720 mL/d of caffeinated coffee had increases in plasma levels of total cholesterol (0.25 mmol/L, P = .02), low-density lipoprotein cholesterol (0.15 mmol/L, P = .17), and high-density lipoprotein cholesterol (0.09 mmol/L, P = .12) after adjustment for changes in diet. CONCLUSION: --Consumption of 720 mL/d of filtered, caffeinated coffee leads to a statistically significant increase in the plasma level of total cholesterol, which appears to be due to increases of both low-density lipoprotein and high-density lipoprotein cholesterol levels.