Higher blood pressure in middle-aged American adults with less education-role of multiple dietary factors: the INTERMAP study.

Extensive evidence exists that an inverse relation between education and blood pressure prevails in many adult populations, but little research has been carried out on reasons for this finding. A prior goal of the INTERMAP Study was to investigate this phenomenon further, and to assess the role of dietary factors in accounting for it. Of the 4680 men and women aged 40-59 years, from 17 diverse population samples in Japan, People's Republic of China, UK, and USA, a strong significant inverse education-BP relation was manifest particularly for the 2195 USA participants, independent of ethnicity. With participants stratified by years of education, and assessment of 100+ dietary variables from four 24-h dietary recalls and two 24-h urine collections/person, graded relationships were found between education and intake of many macro- and micronutrients, electrolytes, fibre, and body mass index (BMI). In multiple linear regression analyses with systolic BP (SBP) and diastolic BP (DBP) of individuals the dependent variables (controlled for ethnicity, other possible nondietary confounders), BMI markedly reduced size of education-BP relations, more so for women than for men. Several nutrients considered singly further decreased size of this association by > or =10%: urinary 24-h Na and K excretion, Keys dietary lipid score, vegetable protein, fibre, vitamins C and B6, thiamin, riboflavin, folate, calcium, magnesium, and iron. Combinations of these dietary variables and BMI attenuated the education-SBP inverse coefficient by 54-58%, and the education-DBP inverse coefficient by 59-67%, with over half these effects attributable to specific nutrients (independent of BMI). As a result, the inverse education-BP coefficients ceased to be statistically significant. Multiple specific dietary factors together with body mass largely account for the more adverse BP levels of less educated than more educated Americans. Special efforts to improve eating patterns of less educated strata can contribute importantly to overcoming this and related health disparities in the population.

Nutrient intake of obese female binge eaters.

OBJECTIVE: To compare the 6-month change in selected nutrients and number of binge days (from 7-day food records) between obese binge eaters randomly assigned to either a behavioral self-management (BSM) or waiting list control (WLC) group. Within each of the 2 groups, the average intake of selected nutrients on binge and nonbinge days at baseline and at 6 months were compared. DESIGN: A randomized, controlled, intervention study with assessments at entry and 6 months later. SUBJECTS: Forty-six women in the BSM group and 36 in the WLC group completed the 6-month measurement. Participants were 25 to 50 years of age, 30 to 90 pounds overweight, did not have a history of physical or psychological illnesses, and scored 20 or greater on the binge eating scale. INTERVENTION: Participants in the BSM intervention received 6 months of weekly, 1-hour classes taught by registered dietitians. Participants in the WLC group were not contacted during the 6 months. OUTCOME MEASURES: The main outcome measures were change in energy consumed (kilocalories); percentage of energy from fat, protein, and carbohydrate; grams of fiber/1,000 kcal; and change in the number of self-reported binge days. STATISTICAL ANALYSES: Weight at 6 months was compared using a 2-sample t test. The change in the number of binge days at 6 months and the amount of change in selected nutrients by group was compared using the 2-sample t test. The paired t test was used to compare the average nutrient intakes on binge and nonbinge days within groups. RESULTS: No significant difference was found in the 6-month change between groups in any of the selected nutrients. The BSM group reported a greater reduction in binge days between baseline and 6 months compared with the WLC group (mean 1.0 vs 1.7, P < 0.03). Within the BSM group at 6 months, energy intake and percentage of energy from fat on nonbinge days were significantly reduced compared with binge days. At baseline within the WLC group, energy intake increased and percentage of energy from protein decreased significantly on nonbinge days compared with binge days. Within the WLC group at 6 months, energy intake and percentage of energy from fat significantly decreased and percentage of energy from protein significantly increased on nonbinge days. CONCLUSIONS: Our results suggest that collecting dietary information from participants identified with binge eating disorder is challenging. Dietitians who conduct behavioral weight management programs may require additional training in identifying and understanding the psychological characteristics of participants with binge-eating disorder.

Community-wide coronary heart disease mortality in Mexican Americans equals or exceeds that in non-Hispanic whites: the Corpus Christi Heart Project.

PURPOSE: Previous comparisons of coronary heart disease mortality between Mexican Americans and non-Hispanic whites have given paradoxic results: despite their adverse cardiovascular risk profiles, especially a greater prevalence of diabetes, Mexican Americans are reported to have lower rates of mortality from coronary heart disease. SUBJECTS AND METHODS: We performed a community-based surveillance among all residents of Nueces County, Texas, aged 25 to 74 years, from 1990 to 1994. All death certificates were obtained and coded, and deaths potentially related to coronary heart disease were selected and validated by standardized methods blinded to ethnicity. Validated in-hospital and out-of-hospital coronary heart disease mortality was compared between 785 Mexican Americans and 862 non-Hispanic white women and men. RESULTS: Validated coronary heart disease mortality in Mexican Americans exceeded that for non-Hispanic whites in the same community. Among women, definite coronary heart disease mortality was 40% greater among Mexican Americans (rate ratio [RR] 1.43, 95% confidence interval [CI]: 1.12 to 1.82), as was all coronary heart disease mortality (RR, 1.32, 95% CI: 1.08 to 1.63). Among men, Mexican Americans had greater rates of all (RR, 1.11; 95% CI: 0.96 to 1.28) and definite coronary heart disease mortality (RR, 1.16; 95% CI: 0.91 to 1.47), but the associations were not statistically significant. CONCLUSIONS: When community-wide mortality rates from coronary heart disease are properly validated, Mexican Americans have rates equal to or higher than those of non-Hispanic whites. Community-based surveillance with validation of coronary heart disease as the cause of death is necessary to avoid the errors that occur with the use of death certificates alone.

Change in level of physical activity and risk of all-cause mortality or reinfarction: The Corpus Christi Heart Project.

BACKGROUND: The role of physical activity (PA) in reducing the risk of all-cause mortality or reinfarction after a first myocardial infarction (MI) remains unresolved, particularly for minority populations. The association between change in level of PA and risk of death or reinfarction was studied in 406 Mexican American and non-Hispanic white women and men who survived a first MI. METHODS AND RESULTS: MI patients were interviewed at baseline and annually thereafter about PA, medical history, and risk factors of coronary heart disease. Change in level of PA after the index MI was categorized as (1) sedentary, no change (referent group), (2) decreased activity, (3) increased activity, and (4) active, no change. Over a 7-year period, the relative risk (95% CI) of death was as follows: 0.21 (0.10 to 0.44) for the active, no change group; 0.11 (0.03 to 0.46) for the increased activity group; and 0.49 (0.26 to 0.90) for the decreased activity group. The relative risk of reinfarction was as follows: 0.40 (0.24 to 0.66) for the active, no change group; 0.22 (0.09 to 0.50) for the increased activity group; and 0.93 (0.59 to 1.42) for the decreased activity group. CONCLUSIONS: These findings are consistent with a beneficial role of PA for Mexican American and non-Hispanic white women and men who survive a first MI and have practical implications for the management of MI survivors.

Low cardiorespiratory fitness and physical inactivity as predictors of mortality in men with type 2 diabetes.

BACKGROUND: Although physical activity is recommended as a basic treatment for patients with diabetes, its long-term association with mortality in these patients is unknown. OBJECTIVE: To evaluate the association of low cardiorespiratory fitness and physical inactivity with mortality in men with type 2 diabetes. DESIGN: Prospective cohort study. SETTING: Preventive medicine clinic. PATIENTS: 1263 men (50+/-10 years of age) with type 2 diabetes who received a thorough medical examination between 1970 and 1993 and were followed for mortality up to 31 December 1994. MEASUREMENTS: Cardiorespiratory fitness measured by a maximal exercise test, self-reported physical inactivity at baseline, and subsequent death determined by using the National Death Index. RESULTS: During an average follow-up of 12 years, 180 patients died. After adjustment for age, baseline cardiovascular disease, fasting plasma glucose level, high cholesterol level, overweight, current smoking, high blood pressure, and parental history of cardiovascular disease, men in the low-fitness group had an adjusted risk for all-cause mortality of 2.1 (95% CI, 1.5 to 2.9) compared with fit men. Men who reported being physically inactive had an adjusted risk for mortality that was 1.7-fold (CI, 1.2-fold to 2.3-fold) higher than that in men who reported being physically active. CONCLUSIONS: Low cardiorespiratory fitness and physical inactivity are independent predictors of all-cause mortality in men with type 2 diabetes. Physicians should encourage patients with type 2 diabetes to participate in regular physical activity and improve cardiorespiratory fitness.

Congestive heart failure in the United States: is there more than meets the I(CD code)? The Corpus Christi Heart Project.

BACKGROUND: Congestive heart failure (CHF) is increasing as a public health problem in the United States. The ability to quantify this problem has been limited by a lack of data regarding the validity of CHF identification. OBJECTIVE: To assess the validity of the use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD) codes to identify hospitalizations with clinical evidence of an episode of acute CHF in data of The Corpus Christi Heart Project, a population-based surveillance program for hospitalized coronary heart disease. METHODS: The validation standard was a composite variable including the presence of physician diagnosed acute CHF or radiographic evidence of pulmonary edema. Data were abstracted from the medical records of 5083 patients identified as hospitalized for possible acute myocardial infarction, aortocoronary bypass surgery, percutaneous transluminal coronary angioplasty, and related revascularization procedures in the Corpus Christi Heart Project. Discharge diagnoses, a secondary source of data, were used to apply 3 computer algorithms to assess the assignment of ICD codes. RESULTS: The prevalence of clinically documented CHF was 27.1% (1376/5083). The ICD code 428 (CHF), assigned as the primary or a secondary discharge diagnosis, was associated with 62.8% sensitivity, 95.4% specificity, 83.5% positive predictive value, 87.4% negative predictive value, and a 24.8% underenumeration of CHF-related hospitalizations. An algorithm based on a series of ICD codes was associated with 67.1% sensitivity, 92.6% specificity, 77.1% positive predictive value, 88.3% negative predictive value, and a 13.0% underenumeration of CHF-related hospitalizations. CONCLUSIONS: Reliance on ICD codes results in the exclusion of one third of the patients with clinical evidence of acute CHF. This underenumeration is compounded by the typical reliance on the first listed diagnosis. Congestive heart failure may be a greater public health problem than currently recognized. The allocation of resources for relevant surveillance, research, medical care, and preventive efforts should be reevaluated.

Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men.

CONTEXT: Recent guidelines for treatment of overweight and obesity include recommendations for risk stratification by disease conditions and cardiovascular disease (CVD) risk factors, but the role of physical inactivity is not prominent in these recommendations. OBJECTIVE: To quantify the influence of low cardiorespiratory fitness, an objective marker of physical inactivity, on CVD and all-cause mortality in normal-weight, overweight, and obese men and compare low fitness with other mortality predictors. DESIGN: Prospective observational data from the Aerobics Center Longitudinal Study. SETTING: Preventive medicine clinic in Dallas, Tex. PARTICIPANTS: A total of 25714 adult men (average age, 43.8 years [SD, 10.1 years]) who received a medical examination during 1970 to 1993, with mortality follow-up to December 31, 1994. MAIN OUTCOME MEASURES: Cardiovascular disease and all-cause mortality based on mortality predictors (baseline CVD, type 2 diabetes mellitus, high serum cholesterol level, hypertension, current cigarette smoking, and low cardiorespiratory fitness) stratified by body mass index. RESULTS: During the study period, there were 1025 deaths (439 due to CVD) during 258781 man-years of follow-up. Overweight and obese men with baseline CVD or CVD risk factors were at higher risk for all-cause and CVD mortality compared with normal-weight men without these predictors. Using normal-weight men without CVD as the referent, the strongest predictor of CVD death in obese men was baseline CVD (age- and examination year-adjusted relative risk [RR], 14.0; 95% confidence interval [CI], 9.4-20.8); RRs for obese men with diabetes mellitus, high cholesterol, hypertension, smoking, and low fitness were similar and ranged from 4.4 (95% CI, 2.7-7.1) for smoking to 5.0 (95% CI, 3.6-7.0) for low fitness. Relative risks for all-cause mortality in obese men ranged from 2.3 (95% CI, 1.7-2.9) for men with hypertension to 4.7 (95% CI, 3.6-6.1) for those with CVD at baseline. Relative risk for all-cause mortality in obese men with low fitness was 3.1 (95% CI, 2.5-3.8) and in obese men with diabetes mellitus 3.1 (95% CI, 2.3-4.2) and as slightly higher than the RRs for obese men who smoked or had high cholesterol levels. Low fitness was an independent predictor of mortality in all body mass index groups after adjustment for other mortality predictors. Approximately 50% (n = 1674) of obese men had low fitness, which led to a population-attributable risk of 39% for CVD mortality and 44% for all-cause mortality. Baseline CVD had population attributable risks of 51% and 27% for CVD and all-cause mortality, respectively. CONCLUSIONS: In this analysis, low cardiorespiratory fitness was a strong and independent predictor of CVD and all-cause mortality and of comparable importance with that of diabetes mellitus and other CVD risk factors.

Greater stroke rate during hospitalization for acute heart disease among Mexican Americans than non-Hispanic whites.

BACKGROUND AND PURPOSE: This study compared the risk for stroke during acute myocardial infarction (AMI), percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) between Mexican Americans (MAs) and non-Hispanic whites. METHODS: We examined the age-specific rate ratios (RR) of acute stroke during hospitalization for AMI, CABG and PTCA in a population-based study in Corpus Christi, Tex. by searching the cardiac surveillance data for ICD-9 codes for stroke (430-437). ICD-9 stroke codes were validated by comparing medical chart abstraction with ICD-9 discharge diagnoses. RESULTS: Stroke codes were found in 220 of the 5,697 admissions for AMI, CABG and PTCA. In the 45- to 59-year age-group MAs had a RR of 2.66 (95% CI 1.36-5.23) relative to non-Hispanic whites. In the 60- to 74-year age-group the RR was 1.52 (95% CI 1.11-2.08). There were no significant differences in the 25- to 44-year age-group. These ethnic relationships were found in nondiabetics but not in diabetics. Women in the 45- to 59-year age-group had a RR of 1.88 (95% CI 1.09-3.25) compared with men, but there were no significant sex differences in the 25- to 44- or 59- to 74-year age-groups. Stroke ICD-9 codes have a poor positive predictive value for acute stroke ranging from 10 to 76%. The stroke misclassifications were nondifferential with respect to ethnicity or sex. CONCLUSIONS: MAs have a higher stroke rate complicating acute heart disease in Corpus Christi. A rigorous stroke surveillance project is needed to study the burden of stroke in MAs, the United States' largest Hispanic population.

Knowledge of heart attack symptoms in a population survey in the United States: The REACT Trial. Rapid Early Action for Coronary Treatment.

BACKGROUND: Greater use of thrombolysis for patients with myocardial infarction has been limited by patient delay in seeking care for heart attack symptoms. Deficiencies in knowledge of symptoms may contribute to delay and could be a target for intervention. We sought to characterize symptom knowledge. METHODS: Rapid Early Action for Coronary Treatment is a community trial designed to reduce this delay. At baseline, a random-digit dialed survey was conducted among 1294 adult respondents in the 20 study communities. Two open-ended questions were asked about heart attack symptom knowledge. RESULTS: Chest pain or discomfort was reported as a symptom by 89.7% of respondents and was thought to be the most important symptom by 56.6%. Knowledge of arm pain or numbness (67.3%), shortness of breath (50.8%), sweating (21.3%), and other heart attack symptoms was less common. The median number of correct symptoms reported was 3 (of 11). In a multivariable-adjusted model, significantly higher mean numbers of correct symptoms were reported by non-Hispanic whites than by other racial or ethnic groups, by middle-aged persons than by older and younger persons, by persons with higher socioeconomic status than by those with lower, and by persons with previous experience with heart attack than by those without. CONCLUSIONS: Knowledge of chest pain as an important heart attack symptom is high and relatively uniform; however, knowledge of the complex constellation of heart attack symptoms is deficient in the US population, especially in low socioeconomic and racial or ethnic minority groups. Efforts to reduce delay in seeking medical care among persons with heart attack symptoms should address these deficiencies in knowledge.

Cardiovascular risk factors in Mexican-American and non-Hispanic white children: The Corpus Christi Child Heart Study.

BACKGROUND: Information concerning differences in cardiovascular disease risk factors between Mexican-American and non-Hispanic white children is limited. We conducted a study to determine if there were ethnic differences in cardiovascular disease risk factors in children and whether such differences were explained by differences in body mass index. METHODS AND RESULTS: Fasting glucose, insulin, and blood lipid concentrations, blood pressure, weight, and height were measured in a cross-sectional survey among 403 third-grade children in Corpus Christi, Tex. We found significantly higher fasting insulin and glucose concentrations among Mexican-American than among non-Hispanic white children. Mexican-American boys had slightly lower levels of HDL cholesterol and higher systolic blood pressure than non-Hispanic white boys. Ethnic differences in insulin and glucose were not explained by body mass index. CONCLUSIONS: These results provide preliminary evidence that ethnic differences in insulin, glucose, body mass index, and other risk factors occur as early as age 8 to 10 years. Additional research is warranted on differences in risk factors in Mexican-American and non-Hispanic white children and the potential importance of insulin in influencing the natural history of these characteristics.

Development of cardiovascular risk factors from ages 8 to 18 in Project HeartBeat! Study design and patterns of change in plasma total cholesterol concentration.

BACKGROUND: Project HeartBeat! is a longitudinal study of the development of cardiovascular risk factors as growth processes. Patterns of serial change, or trajectories, from ages 8 to 18 years for plasma total cholesterol concentration (TC) and percent body fat illustrate the design and synthetic cohort approach of the study. METHODS AND RESULTS: Six hundred seventy-eight children (49.1% female, 20.1% black) entered the study at ages 8, 11, and 14 years and were followed up with examinations every 4 months for < or = 4 years. Multilevel analysis demonstrated trajectories for population mean values of TC and percent body fat in sex-specific synthetic cohorts from ages 8 to 18 years. Polyphasic patterns of change in TC were confirmed, with notable sex differences in age patterns and with minimum mean values of TC of 3.85 mmol/L for females and 3.59 for males. As illustrated by data for males, the approximate 75th percentile values of mean TC ranged from 4.78 mmol/L at its early peak to 4.06 at its late-teen nadir. Percent body fat exhibited a trajectory closely parallel with that for TC only for males and appeared to be unrelated for females. CONCLUSIONS: The polyphasic trajectory for TC from ages 8 to 18 years differs between females and males, indicates marked age variation in 75th percentile values and, in males only, closely parallels the trajectory for percent body fat. These and other results indicate the value of both follow-up every 4 months across age intervals to detect rapid risk factor change and the synthetic cohort approach for gaining new insights into the dynamics and possible determinants of this change from ages 8 to 18 years.

Sex and ethnic differences in use of myocardial revascularization procedures in Mexican Americans and non-Hispanic whites: the Corpus Christi Heart Project.

Age-adjusted rates of percutaneous transluminal coronary angioplasty (PTCA) and aortocoronary bypass surgery (ACBS) were determined for Mexican American (MA) and non-Hispanic white (NHW) patients hospitalized for coronary heart disease. Hypotheses of equal receipt of procedures between gender and ethnic groups were tested. Following myocardial infarction (MI), women were less likely than men to receive either procedure (22 versus 32%, p < 0.01), and MA were less likely than NHW to receive PTCA (13 versus 23%, p < 0.01) but not ACBS. After adjustment for extent of disease and other potential confounders, ethnic groups differed marginally in receipt of PTCA but not ACBS, while gender differences were not significant. Although women received revascularization procedures less frequently than men, this difference did not persist after controlling for extent of coronary artery disease by angiography: therefore, these observed differences in delivery of health care services may be appropriate. Mexican Americans received PTCA, but not ACBS, less frequently than NHW. This selective ethnic difference in receipt of PTCA does not appear to be associated with the extent of disease or other medical characteristics, and may represent inappropriate bias in delivery of health care services.

Greater incidence of hospitalized myocardial infarction among Mexican Americans than non-Hispanic whites. The Corpus Christi Heart Project, 1988-1992.

BACKGROUND: Since Mexican Americans have adverse patterns of risk factors for myocardial infarction relative to non-Hispanic whites, the incidence of myocardial infarction should be greater among Mexican Americans than among non-Hispanic whites. This expectation conflicts with reports generated from death certificate registries. METHODS AND RESULTS: Data regarding myocardial infarction attacks and incident events were collected for a 4-year period in the Corpus Christi Heart Project, a population-based surveillance project for hospitalized coronary heart disease events. For both women and men, Mexican Americans experienced greater hospitalization rates for both attacks and incident events than non-Hispanic whites. Age-adjusted attack rate ratios comparing Mexican Americans with non-Hispanic whites were 1.59 (95% CI, 1.05 to 2.41) and 1.31 (95% CI, 1.18 to 1.45) among women and men, respectively. Corresponding incidence ratios were 1.52 (95% CI, 1.28 to 1.80) and 1.25 (95% CI, 1.10 to 1.42). CONCLUSIONS: This is the first report documenting greater incidence of hospitalized myocardial infarction among Mexican Americans than among non-Hispanic whites, a biologically plausible finding given the risk factor patterns observed in the Mexican-American population. Public health planners and clinicians should be aware of the importance of myocardial infarction as a health problem in the Mexican-American population. Culturally appropriate prevention strategies should be developed for and tested in Mexican-American populations.

African Americans and women have the highest stroke mortality in Texas.

BACKGROUND AND PURPOSE: Hispanic American (HA), African American (AA), and non-Hispanic white (NHW) populations are well represented in Texas. The Texas HA population is 95% Mexican American, affording comparison with other Hispanic populations. From risk factor profiles we expected stroke mortality to be highest in AAs and HAs. We also expected stroke mortality to be considerably higher for men than for women based on previous data. METHODS: We used International Classification of Diseases, 9th Revision, codes 430 to 438 to search Texas vital statistics data for the 5-year period from 1988 through 1992. Race/ethnic differences are presented in age- and sex-specific format to avoid masking the important interaction of age and sex with stroke mortality. RESULTS: Women constituted 61% of the 40,346 stroke deaths in Texas during this period. The ratio of stroke deaths for women versus men approximates the ratio of women to men in the population. AAs had a threefold to fourfold increased stroke mortality relative to NHWs at young ages. At older ages, when stroke mortality is the highest, the stroke mortality rate in NHWs approached the stroke mortality rate of AAs. HAs had a significantly higher rate of stroke mortality at younger ages relative to NHWs but a significantly lower rate at older ages. CONCLUSIONS: Measures to prevent stroke mortality should emphasize its predilection for young AAs and women. A rigorous surveillance project is needed to determine whether stroke mortality is underestimated in the HA population.

Summary measures of the insulin resistance syndrome are adverse among Mexican-American versus non-Hispanic white children: the Corpus Christi Child Heart Study.

BACKGROUND: Mexican-American (MA) adults are known to have a greater burden of diabetes and insulin resistance than non-Hispanic white (NHW) people. In this report, we examined data obtained from MA and NHW third-grade children for evidence of a pattern consistent with the insulin resistance syndrome. In addition, we developed two summary measures characterizing insulin resistance syndrome to compare measures of this syndrome among our population. METHODS AND RESULTS: Data regarding fasting insulin, triglycerides, HDL cholesterol, systolic blood pressure, and body mass index (BMI) were available for 403 third-grade children. Median levels of insulin and glucose were significantly higher in MA boys and girls than in NHW boys and girls. Risk factors characterizing insulin resistance, including levels of insulin, triglycerides, systolic blood pressure, HDL cholesterol, and BMI were categorized as above or below the total population median. MA children were more likely than NHW children to have three or more adverse risk factors (55% versus 37%). When risk factors were converted to Z scores, and the five Z scores were summed for each individual, MA boys and girls had higher mean scores than NHW boys and girls (means for boys, 0.65 versus -0.97, P<.0001; girls, 0.52 versus -0.30, P<.04). Principal components analysis was used to create a summary score or index representing the insulin resistance syndrome. This summary score was significantly higher among MA boys and girls than NHW boys and girls (means for boys, 0.34 versus -0.72, P<.0001; girls, 0.35 versus -0.04, P=.056). CONCLUSIONS: Our results support the hypothesis that MA children exhibit a greater degree of the insulin resistance syndrome than NHW children, especially among boys. We conclude that some of the factors responsible for the increased risk of NIDDM seen among MA adults are demonstrable in childhood.

An assessment of the validity of ICD Code 410 to identify hospital admissions for myocardial infarction: The Corpus Christi Heart Project.

BACKGROUND: The identification of myocardial infarction (MI) is typically based on finding events designated by a nosologist with the appropriate International Classification of Diseases (ICD) code, currently code 410. These codes are applied based on review of medical records or death certificates. However, other factors, including reimbursement considerations, may influence the coding process, especially for hospitalizations. Thus, the validity of using ICD code 410 to identify MI must be assessed. METHODS: The Corpus Christi Heart Project (CCHP) is a population-based surveillance programme for hospitalized MI. Patients were identified using concurrent ascertainment in coronary care units and retrospective review of medical records. Events were validated as definite or possible MI using data regarding chest pain, electrocardiographic changes and cardiac enzymes. The validity of using ICD code 410 to identify cases of MI was assessed by calculating the sensitivity, specificity, predictive values and efficiency of ICD code 410 versus the CCHP 'gold standard'. RESULTS: Use of ICD code 410 identified 80.9% (401/496) of definite MI, but only 19.0% (243/1280) of possible MI. Only 12.3% (90/734) of discharges with an ICD 410 code received a 'no MI' designation based on the 'gold standard'. The efficiency of ICD code 410 for identifying MI was 92.0% for definite MI and 77.1% for definite and possible MI. CONCLUSIONS: The use of ICD code 410 to identify hospitalized cases of MI results in a modestly biased overestimate of the number of definite MI hospitalizations; however, this approach warrants consideration due to the expense of validation procedures.

Recruitment and enrollment for Project HeartBeat! Achieving the goals of minority inclusion.

OBJECTIVE: The inclusion of women and minorities in health research supported by the National Institutes of Health (NIH) has received increasing attention since the adoption of related guidelines by NIH in 1990. Investigators in population-based and clinical research may need to identify and recruit research participants from community settings in which little is known by investigators of the dynamics and day-to-day needs of the community. This was the case at the start of Project HeartBeat!, an intensive longitudinal study of the development of cardiovascular risk factors against the background of growth and maturation. This paper identifies those elements found essential when recruiting and enrolling minority participants for Project HeartBeat! METHODS: No prior experience had existed in the community from which the majority of Black participants were recruited to the Project. Therefore, recruitment methods were based on previous experience of the investigators as well as on the published reports of others. RESULTS: Immediate costs were substantially greater than projected, and the recruitment period was two years rather than one-a circumstance with longer-term implications as well. However, with the support of a community-based advisory committee, the school district, and a local recruitment staff, the recruitment goal was obtained. CONCLUSIONS: Recruitment and enrollment of minority participants can be especially challenging; however, many of those challenges are common to any target population. Elements that need to be adequately addressed include the researchers' involvement with the community in which the participants live, a tracking system to assess recruitment efforts, flexibility in the methods of recruitment, and adequate resources in time, money and personnel.

NIDDM incidence in a tri-ethnic population of diagnosed hypertensives.

OBJECTIVE: Significant racial/ethnic differences exist in the prevalence of hypertension (HTN) and non-insulin dependent diabetes mellitus (NIDDM). The purpose of this study was to determine if ethnicity (African-American, Hispanic and non-Hispanic white) was related to NIDDM incidence over a maximum follow-up period of 10 years. DESIGN: Retrospective cohort study. SETTING: A large, urban public health care system serving over 200,000 predominantly minority persons. The system includes nine primary care health centers. PATIENTS: African-American, Hispanic and non-Hispanic white patients with diagnosed hypertension who received primary care in the study setting. METHODS: Medical records of 2,941 hypertensives free of NIDDM at their baseline visit were reviewed to document incident NIDDM during follow-up. Sociodemographic characteristics and physiologic covariates consistently available in the medical record (blood pressure, height, weight, and blood glucose) were also abstracted. RESULTS: The mean age of patients at the baseline visit was 56 years; 67% were female, 63% were African-American. 17% Hispanic, and 20% non-Hispanic white. Two hundred thirty-six incident cases of NIDDM were identified in the cohort. In Cox proportional hazards analysis, the risk of developing NIDDM was not related to ethnicity either in univariate analysis or after adjusting for age, baseline blood glucose, and body mass index (adjusted RR for African Americans compared with whites = .82, 95% CI = .57-1.18; adjusted RR for Hispanics compared with whites = .84, 95% CI = .51-1.38). CONCLUSION: The lack of association between ethnicity and NIDDM risk among hypertensives is unexpected, and may indicate differences in the pathogenetic mechanisms that underlie the development of hypertension and NIDDM in these three ethnic groups.

Cardiovascular risk factors among children after a 2 1/2-year intervention-The CATCH Study.

BACKGROUND: Cardiovascular risk factors and related behaviors begin during youth. METHODS: As part of the Child and Adolescent Trial for Cardiovascular Health, 4,019 children from four states and representing multiple ethnic groups were measured for selected risk factors both at baseline and after 2(1/2) years of intervention. Common protocols were used for both examinations at the four sites. RESULTS: Overall, changes in obesity, blood pressure, and serum lipids in the intervention group, compared with the control group, were not statistically significant. Total cholesterol, the primary physiologic outcome measure, decreased by 1.3 mg/dl over time in the intervention group and by 0.9 mg/dl (P > 0.05) in the control group. Different risk factor patterns for boys and girls and among three ethnic groups were noted. CONCLUSIONS: Although the school-based program effected significant institutional changes in food service and physical education class and although the children made significant changes in eating and physical activity behaviors, these did not translate to significant changes in risk factors at these ages. These behavioral changes, however, if sustained into adulthood, have the potential to influence cardiovascular risk reduction.

Impact of fat reduction on micronutrient density of children's diets: the CATCH Study.

BACKGROUND: The purpose of this study was to examine the impact of fat reduction on vitamin and mineral density in the diets of groups of children who participated in the CATCH school-based intervention study for 2 1/2 years. METHODS: Twenty-four-hour dietary recalls were collected on 1,182 children residing in four states and with diverse ethnic backgrounds, at baseline when they were in third grade and again at follow-up when they were in fifth grade. RESULTS: With a 2.4% reduction in total fat intake from baseline levels in the intervention group, mean changes in vitamin and mineral intakes per 1,000 kcal of this group were small yet significant compared with the control group. As mean fat intake decreased, the nutrient density of most vitamins and minerals increased; the sole exceptions were vitamin E and sodium. Mean intake of all vitamins and minerals studied exceeded 2/3 of the RDA at both baseline and follow- up for both the intervention and the control groups. No significant differences were noted between treatment groups for the percentages of children meeting 2/3 or more of the RDA at both baseline and follow-up periods. CONCLUSIONS: CATCH was successful in maintaining mean vitamin and mineral intakes of intervention group children when total dietary fat was reduced.