Cardiovascular health in young and middle adulthood and medical care utilization and costs at older age - The Chicago Heart Association Detection Project Industry (CHA).

It is unclear how long-term medical utilization and costs from diverse care settings and their age-related patterns may differ by cardiovascular health (CVH) status earlier in adulthood. We followed 17,195 participants of the Chicago Heart Association Detection Project Industry (1967-1973) with linked Medicare claims (1992 to 2010). Baseline CVH is a composite measure of blood pressure, body mass index, diabetes, cholesterol, and smoking and includes four mutually exclusive strata: all factors were favorable (5.5%), one or more factors were elevated but none high (20.3%), one factor was high (40.9%), and two or more factors were high (33.2%). We assessed differences in the quantities (using negative binomial models) of and costs (using quantile regressions) for inpatient admissions, ambulatory care, home health care, and others between less favorable and all favorable CVH. All analyses adjusted for baseline age, race, sex, education, age at follow-up, year, state of residence, and death. We found that all favorable CVH in earlier adulthood was associated with lower long-term utilization and costs in all settings and the gap widened with age. Compared to all favorable CVH, the annual number of acute inpatient admissions per person was 79% greater (p-value < 0.001) for poor CVH, the median annual Medicare payment per person was $640 greater (41%, p-value < 0.001), and the mean was $4628 greater (67%, p-value < 0.001). The cost differences were greatest for acute inpatient, followed by ambulatory, post-acute inpatient, home health, and other. Early prevention efforts may potentially result in compressed all-cause morbidity in later years of age, along with reductions in resource use and health care costs for associated conditions.

Long-term favorable cardiovascular risk profile and 39-year development of major and minor electrocardiographic abnormalities - The Chicago Healthy Aging Study (CHAS).

BACKGROUND: Data are limited on long-term associations of favorable cardiovascular risk profile (i.e., low-risk) and changes in risk profile with ECG abnormality development. METHODS: The Chicago Healthy Aging Study (CHAS) involved re-examination of 1395 participants, ages 65-84 years in 2007-10, free of baseline major ECG abnormalities or MI in 1967-1973. Stratified sampling method was used to recruit participants based on their baseline risk profile (low-risk and not low-risk). Low-risk status was defined as untreated SBP/DBP ≤ 120/≤80 mm Hg, untreated total cholesterol <200 mg/dl, not smoking, BMI <25 kg/m2, and no diabetes. ECG abnormalities were defined by Minnesota code criteria. Multinomial logistic regression was used. RESULTS: There were 28% women, 9% blacks, and 20% with baseline low-risk status. At follow-up, 21% developed ≥1 major ECG abnormalities, and 58% developed ≥1 minor ECG abnormalities. With multivariable adjustment, compared to those with 2 + high-risk factors, odds for developing from normal to any major ECG abnormalities were lower by 57%, 49%, and 35%, respectively, in persons with low-risk, any moderate-risk, and 1 high-risk factor (P-trend = 0.002). Findings were similar for some common specific subtypes of major and minor abnormalities. Associations were mainly due to baseline smoking and BMI. Remaining free of high-risk factors, or improving risk profile over time was also associated with lower major ECG abnormality development by 70% vs. always having any high-risk factor. CONCLUSIONS: Favorable CVD risk profile earlier in life and maintenance or improvement in risk profile over time are associated with lower risk of ECG abnormality development at older age.

Description and initial evaluation of incorporating electronic follow-up of study participants in a longstanding multisite cohort study.

BACKGROUND: The objective of this study was to evaluate a pilot program that allowed Chicago field center participants of the Coronary Artery Risk Development in Young Adults (CARDIA) study to submit follow-up information electronically (eCARDIA). METHODS: Chicago field center participants who provided email addresses were invited to complete contact information and follow-up questionnaires on medical conditions electronically in 2012-2013. Sociodemographic characteristics were compared between those who did and did not complete follow-up electronically. The number of participant contacts by CARDIA staff needed before follow-up was completed was also evaluated. RESULTS: Blacks and low socioeconomic position individuals were less likely to complete follow-up using the electronic questionnaire. Participants who used the electronic questionnaire for follow-up needed fewer contacts (e.g., median 1 contact compared with 3for contact information follow-up), but they also needed fewer contacts prior to eCARDIA (median 1 before and after eCARDIA). CONCLUSIONS: Findings suggest other approaches will be needed to maintain contact and elicit follow-up information from harder-to-reach individuals.

Lifetime risks of cardiovascular disease.

BACKGROUND: The lifetime risks of cardiovascular disease have not been reported across the age spectrum in black adults and white adults. METHODS: We conducted a meta-analysis at the individual level using data from 18 cohort studies involving a total of 257,384 black men and women and white men and women whose risk factors for cardiovascular disease were measured at the ages of 45, 55, 65, and 75 years. Blood pressure, cholesterol level, smoking status, and diabetes status were used to stratify participants according to risk factors into five mutually exclusive categories. The remaining lifetime risks of cardiovascular events were estimated for participants in each category at each age, with death free of cardiovascular disease treated as a competing event. RESULTS: We observed marked differences in the lifetime risks of cardiovascular disease across risk-factor strata. Among participants who were 55 years of age, those with an optimal risk-factor profile (total cholesterol level, <180 mg per deciliter [4.7 mmol per liter]; blood pressure, <120 mm Hg systolic and 80 mm Hg diastolic; nonsmoking status; and nondiabetic status) had substantially lower risks of death from cardiovascular disease through the age of 80 years than participants with two or more major risk factors (4.7% vs. 29.6% among men, 6.4% vs. 20.5% among women). Those with an optimal risk-factor profile also had lower lifetime risks of fatal coronary heart disease or nonfatal myocardial infarction (3.6% vs. 37.5% among men, <1% vs. 18.3% among women) and fatal or nonfatal stroke (2.3% vs. 8.3% among men, 5.3% vs. 10.7% among women). Similar trends within risk-factor strata were observed among blacks and whites and across diverse birth cohorts. CONCLUSIONS: Differences in risk-factor burden translate into marked differences in the lifetime risk of cardiovascular disease, and these differences are consistent across race and birth cohorts. (Funded by the National Heart, Lung, and Blood Institute.).

Association of depressive symptoms, trait anxiety, and perceived stress with subclinical atherosclerosis: results from the Chicago Healthy Aging Study (CHAS).

OBJECTIVE: Examine the association between multiple psychological factors (depressive symptoms, trait anxiety, perceived stress) and subclinical atherosclerosis in older age. METHOD: This cross-sectional study included 1101 adults ages 65-84 from the Chicago Healthy Aging Study (CHAS - 2007-2010). Previously validated self-report instruments were used to assess psychological factors. Non-invasive methods were used to assess subclinical atherosclerosis in two regions of the body, i.e., ankle-brachial blood pressure index (ABI) and coronary artery calcification (CAC). Multivariate logistic regression was used to examine the association between each psychological measure and subclinical atherosclerosis, after the adjustment for socio-demographic factors, sleep quality, young adulthood/early middle age and late-life CVD risk status, and psychological ill-being as appropriate. RESULTS: The burden of major cardiovascular disease risk factors did not significantly differ across tertiles of psychological factors. In multivariate adjusted models, trait anxiety was associated with calcification: those in the second tertile were significantly more likely to have CAC >0 compared to those in the lowest anxiety tertile [OR=1.68; 95% CI=1.09-2.58], but no significant difference was observed for Tertile III of trait anxiety [OR=1.31; 95% CI=0.75-2.27]. No association was seen between psychological measures and ABI. CONCLUSION: Of several psychological factors, only trait anxiety was significantly associated with CAC.

Chicago Healthy Aging Study: objectives and design.

Investigators in the Chicago Healthy Aging Study (CHAS) reexamined 1,395 surviving participants aged 65-84 years (28% women) from the Chicago Heart Association Detection Project in Industry (CHA) 1967-1973 cohort whose cardiovascular disease (CVD) risk profiles were originally ascertained at ages 25-44 years. CHAS investigators reexamined 421 participants who were low-risk (LR) at baseline and 974 participants who were non-LR at baseline. LR was defined as having favorable levels of 4 major CVD risk factors: serum total cholesterol level <200 mg/dL and no use of cholesterol-lowering medication; blood pressure 120/≤80 mm Hg and no use of antihypertensive medication; no current smoking; and no history of diabetes or heart attack. While the potential of LR status in overcoming the CVD epidemic is being recognized, the long-term association of LR with objectively measured health in older age has not been examined. It is hypothesized that persons who were LR in 1967-1973 and have survived to older age will have less clinical and subclinical CVD, lower levels of inflammatory markers, and better physical performance/functioning and sleep quality. Here we describe the rationale, objectives, design, and implementation of this longitudinal epidemiologic study, compare baseline and follow-up characteristics of participants and nonparticipants, and highlight the feasibility of reexamining study participants after an extended period postbaseline with minimal interim contact.

The MMPI factor scales and risk of death in men during 45 years of follow-up: The Western Electric study.

We examined associations between personality traits measured in 1958 and both all-cause and cause-specific mortality assessed 45 years later in 2003. Participants were 1,862 middle-aged men employed by the Western Electric Company. Outcomes were days to death from all causes, coronary heart disease, stroke, cancer, and causes other than circulatory diseases, cancer, accidents/homicide/suicides, or injuries (other causes). Measures in 1958 included age, education, health behaviors, biomedical risk factors, and nine content factors identified in the Minnesota Multiphasic Personality Inventory (MMPI). Four content factors-neuroticism, cynicism, extraversion, and intellectual interests-were related to the five-factor model domains of neuroticism, agreeableness, extraversion, and openness, respectively. The remaining five-psychoticism, masculinity versus femininity, religious orthodoxy, somatic complaints, and inadequacy-corresponded to the five-factor model's facets and styles (combinations of two domains) or were unrelated to the five-factor model. In age-adjusted and fully adjusted models, cynicism was associated with greater all-cause and cancer mortality. In fully adjusted models, inadequacy was associated with lower all-cause mortality and lower mortality from other causes. In age-adjusted models, religious orthodoxy was associated with lower cancer mortality. Further analyses revealed that the association between cynicism and all-cause mortality waned over time. Exploratory analyses of death from any disease of the circulatory system revealed no further associations. These findings reveal the importance of cynicism (disagreeableness) as a mortality risk factor, show that associations between cynicism and all-cause mortality are limited to certain periods of the lifespan, and highlight the need to study personality styles or types, such as inadequacy, that involve high neuroticism, low extraversion, and low conscientiousness. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Biomarkers of inflammation and thrombosis as predictors of near-term mortality in patients with peripheral arterial disease: a cohort study.

BACKGROUND: Traditional atherosclerotic risk factors predict long-term cardiovascular disease events but are poor predictors of near-term events. OBJECTIVE: To determine whether elevated levels of D-dimer and biomarkers of inflammation were more closely associated with near-term than long-term mortality in patients with lower-extremity peripheral arterial disease (PAD) and whether greater increases in biomarker levels were associated with higher mortality rates during the first year after the increase than during later years. DESIGN: Prospective cohort study with a mean follow-up of 3.4 years. SETTING: Academic medical center. PATIENTS: 377 men and women with PAD. MEASUREMENTS: Mortality within 1 year after biomarker measurement, 1 to 2 years after biomarker measurement, and 2 to 3 years after biomarker measurement. Cox regression analyses were used to evaluate associations of biomarkers levels and changes in biomarkers with cardiovascular and all-cause mortality. Hazard ratios were calculated for each 1-unit increase in log1.5(biomarker level). Analyses were adjusted for age, sex, race, comorbid conditions, ankle-brachial index, and other confounders. RESULTS: Seventy-six patients (20%) died during follow-up. Higher levels of D-dimer, C-reactive protein, and serum amyloid A were associated with higher all-cause mortality among patients who died within 1 year after biomarker measurement (hazard ratio, 1.20 [95% CI, 1.08 to 1.33], 1.13 [CI, 1.05 to 1.21], and 1.12 [CI, 1.04 to 1.20], respectively; P < 0.001, P < 0.001, and P = 0.003) and among patients who died 1 to 2 years after biomarker measurement (hazard ratio, 1.14 [CI, 1.02 to 1.27], 1.15 [CI, 1.06 to 1.24], and 1.13 [CI, 1.04 to 1.24]; P = 0.022, P = 0.001, and P = 0.005]). However, higher levels of each biomarker were not associated with all-cause mortality for deaths occurring 2 to 3 years after biomarker measurement. Similar results were observed for cardiovascular mortality. Greater increases in each biomarker were associated with higher all-cause and cardiovascular mortality during the following year. LIMITATION: The small number of deaths limited the statistical power of the analyses. CONCLUSION: Among persons with PAD, circulating levels of D-dimer and inflammatory markers are higher in the 1 to 2 years before death than in periods more remote from death. Increasing levels of D-dimer and inflammatory biomarkers are independently associated with higher mortality in persons with PAD.

Association of Long-Term Risk Factor Levels With Carotid Atherosclerosis: The Chicago Healthy Aging Magnetic Resonance Imaging Plaque Study (CHAMPS).

BACKGROUND: Absence of cardiovascular risk factors (RF) in young adulthood is associated with a lower risk for cardiovascular disease. However, it is unclear if low RF burden in young adulthood decreases the quantitative burden and qualitative features of atherosclerosis. METHODS: Multi-contrast carotid magnetic resonance imaging was performed on 440 Chicago Healthy Aging Study participants in 2009 to 2011, whose RF (total cholesterol, blood pressure, diabetes mellitus, and smoking) were measured in 1967 to 1973. Participants were divided into 4 groups: low-risk (with total cholesterol <200 mg/dL and no treatment, blood pressure <120/80 mm Hg and no treatment, no smoking, and no diabetes mellitus), 0 high RF but some RF unfavorable (≥1 RF above low-risk threshold but below high-risk threshold), 1 high RF (total cholesterol ≥240 mg/dL or treated, blood pressure ≥140/90 or treated, diabetes mellitus, or smoking), and 2 or more high RF. Association of baseline RF status with carotid atherosclerosis (overall mean carotid wall thickness and lipid-rich necrotic core) at follow-up was assessed. RESULTS: Among 424 participants with evaluable carotid magnetic resonance images, the mean age was 32 years at baseline and 73 years at follow-up; 67% were male, 86% white, and 36% were low-risk at baseline. Two or more high RF status was associated with higher carotid wall thickness (0.99±0.11 mm) and lipid-rich necrotic core prevalence (30%), as compared with low-risk group (0.94±0.09 mm and 17%, respectively). Each increment in baseline RF status was associated with higher carotid wall thickness (ß-coefficient, 0.015; 95% CI, 0.004-0.026) and with higher lipid-rich necrotic core prevalence at older age (odds ratio, 1.26; 95% CI, 1.00-1.58) in models adjusted for baseline RF and demographics. CONCLUSIONS: RF status in young adulthood is associated with the burden and quality of carotid atherosclerosis in older age suggesting that the decades-long protective effect of low-risk status might be mediated through a lower burden of quantitative and qualitative features of atherosclerotic plaque.

Favorable Cardiovascular Health at Young and Middle Ages and Dementia in Older Age-The CHA Study.

Background Data are sparse on the association of cardiovascular health ( CVH ) in younger/middle age with the incidence of dementia later in life. Methods and Results We linked the CHA (Chicago Heart Association Detection Project in Industry) study data, assessed in 1967 to 1973, with 1991 to 2010 Medicare and National Death Index data. Favorable CVH was defined as untreated systolic blood pressure/diastolic blood pressure ≤120/≤80 mm Hg, untreated serum total cholesterol <5.18 mmol/L, not smoking, bone mass index <25 kg/m2, and no diabetes mellitus. International Classification of Diseases, Ninth Revision (ICD-9) codes and claims dates were used to identify the first dementia diagnosis. Cox models were used to estimate hazard ratios of incident dementia after age 65 years by baseline CVH status. Among 10 119 participants baseline aged 23 to 47 years, 32.4% were women, 9.2% were black, and 7.3% had favorable baseline CVH . The incidence rate of dementia during follow-up after age 65 was 13.9%. After adjustment, the hazard ratio for incident dementia was lowest in those with favorable baseline CVH and increased with higher risk factor burden ( P-trend<0.001). The hazards of dementia in those with baseline favorable, moderate, and 1-only high-risk factor were lower by 31%, 26%, and 20%, respectively, compared with those with ≥2 high-risk factors. The association was attenuated but remained significant ( P-trend<0.01) when the model was further adjusted for competing risk of death. Patterns of associations were similar for men and women, and for those with a higher and lower baseline education level. Conclusions In this large population-based study, a favorable CVH profile at younger age is associated with a lower risk of dementia in older age.

Relation of Dietary Sodium (Salt) to Blood Pressure and Its Possible Modulation by Other Dietary Factors: The INTERMAP Study.

Available data indicate that dietary sodium (as salt) relates directly to blood pressure (BP). Most of these findings are from studies lacking dietary data; hence, it is unclear whether this sodium-BP relationship is modulated by other dietary factors. With control for multiple nondietary factors, but not body mass index, there were direct relations to BP of 24-hour urinary sodium excretion and the urinary sodium/potassium ratio among 4680 men and women 40 to 59 years of age (17 population samples in China, Japan, United Kingdom, and United States) in the INTERMAP (International Study on Macro/Micronutrients and Blood Pressure), and among its 2195 American participants, for example, 2 SD higher 24-hour urinary sodium excretion (118.7 mmol) associated with systolic BP 3.7 mm Hg higher. These sodium-BP relations persisted with control for 13 macronutrients, 12 vitamins, 7 minerals, and 18 amino acids, for both sex, older and younger, blacks, Hispanics, whites, and socioeconomic strata. With control for body mass index, sodium-BP-but not sodium/potassium-BP-relations were attenuated. Normal weight and obese participants manifested significant positive relations to BP of urinary sodium; relations were weaker for overweight people. At lower but not higher levels of 24-hour sodium excretion, potassium intake blunted the sodium-BP relation. The adverse association of dietary sodium with BP is minimally attenuated by other dietary constituents; these findings underscore the importance of reducing salt intake for the prevention and control of prehypertension and hypertension. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00005271.

Weekly sleep trajectories and their associations with obesity and hypertension in the Hispanic/Latino population.

Study Objectives: To identify weekly sleep trajectories (sleep pattern changing by day over a course of week) of specific characteristics and examine the associations between trajectory classes and obesity and hypertension. Methods: A total of 2043 participants (mean age 46.9, 65.5% female) completed at least 7 days of actigraphy aged 18-64 from the Sueño ancillary study of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Weekly sleep trajectories for three daily level measures (wake after sleep onset [WASO], daytime napping duration, and intranight instability index) were identified using latent class growth models. The outcomes were obesity and hypertension. Results: Using the trajectory with low-stable WASO as reference, the trajectory classes with increasing and high-concave patterns had significantly higher odds for obesity (OR 3.64 [1.23-10.84]) and hypertension (OR 5.25 [1.33, 20.82]), respectively. Compared with individuals with a low-stable napping duration trajectory, those with the high-concave pattern class were associated with hypertension (OR 2.27 [1.10-4.67]), and the association was mediated in part by obesity (OR 1.11 [1.00-1.22]). Individuals in the high intranight instability index trajectory had significantly larger likelihood for both obesity (OR 1.90 [1.26-2.86]) and hypertension (OR 1.86 [1.13-3.06]) compared with those in the low intranight instability index trajectory. Conclusions: Weekly trajectories varied for WASO, daytime napping duration, and intranight instability index. The trajectories with relatively larger values for these three measures were associated with greater risk for obesity and hypertension. These findings suggest that a stable pattern with relatively small weekly and nightly variability may be beneficial for cardiovascular health.

Framingham risk score and prediction of coronary heart disease death in young men.

BACKGROUND: We tested the ability of the Framingham Risk Score (FRS) and the online ATP III risk estimator to estimate risk and to predict 10-year and longer-term coronary heart disease (CHD) death in younger adults (age 18-39 years). Although prediction with individual risk factors has been tested in individuals <30 years, current multivariate risk prediction strategies have not been applied to prediction of clinical CHD in this age range. METHODS: We included 10,551 male participants of the CHA study who were aged 18 to 39 years and free of baseline CHD and diabetes at enrollment from 1967 to 1973. Risk of CHD was estimated using both FRS and ATP III online risk estimator for each individual. Men were stratified into deciles according to the magnitude of predicted risk calculated from measured baseline risk factors (CHA-predicted risk). Observed CHD mortality rates for 10, 20, and 30 years of follow-up were compared with estimated risks. Death rates of CHD were low across 30 years of follow-up. RESULTS: The FRS remained <10% for all deciles of CHA-predicted risk in the 18- to 29-year-old cohort. Framingham-predicted risk reached 12% only in the 30- to 39-year-old cohort in the highest decile of CHA-predicted risk despite substantial risk factor burden. CONCLUSIONS: Neither method classified individuals <30 years as high risk despite substantial risk factor burden. Future clinical guidelines should consider alternative strategies to estimate and communicate risk in populations <30 years.

Social avoidance and long-term risk for cardiovascular disease death in healthy men: the Western Electric study.

PURPOSE: Although personality traits may contribute to risk for cardiovascular disease (CVD), inconsistent findings have prompted efforts to refine their measurement to include only the hostile and aggressive components. Data are sparse on the "social avoidance" (SA) subscale that measures more indirectly negative traits such as shyness. Thus, we sought to examine the association between SA and CVD, coronary heart disease (CHD), and non-CVD death. METHODS: A total of 2107 men (ages 40-55 years) free of baseline CVD were enrolled in 1957 in the Western Electric Study. SA was measured at study entry using the four-item subscale of the Cook-Medley hostility scale to divide the cohort into four groups according to the degree of social avoidance. CHD mortality, CVD mortality, and non-CVD mortality were determined by death certificate. RESULTS: After 30 years of follow-up, SA was associated with CVD mortality for the highest vs. the lowest SA group in age-adjusted models (hazard ratio 1.39; 95% confidence interval [95% CI] 1.04-1.84) and after adjustment for traditional CVD risk factors (hazard ratio 1.49; 95% CI 1.12-2.00). After further adjustment for measures of hostility, the findings were similar. Findings for CHD mortality were similar. However, there was no significant association between SA and non-CVD mortality. CONCLUSIONS: Social avoidance is associated with CVD mortality but not with non-CVD mortality in middle-aged men. These findings suggest the hypothesis that social avoidance might promote CVD through physiologic, non-behavioral mechanisms.

Comparison of risk factors for cardiovascular mortality in black and white adults.

BACKGROUND: Recent attention to racial and ethnic disparities in health outcomes highlights the excess coronary heart disease mortality in black patients compared with white patients. We investigated whether traditional cardiovascular disease (CVD) risk factors were similarly associated with CVD mortality in black and white men and women. METHODS: Participants included 3741 black and 33,246 white men and women (44%) without a history of myocardial infarction, aged 18 to 64 years at baseline (1967-1973) from the Chicago Heart Association Detection Project in Industry study. Blood pressure, total cholesterol level, body mass index, cigarette smoking, and physician-diagnosed diabetes were assessed at baseline using standard methods. RESULTS: Through 2002, there were 107, 1586, 177, and 2866 deaths from CVD in black women, white women, black men, and white men, respectively. In general, the magnitude and direction of associations between traditional risk factors and CVD mortality were similar by race. However, in black women the multivariable-adjusted hazard ratio (HR) per 12 mm Hg of diastolic blood pressure was 1.08 (95% confidence interval [CI], 0.90-1.29), whereas it was 1.31 in white women (95% CI, 1.25-1.38). There was no association between higher cholesterol level (per 40 mg/dL [1.04 mmol/L]) and CVD mortality in black men (HR, 0.94; 95% CI, 0.80-1.10), whereas the risk was elevated in white men (HR, 1.21; 95% CI, 1.16-1.26). CONCLUSIONS: Most traditional risk factors demonstrated similar associations with mortality in black and white adults of the same sex. Small differences were primarily in the strength, not the direction, of association.

Association between protein intake and blood pressure: the INTERMAP Study.

BACKGROUND: Findings from epidemiological studies suggest an inverse relationship between individuals' protein intake and their blood pressure. METHODS: Cross-sectional epidemiological study of 4680 persons, aged 40 to 59 years, from 4 countries. Systolic and diastolic blood pressure was measured 8 times at 4 visits. Dietary intake based on 24-hour dietary recalls was recorded 4 times. Information on dietary supplements was noted. Two 24-hour urine samples were obtained per person. RESULTS: There was a significant inverse relationship between vegetable protein intake and blood pressure. After adjusting for confounders, blood pressure differences associated with higher vegetable protein intake of 2.8% kilocalories were -2.14 mm Hg systolic and -1.35 mm Hg diastolic (P<.001 for both); after further adjustment for height and weight, these differences were -1.11 mm Hg systolic (P<.01) and -0.71 mm Hg diastolic (P<.05). For animal protein intake, significant positive blood pressure differences did not persist after adjusting for height and weight. For total protein intake (which had a significant interaction with sex), there was no significant association with blood pressure in women, nor in men after adjusting for dietary confounders. There were significant differences in the amino acid content of the diets of persons with high vegetable and low animal protein intake vs the diets of persons with low vegetable and high animal protein intake. CONCLUSIONS: Vegetable protein intake was inversely related to blood pressure. This finding is consistent with recommendations that a diet high in vegetable products be part of healthy lifestyle for prevention of high blood pressure and related diseases.

Cardiovascular risk profile earlier in life and Medicare costs in the last year of life.

BACKGROUND: Health care costs are generally highest in the year before death, and much attention has been directed toward reducing costs for end-of-life care. However, it is unknown whether cardiovascular risk profile earlier in life influences health care costs in the last year of life. This study addresses this question. METHODS: Prospective cohort of adults from the Chicago Heart Association Detection Project in Industry included 6582 participants (40% women), aged 33 to 64 years at baseline examination (1967-1973), who died at ages 66 to 99 years. Medicare billing records (1984-2002) were used to obtain cardiovascular disease-related and total charges (adjusted to year 2002 dollars) for inpatient and outpatient services during the last year of life. Participants were classified as having favorable levels of all major cardiovascular risk factors (low risk), that is, serum cholesterol level lower than 200 mg/dL (<5.2 mmol/L), blood pressure 120/80 mm Hg or lower and no antihypertensive medication, body mass index (calculated as weight in kilograms divided by the square of height in meters) lower than 25, no current smoking, no diabetes, and no electrocardiographic abnormalities, or unfavorable levels of any 1 only, any 2 only, any 3 only, or 4 or more of these risk factors. RESULTS: In the last year of life, average Medicare charges were lowest for low-risk persons. For example, cardiovascular disease-related and total charges were lower by 10,367 dollars and 15,318 dollars compared with those with 4 or more unfavorable risk factors; the fewer the unfavorable risk factors, the lower the Medicare charges (P for trends <.001). Analyses by sex showed similar patterns. CONCLUSION: Favorable cardiovascular risk profile earlier in life is associated with lower Medicare charges at the end of life.

Midlife body mass index and hospitalization and mortality in older age.

CONTEXT: Abundant evidence links overweight and obesity with impaired health. However, controversies persist as to whether overweight and obesity have additional impact on cardiovascular outcomes independent of their strong associations with established coronary risk factors, eg, high blood pressure and high cholesterol level. OBJECTIVE: To assess the relation of midlife body mass index with morbidity and mortality outcomes in older age among individuals without and with other major risk factors at baseline. DESIGN: Chicago Heart Association Detection Project in Industry study, a prospective study with baseline (1967-1973) cardiovascular risk classified as low risk (blood pressure < or =120/< or =80 mm Hg, serum total cholesterol level <200 mg/dL [5.2 mmol/L], and not currently smoking); moderate risk (nonsmoking and systolic blood pressure 121-139 mm Hg, diastolic blood pressure 81-89 mm Hg, and/or total cholesterol level 200-239 mg/dL [5.2-6.2 mmol/L]); or having any 1, any 2, or all 3 of the following risk factors: blood pressure > or =140/90 mm Hg, total cholesterol level > or =240 mg/dL (6.2 mmol/L), and current cigarette smoking. Body mass index was classified as normal weight (18.5-24.9), overweight (25.0-29.9), or obese (> or =30). Mean follow-up was 32 years. SETTING AND PARTICIPANTS: Participants were 17,643 men and women aged 31 through 64 years, recruited from Chicago-area companies or organizations and free of coronary heart disease (CHD), diabetes, or major electrocardiographic abnormalities at baseline. MAIN OUTCOME MEASURES: Hospitalization and mortality from CHD, cardiovascular disease, or diabetes, beginning at age 65 years. RESULTS: In multivariable analyses that included adjustment for systolic blood pressure and total cholesterol level, the odds ratio (95% confidence interval) for CHD death for obese participants compared with those of normal weight in the same risk category was 1.43 (0.33-6.25) for low risk and 2.07 (1.29-3.31) for moderate risk; for CHD hospitalization, the corresponding results were 4.25 (1.57-11.5) for low risk and 2.04 (1.29-3.24) for moderate risk. Results were similar for other risk groups and for cardiovascular disease, but stronger for diabetes (eg, low risk: 11.0 [2.21-54.5] for mortality and 7.84 [3.95-15.6] for hospitalization). CONCLUSION: For individuals with no cardiovascular risk factors as well as for those with 1 or more risk factors, those who are obese in middle age have a higher risk of hospitalization and mortality from CHD, cardiovascular disease, and diabetes in older age than those who are normal weight.

One-hour postload plasma glucose in middle age and Medicare expenditures in older age among nondiabetic men and women: the Chicago Heart Association Detection Project in Industry.

OBJECTIVE: To examine associations in nondiabetic individuals of 1-h postload plasma glucose measured in young adulthood and middle age with subsequent Medicare expenditures for cardiovascular disease (CVD), diabetes, cancer, and all health care at age 65 years or older using data from the Chicago Heart Association Detection Project in Industry (CHA). RESEARCH DESIGN AND METHODS: Medicare data (1984-2000) were linked with CHA baseline records (1967-1973) for 8,580 men and 6,723 women ages 33-64 years who were free of coronary heart disease, diabetes, and major electrocardiogram (ECG) abnormalities and who were Medicare eligible (65+ years) for at least 2 years. Participants were classified based on 1-h postload plasma glucose levels <120, 120-199, or > or =200 mg/dl. RESULTS: With adjustment for baseline age, cigarette smoking, serum cholesterol, systolic blood pressure, BMI, ethnicity, education, and minor ECG abnormalities, the average annual and cumulative Medicare, total, and diabetes- and CVD-related charges were significantly higher with higher baseline plasma glucose in women, while only diabetes-related charges were significantly higher in men. For example, in women, multivariate-adjusted CVD-related cumulative charges were, respectively, USD 14,260, 18,909, and 21,183 for the three postload plasma glucose categories (P value for trend = 0.035). CONCLUSIONS: These findings suggest that maintaining low glucose levels early in life has the potential to reduce health care costs in older age.

Optimal Levels of All Major Cardiovascular Risk Factors in Younger Age and Functional Disability in Older Age: The Chicago Heart Association Detection Project in Industry 32-Year Follow-Up Health Survey.

BACKGROUND: The associations of optimal levels of all major cardiovascular disease risk factors, that is, low risk, in younger age with subsequent cardiovascular disease morbidity and mortality have been well documented. However, little is known about associations of low-risk profiles in younger age with functional disability in older age. METHODS AND RESULTS: The sample included 6014 participants from the Chicago Heart Association Detection Project in Industry Study. Low-risk status, defined as untreated systolic/diastolic blood pressure ≤120/≤80 mm Hg, untreated serum total cholesterol <5.18 mmol/l, not smoking, body mass index < 25 kg/m(2), and no diabetes mellitus, was assessed at baseline (1967 to 1973). Functional disability, categorized as (1) any disability in activities of daily living (ADLs), (2) any disability in instrumental ADLs but not in ADL, or (3) no disability, was assessed from the 2003 health survey. There were 39% women, 4% Black, with a mean age of 43 years and 6% low-risk status at baseline. After 32 years, 7% reported having limitations in performing any ADL and 11% in any instrumental ADL only. The prevalence of any ADL limitation was lowest in low-risk people and increased in a graded fashion with less-favorable risk factor groups (P trend <0.001). Compared with those with 2+ high-risk factors, the multivariable-adjusted odds of having any disability in ADLs versus no disability in people with low risk, any moderate risk, and 1 high-risk factor at baseline were lower by 58%, 48%, and 37%, respectively. Results were similar for instrumental ADLs, in both men and women. CONCLUSIONS: Having an optimal cardiovascular disease risk factor profile at younger age is associated with the lowest rate of functional disability in older age.