bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P104: Change in Measures of Adiposity in Young Adulthood and Middle-Age Sleep Apnea Risk: The Bogalusa Heart Study
Authors: HU TIAN , Bertisch Suzanne , Chen Wei , Gustat Jeanette , Webber Larry , Li Shengxu , Pak Kirk , Srinivasan Sathanur , Berenson Gerald , Bazzano Lydia
Published: July 2021

Background:
Persons with obesity are at high risk of obstructive sleep apnea (OSA); however, the relationship between obesity in young adulthood and future OSA risk is unknown.

Methods:
We prospectively examined the association between changes in measures of adiposity in young adulthood and subsequent risk of OSA in 857 middle-aged adults free of cardiovascular disease at baseline. Data included at least 2 measures of adiposity (BMI, waist circumference, waist/hip ratio, and waist/height ratio) after 18 years of age. High-risk of OSA was defined as 2 of the following: hypertension, persistent snoring, and persistent daytime sleepiness, based on modified Berlin Questionnaire score, excluding BMI. Persistent snoring was defined as snoring on ≥3 nights/week, snoring louder than talking or very loud, and breathing pauses on ≥3 nights/week. Persistent daytime sleepiness was defined as feeling tired ≥3 days/week after sleeping, feeling tired during time awake ≥3 days/week, and falling asleep while driving.

Results:
The sample was 42% male and 32% African-American. Mean age was 43 years and mean BMI was 31 kg/m
2
when sleep outcomes were measured. BMI increased by 6.1 kg/m
2
over 25 years, waist circumference increased by 16.4 cm over 22 years, waist/hip ratio increased by 0.05 over 15 years, and waist/height ratio increased by 0.09 over 22 years. There were 235 (27%) participants with high-risk of OSA. In multivariate log linear regression models, participants with a one standard deviation increase in BMI had 1.30 (95% CI: 1.14, 1.49) times the risk of OSA, after adjustment for age, gender, race, educational level, leisure-time physical activity, regular drinking, current smoking, and years of follow-up. Participants with a one standard deviation increase in BMI, waist circumference, and waist/height ratio had 1.35 (95% CI: 1.22, 1.50), 1.17 (95% CI: 1.08, 1.27), and 1.22 (95% CI: 1.11, 1.34) times the risk of persistent snoring. The association was not significant for persistent daytime sleepiness. Waist/hip ratio was not significantly associated with any sleep-related outcome.

Conclusions:
Our findings suggest that an increase in BMI in young adulthood is an independent predictor of high-risk of OSA in middle age. Increases in BMI, waist circumference, and waist/height ratio are independently associated with persistent snoring in middle age.
Abstract P105: Sleep Disordered Breathing and Cardiac Autonomic Modulation in Adolescents - Penn State Child Cohort (PSCC) Study
Authors: Bixler Edward O , He Fan , Rodriguez-Colon Sol , Fernandez-Mendoza Julio , Vgontzas Alexandros , Calhoun Susan , Liao Duanping
Published: July 2021

Objectives:
To investigate the relationship between sleep disordered breathing (SDB) and cardiac autonomic modulation (CAM) in a population-based sample of adolescents.

Methods:
We used available data from 400 adolescents who completed the follow up examinations in the population-based PSCC study. 1-night polysomnography was used to assess apnea hypopnea index (AHI). AHI was used to define no-SDB (AHI<1), mild SDB (1≤AHI<5), and moderate SDB (AHI≥5). CAM was assessed by heart rate variability (HRV) analysis of beat-to-beat normal R-R intervals from a 39-hour high resolution Holter ECG. The HRV indices in frequency domain [high frequency power (HF), low frequency power (LF), and LF/HF ratio] and time domain [standard deviation of normal RR intervals (SDNN), and the square root of the mean squared difference of successive normal RR intervals (RMSSD), and heart rate (HR)] were calculated on a 30-minute basis (78 repeated measures). Mixed-effects models were used to assess the SDB and HRV relationship.

Results:
The mean age was 16.9 yrs (SD=2.19), with 54% male and 77% white. The mean (SD) AHI were 0.52 (0.26), 2.38 (1.03), and 12.27 (14.54) for no-, mild-, and moderate-SDB participants. The age, race, sex, and BMI percentile adjusted mean (SE) HRV indices across three SDB groups are presented in Table 1. In summary, sleep disordered breathing was associated with lower HRV and higher HR in this population-based adolescent sample, with a significant dose-response relationship.

Conclusion:
moderate SDB in adolescents is already associated with lower HRV, indicative of sympathetic activation and lower parasympathetic modulation, which has been associated with cardiac events in adults.
Abstract P110: Short And Sweet: Short Sleep Duration Is Associated With Increased Sugar Sweetened Beverage Consumption In The United States
Authors: Prather Aric A , Leung Cindy , Adler Nancy E , Epel Elissa S , Ritchie Lorrene , Laraia Barbara
Published: July 2021

Growing epidemiologic and laboratory evidence links short sleep duration with increased incidence of obesity; however, the behavioral mechanisms have not been fully elucidated. Sugar-sweetened beverage (SSBs) consumption has been identified as a significant contributor to weight gain. The aim of this study was to examine whether self-reported sleep duration and consumption of SSB were associated among a sample of 8,130 adults, aged 16-70 years, who participated in the 2005-2008 National Health and Nutrition Examination Survery (NHANES). Analyses revealed elevated average rates of daily SSB consumption in participants who reported sleeping ≤5 hours (Relative Difference (RD)=1.21, 95% CI 1.12, 1.31) and 6 hours per night (RD=1.15, 95% CI 1.08, 1.23) compared to those sleeping 7 to 8 hours per night (reference group). These associations were independent of age, gender, race/ethnicity, highest level of education, poverty income ratio, smoking status, marital status, BMI, self-reported health status, depressive symptoms, history of trouble sleeping, history of sleep disorders, total energy, coffee intake, and tea intake. Sub-analyses of specific types of SSBs revealed that the strongest associations emerged for regular soda consumption (caffeinated: ≤5 hours RD=1.46, 95% CI 1.27, 1.67 and 6 hours per night RD=1.18, 95% CI 1.04, 1.35; decaffeinated: ≤5 hours RD=1.15, 95% CI 1.07, 1.25 and 6 hours per night RD=1.08, 95% CI 1.02, 1.13) and non-carbonated SSBs (≤5 hours RD=1.10, 95% CI 1.03, 1.18). These associations varied by gender, race, and age group. Overall, the inverse associations between sleep duration and SSB consumption were significantly stronger among women, Caucasians, and participants in midlife. These findings provide initial observational evidence for associations between short sleep duration and increased intake of SSBs, providing a plausible behavioral pathway through which sleep may promote excess weight gain and obesity.
Abstract P115: How Many Coronary Heart Disease Deaths In Poland In 2020 Might Be Prevented By Further Reductions In Population Risk Factor Levels?
Authors: Bandosz Piotr , Guzman-Castillo Maria , Capewell Simon , Zdrojewski Tomasz , Critchley Julia , Rutkowski Marcin , O'Flaherty Martin
Published: July 2021

Background:
Poland has experienced one of the most dramatic declines in coronary heart disease (CHD) mortality rates in recent decades. This decline reflects the use of evidence based treatments and, crucially, population wide changes in diet. Our aim is to explore the potential for further gains in Poland by achieving population wide reductions in smoking, dietary salt and saturated fat intake and physical inactivity levels.

Methods:
A validated and updated policy model was used to forecast potential decreases in CHD deaths by 2020 as consequence of lifestyle and dietary changes in the population. Data from the most recent Polish risk factor survey was used for the baseline (2011). We modeled two different policy scenarios regarding possible future changes in risk factors:

A) conservative scenario: reduction of smoking prevalence and physically inactivity rates by 5% between 2011 and 2020, and reduction of dietary consumption of energy from saturated fats by 1% and of salt by 10%.

B) ideal scenario: reduction of smoking and physically inactivity prevalence by 15%, and dietary reduction of energy from saturated fats by 3% and of salt by 30%. We also conducted extensive sensitivity analysis using different counterfactual scenarios of future mortality trends.

Results:
Baseline scenarios. By assuming continuing declines in mortality and no future improvements in risk factors the predicted number of CHD deaths in 2020 would be approximately 13,600 (9,838-18,184) while if mortality rates remain stable, the predicted number of deaths would approximate 22,200 (17,792-26,688). Conservative scenario. Assuming continuing declines in mortality, small changes in risk factors could result in approximately 1,500 (688-2,940) fewer deaths. This corresponds to a 11% mortality reduction. Under the ideal scenario, our model predicted some 4,600 (2,048-8,701) fewer deaths (a 34% mortality reduction). Reduction in smoking prevalence by 5% (conservative scenario) or 15% (ideal scenario) could result in mortality reductions of 4.5% and 13.8% respectively. Decreases in salt intake by 10% or 30% might reduce CHD deaths by 3.0% and 8.6% respectively. Replacing 1% or 3% of dietary saturated fats by poly-unsaturates could reduce CHD deaths by 2.6% or 7.7% Lowering the prevalence of physically inactive people by 5%-15% could decrease CHD deaths by 1.2%-3.7%.

Conclusion:
Small and eminently feasible population reductions in lifestyle related risk factors could substantially decrease future number of CHD deaths in Poland, thus consolidating the earlier gains.
Abstract P116: County Cardiovascular Health is Associated with County-Level Health Care Resources
Authors: Frisbee Stephanie J , Pilkerton Courtney , Bias Thomas K
Published: July 2021

Cardiovascular disease (CVD) remains the leading cause of death in the U.S. Reducing the population burden of CVD will require an increased focus on understanding how to promote and support population-level cardiovascular health (CVH), which will include the ability to measure the presence of CVH, not merely the presence or absence of CVD. Recently, the American Heart Association developed a comprehensive metric designed to measure CVH at the population level. The metric includes smoking, body mass index, physical activity, diet, cholesterol, blood pressure, and blood glucose. The purpose of this study was to assess how population-level CVH is related to the availability of health care providers and services within the county. Data from the Behavioral Risk Factor Surveillance System were used to calculate age-adjusted CVH for each county in 2009. Federal Information Processing Standards codes were used to obtain scores for counties with a sample size of 15 or more. Data on county-level health care services and providers were abstracted from the Area Resource File. The main outcomes were age-standardized mean CVH score. In total, 2236 counties were included in the analysis. Mean CVH score was 3.49 (0.39 SD). After adjustment for county population, county-level CVH score was positively correlated to per capita primary care physicians (rho=0.33, p<0.0001) and nurse practitioners (rho=0.106, p<0.0001). County CVH was also positively and significantly correlated to cardiovascular disease specialists (rho=0.220, p<0.0001). The number of per capita physicians assistants and dieticians / nutritionists were also positively associated with county CVH (rho=0.232, p<0.0001; rho=0.112, p=0.003, respectively). In assessing the effect of the availability of health care facilities, county CVH was positively associated with per capita county-level long term hospital beds, nursing home beds, and community mental health centers (rho/p-values respectively: 0.122/<0.0001; 0.062/p=0.003; 0.078/<0.0001) but negatively associated with per capita county-level beds in skilled nursing facilities, home health agencies and federally qualified health centers (rho/p-values respectively: -0.189/<0.0001; -0.086/<0.0001; -0.065/0.002). Further study is needed to understand the marginal impact of health care providers and facilities on county CVH.
Abstract P117: County Level Cardiovascular Health in the United States
Authors: Pilkerton Courtney S , Bias Thomas K , Frisbee Stephanie J
Published: July 2021

Background:
Cardiovascular disease is the leading cause of death in the United States, so improving cardiovascular health (CVH) is a key population health goal. As part of public health efforts to achieve this, the American Heart Association recently developed a comprehensive CVH metric that incorporates smoking, body mass index, physical activity, diet, cholesterol, blood pressure, and blood glucose. The objectives of the current study were to measure CVH in all US counties and identify key socioeconomic determinants of county-level CVH.

Methods:
Data from the Behavioral Risk Factor Surveillance System were used to determine calculate CVH for each county in 2009. Federal Information Processing Standards codes were used to obtain scores for counties with a sample size of 15 or more; 62% (1948 of 3142) of United States counties had available data . The main outcomes were age-standardized mean CVH score and percentage of poor or ideal health. Data on county-level socioeconomic indicators were abstracted from the Area Resource File.

Results and Conclusions:
Overall, 18% of the population had poor CVH, 77% had intermediate, and 5% had ideal. Between counties the average overall CVH varied from 2.13 to 4.80, the percentage of ideal health varied from 0% to 46%, and the percentage of poor health varied from 1% to 76%. Counties with the poorest health were in the Midwest and Southern regions. There is a moderate positive relationship between mean CVH and per capita income (r=0.355) and a weak positive relationship between mean CVH and percent urban population (r=0.245). In conclusion, there are few counties with a substantial percentage of their population with ideal health, there is a wide range of cardiovascular health status within the United States, and there is some association of increasing CVH with increasing income and urbanization.
Abstract P122: An Interactive Intervention to Increase Stroke Knowledge: Results of the SWIFT Study
Authors: Roberts Eric T , Benn Emma K , Quarles Leigh , Perez Veronica , Boden-Albala Bernadette
Published: July 2021

Introduction:
The majority of acute stroke patients do not seek care within the optimal 3 hour time frame. General informational strategies have not increased stroke preparedness, possibly due to a lack of attention to health literacy or cultural tailoring. Several interventions have successfully increased stroke knowledge yet there remains skepticism that knowledge alone can lead to behavior change. The Stroke Warning Information and Faster Treatment (SWIFT) trial is the first intervention to rigorously test whether an interactive educational intervention (II; 2 in-hospital educational sessions and health literate, culturally tailored materials), compared to an enhanced educational intervention (EE; only educational materials) can increase arrival times for stroke/TIA recurrence to the emergency department (ED) in 1193 participants.

Aims:
SWIFT found large, non-differential increases in the proportion of participants arriving to the ED within 3 hours in both the II and EE group. Here we assess the effect of SWIFT on stroke knowledge (SK), and stroke preparedness (SP), and assess differences by race.

Methods:
SK was assessed with the 29 item stroke knowledge scale and dichotomized as high/low SK (≥ 23/< 23 correct). SP was dichotomized into those that knew the three important things to tell a health professional after the onset of stroke symptoms and those that identified less than 3 things. These scales were measured at baseline, and one and twelve months after baseline. We fit logit-linear models for high SK and high SP using generalized estimating equations.

Results:
We observed no difference between groups at baseline in SK (p-value = 0.44) or SP (p-value = 0.36). For SK, we observed statistically significant effect modification such that knowledge increased over time (p-value = 0.02) and the effect was differential by intervention group (p-value = 0.04). At one month the II group had 1.63 (95%CI = 1.23, 2.15) times greater odds of having high SK compared to the EE group but by twelve months there was no difference between groups (OR=1.21; 0.87, 1.67). However, for SP there is not a statistically significant effect of time (p-value = 0.07) but there is a difference in the rate of change by group. The II group had greater odds of having high SP at one month (OR=3.36; 1.86, 6.10) and twelve months (OR=7.64; 2.49, 23.49) compared to the EE group. We did not observe differences in rates of change by race for SK (p-value = 0.21) or SP (p-value = 0.86) but SK (p-value < 0.01) and SP (p-value < 0.01) increased over time for all races. Overall, we find that both II and EE increase SK over 12 months but that only II was able to increase SP. Moreover, this effect was observed for all race ethnic groups.

Conclusions:
The provision of culturally tailored, health literate information alone was able to increase SK; it did not eliminate racial disparities in SK but did improve SK for all race/ethnic groups studied.
Abstract P127: Ayurveda Improves Arterial Stiffness and Cardiometabolic Risk in Coronary Patients: A Prospective Pilot Study
Authors: DuBroff Robert , Lad Vasant , Murray-Krezan Cristina
Published: July 2021

Introduction:
Ayurveda is the ancient East Indian holistic approach to health that includes yoga, meditation, breathing exercises, medicinal herbs, and other practices. Although it has been practiced for nearly 5000 years there is little objective data regarding its efficacy in coronary disease.

Hypothesis:
Can the addition of Ayurveda to usual care improve markers and risk factors of cardiovascular disease?

Methods:
Twenty-six volunteers with a history of prior myocardial infarction, coronary bypass surgery, or coronary angioplasty/stent were recruited from the University of New Mexico cardiology clinics. Each patient underwent consultation with a single Ayurvedic specialist and received personalized instruction in daily yoga, meditation, breathing, medicinal herbs, and a caloric unrestricted Ayurvedic diet. Standardized measurements of arterial stiffness (pulse wave velocity) and cardiometabolic risk factors were obtained at baseline and after 90 days of therapy.

Results:
Nineteen patients, mean age 71.6 years, completed the study, six dropped out and one was lost to follow up. Among hypertensive patients (n=15), 60% (9 of 15) had either a >10 mm Hg drop in systolic blood pressure (n=4) or required a reduction in anti-hypertensive medications due to persistent systolic blood pressure < 110 mm Hg (n=5). Statistical analysis was performed using the paired student’s t test.

Conclusion:
This pilot study suggests that short term Ayurvedic therapy improves arterial stiffness and many cardiometabolic risk factors in patients with coronary artery disease. These findings support the need for a randomized controlled trial to further study the effects of Ayurveda on cardiovascular disease.
Abstract P131: Association between Marijuana Exposure and Cognitive Function in Middle Age: the Coronary Artery Risk Development in Young Adults (CARDIA) study.
Authors: Auer Reto , Vittinghoff Eric , Yaffe Kristine , Kertesz Stefan G , Levine Deborah A , Sidney Steve , Glymour M. Maria , Pletcher Mark J
Published: July 2021

Background:
Smoking marijuana is increasingly common, and understanding whether it is associated with long-term cognitive dysfunction has important implications for public health messaging.

Aims:
We estimated associations between cumulative exposure to marijuana and cognitive function (CF), adjusted for current marijuana use, cigarette smoking and other determinants of CF.

Methods:
Participants in the CARDIA Study, a population-based study of African Americans and European Americans recruited in 1985/6 at age 18-30 and followed over 25 years. Marijuana use was assessed at clinical visits at years 0, 2, 5, 7, 10, 15, 20 and 25 (2010/11); and cigarette smoking each year. Lifetime exposure to marijuana was expressed in joint-years, with 1 joint-year equivalent to smoking 365 joints. CF at year 25 was assessed with the Rey Auditory Verbal Learning Test (RAVLT), the Digit Symbol Substitution Test (DSST) and the Stroop Interference Test, each expressed as standardized z-scores. We estimated associations between current and lifetime marijuana exposure and each CF score using linear regressions, adjusted for baseline demographics, current smoking and diabetes and cumulative exposure to cigarette smoking, alcohol, illicit drugs, cardiovascular risk factors, physical activity and depression (see Table footnote).

Results:
Of 3385 participants with CF data, 24% had never reported marijuana use, 43% had smoked <0.5 joint-year during their lifetime, 22% 0.5 to 5 joint-years and 11% ≥5 joint-years; 9% had smoked marijuana within the last 30 days. In adjusted models, current marijuana use was significantly associated with a worse RAVLT test score, but we found no association between cumulative exposure to marijuana use and CF (Table). In contrast, current and cumulative exposure to cigarette smoking were associated with lower CF.

Conclusion:
Cigarette smoking (current and cumulative) and current marijuana use are associated with lower CF, but we found no evidence of an association with cumulative lifetime exposure of marijuana on CF.
Abstract P138: Apolipoprotein CIII Is Associated With Risk Of Diabetes And Defines A High-density Lipoprotein Subtype That Isn’t Protective
Authors: Jensen Majken K , Li Junlong , Mukamal Kenneth J , Furtado Jeremy D , Tjoenneland Anne , Overvad Kim , Cai Tianxi
Published: July 2021

Background:
Apolipoprotein CIII (apoCIII) is a proinflammatory protein that may affect insulin sensitivity by promoting β-cell apoptosis. ApoCIII is present on some lipoproteins (HDL, LDL and VLDL). We hypothesized that the presence of apoCIII on HDL may modulate the inverse association of HDL with risk of diabetes.

Aim:
To investigate relations of concentrations of apoCIII in plasma, the concentration of apoCIII in HDL, and HDL subtypes defined according to presence and absence of apoCIII with risk of diabetes.

Methods:
Concentrations of total apoCIII, apoCIII in HDL, and HDL-cholesterol in plasma separated according to apoCIII (by immunoaffinity chromatography) were assessed in 3,459 initially healthy women and men from the prospective Danish Diet, Cancer and Health Study. Between 1994 and 2007, 439 incident diabetes events occurred. We used standard inverse probability weighted estimators to resample the original study population (n=57,053).

Results:
In multivariable Cox regression models, total apoCIII concentration was statistically significantly associated with risk of diabetes (Hazard Ratio [HR] was 3.5, 95% CI=1.9-6.5 comparing extreme quintiles). The concentration of apoCIII within HDL was not associated with risk of diabetes, but when HDL was separated according to presence and absence of apoCIII, only HDL without apoCIII was inversely associated with diabetes (HR= 0.5, 95% CI=0.3-0.9 comparing extreme quintiles), whereas HDL with apoCIII was not associated with diabetes (HR= 1.0, 95% CI= 0.5-2.0)(Figure). The associations of the two HDL fractions were significantly different (p for heterogeneity = 0.002) and added significant information above and beyond the measure of total HDL (p=0.01).

Conclusion:
ApoCIII is associated with risk of diabetes. Further, while the concentration of apoCIII in HDL is not associated with diabetes risk, the presence of apoCIII on HDL may mark a dysfunctional subtype of HDL that lacks a protective association with diabetes.
Abstract P144: Diabetes as a Risk Factor for Stroke in Women Compared with Men
Authors: Peters Sanne A , Huxley Rachel R , Woodward Mark
Published: July 2021

Introduction:
Diabetes mellitus is a major cause of death and disability worldwide and is a strong risk factor for stroke. It is currently unknown if, and to what extent, the excess risk of stroke conferred by diabetes differs between the sexes. We performed a systematic review and meta-analysis to estimate the relative effect of diabetes on stroke risk in women compared with men.

Methods:
PubMed MEDLINE was systematically searched for prospective population-based cohort studies published between on January 1, 1966 and February 13, 2013. Studies were selected if they reported sex-specific estimates of the relative risk (RR) for stroke associated with diabetes, and its associated variability. The sex-specific RRs and their ratio, comparing women with men, were pooled using random effects meta-analysis with inverse variance weighting.

Results:
Data from 58 cohort studies representing 773,379 individuals and 12,253 fatal and non-fatal strokes were included in this analysis. The pooled maximal-adjusted RR of stroke associated with diabetes was 2.29 (95% confidence interval [CI]:1.93, 2.72) in women and 1.85 (1.61, 2.12) in men. Compared with men, women with diabetes thus had a greater risk of stroke: pooled ratio RR 1.26 (1.09, 1.46), I2=0%, with no evidence of publication bias. This finding was statistically robust and observed within all of the pre-specified subgroups and did not differ materially within any of the sensitivity analyses that were undertaken.

Conclusions:
The excess risk of stroke associated with diabetes is significantly higher in women than men, independent of sex differences in levels of other major cardiovascular risk factors. These data further strengthen the observation that men and women experience diabetes-related diseases differently and heighten the need for further work to clarify the biological, behavioral or social mechanisms that are involved.
Abstract P148: Association between Chronic Kidney Disease, Blood Pressure, HbA1c, and Body Mass Index with Healthcare Resource Utilization and Costs in Type 2 Diabetes Mellitus Patients
Authors: Chuang Chien-Chia , Lee Edward , Yang Erru , Ghosh Sabyasachi , Tawah Alie , Chen Shih-Yin
Published: July 2021

Background:
Newer classes of oral anti-diabetic medications affect not only HbA1c but also weight and blood pressure (BP); however, the use and effects may be limited in patients with chronic kidney disease (CKD). To better understand the potential value of newer anti-diabetic medications, we assessed the individual and collective contribution of these co-existing conditions on healthcare resource utilization (HRU) and costs within a large US T2DM patient population.

Methods:
This study analyzed electronic health records from integrated delivery networks across the US between 2008 and 2012. Beginning at first evidence of T2DM diagnosis, adults with T2DM and medical and laboratory data observed were categorized by CKD, BP, HbA1c, and obesity status as observed in the 12-month post-index period.CKD stage 5 patients were excluded. HRU was assessed during the 12-month post-index period (i.e., physician office, outpatient, and emergency room [ER) visits and hospitalizations). Unit costs were assigned to HRU to estimate total medical costs. Regression models were performed to assess the association between clinical variables and HRU/costs.

Results:
The final study sample included 23,492 T2DM patients (mean age: 60.7 years; female: 52.2%). More advanced CKD and a higher systolic BP were associated with a higher risk of hospitalization/ER visits and more outpatient/physician visits. Higher HbA1c levels were associated with a higher risk of hospitalization/ER visits. The relationship between body mass index (BMI) and HRU varied. Compared to overweight patients, normal/underweight patients had significantly greater risk of being hospitalized and ER visits, while patients with obesity classes 1-3 had similar risk. CKD stage 1, 2, 3A, 3B, and 4 had total costs of 1.18, 1.17, 1.44, 1.54, and 1.80 times those of patients without CKD (all p<0.01). Compared to patients with HbA1c <7%, those with an HbA1c 7.5%-<8%, 8%-<9%, and ≥9% had 1.07, 1.17, and 1.24 times of total costs, respectively (all p<0.05). Patients with systolic BP 130-<140 and ≥140 mmHg had total costs 1.12 and 2.30 times those of patients with systolic BP<130mmHg (both p<0.01). Normal/underweight and obesity stage 1, 2, 3 patients showed a non-linear trend of having total costs of 1.13, 0.91, 0.92 and 1.07 times those of overweight patients, respectively (all p<0.01).

Conclusions:
Among T2DM patients,
t
here is a positive relationship between CKD, BP, and HbA1c on HRU/costs. These findings highlight the importance of managing comorbid conditions in T2DM patients. Future studies should investigate reasons for the relationships we observed between BMI and HRU/costs.
Abstract P152: Clinical Utility Of Visceral Adipose Tissue Volume In Identification Of Middle Age Adults With Type 2 Diabetes
Authors: Motghare Prasenjeet N , Shay Christina , Carnethon Mercedes R , Jacobs David R R , Lewis Cora E. E , Terry J. Greg , Carr Jeffrey
Published: July 2021

Background:
Higher visceral adipose tissue (VAT) volume is associated with greater risk for the development of type 2 diabetes (T2D). Although VAT volume and prevalence of T2D vary by sex and race, differences in VAT volumes that are associated with the identification of individuals with prevalent T2D across these groups has not been fully examined.

Objective:
Our goal was to determine VAT volume cut points that maximize true positive, true negative, and optimal identification of individuals with T2D according to sex and race.

Methods:
Data were examined from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a multi-center longitudinal study of the development of cardiovascular risk in black and white men and women ages 18-30 years at baseline. In 2010-2011, the Year 25 exam was performed (43-55 years). VAT (cm
3
) was quantified by computed tomography based on two 5 mm contiguous slices at the level of the 4
th
-5
th
lumbar vertebra (n=3,161). T2D was defined based on the presence of fasting plasma glucose ≥126 mg/dL, 2-hour post load blood glucose ≥200 mg/dL, HbA1c ≥6.5% and/or diabetes medication use. Receiver operating characteristic (ROC) curve analysis was used to identify VAT cut points associated with identification of T2D.

Results:
Prevalence of T2D at the year 25 exam ranged from 8.8% in white women to 17.7% in black men; mean (SD) VAT volume ranged from 113.5 (79.9) cm
3
in white women to 170.2 (80.2) in white men. White men exhibited the highest cut points of VAT volume needed to identify cases of T2D (26-35% higher) and black women exhibited the lowest cut points (4-36% lower) for true positive, true negative, and optimal identification of T2D compared to other race and sex groups (Table 1).

Conclusions:
Although the utility of VAT volume to identify individuals with T2D is modest [[Unable to Display Character: –]] likely a result of other unaccounted metabolic risk factors [[Unable to Display Character: –]] these cross-sectional findings display race and sex differences in the VAT volume cut points associated with prevalent T2D.
Abstract P156: Health Literacy and Health Behaviors Associated with Racial Disparities in Blood Pressure
Authors: Pu Jia , Vanness Dave , Kreling David , Chewning Betty
Published: July 2021

Introduction:
Racial disparity in cardiovascular disease has prompted efforts to improve cardiovascular outcomes through patient education and health behavior promotion. However, little is known about the long-term effects of health literacy and health behaviors on cardiovascular disease outcomes.

Hypothesis:
This study aims to explore whether racial differences in long-term blood pressure outcomes are associated with baseline levels of health literacy, mediated through longitudinal patterns of health behaviors.

Methods:
This study used a prospective cohort from the Coronary Artery Risk Development in Young Adults (CARDIA) project, funded by NHLBI. Blood pressure was measured by trained CARDIA researchers at seven examinations between 1985 and 2005. Self-reported health behaviors (including smoking, binge drinking, overweight and sedentary lifestyle) were obtained at each examination. Cardiovascular health literacy was assessed as part of the 1990 observation. We used growth curve modeling to explore racial disparities in blood pressure and to examine if blood pressure outcomes could be explained by participants’ health literacy and their health behavior change.

This study included 3,546 CARDIA study participants who remained in the most recent examination at year 2005, with 47% African Americans and 43% males.

Results:
Racial disparities were observed in participants’ initial blood pressure, blood pressure progression rate, health literacy and health behaviors. African Americans had higher blood pressure at baseline (systolic: 109 vs. 105; diastolic: 70 vs. 67 P<0.0001) and greater increases over time. Caucasians had a higher health literacy score (4 vs. 3.5 P<0.0001) and reported fewer risk behaviors on average. There was a positive relationship between health literacy, education attainment, parents’ education attainment, family income, having health insurance and having fewer risk behaviors. Participants with fewer risk behaviors had lower blood pressure. Blood pressure improved in years with fewer risk behaviors. Higher baseline health literacy was associated with having fewer risk behaviors in the following fifteen years. Overall, the results indicated that blood pressure outcomes were indirectly influenced by baseline health literacy through longitudinal patterns of risk behaviors. This relationship was stronger in Caucasians.

Conclusions:
This study suggests that racial differences in blood pressure are associated with both health literacy and health behaviors. In response to these findings, important gaps in hypertension preventive care and health behavior promotion should be identified and addressed through efforts to improve cardiovascular health literacy. For minority and high risk populations, multifaceted approaches in addition to patient education may be needed to initiate behavior change.
Abstract P157: Leading Causes of Death Among Asian Americans
Authors: Hastings Katherine G
Published: July 2021

Background:
Asian Americans are one of the fastest growing racial/ethnic groups in the United States (U.S). Our current understanding of Asian American mortality patterns have been distorted by the aggregation of distinct subgroups, which masks the heterogeneity of the leading causes of death among diverse Asian American subgroups. There is currently a knowledge gap on the health of these rapidly expanding populations with little evidence to recommend research agendas, create public health policy, and offer clinical guidelines. In this analysis, we examined the leading causes of death among Asian American subgroups to determine racial/ethnic differences in mortality within the U.S.

Methods:
We examined national mortality rates for the six largest Asian American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) from 2003-2010. U.S. death records from 34 U.S. states and the District of Columbia were used to identify race/ethnicity and cause of death by ICD-10 coding. Standardized mortality ratios (SMR), were calculated for each sex and racial/ethnic group relative to Non-Hispanic Whites (NHW), adjusting for age. Mortality counts were used to rank the top ten causes of death among Asian Americans and the leading causes of death, death counts, and overall death percentage for each Asian American subgroup by sex were determined.

Results:
We examined 15,943,806 U.S. death records. SMRs were lower for all Asian subgroups compared to NHWs (0.52 female, 0.5 male vs. 1.0 male and female) for all causes of mortality. There was heterogeneity in mortality rates across Asian subgroups. Filipino (0.59) and Japanese men (0.63) and women (0.58) had the highest SMRs compared to other Asian subgroups. Cancer is the leading cause of death for all Asian women (27.6% of all Asian deaths), except Asian Indian women with cardiovascular disease (CVD) as the leading cause of death (28% of all deaths). The leading cause of death varies among Asian subgroups for men. Aggregate data for Asian men indicates cancer as the leading cause of death (27.4% of all Asian deaths), however this is only true for Chinese (31.9%), Korean (33.9%) and Vietnamese men (32.4%). CVD is the leading cause of death for Filipino (28.5%), Japanese (26.5%), and Asian Indian (31.8%) men. Proportions of death among Asian Indian males due to CVD (31.8%) are nearly double that of cancer (17.7%). CVD is the leading cause of death for NHWs (25.9% females, 26.9% males) followed by cancer (21.9% females, 24.9% males).

Conclusions:
There is significant heterogeneity in mortality patterns among Asian American subgroups. While Asian Americans in general have lower rates of mortality, CVD is an important cause of death for some subgroups. This heterogeneity calls to attention the need for more research in the distinct subgroups to help direct treatment and prevention efforts to reduce health disparities for this rapidly growing population.
Abstract P159: The Impact of Acculturation on Ideal Cardiovascular Health Metrics Among Hispanic Adults: Results from the National and Nutrition Examination Survey 1999-2010
Authors: Rodriguez Fatima , Meigs James B , Porneala Bianca C , Lopez Lenny
Published: July 2021

Background:
The American Heart Association has identified a set of 7 ideal health metrics that are associated with reduced cardiovascular disease mortality. Higher acculturation has been linked to increased risk of cardiovascular disease risk factors among Hispanics. We tested whether acculturation is associated with these ideal metrics in a large contemporary sample of Hispanic adults.

Methods:
We examined the association between acculturation and 7 ideal cardiovascular health metrics in the National Health and Nutrition Examination Survey (NHANES) from 1999-2010. Acculturation was measured by language use, with higher acculturation defined as the use of at least equal English and Spanish. The 7 ideal health metrics included not smoking, a body mass index (BMI) <25 kg/m2, moderate intensity exercise (defined by weekly METs), a healthy diet (healthy diet score ≥2), and maintenance of normal values of cholesterol (<200 mg/dL), fasting glucose (<100 mg/dL), and blood pressure (<120/<80 mm Hg). Based on established guidelines, components were defined as poor, intermediate, or ideal. Chi-squared analyses and logistic regression models were used to examine the independent association between ideal health metrics and acculturation, adjusting for age, gender, insurance status, usual place of care and appropriate sampling weights. P values ≤ 0.05 were significant.

Results:
The study sample consisted of 8,707 Hispanic adults. As compared with more acculturated adults, less acculturated adults were slightly older (mean age 41.1 vs. 39.2, p=0.004), were more likely to have less than a high school education (67.1 vs. 25.1%, p<0.001), less likely to have a usual source of care (61.3 vs. 79.1%, p<0.001) and more likely to be uninsured (57.0 vs. 27.4%, p<0.001). Less acculturated Hispanics were more likely to be nonsmokers (64.0 vs. 54.7%, p<0.001) but were less likely to meet ideal health metrics for BMI, physical activity, cholesterol, and glycemic control as compared with more acculturated adults. There was no difference in the healthy diet score by acculturation. In a subset of participants with all 6 ideal health metrics (N=1516) excluding diet, lower acculturation was associated with a trend for higher odds of having 6 of the ideal health metrics in fully adjusted models (Odds Ratio 1.8 [95% CI 1.0-3.1]).

Conclusion:
Contrary to prior reports of the positive health effects of low acculturation, we found that lower acculturation is associated with poor cardiovascular health metrics in a national sample of Hispanic adults. However, this group is also heterogeneous and future studies should explore the complex role of acculturation in cardiovascular disease risk profiles.
Abstract P161: Drug-Eluting Stent Utilization and Post-Coronary Revascularization Procedure Mortality: Do Racial Disparities Matter?
Authors: Sergeev Alexander V
Published: July 2021

Background:
Besides being a major risk factor for coronary artery disease (CAD), diabetes mellitus (DM) also worsens CAD patients’ prognosis. Percutaneous coronary intervention (PCI) with stenting is an effective treatment procedure for certain categories of CAD patients with DM (CAD-DM). Newer drug-eluting stents (DES) were developed to minimize the occurrence of restenosis known to hinder PCI with older non-drug-eluting stents (non-DES). We hypothesized that disparities in DES utilization and post-procedure mortality would exist in CAD-DM patients.

Methods:
We conducted a retrospective cohort study of in-hospital mortality in 132,934 CAD-DM patients [mean+SD age: 65.3+11.4 years; 62.7% (83,409 of 132,934) males] after PCI with DES and non-DES in the years 2007,2009. Patient race was classified as white, black, or other Asian, Pacific Islander, Native American). Due to short length of stay, in-hospital death was defined as a binary variable (discharged alive vs. deceased). Multivariable logistic regression was used to obtain adjusted odds ratios (ORs) for in-hospital death after DES and non-DES PCI in relation to patients’ race, adjusting for confounders: age, gender, comorbidities, number of stents inserted, number of vessels treated, socio-economic status, emergency department (ED) admission, rural/urban area status.

Results:
Blacks were less likely to receive newer DES stent than any other racial group: 75.7% blacks, 76.9% whites, 79.0% other (p<0.04). Blacks were more likely to undergo an emergency rather than planned procedure: 45.7% blacks, 39.8% whites, and 42.7% other were ED-admitted (p<0.01). In adjusted multivariable analysis, controlling for the type of stent and confounding factors, post-PCI mortality in blacks was similar to whites (adjusted OR 0.824, 95% CI: 0.672-1.010, p=0.06), but in other was higher than in whites (adjusted OR 1.284, 95% CI: 1.151-1.434, p<0.001).

Conclusions:
Racial disparities exist in DES utilization by CAD-DM patients and in post-PCI in-hospital mortality: blacks are least likely to receive DES, but patients of other racial groups are more likely to die after PCI. Further studies investigating the mechanisms responsible for these disparities are warranted.
Abstract P168: Vitamin D Status does not influence Bone Density in Africans
Authors: Thoreson Caroline K , O'Connor Michelle Y , Ricks Madia , Chung Stephanie T , Reynolds James C , Sumner Anne E
Published: July 2021

Without regard to race, the Institute of Medicine states that to protect bone health vitamin D, measured as 25(OH)D, should be >20 ng/mL while levels of 12-19 ng/mL are inadequate and levels of <12 ng/mL are deficient. However, even when 25(OH)D levels are low, bone mineral density (BMD) is not compromised in African-Americans. The relationship of 25(OH)D levels to BMD in Africans is unknown. Therefore 78 African immigrants to the United States (77% male, median age 35y, age range 22-63y (95% CI: 36, 40)) had 25(OH)D levels and dual-energy X-ray absorptiometry (DXA) scans. Distribution of 25(OH)D levels by quartile was determined (Fig. 1). The distribution of whole body BMD across quartiles of 25(OH)D was assessed (Fig. 2). Median 25(0H)D levels was 21 ng/mL (95% CI: 20, 23) with 47% having 25(OH)D<20 ng/mL and 8% having 25(OH)D <12 ng/mL. BMD did not change across quartiles of 25(OH)D (Fig. 2). Spearman correlation between BMD and 25(OH)D was r =0.1, P=0.5. As there was no relationship between vitamin D levels and BMD, low 25(OH)D levels are not a predictor of low bone density in Africans.
Abstract P180: Intake of soy protein and isoflavones with risk of cardiovascular mortality: the Singapore Chinese Health Study
Authors: Pan An , Talaei Mohammad , van Dam Rob M , Yuan Jian-Min , Koh Woon-Puay
Published: July 2021

Introduction:
These is a long-standing interest in the plausible cardiovascular benefits of soy protein and isoflavones, given the effects on several cardio-metabolic pathways (e.g., lipid profile, blood pressure, endothelial function, vascular reactivity, inflammation, insulin resistance) from pre-clinical studies and short-term intervention trials. However, the long-term prospective association between habitual soy food intake and cardiovascular mortality remains unclear. Thus, we evaluated the relation of soy protein and isoflavones intake with risk of cardiovascular mortality in middle-aged and elderly Chinese residing in Singapore.

Methods:
The Singapore Chinese Health Study is a population-based cohort that recruited 63,257 Chinese adults aged 45-74 years from 1993 to 1998. Usual diet was measured at recruitment using a validated semi-quantitative food-frequency questionnaire, and mortality information was identified via registry linkage to December 31, 2011. Cox proportional hazard models were used to calculate hazard ratios (HRs) with adjustment for potential confounders.

Results:
The median intake was 5.17 g/d for soy protein, 15.83 mg/d for soy isoflavones and 88.06 g/d for units of plain tofu-equivalent. We documented 4,780 total cardiovascular deaths during 890,473 person-years of follow-up. After adjustment for socio-demographic, lifestyle and other dietary factors, soy protein intake was not significantly associated with cardiovascular mortality: the HR (95% confidence interval) was 1.00 (reference), 1.02 (0.94-1.11), 1.02 (0.93-1.11), and 1.06 (0.97-1.17) for increasing quartiles of soy protein (P-trend=0.24). Null associations were also found for intakes of soy isoflavones (P-trend=0.83) and total tofu-equivalent (P-trend=0.79), as well as with deaths from CHD (n=2,697; P-trend=0.58) or stroke (n=1,298; P-trend=0.96). A statistically significant interaction with gender (P-interaction=0.04) was found for the relation between soy protein and cardiovascular mortality: the HRs (95% confidence intervals) across quartiles were 1.00 (reference), 1.00 (0.87-1.12), 1.05 (0.93-1.17), and 1.16 (1.03-1.31) in men (P-trend=0.02), and 1.00 (reference), 1.01 (0.88-1.16), 0.96 (0.84-1.11), and 0.95 (0.81-1.10) in women (P-trend=0.31).

Conclusions:
In this large cohort study of Chinese men and women, intake of soy foods (soy protein, isoflavones, tofu products) was not significantly associated with risk of cardiovascular mortality. However, a moderately increased risk in men cannot be excluded and requires further investigation. Overall, our results do not provide evidence for the recommendation of increasing soy food intake alone as a cardiovascular disease prevention strategy.