Television viewing and incident cardiovascular disease: prospective associations and mediation analysis in the EPIC Norfolk Study

Background

Although television viewing time is detrimentally associated with intermediate cardiovascular risk factors, the relationship with incident total (i.e. combined fatal and non-fatal) cardiovascular disease (CVD), non-fatal CVD and coronary heart disease is largely unknown. This study examined whether television viewing time is associated with these three outcomes, independently of physical activity energy expenditure and other confounding variables.

Methodology/Principal Findings

A population-based cohort of 12,608 men and women (aged 61.4±9.0), free from stroke, myocardial infarction and cancer at baseline in 1998–2000 were followed up until 2007 (6.9±1.9 years). Participants self-reported education, smoking, alcohol use, antihypertensive, lipid lowering and antidepressant medication, disease history, total energy intake, sleep duration, physical activity and television viewing. BMI, waist circumference, blood pressure, triglycerides, HDL cholesterol and glycated haemoglobin (HbA_1c) were measured by standardized procedures; a clustered metabolic risk score was constructed. Every one hour/day increase in television viewing was associated with an increased hazard for total (HR = 1.06, 95%CI = 1.03–1.08; 2,620 cases), non-fatal CVD (HR = 1.06, 95%CI = 1.03–1.09; 2,134 cases), and coronary heart disease (HR = 1.08, 95%CI = 1.03–1.13; 940 cases), independent of gender, age, education, smoking, alcohol, medication, diabetes status, CVD family history, sleep duration and physical activity energy expenditure. Energy intake, BMI, waist circumference, blood pressure, triglycerides, HDL cholesterol, HbA_1c and the clustered metabolic risk score only partially mediated these associations.

Conclusions

These results indicate that the most prevalent leisure time (sedentary) behaviour, television viewing, independently contributes to increased CVD risk. Recommendations on reducing television viewing time should be considered.     

Socioeconomic status and incident type 2 diabetes mellitus: data from the Women's Health Study

Objectives

We prospectively examined whether socioeconomic status (SES) predicts incident type II diabetes (diabetes), a cardiovascular risk equivalent and burgeoning public health epidemic among women.

Methods

Participants include 23,992 women with Hb_A1c levels <6% and no CVD or diabetes at baseline followed from February 1993 to March 2007. SES was measured by education and income while diabetes was self-reported.

Results

Over 12.3 years of follow-up, 1,262 women developed diabetes. In age and race adjusted models, the relative risk of diabetes decreased with increasing education (<2 years of nursing, 2 to <4 years of nursing, bachelor''s degree, master''s degree, and doctorate: 1.0, 0.7 [95% Confidence Interval (CI), 0.6–0.8], 0.6 (95% CI, 0.5–0.7), 0.5 (95% CI, 0.4–0.6), 0.4 (95% CI, 0.3–0.5); p_trend<0.001). Adjustment for traditional and non-traditional cardiovascular risk factors attenuated this relationship (education: p_trend = 0.96). Similar associations were observed between income categories and diabetes.

Conclusion

Advanced education and increasing income were both inversely associated with incident diabetes even in this relatively well-educated cohort. This relationship was largely explained by behavioral factors, particularly body mass index.     

Job Strain,Health and Sickness Absence: Results from the Hordaland Health Study

Objectives

While it is generally accepted that high job strain is associated with adverse occupational outcomes, the nature of this relationship and the causal pathways involved are not well elucidated. We aimed to assess the association between job strain and long-term sickness absence (LTSA), and investigate whether any associations could be explained by validated health measures.

Methods

Data from participants (n = 7346) of the Hordaland Health Study (HUSK), aged 40–47 at baseline, were analyzed using multivariate Cox regression to evaluate the association between job strain and LTSA over one year. Further analyses examined whether mental and physical health mediated any association between job strain and sickness absence.

Results

A positive association was found between job strain and risk of a LTSA episode, even controlling for confounding factors (HR = 1.64 (1.36–1.98); high job strain exposure accounted for a small proportion of LTSA episodes (population attributable risk 0.068). Further adjustments for physical health and mental health individually attenuated, but could not fully explain the association. In the fully adjusted model, the association between high job strain and LTSA remained significant (HR = 1.30 (1.07–1.59)).

Conclusion

High job strain increases the risk of LTSA. While our results suggest that one in 15 cases of LTSA could be avoided if high job strain were eliminated, we also provide evidence against simplistic causal models. The impact of job strain on future LTSA could not be fully explained by impaired health at baseline, which suggests that factors besides ill health are important in explaining the link between job strain and sickness absence.     

Causes of atypical pneumonia: results of a 1-year prospective study.

In a protocol study of cases of atypical pneumonia over a 1-year period an etiologic agent was established in 16 cases: Legionella pneumophila in 8, Coxiella burnetii in 3, Chlamydia trachomatis in 2, Mycoplasma pneumoniae in 1, para-influenza 3 virus in 1 and cytomegalovirus in 1. In the remaining 11 cases no agent was identified; the illnesses in these cases tended to be less severe. The pneumonia took much longer to resolve in the patients with Legionnaires'' disease than in all the other patients (mean interval from onset of symptoms to clearing of the chest roentgenogram: 69 days v. an average of 16 days). However, the length of stay in hospital was similar for the three groups: those with Legionnaires'' disease, those with atypical pneumonia of unknown cause and those with atypical pneumonia of various other established causes. L. pneumophila infection may explain a proportion of atypical pneumonias that previously could not be diagnosed, although in this series the cause of 41% of the pneumonias remained unexplained.     

Women's psychosocial outcomes of breast augmentation with silicone gel-filled implants: a 2-year prospective study

This study examined the experiences of 360 women receiving bilateral breast augmentation with Dow Corning's Silastic MSI (textured) or Silastic II (smooth) gel-filled mammary implants. Before surgery, the women completed a quantitative assessment of their surgical expectations and concerns. At 6, 12, and 24 months postoperatively, they rated their satisfaction with surgery and its specific psychosocial outcomes, their concerns, and benefits-to-risks appraisals of the augmentation. The women reported very high levels of satisfaction with the procedure and its psychosocial outcomes, which did not change over time. Throughout the 2-year period, over 90 percent of the women were satisfied with surgery and their resultant body-image changes. Their concerns about risks, reported by 19 percent before surgery, declined after surgery and remained subsequently stable. Most participants (75 to 85 percent) reported that the benefits of surgery exceeded its risks. Postoperative events such as significant capsular contracture that compromised aesthetic results diminished aspects of satisfaction, whereas less obvious events did not. Systematic analysis of attrition (i.e., missing assessments) did not indicate any biases because of complications or psychosocial outcomes. Evaluation of a possible impact of the publicity surrounding the Food and Drug Administration's voluntary moratorium on the use of silicone gel-filled breast implants, which occurred during the study, revealed a limited effect, if any, on women's psychosocial outcomes. Findings are discussed in relation to the study's methodological strengths and limitations and with respect to the broader context of patient care.     

Prognostic factors of 10-year radiographic outcome in early rheumatoid arthritis: a prospective study

Introduction  

The objectives of this study were to determine the predictive factors of long-term radiographic outcome of rheumatoid arthritis (RA) and to describe the relationship between joint damage and disability over the course of the disease.     

Disease evolution in mixed connective tissue disease: results from a long-term nationwide prospective cohort study

Background

The phenotypic stability of mixed connective tissue disease (MCTD) is not clear, and knowledge about disease activity and remission is scarce. We aimed to establish the occurrence of evolution from MCTD to another defined rheumatic condition, and the prevalence and durability of remission after long-term observation.

Methods

In this large population-based prospective observational MCTD cohort study (N?=?118), disease conversion was defined by the development of new auto-antibodies and clinical features compliant with another well-defined rheumatic condition. Remission was defined by a combination of systemic lupus erythematosus disease activity index 2000 (SLEDAI-2 K) of 0 and European League Against Rheumatism scleroderma trials and research (EUSTAR) activity index <2.5. Predictors of phenotypic stability and disease remission were assessed by logistic regression.

Results

Among 118 patients, 14 (12%) developed another well-defined rheumatic condition other than MCTD after mean disease duration of 17 (SD 9) years. Puffy hands predicted a stable MCTD phenotype in univariable regression analysis (OR 7, CI 2–27, P?=?.010). Disease activity defined by SLEDAI-2 K, decreased gradually across the observation period and?>?90% of patients had EUSTAR activity index <2.5. There were 13% patients in remission throughout the whole mean observation period of 7 (SD 2) years. The strongest predictor of remission was percentage of predicted higher forced vital capacity.

Conclusions

Our results strengthen the view of MCTD as a relatively stable disease entity. Long-term remission in MCTD is not frequent; however, the low SLEDAI-2 K and EUSTAR scores during the observation period suggests that the disease runs a milder course than systemic lupus erythematosus and systemic sclerosis.

     

Geographic variation in cardiovascular inflammation among healthy women in the Women's Health Study

Background

Geographic variation in traditional cardiovascular disease (CVD) risk factors has been observed among women in the US. It is not known whether state-level variation in cardiovascular inflammation exists or could be explained by traditional clinical risk factors and behavioral lifestyle factors.

Methods and Results

We used multilevel linear regression to estimate state-level variation in inflammatory biomarker patterns adjusted for clinical and lifestyle characteristics among 26,029 women free of CVD. Participants derived from the Women''s Health Study, a national cohort of healthy middle-aged and older women. Inflammatory biomarker patterns (plasma levels of high-sensitivity C-reactive protein (hsCRP), soluble intercellular adhesion molecule-1 (sICAM-1), and fibrinogen) were compared to state-level patterns of traditional CVD risk factors and global risk scores. We found that all three inflammatory biomarkers exhibited significant state-level variation including hsCRP (lowest vs. highest state median 1.3 mg/L vs. 2.7 mg/L, unadjusted random effect estimate 1^st to 99^th percentile range for log hsCRP 0.52, p<.001), sICAM-1 (325 ng/ml vs. 366ng/ml, unadjusted random effect estimate 1^st to 99^th percentile range 0.44, p<.001), and fibrinogen (322 mg/dL vs. 367 mg/dL, unadjusted random effect estimate 1^st to 99^th percentile range 0.41, p = .001). Neither demographic, clinical or lifestyle characteristics explained away state-level effects in biomarker patterns. Southern and Appalachian states (Arkansas, West Virginia) had the highest inflammatory biomarker values. Regional geographic patterns of traditional CVD risk factors and risk scores did not completely overlap with biomarkers of inflammation.

Conclusions

There is state-level geographic variation in inflammatory biomarkers among otherwise healthy women that cannot be completely attributed to traditional clinical risk factors or lifestyle characteristics. Future research should aim to identify additional factors that may explain geographic variation in biomarkers of inflammation among healthy women.     

Risk factor control in secondary prevention of cardiovascular disease: results from the multi-ethnic HELIUS study

Objective

To evaluate the quality of contemporary secondary prevention of cardiovascular disease (CVD), and the differences between six ethnic groups in a large, observational cohort.

Design

We included participants with a self-reported history of CVD from the HEalthy LIfe in an Urban Setting (HELIUS) study, which investigates inequalities in health between six ethnic groups living in Amsterdam, the Netherlands. We quantified the proportions of patients who were at the preventive treatment goal according to the guidelines of the European Society of Cardiology for six risk factors: hypertension, dyslipidaemia, smoking, overweight, physical inactivity and diabetes mellitus, and the use preventive medication.

Results

Of 22,165 participants, 1163 (5%) reported a history of CVD. Mean age was 54 years. Overall, 69% had a systolic blood pressure of <140?mm?Hg, and 42% had a low-density lipoprotein (LDL) cholesterol of <2.5?mmol/l. Non-smoking was found in 67%. Body mass index (BMI) <25?kg/m² was found in 24%, and 54% reported adequate physical activity. The mean number of risk factors per patient was three (±1.1) out of six, and only 2% had all risk factors on target. Across the ethnic groups, non-smoking was more prevalent in the Ghanaian and Moroccan groups than in the Dutch (p < 0.001 and p = 0.001, respectively); BMI <25?kg/m² and adequate physical activity were less prevalent among all ethnic minority groups compared with the Dutch group.

Conclusion

We found large treatment gaps in secondary prevention of CVD. Ethnic differences in risk factors were found; however, strategies to improve overall risk factor management may be mandated before designing ethnic-specific strategies.

     

Plant-based diets and incident cardiovascular disease and all-cause mortality in African Americans: A cohort study

BackgroundPrior studies have documented lower cardiovascular disease (CVD) risk among people with a higher adherence to a plant-based dietary pattern. Non-Hispanic black Americans are an understudied group with high burden of CVD, yet studies of plant-based diets have been limited in this population.Methods and findingsWe conducted an analysis of prospectively collected data from a community-based cohort of African American adults (n = 3,635) in the Jackson Heart Study (JHS) aged 21–95 years, living in the Jackson, Mississippi, metropolitan area, US, who were followed from 2000 to 2018. Using self-reported dietary data, we assigned scores to participants’ adherence to 3 plant-based dietary patterns: an overall plant-based diet index (PDI), a healthy PDI (hPDI), and an unhealthy PDI (uPDI). Cox proportional hazards models were used to estimate associations between plant-based diet scores and CVD incidence and all-cause mortality. Over a median follow-up of 13 and 15 years, there were 293 incident CVD cases and 597 deaths, respectively. After adjusting for sociodemographic characteristics (age, sex, and education) and health behaviors (smoking, alcohol intake, margarine intake, physical activity, and total energy intake), no significant association was observed between plant-based diets and incident CVD for overall PDI (hazard ratio [HR] 1.06, 95% CI 0.78–1.42, p-trend = 0.72), hPDI (HR 1.07, 95% CI 0.80–1.42, p-trend = 0.67), and uPDI (HR 0.95, 95% CI 0.71–1.28, p-trend = 0.76). Corresponding HRs (95% CIs) for all-cause mortality risk with overall PDI, hPDI, and uPDI were 0.96 (0.78–1.18), 0.94 (0.76–1.16), and 1.06 (0.86–1.30), respectively. Corresponding HRs (95% CIs) for incident coronary heart disease with overall PDI, hPDI, and uPDI were 1.09 (0.74–1.61), 1.11 (0.76–1.61), and 0.79 (0.52–1.18), respectively. For incident total stroke, HRs (95% CIs) for overall PDI, hPDI, and uPDI were 1.00 (0.66–1.52), 0.91 (0.61–1.36), and 1.26 (0.84–1.89) (p-trend for all tests > 0.05). Limitations of the study include use of self-reported dietary intake, residual confounding, potential for reverse causation, and that the study did not capture those who exclusively consume plant-derived foods.ConclusionsIn this study of black Americans, we observed that, unlike in prior studies, greater adherence to a plant-based diet was not associated with CVD or all-cause mortality.

In a cohort study, Leah J. Weston and colleagues investigate the associations between consumption of plant-based diets and incident cardiovascular disease and all-cause mortality in African Americans.     

Associations between copper and zinc intakes from diet and mortality from cardiovascular disease in a large population-based prospective cohort study

Several studies have related cardiovascular disease (CVD) to serum concentrations of copper and zinc but not to their dietary intakes. We thought to examine the association between dietary intakes of copper and zinc with risk of mortality from CVD in a prospective study encompassing 58,646 healthy Japanese men and women aged 40-79 years. The intakes of copper and zinc were determined by a validated self-administered food frequency questionnaire, and their associations with risk of mortality from CVD were evaluated by Cox proportional hazard modelling. During 965, 970 person-years of follow-up between 1989-2009, we documented 3,388 CVD deaths [1,514 from stroke, 702 from coronary heart disease (CHD) and 1,172 from other CVD]. Copper intake was not associated with CHD mortality; however, the multivariable hazard ratios (HRs) with 95% confidence intervals (CIs) for mortality from stroke, other CVD and total CVD in the highest versus the lowest quintiles of copper intake among men were 1.78 (1.16-2.77; P-trend=0.007), 1.61 (1.01-2.81; P-trend =0.03) and 1.63 (1.21-2.33; P-trend=0.001), respectively, and those among women were 1.49 (1.00-2.19; P-trend=0.04), 1.59 (1.09-2.55; P-trend =0.02) and 1.36 (1.06-1.69; P-trend=0.01), respectively. Higher intakes of zinc was inversely associated with mortality from CHD in men; 0.68 (0.58-1.03; P-trend=0.05) but not women; 1.13 (0.71- 1.49; P-trend=0.61). No associations were observed with other mortality endpoints. In conclusion, dietary copper intake was positively associated with mortality from CVD in both genders; whereas, higher dietary zinc intake was inversely associated with mortality from CHD in men but not women.     

Which measuring site in ankylosing spondylitis is best to detect bone loss and what predicts the decline: results from a 5-year prospective study

Background

Studies have shown increased prevalence of osteoporosis and increased risk for vertebral fractures in patients with ankylosing spondylitis (AS). Measurements of bone mineral density (BMD) in the lumbar spine anterior-posterior (AP) projection may be difficult to interpret due to the ligamentous calcifications, and the lateral projection might be a better measuring site. Our objectives were to investigate BMD changes after 5 years at different measuring sites in patients with AS and to evaluate disease-related variables and medications as predictors for BMD changes.

Methods

In a longitudinal study, BMD in Swedish AS patients, 50?±?13 years old, was measured with dual-energy x-ray absorptiometry (DXA) at the hip, the lumbar spine AP and lateral projections, and the total radius at baseline and after 5 years. Patients were assessed with questionnaires, blood samples, and spinal radiographs for grading of AS-related alterations in the spine with the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) and assessment of vertebral fractures by the Genant score. Multiple linear regression analyses were used to investigate predictors for BMD changes.

Results

Of 204 patients included at baseline, 168 (82%) were re-examined after 5 years (92 men and 76 women). BMD decreased significantly at the femoral neck and radius and increased significantly at the lumbar spine, both for AP and lateral projections. Mean C-reactive protein during follow-up predicted a decrease in the femoral neck BMD (change in %, β?=?–0.15, p?=?0.046). Use of bisphosphonates predicted an increase in BMD at all measuring sites (p?<?0.001 to 0.013), except for the total radius. Use of tumor necrosis factor inhibitors (TNFi) predicted an increase in AP spinal BMD (β?=?3.15, p?=?0.012).

Conclusion

The current study (which has a long follow-up, many measuring sites, and is the first to longitudinally assess the lateral projection of the spine in AS patients) surprisingly showed that lateral projection spinal BMD increased. This study suggests that the best site to assess bone loss in AS patients is the femoral neck and that inflammation has an adverse effect, and the use of bisphosphonates and TNFi has a positive effect, on BMD in AS patients.