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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 $4,628 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.

Recent guidelines highlight the importance of improving cardiovascular health in the general population in addition to disease prevention among high risk individuals. We investigated factors associated with ethnic and nativity-related differences in the prevalence of low cardiovascular risk (optimal levels of all major cardiovascular risk factors).We used logistic regression to estimate differences in likelihood of being low risk (not currently smoking; no diabetes; untreated total cholesterol200mg/dL; untreated blood pressure120/80; and body mass index25 kg/m(2)) among 8693 foreign- and U.S.-born Mexican-American and non-Hispanic White 2003-2008 U.S. National Health and Nutrition Examination Survey participants before and after adjustment for socioeconomic, lifestyle, and acculturation-related factors.Foreign-born Mexican-Americans were more likely to be low risk than non-Hispanic Whites after adjustment for all covariates (Odds Ratio [OR]: 1.53; 95% Confidence Interval [CI]: 1.00, 2.34). In contrast, U.S.-born Mexican-Americans were less likely to be low risk compared to Whites (OR: 0.60; 95% CI: 0.43, 0.84). Differences between foreign-born and U.S.-born Mexican-Americans were largely attenuated after adjustment for acculturation indicators.Our findings support the healthy migrant hypothesis and suggest that acculturation-related factors may be important drivers of ethnic and nativity-related differences in low cardiovascular risk.

Examine the association between multiple psychological factors (depressive symptoms, trait anxiety, perceived stress) and subclinical atherosclerosis in older age.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.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 CAC0 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.Of several psychological factors, only trait anxiety was significantly associated with CAC.

Background. Questions regarding the efficacy of nonpharmacologic approaches for the treatment of stage 1 hypertension were addressed as part of the Treatment of Mild Hypertension Study (TOMHS), a 4-year, randomized clinical trial (N = 902). This report describes the lifestyle intervention program used in TOMHS, presents data on the lifestyle changes observed, and focuses on the effect of weight loss on blood pressure and blood lipid levels. Methods. Participants were randomly assigned to receive either placebo or one of five different antihypertensive medications. All took part in a lifestyle intervention program to reduce weight and sodium and alcohol intake and to increase physical activity. Results. Substantial changes from baseline levels were achieved for all lifestyle intervention variables. Mean weight change was −10.5 lb (−5.6%) at 1 year, −8.5 lb (−4.5%) at 2 years, −7.4 lb (−4.0%) at 3 years, and −5.7 lb (−3.0%) at 4 years. At 4 years, 70% of participants remained below baseline weight and 34% maintained a weight loss of 10 lb or greater. Mean change in urinary sodium excretion was −12.5 mmol/8 hr (−23%) at 1 year, −10.7 mmol/8 hr (−20%) at 2 years, −8.4 mmol/8 hr (−16%) at 3 years, and −4.6 mmol/8 hr (−9%) at 4 years. Alcohol intake declined by 1.6 drinks/week among drinkers at 4 years. Reported leisure physical activity increased by 86% at 1 year and remained 50% above baseline at 4 years. Beneficial changes in blood pressure and serum lipids were associated with these changes. Conclusions. These results support a role for lifestyle interventions as the initial treatment for stage 1 hypertension and demonstrate that such interventions can be successfully implemented in the clinical setting.

The results are presented for the first 4 years of the Multiple Risk Factor Intervention Trial (MRFIT) nutrition intervention program. Study participants were at high risk (upper 10–15%) for Coronary Heart Disease (CHD). The Special Intervention (SI) group reached and sustained the goals of an eating pattern originally designed to limit cholesterol intake to less than 300 mg/day, with less than 10% of calories as saturated fat and not more than 10% as polyunsaturated fat. By the end of the first year, mean serum total cholesterol had fallen by 6.3% from the mean initial value of 254 mg/dl. The magnitude of the decrease became slightly greater in the ensuing years, reaching 7.4% by the fourth annual visit. Substantially larger decreases in mean serum cholesterol level were observed in the subgroups with the highest baseline level, greatest weight loss, in those who did not smoke, and in those who had normal blood pressure on entry. The changes in cholesterol level were accompanied by parallel changes in mean plasma LDL cholesterol, which also fell by 6.6% over the 4 years, but mean HDL cholesterol was not substantially altered. Comparison with earlier population data suggests that the overall responses to the MRFIT eating pattern were limited by the apparent fact that participants had already made self-initiated changes toward the fatcontrolled dietary pattern before they entered the study.

Data from 10,559 men and women, aged 30–64, participating in the morning and afternoon in a Chicago Health Department multiphasic screening project, were used to evaluate the relationship of time of day and time since last meal to group mean serum cholesterol, hematocrit, systolic and diastolic blood pressure, and heart rate. Serum cholesterol showed no definable differences with time of day and time since last meal. Hematocrit values tended to be slightly higher in the morning than in the afternoon and showed no consistent differences with time since last meal. Systolic blood pressure values, but not diastolic, were slightly higher in the afternoon than in the morning. Mean heart rates tended to be slightly higher in the afternoon and lower with time elapsed since last meal. All these differences were small and not of an order to present significant problems with regard to carrying out mass screening for these variables over the course of the day.

The coronary heart disease mortality rate in Italy—lower than in many other industrialized countries—has changed little in the last 20 years, whereas in the United States, a major decline in deaths resulting from coronary heart disease has occurred. These differing trends have reduced considerably the gap between the two countries in coronary mortality rates. Several recent population studies in Italy have found a change in the previously more favorable risk factor profile. In the northern hill town of Gubbio, studied in 1983–1985, median serum cholesterol level of men ages 40–59 was 223 mg/dl, considerably higher than was found in the 1960 Italian population samples of the Seven Countries Study (197–206 mg/dl). In the earlier study, the cholesterol levels in the Italian men who were still mainly consuming the traditional Mediterranean diet were 30–40 mg/dl lower than in the U.S. sample. The 1980 Gubbio levels, however, were at least as high as those of their U.S. contemporaries. Cigarette smoking was much higher among the middle-aged men of Gubbio than among a similar U.S. population sample (56% vs 36%). Hypertension prevalence was high, and several risk factors for hypertension—obesity, high salt intake, and alcohol—were common in the Gubbio as well as in other recent Italian population studies. The changing coronary risk profile in Italy, which now includes higher population levels of serum cholesterol as well as the other major coronary heart disease risk factors of cigarette smoking and hypertension, threatens to reduce markedly the “Mediterranean advantage” enjoyed by Italy in the past.

Ability to safely withdraw well-controlled mild hypertensives from drugs is being tested in a three-group randomized trial. Group I (intervention) was removed from drugs after the first 2 months of nutrition counseling. Counseling is continuing through the remaining years of the trial to achieve a minimum weight loss of 10 lb if overweight, reduction of sodium intake to less than 1,800 mg, and reduction of alcohol intake to not more than two drinks per day. Group II (the first control group) was also removed from drugs to see if previous long-term blood pressure control had a carryover effect without dietary change. Blood pressure is monitored frequently in both groups, with return to drug treatment in the event of specified blood pressure rise. Group III (the second control group) has remained on drugs for comparison of blood pressure and biochemical variables. In Group I mean 30-month weight loss was 8 lb, with 35% losing 10+ lb; sodium intake was reduced by 38%. Blood pressure control without drugs was maintained for 47% of Group I patients but only 16% of group II patients (P less than 0.05). These findings indicate it may be possible, after establishing good blood pressure control, to maintain control in a sizable proportion without medication, when reduction of weight, sodium, and alcohol intake is achieved.

The need to prevent and control high blood pressure (HBP), including so-called "mild" hypertension [diastolic blood pressure (DBP) 90-104 mm Hg in adults age 30+] stems from the extensive data on the increased risks due to these common blood pressure (BP) levels, including risk of catastrophic cardiovascular events (coronary, cerebrovascular, etc.), both nonfatal and fatal. Prospective population data from the national cooperative Pooling Project and the Chicago Heart Association Detection Project in Industry illustrate the extensively documented facts. They also show that only a small minority of middle-aged and older Americans have optimal low-normal BP levels, i.e., DBP less than 80 mm Hg (SBP less than 120). Thus, the problem of BP above optimal level for health over a long life span is a population-wide problem. The data also show that the great majority of excess catastrophic events attributable to elevated BP occur among people with DBP 90-104 and 80-89 mm Hg, levels very common in the population. Most people with such BP levels also have one or more other major risk factors (e.g., hypercholesterolemia, cigarette use, ECG abnormalities) and thus are at markedly increased risk, both relative and absolute. In addition to these excess risks for major illness, disability, and death, people with BP above optimal levels are more highly prone to other events, clinical and subclinical, that have adverse effects on long-term prognosis, including development of target organ damage and severe hypertension. These data lead to the following inferences about medical care and public health strategy: (a) A key task is, by safe nutritional-hygienic means, to shift the entire population distribution of BP downward, for both primary and secondary prevention of HBP. Such means include prevention and control of obesity, high sodium and alcohol intake, and sedentary habit, from early childhood on. (b) People with DBP 80-89 mm Hg need to be identified promptly, with institution of nutritional-hygienic measures to prevent development of frank hypertension and to correct other risk factors. (c) People with DBP 90-104 and higher need to be identified promptly, with institution of measures to normalize BP and control other major risk factors, by nutritional-hygienic means alone whenever possible or in combination with drug treatment for HBP when necessary to prevent organ system damage, serious illness, disability, and premature death.(ABSTRACT TRUNCATED AT 400 WORDS)

The association between baseline alcohol intake and mortality from all causes and specific causes based on 17 years of follow-up experience was analyzed for 1,832 white males originally age 40–55 from the Chicago Western Electric Company study. Alcohol consumption was expressed as number of drinks per day for all intake combined, including hard liquor, beer, and wine, based on the maximum intake reported on three questionnaires. With mortality rates adjusted only for age, total intake was associated with increased risk of death from all causes, the cardiovascular diseases, coronary heart disease, cancer, and other causes at the level of six or more drinks per day. There was no increase in mortality with increasing alcohol consumption below this level. Only the associations between alcohol intake and death from the cardiovascular diseases and coronary heart disease failed to persist after adjustment for other risk factors, such as smoking and blood pressure. When the deaths were divided into those occurring within the first 10 years of follow-up and those occurring more than 10 years after entry, the association between baseline alcohol intake and mortality was generally stronger for those deaths occurring more than 10 years after entry.

Publisher Summary This chapter provides an overview of public health aspects of optimal serum lipid–lipoprotein levels. It discusses why optimal serum lipid–lipoprotein levels are a major public health concern. The concern with the public health aspects of optimal serum lipid–lipoprotein levels stems from the key role of serum lipids–lipoproteins in the etiology and pathogenesis of the atherosclerotic diseases, especially the premature coronary heart disease (CHD) epidemic in the western industrialized countries. This is the key epidemic disease of modern times in western industrialized countries, particularly the United States. In these countries, in the era of their full development and economic maturity, irrespective of social system, it is the great white plague, replacing tuberculosis, which was the massive epidemic disease of the infancy and childhood of modern urban society. The chapter further reviews the societal roots of epidemic disease, the need and rationale for the primary prevention of the atherosclerotic diseases, and scientific evidence on the key role of rich diet and nonoptimal serum lipids–lipoproteins in the etiology and pathogenesis of epidemic atherosclerotic disease. Improved nutrition is the central public health issue regarding further progress toward optimal serum lipid–lipoprotein levels.

This brief overview of outcome in studies on the primary and secondary prevention of CHD with drugs influencing cholesterol-lipid-lipoprotein metabolism or with platelet-influencing drugs indicates the following conclusions: (1) The central finding of the European trial on primary prevention with clofibrate—significant adverse effects on long-term mortality from all causes—compels the conclusion that this drug has no place in the broad effort to reduce CHD risk by lowering plasma lipids-lipoproteins. (2) No other disease endpoint data are as yet available on lipid reduction by other drugs for primary prevention; data from a U.S. cholestyramine trial are due in 1983 or 1984. (3) Results of the Coronary Drug Project with lipid-influencing drugs for secondary prevention in middle-aged post-MI men were negative for 5.0 and 2.5 mg/day mixed conjugated equine estrogens, and for dextrothyroxine, with early termination of all three of these regimens because of possible adverse effects. At the scheduled end of the trial, clofibrate showed no evidence of benefit and some signs of adverse effects. Nicotinic acid showed no evidence of benefit in regard to the primary CDP endpoint, all causes mortality, but it yielded a significant reduction in rates of nonfatal MI, nonfatal MI + CHD death, and stroke events. (4) Combined therapy with resin + nicotinic acid has a much greater capacity—over and above diet—than any single lipid-lowering drug to reduce markedly all atherogenic lipids-lipoproteins, while simultaneously raising HDL, but no disease endpoint data are available on benefit/risk ratio with this regimen. (5) Eight secondary prevention trials with platelet—influencing drugs indicate encouraging but not statistically significant results in five of six aspirin trials, in a trial with aspirin + dipyridamole, and in a trial with sulfinpyrazone. (6) Viewed in perspective, these discouraging data on lipid—influencing drugs for the primary and secondary prevention of CHD, and these equivocal data with platelet-influencing drugs for secondary prevention reinforce the fundamental conclusion that the main strategic thrust for the control of epidemic premature CHD must be primary prevention by nutritional-hygienic means , i.e., avoidance and correction of the lifestyles—especially “rich” diet and cigarette smoking, also sedentary living and incongruent behavior—that are the cause of the mass problem.

The Multiple Risk Factor Intervention Trial (MRFIT) was a randomized primary prevention trial to test whether a special intervention (SI) program to reduce high blood pressure, elevated blood cholesterol, and/or cigarette smoking could lower coronary heart disease (CHD) mortality in middle-aged men at above average risk. After an average follow-up period of 7 years, risk factor levels were reduced substantially more in SI than in usual-care (UC) men; however, SI-UC differences in CHD mortality (7.1%) and total mortality (-2.1%) were not statistically significant. Subgroup analysis showed 35% fewer SI than UC CHD deaths (P = 0.14) but no all-causes mortality difference in men comparable to the cohort having dietary and smoking intervention in Oslo (the "Oslo-like" cohort). Among the subgroup hypertensive at entry, SI-UC differences in CHD and total mortality appeared to be heterogeneous: CHD mortality was 24% lower in SI than UC men with a normal resting ECG at baseline, but 67% higher if baseline ECG abnormalities were present (nominal P = 0.02, for difference in relative risk estimates). These findings were supported by within-group analyses and are generally consistent with results of other CHD/cardiovascular disease prevention trials. They pose a new hypothesis about possible adverse effects of diuretic therapy in a minority of the hypertensive population.

Research evidence on the role of dietary sodium in the etiology and pathogenesis of hypertension is briefly reviewed. This matter is assuming new importance at present, given new data on the efficacy of normalization of blood pressure for adults with so-called “mild” hypertension (average diastolic 90–104 mm Hg), hence the need for safe nutritional-hygienic alternatives to years-long drug treatment for millions of people with such hypertension. Two trials by the authors deal with some unresolved questions in this area. The first, a preliminary study, involved 21 lacto-ovo-vegetarian high school students living in a boarding school. With decrease in daily Na intake from 216 to 72 meq for the experimental compared with the control group, red blood cell Na concentration was significantly lower in the former; systolic pressure was slightly but not significantly lower. The second trial, the Primary Prevention of Hypertension, involves over 200 hypertension-prone persons aged 30–44, and explores the ability in the experimental group to reduce blood pressure and prevent development of hypertension by safe nutritional-hygienic means (weight reduction, dietary Na decrease, avoidance of excess alcohol, rhythmic exercise). Initial results at 6 months are presented. Trials on the prevention and control of hypertension by nonpharmacologic means, including reduced Na intake, and involving analyses of the interrelationships among dietary Na, other dietary factors, Na metabolism, and blood pressure in samples from different population strata, are an important present-day research need.

Candidates for future development of premature coronary heart disease (CHD) can now be identified with a degree of probability unsurpassed for most other diseases, and equaled for few. This remarkable achievement has not come about fortuitously, but through the deliberate planning of long-term epidemiological studies. The ultimate purpose of defining risk in quantitative terms is the identification of susceptibles in the community, in order to institute ereventive measures. The predictability of coronary disease in middle age from simple risk factor measurements provides an invaluable scientific base for curbing the contemporary epidemic of this preeminent chronic disease. The eventual elimination of this epidemic demands, in addition to identification and care of susceptibles, changes in the mode of life in the national community at large (la.