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The risk for coronary artery disease (CAD) is substantially increased in type 1 diabetes and it has been postulated that insulin resistance may contribute to this risk. The current study measured insulin resistance in type 1 diabetes with vs without CAD and with a focus upon skeletal muscle, to test the hypothesis that insulin resistance is more severe in participants who have type 1 diabetes and CAD. Additionally, in type 1 diabetes, we examined the hypothesis that insulin resistance is more severe in soleus (an oxidative type muscle) vs tibialis anterior (a more glycolytic type of muscle). Insulin resistance was measured in participants with type 1 diabetes with (n = 9, CAD+) and without CAD (n = 10, CAD−) using euglycaemic insulin infusions combined with positron emission tomography (PET) imaging of [18F]fluorodeoxyglucose (FDG) uptake into soleus and tibialis anterior skeletal muscles. Coronary artery calcium (CAC) score was quantified by electron beam tomography. CAD+ participants with type 1 diabetes had a >100-fold higher CAC score than did CAD− participants with type 1 diabetes but groups did not differ in HbA1c or insulin dose. During clamp studies, CAD+ and CAD− groups had similar glucose disposal but were insulin resistant compared with historical non-diabetic participants (n = 13). FDG uptake by soleus muscle was similarly reduced, overall, in individuals with type 1 diabetes with or without CAD compared with non-diabetic individuals. However, FDG uptake by tibialis anterior muscle was not reduced in CAD− participants with type 1 diabetes while in CAD+ participants with type 1 diabetes it was 75% greater (p

Sodium-glucose cotransporter (SGLT2) inhibitors and glucagon like peptide 1 (GLP-1) receptor agonists have been demonstrated to provide cardio-renal benefits in patients with type 2 diabetes (T2D). Little is known about confidence and perceptions of healthcare professionals (HCPs) across medical specialties to utilize these agents in clinical practice. An online survey was conducted among a national sample of 1,006 physicians, nurse practitioners, and physician assistants in cardiology, endocrinology, nephrology, and primary care. They were asked about current and past perceptions and confidence in prescribing SGLT2s and GLP-1s for cardio-renal benefit. Survey results were analyzed using weighting for gender, region, and practice type. Participants were 56% male, 53% had >10 years of experience, and 32% saw >100 patients/month with T2D. Two-thirds of HCPs reported greater confidence now in prescribing SGLT2s compared to one year ago, with highest proportions among cardiologists (77%) and nephrologists (76%). Over half of HCPs (55%) were more confident now compared to one year ago with prescribing GLP-1s. A greater proportion of participants felt HCPs across all specialties are more responsible now for prescribing SGLT2s and GLP-1s compared to one year ago. Specifically, cardiologists (84%) and nephrologists (76%) felt their own specialties are now responsible for prescribing these agents for cardio-renal protection. These results suggest confidence to prescribe SGLT2s and GLP-1s for cardio-renal benefit has recently increased among medical specialties involved in T2D care. Lower HCP confidence to prescribe GLP-1s compared to SGLT2s may be due to the injectable mode of administration for GLP1s. These results also indicate a growing perception that prescribing these agents is not just the responsibility of a single specialty but is a shared responsibility across the T2D care team. Disclosure D. Zytnick: None. R. Woolley: None. M. Bruns: None. C. M. Shay: None.

Background:The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).Methods:The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year’s worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year’s edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.Results:Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.Conclusions:The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Background: High awareness that cardiovascular disease is the leading cause of death (LCOD) among women is critical to prevention. This study evaluated longitudinal trends in this awareness among women. Methods and Results: Online surveys of US women (≥25 years of age) were conducted in January 2009 and January 2019. Data were weighted to the US population distribution of sociodemographic characteristics. Multivariable logistic regression was used to evaluate knowledge of the LCOD. In 2009, awareness of heart disease as the LCOD was 65%, decreasing to 44% in 2019. In 2019, awareness was greater with older age and increasing education and lower among non-White women and women with hypertension. The 10-year awareness decline was observed in all races/ethnicities and ages except women ≥65 years of age. The greatest declines were among Hispanic women (odds ratio of awareness comparing 2019 to 2009, 0.14 [95% CI, 0.07–0.28]), non-Hispanic Black women (odds ratio, 0.31 [95% CI, 0.19–0.49]), and 25- to 34-year-olds (odds ratio, 0.19 [95% CI, 0.10–0.34]). In 2019, women were more likely than in 2009 to incorrectly identify breast cancer as the LCOD (odds ratio, 2.59 [95% CI, 1.86–3.67]), an association that was greater in younger women. Awareness of heart attack symptoms also declined. Conclusions: Awareness that heart disease is the LCOD among women declined from 2009 to 2019, particularly among Hispanic and non-Hispanic Black women and in younger women (in whom primordial/primary prevention may be most effective). An urgent redoubling of efforts by organizations interested in women’s health is required to reverse these trends.

Background The American Heart Association and Healthy People 2020 established objectives to reduce coronary heart disease (CHD) and stroke death rates by 20% by the year 2020, with 2007 as the baseline year. We examined county‐level achievement of the targeted reduction in CHD and stroke death rates from 2007 to 2017. Methods and Results Applying a hierarchical Bayesian model to National Vital Statistics data, we estimated annual age‐standardized county‐level death rates and the corresponding percentage change during 2007 to 2017 for those aged 35 to 64 and ≥65 years and by urban‐rural classification. For those aged ≥35 years, 56.1% (95% credible interval [CI], 54.1%–57.7%) and 39.8% (95% CI, 36.9%–42.7%) of counties achieved a 20% reduction in CHD and stroke death rates, respectively. For both CHD and stroke, the proportions of counties achieving a 20% reduction were lower for those aged 35 to 64 years than for those aged ≥65 years (CHD: 32.2% [95% CI, 29.4%–35.6%] and 64.1% [95% CI, 62.3%–65.7%]), respectively; stroke: 17.9% [95% CI, 13.9%–22.2%] and 45.6% [95% CI, 42.8%–48.3%]). Counties achieving a 20% reduction in death rates were more commonly urban counties (except stroke death rates for those aged ≥65 years). Conclusions Our analysis found substantial, but uneven, achievement of the targeted 20% reduction in CHD and stroke death rates, defined by the American Heart Association and Healthy People. The large proportion of counties not achieving the targeted reduction suggests a renewed focus on CHD and stroke prevention and treatment, especially among younger adults living outside of urban centers. These county‐level patterns provide a foundation for robust responses by clinicians, public health professionals, and communities.

Background: Growing evidence exists indicate that subjective perceptions of well-being (i.e. life satisfaction) are favorably associated with overall health status. Few reports are available that explore this association in nationally representative samples of US adults. Methods: Data from were collected from 115,929 US adults (18+ y) from all 50 states via dual mail and web-based sampling through the 2018 Gallup National Health and Well-Being Survey. Well-being was assessed by asking individuals to place themselves on a 10-step ladder with ‘worst possible life’ representing the lowest rung and ‘best possible life’ the top rung; ratings were collected for both their current life and their life in 5 years. Based on both current and future life ratings, individuals were categorized as thriving, struggling, or suffering. General health status was assessed based 5 options (excellent to poor). Results: Significant positive trends were observed between current and future levels of life satisfaction with ratings of general health status after accounting for age, sex, education, an income (p Conclusions: Level of well-being assessed by subjective rating of life satisfaction is strongly, positively, and independently associated with perception of general health status in a large sample of US adults. These results may demonstrate the strong influence of well-being on the preservation of health, however, further prospective examination of these associations are warranted.

Background: The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). Methods: The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year’s worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year’s edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association’s 2020 Impact Goals. Results: Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. Conclusions: The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Each decade, the American Heart Association (AHA) develops an Impact Goal to guide its overall strategic direction and investments in its research, quality improvement, advocacy, and public health programs. Guided by the AHA’s new Mission Statement, to be a relentless force for a world of longer, healthier lives, the 2030 Impact Goal is anchored in an understanding that to achieve cardiovascular health for all, the AHA must include a broader vision of health and well-being and emphasize health equity. In the next decade, by 2030, the AHA will strive to equitably increase healthy life expectancy beyond current projections, with global and local collaborators, from 66 years of age to at least 68 years of age across the United States and from 64 years of age to at least 67 years of age worldwide. The AHA commits to developing additional targets for equity and well-being to accompany this overarching Impact Goal. To attain the 2030 Impact Goal, we recommend a thoughtful evaluation of interventions available to the public, patients, providers, healthcare delivery systems, communities, policy makers, and legislators. This presidential advisory summarizes the task force’s main considerations in determining the 2030 Impact Goal and the metrics to monitor progress. It describes the aspiration that these goals will be achieved by working with a diverse community of volunteers, patients, scientists, healthcare professionals, and partner organizations needed to ensure success.

Background: The Patient-Centered Outcomes Research Institute (PCORI) funded National Blood Pressure Surveillance System (BP Track) is a new national system that generates quarterly metrics of blood pressure (BP) control and BP-related quality metrics for participating healthcare systems from electronic health record (EHR) data. Methods: Queries against standardized EHR data in the national Patient-Centered Clinical Research Network (PCORnet) Common Data Model format produce a set of quality metrics relevant to improving BP control, including Controlling High BP (NQF 0018) and Improvement in BP (CMS65v7), and eight process measures specific to clinical management and treatment practices for improving BP control ( Table ). The metrics, aggregated overall and by health system are reported back to health systems via user-friendly Tableau dashboards, and allow for observation of metric trends. Results: To date, 19 datamarts have contributed EHR data from 1,177,232 patients who met the eligibility criteria for the BP Control measure and 4,454,729 encounters that included a BP measurement during the measurement period. Average age was 62 years; 10% were young adults (Table ). Conclusion: Major opportunities exist for improving BP control, especially in improving the frequency and quality of BP medication prescribing for patients with high BP. The BP Track National BP Surveillance System will track these metrics, by demographic subgroup and over time, and will generate data that can guide and focus quality improvement initiatives aimed at effective BP management.

Background: Uncontrolled blood pressure (BP) is a leading preventable cause of death that remains common in the US population despite the availability of effective medications. New technology and program innovation has high potential to improve BP but may be expensive and burdensome for patients, clinicians, health systems, and payers and may not produce desired results or reduce existing disparities in BP control. Methods and Results: The PCORnet Blood Pressure Control Laboratory is a platform designed to enable national surveillance and facilitate quality improvement and comparative effectiveness research. The platform uses PCORnet, the National Patient-Centered Clinical Research Network, for engagement of health systems and collection of electronic health record data, and the Eureka Research Platform for eConsent and collection of patient-reported outcomes and mHealth data from wearable devices and smartphones. Three demonstration projects are underway: BP track will conduct national surveillance of BP control and related clinical processes by measuring theory-derived pragmatic BP control metrics using electronic health record data, with a focus on tracking disparities over time; BP MAP will conduct a cluster-randomized trial comparing effectiveness of 2 versions of a BP control quality improvement program; BP Home will conduct an individual patient-level randomized trial comparing effectiveness of smartphone-linked versus standard home BP monitoring. Thus far, BP Track has collected electronic health record data from over 826 000 eligible patients with hypertension who completed ≈3.1 million ambulatory visits. Preliminary results demonstrate substantial room for improvement in BP control ( Conclusions: The PCORnet Blood Pressure Control Laboratory is designed to be a reusable platform for efficient surveillance and comparative effectiveness research; results from demonstration projects are forthcoming.

Background Hypertrophic cardiomyopathy (HCM) is a clinically and genetically heterogeneous disorder and an important cause of sudden death and heart failure. Limited studies exist that describe diagnosis, treatment, and management experiences of patients with hypertrophic cardiomyopathy. The purpose of this investigation was to use qualitative data collection methodologies to characterize HCM patient experiences related to HCM diagnosis, treatment, self-management, and the life impacts of HCM. Methods Adults aged ≥18 years diagnosed with HCM ≥1-year prior were recruited to participate. Semi-structured interviews were conducted via teleconference using open-ended questions and question probes. Interview recordings were transcribed verbatim and inductive and deductive thematic analyses were conducted. Results A total of 32 interviews were conducted. The majority of participants were female (53.1%), aged ≥45 years (90.6%), white (96.9%), and non-Hispanic (96.9%). Time to diagnosis from symptom onset ranged from Conclusion These results indicate that adults living with HCM can experience many involuntary physical and psychological limitations and restrictions on life. This study indicates a need for healthcare professionals to be aware of the potential impact of HCM on patients and to provide patient support focused on increasing resilience for patients in need. These findings provide information useful for developing strategies and resources for patients and their families. The negative consequences experienced by patients as a result of inaccurate and/or delayed diagnoses and suboptimal interdisciplinary communication between healthcare professionals indicate potential areas of need. Identifying interventions aimed at improving recognition of typical and atypical of HCM symptomology, adherence to clinical practice guidelines for HCM diagnosis and treatment, and collaborative and effective interdisciplinary communication, are critical for exceptional patient care for those with HCM.

Aims To determine association between HbA 1C variability and hypoglycemia requiring hospitalization (HH) in adults with type 1 diabetes (T1D) and type 2 diabetes (T2D). Methods Using nested case-control design in electronic health record data in England, one case with first or recurrent HH was matched to one control who had not experienced HH in incident T1D and T2D adults. HbA 1C variability was determined by standard deviation of ≥3 HbA 1C results. Conditional logistic models were applied to determine association of HbA 1C variability with first and recurrent HH. Results In T1D, every 1.0% increase in HbA 1C variability was associated with 90% higher first HH risk (95% CI, 1.25–2.89) and 392% higher recurrent HH risk (95% CI, 1.17–20.61). In T2D, a 1.0% increase in HbA 1C variability was associated with 556% higher first HH risk (95% CI, 3.88–11.08) and 573% higher recurrent HH risk (95% CI,1.59–28.51). In T2D for first HH, the association was the strongest in non-insulin non-sulfonylurea users ( P P =0.07). The HbA 1C variability-HH association was stronger in more recent years in T2D ( P ≤0.004). Conclusions HbA 1C variability is a strong predictor for HH in T1D and T2D.

Objective— Excess deposition of fat within and around vital organs and nonadipose tissues is hypothesized to contribute to cardiovascular disease (CVD) risk. We evaluated the association of abdominal intermuscular adipose tissue (IMAT) volume with coronary artery calcification in the CARDIA study (Coronary Artery Risk Development in Young Adults) participants. Approach and Results— We measured IMAT in the abdominal muscles, visceral adipose tissue and pericardial adipose tissue, and coronary artery calcification using computed tomography in 3051 CARDIA participants (56% women) at the CARDIA year 25 examination (2010–2011). Mean IMAT volume and mean IMAT/total muscle volume (IMAT normalized for muscle size) were calculated in a 10-mm block of slices centered at L3–L4. Multivariable analyses included potential confounders and traditional cardiovascular disease risk factors. Compared with the lowest quartile, the upper quartile of abdominal IMAT volume was associated with higher coronary artery calcification prevalence (odds ratio [95% confidence interval], 1.6 [1.2–2.1]) after adjusting for cardiovascular disease risk factors. Results were similar for highest versus lowest quartile of IMAT normalized to total muscle volume (odds ratio [95% confidence interval], 1.5 [1.1–2.0]). Significant associations of higher IMAT and normalized IMAT with coronary artery calcification prevalence persisted when body mass index, visceral adipose tissue, or pericardial adipose tissue were added to the models. Conclusions— In a large, community-based, cross-sectional study, we found that higher abdominal skeletal muscle adipose tissue volume was associated with subclinical atherosclerosis independent of traditional cardiovascular disease risk factors and other adipose depots.

Background Visceral fat has been shown to be associated with increased cardiometabolic risk, but the role of subcutaneous fat remains unclear, and evidence from diverse populations is lacking. We hypothesized that visceral fat, but not subcutaneous fat, would be independently associated with incident cardiovascular disease (CVD) and all-cause mortality. Methods Among 1910 participants from the Multi-Ethnic Study of Atherosclerosis with abdominal fat measurements from computed tomography scans and followed for an average of 9.3 years, we used multivariable Cox proportional hazards models to investigate the relationship of both visceral and subcutaneous fat tertiles with CVD and all-cause mortality. We tested for interaction and performed sensitivity analysis for subgroups and missing values of visceral fat. Results Participants had mean age of 65 years, visceral fat 150 cm2, subcutaneous fat 263 cm2, and 50% were female, 21% African American, 13% Asian, and 26% Hispanic. In models adjusted for age, sex, race/ethnicity, income, education, smoking, and subcutaneous fat, there was a statistically significant positive association between visceral fat and CVD, but not mortality. The association for combined CVD may be driven by incident coronary heart disease [tertile 2: hazard ratio, 2.43 (1.38 to 4.28); tertile 3: hazard ratio, 3.00 (1.66 to 5.43)]. Additionally, we found no substantial associations between subcutaneous fat and CVD or mortality. There were no statistically significant interactions by age, sex, or race/ethnicity. Conclusions Visceral fat, but not subcutaneous fat, is significantly associated with increased risk for CVD in a multiethnic cohort. These data support the need for effective strategies for lifestyle changes that prevent and reduce visceral fat.

The release of the American Heart Association’s 2030 Impact Goal and associated metrics for success underscores the importance of cardiovascular health and cardiovascular disease surveillance systems for the acquisition of information sufficient to support implementation and evaluation. The aim of this policy statement is to review and comment on existing recommendations for and current approaches to cardiovascular surveillance, identify gaps, and formulate policy implications and pragmatic recommendations for transforming surveillance of cardiovascular disease and cardiovascular health in the United States. The development of community platforms coupled with widespread use of digital technologies, electronic health records, and mobile health has created new opportunities that could greatly modernize surveillance if coordinated in a pragmatic matter. However, technology and public health and scientific mandates must be merged into action. We describe the action and components necessary to create the cardiovascular health and cardiovascular disease surveillance system of the future, steps in development, and challenges that federal, state, and local governments will need to address. Development of robust policies and commitment to collaboration among professional organizations, community partners, and policy makers are critical to ultimately reduce the burden of cardiovascular disease and improve cardiovascular health and to evaluate whether national health goals are achieved.

IR in T1D may contribute to CAD risk. We recently reported that SM IR in T1D primarily involves oxidative SM while glycolytic SM is comparable to healthy controls. This study compared systemic glucose disposal (GD) and SM IR in T1D with and without CAD. Insulin-infusion glucose clamps measured systemic GD concurrent with positron emission tomography (PET) imaging of SM glucose uptake with [18F]fluorodeoxyglucose (FDG) to profile glucose transport and phosphorylation, rate-limiting steps for GD. PET images were co-registered with MRI of the calf to determine FDG uptake (Patlak K) in soleus (SO) SM (largely oxidative muscle, type 1 fibers) vs. tibialis anterior (TA) SM (largely glycolytic muscle, type 2 fibers). Subjects with (n=9) and without (n=10) CAD were from the Epidemiology of Diabetes Complications (EDC) study, a 30-year prospective study of childhood onset T1D. Those CAD+ were older (52.4 vs. 43.1 years, p Disclosure K.V. Williams: None. C.M. Shay: None. J. Price: None. T.J. Orchard: Consultant; Self; Boehringer Ingelheim International GmbH. D. Kelley: Consultant; Self; Kallyope, Regeneron Pharmaceuticals, Takeda Pharmaceutical Company Limited. Other Relationship; Self; Merck & Co., Inc. Funding National Institutes of Health (DK071487)

In addition to a severe deficiency of insulin secretory capacity, systemic IR has also been identified as contributing to the pathophysiology of T1D. This study was undertaken to examine the contribution of SM, the major site for insulin-stimulated glucose uptake, to the IR of T1D, and more specifically, the role of impaired glucose transport. During euglycemic insulin infusion, dynamic PET imaging of SM was done using [18F]fluorodeoxyglucose (FDG), the metabolism of which is restricted to transport/phosphorylation. PET images were co-registered with calf MRI to assess and compare FDG uptake (Patlak K) in soleus (SO) SM (largely oxidative, type 1 fiber) and in tibialis anterior (TA) SM (largely glycolytic, type 2 fiber) to determine the respective severity of IR in these two types of SM. Systemic IR was assessed as glucose disposal rate (GDR) during the clamps. Participants (n=10) with T1D with no evidence of coronary artery or renal disease were recruited from the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, a 30-year prospective study of childhood onset T1D. Mean HbA1c in T1D was 7.6±1.3%. Nondiabetic healthy controls (n=13) of comparable age (40.4 years) and BMI (24.1 kg/m2) as the T1D group (43.1 years, 24.3 kg/m2) were studied. Systemic IR was evident in T1D, with GDR reduced by ∼25% (4.95 vs. 6.60 mg/kg-FFM, p=0.06). SM IR was clearly present in oxidative SO SM in T1DM, as values for K were reduced by nearly 50% (0.0075 vs. 0.0126 mL/cm3-minutes, p Disclosure K.V. Williams: None. C.M. Shay: None. J. Price: None. T.J. Orchard: Consultant; Self; Boehringer Ingelheim International GmbH. D. Kelley: Consultant; Self; Kallyope, Regeneron Pharmaceuticals, Takeda Pharmaceutical Company Limited. Other Relationship; Self; Merck & Co., Inc. Funding National Institutes of Health (DK071487)

Introduction: Growing evidence suggests that higher levels of sedentary behavior (SB) are associated with higher risk of death. Multiple systematic reviews with meta-analyses (SRMA) have been published on this topic and synthesis of these results would have great utility in facilitating knowledge uptake. Purpose: The purpose of this project is to synthesize existing SRMAs in order to examine associations between SB and all-cause mortality. Methods: A systematic literature review was conducted by querying multiple electronic databases and hand-searching references. Inclusion criteria were SMRAs that reported associations in adults (18+ years old); examined SB as an exposure; included all-cause mortality as an outcome; and where sufficient results were available. Eligibility assessment and data extraction were done in duplicate by two independent reviewers. Discrepancies were solved by consensus. Descriptive characteristics, point estimates, confidence intervals and I 2 were extracted from eligible studies. Results: A total of 676 records were initially identified. After exclusions based on title, abstract, and full-text assessments, 5 eligible meta-analyses were identified, which included results based on 3,575,480 adults. Among the 5 meta-analyses, the studies per meta-analysis ranged from 3 to 12 and sitting time and television viewing time were the types of sedentary behaviors assessed. Effect sizes (OR, RR, HR) in the identified reports ranged from 0.96 to 1.59 (Figure 1). Conclusions: This systematic review of meta-analyses indicates a consistent dose-response of effect sizes between level of SB and all-cause mortality. This emphasizes the importance of targeting SB as a way of improving CV and overall health.

OBJECTIVE To assess associations between nonalcoholic fatty liver disease (NAFLD) and measures of brain health in a population-based sample of adults. METHODS Participants from the CARDIA study (Y25 exam; age 43-55 years) with concurrent computed tomography quantification of liver fat, visceral adipose tissue (VAT), and brain magnetic resonance (MR) images were included (n = 505). NAFLD was identified after exclusion of other causes of liver fat. Total tissue volume (TTV) and gray matter cerebral blood flow (GM-CBF) were estimated using 3T brain MR images. RESULTS NAFLD prevalence was 18%. NAFLD was associated with lower TTV and GM-CBF after adjusting for intracranial volume, demographics, and health behaviors (P

Context Hemoglobin A1C (HbA1C) is an important predictor of severe hypoglycemia. Objective To determine the association of proximal HbA1C level with first hypoglycemia hospitalization (HH) in adults with incident type 2 diabetes (T2D). Design, setting, and participants A nested case-control study was designed using linked data from the Clinical Practice Research Datalink and Hospital Episode Statistics in England in 1997 to 2014. The first hypoglycemia event as primary diagnosis for hospitalization after T2D diagnosis was identified. Proximal HbA1C was measured within 90 days before the first HH. Main outcome measure OR for developing HH. Results The association of proximal HbA1C level with first HH was similar between HbA1C levels of 6.0% (OR, 1.54; 95% CI, 1.12 to 2.11) and 9.0% [1.48 (1.01 to 2.17)] compared with the reference HbA1C level of 7.0%. For proximal HbA1C level of 4.0% to 6.5%, every additional 0.5% increase in HbA1C was associated with lower first HH risk, with ORs (95% CI) ranging between 0.37 (0.20 to 0.67) and 0.86 (0.76 to 0.98). For proximal HbA1C level of 8.0% to 11.5%, every additional 0.5% increase in HbA1C was associated with higher first HH risk, with ORs (95% CI) ranging between 1.16 (1.04 to 1.29) and 1.34 (1.18 to 1.52). The U-shaped association between proximal HbA1C level and first HH did not exist among current sulfonylurea users but persisted among current insulin users (Pinteraction = 0.002). Among current noninsulin nonsulfonylurea users who had a first HH, 78% took insulin or sulfonylureas before the HH. Conclusions Having either poor or near-normal HbA1C was associated with a higher risk of first HH within 3 months in T2D.

Objective: Describe the effects of the 2017 Hypertension Guideline (HTN GL) compared to JNC-7 guideline on recommended blood pressure (BP) treatment status among US adults and identify the potential need for expanded clinical- and community-based BP management services. Methods: Analyze data from 2011-2014 National Health and Nutrition Examination Survey, with analytic sample of 10,031 aged ≥18 years. Results: The new HTN GL reclassifies 32.3 million US adults as newly hypertensive and recommends BP-related treatment for 133.7 million adults, including 4.9 million newly recommended pharmacologic therapy and 50.5 million newly recommended lifestyle modifications alone. An estimated 1.1 million adults newly recommended to initiate pharmacologic treatment and 20.6 million adults newly recommended lifestyle modification alone report not having established healthcare linkages. Application of the new HTN GL affects some groups significantly more than others in being reclassified as having hypertension or being newly recommended to initiate BP treatment. This includes adults aged 18-64 years and males, two groups who historically have limited access to or low utilization of healthcare services for hypertension management. In addition, 3.6 million of the 4.9 million US adults who are newly recommended pharmacologic treatment and 36.4 million of the 50.5 million of those newly recommended lifestyle modification alone, are overweight or obese. Conclusions: The new HTN GL results in millions of additional US adults being recommended for lifestyle modification to manage their BP and a smaller proportion for pharmaceutical treatment. With many of those individuals not having established linkages to healthcare, these results can aid in translating the new HTN GL into clinical practice and public health programs necessary to meet the increased demand for services. Expanded clinical and public health resources are likely to be required to manage the additional millions of US adults recommended to newly initiate pharmacologic treatment and/or lifestyle modification, including many who previously had only limited healthcare system interaction. Community-based prevention strategies can aid in addressing this added burden on the health care system.

Application of the 2017 ACC/AHA Hypertension Guideline expands the number of US adults requiring blood pressure (BP) management. The authors use 2011-2014 NHANES data to describe the population groups most affected by the new guideline, compared with the previous JNC-7 guideline, and describe the previous interaction with the health care sector among those adults recommended new or intensified pharmacologic treatment and/or lifestyle modification. The 2017 Hypertension Guideline reclassifies 32.3 million US adults as newly hypertensive and recommends BP-related treatment of 133.7 million adults, including 57.8 million with uncontrolled BP recommended to initiate or intensify pharmacologic treatment and 50.5 million newly recommended lifestyle modification alone. An estimated 13.1 million (22.7%) adults recommended to initiate or intensify pharmacologic treatment, and 20.6 million (40.8%) adults newly recommended lifestyle modification alone report not having established health care linkages. Among the adults newly recommended lifestyle modification alone, the odds of reclassification from no recommended intervention, under JNC-7, to recommended lifestyle modification alone were lower for adults with established linkages to care (aOR: 0.78 [95% CI: 0.67-0.91]) compared to those without, decreased with increasing age, were greater for men (1.72 [1.52-1.94]) compared to women and were greater for obese adults (1.23 [1.00-1.53]) compared with normal or underweight adults. Application of the 2017 Hypertension Guideline increases the number and alters the distribution of US adults in need of initiating or intensifying BP treatment. This includes identifying millions of US adults who previously had limited interaction with health care and are now recommended new or intensified pharmacologic treatment and/or lifestyle modification.

Background— The American Heart Association recently defined cardiovascular health (CVH) to monitor it over time for all Americans. Nationally representative prevalence estimates for children under 12 years according to sex and race/ethnicity have not been reported. Methods and Results— The study sample comprised 8961 children aged 2 to 11 years from 2003 to 2010 National Health and Nutrition Examination Surveys. National prevalence of ideal, intermediate, and poor CVH as defined by American Heart Association was estimated for each of 4 available metrics (body mass index [BMI], healthy diet score, total cholesterol, and blood pressure). No children had ideal levels for either zero or all 4 metrics. Ideal healthy diet score was least prevalent, ranging from 0 to 0.1%, whereas ideal blood pressure was most prevalent ranging from 88% to 93% across sex, race/ethnicity groups. Ideal BMI was less frequent at ages 6 to 11 years than at ages 2 to 5 years (67% versus 77%). Approximately 40% of children had intermediate or poor total cholesterol levels. The dietary intake of diet score components was associated with BMI, which was associated with blood pressure and total cholesterol. Conclusions— Ideal CVH status for BMI, total cholesterol, and blood pressure was prevalent in young children, whereas ideal diet was rare. Diet and BMI were important components to achieve ideal CVH metrics in children. Limited availability of data for all CVH metrics is a major obstacle for CVH assessment in the youngest age groups and represents an important missed opportunity for surveillance and secular trends analyses with aging.

BACKGROUND: The aim of this study was to determine whether long-term patterns of change in adiposity throughout young adulthood are associated with systolic and diastolic function in midlife. METHODS: Participants in the Coronary Artery Risk Development in Young Adults study, a multicenter, population-based cohort, underwent repeated anthropometric assessment (body mass index [BMI], waist circumference, and waist-to-hip ratio) from examination years 0 to 25. At year 25, longitudinal, circumferential, and radial strain and tissue Doppler velocities were assessed by echocardiography. Group-based trajectory modeling was used to identify 25-year trajectories of change in anthropometric measures and to examine associations between trajectories of adiposity change and indices of cardiac mechanics. RESULTS: Among 3,310 participants, four distinct trajectories of BMI change were identified: stable BMI (36% of the cohort; mean εBMI, 1.6 kg/m(2)), mild increase (40%; mean ABMI, 6.0 kg/m(2)), moderate increase (18%; mean ΔBMI, 10.8 kg/m(2)), and major increase (6%; mean ΔBMI, 15.5 kg/m(2)). Trajectories of greater BMI increase were associated with lower adjusted e′ velocity and higher E/e′ ratio compared with the stable BMI group, independent of year 0 or year 25 BMI. Participants in increasing BMI trajectory groups compared with the stable BMI group had lower absolute longitudinal strain and greater odds of diastolic dysfunction, independent of year 0 BMI but not year 25 BMI. Similar patterns were observed for change in waist circumference and waist-to-hip ratio trajectory groups. CONCLUSIONS: Steeper trajectories of BMI increase from young adulthood to middle age, a vulnerable period for weight gain, are independently associated with lower E/e′ velocity and higher E/e′ ratio, but not systolic dysfunction, in midlife. (J Am Soc Echocardiogr 2018;■:■-■.)

Importance Few tools exist for assessing the risk for early atherosclerotic cardiovascular disease (ASCVD) events in young adults. Objective To assess the performance of the Healthy Heart Score (HHS), a lifestyle-based tool that estimates ASCVD events in older adults, for ASCVD events occurring before 55 years of age. Design, Setting, and Participants This prospective cohort study included 4893 US adults aged 18 to 30 years from the Coronary Artery Risk Development in Young Adults (CARDIA) study. Participants underwent measurement of lifestyle factors from March 25, 1985, through June 7, 1986, and were followed up for a median of 27.1 years (interquartile range, 26.9-27.2 years). Data for this study were analyzed from February 24 through December 12, 2016. Exposures The HHS includes age, smoking status, body mass index, alcohol intake, exercise, and a diet score composed of self-reported daily intake of cereal fiber, fruits and/or vegetables, nuts, sugar-sweetened beverages, and red and/or processed meats. The HHS in the CARDIA study was calculated using sex-specific equations produced by its derivation cohorts. Main Outcomes and Measures The ability of the HHS to assess the 25-year risk for ASCVD (death from coronary heart disease, nonfatal myocardial infarction, and fatal or nonfatal ischemic stroke) in the total sample, in race- and sex-specific subgroups, and in those with and without clinical ASCVD risk factors at baseline. Model discrimination was assessed with the Harrell C statistic; model calibration, with Greenwood-Nam-D’Agostino statistics. Results The study population of 4893 participants included 2205 men (45.1%) and 2688 women (54.9%) with a mean (SD) age at baseline of 24.8 (3.6) years; 2483 (50.7%) were black; and 427 (8.7%) had at least 1 clinical ASCVD risk factor (hypertension, hyperlipidemia, or diabetes types 1 and 2). Among these participants, 64 premature ASCVD events occurred in women and 99 in men. The HHS showed moderate discrimination for ASCVD risk assessment in this diverse population of mostly healthy young adults (C statistic, 0.71; 95% CI, 0.66-0.76); it performed better in men (C statistic, 0.74; 95% CI, 0.68-0.79) than in women (C statistic, 0.69; 95% CI, 0.62-0.75); in white (C statistic, 0.77; 95% CI, 0.71-0.84) than in black (C statistic, 0.66; 95% CI, 0.60-0.72) participants; and in those without (C statistic, 0.71; 95% CI, 0.66-0.76) vs with (C statistic, 0.64; 95% CI, 0.55-0.73) clinical risk factors at baseline. The HHS was adequately calibrated overall and within each subgroup. Conclusions and Relevance The HHS, when measured in younger persons without ASCVD risk factors, performs moderately well in assessing risk for ASCVD events by early middle age. Its reliance on self-reported, modifiable lifestyle factors makes it an attractive tool for risk assessment and counseling for early ASCVD prevention.

Non-alcoholic fatty liver disease (NAFLD) is an obesity-related condition associated with cardiovascular mortality. Yet, whether or not NAFLD is independently related to atherosclerosis is unclear. In a population-based cross-sectional sample of middle-aged adults free from liver or heart disease, we tested the hypothesis that NAFLD is associated with subclinical atherosclerosis (coronary artery (CAC) and abdominal aortic calcification (AAC)) independent of obesity.Participants from the Coronary Artery Risk Development in Young Adults study with CT quantification of liver fat, CAC and AAC were included (n = 2424). NAFLD was defined as liver attenuation ≤40 Hounsfield Units after exclusion of other causes of liver fat. CAC and AAC presence was defined as Agatston score0.Mean participant age was 50.1 ± 3.6 years, (42.7% men, 50.0% black) and BMI was 30.6 ± 7.2 kg/m(2). The prevalence of NAFLD, CAC, and AAC was 9.6%, 27.1%, and 51.4%. NAFLD participants had increased prevalence of CAC (37.9% vs. 26.0%, p 0.001) and AAC (65.1% vs. 49.9%, p 0.001). NAFLD remained associated with CAC (OR, 1.33; 95% CI, 1.001-1.82) and AAC (OR, 1.74; 95% CI, 1.29-2.35) after adjustment for demographics and health behaviors. However, these associations were attenuated after additional adjustment for visceral adipose tissue (CAC OR, 1.05; 95% CI, 0.74-1.48, AAC OR = 1.20; 95% CI, 0.86-1.67). There was no interaction by race or sex.In contrast to prior research, these findings suggest that obesity attenuates the relationship between NAFLD and subclinical atherosclerosis. Further studies evaluating the role of NAFLD duration on atherosclerotic progression and cardiovascular events are needed.

Purpose To examine associations of adolescent body mass index (BMI), tobacco use, and physical activity with optimal physiologic cardiovascular health (CVH) in adulthood. Methods Data were from 12,139 participants in Waves I (1995–1996) and IV (2007–2008) of the National Longitudinal Study of Adolescent Health. We defined optimal CVH as normal blood pressure, glucose, and cholesterol without diabetes or cardiovascular disease. We used logistic regression to estimate odds of having optimal CVH at ages 24–32 years (Wave IV) according to BMI category, smoking status, and physical activity at ages 11–19 years (Wave I). Results Few young adults (16%) had optimal CVH. Adolescents with normal BMI were more than twice as likely to have optimal young adult CVH compared to those who were obese (adjusted odds ratio, 2.77; 95% confidence interval, 1.97–3.89). Adolescent smoking and physical activity did not predict young adult CVH. Conclusions Lower adolescent BMI is associated with young adult CVH.

Background— The American Heart Association (AHA) has defined the concept of ideal cardiovascular health in promotion of the 2020 Strategic Impact Goals. We examined whether adherence to ideal levels of the 7 AHA cardiovascular health metrics was associated with incident cancers in the Atherosclerosis Risk In Communities (ARIC) study over 17 to 19 years of follow-up. Methods and Results— After exclusions for missing data and prevalent cancer, 13 253 ARIC participants were included for analysis. Baseline measurements were used to classify participants according to 7 AHA cardiovascular health metrics. Combined cancer incidence (excluding nonmelanoma skin cancers) from 1987 to 2006 was captured using cancer registries and hospital surveillance; 2880 incident cancer cases occurred over follow-up. Cox regression was used to calculate hazard ratios for incident cancer. There was a significant ( P trend P trend =0.03). Conclusions— Adherence to the 7 ideal health metrics defined in the AHA 2020 goals is associated with lower cancer incidence. The AHA should continue to pursue partnerships with cancer advocacy groups to achieve reductions in chronic disease prevalence.

Importance Coronary artery calcium (CAC) is associated with coronary heart disease (CHD) and cardiovascular disease (CVD); however, prognostic data on CAC are limited in younger adults. Objective To determine if CAC in adults aged 32 to 46 years is associated with incident clinical CHD, CVD, and all-cause mortality during 12.5 years of follow-up. Design, Setting, and Participants The Coronary Artery Risk Development in Young Adults (CARDIA) Study is a prospective community-based study that recruited 5115 black and white participants aged 18 to 30 years from March 25, 1985, to June 7, 1986. The cohort has been under surveillance for 30 years, with CAC measured 15 (n = 3043), 20 (n = 3141), and 25 (n = 3189) years after recruitment. The mean follow-up period for incident events was 12.5 years, from the year 15 computed tomographic scan through August 31, 2014. Main Outcomes and Measures Incident CHD included fatal or nonfatal myocardial infarction, acute coronary syndrome without myocardial infarction, coronary revascularization, or CHD death. Incident CVD included CHD, stroke, heart failure, and peripheral arterial disease. Death included all causes. The probability of developing CAC by age 32 to 56 years was estimated using clinical risk factors measured 7 years apart between ages 18 and 38 years. Results At year 15 of the study among 3043 participants (mean [SD] age, 40.3 [3.6] years; 1383 men and 1660 women), 309 individuals (10.2%) had CAC, with a geometric mean Agatston score of 21.6 (interquartile range, 17.3-26.8). Participants were followed up for 12.5 years, with 57 incident CHD events and 108 incident CVD events observed. After adjusting for demographics, risk factors, and treatments, those with any CAC experienced a 5-fold increase in CHD events (hazard ratio [HR], 5.0; 95% CI, 2.8-8.7) and 3-fold increase in CVD events (HR, 3.0; 95% CI, 1.9-4.7). Within CAC score strata of 1-19, 20-99, and 100 or more, the HRs for CHD were 2.6 (95% CI, 1.0-5.7), 5.8 (95% CI, 2.6-12.1), and 9.8 (95% CI, 4.5-20.5), respectively. A CAC score of 100 or more had an incidence of 22.4 deaths per 100 participants (HR, 3.7; 95% CI, 1.5-10.0); of the 13 deaths in participants with a CAC score of 100 or more, 10 were adjudicated as CHD events. Risk factors for CVD in early adult life identified those above the median risk for developing CAC and, if applied, in a selective CAC screening strategy could reduce the number of people screened for CAC by 50% and the number imaged needed to find 1 person with CAC from 3.5 to 2.2. Conclusions and Relevance The presence of CAC among individuals aged between 32 and 46 years was associated with increased risk of fatal and nonfatal CHD during 12.5 years of follow-up. A CAC score of 100 or more was associated with early death. Adults younger than 50 years with any CAC, even with very low scores, identified on a computed tomographic scan are at elevated risk of clinical CHD, CVD, and death. Selective use of screening for CAC might be considered in individuals with risk factors in early adulthood to inform discussions about primary prevention.

OBJECTIVE To determine trends in hospitalization for hypoglycemia in adults with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) in England. RESEARCH DESIGN AND METHODS Adults with T1DM or T2DM were identified from 398 of the 684 practices within the Clinical Practice Research Datalink, for which linkage to the Hospital Episode Statistics was possible. Hypoglycemia as the primary reason for hospitalization between 1998 and 2013 was extracted. Trends were estimated using joinpoint regression models for adults with T1DM, young and middle-aged adults with T2DM (18–64 years), and elderly adults with T2DM (≥65 years), respectively. RESULTS Among 23,246 adults with T1DM, 1,591 hypoglycemia hospitalizations occurred during 121,262 person-years. Among 241,441 adults with T2DM, 3,738 hypoglycemia hospitalizations occurred during 1,344,818 person-years. In adults with T1DM, the incidence increased 3.74% (95% CI 1.70–5.83) annually from 1998 to 2013. In young and middle-aged adults with T2DM, the annual incidence increase was 4.12% (0.61–7.75) from 1998 to 2013. In elderly adults with T2DM, the incidence increased 8.59% (5.76–11.50) annually from 1998 to 2009, and decreased 8.05% (−14.48 to −1.13) annually from 2009 to 2013, but the incidence was still higher in 2013 than 1998 (adjusted rate ratio 3.01 [1.76–5.14]). Trends in HbA1c level did not parallel trends of hypoglycemia hospitalization for both diabetes types. A possible reason for declined hypoglycemia trend in 2009–2013 in elderly adults with T2DM may be continuously decreased sulfonylurea use after 2009, which was not seen in young and middle-aged adults with T2DM. CONCLUSIONS Hypoglycemia requiring hospitalization has been an increasing burden in adults with T1DM and T2DM in England in the previous two decades, with the exception of the decline in elderly adults with T2DM starting in 2009.

To determine the association between dietary intake and risk of non-severe hypoglycemia in adolescents with type 1 diabetes.Type 1 adolescents from a randomized trial wore a blinded continuous glucose monitoring (CGM) system at baseline for one week in free-living conditions. Dietary intake was calculated as the average from two 24-h dietary recalls. Non-severe hypoglycemia was defined as having blood glucose70mg/dL for ≥10min but not requiring external assistance, categorized as daytime and nocturnal (11PM-7AM). Data were analyzed using logistic regression models.Among 98 participants with 14,277h of CGM data, 70 had daytime hypoglycemia, 66 had nocturnal hypoglycemia, 55 had both, and 17 had neither. Soluble fiber and protein intake were positively associated with both daytime and nocturnal hypoglycemia. Glycemic index, monounsaturated fat, and polyunsaturated fat were negatively associated with daytime hypoglycemia only. Adjusting for total daily insulin dose per kilogram eliminated all associations.Dietary intake was differentially associated with daytime and nocturnal hypoglycemia. Over 80% of type 1 adolescents had hypoglycemia in a week, which may be attributed to the mismatch between optimal insulin dose needed for each meal and actually delivered insulin dose without considering quality of carbohydrate and nutrients beyond carbohydrate.ClinicalTrials.gov identifier: NCT01286350.

This document provides a pediatric-focused companion to “Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction: The American Heart Association’s Strategic Impact Goal Through 2020 and Beyond,” focused on cardiovascular health promotion and disease reduction in adults and children. The principles detailed in the document reflect the American Heart Association’s new dynamic and proactive goal to promote cardiovascular health throughout the life course. The primary focus is on adult cardiovascular health and disease prevention, but critical to achievement of this goal is maintenance of ideal cardiovascular health from birth through childhood to young adulthood and beyond. Emphasis is placed on the fundamental principles and metrics that define cardiovascular health in children for the clinical or research setting, and a balanced and critical appraisal of the strengths and weaknesses of the cardiovascular health construct in children and adolescents is provided. Specifically, this document discusses 2 important factors: the promotion of ideal cardiovascular health in all children and the improvement of cardiovascular health metric scores in children currently classified as having poor or intermediate cardiovascular health. Other topics include the current status of cardiovascular health in US children, opportunities for the refinement of health metrics, improvement of health metric scores, and possibilities for promoting ideal cardiovascular health. Importantly, concerns about the suitability of using single thresholds to identify elevated cardiovascular risk throughout the childhood years and the limits of our current knowledge are noted, and suggestions for future directions and research are provided.

Aims/hypothesisThe prospective association between cardiorespiratory fitness (CRF) measured in young adulthood and middle age on development of prediabetes, defined as impaired fasting glucose and/or impaired glucose tolerance, or diabetes by middle age remains unknown. We hypothesised that higher fitness levels would be associated with reduced risk for developing incident prediabetes/diabetes by middle age.MethodsParticipants were from the Coronary Artery Risk Development in Young Adults (CARDIA) study who were free from prediabetes/diabetes at baseline (year 0 [Y0]: 1985-1986). CRF was quantified by treadmill duration (converted to metabolic equivalents [METs]) at Y0, Y7 and Y20 and prediabetes/diabetes status was assessed at Y0, Y7, Y10, Y15, Y20 and Y25. We use an extended Cox model with CRF as the primary time-varying exposure. BMI was included as a time-varying covariate. The outcome was development of either prediabetes or diabetes after Y0. Model 1 included age, race, sex, field centre, CRF and BMI. Model 2 additionally included baseline (Y0) smoking, energy intake, alcohol intake, education, systolic BP, BP medication use and lipid profile.ResultsHigher fitness was associated with lower risk for developing incident prediabetes/diabetes (difference of 1 MET: HR 0.99898 [95% CI 0.99861, 0.99940], p

Background— The American Heart Association's 2020 Strategic Impact Goals define a new concept, cardiovascular (CV) health; however, current prevalence estimates of the status of CV health in US adults according to age, sex, and race/ethnicity have not been published. Methods and Results— We included 14 515 adults (≥20 years of age) from the 2003 to 2008 National Health and Nutrition Examination Surveys. Participants were stratified by young (20–39 years), middle (40–64 years), and older (≥65 years) ages. CV health behaviors (diet, physical activity, body mass index, smoking) and CV health factors (blood pressure, total cholesterol, fasting blood glucose, smoking) were defined as poor, intermediate, or ideal. Fewer than 1% of adults exhibited ideal CV health for all 7 metrics. For CV health behaviors, nonsmoking was most prevalent (range, 60.2%–90.4%), whereas ideal Healthy Diet Score was least prevalent (range, 0.2%–2.6%) across groups. Prevalences of ideal body mass index (range, 36.5%–45.3%) and ideal physical activity levels (range, 50.2%–58.8%) were higher in young adults compared with middle or older ages. Ideal total cholesterol (range, 23.7%–36.2%), blood pressure (range, 11.9%–16.3%), and fasting blood glucose (range, 31.2%–42.9%) were lower in older adults compared with young and middle-aged adults. Prevalence of poor CV health factors was lowest in young age but higher at middle and older ages. Prevalence estimates by age and sex were consistent across race/ethnic groups. Conclusions— These prevalence estimates of CV health represent a starting point from which effectiveness of efforts to promote CV health and prevent CV disease can be monitored and compared in US adult populations.

Background: The extent to which adult height, a biomarker of the interplay of genetic endowment and early-life experiences, is related to risk of chronic diseases in adulthood is uncertain. Methods: We calculated hazard ratios (HRs) for height, assessed in increments of 6.5 cm, using individual-participant data on 174 374 deaths or major non-fatal vascular outcomes recorded among 1 085 949 people in 121 prospective studies. Results: For people born between 1900 and 1960, mean adult height increased 0.5-1 cm with each successive decade of birth. After adjustment for age, sex, smoking and year of birth, HRs per 6.5 cm greater height were 0.97 (95% confidence interval: 0.96-0.99) for death from any cause, 0.94 (0.93-0.96) for death from vascular causes, 1.04 (1.03-1.06) for death from cancer and 0.92 (0.90-0.94) for death from other causes. Height was negatively associated with death from coronary disease, stroke subtypes, heart failure, stomach and oral cancers, chronic obstructive pulmonary disease, mental disorders, liver disease and external causes. In contrast, height was positively associated with death from ruptured aortic aneurysm, pulmonary embolism, melanoma and cancers of the pancreas, endocrine and nervous systems, ovary, breast, prostate, colorectum, blood and lung. HRs per 6.5 cm greater height ranged from 1.26 (1.12-1.42) for risk of melanoma death to 0.84 (0.80-0.89) for risk of death from chronic obstructive pulmonary disease. HRs were not appreciably altered after further adjustment for adiposity, blood pressure, lipids, inflammation biomarkers, diabetes mellitus, alcohol consumption or socio-economic indicators. Conclusion: Adult height has directionally opposing relationships with risk of death from several different major causes of chronic diseases. Published by Oxford University Press on behalf of the International Epidemiological Association © The Author 2012; all rights reserved.

Levels of ideal cardiovascular health (ICH) and incident type 2 diabetes mellitus have not been examined in a multiethnic population. We assessed the total and race/ethnicity-specific incidence of diabetes based on American Heart Association (AHA) ICH components. Incident diabetes was assessed among 5341 participants in the Multi-Ethnic Study of Atherosclerosis without prevalent diabetes between 2002 and 2012. ICH components (total cholesterol, BP, dietary intake, tobacco use, physical activity and BMI) were assessed at baseline and participants were categorised as having ideal, intermediate or poor cardiovascular health, as defined by the AHA 2020 impact goals. We developed a scoring system based on the number of ICH components (0–1 ‘poor’, 2–3 ‘intermediate’, and ≥4 ‘ideal’). HRs were calculated using Cox models. During a median follow-up of 11.1 years, we identified 587 cases of incident diabetes. After multivariable adjustment, participants with 2–3 and ≥4 ICH components vs 0–1 components had a 34% lower (HR 0.66; 95% CI 0.54, 0.80) and a 75% lower (HR 0.25; 95% CI 0.18, 0.35) diabetes incidence, respectively. There were significant differences by race/ethnicity: African-American and Hispanic-American participants with ≥4 ICH components had diabetes incidence rates per 1000 person-years of 5.6 (95% CI 3.1, 10.1) and 10.5 (95% CI 6.7, 16.4), respectively, compared with 2.2 (95% CI 1.3, 3.7) among non-Hispanic white Americans. Meeting an increasing number of AHA 2020 impact goals for dietary intake, physical activity, smoking, BP, cholesterol and BMI was associated with a dose-dependent lower risk of diabetes with significant variation by race/ethnicity.

The purpose of this study was to quantify associations between hemoglobin A1C (A1C) and diabetes knowledge score using an assessment tool developed to evaluate the level of diabetes knowledge in young adults with Type 1 diabetes (T1DM) and their parent/primary caregiver. Seventy-five participants with T1DM, ages 15-22 years, completed questionnaires. Two 25-item questionnaires were developed: one for patient and one for caregiver. Linear regression quantified associations between correct items on the tools and participant A1C and demographic characteristics. Mean age of participants was 16.7 ± 1.7 years, diabetes duration 5.9 ± 4.2 years, 46.7% male, 74.7% Caucasian, 69.3% on multiple daily injections, and 30.7% on continuous subcutaneous insulin infusion therapy; 78.7% of parents/caregivers completed the questionnaire. A significant interaction was observed between patient and caregiver scores with A1C by diabetes duration. Among patients with diabetes

Background Clinical practice focuses on the primary prevention of cardiovascular (CV) disease ( CVD) through the modification and pharmacological treatment of elevated risk factors. Prediction models based on established risk factors are available for use in the primary prevention setting. However, the prevention of risk factor development through healthy lifestyle behaviors, or primordial prevention, is of paramount importance to achieve optimal population‐wide CV health and minimize long‐term CVD risk. Methods and Results We developed a lifestyle‐based CVD prediction model among 61 025 women in the Nurses’ Health Study and 34 478 men in the Health Professionals Follow‐up Study, who were free of chronic disease in 1986 and followed for ≤24 years. Lifestyle factors were assessed by questionnaires in 1986. In the derivation step, we used the Bayes Information Criterion to create parsimonious 20‐year risk prediction models among a random two thirds of participants in each cohort separately. The scores were validated in the remaining one third of participants in each cohort. Over 24 years, there were 3775 cases of CVD in women and 3506 cases in men. The Healthy Heart Score included age, smoking, body mass index, exercise, alcohol, and a composite diet score. In the validation cohort, the risk score demonstrated good discrimination (Harrell's C‐index, 0.72; 95% confidence interval [ CI], 0.71, 0.74 [women]; 0.77; 95% CI, 0.76, 0.79 [men]), fit, and calibration, particularly among individuals without baseline hypertension or hypercholesterolemia. Conclusions The Healthy Heart Score accurately identifies individuals at elevated risk for CVD and may serve as an important clinical and public health screening tool for the primordial prevention of CVD .

Background: Dietary Reference Intakes (DRIs) are reference values established by the Food and Nutrition Board of the Institute of Medicine and are intended for purposes of planning and assessing diets for healthy populations. As consumption of fast food has continued to increase, the question of nutrient adequacy is of growing concern. Purpose: The purpose of this investigation is to quantify the association between frequency of fast food consumption and likelihood of meeting DRIs in a middle age adult population. Methods: Coronary Artery Risk Development in Young Adults (CARDIA) is a multi-center longitudinal study among black and white men and women who, at year 20 of follow up, were ages 38-50 years (n=3,089). Dietary intake was assessed by trained, certified interviewers using the validated CARDIA Diet History questionnaire. Fast food frequency was quantified based on responses to a dietary behavior questionnaire and categorized according to 0, >0- Results: More frequent consumption of fast food was associated with lower likelihood of meeting recommended levels of several essential nutrients and greater likelihood of exceeding recommended intakes of sodium and sugar (Table1). Conclusions: These findings raise awareness of the need for targeting public health messages aimed at improving diets of fast food consumers, for example, by improving foods served at fast food restaurants to help meet nutrient needs in the US diet.

Dietary fiber intake might reduce cardiovascular risk factor levels and, in turn, might lower the long-term risk of cardiovascular disease (CVD). A total of 11,113 subjects, aged 20 to 79 years with no history of CVD, from the 2005 to 2010 National Health and Nutrition Examination Survey were included in the present study to examine associations of dietary fiber intake with predicted lifetime CVD risk and C-reactive protein levels. Dietary fiber intake showed a significant gradient association with the likelihood of having a low or an intermediate predicted lifetime CVD risk among young and middle-age adults. In fully adjusted multinomial logistic models, dietary fiber intake was related to a low lifetime CVD risk with an odds ratio of 2.71 (95% confidence interval 2.05 to 3.59) in the young adults and 2.13 (95% confidence interval 1.42 to 3.20) in the middle-age adults and was related to an intermediate lifetime risk of 2.65 (95% confidence interval 1.79 to 3.92) in the young and 1.98 (95% confidence interval 1.32 to 2.98) in the middle-age adults compared with a high lifetime risk. A significant inverse linear association was seen between dietary fiber intake and log-transformed C-reactive protein levels with a regression coefficient ± standard error of −0.18 ± 0.04 in the highest quartile of fiber intake compared with the lowest fiber intake. In conclusion, these data suggest that dietary fiber intake is independently associated with the predicted lifetime CVD risk, especially in young and middle-age adults. A greater amount of dietary fiber intake might be associated with lower C-reactive protein levels.

Background— The American Heart Association's 2020 Strategic Impact Goals target a 20% relative improvement in overall cardiovascular health with the use of 4 health behavior (smoking, diet, physical activity, body mass) and 3 health factor (plasma glucose, cholesterol, blood pressure) metrics. We sought to define current trends and forward projections to 2020 in cardiovascular health. Methods and Results— We included 35 059 cardiovascular disease–free adults (aged ≥20 years) from the National Health and Nutrition Examination Survey 1988–1994 and subsequent 2-year cycles during 1999–2008. We calculated population prevalence of poor, intermediate, and ideal health behaviors and factors and also computed a composite, individual-level Cardiovascular Health Score for all 7 metrics (poor=0 points; intermediate=1 point; ideal=2 points; total range, 0–14 points). Prevalence of current and former smoking, hypercholesterolemia, and hypertension declined, whereas prevalence of obesity and dysglycemia increased through 2008. Physical activity levels and low diet quality scores changed minimally. Projections to 2020 suggest that obesity and impaired fasting glucose/diabetes mellitus could increase to affect 43% and 77% of US men and 42% and 53% of US women, respectively. Overall, population-level cardiovascular health is projected to improve by 6% overall by 2020 if current trends continue. Individual-level Cardiovascular Health Score projections to 2020 (men=7.4 [95% confidence interval, 5.7–9.1]; women=8.8 [95% confidence interval, 7.6–9.9]) fall well below the level needed to achieve a 20% improvement (men=9.4; women=10.1). Conclusions— The American Heart Association 2020 target of improving cardiovascular health by 20% by 2020 will not be reached if current trends continue.

Background: The assessment of fat mass and fat-free mass in relation to the symptom-limited maximal exercise duration (Maxdur) of a treadmill test allows for insight into the association of body composition with treadmill performance potential. Objective: We investigated the complex associations between fat mass and fat-free mass and Maxdur in a population setting. Design: The Maxdur of a graded exercise treadmill test and body composition by dual-energy X-ray absorptiometry were estimated in 2413 black and white men and women aged 38–50 y from the Coronary Artery Risk Development in Young Adults (CARDIA) cohort. Results: The mean Maxdur was ’7.5 s shorter per kilogram of fat mass in both men and women and independent of the fat-free mass, height, race, television watching, physical activity, systolic blood pressure, lung function, and education. Fat mass modified the association of the fat-free mass with the Maxdur (2-way interaction P , 0.001), and the interaction was stronger in women than in men. In men in the lowest fat-mass quartile, the Maxdur was 1.3 s longer per kilogram of fat-free mass and was 0.5 s shorter per kilogram of fat-free mass in the highest fat-mass quartile. In contrast, in women with the least fat mass, the Maxdur was 2.7 s longer per kilogram of fat-free mass and was 2.8 s shorter per kilogram of fat-free mass in the highest fat-mass quartile. Conclusions: The Maxdur was negatively related to fat mass. Fatfree mass in obese people contributed little to the treadmill performance potential as assessed by the Maxdur, although the contribution of fat-free mass was positive in thinner people. Am J Clin Nutr doi: 10.3945/ajcn.110.008995.

Lower extremity fat mass (LEFM) has been shown to be favorably associated with glucose metabolism. However, it is not clear whether this relationship is similar across varying levels of obesity. We hypothesized that lower amounts of LEFM is associated with higher insulin resistance (IR) and this association may vary according to weight status. Participants with available measures were examined from the Coronary Artery Risk Development in Young Adults study (CARDIA), a multi-center longitudinal study of the etiology of atherosclerosis in black and white men and women aged 38-50 years old in 2005-2006 (n = 1,579). The homeostasis model assessment of IR (HOMA(IR)) was calculated to estimate IR, regional adiposity was measured using dual energy X-ray absorptiometry (DXA), and weight status was defined according to BMI categories. Obese and overweight participants exhibited higher IR, total fat mass (FM), trunk FM (TFM), and LEFM compared to normal weight participants. After controlling for age, height, race, study center, education, smoking, and cardiorespiratory fitness (CRF), greater LEFM was significantly associated with higher IR only in normal weight men and women. Further adjustment for TFM revealed that lower LEFM was significantly associated with higher IR in overweight and obese men and women and the positive association in normal weight individuals was attenuated. These results suggest that excess adiposity in the lower extremities may attenuate the metabolic risk observed at a given level of abdominal adiposity in overweight and obese individuals. Weight status presents additional complexity since the metabolic influence of adipose tissue may not be homogenous across anatomic regions or level of obesity.

Aims Evidence suggests that the degree of gluteal-femoral adiposity may be inversely associated with coronary artery disease (CAD) risk; however, this association has not been evaluated in type 1 diabetes (T1D). Methods The relationship between regional adiposity, cardiovascular risk factors, and presence of CAD was examined in participants from the Pittsburgh Epidemiology of Diabetes Complications (EDC) study using data collected from the 18-year exam ( n = 163). Total and regional adiposity was assessed by dual X-ray absorptiometry (DEXA). Results Participants with CAD exhibited lower % leg fat mass (FM) (33.42 vs. 36.96, p = 0.006) and higher % trunk FM (48.33 vs. 45.18, p = 0.02), respectively, after adjusting for age, sex, height, and total adiposity compared to those without CAD. Multivariate logistic regression analyses revealed that in females, every 1 SD increase in % leg FM was associated with an approximate 60% reduction in CAD risk (OR = 0.40, 95% CI 0.16–0.99). Higher % trunk FM was also associated with greater risk of CAD prevalence in females (OR = 2.79, 95% CI 1.08–7.20 per SD change). These associations were not observed in males. Conclusions This is novel evidence that DEXA-assessed lower body adiposity is inversely associated with CAD in T1D, however, this association seems to only exist in females.

IMPORTANCE Single measures of blood pressure (BP) levels are associated with the development of atherosclerosis; however, long-term patterns in BP and their effect on cardiovascular disease risk are poorly characterized. OBJECTIVES To identify common BP trajectories throughout early adulthood and to determine their association with presence of coronary artery calcification (CAC) during middle age. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort data from 4681 participants in the CARDIA study, who were black and white men and women aged 18 to 30 years at baseline in 1985-1986 at 4 urban US sites, collected through 25 years of follow-up (2010-2011). We examined systolic BP, diastolic BP, and mid-BP (calculated as [SBP+DBP]/2, an important marker of coronary heart disease risk among younger populations) at baseline and years 2, 5, 7, 10, 15, 20, and 25. Latent mixture modeling was used to identify trajectories in systolic, diastolic, and mid-BP over time. MAIN OUTCOMES AND MEASURES Coronary artery calcification greater than or equal to Agatston score of 100 Hounsfield units (HU) at year 25. RESULTS We identified 5 distinct mid-BP trajectories: low-stable (21.8%; 95% CI, 19.9%-23.7%; n=987), moderate-stable (42.3%; 40.3%-44.3%; n=2085), moderateincreasing (12.2%; 10.4%-14.0%; n=489), elevated-stable (19.0%; 17.1%-20.0%; n=903), and elevated-increasing (4.8%; 4.0%-5.5%; n=217). Compared with the low-stable group, trajectories with elevated BP levels had greater odds of having a CAC score of 100 HU or greater. Adjusted odds ratios were 1.44 (95% CI, 0.83-2.49) for moderate-stable, 1.86 (95% CI, 0.91-3.82) for moderate-increasing, 2.28 (95% CI, 1.24-4.18), for elevated-stable, and 3.70 (95% CI, 1.66-8.20) for elevated-increasing groups. The adjusted prevalence of a CAC score of 100 HU or higher was 5.8% in the low-stable group. These odds ratios represent an absolute increase of 2.7%, 5%, 6.3%, and 12.9% for the prevalence of a CAC score of 100 HU or higher for the moderate-stable, moderate-increasing, elevated-stable and elevated-increasing groups, respectively, compared with the low-stable group. Associations were not altered after adjustment for baseline and year 25 BP. Findings were similar for trajectories of isolated systolic BP trajectories but were attenuated for diastolic BP trajectories. CONCLUSIONS AND RELEVANCE Blood pressure trajectories throughout young adulthood vary, and higher BP trajectories were associated with an increased risk of CAC in middle age. Long-term trajectories in BP may assist in more accurate identification of individuals with subclinical atherosclerosis.