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Background: Limited previous studies in the United Kingdom or a single US state have demonstrated an association between intake of glucosamine/chondroitin and mortality. This study sought to investigate the association between regular consumption of glucosamine/chondroitin and overall and cardiovascular (CVD) mortality in a national sample of US adults. Methods: Combined data from 16,686 participants in National Health and Nutrition Examination Survey 1999 to 2010, merged with the 2015 Public-use Linked Mortality File. Cox proportional hazards models were conducted for both CVD and all-cause mortality. Results: In the study sample, there were 658 (3.94%) participants who had been taking glucosamine/chondroitin for a year or longer. During followup (median, 107 months), there were 3366 total deaths (20.17%); 674 (20.02%) were due to CVD. Respondents taking glucosamine/chondroitin were less likely to have CVD mortality (hazard ratio [HR] = 0.51; 95% CI, 0.28-0.92). After controlling for age, use was associated with a 39% reduction in all-cause (HR = 0.61; 95% CI, 0.49–0.77) and 65% reduction (HR = 0.35; 95% CI, 0.20–0.61) in CVD mortality. Multivariable-adjusted HR showed that the association was maintained after adjustment for age, sex, race, education, smoking status, and physical activity (all-cause mortality, HR = 0.73; 95% CI, 0.57–0.93; CVD mortality, HR = 0.42; 95% CI, 0.23–0.75). Conclusions: Regular intake of glucosamine/chondroitin is associated with lower all-cause and CVD mortality in a national US cohort and the findings are consistent with previous studies in other populations. Prospective studies to confirm the link may be warranted.

Background: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States (US), with West Virginia bearing a disproportionate disease burden. Complex COPD cases can be difficult to manage during a standard primary care provider (PCP) visit, and pharmacological treatment regimens should be individually tailored to each patient. Methods: To address these needs, the West Virginia University Department of Family Medicine created an interdisciplinary COPD specialty clinic that uses a team-based approach to treat patients with COPD. In order to evaluate the effectiveness of the specialty clinic, we conducted a retrospective chart review to examine the impact of the clinic on patient hospitalizations, emergency department visits, and urgent care visits six months and one year before and after initiating care at the clinic. We also examined the impact of the clinic on patients’ self-reported nicotine dependency, COPD symptoms, and tobacco use behavior. Patients referred to the clinic and having at least one visit from February 2015 to February 2019 were included in this study (n = 149). Results: Patients treated at the COPD specialty clinic had significantly fewer hospital admissions and ED visits six months after and one year after initiating care at the clinic as compared to six months before and one year before, respectively. Patients at this clinic also reported smoking significantly fewer cigarettes per day with significantly fewer self-identifying as smokers and experiencing significantly reduced COPD symptoms. Conclusion: An interdisciplinary, team-based approach was effective for improving the health of COPD patients in an Appalachian academic primary care practice.

OBJECTIVE: The Dietary Inflammatory Index (DII) is a recently developed dietary inflammation assessment tool. The current study examined the association between DII and the presence and severity of diabetes in adults age ≥20 years. RESEARCH DESIGN AND METHODS: Cross-sectional analysis of 4434 adult participants in the National Health and Nutrition Examination Survey (NHANES 2013 to 2014). The DII was calculated based on 24-hour dietary recall data. Linear and logistic regression models were used to estimate the relationship and control for possible confounding factors. RESULTS: Among 4434 participants, mean age was 49.4 years, mean BMI (body mass index) was 29.3 kg/m(2), and mean DII (higher is more inflammatory) was 0.65 (range, −3.41 to +9.05). The mean DII scores in participants with and without diabetes were 0.79 and 0.50, respectively (P = .0098). Participants with Hemoglobin A1c (HgbA1c) >9% had higher DII scores than those with 6.5% to 9% HgbA1c (1.37 vs 0.54, P = .0002) and those with 9%. Further research will help clarify the association between inflammation and diet and the utility of the DII as a tool in risk assessment and management of patients with diabetes.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of an interdisciplinary diabetes team model of care in assisting patients to achieve improved glucose control in a primary care rural setting. METHODS: A family medicine clinic at a rural university medical center developed an interdisciplinary diabetes team clinic composed of a certified diabetes educator/dietitian, a case manager, a pharmacist, nursing staff, a family medicine resident, a psychologist, and a board-certified family medicine attending physician. Patients were referred if their hemoglobin A1c (HbA1c) was ≥9% (75 mmol/mol); patients were seen for an initial consultation and for additional visits as needed. RESULTS: A total of 94 patients attended an initial visit and at least 1 follow-up within 6 months. Mean age was 57 ± 13 years, and 54% were female. Median time from the initial intensive diabetes clinic visit to a follow-up visit was 2.8 months. There was a significant reduction in median HbA1c percentage from 10.25% (88.5 mmol/mol) ± 1.4% (range 73–104 mmol/mol) at the initial intensive diabetes clinic visit to 8.7% (72 mmol/mol) ± 1.8% (range 52–92 mmol/mol) at a 1- to 6-month follow-up (z = −7.161, P < 0.001) and a significant difference between baseline HbA1c (10.25% [88.5 mmol/mol] ± 1.4% [range 73–104 mmol/mol]) and latest HBA1c (1–18 months later) 8.4% (68 mmol/mol) ± 2.2% (range 44–92 mmol/mol; z = −7.022, P < 0.001). Overall, 86% of patients had a lower HbA1c at follow-up, and 33% had an HbA1c 0.05). CONCLUSIONS: An interdisciplinary team approach to glycemic control can achieve significant reductions in HbA1c in the rural primary care setting.

OBJECTIVES The objective of this study was to assess the cardiovascular health status of baby boomers with diabetes mellitus (DM) in comparison to the same-age population with DM 10 years previously. METHODS The study was conducted in baby boomers with DM using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2012 compared with NHANES 1999-2002. Cardiovascular health metrics were derived from the American Heart Association's Life's Simple 7. The primary outcome was the comparison of the proportion of individuals with each characteristic, including healthy diet, healthy weight, not smoking, exercising regularly, and maintaining an optimal level of glycated hemoglobin (HbA1C), cholesterol, and blood pressure. RESULTS Current baby boomers with DM (NHANES 2009-2012) had more obesity (70.9% vs 58.8%; P = 0.009) and a lower proportion of ideal physical activity (20.9% vs 31.7%; P = 0.01) than people of the same age 10 years ago; fewer than 1% adhere to an ideal healthy diet. Current baby boomers more often had ideal cholesterol (59.4% vs 47.2; P = 0.01) and reached an ideal HbA1C (51.0% vs 43.4%; P = 0.047). Blood pressure control, adherence to ideal diet, and smoking rates were not significantly different from 10 years ago. In logistic regression analyses controlling for likely confounders, baby boomers persisted in having more obesity and exercising less often, and reaching an ideal cholesterol level more often (P < 0.01). CONCLUSIONS Although improving in cholesterol and HbA1C, baby boomers demonstrated worsening in several key cardiovascular health indicators, particularly obesity and physical activity.

Despite recent national emphasis, outpatient hand washing can be less than optimal. We tested a new approach involving both patient and physician hand washing. The study consisted of 384 questionnaires, 184 from phase 1 and 200 from phase 2. Patients stated doctors washed their hands 96.6% before examining them pre-intervention and 99.5% of the time post-intervention. Patients endorsed the importance of hand washing 98.7% of the time. “Co-washing” may offer a process to increase the practice of hand washing and decrease infection risk.

Paul A. Heidenreich, MD, MS, FACC, FAHA, Chair Nancy M. Albert, PhD, CCNS, CCRN, FAHA Paul S. Chan, MD, MSc, FACC Lesley H. Curtis, PhD T. Bruce Ferguson, Jr, MD, FACC Gregg C. Fonarow, MD, FACC, FAHA P. Michael Ho, MD, PhD, FACC, FAHA Corrine Jurgens, PhD, RN, ANP-BC, FAHA Sean O’Brien

Introduction: An improper immune response has been shown to increase mortality following acute ischemic stroke (AIS), and targeting the immune system may offer a critical, novel treatment option in AIS. Recently, several immune-modulating agents, such as neutrophil inhibitory factor (UK-279, 276) showed promise in preclinical AIS models; however, either failed or were detrimental in clinical trials. One potential reason for their failure may be an improper time of administration, due to a lack of characterization of a healthy versus a detrimental peripheral immune profile following AIS. The aim of this study is to characterize the pattern of peripheral neutrophil and lymphocyte expression and neutrophil-lymphocyte ratio (NLR) following AIS. Hypothesis: We hypothesized that patients with mild AIS or good functional outcome following AIS will display an elevated NLR from 0-48 hours due to increased neutrophil activation, followed by a reduction in NLR from 48-96 hours due to an increase in lymphocyte activation. Methods: We analyzed data from 300 AIS patients for this study. White blood cell differentials were used to record neutrophil and lymphocyte percentages at several time points during hospitalization and to calculate NLR. AIS patients were grouped by severity using their National Institutes of Health Stroke Score (NIHSS) at admission and by functional outcome using their Modified Rankin Scale (MRS) at discharge. Results: Regardless of severity or outcome, patients have an elevated neutrophil percentage from 0-48 hours following AIS. From 48-96 hours following AIS, patients with mild AIS or MRS 0-2 have a significant decrease in neutrophil percentage, with a concordant increase in lymphocyte percentage compared to severe AIS patients. Further, NLR at discharge is significantly higher in severe AIS patients or patients with MRS>2 (p=0.014). Conclusion: In conclusion, our study is the first to describe the patterns of peripheral neutrophil and lymphocyte expression in the acute phase of AIS. These findings may shed light on the failure of UK-279,276 in clinical trial. This study also provides support for the use of the NLR as a prognostic marker, especially at ~48 hours following AIS, compared to the traditional assessment at admission.

OBJECTIVES The dietary habits of baby boomers (people born between 1946 and 1964) undoubtedly will have a substantial impact on their future health; however, dietary information regarding the intake of key chronic disease-related nutrients is lacking for this generation. The objective of this study was to compare the dietary intake of key chronic disease-related nutrients of the baby boomer generation with the previous generation of middle-aged adults. METHODS National cross-sectional study comparison analyzing data from the National Health and Nutrition Examination Survey (NHANES) including NHANES III (1988-1994) and the NHANES for 2007-2010, focused on adult respondents ages 46 to 64 years who were not institutionalized at the time of each survey. The two cohorts were compared with regard to dietary intake of key nutritional components. The main outcome measures were intake of total calories, sodium, cholesterol, fat, fruits, vegetables, vitamin C, water, and fiber. RESULTS The baby boomers' average daily intake of nutrients exceeded that of the previous generation of middle-aged adults for total calories (2118/1999), total fat (82/76 g), sodium (3513/3291 mg), and cholesterol (294/262 g; all P < 0.001). The intake of vitamin C (105/89 g), water (1208/1001 g), and vegetables (199/229 g) was less than that of the previous generation (P < 0.001), and the dietary intake of fruit and fiber was unchanged. In regression analyses, dietary changes remained significant after controlling for age, race, sex, and socioeconomic status (all P < 0.01). CONCLUSIONS The study findings document higher dietary intake of key chronic disease-related nutrients along with reduced vegetable intake among baby boomers compared with the previous generation of middle-aged adults. These findings are indicative of a diet that may contribute to increased rates of chronic disease among individuals in this age group.

Background: The evidence of the relationship between fiber intake and control of diabetes is mixed. The purpose of this study was to determine if an increase in dietary fiber affects glycosylated hemoglobin (HbA1c) and fasting blood glucose in patients with type 2 diabetes mellitus. Methods: Randomized studies published from January 1, 1980, to December 31, 2010, that involved an increase in dietary fiber intake as an intervention, evaluated HbA1c and/or fasting blood glucose as an outcome, and used human participants with known type 2 diabetes mellitus were selected for review. Results: Fifteen studies met inclusion and exclusion criteria. The overall mean difference of fiber versus placebo was a reduction of fasting blood glucose of 0.85 mmol/L (95% CI, 0.46–1.25). Dietary fiber as an intervention also had an effect on HbA1c over placebo, with an overall mean difference of a decrease in HbA1c of 0.26% (95% CI, 0.02–0.51). Conclusion: Overall, an intervention involving fiber supplementation for type 2 diabetes mellitus can reduce fasting blood glucose and HbA1c. This suggests that increasing dietary fiber in the diet of patients with type 2 diabetes is beneficial and should be encouraged as a disease management strategy.

PURPOSE Hot tea and coffee have been found to have antimicrobial properties. The purpose of this study was to determine whether the consumption of tea, cof- fee, or both is associated with less frequent nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA). METHODS We performed a secondary analysis of data from the 2003-2004 National Health and Nutrition Examination Survey to investigate the relationship between the consumption of coffee, hot tea, cold tea, and soft drinks, and MRSA nasal carriage among the noninstitutionalized population of the United States. RESULTS An estimated 2.5 million persons (1.4% of the population) were MRSA nasal carriers. In an adjusted logistic regression analysis controlling for age, race, sex, poverty-income ratio, current health status, hospitalization in the past 12 months, and use of antibiotics in the past month, individuals who reported consuming hot tea were one-half as likely to have MRSA nasal carriage relative to individuals who drank no hot tea (odds ratio = 0.47; 95% confi dence interval, 0.31-0.71). Similarly, individuals who reported consuming coffee had about a one-half reduction in the risk of MRSA nasal carriage relative to individuals who drank no coffee (odds ratio = 0.47; 95% confi dence interval, 0.24-0.93). CONCLUSIONS Consumption of hot tea or coffee is associated with a lower likeli- hood of MRSA nasal carriage. Our fi ndings raise the possibility of a promising new method to decrease MRSA nasal carriage that is safe, inexpensive, and eas- ily accessible.

Aim This randomized clinical trial was conducted 2008 – 2009 to investigate a cryotherapy (cooling) gel wrap applied to lower leg skin affected by chronic venous disorders to determine whether therapeutic cooling improves skin microcirculation. Impaired skin microcirculation contributes to venous leg ulcer development, thus new prevention therapies should address the microcirculation to prevent venous leg ulcers.

The role of dietary fiber in the prevention of cardiovascular disease has received increasing attention as supportive data have accumulated. Recent studies have found a consistently protective effect of diets that are high in fiber on cardiovascular disease outcomes, prompting many leading organizations to recommend increased fiber in the daily diet. However, the biologic mechanisms underlying how fiber influences the cardiovascular system have yet to be fully elucidated. Epidemiologic evidence demonstrating that high fiber diets (>20–30 g/day) are beneficial, coupled with new evidence of a possible metabolic effect on inflammatory markers, insulin resistance and lipids, suggest that there may be several important mediators in the association between dietary fiber and cardiovascular disease. Further research is needed regarding the optimal intake amount of fiber and which sources of fiber are most beneficial in the prevention of cardiovascular disease in older adults.

Objective To determine whether moderate alcohol intake modifies the association between low vitamin D levels and insulin resistance (IR), we hypothesized that moderate alcohol intake would have a modifying effect on IR in people with low vitamin D levels. Methods This was a cross-sectional analysis of subjects ≥20 y old without a history of diabetes, coronary heart disease, or stroke in the National Health and Nutrition Examination Survey 2001–2004. Main outcome was IR status measured by homeostasis model assessment for IR (HOMA-IR; ≥ 2.6) and fasting insulin (>12.2 μU/mL) in moderate drinkers compared with non-drinkers by vitamin D levels (deficient ≤20 ng/mL, insufficient 21–32 ng/mL, normal >32 ng/mL). Results Two thousand seven hundred twenty-one subjects met the inclusion criteria, representing a weighted total of >138 million people. Of these, 34% were vitamin D deficient and 47% insufficient. In adjusted analysis, compared with moderate drinkers with normal vitamin D levels, non-drinkers had no increased risk of IR by HOMA-IR levels (odds ratio [OR] 1.18, 95% confidence interval [CI] 0.61–2.30). Vitamin D–deficient individuals had a higher risk of IR regardless of alcohol consumption (moderate drinkers OR 2.12, 95% CI 1.41–3.19; non-drinkers OR 2.22, 95% CI 1.29–3.83). However, in those with insufficient vitamin D levels, moderate alcohol intake had a modifying effect on the odds of IR, with no difference seen in moderate drinkers (OR 1.29, 95% CI 0.92–1.80) and an increased risk found in non-drinkers (OR 1.82, 95% CI 1.07–3.11). Similar results were seen with fasting insulin. Conclusion Moderate alcohol consumption appears to have a modifying effect on the risk of IR in individuals with insufficient levels of vitamin D.

The objective of this study was to compare rates of use of medications for diabetes, hypertension, and hypercholesterolemia between 1988-1994 and 2001-2006 and determine whether increased medication use may be partly attributable to nonadherence to healthy lifestyle habits. This study analyzed and compared data from two different time periods in the National Health and Nutrition Examination Survey (NHANES). Disease prevalence rates increased 23% (P < 0.01), and medication use increased 121% (P < 0.05) over the study's period. Diabetes medication use increased from 5.3% to 8.7%, antihypertension medication from 23.0% to 32.4%, and cholesterol-lowering medication from 4.5% to 16.7% (all P < 0.05). By race, diabetes medication use increased most among Hispanics (7.2% to 13.2%), antihypertension use increased most among non-Hispanic blacks (30.8% and 39.6%), and cholesterol medication increased most in non-Hispanic whites (4.9% to 17.8%) (all P < 0.05). Greater adherence to healthy lifestyle habits was associated with less use of medication (P < 0.01). Medication use for diabetes, hypertension, and hypercholesterolemia has increased between 1988-1994 and 2001-2006 and is greater in people with fewer healthy lifestyle habits.

Asymmetric dimethylarginine (ADMA) is an emerging biomarker that has been associated with oxidative metabolism and increased cardiovascular risk. Little information is available regarding the effect of diet on ADMA.The authors studied 86 overweight/obese adults as part of a clinical trial of psyllium supplementation to determine whether 3 months of such supplementation would affect ADMA levels. Forty-one people in the intervention group received 14 g/day of psyllium in addition to their usual diet compared with 45 controls who followed their usual diet alone. The 2 groups were comparable at baseline in demographic characteristics and body mass index.Baseline ADMA levels were elevated in this overweight/obese population compared with published reference values in healthy individuals (0.75 vs 0.50 micromol/L). The change in ADMA levels over 3 months was not different in the psyllium group compared with the control group (-.03 vs -.01 micromol/L, P=.73).These findings do not support a significant effect of psyllium fiber supplementation on ADMA.

PURPOSE Recent evidence supports a signifi cant association between the intake of dietary fi ber and levels of infl ammatory markers. The objective of this study was to determine whether daily fi ber supplementation would reduce levels of infl ammatory markers. METHODS This study was a prospective randomized controlled trial at a single university medical center. Participants were overweight or obese adults with no history of heart disease. The intervention was psyllium supplementation at either 7 or 14 g/d for 3 months compared with no supplements in a control group. The main outcome measure was change in level of high-sensitivity C-reactive protein (hsCRP) concentration; secondary outcomes included changes in interleukin-6 (IL- 6) levels, fi brinogen levels, and white blood cell (WBC) count. Protocol completers attended at least 2 visits and took more than 75% of the prescribed fi ber dose. RESULTS In this intent-to-treat analysis (n = 158), there were no signifi cant dif- ferences between either of the 2 treatment groups and the control group in the amount of change in CRP, fi brinogen, or IL-6 levels or in WBC count (P >.05). In the analysis of protocol completers (n = 132), there also were no signifi cant dif- ferences between the groups except for a small decrease in fi brinogen level in the high-fi ber group (-6 mg/dL (-0.18 μmol/L) compared with 13 mg/dL (0.38 μmol/L) in the control group, P

People with chronic venous disease are at high risk for developing venous leg ulcers. Inflammation is posited as a pathological factor for this chronic condition as evidenced by persistently elevated skin temperature. As part of a larger trial to test the effects of a cooling regimen on leg ulcer prevention, the objective of this preliminary study was to evaluate the first 30 days of intense daily cooling. Compared to a placebo control cuff, a gel cuff applied to the most severely affected lower leg skin for 30 min daily showed no statistically significant differences between temperatures taken in the home at baseline compared to those measured at the 1 month follow up visit. There were also no differences in temperatures noted between the two groups, although the temperatures in the treatment group were lower 30 min after treatment, an indication of adherence. There was no discernable decrease or increase in temperature at a given time point during the 30 day treatment period compared to the control group. It may be better to have patients monitor skin temperature on a daily basis and then apply the cuff as necessary, rather than requiring daily cooling based on baseline measurement. This "prn" approach may provide a sufficient cooling milieu to prevent escalation of inflammation and thwart ulcer occurrence or recurrence. Clinical trials registration #NCT01509599.

Increased resting heart rate increases cardiovascular risk in individuals with hypertension. The extent to which such risk extends to people with prehypertension is not known. The purpose of this study was to determine whether elevated resting heart rate contributes to increased coronary heart disease (CHD) risk in people with prehypertension.The cohort for the current study consisted of 3275 persons from the Atherosclerosis Risk in Communities (ARIC) study, 45 to 64 years old in 1986 to 1989, with a mean follow-up of 10.1 years. The primary outcomes were CHD and all-cause mortality.Individuals with prehypertension and elevated resting heart rate had 50% higher all-cause mortality than people with prehypertension and lower resting heart rate (hazard ratio [HR] 1.50, 95% confidence interval [CI] 1.0-2.15), which was essentially unchanged after controlling for age, ethnicity, gender, diabetes, smoking status, LDL-cholesterol, exercise, and use of antilipemic agents (P.01). Similarly, in unadjusted analyses, CHD risk was 49% higher for people with increased heart rate (HR 1.49, 95% CI 1.03-2.14). In adjusted analyses, elevated resting heart rate remained a factor in increased risk of CHD in women (adjusted HR 2.18, 95% CI 1.08-4.42), but not in men.Resting heart rate is an easily accessible tool that may be helpful for stratifying CHD and mortality risk in people with prehypertension.

Previous research has indicated that dietary magnesium may be a key component in the association between diet and inflammation; however, the role of intake from magnesium supplements has not been elucidated. The objective of this study was to determine the likelihood of elevated C-reactive protein (CRP) in people taking magnesium-containing supplements of 50 mg/d or more. We examined this issue in a study sample derived from the National Health and Nutrition Examination Survey 1999-2002, a nationally representative, survey of the civilian, noninstitutionalized population of the United States. Among US adults, 25.6% were taking a magnesium supplement of at least 50 mg daily. Only 21.9% of individuals not taking supplemental magnesium met or exceeded the recommended daily allowances (RDA) for magnesium intake compared with 60.2% of adults who were taking magnesium supplements. In adjusted logistic regression analyses, people whose total daily magnesium intake was below the RDA were significantly 40% more likely to have elevated CRP regardless of whether they were taking magnesium supplements ( P

The objective of this study was to determine whether 3 months of treatment with extended-release metoprolol succinate would reduce C-reactive protein (CRP) levels. Seventy-five patients aged 30-65 years with uncontrolled hypertension were treated with extended-release metoprolol at 25-50 mg, titrated up to 100-200 mg daily. CRP was evaluated at baseline and at 1 and 3 months. In the 61 hypertensive patients who completed the study, CRP decreased from 6.2+/-7.5 mg/L at baseline to 5.4+/-7.0 mg/L (p=0.03) at 1 month and showed no further change at 3 months (5.6+/-6.5 mg/L; p=0.13). The 13 patients who received 200 mg of extended-release metoprolol had a 32% decline in CRP from 7.0+/-9.0 mg/L to 4.8+/-6.6 mg/L (-2.2 mg/L) (p=0.005) over the 3-month period, whereas lower doses did not reduce CRP (p0.05). Age, race, sex, and change in blood pressure were not related to the reduction in CRP in multivariate analysis. If CRP evolves into a confirmed modifiable risk factor, a beta blocker such as metoprolol may be a useful addition to pharmacotherapy options.

References 1992 Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 1993 Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 1994 ### 1.1. Structure and Membership of the Writing Committee Members of the Writing Committee included experienced clinicians and specialists in cardiology, cardiac rehabilitation, quality improvement, outcomes research, epidemiology, and performance measures (PMs) methodology, as well as patient advocates. The Writing Committee also included representatives from the American Association for Cardiovascular and Pulmonary Rehabilitation (AACVPR), the American Academy of Family Physicians (AAFP), the American Medical Association–Physician Consortium for Performance Improvement (AMA-PCPI), the American Nurses Association (ANA), the American Society of Health-System Pharmacists (ASHP), the National Committee for Quality Assurance …

PURPOSE The Seventh Report of the Joint National Commission (JNC 7) on High Blood Pressure established prehypertension (120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic) as a new risk category. We aim to determine the risk of major cardiovascular events associated with blood pressure in the prehypertensive range in a longitudinal, population-based cohort. METHODS Analyses were conducted on participants in the National Health and Nutrition Examination Survey I (1971–1975) observed for 18 years for major cardiovascular disease events. Cox proportional hazard ratios were calculated to assess relative risk of cardiovascular disease, including stroke, myocardial infarction, and heart failure, in participants with prehypertension and normal blood pressure (

The role of dietary fiber in the prevention of cardiovascular disease has received increasing attention as data have accumulated. Recent cohort studies have found a consistent protective effect of dietary fiber on cardiovascular disease outcomes, prompting many leading organizations to recommend increased fiber in the daily diet. However, the biologic mechanisms explaining how a fiber influences the cardiovascular system have yet to be fully elucidated. Recent research in large national sample in the USA has demonstrated an association between dietary fiber and levels of C-reactive protein (CRP), a clinical indicator of inflammation. Epidemiologic evidence demonstrating that high-fiber diets are beneficial, coupled with this newer evidence of a possible metabolic effect on inflammatory markers, suggest that inflammation may be an important mediator in the association between dietary fiber and cardiovascular disease (CVD). This paper reviews the evidence for the connections among inflammation, CRP, dietary fiber, and CVD, and recommends further clinical studies using fiber supplementation to isolate and prospectively confirm these important relationships.

The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 7 recommendations include early identification of prehypertension (120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic). Although prehypertension is a risk factor for hypertension, little is known of prehypertension's independent risk for mortality. We conducted an analysis of a nationally representative cohort in the second National Health and Nutrition Examination Survey 1976 to 1980 (NHANES II) and the NHANES II Mortality Study, 1992. The cohort included 9,087 patients aged 30 to 74 years at baseline, who represented nearly 95 million Americans. Cox proportional-hazards models were conducted for both cardiovascular disease (CVD) and all-cause mortality. The unadjusted relative risk of both all-cause (hazard ratio [HR] 1.27, 95% confidence interval [CI] 1.02 to 1.58) and CVD (HR 1.66, 95% CI 1.21 to 2.26) mortality is increased for patients with prehypertension over patients with normal blood pressure (BP). Almost all patients with hypertension (93%), prehypertension (90%), and normal BP (85%) have other CVD risk factors. When the presence of any CVD risk factor is adjusted for in the survival analysis, the adjusted relative risk of both all-cause (HR 0.82, 95% CI 0.64 to 1.04) and CVD (HR 1.00, 95% CI 0.72 to 1.39) mortality is no longer increased for patients with prehypertension. Similarly, in analyses of patients aged/=55 years, there is no significant independent mortality risk for prehypertension. Lifestyle interventions targeting multiple risk factors including BP may be the most effective prevention strategy.

Recent evidence supports an association between elevation of inflammatory markers, such as C-reactive protein, and subsequent cardiovascular disease risk. The American Heart Association released guidelines in 2003 to help clinicians know when to use such markers. Because inflammatory markers are associated with diabetes, obesity, and hypertension, knowledge of the role of such markers is extremely important for prevention and chronic disease management. Newer studies published after the guidelines, and another recent review provide further documentation of the growing role of inflammation in cardiovascular risk. Based on the available literature, this article reviews the new guidelines, more recent evidence since the guidelines, and forms recommendations for primary care clinical practice.

The objective of this study was to determine the relationship of C‐reactive protein (CRP) and blood pressure (BP) across the range of BP categories including prehypertension. The Third National Health and Nutrition Examination Survey (NHANES III) data collected from 1988 to 1994 were analyzed. In unadjusted analyses, there was a step‐wise increase in the probability of elevated CRP across a wide range of BP categories. Prehypertensive participants had a higher prevalence of elevated CRP than normotensive people (27.4% vs. 19.8%; p

C-reactive protein (CRP) and lipids (e.g., low-density lipoprotein [LDL]) are both markers of cardiovascular disease risk, yet they are not highly correlated. Oxidative stress of lipids induced by iron may play a role in vascular inflammation, as indicated by CRP. The purpose of this study was to examine, in a representative sample of United States adults, the relation between ferritin, lipids, and CRP. We analyzed data on adults (aged ≥25 years) in the National Health and Nutrition Examination Survey III, a national public-use data set collected between 1988 and 1994. Ferritin, total cholesterol, LDL, high-density lipoprotein, and ferritin-lipid combinations were analyzed in relation to CRP in age-, gender-, and race-adjusted models as well as models with other potential confounding variables. In adjusted models, neither elevated ferritin (odds ratio [OR] 1.11, 95% confidence interval [CI] 0.94 to 1.32) nor elevated LDL was significantly associated with elevated CRP (OR 1.03, 95% CI 0.79 to 1.33). Patients with elevated ferritin and elevated LDL were more likely to have elevated CRP (OR 1.68; 95% CI 1.06 to 2.68). Patients with elevated ferritin and low high-density lipoprotein were also more likely to have elevated CRP (OR 1.71; 95% CI 1.28 to 2.27). These results suggest that both iron and lipids induce inflammation. Future research needs to focus on preventive medicine to decrease iron in patients with elevated lipids.

We examined the relation of dietary fiber, fat, and other dietary factors to levels of highly sensitive C-reactive protein (CRP) in 4,900 adult participants in the 1999 to 2000 National Health and Nutrition Examination Survey (NHANES 99-00), which was a cross-sectional study of a nationally representative sample of noninstitutionalized United States residents. After controlling for demographic factors, body mass index, smoking, alcohol consumption, exercise, and total caloric intake, subjects in the third and fourth highest quartiles of fiber consumption had a lower risk of elevated CRP (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.43 to 0.96; OR 0.58, 95% CI 0.38 to 0.88, respectively) compared with the lowest quartile. Saturated fat consumption was modestly associated with elevated CRP (third quartile: OR 1.58, 95% CI 1.02 to 2.44; fourth quartile 1.44, 95% CI 0.80 to 2.58). The findings suggest that inflammation may link dietary fiber and fat to cardiovascular disease.

Background The purpose of this study was to determine which patient-related factors are most strongly associated with having uncontrolled hypertension among outpatients. Methods A sample of 300 outpatients with diagnosed hypertension from three different settings was reviewed, focusing on demographics, comorbidity, adherence, and treatment factors. Regression analyses were conducted to determine which factors were associated with poor BP control (> 140 mmHg systolic or > 90 mmHg diastolic). Results Those most strongly associated with blood pressure control were men (OR 2.04, 95% CI 1.17-3.55) living in a rural setting (OR 0.30, 95% CI 0.16-0.55). Age, race, total number of medicines, number of visits, and the number of comorbidities were not significantly associated with poor blood pressure control in this population. Conclusions Being urban and male are strongly associated with uncontrolled hypertension. Public health blood pressure control efforts in the Southeast region should be directed toward this population.

Patient education is a critical component of the patient-centered medical home and is a powerful and effective tool in chronic disease management. However, little is known about the effect of practice payment on rates of patient education during office encounters.For this study we took data from the 2009 National Ambulatory Medical Care Survey. This was a cross-sectional analysis of patient visits to primary care providers to determine whether practice payment in the form of capitated payments is associated within patient education being included more frequently during office visits compared with other payment methods.In a sample size of 9863 visits in which capitation status was available and the provider was the patient's primary care provider, the weighted percentages of visits including patient education were measured as a percentages of education (95% confidence intervals):25% capitation, 42.7% (38.3-47.3); 26% to 50% capitation, 37.6% (23.5-54.2); 51% to 75% capitation, 38.4% (28.1-49.8);75% capitation, 74.0% (52.2-88.1). In an adjusted logistic model controlling for new patients (yes/no), number of chronic conditions, number of medications managed, number of previous visits within the year, and age and sex of the patients, the odds of receiving education were reported as odds ratios (95% confidence intervals):25% capitation, 1.00 (1.00-1.00); 26% to 50% capitation, 0.77 (0.38-1.58); 51% to 75% capitation, 0.81 (0.53-1.25); and75% capitation, 3.38 (1.23-9.30).Patients are more likely to receive education if their primary care providers receive primarily capitated payment. This association is generally important for health policymakers constructing payment strategies for patient populations who would most benefit from interventions that incorporate or depend on patient education, such as populations requiring management of chronic diseases.

Presentations of research are important in the dissemination of new knowledge, but they do not reach the same audience as research published in journals. The purpose of this study was to evaluate the proportion of presentations at recent major primary care research conferences that have become published.Oral and poster presentations for completed and work-in-progress projects from the 2007 and 2008 North American Primary Care Research Group (NAPCRG) and Society of Teachers of Family Medicine (STFM) annual conferences were included in the analysis. The first presenter for each presentation was searched on PubMed, and titles and abstracts for presentations were compared for content to titles and abstracts of potential matches found on PubMed. We analyzed the proportion of presentations that were published in peer-reviewed journals, mean time to publication, and the proportions of the type of journal in which the article appeared (family medicine vs other) were analyzed.There were 1,329 presentations included in the study. Overall, 34.4% of projects presented were also published. More oral presentations (42.9%) were published than were poster presentations (25.3%) (P.001). Mean time to publication was 15.4 months. Oral presentations were published more quickly (13.7 months) than poster presentations (18.6 months) (P.001). Published reports appeared in 192 different journals. Family medicine journals accounted for 36.5% of published.More than one-third of all presentations at STFM and NAPCRG conferences were published in journals indexed in PubMed. Time to publication was comparable to that of other specialties. Fewer than 2 of every 5 reports were published are in a family medicine journal, suggesting vast breadth in family medicine research. Family medicine academicians need to refocus efforts on transforming presentations into published articles in peer-reviewed journals for broader dissemination of research findings.

This study compared ankle range of motion (AROM) including dorsiflexion, plantar flexion, inversion and eversion, and venous refill time (VRT) in leg skin inflamed by venous disorders, before and after a new cryotherapy ulcer prevention treatment. Fifty-seven individuals participated in the randomized clinical trial; 28 in the experimental group and 29 received usual care only. Results revealed no statistically significant differences between the experimental and usual care groups although AROM measures in the experimental group showed a consistent, non-clinically relevant decrease compared to the usual care group except for dorsiflexion. Within treatment group comparisons of VRT results showed a statistically significant increase in both dorsiflexion and plantar flexion for patients with severe VRT in the experimental group (6.9 ± 6.8; p = 0.002 and 5.8 ± 12.6; p = 0.02, respectively). Cryotherapy did not further restrict already compromised AROM, and in some cases, there were minor improvements.

Objectives Although conceptually there is agreement on how the Patient-Centered Medical Home (PCMH) should be organized, there is little information regarding which PCMH components are the most important to patients. Methods An anonymous, voluntary survey was administered to patients at three US academic medical centers. Questions sought opinions regarding the National Committee for Quality Assurance's key components and essential elements of the PCMH. Analysis of the survey responses was conducted using SAS version 9.1. Results A total of 780 surveys were returned. Patients expressed believing strongly that the ability to coordinate care, help patients to manage their own disease, and track laboratory results were the most important aspects of a PCMH office. There were no differences in response to the survey according to age, sex, race, or site. Patients listed care coordination, patient self-management, and improved access to care as the top priority attributes of a PCMH. Conclusions Patients were consistent in their opinions that care coordination, access, and patient self-management were the most important elements of a PCMH.

Aims To determine whether pioglitazone 30mg daily reduces levels of ADMA in adult patients with diabetes, and whether there is improvement in markers of oxidative stress. Methods Prospective randomized cross-over placebo-controlled study of 36 adults age 40–75 years with type 2 diabetes recruited from a single academic health center. Intervention was for 12 weeks, followed by a 4-week wash-out period, followed by a second 12-week cross-over treatment period. The main outcome was comparison of the change in ADMA levels in the two treatment periods. Secondary outcomes included change in NOx and F2-isoprostanes. Results Thirty-six patients were enrolled in the study, 31 completed the protocol; the study enrollment met the sample size required to detect a change of 18% in levels. There were no differences in ADMA, NOx and F2-isoprostanes levels in the two treatment periods. Non-study medication changes or changes in dose were infrequent, and a statin was added during the study period in only one patient. Conclusions Despite previous animal data that showed an effect of pioglitazone on ADMA, the current study in human patients did not demonstrate any differences in ADMA, NOx, or F2-isoprostane levels. The results do not favor that pioglitazone has a significant impact on ADMA levels in human patients with diabetes.

The association of 9 urinary monohydroxy polycyclic aromatic hydrocarbons (OH-PAHs) with serum C-reactive protein (CRP) was investigated using the National Health and Nutrition Examination Survey (NHANES) 2003-2004. The unweighted number of participants included was 999, which represented 139,362,776 persons in the non-institutionalized US population. In adjusted logistic regressions, two OH-PAHs, 2-hydroxyphenanthrene and 9-hydroxyfluorene, were associated with elevated CRP (3mg/l). Logistic regressions were adjusted for age, gender, race, exercise, body mass index, smoking status, diabetes, and hypertension. 2-Hydroxyphenanthrene148ng/g creatinine had an odds ratio of 3.17 (95% CI 1.73-5.81) compared to 2-hydroxyphenanthreneor =48ng/g creatinine, and 9-hydroxyfluorene749ng/g creatinine had an odds ratio of 2.28 (95% CI 1.08-4.83) compared to 9-hydroxyfluoreneor =160ng/g creatinine. Intermediate levels of 2-hydroxyphenanthrene (49-148ng/g creatinine), and 9-hydroxyfluorene (161-749ng/g creatinine) were also significantly associated with elevated CRP compared to the respective reference categories. In a combined analysis, OH-PAHs were classified as low, medium, and high. Low OH-PAH was 2-hydroxyphenanthreneor =48ng/g creatinine and 9-hydroxyfluoreneor =160ng/g creatinine. High OH-PAH was 2-hydroxyphenanthrene148ng/g creatinine or 9-hydroxyfluorene749ng/g creatinine. Participants not assigned to the low or high categories were classified as having medium OH-PAH concentrations. Compared to the low OH-PAH group, high OH-PAH had an odds ratio of 3.60 (95% CI 2.01-6.46) in an adjusted logistic regression. Given that inflammation (characterized here by CRP) is an important factor in the development of atherosclerosis and cardiovascular disease, these results suggest a role for OH-PAHs in the progression of atherosclerosis.

Objective: The aim of this study was to examine the relationship of hepatitis antibodies and liver enzymes with impaired fasting glucose and undiagnosed diabetes in adults. Methods: We analyzed the National Health and Nutrition Examination Survey, 1999 to 2004, a nationally representative sample of the noninstitutionalized US population. Among adults (aged >20 years of age) who were not problem drinkers, we examined hepatitis B and C antibodies and the liver enzymes aspartate aminotransferase (AST), alanine aminotransferase (ALT), and glutamyl transaminase (GGT) with impaired fasting glucose and undiagnosed diabetes (unweighted, n 5234; weighted, n 172,626,805). Logistic regression models were computed controlling for major risk factors that drive diabetes screening, including age, gender, race, diagnosed hypertension, diagnosed hypercholesterolemia, and obesity. Results: In unadjusted analyses 51% of individuals with undiagnosed diabetes have elevated GGT versus 20% of individuals without diabetes or impaired fasting glucose (P .01). Similarly, 43% of individuals with undiagnosed diabetes have elevated ALT versus 23% of individuals without diabetes or impaired fasting glucose (P .01). AST and Hepatitis C antibodies were not associated with undiagnosed diabetes. In adjusted analyses, elevated GGT (odds ratio, 2.15; 95% CI, 1.44 –3.20) and ALT (odds ratio, 1.84; 95% CI, 1.06 –3.20) are associated with undiagnosed diabetes. Similarly, in adjusted analyses, elevated GGT (odds ratio, 1.23; 95% CI, 1.00 –1.53) and ALT (odds ratio, 1.44; 95% CI, 1.15– 1.79) are associated with impaired fasting glucose. Hepatitis antibodies, reporting a current liver problem, or AST were associated with having undiagnosed diabetes in adjusted analyses. Conclusions: Liver function is associated with undiagnosed diabetes and impaired fasting glucose and may justify further investigation as a risk stratification variable for undiagnosed diabetes or impaired fasting glucose. (J Am Board Fam Med 2008;21:497–503.)

Lifestyle choices are associated with cardiovascular disease and mortality. The purpose of this study was to compare adherence to healthy lifestyle habits in adults between 1988 and 2006.Analysis of adherence to 5 healthy lifestyle trends (or=5 fruits and vegetables/day, regular exercise12 times/month, maintaining healthy weight [body mass index 18.5-29.9 kg/m(2)], moderate alcohol consumption [up to 1 drink/day for women, 2/day for men] and not smoking) in the National Health and Nutrition Examination Survey 1988-1994 were compared with results from the National Health and Nutrition Examination Survey 2001-2006 among adults aged 40-74 years.Over the last 18 years, the percent of adults aged 40-74 years with a body mass indexor=30 kg/m(2) has increased from 28% to 36% (P.05); physical activity 12 times a month or more has decreased from 53% to 43% (P.05); smoking rates have not changed (26.9% to 26.1%); eating 5 or more fruits and vegetables a day has decreased from 42% to 26% (P.05), and moderate alcohol use has increased from 40% to 51% (P.05). Adherence to all 5 healthy habits has gone from 15% to 8% (P.05). Although adherence to a healthy lifestyle was lower among minorities, adherence decreased more among non-Hispanic Whites over the period. Individuals with a history of hypertension/diabetes/cardiovascular disease were no more likely to be adherent to a healthy lifestyle than people without these conditions.Generally, adherence to a healthy lifestyle pattern has decreased during the last 18 years, with decreases documented in 3 of 5 healthy lifestyle habits. These findings have broad implications for the future risk of cardiovascular disease in adults.

Background: Asthma has been linked to stroke, but it is unknown if hay fever is related to stroke. This study was designed to investigate if there is an association between a reported history of hay fever and stroke during a 4.4-year study period. Methods: Analysis was performed of the Atherosclerosis Risk in Communities study, a cohort of middle aged and elderly adults. We examined the association of a reported history of hay fever to the development of stroke. Results: There were 9272 participants meeting our criteria, of which 125 had strokes. Of those with a history of hay fever, 2.2% had a stroke. Of those without a history of hay fever, 1.25% had a stroke. Participants with a history of hay fever had an unadjusted hazard ratio of 1.72 (95% CI, 1.08–2.27) for stroke versus participants without hay fever. Risk of stroke remained significant (hazard ratio, 1.87 [95% CI, 1.17–2.99]) after controlling for age, sex, race, smoking status, body mass index, diabetes, hypertension, alcohol use, and hyperlipidemia. Conclusion: A history of hay fever seems to be a risk factor for stroke, and this association may be an area for future research and intervention.

PURPOSE This study explored the influence of trait anger and long-term psychological stress on progression to hypertension and incident coronary heart disease (CHD) in persons with prehypertension. METHODS A secondary data analysis was performed using the Atherosclerosis Risk in Communities (ARIC) study, a cohort of men and women aged 45 to 64 years at enrollment. Participants with blood pressures in the prehypertension range at the second visit conducted between 1990 and 1992, free of heart disease or stroke, and observed through the end of the ARIC study (1996–1998) were included (N = 2,334). The main outcomes were progression from prehypertension to hypertension and prehypertension to CHD or CHD death. RESULTS After adjusting for various covariates, high levels of trait anger, compared with low/moderate levels (odds ratio [OR] 1.53; 95% confidence interval [CI], 1.05–2.24), were associated with progression from prehypertension to hypertension. After stratifying on sex, trait anger was predictive for men only (OR 1.71; 95% CI 1.04–2.83). In survival analysis, trait anger was associated with progression to CHD for men (hazard ratio [HR] 1.92; 95% CI, 1.07–3.54). Long-term psychological stress was also associated with risk of incident CHD (HR 1.68; 95% CI 1.18–2.40). CONCLUSIONS High levels of trait anger in middle-aged prehypertensive men were associated with increased risk of progressing to hypertension and incident CHD. Long-term stress was also associated with increased risk of incident CHD in both men and women.

Markers of inflammation such as high-sensitivity C-reactive protein (CRP) were shown to be elevated in patients with hypertension. Small trials using statin therapy showed blood-pressure (BP) reductions, but it is unknown whether this association extends to larger populations. The objective of this study was to determine whether statin use was associated with better blood-pressure control in adults with hypertension and whether inflammation levels mediated this relationship.This was a cross-sectional study of 2584 hypertensive adults agedor=40 years with no known cardiovascular disease from the National Health and Nutrition Examination Survey 1999-2002. Logistic regression models were calculated to determine whether there was an association between statin use and blood-pressure control. C-reactive protein was added to the full model to determine its impact on the association.Compared with people not using statin medication, significantly more statin users had their blood pressure under control (52.2% v 38.0%). After adjustment for demographic factors, statin users were two times (95% confidence interval [CI], 1.46 to 2.72) more likely to have their blood pressure under control (140/90 mm Hg) than nonusers. After further adjustment for body mass index, diabetes, smoking, exercise, low-salt diet, and antihypertensive medications, the likelihood of having blood pressure under control remained more likely among statin users (odds ratio, 1.46; 95% CI, 1.05 to 2.05). The association between statin use and lower BP was most evident among participants who used antihypertensive medication as well as statins and was unchanged with the addition of CRP to the model.Statin use was associated with a BP level140/90 mm Hg in a representative sample of US adults with hypertension. Levels of CRP did not attenuate the association. Further studies are needed to explore the effects of statin use on blood pressure and to determine how best to apply this knowledge in clinical care.

BACKGROUND Elevated levels of serum biomarkers such as C-reactive protein (CRP) and homocysteine have been independently associated with cardiovascular risk. However, the prevalence of concurrent elevations of these biomarkers in the general population is unknown, as is their association with cardiovascular disease (CVD). METHODS Data from adults (n = 4900) in the National Health and Nutrition Examination Survey were used to investigate the relationship between combinations of serum biomarkers of inflammation (CRP), atherosclerosis (homocysteine), and insulin sensitivity [homeostatic model assessment (HOMA) fasting insulin] and CVD. Using SUDAAN, logistic regression models were constructed to examine the relationships between elevated serum biomarkers (CRP, homocysteine, HOMA, or insulin), singly or in combination, and having a history of heart failure, myocardial infarction (MI), stroke, or any CVD, while controlling for age, race, sex, obesity, smoking, cholesterol level, diabetes history, hypertension history, exercise level, and dietary fiber intake. RESULTS After adjustment for covariates, there was a significant relationship between concomitant elevations of CRP plus homocysteine and a history of MI [odds ratio (OR) 2.21], heart failure (OR 2.14), and any CVD (OR 1.87) that was stronger than the relationship between individual biomarkers alone and a history of CVD. In addition, combinations of elevated CRP plus HOMA and CRP plus insulin, remained significantly related to having a history of any CVD. CONCLUSION Recent scientific evidence and the present findings demonstrate the possibility for improving cardiovascular risk stratification through the concurrent evaluation of multiple biomarkers. In particular, these findings demonstrate the need to evaluate the combination of CRP and homocysteine prospectively as predictors of CVD.

Summary Objective Cardiovascular disease has been reported to be more common in patients with elevated levels of TSH and with normal thyroxine levels, termed subclinical hypothyroidism (SCH). The aim of this study was to determine whether individuals with SCH were more likely than euthyroid controls to have elevations in inflammatory biomarkers that are associated with cardiac disease. Methods From the National Health and Nutrition Examination Survey (NHANES) 1999–2002 data we identified respondents aged ≥ 40 who met the laboratory criteria for SCH. We compared the average values and frequencies of elevated C-reactive protein (CRP) and homocysteine in the SCH individuals to those in euthyroid individuals. Results A total of 1608 individuals were included in the analysis of whom 45 (2·8%) met the criteria for SCH, with seven (15·6%) having TSH levels between 10 and 15 IU/l. We found no differences in median, mean or the percentage of elevated CRP or homocysteine in individuals with SCH compared to euthyroid controls. Linear regression models adjusting for age, gender, the presence of other cardiac risk factors, and whether the individual was using a cholesterol-lowering drug also failed to show any association between SCH and either high-sensitivity CRP (hsCRP) (P = 0·62) or homocysteine (P = 0·63) levels. When we examined the subset of people with TSH levels between 10 and 15 IU/l, we again found no difference in mean hsCRP or homocysteine compared to control. Conclusions In this large population-based sample, hsCRP and homocysteine levels do not differ for individuals with SCH compared to euthyroid individuals. This suggests that cardiac inflammation is not greater in individuals with SCH.

Current dietary guidelines recommend adequate intake of magnesium (310-420 mg daily) in order to maintain health and lower the risk of cardiovascular disease. Recent evidence from animal and clinical studies suggests that magnesium may be associated with inflammatory processes. The objective of this study was to determine whether dietary magnesium consumption is associated with C-reactive protein (CRP), a marker of inflammation, in a nationally representative sample.Analysis of adult (or =17 years) participants in a cross-sectional nationally representative survey (National Health and Nutrition Examination Survey 1999-2000 [NHANES]) who were not taking magnesium or magnesium-containing supplements. The primary outcome measure was high sensitivity CRP (elevatedor =3.0 mg/L).Among US adults, 68% consumed less than the recommended daily allowance (RDA) of magnesium, and 19% consumed less than 50% of the RDA. After controlling for demographic and cardiovascular risk factors, adults who consumedRDA of magnesium were 1.48-1.75 times more likely to have elevated CRP than adults who consumedor =RDA (Odds Ratio [OR] for intake50% RDA = 1.75, 95% Confidence Interval [CI] 1.08-2.87). Adults who were over age 40 with a BMI25 and who consumed50% RDA for magnesium were 2.24 times more likely to have elevated CRP (95% CI 1.13-4.46) than adultsor =RDA.Most Americans consume magnesium at levels below the RDA. Individuals with intakes below the RDA are more likely to have elevated CRP, which may contribute to cardiovascular disease risk.

Elevated levels of C-reactive protein (CRP) have been associated with increased risk of cardiovascular disease among the general population (1–6). People with diabetes (7), hypertension (8), and obesity (9) have CRP levels that are higher than those in people without these conditions in the general population. Previous studies indicate an inverse association between dietary fiber intake and levels of inflammatory biomarkers (10,11). Acknowledging that individuals with certain conditions (e.g., diabetes) are at higher risk for elevated CRP, it is unclear whether intake of dietary fiber may have more impact on inflammatory markers among such people. To investigate the relationship between dietary fiber and inflammatory markers in people with diabetes, hypertension, and obesity, we conducted a study using the nationally representative 1999–2002 National Health and Nutrition Examination Survey (NHANES). We conducted an analysis of the 1999–2002 NHANES (http://www.cdc.gov/nchs/nhanes.htm). Our sample was limited to participants ≥20 years of age who had valid high-sensitivity CRP measurements and dietary information (unweighted n = 7,891). The study was approved by the institutional review board at the Medical University of South Carolina. Individuals were considered to have a previous diagnosis of diabetes or hypertension based on questions asking whether the individual had ever been told by a doctor that he or she had the condition. People with …

Objective: The purpose of this study was to determine whether a relationship exists between religious attendance and continuity of care. Methods: We investigated this relationship in a large national database—the National Health and Nutrition Examination Survey III—which contains information on religious attendance, continuity of care, and potential confounders that might mediate the relationship such as health status and socioeconomic status. Results: A total of 18,162 participants 17 years of age or older were included in the analysis. People who attended religious services were more likely to have continuity with a provider than people who did not attend such services (65% vs. 35%, p < .001). This association persisted after controlling for demographic, socioeconomic, and health status variables using regression analysis. Conclusion: This study documents a significant association between attendance at religious services and continuity with a usual provider. Continuity with a regular medical provider may influence the association of religious attendance and health outcomes.