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Caregivers support heart failure (HF) self-care with little HF education. The purpose of this study was to evaluate the effectiveness of a caregiver-only educational intervention aimed at improving caregiver self-efficacy, perceived control, and HF knowledge, as well as patient self-care and 30-day cardiac readmission. In total, 37 patients and their caregivers were randomly assigned to a control condition or a caregiver-only educational intervention with telephone follow-up. Outcomes included patient 30-day cardiac readmission, patient self-care, caregiver self-efficacy, caregiver perceived control, and caregiver HF knowledge. Linear mixed model, Kaplan–Meier, and Cox regression analyses were used to determine the effects of the intervention on outcomes. Self-care maintenance ( p = 0.002), self-care management ( p = 0.005), 30-day cardiac readmission ( p = 0.003), and caregiver perceived control ( p < 0.001) were significantly better in the intervention group. The results suggest that interventions targeting caregiver HF education could be effective in improving HF patients’ 30-day cardiac readmissions, patient self-care, and caregiver perceived control.

Antioxidant insufficiency, elevated inflammatory markers, and poor health-related quality of life (HRQOL) are prevalent in patients with heart failure (HF).The objective of this study was to examine the associations among dietary antioxidant intake, inflammatory markers, and HRQOL in patients with HF.This was a secondary analysis of 265 patients with HF who completed a 4-day food diary. We assessed intake of 10 antioxidants: alpha carotene, beta carotene, beta cryptoxanthin, lutein, zeaxanthin, lycopene, vitamins C and E, zinc, and selenium. Antioxidant insufficiency was reflected by a measured level for each antioxidant that was below the estimate average requirement or lower than median for antioxidants without an estimate average requirement. Inflammatory markers including serum C-reactive protein, cytokines (interleukins 6 and 10), tumor necrosis factor-alpha, and soluble receptors (sTNFR1 and sTNFR2) were assessed with enzyme immunoassay. Health-related quality of life was measured using the Minnesota Living with Heart Failure at 12 months.Dietary antioxidant insufficiency predicted C-reactive protein (β = 0.135, P = .032) and interleukin 10 (β = -.155, P = .027). Patients with higher antioxidant insufficiency had higher C-reactive protein and lower interleukin 10. Both antioxidant insufficiency (β = 0.13, P = .049) and higher C-reactive protein (β = 0.16, P = .019) were independently associated with poorer HRQOL while adjusting for covariates.Dietary antioxidant insufficiency was associated with increased markers of inflammation and poorer HRQOL. Improvement of diet quality among patients with HF may be a fruitful area of research for enhancing HRQOL.

Psychological symptoms, physical symptoms, and behavioral factors can affect health-related quality of life (HRQOL) through different pathways, but the relationships have not been fully tested in prior theoretical models. The purpose of this study was to examine direct and indirect relationships of demographic (age), biological/physiological (comorbidity), psychological (depressive symptoms), social (social support), physical (physical symptoms and functional status), and behavioral (dietary sodium adherence) factors to HRQOL. Data from 358 patients with heart failure were analyzed using structural equation modeling. There was a good model fit: Chi-square = 5.488, p = .241, RMSEA = .032, CFI = .998, TLI = .985, and SRMR = .018. Psychological symptoms, physical symptoms, and demographic factors were directly and indirectly associated, while behavioral and biological/physiological factors were indirectly associated with HRQOL through different pathways. Behavioral factors need to be included, and psychological factors and physical factors need to be separated in theoretical models of HRQOL.

BACKGROUND Heart failure (HF) is associated with chronic inflammation, which is adversely associated with survival. Although sex-related differences in inflammation have been described in patients with HF, whether sex-related differences in inflammation are associated with event-free survival has not been examined. AIM The aim of this study was to determine whether the association between inflammation as indicated by tumor necrosis factor-α and event-free survival differs between men and women with HF after controlling for demographic and clinical variables. METHOD This was a secondary analysis of data from 301 male (age, 61.0 ± 11.4 years) and 137 female (age, 60.3 ± 12.1 years) patients with HF. Serum levels of soluble tumor necrosis factor receptor 1 were used to indicate inflammatory status. Patients were grouped according to median split of soluble tumor necrosis factor receptor 1 level and sex into male with low inflammation (≤1820 pg/mL) (n = 158) or high inflammation (>1820 pg/mL) (n = 143), and female with low inflammation (n = 63) or high inflammation (n = 74). Cox regression models were run separately for men and women to determine whether inflammation contributed to differences in event-free survival between sexes with HF. RESULTS There were 84 male (27.9%) and 27 female (19.7%) patients who had an event. Event-free survival in women did not differ by the severity of inflammation in the Cox regression analysis. In contrast, men with high inflammation had 1.85 times higher risk for an event compared with men with low inflammation. CONCLUSION These data provide evidence that inflammation contributed to differences in event-free survival in men but not women with HF. Clinicians should be aware that men who have higher inflammation may be at a greater risk of HF or cardiac-related events than others with HF.

Aims Fatigue, a distressing symptom in patients with heart failure (HF), is associated with progress and health outcomes. Fatigue has been identified as having multidimensions, but a few studies have used a multidimensional fatigue scale. Many factors related to HF, including physical, psychological, and situational factors, may impact fatigue. However, there is limited knowledge about how these HF-related factors are associated with multidimensional fatigue in outpatients with HF in Japan. The aim of this study was to identify HF-related factors [physical; clinical characteristics, New York Heart Association (NYHA) functional class and physical function, psychological; depressive symptoms and anxiety, situational; health literacy and perceived control] associated with the five dimensions of fatigue in outpatients with HF. Methods and results Outpatients with HF (N = 165, mean age = 69.5 years, 78.8% male) completed the survey and physical assessment of gait speed. Fatigue was assessed using five dimensions of the Multidimensional Fatigue Inventory-20. Multiple linear regression analysis was conducted for each dimension of fatigue. General fatigue was predicted by age, NYHA, and perceived control. Physical fatigue was predicted by NYHA, depressive symptoms, and perceived control. Reduced activity was predicted by NYHA, gait speed, depressive symptoms, communicative health literacy, and critical health literacy. The reduced motivation was predicted by depressive symptoms and perceived control. Mental fatigue was predicted by depressive symptoms. Conclusion Different factors were significantly associated with each fatigue dimension. Further research is needed to alleviate fatigue in patients with HF.

Aims Patients with heart failure (HF) and their family caregivers commonly experience depressive symptoms associated with low quality of life (QOL) at the individual level. However, there is a lack of knowledge about how QOL and family function are associated with depressive symptoms at the dyad level. The aim of this article is to compare QOL and family function among dyads stratified by depressive symptoms. Methods and results Outpatients with HF and their primary caregivers completed the Beck Depression Inventory-II for depressive symptoms, the Short Form 36 for physical and mental QOL, and the McMaster Family Assessment Device for a family function. Analysis of variance was used to compare QOL and family function among the four dyad groups. A total of 91 dyads were categorized into four groups: neither member having depressive symptoms (43.9%), only the caregiver having depressive symptoms (13.2%), only the patient having depressive symptoms (23.1%), and both members having depressive symptoms (20.9%). Dyads without depressive symptoms had the highest levels of physical and mental QOL among the groups. The dyads with both members having depressive symptoms had the lowest levels of physical and mental QOL (P < 0.001) and the lowest levels of general family functioning, problem-solving ability, and communication ability (P < 0.001). Intermediate levels of QOL were seen in dyads with only one member having depressive symptoms, and a similar pattern of intermediate scores was found in all three subscales of family function. Conclusion Dyads with both members having depressive symptoms may be at greatest risk of having poor QOL and low family functioning.

Cardiovascular disease (CVD) encompasses diseases that contain the heart or vascular device consisting of coronary artery disease, angina, and hypertension.1 CVD is a enormous public health trouble inside the u.S. Affecting one in 3 American adults and accounting for nearly 33% of all deaths.2 coronary heart failure (HF) is the end level of CVD and is the maximum high-priced CVD-associated circumstance regarding fitness care prices of which the largest component is associated with repeated hospitalizations. Consequently, prevention of CVD is essential to reducing the occurrence of HF and associated costs. A sedentary way of life is a number one risk element for CVD.2 In a potential case-manipulate have a look at with over 12,000 cases and 14,000 controls, a sedentary life-style accounted for 12.2% of the threat of developing coronary coronary heart disorder after accounting for different CVD hazard factors which includes smoking, diabetes mellitus, high blood pressure, and lipid profile.3 In two potential studies with over 17000 individuals who had been observed for greater than 12 years, extended time spent sitting expected CVD mortality fees independent of age, smoking, and frame mass index (BMI).Four,5 A dose-reaction relationship has been located among sedentary behaviors and mortality from CVD. Numerous elements may give an explanation for the affiliation among a sedentary lifestyle and an increased hazard of developing CVD. One of the established results of a sedentary way of life is metabolic syndrome

BACKGROUND African Americans are at the highest risk of developing heart failure (HF) compared with other races and are hospitalized at 7 to 8 times the rate of Whites. Poor overall self-care, low self-care confidence, and lower levels of perceived social support are factors related to increased risk for hospitalizations in HF. Yet, limited evidence is available regarding the factors that may differentially impact self-care confidence by race in patients with HF. OBJECTIVE The aim of this study was to examine to what extent race moderates the relationship between perceived social support and self-care confidence. METHOD This is a secondary analysis of cross-sectional data from African American and White patients with HF in North America (n = 429). Patients completed the Multidimensional Scale of Perceived Social Support and the Self-Care Confidence Scale of the Self-Care of Heart Failure Index. A moderation analysis was conducted using hierarchal linear regression. RESULTS Sample mean age was 60.8 ± 11.5 years, 22.4% were African American, and 54.7% were in New York Heart Association class I or II. Moderation analyses yielded a significant interaction of perceived social support and race, showing White patients, not African Americans, have significantly different self-care confidence scores depending on level of social support: White, b = 0.224, 95% confidence interval [0.046-0.094], t = 5.65, and P < .001; African American, b = -0.776, 95% confidence interval [-0.049 to 0.060], t = 0.212, and P = .832. CONCLUSIONS Our findings show a variable effect of perceived social support on self-care confidence as a function of race, suggesting the need for further research to develop and test interventions tailored to race and levels of social support in HF.

Introduction: Persons with diabetes and COVID-have higher rates of morbidity and mortality than those without diabetes. Engagement in Diabetes Self-Management Education and Support (DSMES) services may improve diabetes self-management adherence. The purpose of this study was to determine whether COVID-impact and attendance of DSMES services were predictors of diabetes self-management among individuals with T2D during the pandemic. Methods: Participants (N=86) of this cross-sectional survey study were adults with T2D who either had (n=29) or had not (n=57) previously attended at least one DSMES class. The Coronavirus Impact Scale (range 0-24) was used to measure impact of the pandemic on daily life. The Self-Management Profile for Type 2 Diabetes was used to measure overall self-management and subscales for adherence, ease, coping, and importance. Multiple linear regressions were conducted to determine whether COVID-impact and DSMES participation predicted self-management total scores or subscale scores, controlling for age, sex, marital status, financial status, and time since diabetes diagnosis, with separate models for each predictor. Results: Participants were 57±12.3 years; 50% female, and 90% non-Hispanic White. DSMES attendance did not significantly predict subscale or overall scores for self-management. Higher COVID-impact predicted worse self-management adherence (F 3.71, p=0.002) , greater self-management ease (F 3.72, p=0.002) , decreased coping (F 4.65, p Conclusions: Findings underscore the negative impact of the COVID-pandemic on diabetes self-management and highlight the need for interventions to improve self-management practices during times of crisis. Disclosure L.Koonmen: None. T.A.Lennie: None. M.Ickes: None. L.B.Hieronymus: None. J.L.Miller: None. G.Mudd-martin: None. Funding Jonas Nurse Scholars Program, University of Kentucky College of Nursing PhD Dissertation Research Award

BACKGROUND Publicly available patient-focused mobile health applications (mHealth apps) are being increasingly integrated into routine heart failure (HF)-related self-care. However, there is a dearth of research on patients’ experiences using mHealth apps for self-care in real-world settings. OBJECTIVE The purpose of this study was to explore patients’ experiences using a commercially available mHealth app, OnTrack to Health, for HF self-care in a real-world setting. METHODS Patient satisfaction, measured with a 5-point Likert scale, and an open-ended survey were used to gather data from 23 patients with HF who were provided the OnTrack to Health app as a part of routine HF management. A content analysis of patients’ responses was conducted with a qualitative software, Atlas. ti version 8. RESULTS Patients (median IQR age 64, 57-71 years; 17/23, 74% male) used OnTrack to Health for a median(IQR) duration of 164 (51-640) days before the survey. All patients reported excellent experiences related to app use and would recommend the app to other patients with HF. Five themes emerged from the responses to the open-ended questions: (1) features that enhanced self-care of HF (medication tracker, graphic performance feedback and automated alerts, secured messaging features, and HF self-care education); (2) perceived benefits (provided assurance of safety, improved HF self-care, and decreased hospitalization rates ); (3) challenges with using apps for self-care (giving up previous self-care strategies); (4) facilitators (perceived ease of use, availability of technical support); and (5) suggested improvements (streamlining data entry, integration of apps with an electronic medical record, and personalization of app features). CONCLUSIONS Patients were satisfied with using Ontrack to Health for self-care. They perceived the features of the app as valuable tools for improving self-care ability and decreasing hospitalization rates. The development of apps in collaboration with end-users is essential to ensure high-quality patient experiences related to app use for self-care. CLINICALTRIAL

The purpose of this study was to determine whether deficiencies of water-soluble vitamin intake predicted health-related quality of life (HRQOL) and the composite end point of all-cause mortality or cardiac- or heart failure (HF)-related hospitalization in HF patients. Patients with HF may be at risk for inadequate consumption of water-soluble vitamins due to poor appetite and dietary sodium restriction. Because water-soluble vitamins are important in metabolic processes, inadequate dietary intake of these vitamins may negatively affect health outcomes. We consecutively recruited patients with HF from outpatient clinics affiliated with academic medical centers. Patients were referred by providers to investigators who verified their eligibility. Patients with HF completed a four-day food diary to determine dietary deficiencies of water-soluble vitamins and the Minnesota Living with HF questionnaire to assess HRQOL at baseline. Patients were followed to determine an event. A total of 216 patients were included. Patients with a higher number of dietary deficiencies of water-soluble vitamins had poorer HRQOL (unstandardized coefficient = 4.92, 95% confidence interval 2.20–7.27). Cox regression showed that for each additional deficiency of a water-soluble vitamin intake, there was a 30% increase in risk for an event (95% confidence interval 1.03–1.75), controlling for demographic and clinical variables. Inadequate dietary consumption of water-soluble vitamins was associated with poor HRQOL and prognosis and in HF. Our findings highlight that clinicians should understand the importance of encouraging patients to consume water-soluble vitamin-rich foods, which may result in enhancing outcomes in HF.

Background Caregivers of patients with heart failure (HF) report depressive symptoms and poor quality of life (QOL) related to caregiving and poor family functioning, placing them at risk for poor health. Objectives The purpose of this study was to examine the effect of depressive symptoms on the relationship between family functioning and quality of life in the HF caregiver. Methods A sample of 92 HF caregivers were enrolled from an ambulatory clinic at a large academic medical center. A mediation analysis was used to analyze data obtained from the Family Assessment Device (FAD), the Patient Health Questionaire-9 (PHQ-9), and the Short Form-12 Health Survey Version 2 (SF-12v2). Results Depressive symptoms were found to be a significant mediator in the relationship between family functioning and caregiver quality of life. Conclusions The results of this study suggest that interventions targeting caregiver depression and family functioning could be effective in enhancing HF caregivers’ physical and mental QOL.

Aims Eating a varied diet promotes adequate micronutrient intake. Poor appetite could decrease the desire to eat a varied diet leading to dietary micronutrient insufficiencies. The interrelationships among appetite, diet variety, and dietary micronutrient intake have not been investigated in patients with heart failure (HF). The purpose of the study was to determine whether the relationship between appetite and micronutrient insufficiency was mediated through diet variety. Methods and results A total of 238 patients with HF, mean age 61 ± 12.1; 68% male, and 45% NYHA class III/IV were included in this secondary analysis. Data collection consisted of a 4-day food diary and self-reported appetite on a 10-point visual analogue scale. Micronutrient insufficiency was defined as the total number of 17 minerals and vitamins that were insufficient in the diet. Diet variety was calculated as the number of 23 food types consumed over the 4 days. Mediation analysis, controlling for covariates age, gender, NYHA class, and body mass index showed that diet variety mediated the relationship between appetite and micronutrient insufficiencies [indirect effect = −0.0828, 95% confidence interval (CI): −0.1585 to −0.0150]. There was no direct effect of appetite on micronutrient insufficiency (c´ = −0.1802; 95% CI = −0.3715 to.0111). Conclusions Diet variety played a previously unrecognized role in the relationship between appetite and dietary micronutrient intake in patients with HF. More research is needed to validate these associations in patients with HF.

Background: Trauma and management of injuries can result in reduction or loss of mobility, which can lead to skeletal muscle deconditioning and sustained disability. Prior investigators have examined changes in skeletal muscle due to injury and immobility separately. The muscular consequences of combined immobility and trauma have not been systematically investigated. Objective: The purpose of this study was to explore the association of time to first ambulation with skeletal muscle size and strength in patients after major trauma. Methods: Adults ( N = 19) admitted for major trauma (Injury Severity Score [ISS] > 15) provided daily measures of muscle size (ultrasound) and strength (dynamometry) during hospitalization. Participants were grouped based on time to first ambulation. Repeated measures analysis of variance was used to compare muscle measures between the groups across 5 days while controlling for age and gender. Results: Participants were primarily male (63%) aged 40 ± 17 years with a mean ISS of 21 ± 4. Early ambulation was associated with a 10% increase from baseline in bicep size on Days 3 and 4 and a 15% increase from baseline on Day 5. There were no changes in rectus femoris size in either group. The early ambulation group was significantly stronger than the delayed ambulation group throughout the study in measures taken with the biceps (22%–37%) and quadriceps (26%–46%). Conclusion: Early ambulation following major trauma was associated with increased bicep size and greater muscle strength in the biceps and quadriceps muscles over time.

Introduction Family caregivers of patients with heart failure (HF) commonly experience emotional distress and caregiving burden. Despite their caregiving distress, caregivers may experience positive or negative changes in their life compared with before caregiving. Greater perceived control is associated with better health outcomes, but little is known about whether perceived control is related to caregivers' perceptions of positive or negative changes in life, independent of their distress and burden in providing care for patients with HF. The specific aims were to compare emotional distress and caregiving burden between caregivers who perceived positive versus negative changes in life due to caregiving and to examine whether perceived control predicts the perception of positive or negative changes in life while controlling for emotional distress and caregiving burden. Methods Primary caregivers of patients with HF (N = 140, 75% women) completed questionnaires about perceived positive or negative changes in life as a result of caregiving, perceived control, depressive symptoms, anxiety, and caregiving burden. Independent t test, χ, and logistic regressions were used to accomplish specific aims. Results Compared with caregivers who reported positive changes in life (42%), caregivers who perceived negative changes in life (58%) had higher levels of depressive symptoms, anxiety, and caregiving burden. Lower level of perceived control was an independent predictor of perceived negative changes in life, controlling for age, gender, depressive symptoms, anxiety, and caregiving burden (odds ratio, 0.89; 95% confidence interval, 0.79-0.99; P = .0038). Conclusion Greater perceived control played a protective role for caregivers independent of caregiver burden. Interventions designed to enhance perceived control may improve caregivers' perceptions of changes in their life.

BACKGROUND Adherence to a low-sodium diet is essential to self-care of heart failure (HF). Genetic determinants of preference for high-sodium foods may impede adherence but have not been well-studied. OBJECTIVE Our purpose was to examine if TAS2R38 haplotype predicted salt taste sensitivity and dietary sodium intake among patients with HF. METHOD This pilot study used baseline data from a large interventional randomized control trial to support adherence to a low-sodium diet in patients with HF and their family caregivers. Participants were tested for salt taste sensitivity and provided a 24-hour urinary sodium sample and a blood sample for DNA analysis at baseline. Fungiform papillae were counted. χ2 Test and 1-way analysis of variance were used to compare haplotype groups. Linear regression was performed to examine predictors of salt taste sensitivity and 24-hour urinary sodium excretion, controlling for age, gender, ethnicity, smoking status, and fungiform papillae density. RESULTS There were 42 patients with HF and their family caregivers (age, 64.6 ± 13.4 years, 46.5% male, 97.7% white, and 90.7% nonsmoker). Pronine-alanine-valine homozygous haplotype predicted lower urinary sodium excretion (b = -1780.59, t41 = -2.18, P = .036), but genotype was not a significant predictor of salt taste sensitivity. CONCLUSIONS The results of our study partially supported our hypothesis that PAV homozygous haplotype predicts 24-hour urinary sodium excretion. With our small sample size, more research is needed. Understanding genetic influences on taste can lead to development of educational interventions tailored to patients with HF and their family caregivers to better support dietary adherence.

BackgroundSymptom status is an important indicator of disease progression in patients with heart failure (HF). Perceived control is a target of most self-care interventions and is associated with better outcomes in HF; however, little is known about the relationship between perceived control and symptom status in patients with HF.ObjectiveThe aims of this study were to (1) determine the relationship of perceived control to HF symptom status and (2) examine the associations of perceived control to self-care and of self-care to symptom status.MethodsA total of 115 patients with HF were included. Data on symptom status (Memorial Symptom Assessment Scale-HF), perceived control (Control Attitudes Scale-Revised), and self-care (Self-Care of Heart Failure Index) were collected. Other covariates included were age, gender, New York Heart Association class, comorbidity burden, and depressive symptoms. Multiple regression analyses were performed to analyze the data.ResultsLower perceived control predicted worse symptom status after controlling for covariates (P = .009). Other covariates predictive of worse symptom status were younger age, New York Heart Association class III/IV, and higher levels of depressive symptoms. Higher levels of perceived control were associated with better self-care (P = .044). Better self-care was associated with better symptom status (P = .038).ConclusionsLower levels of perceived control were independently associated with worse symptom status in patients with HF. Intervention strategies targeting perceived control should be tested to determine whether they could improve symptom status.

BACKGROUND To improve the health outcomes of survivors of stroke, it is critical that they are highly motivated to engage in rehabilitation activities. Despite the increasing prevalence of strokes among middle-aged adults, there is limited knowledge regarding factors that may affect survivors' motivation to engage in rehabilitation. OBJECTIVE The aim of this study was to examine the relationship among factors that predict the rehabilitation motivation of middle-aged survivors after a stroke through structural equation modeling. METHODS A total of 200 middle-aged (40-64 years) survivors of stroke from 9 rehabilitation hospitals in Korea completed questionnaires on depressive symptoms, self-efficacy, social support, and rehabilitation motivation. Information on clinical characteristics, including physical function (activities performed during daily life), was collected through the review of medical records. Structural equation modeling was used to construct a prediction model of rehabilitation motivation. RESULTS The average subject's age was 56.2 ± 6.6 years, and the mean time since the event of their stroke was 15.02 ± 8.95 months. Subjects' self-efficacy (being able to live everyday life) after their stroke (β = .500, P < .001) and the social support provided by family and medical personnel (β = .284, P < .010) directly affected their rehabilitation motivation. The bootstrapping method showed that depressive symptoms indirectly affected rehabilitation motivation through self-efficacy, as did physical function. CONCLUSIONS In middle-aged survivors of stroke, self-efficacy and social support play a critical role in maintaining intrinsic motivation to engage in rehabilitation activities. Self-efficacy should be evaluated periodically and improved by encouraging individuals to achieve goals, emphasizing their self-regulation, especially among those who reported depressive symptoms and low physical function.

Introduction: A heart-healthy diet might reduce cardiovascular disease (CVD) risk. Genetic variants that affect taste are associated with food choices. This study aims to investigate the associations of the TAS2R38 haplotype with consumption of sodium, sugar, saturated fats, and vegetables. Hypothesis: We hypothesized that, compared to people who are alanine-valine-isoleucine (AVI) homozygous for the TAS2R38 gene, those who are heterozygous or homozygous for the proline-alanine-valine (PAV) haplotype would have (a) a higher intake of sodium, sugar, and saturated fat, and (b) a lower vegetable intake. Methods: DNA from participants at risk for CVD was genotyped, and participants were assigned to groups by haplotype. Intake for sodium, sugar, saturated fat, and vegetables was assessed using the Viocare Food Frequency Questionnaire. Intake was categorized as higher versus lower consumption, divided at the median, and examined by logistic regressions. All models controlled for age, sex, smoking status, body mass index, education level, and financial status. Results: The 175 participants had a mean age of 52 ± 13 years, 72.6% were female, 100% were Caucasian, 89.1% were overweight or obese, and 82.9% were nonsmokers. Participants with one or two PAVs were grouped together, as PAV is the dominant gene, and comprised a majority of the sample (80.6%). Haplotype did not predict intake of sodium, sugar, or saturated fats. Compared to AVI homozygotes, participants with PAV homozygous or heterozygous haplotype had lower odds of being in the higher vegetable intake group (95% CI [0.17, 0.92], p = .032). Conclusions: PAV haplotype predicted lower consumption of vegetables. Variants of taste-related genes appear to play a role in food choices.

Depression is common in patients with cardiovascular disease (CVD) and associated with inflammation. Inflammation contributes to the development of CVD and can be modulated by diet. However, the role of inflammatory properties of diet in the relationship between depressive symptoms and CVD risk is not well understood. We hypothesized that the inflammatory properties of diet mediate the relationship between depressive symptoms and CVD risk in men and women. Cross-sectional data collected by the National Health and Nutrition Examination Survey (2007-2014) were used for the study. Depressive symptoms scores, inflammatory properties of diet, and CVD risk were measured by the Patient Health Questionnaire-9 (PHQ-9), the Dietary Inflammatory Index (DII), and the Framingham risk score (FRS), respectively. Generalized linear models were used for the mediation analysis. There were significant differences in the proportions of men and women in the depressed group (PHQ-9 ≥ 10; 5.24 ± 0.65% vs 9.36 ± 0.87%, P 20%; 16.47 ± 0.79% vs 6.03 ± 0.32%, P

Background Men with heart failure are reported to be less adherent to low-sodium diets than women are. One potential reason may be that men consume more food and, consequently, more sodium than women do. Objectives The aims of this study were to compare dietary sodium intake, urine sodium excretion, and sodium density of diet consumed between men and women with heart failure and to determine whether sex moderated the relationship of kilocalories (kcals) consumed with dietary and urine sodium. Methods A total of 223 patients with heart failure (mean age, 62 ± 12 years; 70% men, 46% New York Heart Association class III-IV) completed detailed 4-day food diaries and provided 24-hour urine sodium samples. To account for sodium density of food, dietary sodium and urine sodium were referenced to sodium per 1000 kcal. Results On an absolute basis, men consumed 23% more kcals and 28% more sodium than women did; 24-hour sodium excretion was 16% higher in men than in women. There were no differences between men and women when dietary sodium and urinary sodium were referenced to 1000 kcal, indicating they consumed foods with similar sodium density. However, both moderation analyses showed that the dietary sodium intake of men and women with lower kcal intake was similar, whereas men with higher kcal intake consumed more sodium-dense foods than women did. Conclusion The results suggest that the men with higher sodium intake than women had 2 reasons for nonadherence. They consumed more food and foods with higher sodium density than women did.

Introduction: Rural caregivers of those with chronic illnesses have higher cardiovascular disease (CVD) risk than urban caregivers. Diet is a major lifestyle factor that contributes to CVD risk. We conducted a randomized controlled trial of a CVD risk reduction intervention called Rural Intervention for Caregivers’ Heart Health (RICHH), that was designed to promote CVD risk reduction, including healthy eating and that was designed to be accessible to those with low health literacy (HL). We tested the moderating effect of HL on the impact of the intervention on diet quality. Hypothesis: Rural caregivers with low HL would gain equal or greater benefits from the RICHH intervention on diet quality compared to those with high HL. Methods: The newest vital sign (NVS), rural-urban commuting area (RUCA) code ≥4 or living in Appalachian counties, and Healthy Eating Index-2015 (HEI-2015) were used to determine HL, rurality, and diet quality, respectively. The HEI-2015 was computed based on a food frequency questionnaire at baseline and post-intervention. The RICHH intervention was delivered using videoconference technology by nurse interventionists once a week for 12 weeks. A linear mixed effect model was used to evaluate the moderation effect of HL (NVS ≥ 4) on the impact of the intervention on diet quality. Results: A total of 296 rural caregivers (54.5 ± 13.7 years old, 76% female) completed the study. The improvement in HEI-2015 scores was greater in the low HL group than in the high HL group controlling for age and sex (beta estimate = 9.21, SE = 3.31, P = 0.0058). Conclusions: The RICHH intervention was effective in improving diet quality of rural caregivers compared to the control group. In particular, rural caregivers with low HL benefited more from the intervention aimed at increasing diet quality. Thus, addressing low HL could play an important role to improve diet quality and to reduce CVD risk among caregivers residing in rural environment.

Introduction: Caregivers of patients with chronic conditions are at higher risk for cardiovascular disease (CVD) than their urban counterparts. Despite the burden related to caregiving, caregivers need to be activated for their own health to decrease this risk. Health activation has not been studied in rural caregivers. It is particularly relevant because most rural dwellers live in low-resourced, socioeconomically distressed environments where their health activation may be challenging. The purpose of this study was to identify characteristics of rural caregivers with multiple CVD risk factors who were not considered “activated” in their own health. Methods: Rural caregivers who had at least two CVD risk factors completed surveys on caregiver burden (Zarit Burden Interview), adherence to a healthy lifestyle (MOS Specifical Adherence Scale), perceived health status, and caregiving characteristics, and we calculated the Framingham CVD risk score. Health activation was assessed using the Patient Activation Measure, which categorizes people into four categories: overwhelmed, struggling, taking action, and maintaining levels. A multi-nominal logistic regression model was used to determine predictors of patient activation category. Results: Of the total of 269 rural caregivers (mean age= 54.1 years, 78% female), 36% were in the maintaining level, 42% were in the taking action level, and 22% in overwhelmed/struggling level. There were no significant differences in demographic or caregiving characteristics among the groups. Compared to the maintaining group, caregivers who had high caregiving burden (OR = 1.035, P = .007) and high Framingham CVD risk (OR = 1.061, P = .025), and low adherence to healthy behavior (OR = .917, P < .001) were more likely to be in the overwhelmed/struggling group. Caregivers who had a high burden (OR = 1.026, P = .012) and low adherence to healthy behaviors (OR = .926, P < .001) were more likely to be in the taking action group. Conclusions: Most rural caregivers were not activated on their health management even though they have multiple CVD risk factors. Screening health activation levels are needed for caregivers, and developing tailored intervention based on activation levels is needed.

Introduction: Adherence to the sodium-restricted diet (SRD) remains poor due to multiple barriers. We developed a dyadic intervention, a gradual taste adaptation to SRD to improve adherence to the SRD by overcoming sensory and family barriers. The purpose was to determine the efficacy of the gradual taste adaptation approach on dietary sodium intake, preferences for salty food, and enjoyment of SRD. Hypothesis: There will be a greater decline in dietary sodium intake and preference for salty food and an increase in the enjoyment of SRD at 4 and 12 months in dyads receiving the intervention compared to the dyads receiving usual care. Methods: A total of 158 patients with HF and caregiver dyads were randomly assigned to either the intervention (n=79 dyads) or a usual care control group (n=79 dyads). The 12-week intervention was delivered remotely using video conferencing. Outcomes were measured at 4 and 12 months for dyads, including dietary sodium intake using 24-hour urinary sodium excretion and self-reports on preference for salty food and enjoyment of SRD. Repeated measures ANOVA was used to determine intervention effects. Results: There was no difference in patients’ dietary sodium intake at baseline between the groups. Compared to the control group, patients in intervention significantly reduced dietary sodium intake and greater enjoyment of SRD. Sodium was reduced by 1,144 mg sodium at 4 months and 960 mg at 12 months while ratings of enjoyment of SRD increased at 4 and at 12 months (Figure 1). The intervention was not effective in decreasing the preference for salty food. There were also no significant intervention outcomes effects for caregivers. Conclusions: An innovative approach of gradual taste adaptation demonstrated significant short and long-term effects on reducing dietary sodium intake and enjoyment of SRD for patients. The intervention has the potential to expand the application to individuals who need to follow a SRD.

Background: Rural family caregivers experience high levels of stress, burden, and psychological distress related to caregiving and are at higher risk for cardiovascular disease (CVD) compared to non-caregivers. Health activation (known also as patient activation) is an indicator of engagement in self-care and is defined as an individual’s knowledge, skill, and confidence in managing health. Better health activation is associated with better health outcomes. Because rural individuals are at greater risk of CVD and have fewer supportive resources than those in urban environments, we wanted to determine the relationship of health activation with risk for future CVD in this population. Objective: The purpose of this study was to examine the association of health activation with risk for future CVD among rural family caregivers of patients with chronic illness. Methods: This was a cross-sectional study using baseline data from a randomized controlled trial of an intervention to reduce CVD risk for rural caregivers. We measured health activation using the Patient Activation Measure. The predicted10-year risk of CVD was assessed using the Framingham risk score. Covariates potentially related to cardiovascular risks among caregivers were collected including stress (Perceived Stress Scale-Cohen), anxiety (Brief Symptom Inventory), depressive symptoms (Patient Health Questionnaire-9), and caregiver burden (Zarit Burden Interview). Generalized linear regression was used to analyze data. Results: Of 217 caregivers (mean age 53 ± 13 years, 79% female), 48% were caring for a spouse, 20% were caring for a parent, and the remaining 32% were caring for a sibling, a child, or other relatives. Caregivers with higher health activation had a lower risk of developing CVD in the future based on their Framingham risk score (B = -0.081, SE= 0.039, 95% CI= -0.158 to -0.004, p=0.038), independent of the other covariates. Every 10-point increase in health activation score was associated with a nearly 1-point (0.81) decrease in Framingham risk score. Conclusions: Health activation is a good predictor of future risk for developing CVD. Development and testing of interventions to promote health activation before people develop CVD is suggested to decrease the risk of future CVD.

Aims Despite evidence-based recommendations for clinically stable patients with heart failure (HF) to engage in unsupervised exercise, the minimum cumulative dose of exercise per week associated with improvement in HF outcomes, especially in patients with poor functional capacity, has not been examined. We examined whether patients with HF and poor functional capacity who reported engagement in a guideline-recommended minimum weekly exercise had longer event-free survival than patients who did not exercise. Methods and results This analysis included 310 patients with HF who had completed the Duke Activity Status Index (DASI) and reported their level of engagement in exercise. Patients were grouped into good and poor functional capacity using a DASI cut-point of ≥19 and then further stratified based on their self-reported exercise level: high (≥60 min/week) and low ( Conclusion Self-reported engagement in a minimum of 60 min of exercise per week was associated with a significant improvement in event-free survival, even in patients with HF with low functional capacity. These results provide evidence that this dose of exercise is beneficial in patients with HF and poor functional capacity.

Ethnic discrimination is frequently experienced among U.S. Latinx communities, and is linked to CVD risk factors, such as depression. Genetic variants may influence this relationship.The objectives of this study were to examine associations between experiences of discrimination, rs4680 genotype, and depressive symptoms in Latinx adults.We analyzed data from 124 Latinx adults with two or more CVD risk factors, and conducted hierarchical linear regression, adjusting for sex, age, income, education, and acculturation.Participants were predominately female (74.2%) and aged 40.2 ± 9.3 years. More experiences of discrimination were associated with higher depressive symptoms (p = 0.041). Those with Met-Met-and Val-Met-genotypes had increased depressive symptoms than those with Val-Val-genotype (p = 0.049). Rs4680 was not a moderator.Findings suggest discrimination and rs4680 genotype are associated with depressive symptoms in Latinx adults, which may increase CVD risk. Further research is needed to better understand biological mechanisms of these relationships.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Nursing Research grant Background Medication adherence is essential to improve health outcomes in patients with heart failure (HF). Depressive symptoms contribute to decrease adherence behaviors. Although social support is helpful to improving medication adherence, perceived social support (PSS) may differ by living arrangement. How social support and living arrangement contribute to the relationship between depressive symptoms and medication adherence is not well understood in patients with heart failure. Purpose The purpose of this study was to determine whether perceived social support and living arrangement moderated the association between depressive symptoms and medication adherence. Methods This was a secondary analysis from outpatients with HF. Depressive symptoms were measured by the Patient Health Questionnaire-9. Perceived social support was assessed using Multidimensional Scale of Perceived Social Support, and patients were grouped into high and low PSS groups using a score of 79, the upper tertile value. Medication adherence was measured objectively by a medication event monitoring system for 3-months. Living arrangement was classified as (1) living with a spouse, (2) living with non-spouse family or friend, or (3) living alone. Moderated moderation analysis was conducted using PROCESS macro (Model 3) in SPSS with 5,000 bootstrap samples. Results Of the total of 208 patients (mean age = 61 ± 11.5 years, 64% male), 60% lived with spouse, 22% lived with non-spousal family or friend, and 26% lived alone. Three-way interaction (depressive symptoms*living arrangement*PSS) was significant (p = 0.0324, Figure 1). The effect of depressive symptoms on medication adherence was only significant for two groups (Figure 2): the living alone group with high PSS (effect = - 4.1855, p = 0.0021), and the living with a non-spousal family group with low PSS (effect = -1.0180, p = 0.0349). For these groups, their depressive symptoms were inversely associated with medication adherence. Conclusions: These results suggest that living arrangement and perceived social support are factors to be considered in medication adherence when planning care for patients with depressive symptoms. Future research is needed to explore whether the combined intervention of improving depressive symptoms and social support focusing on instrumental social support effectively increases medication adherence.

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): National Institutes of Health (NIH) Background The poor taste foods in a low sodium diet and patients’ preferences for salty foods are known barriers to sodium restricted diet (SRD) adherence. Older adults may experience less enjoyment of SRD due to decreased sense of taste. However, little is known about how age is associated with sodium intake, preference for salt, and enjoyment of SRD in patients with heart failure (HF). Purpose The purpose of this study was to examine effect of age on dietary sodium intake through their preference for salt and enjoyment of SRD in patients with HF. Methods In this cross-sectional study, we used baseline data from participants in a randomized controlled trial of a SRD intervention for patients with HF and their caregivers. Patients were asked to collect 24-hour urine to measure dietary sodium intake. Preference for salty food and enjoyment of SRD were assessed using a question on an 11-point numeric scale (range 0 to 10). Parallel mediation analyses were conducted using the PROCESS macro program in SPSS with 5,000 bootstrap samples. Results A total of 136 patients with HF (64% male, mean age = 60.3 ± 14.4, range 27 to 90, 80.1% white) had a mean 24-hr urine sodium of 4320mg (SD = 2053, range: 1553 mg – 11495 mg) with most (71%) having a 24-hr urine sodium > 3000mg. The mean preference for salty food was 5.3 (SD = 2.8) on a scale from 0 to 10 with 10 indicating greater preference and enjoyment of SRD was 4.4 (SD = 2.5) on the same scale. Age was significantly associated with sodium intake in that older patients were more likely to eat less sodium (effect= -40.3236, 95% CI= [-63.7151, -16.9321]). The indirect effects of age on sodium intake through preference of salty food (effect= .7033, 95% CI = [-2.3361, 4.5357]) and enjoyment of SRD (effect = -.0271, 95% CI = [ -3.2736, 2.2213]) were not significant, indicating that these factors did not mediate the relationship between age and dietary sodium consumption. When we controlled gender, education, and ethnicity, age was also associated with sodium intake, but the two indirect effects were not significant. Conclusion Although most patients consumed foods high in sodium, older patients were more likely to consume foods lower in salt. However, contrary to what we expected, preference for salty foods and enjoyment of SRD did not play mediator roles in the association of age with salt consumption. The findings suggest that older adults may need different types of intervention to promote adherence than younger patients. Further research is needed to explore other factors related to SRD (e.g., efficacy of SRD or perceived control of diet behaviors) that affect sodium intake in patients with HF.

Funding Acknowledgements Type of funding sources: None. Introduction Sedentary lifestyle is one of the modifiable risk factors that account for the high prevalence of cardiovascular diseases (CVD) in the rural areas.1,2 Daily step counting, using wearable devices, is increasingly used to monitor physical activity levels in interventions targeting CVD risk reduction in the rural areas.3,4 However, there is a lack of evidence to support a daily step count threshold that may reduce CVD risk among rural residents. The purpose of this study was to examine the relationship between daily step count cut-points and CVD risk. Methods This secondary analysis included 312 adults living in the rural areas in the southern United States. Daily step counts from pedometers were collected for 14 consecutive days. Established cut-points were used to categorize participants into groups based on mean daily step count as sedentary (≤ 5000 steps/day), less active (5000 -7499 steps/per), and physically active (≥7500 steps/day).5-7 CVD risk was measured with the Framingham risk score. Generalized additive models were used to examine differences among the 3 activity groups in Framingham risk score, controlling for educational level, perceived physical health status, depressive, marital status, and years of residence in a rural county. Results Among the participants (75% female, mean age 50.1 (±13.6) years), 40.7% were sedentary, 35.2% were less active, and 24.0% were physically active. The average Framingham risk score was 11.2% (±9.4%). Framingham risk scores were 1.7% lower in the less active compared to the sedentary group, but the effect was not significant (p < .11), and 2.6% lower in the physically active compared to the sedentary group (p < .04). The model accounted for 22% of the variation in Framingham risk scores. Conclusion These findings indicate that rural residents who averaged 7500 steps or more per day had lower CVD risk, and the difference is clinically significant.

Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): National Institutes of Health R01 NR 009280 & P20 NR 010679 Background Poor appetite is commonly reported in patients with heart failure, which may lead to a diet with limited food variety. Limited food variety, in turn, can result in dietary nutritional insufficiencies. Purpose The purpose of the study was to determine whether the relationship between appetite and dietary nutritional insufficiencies was mediated through diet variety. Methods In this secondary analysis, patients with heart failure rated appetite on a 10-point visual analog scale from 1 to 10. Nutritional insufficiency and diet variety were assessed by a four-day food diary analyzed by Nutrition Data Systems. Nutrition insufficiency was defined as the total number of 18 minerals and vitamins that were insufficient in the diet. Diet variety was calculated as the number of 23 food types consumed over the 4 days. A mediation analysis was conducted controlling for age, gender, New York Heart Association (NYHA), and body mass index using the PROCESS v3.5 macro program with 5,000 bootstrap samples in SPSS. Results A total of 238 patients (mean age 61, SD = 12; male n = 164, 69%; NYHA III/IV, n = 107, 45%) were included. The mean body mass index was 30 kg/m2 (SD = 7). The mean appetite score was 7.5 (SD = 2.3). The mean number of micronutrient insufficiencies was 4.7 (SD = 3.5), and the mean diet variety score was 12.4 (SD = 2.6). Appetite was not directly associated with nutrition insufficiency (effect = -.1802; 95% CI = -.3715, .0111) controlling co-variates. However, there was a significant indirect effect of appetite on nutrition insufficiency through diet variety controlling for covariates (effect = -.0828: 95% CI = -.1585, -.0150). Conclusions Diet variety mediated the association between appetite and dietary micronutrient insufficiency in patients with heart failure. The findings suggest that dietary intervention aimed at increasing patients’ appetite may increase diet variety and enhance the nutritional quality of diets of patients with heart failure.

Background Chronic disease self-management is complex and multidimensional. Optimal performance of self-management behaviors requires support from patient's friends, family, and significant others. The Multidimensional Scale of Perceived Social Support (MSPSS) is a 12-item questionnaire used to measure patient's social support from friends, family, and significant others. Objectives To examine the psychometric properties of the MSPSS in patients with comorbid chronic obstructive pulmonary disease (COPD) and heart failure (HF). Methods Reliability, factorial validity, and construct validity of the MSPSS were examined using Cronbach's alpha, split-half reliability, factor analysis via principal components analysis and hypothesis testing via multivariate linear regression, respectively. Results The MSPSS demonstrated excellent internal consistency with Cronbach's alpha consistently above 0.90. Factor analysis yielded a 3-factor solution, with items loading appropriately on the Friend, Family and Significant Other subscales. Conclusion The MSPSS is a reliable, valid instrument to measure perceived social support in patients with comorbid COPD and HF.

Background The prevalence of multi-morbidity in implantable cardioverter defibrillator (ICD) recipients is approximately 25%. Multi-morbidity is associated with poor health and psychological outcomes in this population and may affect ICD recipients' quality-of-life (QOL). The purpose of this study was to determine the prevalence of psychological distress (anxiety, depressive symptoms, and Type-D personality) in ICD recipients with varying levels of comorbidities, and to examine the association between multi-morbidity burden and QOL in this population. Methods All adults listed in the Swedish ICD and Pacemaker Registry in 2012 with an ICD implanted for at least one year were invited to participate in this study. Binary logistic regression was used to predict QOL using the EQ-5D mean index dichotomized based on median QOL scores. Multi-morbidity burden scores were based on quartile groupings. Results A total of 2658 ICD recipients participated in the study (with a mean age of 65, 20.6% female, mean implant duration of 4.7 years, with 35.4% implanted for primary prevention of sudden cardiac arrest). Greater multi-morbidity burden, female sex, not working outside the home, history of ICD shock, negative ICD experience, higher levels of ICD-related concerns, and the presence of anxiety, depression, or Type D personality were associated with worse QOL in ICD recipients. Predictors differed by multi-morbidity burden level. Conclusions Multi-morbidity burden and psychological distress is an essential factor related to QOL. This issue should be discussed with potential ICD recipients prior to implant. Further exploration of increased recognition and treatment of psychological distress in ICD recipients is warranted.

Dietary guidance for patients with heart failure (HF) has traditionally focused on sodium and fluid intake restriction, but dietary quality is frequently poor in patients with HF and may contribute to morbidity and mortality. Restrictive diets can lead to inadequate intake of macronutrients and micronutrients by patients with HF, with the potential for deficiencies of calcium, magnesium, zinc, iron, thiamine, vitamins D, E, and K, and folate. Although inadequate intake and low plasma levels of micronutrients have been associated with adverse clinical outcomes, evidence supporting therapeutic repletion is limited. Intravenous iron, thiamine, and coenzyme Q10 have the most clinical trial data for supplementation. There is also limited evidence supporting protein intake goals. Obesity is a risk factor for incident HF, and weight loss is an established approach for preventing HF, with a role for bariatric surgery in patients with severe obesity. However weight loss for patients with existing HF and obesity is a more controversial topic owing to an obesity survival paradox. Dietary interventions and pharmacologic weight loss therapies are understudied in HF populations. There are also limited data for optimal strategies to identify and address cachexia and sarcopenia in patients with HF, with at least 10%-20% of patients with ambulatory systolic HF developing clinically significant wasting. Gaps in our knowledge about nutrition status in patients with HF are outlined in this Statement, and strategies to address the most clinically relevant questions are proposed.

Backgrounds: Perceptions of health are important to motivate people to change behaviors. Non-adherence to healthy behaviors that prevent cardiovascular disease may result from inadequate health perceptions. However, there are few studies investigating relationships between health perceptions and psychological states. Objective: To determine whether psychological states (ie, depressive symptoms and anxiety) are associated with the congruency between health perception and estimated risk for cardiovascular disease in adults with 2 or more cardiovascular disease risk factors. Methods: Community dwellers at risk for cardiovascular disease were asked to complete the Patient Health Questionnaire-9 and the anxiety subscale of the Brief Symptom Inventory to measure depressive symptoms and anxiety, respectively. Participants rated their perceived health from excellent to poor. The estimated cardiovascular disease risks were measured with the 10-year cardiovascular disease Framingham risk scores. Participants were grouped into three health perception groups based on congruency between levels of health perception and cardiovascular disease risk. Multivariate multinomial logistic regression was done to examine the association between psychological states and health perception groups. Results: Of 828 participants 54.7%, 12.0%, and 33.3% had congruent, pessimistically biased, and optimistically biased health perception, respectively. Depressive symptoms were significantly associated with pessimistic bias (adjusted odds ratio: 1.070, 95% confidence interval 1.010-1.133), but not anxiety. Optimistic bias was not associated with either depressive symptoms or anxiety. Conclusions: A mismatch between individual health perceptions and cardiovascular disease risks was associated with depressive symptoms. As health perception is affected by depressive symptoms, clinicians should assess depressive symptoms when exploring health perceptions and engaging individuals in decision-making about a healthy lifestyle.

© The Author(s) 2019. Patients’ perceptions of the causes and consequences of heart failure (HF) symptoms may impact effective self-management. The purpose of this study was to describe and explore patients’ perceptions of HF symptom status and the causes and consequences on their daily lives in patients with HF. Descriptive and qualitative data were obtained from 20 patients using a semistructured interview guide. Data were analyzed using content analysis and descriptive statistics. Participants reported 15 symptoms (median = 4). Five themes were (a) multiple causes and multiple symptoms; (b) knowing some causes, but still unclear; (c) not being able to live life as previously did; (d) facing emotional distress due to HF symptoms; and (e) development of new priorities and lifestyles. The findings demonstrate that all participants perceived considerable difficulties living with HF symptoms. More comprehensive interventions need to be delivered to patients to manage multiple causes and symptoms effectively.

PURPOSE Caring for a family member with chronic illness increases cardiovascular disease (CVD) risk by 82%, and rurality imparts additional CVD disparities. The purpose of this study was to describe a profile of rural caregivers of patients with chronic illnesses to determine the prevalence of CVD risk factors, and psychosocial and socioeconomic burden, as well as to compare these variables across gender. METHODS Baseline data from a trial of CVD risk reduction in rural caregivers of patients with chronic illnesses were used. We measured depression and anxiety with the PHQ-9 and Brief Symptom Inventory; social, economic, and environmental factors using the MOS-Social Support and Economic and Environmental surveys; body mass index (BMI); blood pressure (BP); and lipid profile. RESULTS Of 181 caregivers (age 53±14 years, 80% female), 69% were married; 88% were caring for a family member, including 46% caring for a spouse and 18% for a parent. A total of 51% were anxious, 25% depressed, and 25% reported lack of social support. Most (51%) caregivers had one or more types of CVD; and 49% were smokers. By examination, 76% had elevated BP; 35% had total cholesterol >200; 50% low-density lipoprotein >100; 56% triglycerides >150; and 79% high-density lipoprotein

The aim was to determine whether 24-hour urine sodium excretion predicted event-free survival of patients with heart failure (HF) and diabetes mellitus (DM). Twenty-four hour urine sodium, as an indicator of dietary sodium, was collected from 107 patients with HF and comorbid DM. Patients were followed for a median period of 337 days to determine time to the first event of either all-cause hospitalization or cardiac-related mortality. There were 44 patients (41%) who had an event of death or hospitalization. Cox regression showed that higher urine sodium (>3.8 gm/day) was associated with 2.8 times greater risk for an event than lower urine sodium after controlling for age, gender, New York Heart Association class (I/II vs. III/IV), left ventricular ejection fraction, and body mass index. These data suggest that dietary sodium restriction may be beneficial for patients with HF and DM.

Background Impaired psychological state, such as anxiety and depressive symptoms, occurs in up to 40% of patients hospitalized for traumatic injury. These symptoms, in the acute period, may delay engagement in activity, such as ambulation, following injury. The purpose of this study was to determine whether baseline anxiety and depressive symptoms predicted delayed (>48 hr from admission) ambulation in patients hospitalized for major traumatic injury. Methods Adults (n = 19) admitted for major trauma (Injury Severity Score [ISS] = 15) provided a baseline measure of anxiety and depressive symptoms (Hospital Anxiety and Depression Scale [HADS]). Logistic regression was used to determine the predictive power of baseline HADS Anxiety and HADS Depression subscale scores for delayed ambulation while controlling for ISS. Results At baseline, anxiety was present in 32% of patients; 21% reported depressive symptoms. Baseline HADS Anxiety score did not predict the ambulation group. However, for each 1 point increase in baseline HADS Depression score, the likelihood of patients ambulating after 48 hr from admission increased by 67% (odds ratio = 1.67; 95% CI [1.02, 2.72]; p = .041). Conclusion Worsening depressive symptoms were associated with delayed ambulation in the acute period following injury. Future, larger scale investigations are needed to further elucidate the relationship between psychological symptoms and the acute recovery period from trauma to better inform clinicians and guide development of interventions to improve patient outcomes.

The purpose of this study was to determine whether deficiencies of water-soluble vitamin intake predicted health-related quality of life (HRQOL) and the composite end point of all-cause mortality or cardiac- or heart failure (HF)-related hospitalization in HF patients. Patients with HF may be at risk for inadequate consumption of water-soluble vitamins due to poor appetite and dietary sodium restriction. Because water-soluble vitamins are important in metabolic processes, inadequate dietary intake of these vitamins may negatively affect health outcomes.We consecutively recruited patients with HF from outpatient clinics affiliated with academic medical centers. Patients were referred by providers to investigators who verified their eligibility. Patients with HF completed a four-day food diary to determine dietary deficiencies of water-soluble vitamins and the Minnesota Living with HF questionnaire to assess HRQOL at baseline. Patients were followed to determine an event.A total of 216 patients were included. Patients with a higher number of dietary deficiencies of water-soluble vitamins had poorer HRQOL (unstandardized coefficient = 4.92, 95% confidence interval 2.20-7.27). Cox regression showed that for each additional deficiency of a water-soluble vitamin intake, there was a 30% increase in risk for an event (95% confidence interval 1.03-1.75), controlling for demographic and clinical variables.Inadequate dietary consumption of water-soluble vitamins was associated with poor HRQOL and prognosis and in HF. Our findings highlight that clinicians should understand the importance of encouraging patients to consume water-soluble vitamin-rich foods, which may result in enhancing outcomes in HF.

Introduction: There is emerging evidence that ethnic discrimination, commonly experienced among U.S. Hispanics, is associated with depressive symptoms, increasing cardiovascular disease (CVD) risk. Genetic variants in dopaminergic pathways may moderate this association. The catechol-O-methyltransferase Val158Met polymorphism is a potential candidate because the Met allele is associated with increased risk for depressive symptoms. The purposes of this study were to examine associations among ethnic discrimination, Val158Met polymorphism, and depressive symptoms, and to explore if Val158Met moderates the association between discrimination and depressive symptoms in Hispanic adults. Methods: Participants were 124 Hispanic adults with 2+ CVD risk factors. Ethnic discrimination was measured with the Experiences of Discrimination instrument, which measures discrimination experiences across 9 settings (e.g. at work). Scores range from 0 to 45; higher scores indicate more experiences of discrimination. Depressive symptoms were measured using the Patient Health Questionnaire-8. Scores range from 0 to 21; higher scores indicate more depressive symptoms. DNA was isolated from saliva and analyzed for Val158Met genotype. A hierarchical linear regression was conducted adjusting for sex, age, income, education, acculturation, and years in the U.S. Discrimination was entered in Step 1 and Val158Met in Step 2 to examine the association with depressive symptoms. To assess moderation, a discrimination*Val158Met interaction term was entered in Step 3. Results: Participants were aged 40.2 ± 9.3 years and mostly female (74.2%). Discrimination was positively associated with depressive symptoms (p = 0.041). Participants with at least one Met allele at the Val158Met polymorphism had more depressive symptoms than those with a Val-Val genotype (p = 0.049). No moderation effect was found. Conclusion: Findings suggest that discrimination and Val158Met genotype independently influence depression in Hispanic adults, which may increase risk for depression and CVD in certain individuals. This highlights the need to explore mechanisms underpinning these associations, and to address the impact of discrimination on depression and CVD disparities.

Introduction: In patients with heart failure (IHF), health-related quality of life (HRQOL) is as important as longer survival. Deaths are inevitable for all human beings, but clinicians may help patients with HF to maintain or improve HRQOL until almost at the end of their lives. Psychological and physical symptoms can impact HRQOL through different pathways, and behavioral factors can indirectly impact HRQOL, but the relationships have not been tested in prior theoretical models. Hypothesis: Sociodemographic (i.e., age), biological/physiological (i.e., comorbidity), psycho-social (i.e., depressive symptoms and social support), physical (i.e., physical symptoms and functional status), and behavioral factors (i.e., dietary adherence) in Heo-Moser model will be associated with HRQOL directly and indirectly in patients with HF through different pathways. Methods: This is a secondary analysis of baseline data from two observational studies in which baseline data were collected using the same instruments (N = 358 patients with HF, mean age: 60.4 years). Structural equation modeling (SEM) was used to test the hypothesis. Results: In the SEM, the analysis showed desirable model fit: Chi-square = 7.710, p = .260, RMSEA = .028 (95% confidence interval = 0.00, 0.078), CFI = 0.998, TLI = 0.989, and SRMR = 0.023. Age, depressive symptoms, physical symptoms, and functional status were directly associated with HRQOL. Age, comorbidity, depressive symptoms, social support, dietary adherence, and physical symptoms were indirectly associated with HRQOL through different pathways (Figure 1). Conclusions: All the factors in the model were directly and/or indirectly associated with HRQOL through different pathways. The pathways of physical symptoms, depressive symptoms, and dietary adherence differed. This model can be used to develop interventions targeting improvement in HRQOL in patients with chronic diseases.

Introduction: Caregivers have an 82% increased risk of cardiovascular disease (CVD) compared to non-caregivers. Depressive symptoms (DS) and anxiety increase CVD risk, and these are worse in rural dwellers. Knowing predictors of DS and anxiety in rural caregivers of patients with chronic illness is important to reduce CVD risk. Purpose: To identify predictors of DS and anxiety in rural caregivers at risk for CVD using a social determinants of health (SDH) model. Method: In this cross-sectional study we measured multiple SDH. These variables included sociodemographic (i.e., age, gender, race, marital status, health insurance, education, financial status), behavioral (i.e., smoking and body mass index [BMI]), and psychosocial (i.e., caregiver burden measured by the Zarit Burden Interview, perceived stress by the Cohen Perceived Stress Scale, and social support by the Medical Outcomes Study Social Support Survey) factors. The outcomes of DS were measured by the Patient Health Questionnaire-9 and anxiety by the Brief Symptom Inventory – Anxiety subscale. Data were analyzed using two separate multiple regression models, one for DS and one for anxiety. As depression and anxiety are often comorbid, they were considered predictors in the appropriate models. Results: In the 262 participants (mean age 53±13, 78% female, 96% Caucasian, 70% were married), mean years of education were 14±2, 56.1% had enough money to make ends meet, and 55% had no insurance or Medicaid only. Significant predictors of worse DS were higher caregiver burden (β=0.05, p=0.004), higher perceived stress (β=2.04, p=0.001), and higher anxiety (β=3.79, p= Conclusion: Predictors of DS and anxiety in these rural caregivers were psychosocial variables. Caregiver CVD Interventions could be optimized by including stress management, education about the psychological effects of caregiving, and social support components. Future research is needed on the role of DS and anxiety in CVD to better support rural caregivers at highest risk.

Introduction: Inflammation is a common biological process accompanying chronic conditions, such as heart failure (HF) that can be moderated by diet. The association between foods thought to promote inflammation and event-free survival in patients with HF has not been investigated. Hypothesis: The inflammatory potential of individuals’ diets, measured using the dietary inflammatory index (DII), will be associated with event-free survival in patients with HF. Methods: The DII scores were calculated from 4-day food diaries recorded at baseline by 213 patients with HF (age 61±12years, 35% female, 43% NYHA III/IV). Patients were followed for a median of 365 days by monthly phone calls, medical record review, and death records to determine time to all cause-hospitalization or death. The DII scores were dichotomized using median value for the Cox regression model. Hierarchical multivariate Cox proportional hazards model was used to determine whether DII scores predicted event-free survival after controlling for age, gender, body mass index, prescribed angiotensin-converting-enzyme inhibitor, beta-blocker, cholesterol lowering agent, antiinflammatory agent, N-terminal pro B-type natriuretic peptide, comorbidity, depressive symptoms, and the New York Heart Association functional classification. Results: The DII scores independently predicted event-free survival in the model constant ( p = 0.012). Higher DII scores were associated with more than double the risk of an event compared to lower DII scores (HR: 2.28, 95% Confidence Interval =1.21-4.36). Conclusions: Greater intake of foods considered to promote inflammation was associated with shorter event-free survival in patients with HF. These results provide further evidence of the importance of diet to HF outcomes.