A comparison of the effects of cholesterol on CHD mortality in black and white women: twenty-eight years of follow-up in the Charleston Heart Study

A Framework for Interfacing and Partnering with Environmental Justice Communities as a Prelude to Human Health and Hazard Identification in the Vulnerable Census Tracts of Columbus, Ohio

Columbus, Ohio is one of the more prosperous, well-educated, and progressive cities in the United States. However, it ranks as the second worst life expectancy at birth, has a census tract wealth gap (27-year disparity), and one of the higher infant mortality rates in the country. These data suggest that there are likely several high-risk, vulnerable neighborhoods in Columbus with residents experiencing disparate and adverse outcomes. Illustrative of this fact are studies that have examined the social processes and mechanisms through which neighborhood contexts are at the forefront, including exposures to chemical stressors such as particulate matter (PM_2.5) as well as non-chemical stressors including violence, social determinants of health, zoning, and land use policies. It is documented that disparate and adverse outcomes are magnified in the vulnerable neighborhoods on the Near East Side as compared to Columbus city proper, Franklin County and/or the state of Ohio. As such, we developed a nuanced community engagement framework to identify potential environmental hazards associated with adverse pregnancy outcomes in those census tracts. The refined framework uses a blended version of traditional community-based participatory research (CBPR) models and is referred to as E⁶, Enhancing Environmental Endeavors via e-Equity, Education, and Empowerment.

Cardiometabolic risk among African American women: a pilot study

OBJECTIVE

This study aimed to determine the associations of the Homeostatic Model of Assessment-insulin resistance (HOMA-ir), acanthosis nigricans, high-sensitivity C-reactive protein (hs-CRP), and plasminogen activator inhibitor-1 (PAI-1) with 2 of the commonly used definitions of metabolic syndrome (Adult Treatment Panel III [ATP III] and International Diabetes Federation [IDF]) among reproductive-age, healthy, free-living African American women.

METHODS

A pilot study with a cross-sectional design examined 33 African American women aged 20 to 46 years (mean [SD], 31.24 [7.25] years) for the presence of metabolic syndrome determined by ATP III and IDF criteria, insulin resistance (HOMA-ir and/or acanthosis nigricans), degree of inflammation (hs-CRP), and presence of dysfibrinolysis (PAI-1).

RESULTS

HOMA-ir identified insulin resistance in 27 (81.8%) women, whereas the presence of acanthosis nigricans indicated that 16 (48%) of these women manifested insulin resistance. Metabolic syndrome was found in 7 women (21.2%) by ATP III or in 9 (27.3%) women by IDF criteria. Bivariate correlations showed associations between HOMA-ir and waist circumference, body mass index (BMI), acanthosis nigricans, and the ATP III and IDF definitions for metabolic syndrome. Plasminogen activator inhibitor-1 was significantly correlated with waist circumference, BMI, fasting glucose, HOMA-ir, and ATP III. Both HOMA-ir and PAI-1 were significantly and negatively correlated with high-density lipoprotein cholesterol. High-sensitivity CRP was significantly correlated with BMI and 2-hour postglucose.

CONCLUSION

Both dysfibrinolysis (PAI-1 levels) and insulin resistance (HOMA-ir), when individually regressed on the ATP III definition of metabolic syndrome, explained 32% and 29% of the respective variance. The addition of HOMA-ir measurement may significantly improve early recognition of cardiometabolic risk among reproductive-age African American women who have not yet met the criteria for the ATP III or IDF definitions of metabolic syndrome. Likewise, acanthosis nigricans is potentially a clinically significant screening tool when used to determine early recognition of insulin resistance and/or cardiometabolic risk among this population. African American women's risk for cardiovascular disease is likely underestimated based on the sole use of ATP III criteria for diagnosis of metabolic syndrome. Clinicians should consider a broader definition of risk than that contained within ATP III. Inclusion of biomarkers of inflammation and dysfibrinolysis, along with measures of insulin resistance, may add to early detection of cardiometabolic risk and ultimate reduction in cardiovascular health disparities among African American women.

African American Women, Metabolic Syndrome, and National Cholesterol Education Program Criteria

BACKGROUND

The association between elevated levels of triglycerides and insulin may be weaker in African American women (AAW) than in women of other groups, leading to under diagnosis of the metabolic syndrome (MetS) in AAW when using the National Cholesterol Education Program (NCEP) criteria, as those criteria do not include a marker of insulin resistance, using elevated triglycerides to provide an indirect indication of insulin resistance.

OBJECTIVES

To determine the degree of agreement between two definitions for the MetS, that described by the NCEP and the NCEP criteria with the addition of a marker of insulin resistance in a sample of AAW.

METHOD

This non experimental pilot study took place in the General Clinical Research Center of a major medical center. Thirty-three AAW 19-45 years of age were screened using the NCEP criteria for MetS, additional markers of insulin resistance, and a 2-hour Oral Glucose Tolerance Test.

FINDINGS

Six (18%) women were classified as having the MetS using the NCEP criteria. When one of three markers for insulin resistance (hyperinsulinemia, acanthosis nigricans, or Homeostatic Model Assessment Insulin Resistance) was added to the criteria, 15 (45.5%) to 19 (59.5%) of the women were then identified as having MetS.

DISCUSSION

As identified in the literature, the prevalence of cardiovascular disease risk in AAW may be underestimated based on the sole use of the NCEP criteria. Further, because there is some evidence that insulin resistance develops before many other indicators, the addition of a marker of insulin resistance may assist in earlier identification of AAW at high risk for cardiovascular disease.

Effects of policosanol on postmenopausal women with type II hypercholesterolemia

This randomized, double-blind, placebo-controlled study was conducted to investigate the efficacy, safety and tolerability of policosanol, a cholesterol-lowering drug purified from sugar-cane wax, in postmenopausal women with type II hypercholesterolemia. A total of 244 women who had experienced the menopause and showed elevated serum total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels despite 6 weeks on a standard lipid-lowering diet were randomized to receive placebo or policosanol 5 mg/day for 12 weeks, after which the dose was doubled to 10 mg/day for the next 12 weeks. Policosanol (5 and 10 mg/day) significantly lowered LDL-C levels (17.7% and 25.2%, respectively) and total cholesterol (12.6% and 16.7%, respectively), as well as the ratios of LDL-C to high-density lipoprotein cholesterol (HDL-C) (17.0% and 29.3%, respectively) and total cholesterol to HDL-C (16.7% and 27.2%, respectively), compared to the baseline and placebo; at the same time, policosanol significantly raised HDL-C levels by 16.5% and 29.3%, respectively. The drug was safe and well tolerated. No drug-related adverse events were observed, and even the extent of adverse events was less in the policosanol group than in the placebo group. Four serious adverse events occurred in the placebo group (one myocardial infarction, two cases of hypertensive status and one surgical intervention) compared to none in the policosanol group. In conclusion, policosanol is effective, safe and well tolerated in hypercholesterolemic postmenopausal women.

Call to action: cardiovascular disease in women

One third of women between the ages of 50 and 75 have cardiovascular disease, which accounts for more than 50% of all deaths among women annually. Cardiovascular disease not only is the leading cause of death among women; it is more lethal and less aggressively treated in women than in men. Twice as many women--505,440--die from heart disease as from all forms of cancer combined. Despite the compelling statistics, only 8% of women consider cardiovascular disease a personal health threat. The scenario is troubling because women appear to understand so little or to deny their cardiac risks and so not recognize their ability to control them. Clearly, there is an urgent and compelling need for physicians to take an active role in identifying health behaviors that may affect the risk of cardiovascular disease in their female patients. Dialogue between the physician and patient should begin early to foster preventive steps, and the communication and education must continue throughout the patient's life span. Cardiovascular risk factors, including cigarette smoking, physical inactivity, hypertension, elevated cholesterol, overweight, diabetes, and menopause, should be identified and addressed for all women.

Coronary heart disease risk factors in black and white patients with non-insulin-dependent diabetes mellitus

OBJECTIVE

To determine possible racial differences in risk factors for coronary heart disease (CHD) in black and white patients with noninsulin-dependent diabetes mellitus (NIDDM).

METHODS

Study of risk factors for coronary heart disease among 308 subjects who met the WHO criteria for NIDDM.

RESULTS

Both black and white patients were found to have a high prevalence of hypertension, obesity, low high density lipoprotein (HDL) cholesterol, low leisure-time physical activity levels, and an atherogenic dietary profile. Black males were more likely to have hypertension, reported a greater intake of dietary cholesterol, and had lower triglycerides, higher HDL cholesterol levels, a lower CHOL/HDL ratio, and a lower waist to hip ratio (WHR) than white males. Black females had higher mean arterial and diastolic blood pressures, had lower triglycerides, higher HDL cholesterol, a lower CHOL/HDL ratio, a higher subscapular/triceps ratio and lower reported leisure-time energy expenditure compared to white females. There were no racial differences found for obesity level.

CONCLUSION

Our results indicate that racial differences in CHD risk factors exist among black and white patients with NIDDM. The complex genetic, sociocultural and environmental interactions involving CHD risk factors that contribute to the development of CHD may eventually provide clues to the etiology of the disease.

Simulation of micropopulations in epidemiology: tutorial. 3. Simulation model evaluation methods. A series of tutorials illustrated by coronary heart disease models

This is the third in a series of tutorials concerning the simulation of micropopulation models to support epidemiological research. The series emphasizes techniques used in studies at the National Micropopulation Simulation Resource at the University of Minnesota. For pedagogic purposes, applications to coronary heart disease (CHD) models are used to illustrate the principles and methodologies employed. All of the models presented are implemented using available software. A variety of tests and techniques are used to evaluate these models. This tutorial presents some of those methods stressing the advantages and limitations of the tests rather than the formal definitions. To make the evaluation methods more understandable, some of the risk factors for CHD models are introduced. The interpretation of the evaluation depends critically on the goals of the modeling effort. The subset of evaluation methods presented includes investigations of the epidemiological, mathematical and statistical aspects of the models.

Simulation of micropopulations in epidemiology: tutorial 2. Analytic forms of event probabilities. A series of tutorials illustrated by coronary heart disease models

This is the second in a series of tutorials concerning the simulation of micropopulation models to support epidemiological research. The series emphasizes techniques that are included in studies at the National Micropopulation Simulation Resource at the University of Minnesota. For pedagogic purposes, applications to coronary heart disease models are used to illustrate the principles and methodologies employed. All of the models presented are implemented using available software. Both interpretation of the results of survey and surveillance data, and the simulation for predictive purposes of micropopulation models, depend upon the form chosen to represent the probability of the occurrence of an event associated with coronary heart disease. Four different forms are discussed; each can be used to represent the probability of transfer from the healthy state to one of the disease states or, in other words, the probability of occurrence of an event of interest. These four forms are by no means all-inclusive; rather they are ones that are convenient to use with micropopulation simulation models and that exhibit a variety of the different possibilities.

Management of postmenopausal women who have hyperlipidemia

Dyslipoproteinemia is prevalent in women as well as in men. In both, its consequences of premature atherosclerosis and coronary artery disease (CAD) morbidity and mortality are common. Although clinical evidence of the benefits of cholesterol lowering is less abundant in women, it is not entirely absent. As in men, cholesterol lowering in women is associated with a decline in CAD risk and regression of coronary atherosclerosis.

A review of observational studies on the relationship between cholesterol and coronary heart disease

The likelihood that an association observed in epidemiological studies is one of cause and effect is often evaluated using criteria first put forward by Bradford Hill. The evidence on whether abnormal concentrations of cholesterol and lipoproteins in the blood plasma cause coronary heart disease (CHD) is considered using Bradford Hill's criteria. Evidence from observational studies, backed by evidence from clinical, animal and laboratory studies, leaves no doubt that a high plasma cholesterol concentration is a cause of CHD.

Cholesterol lowering, low cholesterol, and mortality

Cholesterol lowering in both primary and secondary prevention has been clearly demonstrated to lower coronary morbidity and, in secondary prevention, to lower coronary mortality as well. Putative dangers of cholesterol lowering remain unproven. Population studies linking low cholesterol to noncoronary mortalities do not demonstrate cause-and-effect relations. In fact, based on current studies, the opposite is more likely to be the case. Neither gender nor age should automatically exclude persons from cholesterol screening. Drug intervention, however, should be used conservatively, particularly in young adults and the elderly. Drugs should be used only after diet and lifestyle interventions have failed. The evidence linking high blood cholesterol to coronary atherosclerosis and cholesterol lowering to its prevention is broad-based and definitive. Concerns about cholesterol lowering and spontaneously low cholesterols should be pursued but should not interfere with the implementation of current public policies to reduce the still heavy burden of atherosclerosis in Western society.

Mortality rates and risk factors for coronary disease in black as compared with white men and women

BACKGROUND

Currently recognized risk factors for coronary artery disease have been identified primarily from investigations of white populations. In this investigation, we estimated mortality rates for coronary disease and for any cause and identified risk factors for death from coronary disease among whites and blacks.

METHODS

Data collected over a 30-year period in the Charleston Heart Study were used to estimate mortality rates and quantify associations with risk factors assessed at the base-line examination in 1960 and 1961 of 653 white men, 333 black men, 741 white women, and 454 black women.

RESULTS

There were no significant racial differences in the rate ratios for death from coronary disease; however, women had significantly lower death rates than men. Over the 30-year period, the mortality rates for coronary disease per 1000 person-years were 5.2 for white men (95 percent confidence interval, 4.1 to 6.3), 4.6 for black men (3.0 to 6.2), 2.1 for white women (1.6 to 2.6), and 3.2 for black women (2.3 to 4.0). Significant, or nearly significant, predictors of mortality due to coronary disease were systolic blood pressure in all four groups; serum cholesterol level among white men, white women, and black women; and smoking among white men, white women, and black men. Although the difference was not statistically significant, the risk of death from coronary disease was consistently increased among diabetics in all four groups. A higher level of education was predictive of lower rates of death due to coronary disease among white men and black women. For all causes of death taken together, the rates for blacks were higher than the rates for whites. The presence of hypertension, a history of smoking, and a history of diabetes were significant or nearly significant predictors of mortality from any cause in all four groups.

CONCLUSIONS

Although the rates of death from coronary disease were somewhat lower among black men than white men and higher among black women than white women, the black:white mortality rate ratios were not statistically significant, and the major risk factors for mortality from coronary disease were similar in blacks and whites in the 30-year follow-up of the Charleston Heart Study.