Risk of cardiovascular disease measured by carotid intima-media thickness at age 49-51: lifecourse study

Associations between early infections and childhood cognition in the Newcastle Thousand Families Study birth cohort

Childhood infections have been shown to stunt growth, contribute to malnutrition and reduce cognition in early adulthood. This study aimed to assess relationships between early life infections and childhood cognition at age 11 years in the Newcastle Thousand Families Study (NTFS). The analysis included 741 members from the NTFS who had complete data for infections between birth and 5 years, and the 11-plus examinations. School records from the 11-plus examinations showed cognitive (IQ), English (EQ) and arithmetic (AQ) abilities. Housing conditions, overcrowding, birth order and social class were recorded at birth. Helicobacter pylori seropositivity was measured at age 49-51 years. Multivariable linear regression was used to examine relationships between infections and cognition. The total number of infections in the first 5 years of life was not significantly associated with IQ, EQ or AQ, nor were there significant relationships between cognitive outcomes and most infections. Tonsillitis did display a positive, significant association with IQ after adjustment for confounders (b = 6.43, 95% CI 0.92, 11.94, p = 0.022). Lower respiratory tract infections (LRTIs) showed significant negative relationships with all cognitive outcomes. H. pylori seropositivity at age 50 exhibited negative, significant relationships with EQ (p = 0.014) and AQ (p = 0.024) after adjustment for confounders. Although no significant relationship between overall infections and cognition were found, there were indications that LRTIs and gastrointestinal system infections may limit cognitive development. Given these infections remain prevalent, further research regarding severity and recurrence of infections and how they affect childhood cognition is needed.

Evaluation of carotid intima media thickness measurement from ultrasound images

A third of deaths in the world are due to cardiovascular diseases [1]. Atherosclerosis is the major cause of myocardial infarction, which occurs by deposition of plaque in the coronary artery. The chance of stroke rises with the thickening of carotid artery due to the plaque. Hence, accurate measurement of the intima-media thickness is necessary for predicting the chance of stroke. The stopping criterion and active resampling are incorporated in greedy snake segmentation technique. This modified algorithm segmented and extracted the intima-media complex in the ultrasound images. The snake control points obtained from the boundary of the region of interest forms the contour and demarcates the boundary of intima-media complex. The thickness ± standard deviation and the intra-observer error values obtained by modified algorithm are in conformity with the measurements by expert. The intra-observer error values for greedy snake segmentation methods were 0.10 and 0.09 for manual snake initialization and automatic snake initialization, respectively. Shapiro-Wilk test and One-way ANOVA test explains there is no statistical difference between group means obtained from these segmentation techniques and the expert measurement. The statistical analysis proves values of the intima-media thickness obtained from both snake segmentation techniques are very close to expert measurements.

Short- and Long-Term Implications of Small for Gestational Age

Fetal growth restriction (FGR) describes a fetus' inability to attain adequate weight gain based on genetic potential and gestational age and is the second most common cause of perinatal morbidity and mortality after prematurity. Infants who have suffered fetal growth restriction are at the greatest risks for short- and long-term complications. This article specifically details the neurologic and cardiometabolic sequalae associated with fetal growth restriction, as well as the purported mechanisms that underlie their pathogenesis. We end with a brief discussion about further work that is needed to gain a more complete understanding of fetal growth restriction.

Light-To-Moderate Raw Garlic Consumption Frequency Is Inversely Associated With Thickened Carotid Intima-Media Thickness: A Population-Based Study

Background: Previous animal and clinical studies have reported beneficial effects of garlic preparations on carotid intima-media thickness (cIMT). However, no epidemiological study has yet investigated the association between dietary raw garlic consumption and cIMT in the general population. The objective of this study was investigating the association between dietary raw garlic consumption and thickened cIMT in Chinese adults.

Methods: This cross-sectional study used data from the Tianjin Chronic Low-grade Systemic Inflammation and Health Cohort Study. A total of 4,329 general adults from 2015 to 2017 were included in this study. Frequency of consumption of raw garlic was summarized as four categories for analysis: < 1 time/week, 1 time/week, 2-3 times/week, ≥4 times/week with a validated food frequency questionnaire. The thickened cIMT was defined as common carotid artery IMT ≥ 1.0 mm or a carotid bifurcation IMT ≥ 1.2 mm by ultrasonography. Multivariable logistic regression analysis was used to examine the association between frequency of raw garlic consumption and thickened cIMT.

Results: The prevalence of thickened cIMT is 22.9% among these participants. The adjusted odds ratios (95% confidence intervals) associated with the different frequencies were 1.00 (reference) for < 1 time/week, 0.74 (0.59, 0.94) for 1 time/week, 0.71 (0.55, 0.92) for 2–3 times/week, and 0.94 (0.71, 1.25) for ≥ 4 times/week.

Conclusions: Light-to-moderate raw garlic consumption was inversely associated with thickened cIMT, whereas greater raw garlic consumption (i.e., ≥4 times/week) was not associated with thickened cIMT. Future longitudinal studies should be conducted to test these findings.

Natural History of Atherosclerosis and Abdominal Aortic Intima-Media Thickness: Rationale, Evidence, and Best Practice for Detection of Atherosclerosis in the Young

Atherosclerosis underlies most myocardial infarctions and ischemic strokes. The timing of onset and the rate of progression of atherosclerosis differ between individuals and among arterial sites. Physical manifestations of atherosclerosis may begin in early life, particularly in the abdominal aorta. Measurement of the abdominal aortic intima-media thickness by external ultrasound is a non-invasive methodology for quantifying the extent and severity of early atherosclerosis in children, adolescents, and young adults. This review provides an evidence-based rationale for the assessment of abdominal aortic intima-media thickness-particularly as an age-appropriate methodology for studying the natural history of atherosclerosis in the young in comparison to other methodologies-establishes best practice methods for assessing abdominal aortic intima-media thickness, and identifies key gaps in the literature, including those that will identify the clinical relevance of this measure.

Analysis of Carotid Plaque Using Multifractal method in Ultrasound Images

This paper analyses the non-linear parameters of the plaque in carotid B-mode ultrasound images. In this work an attempt has been made to differentiate textural features of the symptomatic and asymptomatic plaque by multifractal method. The fractal dimension represents irregularity and hence the fractal nature. The interwoven sets of singularities are characterized by its own scaling behaviour, quantitatively represented as the fractal dimension, explains the multifractal behavior. The multifractal characteristics are plotted using a multifractal formalism proposed by Halsey. Certain multifractal features are extracted namely bandwidth (BW) of the spectrum and singularity exponent peak (SXP_peak). These extracted features have coefficient of variation in the range of 0.1 to 0.3; hence they have lower inter-subject variability. This analysis could aid in the study of the symptomatic and asymptomatic plaques.

A NEW APPROACH FOR CLASSIFICATION OF ATHEROSCLEROSIS OF COMMON CAROTID ARTERY FROM ULTRASOUND IMAGES

Background and objectives: The diagnosis of carotid atherosclerosis is of vital importance, as this cardiovascular disease may cause myocardial infarction. One-third of deaths in the world occur due to myocardial infarction, commonly known as heart attack. Atherosclerosis is deposition of plaque in artery wall. It could be detected from the features of intima-media complex of the artery wall. This study proposes a new classification approach to distinguish between symptomatic and asymptomatic plaques using non-invasive carotid B-mode ultrasound images. These two types of plaques have diverse impacts on human life. In the first condition, slowly plaque formation reaches life-threatening condition and the second condition is acute in nature. Hence treatment protocol is to be decided based on the type of plaque.

Methods: To locate the intima-media-complex region, the images are segmented using snake-based segmentation algorithm. Several features are extracted using fixed size blocks selected from the segmented region using gray-level co-occurrence matrix. Finally classification is performed using support vector machine. Results: The performance shows improvement in accuracy using lesser number of features than previous works. The reduction in feature size is achieved by incorporating segmentation in the pre-processing stage. In the classifier, 10-fold cross-validation protocol is used for training and testing and an accuracy of 100% is obtained.

Conclusion: This proposed technique could work as an adjunct tool in quick decision-making for cardiologists and radiologists.

Early and late childhood telomere length predict subclinical atherosclerosis at age 14 yrs. - The CardioCAPS study

INTRODUCTION

Carotid Intima Media Thickness (CIMT) is a marker of subclinical atherosclerosis, associated with cardiovascular risk in adults. Telomere length (TL) is a marker of cellular ageing. We sought to determine whether telomere length in early childhood and/or at 14-years is associated with CIMT in adolescence, in a community-based cohort study.

METHODS

118 children had TL measured at mean age 3.6-years and 165 children had TL and CIMT, measured at 14-years, from the community-based Childhood Asthma Prevention Study.

RESULTS

TL in early childhood was significantly inversely associated with CIMT at 14 years, p = 0.04. TL in teenage life was also significantly inversely associated with CIMT at 14 years, p = 0.03. This latter association was no longer significant, however, after adjusting for early life TL.

CONCLUSION

TL measured in early childhood and adolescence is significantly associated with CIMT at 14-years, suggesting that telomere length is a biological marker or even early determinant of late cardiovascular risk.

Intrauterine growth restriction results in persistent vascular mismatch in adulthood

KEY POINTS

Intrauterine growth restriction (IUGR) increases offspring risk of chronic diseases later in life, including cardiovascular dysfunction. Our prior studies suggest biventricular cardiac dysfunction and vascular impairment in baboons who were IUGR at birth because of moderate maternal nutrient reduction. The current study reveals changes in artery sizes, distensibility, and blood flow pattern in young adult IUGR baboons, which may contribute to cardiac stress. The pattern of abnormality observed suggests that vascular redistribution seen with IUGR in fetal life may continue into adulthood.

ABSTRACT

Maternal nutrient reduction induces intrauterine growth restriction (IUGR), increasing risks of chronic diseases later in life, including cardiovascular dysfunction. Using ultrasound, we determined regional blood flow, blood vessel sizes, and distensibility in IUGR baboons (8 males, 8 females, 8.8 years, similar to 35 human years) and controls (12 males, 12 females, 9.5 years). The measured blood vessels were larger in size in the males compared to females before but not after normalization to body surface area. Smaller IUGR normalized blood vessel sizes were observed in the femoral and external iliac arteries but not the brachial or common carotid arteries and not correlated significantly with birth weight. Mild decrease in distensibility in the IUGR group was seen in the iliac but not the carotid arteries without between-sex differences. In IUGR baboons there was increased carotid arterial blood flow velocity during late systole and diastole. Overall, our findings support the conclusion that region specific vascular and haemodynamic changes occur with IUGR, which may contribute to the occurrence of later life cardiac dysfunction. The pattern of alteration observed suggests vascular redistribution efforts in response to challenges in the perinatal period may persist into adulthood. Further studies are needed to determine the life course progression of these changes.

The association between socioeconomic status and subclinical atherosclerosis in a rural Bangladesh population

BACKGROUND

In Bangladesh, CVD accounts for the majority of non-communicable mortality. The purpose of this study was to determine the role of socioeconomic status (SES) on subclinical atherosclerosis measured as carotid intima-media thickness (IMT) in a rural Bangladesh population.

METHODS

Carotid IMT was measured between 2010 and 2011 in 1022 participants (average age 46, 40% male) randomly selected from the Health Effects of Arsenic Longitudinal Study (HEALS), a population-based prospective cohort study based in rural Bangladesh. SES was measured as occupation type, land ownership, educational attainment, and television ownership.

RESULTS

Half of the participants received formal education (53%) and under half owned land (48%) and a television (44%). Women were primarily homemakers (95%) and men worked as factory workers (24%), laborers (18%), or in business (55%). In univariate analysis, those owning greater than one acre of land (p=0.03), owning a television (p=0.02), or laborers and business owners compared to factory workers had higher levels of carotid IMT (p<0.01). In multivariate analysis after adjustment for confounders, only men employed in the business sector had elevated carotid IMT compared to factory workers. The association was strongest in older men (58.7μm, 95% CI 17.2-100.0, ≥50years old) compared to younger men (13.7μm, 95% CI -7.8-35.2, <50years old).

CONCLUSION

Business sector employment was positively associated with subclinical atherosclerosis after adjustment for confounders. This finding is consistent with evidence from other developing nations suggesting that certain SES factors are independent predictors of CVD.

The educational gradient in cardiovascular risk factors: impact of shared family factors in 228,346 Norwegian siblings

Background

Various indicators of childhood socioeconomic position have been related to cardiovascular disease (CVD) risk in adulthood. We investigated the impact of shared family factors on the educational gradient in midlife CVD risk factors by assessing within sibling similarities in the gradient using a discordant sibling design.

Methods

Norwegian health survey data (1980–2003) was linked to educational and generational data. Participants with a full sibling in the health surveys (228,346 individuals in 98,046 sibships) were included. Associations between attained educational level (7–9 years, 10–11 years, 12 years, 13–16 years, or >16 years) and CVD risk factor levels in the study population was compared with the corresponding associations within siblings.

Results

Educational gradients in risk factors were attenuated when factors shared by siblings was taken into account: A one category lower educational level was associated with 0.7 (95% confidence interval 0.6 to 0.8) mm Hg higher systolic blood pressure (27% attenuation), 0.4 (0.4 to 0.5) mmHg higher diastolic blood pressure (30%), 1.0 (1.0 to 1.1) more beats per minute higher heart rate (21%), 0.07 (0.06 to 0.07) mmol/l higher serum total cholesterol (32%), 0.2 (0.2 to 0.2) higher smoking level (5 categories) (30%), 0.15 (0.13 to 0.17) kg/m² higher BMI (43%), and 0.2 (0.2 to 0.2) cm lower height (52%). Attenuation increased with shorter age-difference between siblings.

Conclusion

About one third of the educational gradients in modifiable CVD risk factors may be explained by factors that siblings share. This implies that childhood environment is important for the prevention of CVD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4123-0) contains supplementary material, which is available to authorized users.

Developmental origins of cardiovascular disease: Impact of early life stress in humans and rodents

The Developmental Origins of Health and Disease (DOHaD) hypothesizes that environmental insults during childhood programs the individual to develop chronic disease in adulthood. Emerging epidemiological data strongly supports that early life stress (ELS) given by the exposure to adverse childhood experiences is regarded as an independent risk factor capable of predicting future risk of cardiovascular disease. Experimental animal models utilizing chronic behavioral stress during postnatal life, specifically maternal separation (MatSep) provides a suitable tool to elucidate molecular mechanisms by which ELS increases the risk to develop cardiovascular disease, including hypertension. The purpose of this review is to highlight current epidemiological studies linking ELS to the development of cardiovascular disease and to discuss the potential molecular mechanisms identified from animal studies. Overall, this review reveals the need for future investigations to further clarify the molecular mechanisms of ELS in order to develop more personalized therapeutics to mitigate the long-term consequences of chronic behavioral stress including cardiovascular and heart disease in adulthood.

Growth of Carotid Intima-Media Thickness in Black and White Young Adults

Background

There are few longitudinal studies that have comprehensively examined the intima‐media thickness (IMT) growth pattern and its determinants among racial population groups.

Methods and Results

Mean and maximum IMT were measured by B‐mode ultrasonography up to 3 times in 253 white and 268 black participants, aged 13 to 36 years (mean age±standard deviation 24±3.2 years old). The development of IMT was assessed using individual growth curve modeling. A total of 521 participants with 1015 IMT measurements were eligible for this study. We found higher IMT in both left and right sides in blacks compared to whites (P<0.001) in young adulthood. Both whites and blacks showed a strong linear increase in mean IMT with age. Body mass index and father's education level were associated with mean IMT, and only body mass index was associated with maximum IMT (P<0.05). We did not observe an interaction between age and race/ethnicity on the growth of IMT, suggesting that blacks and whites developed IMT in similar patterns. Interestingly, we found a faster increase in mean left‐side IMT than mean right‐side IMT (χ²=11.5, P<0.001) in both black and white subjects as well as in males and females.

Conclusions

Our findings provide compelling prospective evidence that blacks may have thicker IMT compared to whites as young adults. These racial differences could not be explained by traditional risk factors. This implies that differences in this precursor of atherosclerosis may explain racial disparity in cerebrovascular disease.

Accurate lumen diameter measurement in curved vessels in carotid ultrasound: an iterative scale-space and spatial transformation approach

Monitoring of cerebrovascular diseases via carotid ultrasound has started to become a routine. The measurement of image-based lumen diameter (LD) or inter-adventitial diameter (IAD) is a promising approach for quantification of the degree of stenosis. The manual measurements of LD/IAD are not reliable, subjective and slow. The curvature associated with the vessels along with non-uniformity in the plaque growth poses further challenges. This study uses a novel and generalized approach for automated LD and IAD measurement based on a combination of spatial transformation and scale-space. In this iterative procedure, the scale-space is first used to get the lumen axis which is then used with spatial image transformation paradigm to get a transformed image. The scale-space is then reapplied to retrieve the lumen region and boundary in the transformed framework. Then, inverse transformation is applied to display the results in original image framework. Two hundred and two patients' left and right common carotid artery (404 carotid images) B-mode ultrasound images were retrospectively analyzed. The validation of our algorithm has done against the two manual expert tracings. The coefficient of correlation between the two manual tracings for LD was 0.98 (p < 0.0001) and 0.99 (p < 0.0001), respectively. The precision of merit between the manual expert tracings and the automated system was 97.7 and 98.7%, respectively. The experimental analysis demonstrated superior performance of the proposed method over conventional approaches. Several statistical tests demonstrated the stability and reliability of the automated system.

Childhood Psychosocial Cumulative Risks and Carotid Intima-Media Thickness in Adulthood: The Cardiovascular Risk in Young Finns Study

OBJECTIVE

Adverse experiences in childhood may influence cardiovascular risk in adulthood. We examined the prospective associations between types of psychosocial adversity and having multiple adversities (e.g., cumulative risk) with carotid intima-media thickness (IMT) and its progression among young adults. Higher cumulative risk score in childhood was expected to be associated with higher IMT and its progression.

METHODS

Participants were 2265 men and women (age range, 24-39 years in 2001) from the ongoing Cardiovascular Risk in Young Finns study whose carotid IMTs were measured in 2001 and 2007. A cumulative psychosocial risk score, assessed at the study baseline in 1980, was derived from four separate aspects of the childhood environment that may impose risk (childhood stressful life events, parental health behavior family, socioeconomic status, and childhood emotional environment).

RESULTS

The cumulative risk score was associated with higher IMT in 2007 (b = 0.004, standard error [SE] = 0.001, p < .001) and increased IMT progression from 2001 to 2007 (b = 0.003, SE = 0.001, p = .001). The associations were robust to adjustment for conventional cardiovascular risk factors in childhood and adulthood, including adulthood health behavior, adulthood socioeconomic status, and depressive symptoms. Among the individual childhood psychosocial risk categories, having more stressful life events was associated with higher IMT in 2001 (b = 0.007, SE = 0.003, p = .016) and poorer parental health behavior predicted higher IMT in 2007 (b = 0.004, SE = 0.002, p = .031) after adjustment for age, sex, and childhood cardiovascular risk factors.

CONCLUSIONS

Early life psychosocial environment influences cardiovascular risk later in life, and considering cumulative childhood risk factors may be more informative than individual factors in predicting progression of preclinical atherosclerosis in adulthood.

Perinatal inflammation: a common factor in the early origins of cardiovascular disease?

Cardiovascular disease continues to be the leading cause of global morbidity and mortality. Traditional risk factors account for only part of the attributable risk. The origins of atherosclerosis are in early life, a potential albeit largely unrecognized window of opportunity for early detection and treatment of subclinical cardiovascular disease. There are robust epidemiological data indicating that poor intrauterine growth and/or prematurity, and perinatal factors such as maternal hypercholesterolaemia, smoking, diabetes and obesity, are associated with adverse cardiovascular intermediate phenotypes in childhood and adulthood. Many of these early-life risk factors result in a heightened inflammatory state. Inflammation is a central mechanism in the development of atherosclerosis and cardiovascular disease, but few studies have investigated the role of overt perinatal infection and inflammation (chorioamnionitis) as a potential contributor to cardiovascular risk. Limited evidence from human and experimental models suggests an association between chorioamnionitis and cardiac and vascular dysfunction. Early life inflammatory events may be an important mechanism in the early development of cardiovascular risk and may provide insights into the associations between perinatal factors and adult cardiovascular disease. This review aims to summarise current data on the early life origins of atherosclerosis and cardiovascular disease, with particular focus on perinatal inflammation.

Associations of life course socioeconomic position and job stress with carotid intima-media thickness. The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

RATIONALE

The association between life course socioeconomic position (SEP) and subclinical atherosclerosis is not consistent across studies. Socioeconomic adversities early in life are related to an increased probability of a low occupational grade and more stressful jobs in adulthood. However, the role of job stress in explaining the life course social gradient in subclinical atherosclerosis is unknown.

OBJECTIVES

To examine whether life course SEP is associated with carotid intima-media thickness (IMT) and to investigate whether this association is partially mediated by job stress.

METHODS

This study used baseline data (2008-2010) for 8806 current workers from ELSA-Brasil. Maternal education, social class of first occupation and social class of current occupation were used to evaluate childhood, youth and adulthood SEP, respectively. Accumulation of risk across the life course was also evaluated. Job stress was assessed by the Swedish Demand-Control-Support Questionnaire. Directed acyclic graph and linear regression models were used.

RESULTS

Low childhood SEP was associated with increased IMT only in women, but low youth and adulthood SEP were associated with higher IMT in both genders. The simultaneous adjustment for all SEP indicators showed that only adulthood SEP continued to be associated with IMT. However, higher IMT values were observed among men and women sequentially exposed to low SEP in more than one period of life. High-strain jobs and low job control were not associated with IMT independent of SEP.

CONCLUSION

Our results support a model of the cumulative effects of exposures to SEP across the life span because the highest IMT values were observed in individuals sequentially exposed to low SEP in more than one period of life. We did not find that job stress explained the association between life course SEP and IMT, suggesting that strategies to address socioeconomic inequalities in CVD should target additional steps beyond reducing job stress.

Association of parental education with tooth loss among Korean Elders

OBJECTIVE

There are few reports showing an association between childhood socioeconomic circumstances and tooth loss among the elderly. The purpose of this study was (i) to examine the association between early childhood socioeconomic position (parental education level) and tooth loss and (ii) to determine the relative effects of the subjects' education level, occupation, and income on tooth loss in Korean elders.

MATERIAL AND METHODS

Data from the fourth and fifth Korea National Health and Nutritional Examination Survey on 8814 Korean elders (age ≥65 years) were analyzed. Demographic factors (age, survey year, marital status, and residence area), health behaviors (dental check-up during the past year and cigarette smoking), and the presence of a somatic health problem (diabetes) were included in our gender-specific analyses. Tooth loss was defined as edentulism or severe tooth loss (<20 teeth). For our analyses, chi-square test and Student's t-tests and multiple logistic regressions were performed.

RESULTS

A low parental education level was associated with elevated odds of edentulism (OR = 1.87 for father's education and 1.52 for mother's education among male elders and OR = 1.73 for father's education and 1.55 for mother's education among female elders) and with severe tooth loss (OR = 1.58 for father's education and 1.53 for mother's education among male elders and OR = 1.25 for father's education and 1.48 for mother's education among female elders). The association between parental education level and tooth loss was attenuated after adjusting for the subject's education level, occupation, and income. Relative magnitude of attenuation varied with personal factors (education > income > occupation). In a fully adjusted model, father's education level was significantly associated with edentate status (OR = 1.96 for male elders and 1.46 for female elders), but not with severe tooth loss.

CONCLUSION

Our results indicate that early life socioeconomic circumstances measured by the father's education level were independently associated with the edentate status of Korean elders.

Low socioeconomic status over 12 years and subclinical cardiovascular disease: the study of women's health across the nation

BACKGROUND AND PURPOSE

The inverse relation between socioeconomic status and cardiovascular disease is well established. However, few studies have investigated socioeconomic status assessed repeatedly during adulthood in relation to subclinical atherosclerosis. We aimed to test whether consistently low socioeconomic status, as indexed by education, income, and financial strain, for 12 years of midlife was related to later carotid intima-media thickness and plaque among women.

METHODS

The Study of Women's Health Across the Nation is a multisite longitudinal study of midlife women. Education was assessed at the study baseline, income and financial strain were obtained yearly for 12 years, and a carotid ultrasound was obtained at study year 12 among 1402 women. Associations were tested in linear and multinomial logistic regression models adjusted for demographic, biological, and behavioral risk factors.

RESULTS

A high school education or less (odds ratio [OR] [95% confidence interval {CI}], 1.72 [1.15-2.59]; P<0.01), some college education (OR [95% CI], 1.65 [1.17-2.32]; P<0.01), consistently low income (OR [95% CI], 1.83 [1.15-2.89]; P<0.05), and consistent financial strain (OR [95% CI], 1.78 [1.21-2.61]; P<0.01) for 12 years were associated with higher carotid plaque, and consistent financial strain was associated with elevated maximal intima-media thickness (β [SE]=0.02 [0.01]; P<0.05) controlling for standard cardiovascular disease risk factors. When socioeconomic status indices were considered together, financial strain (β [SE]=0.02 [0.01]; P<0.05) and low education (high school education or less: OR [95% CI], 1.55 [1.01-2.37]; P<0.05; some college: OR [95% CI], 1.56 [1.09-2.21]; P<0.05) were most consistently associated with intima-media thickness and plaque, respectively, controlling for risk factors.

CONCLUSIONS

The findings indicate the importance of targeting economically disadvantaged women in efforts to prevent cardiovascular disease among women.

Body mass index and height from infancy to adulthood and carotid intima-media thickness at 60 to 64 years in the 1946 British Birth Cohort Study

OBJECTIVE

Atherosclerosis begins early in life and obesity is a key determinant. We investigated the role of body mass index (BMI) and height from infancy to adulthood in presenting with high adulthood carotid intima-media thickness.

APPROACH AND RESULTS

Odds ratios of BMI, and height Z scores at 2, 4, 6, 7, 11, 15, and 20 years, and changes between 2 and 4, 4 and 7, 7 and 15, and 15 and 20 years, for carotid intima-media thickness at 60 to 64 years in the upper quartile were estimated for 604 men and 669 women. Confounding by early-life environments, mediating by body size and cardiometabolic measures at 60 to 64 years, and effect modification were investigated. In men, there was positive association of BMI at 4 years (odds ratio, 1.256; 95% confidence interval, 1.026-1.538) and 20 years (1.282; 1.022-1.609), negative association of height at 4 years (0.780; 0.631-0.964), and negative association of height growth between 2 and 4 years (0.698; 0.534-0.913) with high carotid intima-media thickness. The childhood estimates were robust, but the estimate for BMI at 20 years was attenuated by adjustment for BMI at 60 to 64 years. The protective influence of greater early childhood height was strongest in those with the lowest systolic blood pressure at 60 to 64 years. In women, there was no pattern of association and all confidence intervals crossed 1.

CONCLUSIONS

Early childhood in men might be a sensitive developmental period for atherosclerosis, in which changes in BMI and height represent 2 distinct biological mechanisms. The maintenance of healthy weight in men from adolescence onward may be a useful strategy to avoid the atherosclerotic complications of adiposity tracking.

Adverse childhood experiences and the cardiovascular health of children: a cross-sectional study

Background

Adverse childhood experiences (ACEs), such as abuse, household dysfunction, and neglect, have been shown to increase adults’ risk of developing chronic conditions and risk factors for chronic conditions, including cardiovascular disease (CVD). Much less work has investigated the effect of ACEs on children’s physical health status that may lead to adult chronic health conditions. Therefore, the present study examined the relationship between ACEs and early childhood risk factors for adult cardiovascular disease.

Methods

1 234 grade six to eight students participated in school-based data collection, which included resting measures of blood pressure (BP), heart rate (HR), body mass index (BMI) and waist circumference (WC). Parents of these children completed an inventory of ACEs taken from the Childhood Trust Events Survey. Linear regression models were used to assess the relationship between experiencing more than 4 ACEs experienced, systolic BP, HR, BMI and WC. In additional analysis, ACEs were assessed ordinally in their relationship with systolic BP, HR, and BMI as well as clinical obesity and hypertension status.

Results

After adjustment for family education, income, age, sex, physical activity, and parental history of hypertension, and WC for HR models, four or more ACEs had a significant effect on HR (b = 1.8 bpm, 95% CI (0.1-3.6)) BMI (b =1.1 kg/m², 95% CI (0.5-1.8)), and WC (b = 3.6 cm, 95% CI (1.8-5.3)). A dose–response relationship between ACE accumulation and both BMI and WC was also found to be significant. Furthermore, accumulation of 4 or more ACEs was significantly associated with clinical obesity (95^th percentile), after controlling for the aforementioned covariates.

Conclusions

In a community sample of grade six to eight children, accumulation of 4 or more ACEs significantly increased BMI, WC and resting HR. Therefore, risk factors related to reported associations between ACEs and cardiovascular outcomes among adults are identifiable in childhood suggesting earlier interventions to reduce CVD risk are required.

Gender differences in the association between socioeconomic status and subclinical atherosclerosis

OBJECTIVES

This study explored the pattern of associations between socioeconomic status (SES) and atherosclerosis progression (as indicated by carotid intima media thickness, CIMT) across gender.

DESIGN

Cross-sectional analysis of a sample of 5474 older persons (mean age 73 years) recruited between 1999 and 2001 in the 3C study (France). We fitted linear regression models including neighborhood SES, individual SES and cardiovascular risk factors.

RESULTS

CIMT was on average 24 µm higher in men (95% CI: 17 to 31). Neighborhood SES was inversely associated with CIMT in women only (highest versus lowest tertiles: -12.2 µm, 95%CI -22 to -2.4). This association persisted when individual SES and risk factors were accounted for. High individual education was associated with lower CIMT in men (-21.4 µm 95%CI -37.5 to -5.3) whereas high professional status was linked to lower CIMT among women (-15.7 µm 95%CI: -29.2 to -2.2). Adjustment for cardiovascular risk factors resulted in a slightly more pronounced reduction of the individual SES-CIMT association observed in men than in women.

CONCLUSION

In this sample, neighborhood and individual SES displayed different patterns of associations with subclinical atherosclerosis across gender. This suggests that the causal pathways leading to SES variations in atherosclerosis may differ among men and women.

IQ in childhood and atherosclerosis in middle-age: 40 Year follow-up of the Newcastle Thousand Families Cohort Study

Objective

Carotid intima-media thickness (IMT) is a known precursor to coronary heart disease (CHD) and other relevant health outcomes such as stroke and cognitive impairment. In addition, higher childhood intelligence has been associated with lower risk of coronary heart disease events in later life, although the mechanisms of effect are unclear. We therefore examined the association between childhood intelligence and atherosclerosis using carotid IMT as a marker of the atherosclerotic process.

Approach

Participants were 412 members of the Newcastle Thousand Families Study, a prospective cohort study of all 1142 births in the city of Newcastle in May and June 1947, who took an IQ test and English and arithmetic tests at age 11 years. Study members participated in a medical examination and lifestyle assessment at age 49–51 years during which IMT was measured using ultrasound techniques.

Results

Individuals with higher childhood IQ score had a lower mean IMT in middle-age. A standard deviation higher score in childhood overall IQ was associated with a 0.053 mm (95% CI −0.102, −0.004) lower IMT in men and a 0.039 mm (95% CI −0.080, −0.002) lower IMT in women. Similar levels of association were found for the English and arithmetic tests. After adjustment for a range of covariates including education, the size of effect was undiminished in men but increased in women.

Conclusions

In the present study, higher childhood IQ scores were associated with a lower degree of atherosclerosis by middle-age.

Relative intima-media thickening after preterm birth

AIM

Preterm infants are at increased risk of early arterial growth arrest and cardiovascular mortality. We assessed intima-media thickness (IMT) - an early marker of accelerated vascular ageing - in very preterm infants.

METHODS

Longitudinal cohort study of 21 very preterm and 29 term infants, all with appropriate birthweights. Intima-media thickness was assessed by M-Mode ultrasound of the aorta and carotid arteries at three occasions during a 6-month period corresponding to the third trimester of pregnancy and ending 3 months after term equivalent age.

RESULTS

No differences in absolute aortic or carotid IMT were found. However, in relation to vessel lumen diameter, the IMT switched from being narrower in preterm infants, compared with foetuses at 28 weeks of gestation, to being significantly thicker in both the aorta and carotid artery in older infants born preterm, compared with term controls of equivalent postmenstrual age. Although the aortic and carotid artery diameters increased significantly with postnatal age, IMT did not.

CONCLUSION

In relation to vessel diameter, subjects born preterm show thicker intima-media in the great arteries than infants born at term. It remains to be established whether this relative intima-media thickening persists and may be a risk marker for future cardiovascular disease.

Young adults with coeliac disease may be at increased risk of early atherosclerosis

BACKGROUND

Accelerated progression of atherosclerosis and increased cardiovascular risk have been described in immune-mediated disorders, but few data are available in coeliac disease.

AIM

To evaluate instrumental and biochemical signs of atherosclerosis risk in 20 adults at first diagnosis of coeliac disease and after 6-8 months of gluten-free diet with mucosal recovery.

METHODS

We analysed total, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, triglycerides, homocysteine, C-reactive protein, folate and vitamin B12; ultrasound measurement of carotid intima-media thickness (IMT) and endothelium-dependent dilatation were both carried on at diagnosis and after gluten withdrawal. Twenty-two healthy members of the hospital staff served as matched controls for vascular examinations.

RESULTS

At baseline, mean total and HDL-cholesterol (HDL-C) were both within normal range, while mean LDL-cholesterol concentration was slightly increased; diet was associated with an increment in total and HDL-C (68.2 ± 17.4 vs. 51.4 ± 18.6 mg/dL; P < 0.001) and a significant improvement in total/HDL-C ratio (3.05 ± 0.71 vs. 3.77 ± 0.92; P < 0.02). Mean plasma homocysteine was elevated and not influenced by diet. C-reactive protein significantly decreased with diet (1.073 ± 0.51 vs. 1.92 ± 1.38 mg/dL; P < 0.05). At baseline, in coeliacs, IMT was increased (0.082 ± 0.011 vs. 0.058 ± 0.012 cm; P < 0.005), while endothelium-dependent dilatation was decreased (9.3 ± 1.3 vs. 11.2 ± 1.2%; P < 0.05). Both parameters improved after gluten abstinence.

CONCLUSIONS

Adults with coeliac disease seem to be at potentially increased risk of early atherosclerosis as suggested by vascular impairment and unfavourable biochemical risk pattern. Chronic inflammation might play a determining role. Gluten abstinence with mucosal normalisation reverts to normal the observed alterations.

Cardiovascular disease in childhood: the role of obesity

In recent years, childhood obesity is becoming an epidemic health problem. It is now evident from many studies that childhood obesity is correlated with adult excess weight status and the development of risk factors for cardiovascular diseases in adulthood, including hypertension, type 2 diabetes mellitus, dyslipidemia, and metabolic syndrome. The exposure to obesity and to the above risk factors during childhood subsequently lead to atherosclerotic development, such as altered vascular structure and function, although the mechanisms are still unclear. Several non-invasive, and thus easy-to-obtain measures of arterial structure and function, have been shown to be clinically useful in providing information about vasculature early in the course of atherosclerosis, including measurement of endothelial function, carotid intima media thickness, and arterial stiffness. The early detection of cardiovascular abnormalities is essential because the control of the atherogenic process is more effective during its early stages. The present review focuses on the cardiovascular consequences of obesity, on the mechanisms and the methods of measurement of endothelial dysfunction in obese children and adolescents, and on the ways of intervention for the improvement of vascular health.

Automatically designed machine vision system for the localization of CCA transverse section in ultrasound images

The common carotid artery (CCA) is a source of important information that doctors can use to evaluate the patients' health. The most often measured parameters are arterial stiffness, lumen diameter, wall thickness, and other parameters where variation with time is usually measured. Unfortunately, the manual measurement of dynamic parameters of the CCA is time consuming, and therefore, for practical reasons, the only alternative is automatic approach. The initial localization of artery is important and must precede the main measurement. This article describes a novel method for the localization of CCA in the transverse section of a B-mode ultrasound image. The novel method was designed automatically by using the grammar-guided genetic programming (GGGP). The GGGP searches for the best possible combination of simple image processing tasks (independent building blocks). The best possible solution is represented with the highest detection precision. The method is tested on a validation database of CCA images that was specially created for this purpose and released for use by other scientists. The resulting success of the proposed solution was 82.7%, which exceeded the current state of the art by 4% while the computation time requirements were acceptable. The paper also describes an automatic method that was used in designing the proposed solution. This automatic method provides a universal approach to designing complex solutions with the support of evolutionary algorithms.

Predictors of carotid intima-media thickness and carotid plaque in young Indian adults: the New Delhi birth cohort

BACKGROUND

Carotid intima-media thickness (CIMT) and carotid plaques represent preclinical markers of atherosclerosis. We sought to describe predictors of CIMT and carotid plaques, including early life growth, in a young urban Indian cohort free of clinical cardiovascular disease (CVD).

METHODS

In 2006-2009, we performed B-mode carotid ultrasound on 600 participants (mean [SD] age 36 [1.1] years; 45% women) from the New Delhi Birth Cohort to evaluate CIMT and carotid plaques (>1mm). Height and weight were recorded at birth, 2 and 11 years of age. Data on CVD risk factors, anthropometry, medical history, socio-economic position, and lifestyle habits were collected in 1998-2002.

RESULTS

Mean (SD) CIMT for men and women was 0.91 (0.12) and 0.86 (0.13) mm, respectively. Carotid plaque was present in 33% of men and 26% of women. Waist circumference in 1998-2002 was positively associated with CIMT (β coefficient 0.26 mm [0.17, 0.36] per SD) and carotid plaque (OR 1.27 [1.06,1.52] per SD) in 2006-2009. Higher triglycerides, PAI-1, insulin resistance, and diastolic blood pressure, metabolic syndrome, and lower HDL-cholesterol and physical activity predicted higher CIMT and/or plaque (p<0.05). Longer length at 2 years was associated with higher CIMT (p<0.05). These associations were attenuated after adjusting for adult waist circumference.

CONCLUSIONS

These are the first prospective data from India showing that early life growth, adult socio-demographics, and CVD risk factors predict future CIMT and/or carotid plaque. These relationships appear primarily mediated through central adiposity, highlighting the importance of maintaining a healthy weight in early adulthood to prevent CVD.

How the Newcastle Thousand Families birth cohort study has contributed to the understanding of the impact of birth weight and early life socioeconomic position on disease in later life

Much has been made of the potential influence of birth weight and early socioeconomic disadvantage in influencing adult health, but little has been published in terms of how important these associations may be with respect to exposures throughout the lifecourse. The objective of this review is to describe the contributions of the Newcastle Thousand Families Study in understanding the relative impacts of factors in early life, particularly birth weight and socio-economic position at birth, in influencing health in later life. The Newcastle Thousand Families Study is a prospective birth cohort established in 1947. It originally included all births to mothers resident in Newcastle upon Tyne, in northern England, in May and June of that year. Study members were followed extensively throughout childhood and intermittently in adulthood. At the age of 49-51 years, study members underwent a large-scale follow-up phase enabling an assessment of how early life may influence their later health, and also incorporating adult risk factors which enabled the relative contributions of factors at different stages of life to be assessed. While some findings from the study do support birth weight and early socio-economic position having influences on adult health status, the associations are generally small when compared to risk factors later in life. Using path analyses on longitudinal data of this nature enables mediating pathways between early life and later health to be assessed and if more studies were to take this approach, the relative importance of early life on adult disease risk could be better understood.

Childhood obesity and risk of the adult metabolic syndrome: a systematic review

BACKGROUND

While many studies have demonstrated positive associations between childhood obesity and adult metabolic risk, important questions remain as to the nature of the relationship. In particular, it is unclear whether the associations reflect the tracking of body mass index (BMI) from childhood to adulthood or an independent level of risk. This systematic review aimed to investigate the relationship between childhood obesity and a range of metabolic risk factors during adult life.

OBJECTIVE

To perform an unbiased systematic review to investigate the association between childhood BMI and risk of developing components of metabolic disease in adulthood, and whether the associations observed are independent of adult BMI.

DESIGN

Electronic databases were searched from inception until July 2010 for studies investigating the association between childhood BMI and adult metabolic risk. Two investigators independently reviewed studies for eligibility according to the inclusion/exclusion criteria, extracted the data and assessed study quality using the Newcastle-Ottawa Scale.

RESULTS

The search process identified 11 articles that fulfilled the inclusion and exclusion criteria. Although several identified weak positive associations between childhood BMI and adult total cholesterol, low-density lipo protein-cholesterol, triglyceride and insulin concentrations, these associations were ameliorated or inversed when adjusted for adult BMI or body fatness. Of the four papers that considered metabolic syndrome as an end point, none showed evidence of an independent association with childhood obesity.

CONCLUSIONS

Little evidence was found to support the view that childhood obesity is an independent risk factor for adult blood lipid status, insulin levels, metabolic syndrome or type 2 diabetes. The majority of studies failed to adjust for adult BMI and therefore the associations observed may reflect the tracking of BMI across the lifespan. Interestingly, where adult BMI was adjusted for, the data showed a weak negative association between childhood BMI and metabolic variables, with those at the lower end of the BMI range in childhood, but obese during adulthood at particular risk.

Life course models of socioeconomic position and cardiovascular risk factors: 1946 birth cohort

PURPOSE

To identify the life course model that best describes the association between life course socioeconomic position (SEP) and cardiovascular (CVD) risk factors (ie, body mass index [BMI], systolic and diastolic blood pressure, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and glycated hemoglobin) and explore BMI across the life course as mediators of the relationship.

METHODS

The Medical Research Council National Survey of Health and Development was used to compare partial F-tests of simpler nested life course SEP models corresponding to critical period, accumulation, and social mobility models with a saturated model. Then, the chosen life course model for each CVD risk factor was adjusted for BMI at age 53 and lifetime BMI (ages 4, 26, 43, and 53 years).

RESULTS

Among women, SEP was generally associated with CVD risk factors in a cumulative manner, whereas childhood critical period was the prominent model for men. When the best-fitting SEP models were used, we found that adjustment for BMI at age 53 reduced associations for all outcomes in both genders. Further adjustment for lifetime BMI (4, 26, 43, and 53 years) did not substantially alter most associations (except for triglycerides).

CONCLUSIONS

SEP at different points across life influences CVD risk factors differently in men and women.

Ecological analysis of the relationship between infant mortality and cardiovascular disease mortality at ages 45-69 in the Brazilian 1935 birth cohort

BACKGROUND

International ecological studies have shown a positive association between infant mortality as a proxy for low birth weight and cardiovascular disease mortality in adult life.

METHODS

Mortality rates due to Cardiovascular Diseases (CVDMR) standardised by age in adults between 45 and 69 years of age and by place of birth (pob) and residence (res) were related to Infant Mortality Rates (IMR) in the Brazilian 1935 birth cohort.

RESULTS

Two relationship patterns were noted between IMR and CVDMR: for the Southeast, South and Centre-West group of regions (r(pob)=0.46; r(res)=0.29) and for the North and Northeast group of regions (r(pob)=0.21; r(res)=0.33). For the latter pattern, two states were identified (Rio Grande do Norte and Paraíba) as atypical areas, whose exclusion strengthened the association (r(pob)=0.73; r(res)=0.91).

CONCLUSIONS

The direction of the associations changed after the analysis by group of Brazilian regions (indirect control of socio-economic levels, coverage and quality of the information). There is a positive, although weak association between IMR and CVDMR. Attempts to control or minimise the interference of migratory movements, cohort effects and socio-economic levels represented methodological progress in ecological analyses of foetal programming in Brazil.

Socioeconomic status and subclinical atherosclerosis in older adults

OBJECTIVE

This study investigated the long-term effects of socioeconomic status (SES) on atherosclerosis.

METHODS

Data from the Epidemiology of Hearing Loss Study and the Beaver Dam Eye Study (Beaver Dam, WI, 1998-2000), were used to examine adult SES (education, household income, and longest-held job) and childhood SES (household density and parental home ownership at age 13) associations with carotid intima-media thickness (IMT) and carotid plaque in a cohort of 2042 men and women aged 53 to 94 years.

RESULTS

For education, income, and occupation (women), those in the lowest SES group had statistically larger age-sex-adjusted IMT than those in the highest SES group (<12 vs. >12 years education: 0.92 vs. 0.86 mm respectively, P<0.0001), (<$10,000 vs. >$45,000: 0.97 vs. 0.87 mm, P<0.0001), (operator/fabricator/labor vs. manager/professional: 0.89 vs. 0.82 mm, P<0.001). Associations were similar using carotid plaque as the outcome. Participants with low levels of both adult and childhood SES measures had age-sex-adjusted IMT greater than those with persistently high levels of SES (0.93 vs. 0.84 mm, P<0.0001).

CONCLUSIONS

Measures of SES at two points in the life-span were associated with subclinical atherosclerosis.

Intima-media thickness and flow-mediated dilatation in the Helsinki study of very low birth weight adults

BACKGROUND

Adults born at a very low birth weight (VLBW) (< 1500 g), compared with those born at term, bear risk factors for cardiovascular disease, including higher blood pressure and insulin resistance.

OBJECTIVE

We studied, in young adults born at a VLBW, early signs of an accelerated atherosclerotic process and the relationship of these signs with postnatal growth.

METHODS

We compared 92 with a VLBW with 68 who were born at term. At age 18 to 27, we measured stiffness and intima-media thickness (IMT) of the right carotid artery and flow-mediated dilatation (FMD) of the right brachial artery.

RESULTS

Those with a VLBW had 1.1% units higher FMD (95% confidence interval [CI]: 0.0-2.2) (P = .06) and 0.5% units higher IMT relative to lumen size (95% CI: 0.1-0.9). IMT or FMD, when analyzed as the absolute change in millimeters, and carotid stiffness in the groups were similar. Among those with a VLBW, each 100-g-greater weight gain during the first 2 postnatal weeks predicted 1.1% units higher FMD (95% CI: 0.2-2.0) in adulthood.

CONCLUSIONS

Although young adults born at VLBWs, compared with those born at term, have higher levels of risk factors for cardiovascular disease, we found no clear evidence for elevated early markers of atherosclerosis. However, in relation to artery lumen diameter, IMT in the participants who had a VLBW was higher than in those who were born at term. In our study, weight gain during the first postnatal weeks had no harmful effect on the arteries in young adulthood.

A fully automated method using active contours for the evaluation of the intima-media thickness in carotid US images

The thickness of the intima-media complex (IMC) of the common carotid artery (CCA) wall is important in the evaluation of the risk for the development of atherosclerosis. This paper presents a fully automated algorithm for the segmentation of the IMC. The segmentation of the IMC of the CCA wall is important for the evaluation of the intima media thickness (IMT) on B-mode ultrasound images. The presented algorithm is based on active contours and active contours without edges. It begins with image normalization, followed by speckle removal. The level set formulation of Chan and Vese using random initialization provides a segmentation of the CCA ultrasound (US) images into different distinct regions, one of which corresponds to the carotid wall region above the lumen whilst another corresponds to the carotid wall region below the lumen and includes the IMC. The results of the corresponding segmentation combined with anatomical information provide a very accurate outline of the lumen-intima boundary. This outline serves as an excellent initialization for segmentation of the IMC using parametric active contours. The method lends itself to the development of a fully automated method for the delineation of the IMC. The mean and standard deviation of the thickness of the automatically segmented regions are 0.65 mm +/-0.17 mm and the corresponding values for the ground truth IMT are 0.66 mm +/-0.18 mm. The Wilcoxon rank sum test shows no significant difference.

Conventional and behavioral risk factors explain differences in sub-clinical vascular disease between black and Caucasian South Africans: the SABPA study

OBJECTIVES

There is an emerging burden of cardiovascular disease among urban black Africans in South Africa, which has been largely explained by the transition from traditional African lifestyles to more westernized behavior. We examined the role of health behaviors in explaining the excess burden of sub clinical vascular disease seen in black Africans compared to Caucasians.

METHODS

This was a cross-sectional study, comprising of urban African teachers (n=192 black, 206 Caucasian) working for one of the four Kenneth Kaunda Education districts in the North West Province, South Africa. Conventional cardiovascular risk factors, 24 h ambulatory blood pressure and objectively measured physical activity (Actical® accelerometers), smoking (confirmed by serum cotinine), and alcohol (serum gamma glutamyl transferase) were assessed. The main outcome was a marker of sub-clinical vascular disease, mean carotid intima media thickness (mCIMT), measured using high resolution ultrasound.

RESULTS

Compared with Caucasians, the black Africans demonstrated higher mCIMT (age and sex adjusted β=0.044, 95% CI, 0.024-0.064 mm). The blacks also had higher 24h systolic and diastolic blood pressure, triglycerides, adiposity, and C-reactive protein. In addition, blacks were less physically active (790.0 kcal/d vs 947.3 kcal/d, p<0.001), more likely to smoke (25% vs 16.3%, p=0.002), and demonstrated higher alcohol abuse (gamma glutamyl transferase, 66.6 μ/L vs 27.2 μ/L, p<0.001) compared with Caucasians. The difference in mCIMT between blacks and Caucasians was attenuated by 34% when conventional risk factors were added to the model and a further 18% when health behaviors were included.

CONCLUSION

There is an excess burden of sub clinical vascular disease seen in black Africans compared to Caucasians, which can be largely explained by health behaviors and conventional risk factors.

Disparities in vascular surgery: is it biology or environment?

Disparities in health care are well documented for several racial, ethnic, and gender groups. In peripheral arterial disease, differences in prevalence, treatment selection, treatment outcomes, and resulting quality of life have negative effects on some minority groups and women. It may be easy to document disparities, but it is harder to understand their underlying causes. Are there biologic differences between members of racial and ethnic groups that influence disease presentation and outcomes? Or is the socioeconomic environment that surrounds them the true driver of observed differences? This article reviews the evidence for racial and gender disparities in vascular surgery and presents some potential mechanisms that may explain the disparities.

A lifecourse study of bone resorption in men ages 49-51years: the Newcastle Thousand Families cohort study

It has been suggested that bone health in adulthood is programmed by development in utero. Most previous investigations addressing this topic have focussed on bone mineral density or content, rather than other indicators of bone health, such as biochemical markers of bone turnover. This study investigated whether potential predictors, from different stages of life, influence bone resorption in men aged 49-51years in the Newcastle Thousand Families birth cohort. The cohort originally consisted of all 1142 births in the city of Newcastle upon Tyne, UK in May and June 1947. Detailed information was collected prospectively during childhood, including birth weight and socio-economic circumstances. At 49-51years of age, 574 study members completed a detailed 'Health and Lifestyle' questionnaire, including the European Prospective Investigation of Cancer (EPIC) food frequency questionnaire and 412 study members attended for clinical examination, including 172 men in whom bone resorption was assessed by measurement of serum beta C-telopeptide of type 1 collagen (CTX). A significant trend was seen between increasingly disadvantaged socio-economic status at birth and increased bone resorption (p=0.04, r-squared 2.6%). However, birth weight, standardised for sex and gestational age, was not associated with serum CTX (p=0.77, r-squared 0.05%). Significant trends were also seen between increasing total energy intake (p=0.03, r-squared 2.9%), dietary intake of saturated fat (p=0.02, r-squared 2.6%), protein (p=0.04, r-squared 2.5%) and carbohydrates (p=0.04, r-squared 2.6%) and higher serum CTX. However, on adjustment for total energy intake, none of the other dietary variables was significant at the univariate level maintained significance. Our findings suggest that early socio-economic disadvantage and later dietary factors may be associated with increased bone resorption in middle aged men. However, as little of the variance in serum CTX was explained by the variables included within this investigation, further longitudinal studies, with sufficient statistical power, are required to assess predictors of bone resorption in adulthood and their relative importance.

Differences in atherosclerosis according to area level socioeconomic deprivation: cross sectional, population based study

OBJECTIVES

To examine the relation between area level social deprivation and ultrasound markers of atherosclerosis (common carotid intima-media thickness and plaque score), and to determine whether any differences can be explained by "classic" (currently recognised) or "emerging" (novel) cardiovascular risk factors.

DESIGN

Cross sectional, population based study.

SETTING

NHS Greater Glasgow Health Board area.

PARTICIPANTS

666 participants were selected on the basis of how their area ranked in the Scottish Index of Multiple Deprivation 2004. Approximately equal numbers of participants from the most deprived areas and the least deprived areas were included, as well as equal numbers of men and women and equal numbers of participants from each age group studied (35-44, 45-54, and 55-64 years).

MAIN OUTCOME MEASURES

Carotid intima-media thickness and plaque score, as detected by ultrasound.

RESULTS

The mean age and sex adjusted intima-media thickness was significantly higher in participants from the most deprived areas than in those from the least deprived areas (0.70 mm (standard deviation (SD) 0.16 mm) v 0.68 mm (SD 0.12 mm); P=0.015). On subgroup analysis, however, this difference was only apparent in the highest age tertile in men (56.3-66.5 years). The difference in unadjusted mean plaque score between participants from the most deprived and those from the least deprived areas was more striking than the difference in intima-media thickness (least deprived 1.0 (SD 1.5) v most deprived 1.7 (SD 2.0); P<0.0001). In addition, a significant difference in plaque score was apparent in the two highest age tertiles in men (46.8-56.2 years and 56.3-66.5 years; P=0.0073 and P<0.001) and the highest age tertile in women (56.3-66.5 years; P<0.001). The difference in intima-media thickness between most deprived and least deprived males remained significant after adjustment for classic risk factors, emerging risk factors, and individual level markers of socioeconomic status (P=0.010). Adjustment for classic risk factors and emerging cardiovascular risk factors, either alone or in combination, did not abolish the deprivation based difference in plaque presence (as a binary measure; adjusted odds ratio of 1.73, 95% confidence interval 1.07 to 2.82). However, adjustment for classic risk factors and individual level markers of early life socioeconomic status abolished the difference in plaque presence between the most deprived and the least deprived individuals (adjusted odds ratio 0.94, 95% CI 0.54 to 1.65; P=0.84).

CONCLUSIONS

Deprivation is associated with increased carotid plaque score and intima-media thickness. The association of deprivation with atherosclerosis is multifactorial and not adequately explained by classic or emerging risk factors.

Sex differences in the association between infant feeding and blood cholesterol in later life: the Newcastle thousand families cohort study at age 49-51 years

Previous studies have suggested an association between being breastfed and later cholesterol levels. We investigated whether duration of total and exclusive breastfeeding were related to circulating total, HDL and LDL cholesterol and triglyceride measures at age 50, and whether such associations differ between men and women. Members of the Newcastle thousand families study were followed from birth in 1947. Men (n = 179) and 226 women (n = 226) with blood cholesterol and triglyceride measures at age 50 and with prospectively recorded duration of both total and exclusive breastfeeding were included. Neither total duration nor duration of exclusive breastfeeding were associated with the outcome measures when analysing both sexes together. However, in sex specific analyses significant associations between duration of exclusive breastfeeding and both total and LDL cholesterol (adjusted regression coefficient (r) per 30 days = 0.12 mmol/l (95% CI 0.04-0.20) P = 0.004 for total cholesterol and adjusted r per 30 days = 0.10 mmol/l (95% CI 0.02-0.18) P = 0.016 for LDL cholesterol) were seen for women with no significant associations observed in men. Significant interactions between duration of exclusive breastfeeding and sex were seen for total and LDL cholesterol (P = 0.02 and P = 0.03, respectively) with a near-significant interaction for HDL cholesterol (P = 0.06). In all cases, greater increases in cholesterol with increasing duration of exclusive breastfeeding were seen for women than for men. In conclusion, the association between breastfeeding and adult cholesterol levels differs between men and women and in women remains a significant association even after adjustment for potential confounders. However, our findings may not reflect the situation in younger generations.

Life-course socioeconomic positions and subclinical atherosclerosis in the multi-ethnic study of atherosclerosis

A major limitation of past work on the social patterning of atherosclerosis has been the reliance on measures of neighborhood or individual-level socioeconomic position (SEP) assessed at a single point in time in adulthood. Risk of chronic disease is thought to accumulate throughout the life-course, so the use of a measure for a single point in time may result in inaccurate estimates of the social patterning of subclinical disease. Using data from the US Multi-Ethnic Study of Atherosclerosis (MESA), we examined the relation between childhood SEP [CSEP] (father or caretaker's education), adulthood SEP [ASEP] (a summary score of income, education, and wealth), and 20-year average exposure to neighborhood poverty [NSEP] (residential addresses geocoded and linked to census data) and the prevalence of subclinical atherosclerosis, as assessed by common carotid intimal-medial thickness (IMT) in mid to late adulthood. Participants were 45-84 years of age at baseline and were sampled from six study sites in the United States. After adjustment for age, CSEP and ASEP were both inversely and independently associated with IMT in men. All three indicators CSEP, ASEP, and NSEP were inversely and independently associated with IMT in women. Associations were somewhat reduced after adjustment for cardiovascular risk factors, suggesting that these factors may play a mediating role. There was evidence of heterogeneity in effects of NSEP by gender, and in the effects of ASEP and NSEP by race/ethnicity. Our results contribute to the growing body of work that shows that SEP at multiple points in the life-course, and at the individual and neighborhood level, contributes to the development of atherosclerosis.

Relationship between birthweight and arterial elasticity in childhood

There is a considerable debate about the potential influence of ‘fetal programming’ on cardiovascular diseases in adulthood. In the present prospective epidemiological cohort study, the relationship between birthweight and arterial elasticity in 472 children between 5 and 8 years of age was assessed. LAEI (large artery elasticity index), SAEI (small artery elasticity index) and BP (blood pressure) were assessed using the HDI/PulseWave™ CR-2000 CardioVascular Profiling System. Blood concentrations of glucose, total cholesterol and its fractions [LDL (low-density lipoprotein)-cholesterol and HDL (high-density lipoprotein)-cholesterol] and triacylglycerols (triglycerides) were determined by automated enzymatic methods. Insulin was assessed by a chemiluminescent method, insulin resistance by HOMA (homoeostasis model assessment) and CRP (C-reactive protein) by immunonephelometry. Two linear regression models were applied to investigate the relationship between the outcomes, LAEI and SAEI, and the following variables: birthweight, gestational age, glucose, LDL-cholesterol, HDL-cholesterol, triacylglycerols, insulin, CRP, HOMA, age, gender, waist circumference, per capita income, SBP (systolic BP) and DBP (diastolic BP). LAEI was positively associated with birthweight (P=0.036), waist circumference (P<0.001) and age (P<0.001), and negatively associated with CRP (P=0.024) and SBP (P<0.001). SAEI was positively associated with birthweight (P=0.04), waist circumference (P=0.001) and age (P<0.001), and negatively associated with DBP (P<0.001). Arterial elasticity was decreased in apparently healthy children who had lower birthweights, indicating an earlier atherogenetic susceptibility to cardiovascular diseases in adolescence and adult life. Possible explanations for the results include changes in angiogenesis during critical phases of intrauterine life caused by periods of fetal growth inhibition and local haemodynamic anomalies as a way of adaptation to abnormal pressure and flow.