Impact of Adiposity on Incident Hypertension Is Modified by Insulin Resistance in Adults: Longitudinal Observation From the Bogalusa Heart Study

Clinical guidelines for the diagnosis, evaluation, and management of hypertension for Korean children and adolescents: the Korean Working Group of Pediatric Hypertension

Pediatric hypertension (HTN) is a significant, growing health concern worldwide and also in Korea. Diagnosis, evaluation, and treatment of HTN in Korean children and adolescents are uncertain due to limitations in using the current international guidelines, since the recommendations by the American Academy of Pediatrics (AAP) and European Society of Hypertension (ESH) guidelines differ. Furthermore, these are guidelines for Western youth, who are racially and ethnically different from Koreans. In addition, reference blood pressure values for all pediatric age groups, which are essential for the diagnosis of HTN according to these two guidelines, are absent in Korea. Therefore, HTN guidelines for Korean children and adolescents should be established. The Korean Working Group of Pediatric Hypertension established clinical guidelines for the diagnosis, evaluation, and management of HTN in Korean children and adolescents. These guidelines were based on reported clinical evidence, expert recommendations, and AAP and ESH guidelines. The characteristics of Korean youth and the Korean medical and insurance system were considered during the establishment of the guidelines. By providing recommendations suitable for Korean youth, these guidelines will help in the prevention and management of childhood HTN, thus relieving the burden of cardiovascular disease in adulthood in Korea.

Additive interactions between obesity and insulin resistance on hypertension in a Chinese rural population

BACKGROUND

Adiposity and insulin resistance (IR) are closely associated with hypertension; however, the role of interactions between obesity phenotypes and IR in hypertension is unclear. This study aimed to evaluate the interactions of body mass index (BMI), waist circumference (WC), and body fat percentage (BF%) with IR on hypertension risk.

METHODS

We analyzed data from 4888 participants (mean age 57 years, 41.2% men) in the China Northwest Natural Population Cohort, Ningxia Project. BMI, WC, and BF% were determined using bioelectrical impedance analysis devices. IR was estimated using a homeostasis model assessment index (HOMA-IR). Multivariable-adjusted logistic regression was used to evaluate the association between HOMA-IR and hypertension risk. We calculated the relative excess risk and attributable proportion with their 95% confidence intervals (CIs) to assess whether adiposity phenotypes modified the effect of HOMA-IR on hypertension risk.

RESULTS

The crude prevalence of hypertension was 52.2%. The multivariable-adjusted odds ratio of HOMA-IR was 1.80 (95% CI: 1.23-2.65) for the risk of hypertension in the highest versus the lowest quartiles, but this association became marginal in models further adjusting for BMI, WC, and BF% (P for trend = 0.056). Relative excess risk and attributable proportion for interaction between high HOMA-IR and high BF% were 0.32 (0.04-0.59) and 0.33 (0.06-0.60), respectively. Additionally, high truncal and leg BF% and high HOMA-IR accounted for the hypertension risk in women, but not in men. We did not observe any significant interactions between BMI or WC and HOMA-IR on hypertension.

CONCLUSION

BF% modified the association between IR and increased risk of hypertension in women with high truncal and leg BF%, but not in men.

[Hypertension-abdominal obesity phenotype as an indicator of dysglycaemia and insulin resistance]

Objective

To determine the usefulness of the hypertension-abdominal obesity phenotype as an indicator of dysglycaemia and insulin resistance.

Materials and Methods

Cross-sectional descriptive study of 964 adults (449 women and 515 men) who attended the Institute of Endocrinology with risk of diabetes mellitus. Demographic (age, sex, skin colour), clinical (blood pressure and acanthosis nigricans), anthropometric (weight, height, waist circumference and body mass index) and laboratory (basal and oral glucose tolerance test-stimulated blood glucose and insulinaemia) variables were analysed. The insulin resistance index was calculated. The abdominal hypertension-obesity phenotype was defined as the presence of systolic pressure ≥130 mm Hg and/or diastolic pressure ≥80 mm Hg or treated hypertension, waist circumference ≥80 cm in women and ≥90 cm in men. Sensitivity, specificity and predictive values of the abdominal obesity hypertension phenotype were calculated to identify dysglycaemia and insulin resistance.

Results

Individuals with the hypertension-abdominal obesity phenotype showed a higher proportion of impaired glucose metabolism and insulin resistance than those without the phenotype (p<0.0001). The hypertension-abdominal obesity phenotype better identifies persons with the presence of double prediabetes, diabetes mellitus and insulin resistance, as they show high sensitivities (85.9%, 77.5%, and 68.9%, respectively), and high negatives predictive values (97.9%, 95.8%, and 74.0%, respectively).

Conclusions

The hypertension-abdominal obesity phenotype is a simple, useful option for identifying persons with dysglycaemia, and insulin resistance.

Integrative bioinformatics analysis to screen key genes and signalling pathways related to ferroptosis in obesity

Ferroptosis is closely associated with the development of disease in the body. However, there are few studies on ferroptosis-related genes (FRGs) in obesity. Therefore, key genes and signalling pathways related to ferroptosis in obesity were screened. Briefly, the RNA sequencing data of obesity and the non-obesity human samples and 259 FRGs were downloaded from GEO database and FerrDb database, respectively. The obesity-related module genes were firstly screened by weighted gene co-expression network analysis (WGCNA) and crossed with differentially expressed genes (DEGs) of obesity/normal samples and FRGs to obtain obesity-ferroptosis related (OFR) DEGs. Then, key genes were screened by PPI network. Next, the correlation of key genes and differential immune cells between obesity and normal samples were further explored by immune infiltration analysis. Finally, microRNA (miRNA)-messenger RNA (mRNA), transcription factor (TF)-mRNA networks and drug-gene interaction networks were constructed. As a result, 17 OFR DEGs were obtained, which mainly participated in processes such as lipid metabolism or adipocyte differentiation. The 4 key genes, STAT3, IL-6, PTGS2, and VEGFA, constituted the network. M2 macrophages, T cells CD8, mast cells activated, and T cells CD4 memory resting had significant differences between obesity and normal samples. Moreover, 51 miRNAs and 164 drugs were predicted for 4 key genes. All in all, this study has screened 4 FRGs, including IL-6, VEGFA, STAT3, and PTGS2, in obesity patients.

Unrecognized hypertension among a general adult Ghanaian population: An urban community-based cross-sectional study of prevalence and putative risk factors of lifestyle and obesity indices

Hypertension (HTN) is the leading cause of cardiovascular diseases. Nevertheless, most individuals in developing countries are unaware of their blood pressure status. We determined the prevalence of unrecognized hypertension and its association with lifestyle factors and new obesity indices among the adult population. This community-based study was conducted among 1288 apparently healthy adults aged 18-80 years in the Ablekuma North Municipality, Ghana. Sociodemographic, lifestyle characteristics, blood pressure and anthropometric indices were obtained. The prevalence of unrecognized HTN was 18.4% (237 / 1288). The age groups 45-54 years [aOR = 2.29, 95% CI (1.33-3.95), p = 0.003] and 55-79 years [aOR = 3.25, 95% CI (1.61-6.54), p = 0.001], being divorced [aOR = 3.02 95% CI (1.33-6.90), p = 0.008], weekly [aOR = 4.10, 95% CI (1.77-9.51), p = 0.001] and daily alcohol intake [aOR = 5.62, 95% CI (1.26-12.236), p = 0.028] and no exercise or at most once a week [aOR = 2.25, 95% CI (1.56-3.66), p = 0.001] were independently associated with HTN. Among males, the fourth quartile (Q4) of both body roundness index (BRI) and waist to height ratio (WHtR) [aOR = 5.19, 95% CI (1.05-25.50), p = 0.043] were independent determinants of unrecognized HTN. Among females, the third quartile (Q3) [aOR = 7.96, 95% CI (1.51-42.52), p = 0.015] and Q4 [aOR = 9.87 95% CI (1.92-53.31), p = 0.007] of abdominal volume index (AVI), the Q3 of both BRI and WHtR [aOR = 6.07, 95% CI (1.05-34.94), p = 0.044] and Q4 of both BRI and WHtR [aOR = 9.76, 95% CI (1.74-54.96), p = 0.010] were independent risk factors of HTN. Overall, BRI (AUC = 0.724) and WHtR (AUC = 0.724) for males and AVI (AUC = 0.728), WHtR (AUC = 0.703) and BRI (AUC = 0.703) for females yielded a better discriminatory power for predicting unrecognized HTN. Unrecognized hypertension is common among the apparently healthy adults. Increased awareness of its risk factors, screening, and promoting lifestyle modification is needed to prevent the onset of hypertension.

Comparison of 10 obesity-related indices for predicting hypertension based on ROC analysis in Chinese adults

OBJECTIVE

To compare the predictive performance of the percentage body fat (PBF), body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-hip ratio (WHR), waist-height ratio (WHtR), a body shape index (ABSI), body roundness index (BRI), abdominal volume index (AVI), and conicity index (CI) for identifying hypertension.

METHODS

A cross-sectional study was conducted among 2,801 adults (1,499 men and 1,302 women) aged 18 to 81 in Ningbo, China. The receiver operator characteristic (ROC) analysis and multiple non-parametric Z tests were used to compare the areas under the curve (AUC). The maximum Youden's indices were used to determine the optimal cut-off points of 10 obesity-related indices (ORI) for hypertension risk.

RESULTS

The AUC of all the indices were statistically significant (P < 0.05). The AUC of all the indices in men and women were 0.67-0.73 and 0.72-0.79, respectively. Further non-parametric Z tests showed that WHR had the highest AUC values in both men [0.73 (95% CI: 0.70, 0.76)] and women (0.79 (95% CI: 0.75, 0.83)], and several central ORI (men: WHR, WC, BRI, AVI, and CI, 0.71-0.73; women: WC, WHR, and AVI, 0.77-0.79) were higher than general ORI (PBF and BMI, 0.68 in men; 0.72-0.75 in women), with adjusted P < 0.05. The optimal cut-off points for identifying hypertension in men and women were as follows: PBF (23.55%, 32.55%), BMI (25.72 kg/m2, 23.46 kg/m2), HC (97.59 cm, 94.82 cm), WC (90.26 cm, 82.78 cm), WHR (0.91, 0.88), WHtR (0.51, 0.55), ABSI (0.08 m7/6/kg2/3, 0.08 m7/6/kg2/3), BRI (4.05, 4.32), AVI (16.31 cm2, 13.83 cm2), and CI (1.23 m2/3/kg1/2, 1.27 m2/3/kg1/2). Multivariate logistic regression models showed that all indices were statistically significant (P < 0.05) with the adjusted ORs (per 1-SD increase) at 1.39-2.06 and ORs (over the optimal cut-off points) at 1.80-2.64.

CONCLUSIONS

All 10 ORI (PBF, BMI, HC, WC, WHR, WHtR, ABSI, BRI, AVI, and CI) can effectively predict hypertension, among which WHR should be recommended as the best predictor. Central ORI (WHR, WC, and AVI) had a better predictive performance than general ORIs (PBF and BMI) when predicting the risk of hypertension.

Gender-specific predictive ability for the risk of hypertension incidence related to baseline level or trajectories of adiposity indices: a cohort study of functional community

BACKGROUND

Early prevention of hypertension is important for global cardiovascular disease morbidity and mortality. This study aims to explore better predictors for hypertension incidence related to baseline level or trajectories of adiposity indices, as well as the gender-specific effect.

METHODS

6085 subjects from a functional community cohort in urban Beijing participated in our study. Restricted cubic splines were used to estimate nonlinear associations of body mass index (BMI) and waist-to-height ratio (WHtR) as continuous variable with risk of hypertension. Stepwise logistic regression model was performed to estimate the relative risks (RRs) of adiposity indices and metabolic status, adjusted for covariates. Nomogram models and receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive power of BMI trajectory groups and WHtR trajectory groups on hypertension incidence. Further, all analysis were performed by gender.

RESULTS

The risk of hypertension incidence was related to BMI trajectory groups (persistent overweight: RR = 1.88, 95% CI: 1.48-2.37; persistent obesity: RR = 2.79, 95% CI: 2.18-3.56; persistent the highest: RR = 4.30, 95% CI: 3.20-5.78) and WHtR trajectory groups (persistent medium: RR = 2.69, 95% CI: 2.07-3.50; persistent high: RR = 3.85, 95% CI: 2.92-5.09; increasing to higher: RR = 7.00, 95% CI: 4.96-9.89). In total population, BMI trajectories and WHtR trajectories showed similar ability to predict the risk of hypertension incidence with AUC 0.723 and 0.726, respectively. After stratified by gender, both BMI trajectories and WHtR trajectories showed higher power in female than male (BMI trajectories: 0.762 vs. 0.661; WHtR trajectories: 0.768 vs. 0.661).

CONCLUSIONS

BMI and WHtR trajectories have higher predictive power for hypertension incidence compared to baseline data. Females are more vulnerable to obesity than males.

Isolated systolic hypertension and insulin resistance assessment tools in young and middle-aged Chinese men with normal fasting glucose: a cross-sectional study

The vital role of insulin resistance (IR) in the pathogenesis of isolated systolic hypertension (ISH) has been expounded at the theoretical level. However, research on the correlation between some specific IR indicators and ISH is still rare, especially at different glycemic statuses. We conducted this study to explore the association between three IR indicators and ISH among young and middle-aged adults with normal fasting plasma glucose (NFG). This large cross-sectional study included 8246 young and middle-aged men with NFG and diastolic blood pressure < 90 mmHg. The homeostasis model assessment for IR (HOMA-IR) index, triglyceride glucose (TyG) index, and the metabolic score for IR (METS-IR) were calculated with the corresponding formula. The proportions of ISH among young and middle-aged men were 6.7% and 4.4%, respectively. After fully adjusting, only HOMA-IR rather than TyG and METS-IR was significantly associated with ISH. Moreover, fully adjusted smooth curve fitting showed that the association between HOMA-IR and ISH were approximately linear in both two age groups (P for non-linearity were 0.047 and 0.430 in young and middle-aged men, respectively). Among young and middle-aged men with NFG, using HOMA-IR instead of noninsulin-dependent IR indicators may have advantages in the hierarchical management of ISH. Further longitudinal research may be needed to determine their potential causal relationship.

Adverse Childhood Experiences Are Associated with Cardiometabolic Risk Indicators and Telomere Length in Low-Income African-American Adolescents

BACKGROUND

Adverse childhood experiences (ACEs) have been linked to increased risk for cardiovascular disease later in life, and to shortened telomere length in children and adolescents, but few studies have examined associations between ACEs and cardiometabolic risk in adolescence or potential associations between ACEs, cardiometabolic risk indicators, and telomere length in this population. The present study examined competing models of associations between adolescent ACEs (as reported by mothers); cardiovascular, inflammatory, and metabolic indicators of health risk; and leukocyte telomere length in youth.

METHOD

Data was collected from 108 low-income African-American adolescents (42.6% male; M_age = 14.27 years, SD = 1.17) living in the southeastern USA. Waist circumference was measured during a home interview, and measures of C-reactive protein, insulin resistance, and leukocyte telomere length were obtained from blood following overnight fasting.

RESULTS

Path analysis supported a main effects model, whereby ACEs were significantly associated with shortened leukocyte telomere length, higher levels of C-reactive protein, and larger waist circumferences, controlling for maternal education and adolescent sex. Exploratory analyses examining whether cardiometabolic risk mediated associations between ACEs and telomere length, or whether telomere length mediated associations between ACEs and cardiometabolic risk, were not supported.

CONCLUSIONS

ACEs are associated with risk of future cardiometabolic disorders and shortened leukocyte telomere length. Because cytogenetic changes are potentially modifiable, interventions to decrease family ACEs or alter responses to ACEs may lessen chronic disease risk in the African-American population. Targeted interventions to improve health are discussed.

Correlation between left ventricular diastolic dysfunction and dyslipidaemia in asymptomatic patients with new-onset type 2 diabetes mellitus

Background

Poor glycaemic control is associated with a greater risk of development of heart failure in diabetic patients. We aimed to study the prevalence of left ventricular (LV) systolic and diastolic dysfunction in asymptomatic patients with new-onset type 2 DM. We conducted a cross-sectional study including patients with newly diagnosed (within 1 year) type 2 DM; all patients were between the ages of 30 and 60 years, normotensive and clinically asymptomatic and attended the outpatient clinic of the endocrinology unit at a university hospital between March 2016 and June 2017. Demographic characteristics, clinical risk factors and waist-hip ratio (WHR) were assessed. Blood samples for laboratory analysis were obtained. Detailed echocardiography was performed to evaluate systolic and diastolic function.

Results

A total of 100 patients were included. Sixty-one percent had diastolic dysfunction with preserved ejection fraction. Left ventricular diastolic dysfunction (LVDD) was more prevalent in diabetic patients with HbA1c ≥ 8.1 (75%) Patients with LVDD had significant dyslipidaemia in comparison to those without LVDD. Multivariate logistic regression analysis showed that WHR and HbA1c levels are the only predictors of impaired diastolic function in patients with new-onset DM. Kaplan-Meier survival curves showed a significant correlation between the incidence of diastolic dysfunction and the duration of DM, with higher incidence with HbA1c ≥ 8.1.

Conclusions

Diastolic dysfunction is highly prevalent in patients with newly diagnosed DM and is positively correlated with HbA1c level, obesity, dyslipidaemia and the duration of diabetes.

Effects of Blood Pressure Lowering Agents on Cardiovascular Outcomes in Weight Excess Patients: A Systematic Review and Meta-analysis

BACKGROUND

Obesity hypertension is an ongoing pandemic. The first-line medications to treat this condition are still subject to debate. We compared diuretics, calcium-channel blockers (CCB), beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) as an initial antihypertensive therapy for prevention of cardiovascular morbimortality of hypertensive individuals who are overweight or obese.

METHODS

We conducted a search of the literature for randomized clinical trials in which at least 50% of the participants were overweight or obese. The primary outcomes were all-cause mortality, cardiovascular mortality, acute myocardial infarction (MI), heart failure (HF), stroke, or end-stage renal disease.

RESULTS

Our search yielded 16 randomized studies. Comparisons of two classes of drugs with at least two studies indicated that (1) CCB and ACEI increased the risk of HF [relative risk (RR) = 2.26; 95% confidence interval (CI) 1.16-4.40] and stroke [hazard ratio (HR) = 1.13; 1.00-1.26]), respectively, compared to diuretics; and (2) CCB showed a reduction in stroke (HR = 0.77; 0.66-0.89) and total mortality (HR = 0.94; 0.87-1.01) compared to the BB atenolol. Comparisons of two classes of antihypertensive medications with only one study showed that the risk of MI was higher with ARB valsartan versus CCB (HR = 1.19; 95% CI 1.02-1.38, p = 0.02). In contrast, losartan lowered the risk of a composite cardiovascular outcome compared to atenolol (HR = 0.87; 95% CI 0.77-0.98, p = 0.02).

CONCLUSIONS

In hypertensive subjects with excess weight, diuretics are more effective for preventing HF and stroke than CCB and ACEI, respectively. CCB are a good first-line choice for prevention of cardiovascular disease, except HF.

The efficacy of angiotensin converting enzyme inhibitors versus angiotensin II receptor blockers on insulin resistance in hypertensive patients: A protocol for a systematic review and meta-analysis

BACKGROUND

Previous studies have shown inconsistent outcomes in the efficacy of angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs) on insulin resistance (IR). Hence, we aim to compare the efficacy of ACE inhibitors with ARBs on IR in hypertensive patients.

METHODS

Five electronic databases (included The Cochrane Library, MEDLINE, Embase, Web of Science, and Cochrane Central Register of Controlled Trials) will be searched. Randomized controlled trials (RCTs) will be included if they recruited hypertensive participants for assessing the effect of ACE inhibitors on IR versus ARBs. The primary outcome will be IR (using recognized methods such as homeostasis model assessment of insulin resistance), secondary outcomes will be blood pressure, fasting plasma glucose, fasting plasma insulin. Relevant literature search, data extraction, and quality assessment will be performed by 2 researchers independently, and the third researcher will be involved in a discussion for any disagreements. All analyses will be performed based on the Cochrane Handbook for Systematic Reviews of Interventions. Stata 12.0 software will be used for statistical analysis. The effect size of dichotomous data will be measured using the odds ratio (OR), and the effect size of continuous data will be measured using the standardized mean difference. And 95% confidence intervals will be calculated. Heterogeneity will be tested by χ-based Cochran Q statistic and I statistic. Sensitivity analysis and subgroup analysis will be used to observe changes in the pooled effect size and heterogeneity between included studies, to assess the reliability and stability of the pooled results. The funnel plot and Egger's and Begg's tests will be used to judge publication bias, and the trim and fill method will be used to correct the funnel asymmetry caused by publication bias. P < 0.05 will be considered to indicate a statistically significant result.

RESULTS

This systematic review and meta-analysis will assess the efficacy of ACE inhibitors versus ARBs on IR in hypertensive patients.

CONCLUSIONS

Our study will show the efficacy of ACE inhibitors versus ARBs on IR in hypertensive patients. And it may find a more beneficial therapeutic option to assist clinicians in making clinical decisions.

ETHICS AND DISSEMINATION

This study is a protocol for systematic review and meta-analysis of the efficacy of ACE inhibitors and ARBs on IR in hypertensive patients. This systematic review and meta-analysis will be published in a journal and disseminated in print by peer-review.

INPLASY REGISTRATION NUMBER

INPLASY202050032.

Community Violence Exposure, Sleep Disruption, and Insulin Resistance in Low-Income Urban Adolescents

BACKGROUND

Exposure to violence, which is experienced at disproportionally higher levels by black versus white youth, is associated with disruptions in sleep and elevated cardiovascular risk. Further, poor sleep hygiene is associated with insulin resistance. However, research to date examining disruptions in sleep and cardiovascular risk in African-American adolescents has not taken the impact of exposure to violence into account, nor considered how gender might affect patterns of association. The present study addressed this gap by testing a path model linking exposure to community violence, sleep disruption, and insulin resistance in a sample of African-American adolescents and evaluating model fit across gender.

METHOD

African-American adolescents (N = 107; 56% female; M_age = 14.29, SD = 1.17) completed structured interviews at home and provided a blood sample after fasting overnight.

RESULTS

The model fit connecting exposure to violence with sleep disruption and insulin resistance, adjusting for depressive symptoms and body mass index z score, was excellent. Multiple group analysis indicated gender differences in model fit. Path analysis revealed significant positive associations between exposure to violence and sleep disruption and sleep disruption and insulin resistance for females but not males.

CONCLUSION

These data indicate that low-income, urban African-American female adolescents who witness violence and experience sleep disruptions may already be at elevated risk for health problems compared with their male counterparts. Additional research should attempt to replicate and explicate the underlying reasons for the gender differences observed here, with the goal of improving health and disrupting the path leading to health disparities.

Prediction of incident hypertension and arterial stiffness using the non-insulin-based metabolic score for insulin resistance (METS-IR) index

Hypertension is associated with insulin resistance (IR), metabolic syndrome (MS), and arterial stiffness. Non-insulin-based IR indexes were developed as tools for metabolic screening. Here, we aimed to evaluate the novel non-insulin-based Metabolic Score for IR (METS-IR) index for the prediction of incident hypertension and arterial stiffness evaluated using pulse wave velocity (PWV) analysis, compared with other non-insulin-based IR indexes. We evaluated two populations, a cross-sectional evaluation of high-risk individuals (n = 305) with a wide range of metabolic comorbidities and dyslipidemia in whom PWV measurement was performed and a 3-year prospective cohort of normotensive individuals (N = 6850). We observed a positive correlation between METS-IR and PWV in the cross-sectional cohort, which was higher compared with other non-insulin-based fasting IR indexes; furthermore, PWV values >75th percentile were associated with the upper tercile of METS-IR values. In the prospective cohort, we observed an increased risk for incident hypertension for the upper METS-IR tercile (METS-IR ≥ 46.42; HR: 1.81, 95% CI: 1.41-2.34), adjusted for known cardiovascular risk factors, and observed that METS-IR had greater increases in the predictive capacity for hypertension along with SBP and the Framingham Hypertension Risk Prediction Model compared with other non-insulin-based IR indexes. Therefore, METS-IR is a novel non-insulin-based IR index which correlates with arterial stiffness and is a predictor of incident hypertension, complementary to previously validated risk prediction models.

Risk of hypertension following perinatal adversity: IUGR and prematurity

Consistent with the paradigm shifting observations of David Barker and colleagues that revealed a powerful relationship between decreased weight through 2 years of age and adult disease, intrauterine growth restriction (IUGR) and preterm birth are independent risk factors for the development of subsequent hypertension. Animal models have been indispensable in defining the mechanisms responsible for these associations and the potential targets for therapeutic intervention. Among the modifiable risk factors, micronutrient deficiency, physical immobility, exaggerated stress hormone exposure and deficient trophic hormone production are leading candidates for targeted therapies. With the strong inverse relationship seen between gestational age at delivery and the risk of hypertension in adulthood trumping all other major cardiovascular risk factors, improvements in neonatal care are required. Unfortunately, therapeutic breakthroughs have not kept pace with rapidly improving perinatal survival, and groundbreaking bench-to-bedside studies are urgently needed to mitigate and ultimately prevent the tsunami of prematurity-related adult cardiovascular disease that may be on the horizon. This review highlights our current understanding of the developmental origins of hypertension and draws attention to the importance of increasing the availability of lactation consultants, nutritionists, pharmacists and physical therapists as critical allies in the battle that IUGR or premature infants are waging not just for survival but also for their future cardiometabolic health.

Integrative Genomics Analysis Unravels Tissue-Specific Pathways, Networks, and Key Regulators of Blood Pressure Regulation

Blood pressure (BP) is a highly heritable trait and a major cardiovascular disease risk factor. Genome wide association studies (GWAS) have implicated a number of susceptibility loci for systolic (SBP) and diastolic (DBP) blood pressure. However, a large portion of the heritability cannot be explained by the top GWAS loci and a comprehensive understanding of the underlying molecular mechanisms is still lacking. Here, we utilized an integrative genomics approach that leveraged multiple genetic and genomic datasets including (a) GWAS for SBP and DBP from the International Consortium for Blood Pressure (ICBP), (b) expression quantitative trait loci (eQTLs) from genetics of gene expression studies of human tissues related to BP, (c) knowledge-driven biological pathways, and (d) data-driven tissue-specific regulatory gene networks. Integration of these multidimensional datasets revealed tens of pathways and gene subnetworks in vascular tissues, liver, adipose, blood, and brain functionally associated with DBP and SBP. Diverse processes such as platelet production, insulin secretion/signaling, protein catabolism, cell adhesion and junction, immune and inflammation, and cardiac/smooth muscle contraction, were shared between DBP and SBP. Furthermore, "Wnt signaling" and "mammalian target of rapamycin (mTOR) signaling" pathways were found to be unique to SBP, while "cytokine network", and "tryptophan catabolism" to DBP. Incorporation of gene regulatory networks in our analysis informed on key regulator genes that orchestrate tissue-specific subnetworks of genes whose variants together explain ~20% of BP heritability. Our results shed light on the complex mechanisms underlying BP regulation and highlight potential novel targets and pathways for hypertension and cardiovascular diseases.

Ideal cardiovascular health, glycaemic status and incident type 2 diabetes mellitus: the REasons for Geographic and Racial Differences in Stroke (REGARDS) study

AIMS/HYPOTHESIS

Ideal cardiovascular health (CVH) is associated with lower diabetes risk. However, it is unclear whether this association is similar across glycaemic levels (normal [<5.6 mmol/l] vs impaired fasting glucose [IFG] [5.6-6.9 mmol/l]).

METHODS

A secondary data analysis was performed in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Incident diabetes was assessed among 7758 participants without diabetes at baseline (2003-2007) followed over 9.5 years. Baseline cholesterol, blood pressure, diet, smoking, physical activity and BMI were used to categorise participants based on the number (0-1, 2-3 and ≥4) of ideal CVH components. Risk ratios (RRs) were calculated using modified Poisson regression, adjusting for cardiovascular risk factors.

RESULTS

Among participants (mean age 63.0 [SD 8.4] years, 56% female, 73% white, 27% African-American), there were 891 incident diabetes cases. Participants with ≥4 vs 0-1 ideal CVH components with normal fasting glucose (n = 6004) had 80% lower risk (RR 0.20; 95% CI 0.10, 0.37), while participants with baseline IFG (n = 1754) had 13% lower risk (RR 0.87; 95% CI 0.58, 1.30) (p for interaction by baseline glucose status <0.0001). Additionally, the magnitude of the association of ideal CVH components with lower diabetes risk was stronger among white than African-American participants (p for interaction = 0.0338).

CONCLUSIONS/INTERPRETATION

A higher number of ideal CVH components was associated with a dose-dependent lower risk of diabetes for participants with normal fasting glucose but not IFG. Tailored efforts that take into account observed differences by race and glycaemic level are needed for the primordial prevention of diabetes.

Prevalence and Severity of High Blood Pressure Among Children Based on the 2017 American Academy of Pediatrics Guidelines

Importance

Based on the new 2017 blood pressure guidelines, the prevalence of high blood pressure (BP) among adults has increased from 32% to 46%. Based on new norms and diagnostic thresholds that better align with adult definitions, new clinical practice guidelines were also published for children. The American Academy of Pediatrics clinical practice guidelines for the management of elevated BP in children replace the 2004 fourth report from the National Heart, Lung, and Blood Institute.

Objectives

To assess the consequences of the American Academy of Pediatrics clinical practice guidelines for the management of elevated BP in children on the prevalence and severity of elevated BP among children and to characterize risk factors for children with new-onset hypertension or a worsening in clinical stage ("reclassified upward").

Design, Setting, and Participants

This study applied both sets of guidelines to classify BP in 15 647 generally healthy, low-risk children aged 5 to 18 years from National Health and Nutrition Examination Surveys (from January 1, 1999, to December 31, 2014). In the case-control portion of the study, children whose BP was reclassified upward (cases) were matched for sex, age, and height with controls with normal BP. Anthropometric and laboratory risk factors were compared, and age- and sex-specific z scores for weight, waist circumference, and body mass index were calculated. Blood pressure was measured by auscultation by trained personnel. After the child rested quietly for 5 minutes, 3 to 4 consecutive BP readings were recorded.

Main Outcomes and Measures

Blood pressure percentiles and clinical classification based on either the 2017 American Academy of Pediatrics guidelines or the 2004 National Heart, Lung, and Blood Institute report.

Results

Among the 15 647 children in the study (7799 girls and 7848 boys; mean [SD] age, 13.4 [2.8] years), based on the American Academy of Pediatrics guidelines, the estimated (weighted) population prevalence of elevated BP increased from 11.8% (95% CI, 11.1%-13.0%) to 14.2% (95% CI, 13.4%-15.0%). Overall, 905 of 15 584 children (5.8%) had newly diagnosed hypertension (n = 381) or a worsening in clinical stage (n = 524), which represents a substantial increase in disease burden for the health care system. Children whose BP was reclassified upward were more likely to be overweight or obese, with higher z scores for weight, waist circumference, and body mass index. The prevalence of abnormal laboratory test results was also increased, with adverse lipid profiles and increased hemoglobin A1c levels (prediabetes).

Conclusions and Relevance

Clustering of cardiovascular risk factors in otherwise healthy US children suggests that those whose BP was reclassified represent a high-risk population whose cardiovascular risk may previously have been underestimated.

Associations Among Fatty Acids, Desaturase and Elongase, and Insulin Resistance in Children

OBJECTIVES

Fatty acid profiles and desaturase (SCD-16, SCD018, D5D, D6D) and elongase (ELOVL6) enzyme activity have been associated with adiposity and metabolic disease. While this has been studied in adults, few studies have included children. The objective of this study was to evaluate these markers in children and identify relationships with markers of metabolic health. It was hypothesized that these lipid markers would be correlated to adiposity and metabolic disease.

METHODS

This study was a cross-sectional analysis of fourth- and fifth-grade children (n = 86, aged 9-12) participating in a comprehensive nutrition program. Any student enrolled in the program was eligible for inclusion in this study. Fasting plasma was collected and analyzed for total fatty acids, glucose, insulin, and full lipid panels. Insulin resistance was estimated using calculated homeostatic model assessment for insulin resistance (HOMA-IR) values.

RESULTS

There were no differences in lipid markers, glucose, insulin, or HOMA-IR among children classified as normal weight, overweight, or obese. SCD-16, D5D, and ELOVL6 activity was significantly correlated to HOMA-IR values (r = 0.39, p = 0.001; r = -0.33, p = 0.006; r = -0.37, p = 0.005, respectively). In regression analysis, body mass index for age percentile, D6D activity, ELOVL6 activity, and systolic blood pressure were the most significant predictors of HOMA-IR values (adjusted r² = 0.39, p ≤ 0.001).

CONCLUSIONS

There was no relationship between these lipid markers and adiposity in this population; however, there were correlations with HOMA-IR. Regardless of adiposity, there may be underlying changes in fatty acid and lipid metabolism associated with the development of metabolic diseases.

Nocturnal but not Diurnal Hypertension Is Associated to Insulin Resistance Markers in Subjects With Normal or Mildly Elevated Office Blood Pressure

OBJECTIVE

The aim was to evaluate the relationships among insulin resistance markers and nocturnal and diurnal hypertension in normotensive or mildly untreated hypertensive adults.

METHODS

The study was performed in both female and male adults referred to the Cardiometabolic Unit of the Hospital San Martín, La Plata, Argentina, in order to perform an ambulatory blood pressure measurement (ABPM) for the evaluation of a possible hypertensive disorder. The population was stratified according to their ABPM in: 1-presence or absence of diurnal hypertension and 2-presence or absence of nocturnal hypertension; both conditions were analyzed separately. Fasting plasma insulin (FPI), homeostasis model assessment of insulin resistance (HOMA-IR), and triglycerides (TG)/high-density lipoprotein cholesterol (HDL-C) ratio were used as surrogate markers of insulin resistance and compared among subjects with vs. without diurnal or nocturnal hypertension.

RESULTS

One hundred and five patients, 55 women, 47 (11) years old, and 50 men, 44 (16) years old, were included. Diurnal and nocturnal hypertension were found in 60% and 64% of the sample, respectively. There were no significant differences among the levels of insulin resistance markers between individuals with or without diurnal hypertension. In contrast, individuals with nocturnal hypertension were more insulin resistant irrespectively of whether they were evaluated using FPI (P = 0.016), HOMA-IR (P = 0.019), or TG/HDL-C ratio (P = 0.011); FPI differences remained significant after adjustment for sex, age, and obesity indicators (P = 0.032).

CONCLUSIONS

Nocturnal but not diurnal hypertension was related to higher levels of 3 insulin resistance markers in normotensive and untreated mildly hypertensive adults; this relationship seems partially independent of obesity.

Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents

These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.

Long-term Impact of Temporal Sequence from Childhood Obesity to Hyperinsulinemia on Adult Metabolic Syndrome and Diabetes: The Bogalusa Heart Study

This study aims to delineate the temporal relations between body mass index (BMI) and insulin in childhood and their impact on adult metabolic syndrome (MetS) and type 2 diabetes mellitus (T2DM).The longitudinal cohort consisted of 609 whites and 339 blacks who had BMI and fasting insulin measured twice in childhood (mean age = 10.5 years at baseline and 15.9 years at follow-up). Incident MetS and T2DM were identified in adulthood (mean age = 30.5 years). Cross-lagged panel and mediation analysis models were used. After adjusting for age, race, gender, and follow-up years, the cross-lagged path coefficient of BMI → insulin (β = 0.326, p < 0.001) was significantly greater than that of insulin → BMI (β = −0.023, p = 0.207) in childhood, with p < 0.001 for the difference in βs. The path coefficient for BMI → insulin was significantly greater in MetS than in non-MetS groups (0.510 vs 0.190, p < 0.001), and greater in hyperglycemia than in normoglycemia groups (0.503 vs 0.285, p = 0.026). The mediation effect of childhood insulin on the BMI-MetS and BMI-hyperglycemia associations was estimated at 19.2% (p < 0.001) and 18.3% (p < 0.001), respectively. These findings provide evidence that higher BMI levels precede hyperinsulinemia during childhood, and this one-directional relation plays a significant role in the development of MetS and T2DM in adult life.

Fasting insulin, insulin resistance and risk of hypertension in the general population: A meta-analysis

BACKGROUND

Studies on the association of fasting insulin concentrations or insulin resistance with subsequent risk of hypertension have yielded conflicting results.

OBJECTIVE

To quantitatively assess the association of fasting insulin concentrations or homeostasis model assessment insulin resistance (HOMA-IR) with incident hypertension in a general population by performing a meta-analysis.

METHODS

We searched the PubMed and Embase databases until August 31, 2016 for prospective observational studies investigating the elevated fasting insulin concentrations or HOMA-IR with subsequent risk of hypertension in the general population. Pooled risk ratio (RR) and 95% confidence interval (CI) of hypertension was calculated for the highest versus the lowest category of fasting insulin or HOMA-IR.

RESULTS

Eleven studies involving 10,230 hypertension cases were identified from 55,059 participants. Meta-analysis showed that the pooled adjusted RR of hypertension was 1.54 (95% CI 1.34-1.76) for fasting insulin concentrations and 1.43 (95% CI 1.27-1.62) for HOMA-IR comparing the highest to the lowest category. Subgroup analysis results showed that the association of fasting insulin concentrations with subsequent risk of hypertension seemed more pronounced in women (RR 2.07; 95% CI 1.19-3.60) than in men (RR 1.48; 95% CI 1.17-1.88).

CONCLUSIONS

This meta-analysis suggests that elevated fasting insulin concentrations or insulin resistance as estimated by homeostasis model assessment is independently associated with an exacerbated risk of hypertension in the general population. Early intervention of hyperinsulinemia or insulin resistance may help clinicians to identify the high risk of hypertensive population.

Gender impacts on the correlations between nonalcoholic fatty liver disease and hypertension in a Chinese population aged 45-60 y

No previous study has reported the association between nonalcoholic fatty liver disease (NAFLD) and the risk of hypertension in the Chinese population. Therefore, the aim of this study was to evaluate the relationship between NAFLD and hypertension in a middle-aged Chinese population. The study subject was (a group of) 1006 Chinese adults aged 45-60 y in Shandong Province who participated in the Weifang Nutrition and Health Survey (2014-2015). Hypertension was defined as systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥ 9 0mmHg. NAFLD was defined as the presence of moderate-severe hepatic steatosis (by B-ultrasonic examination), the absence of excessive alcohol use (>20 g/d in men and 10 g/d in women), no use of steatogenic medications within the past six months, no exposure to hepatotoxins, and no history of bariatric surgery. All anthropometric measurements and biochemical data were collected following standard protocols. Multivariate logistic regression analysis was used to identify the association between NAFLD and hypertension with adjustment of potential confounding variables. Body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), fasting glucose, SBP, DBP, triglycerides (TG), serum uric acid (SUA), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and the prevalence of hypertension and NAFLD were significantly higher in males than in females (p < 0.05). Females had significantly higher levels of total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C). After adjusting for potential confounders, NAFLD was associated with an increased risk of hypertension in both male and female, with odds ratios (ORs) (95% CI) of 2.152 (1.324-3.498) and 2.133 (1.409-3.229), respectively.

CONCLUSIONS

Our findings indicated that NAFLD was significantly associated with the risk of hypertension in males than in females. However, our findings also need to be confirmed in future prospective studies.

ABBREVIATIONS

BMI: body mass index; WC: waist circumference; WHR: waist-hip ratio; SBP: systolic blood pressure; DBP: diastolic blood pressure; FG: fasting glucose; TG: triglycerides; TC: total cholesterol; HDL-C: high-density lipoprotein cholesterol; SUA: serum uric acid; NAFLD: nonalcoholic fatty liver disease; LDL-C: low-density lipoprotein cholesterol; OR: odds ratio; CI: confidence interval; ALT: alanine aminotransferase; AST: aspartate aminotransferase.

Temporal Relationship Between Childhood Body Mass Index and Insulin and Its Impact on Adult Hypertension: The Bogalusa Heart Study

Although obesity and insulin resistance are closely correlated, their temporal sequences in early life and influence on adult hypertension are largely unknown. This study aims to delineate the temporal relationship patterns between body mass index (BMI) and insulin in childhood and their impact on adult hypertension. The longitudinal cohort consisted of 990 adults (630 whites and 360 blacks) who had BMI and fasting insulin measured twice 5.4 years apart in childhood (mean age, 10.5 years at baseline and 15.9 years at follow-up) and blood pressure measured 14.7 years later in adulthood (mean age, 30.5 years). Cross-lagged panel and mediation analysis models were used to examine the temporal relationship between childhood BMI and insulin and its impact on adult hypertension. After adjusting for age, race, sex, and follow-up years, the cross-lagged path coefficient (β=0.33; P<0.001) from baseline BMI to follow-up insulin was significantly greater than the path coefficient (β=-0.02; P>0.05) from baseline insulin to follow-up BMI in childhood with P<0.001 for the difference in βs. Blacks and whites showed similar patterns of the temporal relationship. The path coefficient (β=0.59; P<0.001) from BMI to insulin in the hypertensive group was significantly greater than that (β=0.24; P<0.001) in normotensive group, with P<0.001 for the difference in βs between these 2 groups. The mediation effect of childhood insulin on the childhood BMI-adult hypertension association was estimated at 21.1% (P<0.001). These findings provide evidence that higher BMI levels precede hyperinsulinemia during childhood, and this 1-directional relation plays a role in the development of hypertension.

Evolution of target organ damage and haemodynamic parameters over 4 years in patients with increased insulin resistance: the LOD-DIABETES prospective observational study

OBJECTIVES

We prospectively examined the impact of type 2 diabetes compared with metabolic syndrome (MetS) on the development of vascular disease over 4 years as determined by anatomic and functional markers of vascular disease. By comparing the vascular outcomes of the 2 disorders, we seek to determine the independent effect of elevated glucose levels on vascular disease.

SETTING

2 primary care centres in Salamanca, Spain.

PARTICIPANTS

We performed a prospective observational study involving 112 patients (68 with type 2 diabetes and 44 with MetS) who were followed for 4 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Measurements included blood pressure, blood glucose, lipids, smoking, body mass index, waist circumference, Homeostasis Model Assessment Insulin Resistance (HOMA-IR), hs-c-reactive protein and fibrinogen levels. We also evaluated vascular, carotid intima media thickness (IMT), pulse wave velocity (PWV) and ankle/brachial index, heart and renal target organ damage (TOD). The haemodynamic parameters were central (CAIx) and peripheral (PAIx) augmentation indices.

RESULTS

In year 4, participants with type 2 diabetes had increased IMT thickness. These patients had more plaques and an IMT>0.90 mm. In participants with MetS, we only found an increase in the number of plaques. We found no changes in PWV, CAIx and PAIx. The patients with diabetes had a greater frequency of vascular TOD. There were no differences neither in renal nor cardiac percentage of TOD in the patients with MetS or diabetes mellitus type 2.

CONCLUSIONS

This prospective study showed that the evolution of vascular TOD is different in participants with type 2 diabetes compared with those with MetS. While IMT and PWV increased in type 2 diabetes, these were not modified in MetS. The renal and cardiac TOD evolution, as well as the PAIx and CAIx, did not change in either group.

TRIAL REGISTRATION NUMBER

NCT01065155; Results.