Biomonitoring of per- and polyfluoroalkyl substances in minority angler communities in central New York State

Onondaga Lake in central New York State was listed as a Superfund site in 1994 due to industrial disposal of pollutants. A biomonitoring program was conducted to assess exposure to over 70 legacy contaminants and contaminants of emerging concern in populations disproportionately at risk for exposure residing near Onondaga Lake and to educate these communities on how to reduce exposures. The populations of focus were refugees from Burma and Bhutan and low-income, primarily African American, anglers (urban anglers). These communities consume locally caught fish for economic as well as cultural reasons and therefore may be at higher risk of exposure. This study focuses on assessment of exposure to per- and polyfluoroalkyl substances (PFAS) and associations with local fish consumption. Using respondent driven sampling, 311 refugees and 89 urban anglers were enrolled in the study. Following informed consent, study participants provided blood and urine specimens and completed a questionnaire. Percentiles of locally caught fish meals in the past 12 months by race/ethnicity groups showed that the Burmese participants of Karen ethnicity were the highest consumers, with a median of 135 meals compared to 103 meals for the other Burmese participants, 70 meals for the urban anglers, and 44 meals for the Bhutanese participants. Compared to the National Health and Nutrition Examination Survey (NHANES) 2015-16 sample of the general U.S. population, the Karen participants had markedly elevated perfluorooctane sulfonic acid (PFOS) and perfluorodecanoic acid (PFDA) levels with median serum concentrations 9.5 times greater (41.6 ng/mL vs. 4.4 ng/mL) and 26.9 times greater (2.69 ng/mL vs. 0.10 ng/mL), respectively; the other Burmese participants had moderately elevated levels of PFOS and PFDA with median serum concentrations 3.0 times greater (13.3 ng/mL vs. 4.4 ng/mL) and 7.3 greater times greater (0.73 ng/mL vs. 0.10 ng/mL), respectively; and, PFAS levels were not elevated in the Bhutanese or urban angler cohorts. Male gender was consistently the strongest predictor of PFAS exposure among all study cohorts. A positive association between local fish consumption was indicated only for PFOS among urban anglers. An association between local fish consumption and PFAS was not statistically significant among the refugee cohorts, perhaps due to the lack of 'lower-end' exposure or exposure variability. Community events were held by the program staff to present the biomonitoring results and distribute community outreach materials with visual aids specific for the study populations to promote safe fish eating.

Biomonitoring of exposure to Great Lakes contaminants among licensed anglers and Burmese refugees in Western New York: Toxic metals and persistent organic pollutants, 2010-2015

Between 2010 and 2015, the New York State Department of Health (NYSDOH) conducted a biomonitoring program to gather exposure data on Great Lakes contaminants among licensed anglers and Burmese refugees living in western New York who ate locally caught fish. Four hundred and nine adult licensed anglers and 206 adult Burmese refugees participated in this program. Participants provided blood and urine samples and completed a detailed questionnaire. Herein, we present blood metal levels (cadmium, lead, and total mercury) and serum persistent organic pollutant concentrations [polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs), dichlorodiphenyldichloroethylene (DDE), and trans-nonachlor]. Multiple linear regression was applied to investigate the associations between analyte concentrations and indicators of fish consumption (locally caught fish meals, store-bought fish meals, and consuming fish/shellfish in the past week). Licensed anglers consumed a median of 16 locally caught fish meals and 22 store-bought fish meals while Burmese refugees consumed a median of 106 locally caught fish meals and 104 store-bought fish/shellfish meals in the past year. Compared to the general U.S. adult population, licensed anglers had higher blood lead and mercury levels; and Burmese refuges had higher blood cadmium, lead, and mercury, and higher serum DDE levels. Eating more locally caught fish was associated with higher blood lead, blood mercury, and serum ∑PCBs concentrations among licensed anglers. Licensed anglers and Burmese refugees who reported fish/shellfish consumption in the past week had elevated blood mercury levels compared with those who reported no consumption. Among licensed anglers, eating more store-bought fish meals was also associated with higher blood mercury levels. As part of the program, NYSDOH staff provided fish advisory outreach and education to all participants on ways to reduce their exposures, make healthier choices of fish to eat, and waters to fish from. Overall, our findings on exposure levels and fish consumption provide information to support the development and implementation of exposure reduction public health actions.

Biomonitoring of toxic metals, organochlorine pesticides, and polybrominated biphenyl 153 in Michigan urban anglers

The 32-mile Detroit River and surrounding tributaries have been designated as a Great Lakes Area of Concern due to pollution from decades of municipal and industrial discharges, sewer overflows and urban development. The Agency for Toxic Substances and Disease Registry and the Michigan Department of Health and Human Services conducted a biomonitoring study to assess exposures to persistent toxic substances in Detroit urban shoreline anglers who may be at high exposure risk due to consumption of locally caught fish. Using a modified venue-based sampling approach, 287 adult shoreline anglers along the Detroit River were recruited and participated in the program. Study participants provided blood and urine specimens and completed a questionnaire interview. In this report, we examine percentile estimates for blood lead, blood manganese, urine arsenic, urine mercury, urine cadmium, organochlorine pesticides in serum (mirex, hexachlorobenzene, chlordane), and serum polybrominated biphenyl 153 (PBB 153) concentrations among study participants. Multiple linear regression was used to identify predictors of contaminant concentrations. The Detroit urban anglers' blood lead concentrations were 2 times higher than the general adult U.S. population (median (95% CI): 2.9 μg/dL (1.8-2.3) vs. 0.94 μg/dL (0.90-0.98)). PBB 153 levels were 1.8 times higher than the general adult U.S. population at the 95th percentile (95th percentile, 95% CI: 62.7 ng/g of lipid, 53.2-75.2 vs. 34.6 ng/g of lipid, 12.8-66.8). Percentile estimates of the other study pollutants were similar to background levels found in the general U.S. population. Eating more locally caught fish was not associated with increased body burdens for any of the contaminants examined in this report. Higher blood lead was associated with increased age, male sex, current smoking, residing in a home built before 1960, an annual income less than $25,000, and a work history of lead paint removal. Evidence of PBB exposure in our study cohort likely reflects the continued effect of a widespread contamination of livestock feed in 1973 among Michigan's lower peninsula population. These study results help determine if the pollutants examined warrant further consideration in subsequent population-based biomonitoring of frequent consumers of fish from the Detroit River and surrounding waterways. The biomonitoring data from this study also served to inform public health officials regarding the potential need for environmental public health actions to reduce harmful exposures.

Assessing exposures to per- and polyfluoroalkyl substances in two populations of Great Lakes Basin fish consumers in Western New York State

BACKGROUND

Fish and other seafood are an important dietary source of per- and polyfluoroalkyl substances (PFAS) exposure in many areas of the world, and PFAS were found to be pervasive in fish from the Great Lakes area. Few studies, however, have examined the associations between Great Lakes Basin fish consumption and PFAS exposure. Many licensed anglers and Burmese refugees and immigrants residing in western New York State consume fish caught from the Great Lakes and surrounding waters, raising their risk of exposure to environmental contaminants including PFAS. The aims of this study were to: 1) present the PFAS exposure profile of the licensed anglers and Burmese refugees and 2) examine the associations between serum PFAS levels and local fish consumption.

METHODS

Licensed anglers (n = 397) and Burmese participants (n = 199) provided blood samples and completed a detailed questionnaire in 2013. We measured 12 PFAS in serum. Multiple linear regression was used to assess associations between serum PFAS concentrations and self-reported consumption of fish from Great Lakes waters.

RESULTS

Licensed anglers and Burmese participants reported consuming a median of 16 (IQR: 6-36) and 88 (IQR: 44-132) meals of locally caught fish in the year before sample collection, respectively (data for Burmese group restricted to 10 months of the year). Five PFAS were detected in almost all study participants (PFOS, PFOA, PFHxS, PFNA and PFDA; 97.5-100%). PFOS had the highest median serum concentration in licensed anglers (11.6 ng/mL) and the Burmese (35.6 ng/mL), approximately two and six times that of the U.S. general population, respectively. Serum levels of other PFAS in both groups were generally low and comparable to those in the general U.S.

POPULATION

Among licensed anglers, Great Lakes Basin fish meals over the past year were positively associated with serum PFOS (P < 0.0001), PFDA (P < 0.0001), PFHxS (P = 0.01), and PFNA (P = 0.02) and the number of years consuming locally caught fish was positively associated with serum PFOS (P = 0.01) and PFDA (P = 0.01) levels. In the Burmese group, consuming Great Lakes Basin fish more than three times a week in the past summer was positively associated with serum PFOS (P = 0.004) and PFDA (P = 0.02) among the Burmese of non-Karen ethnicity, but not among those of Karen ethnicity, suggesting potential ethnic differences in PFAS exposure.

CONCLUSIONS

Great Lakes Basin fish consumption was associated with an increase in blood concentrations of some PFAS, and especially of PFOS, among licensed anglers and Burmese refugees and immigrants in western New York State. In the Burmese population, there may be other important PFAS exposure routes related to residential history and ethnicity. Continued outreach efforts to increase fish advisory awareness and reduce exposure to contaminants are needed among these populations.

Biomonitoring of populations in Western New York at risk for exposure to Great Lakes contaminants

The New York State Department of Health conducted the Healthy Fishing Communities Program in collaboration with the Agency for Toxic Substances and Disease Registry to assess human exposure to contaminants common to Lake Ontario, Lake Erie and surrounding rivers and waterways among populations in western New York State who eat locally caught fish. The program enrolled licensed anglers and Burmese refugees and immigrants, living near four designated Great Lakes Areas of Concern: Buffalo River, Niagara River, Eighteenmile Creek, and the Rochester Embayment. These target populations were sampled and enrolled independently into the program between February and October of 2013. A core set of contaminants were measured in blood and urine of 409 licensed anglers and 206 Burmese refugees and immigrants which included lead, cadmium, mercury, PCBs, PBDEs, organochlorine pesticides (hexachlorobenzene, mirex, DDT, DDE, and chlordane and its metabolites oxychlordane and trans-Nonachlor), and PFOS and PFOA. Biomonitoring results showed that both groups had higher geometric means for blood lead, total blood mercury, and serum PFOS compared to the 2013-2014 NHANES reference levels. The Burmese refugee group also showed higher geometric means for creatinine-adjusted urine mercury and lipid-adjusted serum DDE compared to national levels. Licensed angler participants reported eating a median of 16 locally caught fish meals in the past year. Burmese participants consumed local fish throughout the year, and most frequently in the summer (median 39 fish meals or 3 times a week). The study results provide valuable information on populations at high risk of exposure to contaminants in the Great Lakes Basin of western New York. The results provide the foundation for developing and implementing public health actions to reduce potential exposures to Great Lakes pollutants.

Biomonitoring of mercury and persistent organic pollutants in Michigan urban anglers and association with fish consumption

The 32-mile Detroit River and surrounding tributaries have been designated as a Great Lakes Area of Concern due to pollution from decades of municipal and industrial discharges, sewer overflows and urban development. Key pollutants in fish samples from the Detroit River include mercury, polychlorinated biphenyls (PCBs), dichlorodiphenyldichloroethylene (DDE), dioxins and furans. A biomonitoring study was conducted to assess exposures to these persistent toxic substances in Detroit urban shoreline anglers who may be at high exposure risk due to consumption of locally caught fish. Using a modified venue-based sampling approach, 287 adult shoreline anglers along the Detroit River were recruited and participated in the program. Study participants provided blood and urine specimens and completed a questionnaire following informed consent. We examined percentile estimates for total blood mercury, PCBs, DDE, and dioxin-like total toxic equivalency (TEQ) concentrations among study participants. Multiple linear regression was used to identify important predictors of contaminant concentrations. Participants consumed a median of 64 Detroit River caught fish meals in the past year. The Detroit urban anglers' median total blood mercury concentrations was 3.2 times higher than that for the general adult U.S. population. PCB concentrations among the Detroit anglers aged 18-39 years were higher than the U.S. population of the same race/ethnicity. Elevated levels of DDE and total TEQ concentrations were not observed in the cohort. Eating more locally caught fish was associated with higher total blood mercury and serum PCB concentrations. The biomonitoring data served to inform public health officials and help guide environmental public health actions to reduce harmful exposures.

Biomonitoring programs in Michigan, Minnesota and New York to assess human exposure to Great Lakes contaminants

Over the past century, industrialization and urban practices have resulted in the contamination of the Great Lakes ecosystem-the world's largest surface freshwater system-that provides drinking water and recreation to more than 40 million residents. In 2010, the Great Lakes Restoration Initiative was launched to accelerate efforts to protect and restore the Great Lakes and surrounding areas. Funded by GLRI, the Agency for Toxic Substances and Disease Registry initiated the Biomonitoring of Great Lakes Populations (BGLP) program. The objective of the program is to assess human exposure to legacy and emerging contaminants in the Great Lakes by measuring the body burden of contaminants in potentially susceptible populations. The BGLP program consists of a series of cross-sectional studies carried out collaboratively with states that are funded through ATSDR. The first BGLP Program (BGLP-I) began in 2010 and was completed in September 2015 through cooperative agreements with state health departments in Michigan, Minnesota, and New York. The three state programs targeted susceptible adult populations living in designated areas of contamination. Contaminants measured in all populations include mercury, lead, mirex, hexachlorobenzene, dichlorodiphenyltrichloroethane, and selected polychlorinated biphenyl congeners. In addition, some chemicals of emerging concern, such as per- and polyfluoroalkyl substances, were measured in several populations. The biomonitoring results helped guide public health actions to mitigate chemical exposures in these vulnerable Great Lakes populations. We provide an overview of the BGLP-I program's study populations, designs, and general methods. This overview provides a lead-in for subsequent manuscripts that present human biomonitoring data for legacy and emerging contaminants in culturally diverse susceptible populations-i.e., shoreline anglers, sport anglers, American Indians, and Burmese immigrants-residing in seven areas of concern.

Predictors of serum polychlorinated biphenyl concentrations in Anniston residents

The Anniston Community Health Survey was a community-based cross-sectional study of Anniston, Alabama, residents who live in close proximity to a former PCB production facility to identify factors associated with serum PCB levels. The survey comprises 765 Anniston residents who completed a questionnaire interview and provided a blood sample for analysis in 2005-2007. Several reports based on data from the Anniston survey have been previously published, including associations between PCB exposure and diabetes and blood pressure. In this study we examine demographic, behavioral, dietary, and occupational characteristics of Anniston survey participants as predictors of serum PCB concentrations. Of the 765 participants, 54% were White and 45% were African-American; the sample was predominantly female (70%), with a mean age of 55 years. Serum PCB concentrations varied widely between participants (range for sum of 35 PCBs: 0.11-170.4 ng/g wet weight). Linear regression models with stepwise selection were employed to examine factors associated with serum PCBs. Statistically significant positive associations were observed between serum PCB concentrations and age, race, residential variables, current smoking, and local fish consumption, as was a negative association with education level. Age and race were the most influential predictors of serum PCB levels. A small age by sex interaction was noted, indicating that the increase in PCB levels with age was steeper for women than for men. Significant interaction terms indicated that the associations between PCB levels and having ever eaten locally raised livestock and local clay were much stronger among African-Americans than among White participants. In summary, demographic variables and past consumption of locally produced foods were found to be the most important predictors of PCB concentrations in residents living in the vicinity of a former PCB manufacturing facility.

Communities near toluene diisocyanate sources: an investigation of exposure and health

Toluene diisocyanate (TDI) is a well-known cause of occupational asthma, but we know little about the potential for exposure and health effects among residents who live near facilities that release TDI. In the mid-1990's, the North Carolina Department of Health and Human Services and the Agency for Toxic Substances and Disease Registry investigated exposures to TDI and health outcomes in one community, which left some unanswered questions. This cross-sectional study evaluated the potential associations between living near a TDI source and the prevalence of three variables: asthma or asthma-like respiratory symptoms, antibodies specific to TDI, and verifiable levels of TDI in residential air. Results among North Carolina residents living near such facilities (five target communities) were compared with the results from residents living further away (five comparison communities). Overall, the prevalence of reporting either asthma or asthma-like respiratory symptoms was higher (odds ratio = 1.60; 95% confidence interval = 0.97-2.54) among residents in target communities than those in comparison communities. However, this difference was not statistically significant. Symptom prevalence varied greatly among the community populations. The prevalence of respiratory symptoms was higher near facilities with historically higher TDI emissions. Among the 351 participants who provided blood samples, only one had immunoglobulin G specific antibodies to TDI. This participant lived in a target area and may have had non-occupational exposure. TDI was detected at an extremely low level (1 ppt) in one of the 45 air samples from target communities. One ppt is one-tenth the EPA reference concentration. Overall, air sample and antibody test results are not consistent with recent or ongoing exposure to TDI.

Acute hazardous substance releases resulting in adverse health consequences in children: Hazardous Substances Emergency Events Surveillance system, 1996-2003

Because of their small size and ongoing organ development, children may be more susceptible than adults to the harmful effects of toxic chemicals. The objective of the study reported here was to identify frequent locations, released substances, and factors contributing to short-term chemical exposures associated with adverse health consequences experienced by children. The study examined the Hazardous Substances Emergency Events Surveillance (HSEES) system data from 1996-2003. Eligible events involved the acute release of a hazardous substance associated with at least one child being injured. The study found that injured children were predominantly at school, home, or a recreational center when events took place. School-related events were associated with the accidental release of acids and the release of pepper spray by pranksters. Carbon monoxide poisonings occurring in the home, retail stores, entertainment facilities, and hotels were responsible for about 10 percent of events involving child victims. Chlorine was one of the top chemicals harmful to children, particularly at public swimming pools. Although human error contributed to the majority of releases involving child victims, equipment failure was responsible for most chlorine and ammonia releases. The authors conclude that chemical releases resulting in injury to children occur mostly in schools, homes, and recreational areas. Surveillance of acute hazardous chemical releases helped identify contributing causes and can guide the development of prevention outreach activities. Chemical accidents cannot be entirely prevented, but efforts can be taken to provide safer environments in which children can live, learn, and play. Wide dissemination of safety recommendations and education programs is required to protect children from needless environmental dangers.

Healthy and safe school environment, Part II, Physical school environment: results from the School Health Policies and Programs Study 2006

BACKGROUND

As society continues to focus on the importance of academic achievement, the physical environment of schools should be addressed as 1 of the critical factors that influence academic outcomes. The School Health Policies and Programs Study (SHPPS) 2006 provides, for the first time, a comprehensive look at the extent to which schools have health-promoting physical school environment policies and programs.

METHODS

The Centers for Disease Control and Prevention conducts the SHPPS every 6 years. In 2006, computer-assisted telephone interviews or self-administered mail questionnaires were completed by state education agency personnel in all 50 states and the District of Columbia and among a nationally representative sample of school districts (n=424). Computer-assisted personal interviews were conducted with personnel in a nationally representative sample of elementary, middle, and high schools (n=992).

RESULTS

One third (35.4%) of districts and 51.4% of schools had an indoor air quality management program; 35.3% of districts had a school bus engine-idling reduction program; most districts and schools had a policy or plan for how to use, label, store, dispose of, and reduce the use of hazardous materials; 24.5% of states required districts or schools to follow an integrated pest management program; and 13.4% of districts had a policy to include green design when building new school buildings or renovating existing buildings.

CONCLUSIONS

SHPPS 2006 results can guide education and health agency actions in developing and implementing evidence-based tools, policies, programs, and interventions to ensure a safe and healthy physical school environment.

Releases from improper chemical mixing, Hazardous Substances Emergency Events Surveillance system, 1996-2001

OBJECTIVE

To examine the public health consequences of acute hazardous substance releases resulting from the improper mixing of chemicals.

METHODS

Data from the Agency for Toxic Substances and Disease Registry's Hazardous Substances Emergency Events Surveillance system for 1996-2001 events were analyzed.

RESULTS

"Private households" was the most frequent industry classification among improper mixing events, and chlorine was associated with a greater prevalence of improper mixing events. Releases from improper mixing were considerably more likely to involve fire, explosion, and fire-explosion combined; were markedly more likely to result in personal injury (48% for improper mixing events vs. 7% other events); and had a significantly greater percentage of victims with traumatic injury (PR = 3.07, 95% CI = 2.55-3.71).

CONCLUSIONS

Improper chemical mixing can cause dangerous, harmful reactions and are preventable. Consumers should be educated to avoid mixing noncompatible products.

Surveillance of hazardous substance emergency events: identifying areas for public health prevention

The Hazardous Substances Emergency Events Surveillance (HSEES) system is a comprehensive, state-based surveillance system of hazardous substance releases and public health consequences. Maintained by the Agency for Toxic Substances and Disease Registry (ATSDR) since 1990, the system captures information on acute releases of hazardous substances that need to be cleaned up or neutralized according to federal, state, or local law. Information about threatened releases that result in public health action such as evacuation is also included. Of the 39,766 events reported to HSEES for 1996--2001, 8% resulted in deaths or injuries. Funded through a competitive program announcement, 15 states currently participate in HSEES. State coordinators actively collect data from multiple sources after an eligible event occurs and enter data about the event into a standardized ATSDR-provided web-based system. The information in HSEES describes the distribution and characteristics of hazardous substances emergencies and the morbidity and mortality experienced by employees, responders, and the general public as the result of hazardous substances releases. Analysis of HSEES data helps identify risk factors associated with hazardous substances releases. For example, although events in which chlorine was released account for only 1.6% of all events, they were 3.52 times more likely to result in injuries. Knowledge of these factors is useful in planning public safety interventions and can impact the formulation of guidelines and policies to help reduce the number of events (primary prevention) and the morbidity and mortality associated with these events (secondary prevention). Utilizing state-specific analyses of HSEES data, participating states have been able to develop prevention outreach activities such as awareness training of first responders, primary prevention of spills, and secondary prevention of related injuries and deaths caused by ammonia, chlorine, and mercury. Specific examples involving ammonia, chlorine, and mercury releases will be presented in detail.

Trends in hypertension-related death in the United States: 1980-1998

Trends in hypertension-related mortality for groups by race/ethnicity, sex, and age have not been examined previously. National multiple-cause mortality files for 1980-1998 were analyzed for adult decedents with hypertension listed as one of 20 conditions causing death. Racial/ethnic comparisons of hypertension-related death were performed using age-standardized and age-specific rates in years (per 100,000). Age-standardized rate increased from 183.1 in 1980 to 243.7 in 1998, a relative increase of 33% and an average annual increase of 1.5% (p<0.0001). From 1981 to 1998, age-specific death rates increased for persons > or =85 years (average annual increase of 10.4% for blacks, 7.9% for whites), 75-84 years (5.9% for blacks, 3.6% for whites), and 65-74 years (3.2% for blacks, 1.4% for whites). By 1997-1998, blacks had greater death rates compared with whites at all ages. Over the past two decades, there has been a step-by-step increase in hypertension-related mortality, which has continued to show a male over female and black over white predominance. Prevention and control of hypertension must continue to be pursued as a strategy to reduce cardiovascular disease morbidity and mortality.

Risk factors for acute chemical releases with public health consequences: Hazardous Substances Emergency Events Surveillance in the U.S., 1996-2001

BACKGROUND

Releases of hazardous materials can cause substantial morbidity and mortality. To reduce and prevent the public health consequences (victims or evacuations) from uncontrolled or illegally released hazardous substances, a more comprehensive analysis is needed to determine risk factors for hazardous materials incidents.

METHODS

Hazardous Substances Emergency Events Surveillance (HSEES) data from 1996 through 2001 were analyzed using bivariate and multiple logistic regression. Fixed-facility and transportation-related events were analyzed separately.

RESULTS

For fixed-facility events, 2,327 (8%) resulted in at least one victim and 2,844 (10%) involved ordered evacuations. For transportation-related events, 759 (8%) resulted in at least one victim, and 405 (4%) caused evacuation orders. Fire and/or explosion were the strongest risk factors for events involving either victims or evacuations. Stratified analysis of fixed-facility events involving victims showed a strong association for acid releases in the agriculture, forestry, and fisheries industry. Chlorine releases in fixed-facility events resulted in victims and evacuations in more industry categories than any other substance.

CONCLUSIONS

Outreach efforts should focus on preventing and preparing for fires and explosions, acid releases in the agricultural industry, and chlorine releases in fixed facilities.

Increasing trends in hospitalization for atrial fibrillation in the United States, 1985 through 1999: implications for primary prevention

BACKGROUND

Atrial fibrillation, the most common sustained disturbance of heart rhythm, is associated with a 5-fold increase in the incidence of ischemic stroke.

METHODS AND RESULTS

The National Hospital Discharge Survey was used to estimate the annual number and prevalence of hospitalizations with atrial fibrillation among men and women 35 years of age or older. From 1985 through 1999, hospitalizations increased from 154 086 to 376 487 for a first-listed diagnosis and from 787 750 to 2 283 673 for any diagnosis. Prevalence was higher among successive age groups. Age-standardized prevalence was consistently higher among men than women. In 1999, essential hypertension, ischemic heart disease, congestive heart failure, and diabetes were prominent coexisting conditions. The number of male patients discharged home decreased from 77% to 63%, whereas the number of discharges to long-term care increased from 9% to 15%; the corresponding values for women were 72% to 56% and 15% to 23%. A slight increase in discharges to short-term care was indicated, whereas no trends were noted for in-hospital mortality.

CONCLUSIONS

Hospitalizations for atrial fibrillation have increased dramatically (2- to 3-fold) in recent years. The public health burden of atrial fibrillation is enormous and expected to continue to increase over the next decades. Primary prevention of atrial fibrillation must be recognized and pursued as a complementary management strategy for reducing cardiovascular morbidity and mortality.

Establishing data elements for the Paul Coverdell National Acute Stroke Registry: Part 1: proceedings of an expert panel

BACKGROUND AND PURPOSE

Stroke is the third-leading cause of death and a leading cause of disability in adults in the United States. In recent years, leaders in the stroke care community identified a national registry as a critical tool to monitor the practice of evidence-based medicine for acute stroke patients and to target areas for continuous quality of care improvements. An expert panel was convened by the Centers for Disease Control and Prevention to recommend a standard list of data elements to be considered during development of prototypes of the Paul Coverdell National Acute Stroke Registry.

METHODS

A multidisciplinary panel of representatives of the Brain Attack Coalition, professional associations, nonprofit stroke organizations, and federal health agencies convened in February 2001 to recommend key data elements. Agreement was reached among all participants before an element was added to the list.

RESULTS

The recommended elements included patient-level data to track the process of delivering stroke care from symptom onset through transport to the hospital, emergency department diagnostic evaluation, use of thrombolytic therapy when indicated, other aspects of acute care, referral to rehabilitation services, and 90-day follow-up. Hospital-level measures pertaining to stroke center guidelines were also recommended to augment patient-level data.

CONCLUSIONS

Routine monitoring of the suggested parameters could promote community awareness campaigns, support quality improvement interventions for stroke care and stroke prevention in each state, and guide professional education in hospital and emergency system settings. Such efforts would reduce disability and death among stroke patients.

Increased atrial fibrillation mortality: United States, 1980-1998

The authors used death certificate data to evaluate national trends in the reporting of atrial fibrillation as an underlying or contributory cause of death for groups defined by age (45 years or older), sex, and race (Black vs. White) and to examine comorbidity. The multiple-causes mortality files from 1980 through 1998 were analyzed for decedents, with atrial fibrillation (International Classification of Diseases, Ninth Revision, code 427.3) listed as one of up to 20 conditions causing death. The number of decedents with atrial fibrillation increased from 18,947 in 1980 to 61,946 in 1998, and the proportion with atrial fibrillation reported as the underlying cause of death rose from 8.3% in 1980 to 11.6% in 1998. Age-standardized death rates from 1980 to 1998 were consistently highest among White men, followed (in descending order) by White women, Black men, and Black women. Overall, the age-standardized rate (per 100,000) increased from 27.6 in 1980 to 69.8 in 1998 (an average annual increase of 5.4%, p < 0.0001). Ischemic heart disease was the most frequent underlying cause of death among decedents with atrial fibrillation (26.8%). These findings emphasize the need for increased application of proven prevention and control measures to decrease associated cardiovascular morbidity and mortality.

An evaluation of Choose to Move 1999: an American Heart Association physical activity program for women

BACKGROUND

Rates of physical inactivity and poor nutrition, which are 2 of the most important modifiable risk factors for cardiovascular disease in women, are substantial. Even so, studies of interventions designed to improve lifestyle behaviors in women have been limited and often confined to particular geographical areas.

OBJECTIVE

To evaluate the effect of Choose to Move on increasing women's physical activity, improving their knowledge of heart disease and stroke, and improving their nutrition.

PARTICIPANTS AND METHODS

A prospective, nonrandomized, 12-week educational intervention designed by the American Heart Association for women across the United States. Participants received a welcome kit and manual with weekly information about how to manage cardiovascular disease risk factors and how to build a support system for lifestyle change. Women (N = 23 171) aged 25 years or older were recruited by direct mail, the media, health care providers, and other means. Follow-up evaluations were returned from 6389 women at 2 weeks, 5338 at 4 weeks, 4209 at 8 weeks, 3916 at 10 weeks, and 3775 at 12 weeks. Participants self-reported their physical activity, diet, and knowledge about heart disease, stroke, and related symptoms.

RESULTS

Ninety percent of the participants were white and 56% were aged between 35 and 54 years. Among the participants who completed the week 12 follow-up evaluation, the percentage who reported being active (at least moderate exercise > or =5 times per week or >2(1/2) hours per week for the past 1 to 6 months) increased from 32% at baseline to 67% at the program's end (P =.001). Participants currently limiting excess calories or fat increased from 72% to 91% at week 10 follow-up evaluation (P =.001). The proportion correctly identifying heart disease as the leading cause of death increased from 84% to 91% at week 10 follow-up evaluation (P<.001).

CONCLUSIONS

Women who completed the Choose to Move program evaluation reported that they significantly increased their levels of physical activity, reduced their consumption of high-fat foods, and increased their knowledge and awareness of cardiovascular disease risk and its symptoms. This program provides an important model for public health, voluntary, and other health organizations of population-based, targeted low-cost self-help programs that support the Healthy People 2010 objectives for physical activity, nutrition, and cardiovascular health.

Surveillance for poliovirus vaccine adverse events, 1991 to 1998: impact of a sequential vaccination schedule of inactivated poliovirus vaccine followed by oral poliovirus vaccine

BACKGROUND

The elimination of wild-virus-associated poliomyelitis in the Western Hemisphere in 1991 and rapid progress in global polio eradication efforts changed the risk-benefit ratio associated with the exclusive use of oral poliovirus vaccine (OPV) for routine immunization. These changes, plus the November 1987 development of an enhanced-potency inactivated poliovirus vaccine (IPV), which poses no risk of vaccine-associated paralytic poliomyelitis (VAPP), resulted in a change in polio immunization policy in the United States. In September 1996, the Centers for Disease Control and Prevention recommended that IPV replace OPV for the first 2 doses in a sequential poliovirus vaccine schedule. The Vaccine Adverse Event Reporting System (VAERS), a passive surveillance system for adverse events after receipt of any US-licensed vaccine, is used to monitor postlicensure vaccine safety. Postlicensure surveillance of vaccines is important to identify new, rare, or delayed-onset adverse reactions not detected in prelicensure clinical trials or when new vaccine schedules are adopted. Through continual monitoring of adverse events and identification of potential vaccine risks, VAERS can serve as an important resource to ensure continued public acceptance of vaccines. We compared VAERS reports after the receipt of IPV to reports after OPV in infants from 1991 through 1998. Comparisons included reports listing IPV and OPV coadministered with other vaccines.

METHODS

Annual reporting rates per 100 000 doses distributed within 3 severity categories (fatal, nonfatal serious, less serious) were examined. Distributions of severity categories by vaccine type, age, and time period (pre- and postrecommendation) were constructed. Safety profiles (distribution of 21 symptom groupings) for IPV and OPV reports were compared. Analysis was restricted to reports for infants 1 to 3 months old and 4 to 6 months old, corresponding generally to first- and second-dose recipients. Any notable increase in a severity or safety category for IPV compared with OPV was followed up by examining the frequency of specific symptoms, reporting source, and date of vaccination. An important limitation of VAERS is that reports do not necessarily represent adverse events caused by vaccines. In many cases, the events are temporal associations only.

RESULTS

The annual rates of VAERS reports per 100 000 vaccine doses distributed by severity category, 1991 to 1998, were in general similar for reports after IPV compared with those after OPV. The reporting rates for poliovirus vaccine did not increase materially with the shift to IPV usage. The relative frequencies of symptoms in the fatal and nonfatal serious categories for 1998 vaccine administrations were similar to 1997 reports. Severity profiles for IPV and OPV reports in infants 1 to 3 months old and 4 to 6 months old, corresponding to first- and second-dose recipients, were remarkably similar. The frequency of symptoms listed on IPV reports categorized as fatal or serious was examined by age, vaccine combinations, and time period, and the distribution of symptoms was similar for ages 1 to 3 months and 4 to 6 months. In the postrecommendation period, the 10 most frequent symptoms reported with IPV were also reported with OPV in either similar or lower relative frequency. During the postrecommendation period, safety profiles for infants 4 to 6 months old showed a 2.5% higher proportion in the allergic reaction category for IPV than for OPV, but none of the allergic reaction reports indicated anaphylaxis. In general, the distribution of symptom groupings was not markedly different for IPV compared with OPV. No cases of VAPP were reported after the administration of IPV, whereas 5 VAPP cases were reported after the administration of OPV.

CONCLUSIONS

Although VAERS is subject to the limitations of most passive surveillance systems, the large number of reports and national coverage provide a unique database for monitoring vaccine safety. There was a marked increase of IPV reports in VAERS after 1996, consistent with implementation of the Advisory Committee on Immunization Practices recommendation for the sequential IPV/OPV poliovirus vaccination schedule. Given the increased use of IPV, a review of potential adverse events in VAERS compared IPV with OPV reports both before and after the introduction of the sequential vaccination schedule. Vaccine safety surveillance indicated no adverse events patterns of potential concern following the use of IPV in infants after the introduction of the sequential vaccination schedule. Ongoing surveillance is documenting a decrease in VAPP. These findings provide useful information to support the Advisory Committee on Immunization Practices recommendation, made in 1999, to shift to an all-IPV schedule.

Molecular epidemiology of Bordetella pertussis by pulsed-field gel electrophoresis profile: Cincinnati, 1989-1996

Reported cases of pertussis have increased in the United States, with peaks occurring every few years. Bordetella pertussis isolates collected in Cincinnati from 1989 to 1996 were analyzed with pulsed-field gel electrophoresis (PFGE), to evaluate trends. Among 496 isolates, 30 PFGE profiles were identified; 32% were CYXXI-010, the profile that predominated each year. Eighteen profiles (198 strains) were identified in 1989-1992, 20 profiles (197 strains) were identified during the 1993 epidemic, and 11 profiles (101 strains) were identified in 1994-1996. From 1989 to 1996, among 42 patients, isolates from household members in 17 (89%) of 19 households had concordant PFGE profiles. There was no association between PFGE profile and seasonality, age, and hospitalization or pneumonia in infants <1 year old. The 1993 epidemic was associated primarily with an increased prevalence of PFGE profiles that circulated before and after 1993, which suggests that the epidemic was due to factors other than the emergence of a novel B. pertussis strain.

Secular trend of earlier onset of menarche with increasing obesity in black and white girls: the Bogalusa Heart Study

Secular trends in onset of menarche and obesity were examined 14 years apart in two biracial (black-white) cohorts of girls aged 8 to 17 under study for cardiovascular risk. The first cohort (N=1,190, 64% white) was examined in 1978-1979, the second (N=1,164, 57% white) in 1992-1994. The second cohort was heavier in terms of body weight and Rohrer index (weight/height3) than the first (P<0.001), except among black girls aged 12 to 13 years. Subscapular skinfold thickness increased in the second cohort of all ages (P<0.0001), while increases in triceps skinfold were less marked. The onset of menarche occurred at an earlier age in the second cohort compared with the first cohort (P<0.0001), both in black girls (11.4+/-1.3 vs 12.3+/-1.4 years) and white girls (11.5+/-1.3 vs 12.3+/-1.3 years). Furthermore, twice as many girls in the second cohort had reached menarche by ages younger than 12 years (P<0.001). All of these obesity measures were significantly associated with the age of menarche in both cohorts (P<0.001) adjusting for height, race and age at examination. These results suggest that this secular trend toward increasing frequency of early onset of menarche may be the result of increasing obesity noted in girls of both races. Since increases in body fatness and related early onset of menarche are risk factors for disorders in adult life including cardiovascular disease and breast cancer, the secular trend in the increasing incidence of obesity throughout the United States is becoming a major public health problem.

Black-white differences in postprandial triglyceride response and postheparin lipoprotein lipase and hepatic triglyceride lipase among young men

Black-white differences in serum triglycerides and high-density lipoprotein (HDL) cholesterol concentrations are known. However, the metabolic basis for these differences is not clear. This study determined the magnitude of postprandial triglyceride concentrations, lipoprotein lipase and hepatic triglyceride lipase activities in postheparin plasma, and serum lipid and lipoprotein cholesterol concentrations in healthy young adult black men (n = 22) and white men (n = 28). Postprandial triglyceride concentrations were measured at 2, 3, 4, 5, 6, and 8 hours after a standardized test meal. Serum lipid and lipoprotein cholesterol concentrations were similar between the races in this study sample. However, incremental (above basal) increases in triglycerides were significantly greater in white men versus black men at 2 hours (P = .01) and tended to be greater at 3 hours (P = .12) and 4 hours (P = .06) after the fat load. In a multivariate analysis that included age, race, apolipoprotein E (apoE) genotype, fasting triglycerides, obesity measures, alcohol intake, and cigarette use, fasting triglycerides (P = .04) and, to a lesser extent, race (P = .07) were associated independently with the 2-hour incremental increase in triglycerides. The incremental triglyceride response correlated inversely with HDL cholesterol in both whites (r = -.38, P = .04) and blacks (r = -.59, P = .004). Lipoprotein lipase activity was higher (P = .049) and hepatic triglyceride lipase activity lower (P = .0001) in black men compared with white men; racial differences persisted after adjusting for the covariates. While lipoprotein lipase activity tended to associate inversely with the postprandial triglyceride concentration in both races, hepatic triglyceride lipase activity tended to correlate positively in whites and inversely in blacks. These results suggest that compared with whites, blacks may have an efficient lipid-clearing mechanism that could explain the black-white differences in lipoproteins found in the population at large.

Natural history of Helicobacter pylori infection in childhood: 12-year follow-up cohort study in a biracial community

We assessed the pattern of acquisition and loss of Helicobacter pylori infection in a cohort of 212 children from a biracial community with a homogeneous socioeconomic class. The children were followed over 12 years (1973-1974 to 1985-1986) from childhood to young adulthood. H. pylori status was assessed by the presence of serum IgG antibodies to H. pylori. At ages 7-9, 19% of children had H. pylori infection (40% of blacks vs. 11% of whites; P = .0001); 12 years later, 33% were seropositive. The higher prevalence among blacks remained (P = .0001). During follow-up, 22% of children became infected; the rate of acquisition was fourfold greater among blacks than among whites (P = .001). Over the 12-year period, infection was lost in 50% of whites compared with 4% of blacks who either remained infected or became reinfected. H. pylori infection in childhood is affected by both acquisition and loss of infection in different ethnic groups. This observation is critical for understanding the epidemiology and transmission of H. pylori infection.

The importance of serum lipoprotein (a) as an independent risk factor for premature coronary artery disease in middle-aged black and white women from the United States

OBJECTIVE

To determine the association of serum levels of lipoprotein (a) (Lp(a)) with coronary artery disease (CAD) in relation to other risk factor variables in black and white women.

DESIGN

Retrospective case-control study.

SETTING

Community of Bogalusa, Louisiana and Cardiac Catheterization Laboratory at the Medical Center of Louisiana, New Orleans, USA.

SUBJECTS

The study included 47 female cases (52% black; mean +/- SD age: 50.8 +/- 6.3 years) with confirmed myocardial infarction (MI) or at least 75% blockage of one or more major epicardial coronary arteries determined by angiography, and 55 controls (60% black; mean +/- SD age: 49.6 +/- 7.9 years) with no high grade obstructive lesion (< 50% blockage) and no history of CAD.

MAIN OUTCOME MEASURES

Lipoprotein variables, homocysteine, body mass index and cigarette smoking.

RESULTS

In the whole group, mean values of Lp(a), total cholesterol, low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (apoB) and very-low-density lipoprotein cholesterol (VLDL-C) were higher (P < 0.05-0.001) and apoA-I was lower (P < 0.05) in cases than in controls. The multivariate logistic regression analysis showed elevated levels of Lp(a) (> 500 mg L-1) and LDL-C (> 3.36 mmol L-1) as strong independent risk factors, with odds ratios (with 95% confidence intervals) of 13.6 (4.00-46.30) and 4.64 (1.31-16.49), respectively. ApoA-I, with an odds ratio of 0.11 (0.02-0.64), was a protective factor only at high levels (> 53.6 mumol L-1). Between races, significant odds ratios were noted in the black women for Lp(a) (OR = 15.98; P < 0.01) and LDL-C (OR = 7.69; P < 0.05) and in the white women for only Lp(a) (OR = 15.23; P < 0.01).

CONCLUSIONS

Lp(a) is an important risk factor for CAD both in black and in white women.

Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study

BACKGROUND

In adults, cardiovascular risk factors reinforce each other in their effect on cardiovascular events. However, information is scant on the relation of multiple risk factors to the extent of asymptomatic atherosclerosis in young people.

METHODS

We performed autopsies on 204 young persons 2 to 39 years of age, who had died from various causes, principally trauma. Data on antemortem risk factors were available for 93 of these persons, who were the focus of this study. We correlated risk factors with the extent of atherosclerosis in the aorta and coronary arteries.

RESULTS

The extent of fatty streaks and fibrous plaques in the aorta and coronary arteries increased with age. The association between fatty streaks and fibrous plaques was much stronger in the coronary arteries (r=0.60, P<0.001) than in the aorta (r=0.23, P=0.03). Among the cardiovascular risk factors, body-mass index, systolic and diastolic blood pressure, and serum concentrations of total cholesterol, triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol, as a group, were strongly associated with the extent of lesions in the aorta and coronary arteries (canonical correlation [a measure of the association between groups of variables]: r=0.70; P<0.001). In addition, cigarette smoking increased the percentage of the intimal surface involved with fibrous plaques in the aorta (1.22 percent in smokers vs. 0.12 percent in nonsmokers, P=0.02) and fatty streaks in the coronary vessels (8.27 percent vs. 2.89 percent, P=0.04). The effect of multiple risk factors on the extent of atherosclerosis was quite evident. Subjects with 0, 1, 2, and 3 or 4 risk factors had, respectively, 19.1 percent, 30.3 percent, 37.9 percent, and 35.0 percent of the intimal surface covered with fatty streaks in the aorta (P for trend=0.01). The comparable figures for the coronary arteries were 1.3 percent, 2.5 percent, 7.9 percent, and 11.0 percent, respectively, for fatty streaks (P for trend=0.01) and 0.6 percent, 0.7 percent, 2.4 percent, and 7.2 percent for collagenous fibrous plaques (P for trend=0.003).

CONCLUSIONS

These findings indicate that as the number of cardiovascular risk factors increases, so does the severity of asymptomatic coronary and aortic atherosclerosis in young people.

Sibling aggregation of low- and high-density lipoprotein cholesterol and apolipoproteins B and A-I levels in black and white children: the Bogalusa Heart Study

OBJECTIVE

To examine sibling aggregation of low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), apolipoprotein (apo) B and apo A-I in white versus black school-aged children.

DESIGN

Study subjects included 790 full sibships representing 1305 sibpairs aged 5 to 17 years from a biracial community.

METHODS

Intraclass correlation coefficients estimated by analyses of covariance were used to examine sibling aggregation of LDL-C, HDL-C, apo B and apo A-I. The influences of obesity and other lifestyle variables on sibpair differences in LDL-C, HDL-C, apo B and apo A-I were evaluated in black and white children by stepwise multiple regression analyses.

RESULTS

Intraclass correlation coefficients for LDL-C and apo B in black children were lower than those in white children (0.17 and 0.11 versus 0.32 and 0.33, respectively, P < 0.05-0.01); no racial difference was found for HDL-C and apo A-I. Intraclass correlation coefficients for LDL-C and HDL-C were similar to that of apo B and apo A-I, respectively and the sibpair differences in LDL-C and HDL-C were correlated with those of apo B and apo A-I, respectively (P < 0.01). Obesity exerted a greater effect on sibpair differences in LDL-C, HDL-C and apo B in black children than in white children.

CONCLUSIONS

These results suggest that the hereditary influence on LDL-C and apo B is more important in white children than in black children, especially for apo B. Further, genetic influence on LDL-C versus apo B, or HDL-C versus apo A-I may be similar.

Longitudinal changes in cardiovascular risk from childhood to young adulthood in offspring of parents with coronary artery disease: the Bogalusa Heart Study

CONTEXT

Although the association between parental coronary artery disease (CAD) and its risk factors in the offspring is known, the timing and the course of development of risk factors from childhood to adulthood in the offspring is not known.

OBJECTIVE

To examine the association between parental CAD and longitudinal changes in risk factor profile from childhood to young adulthood in offspring.

DESIGN

Cohort study.

SETTING

Bogalusa, La, a semirural, biracial community.

PARTICIPANTS

Individuals with clinically verified parental history of CAD (n=271) vs those without such a history (n = 1253) Mean age at first CAD event was 50 years for fathers and 52 years for mothers.

MAIN OUTCOME MEASURES

Body mass index, subscapular skinfolds, blood pressure, and triglyceride, cholesterol (total, very low-density lipoprotein [VLDL-C], low-density lipoprotein [LDL-C], and high-density lipoprotein [HDL-C] cholesterols), glucose, and insulin levels.

RESULTS

The offspring of parents with CAD were consistently overweight beginning in childhood. Their levels of total serum cholesterol, LDL-C, plasma glucose, and insulin became significantly higher at older ages, because of a higher rate of increase in these risk factors over time. In adulthood, the offspring with a positive parental history had a higher prevalence of obesity (body mass index >85th percentile in the National Health and Nutrition Examination Survey I, 35% vs 26%, P=.01), elevated total cholesterol (>6.2 mmol/L [240 mg/dL], 8.4% vs 4.8%, P=.05) and LDL-C levels (>4.1 mmol/L [160 mg/dL], 12.4% vs 4.7%, P=.05), and hyperglycemia (glucose, >6.6 mmol/L, 2.7% vs 0.4%, P<.001), as well as a higher coexistence of these conditions (P=.01). Further, the prevalence of dyslipidemia, either involving only LDL-C or LDL-C in combination with HDL-C or triglycerides or both, was significantly higher in the adult offspring with parental CAD.

CONCLUSIONS

Offspring of parents with early CAD were overweight beginning in childhood and developed an adverse cardiovascular risk factor profile at an increased rate. These observations have important implications for prevention and intervention.

The relationship of conjoint traits of dyslipidemias between young offspring and their parents in a community-based sample

BACKGROUND

The relationship of dyslipidemias between young offspring and their parents was examined to evaluate its usefulness in predicting lipid disorders among parents and children.

METHODS

Young offspring ages 5-17 years and their parents were studied in a community-based sample of 477 families. The dyslipidemias were defined as: (1) isolated high low-density lipoprotein cholesterol (LDL-C); (2) isolated high triglycerides (TG) and/or low high-density lipoprotein cholesterol (HDL-C); and (3) combined, involving both above.

RESULTS

Children of parents with a given dyslipidemia type had the highest frequency of the same disorder (P < 0.001 to P < 0.05). In discriminant analyses only the corresponding disorders in their parents were selected into the models as significant predictors after controlling parental obesity. In terms of sensitivity, 54.8, 50.0, 66.7, and 69.1% of offspring could be correctly predicted for isolated TG/HDL-C, isolated LDL-C, combined, and any type of disorder, respectively, by the corresponding disorders in both parents. Likewise, the predictability of parent's dyslipidemia from their children's disorder was also modest.

CONCLUSION

The conjoint dyslipidemias have familial basis to provide rationale for parents or children to determine their own risk status; however, sensitivity and positive predictive values are not high enough to be useful as a selective screening tool.

Serum bilirubin distribution and its relation to cardiovascular risk in children and young adults

There is evidence that bilirubin functions as an endogenous tissue protector by its antioxidant and anti-complement actions, properties that are relevant to atherogenesis. Serum bilirubin distribution and its relation to cardiovascular risk were examined in 4156 individuals aged 5-30 years from a biracial (black white) community. Bilirubin levels showed significant differences related to race (whites > blacks) and sex (males > females, except in 5-10 year olds). In males the levels increased with age up to 24 years, while in females the changes were less conspicuous. Both adiposity and cigarette smoking associated independently and inversely with bilirubin. In addition, serum bilirubin correlated positively with HDL cholesterol and inversely with triglycerides, VLDL cholesterol, LDL cholesterol, insulin, glucose and systolic blood pressure although these correlations were significant only in certain age-race-sex groups. Offspring with a parental history of heart attack or hypertension had consistently lower bilirubin levels than those without such parental history. Thus, bilirubin may be an inverse risk factor for cardiovascular disease.

Verification of parental history of coronary artery disease and associations with adult offspring risk factors in a community sample: the Bogalusa Heart Study

Positive parental history of coronary artery disease (CAD) (myocardial infarction, angina, angioplasty, bypass surgery) reported by 371 of 1,930 black and white adults aged 18 to 31 years in 1988 to 1991 in the Bogalusa Heart Study was verified by interviewing parents or next-of-kin. Error rates in reporting information concerning parental CAD and risk factors in offspring with a positive and negative parental history of CAD were examined. The 371 subjects who reported a positive parental history represented 304 families. Parental CAD could not be verified in 43 (14.1%) instances, and false-positive reports occurred in 45 (14.8%) cases. Among 216 families with confirmed CAD histories, the father had CAD in 175 (81.0%) cases and the mother in 70 (32.4%) cases. Both parents had CAD in 29 (13.4%) families. Of the parents with CAD, 46% of the fathers and 25% of the mothers died. The mean age at clinical onset of CAD was 51 years. Offspring with a confirmed positive parental history (n = 271) had significantly higher (P < 0.05) adjusted serum total and low-density lipoprotein cholesterol, plasma insulin and glucose, body mass index, and triceps and subscapular skinfolds than subjects with a negative parental history (n = 1,253). Those with an unconfirmed positive parental history (n = 51) had higher mean plasma insulin and serum high-density lipoprotein levels than those with a negative parental history; low-density lipoprotein levels were similar. Family history of CAD remains a useful indicator for screening adults at risk of developing CAD. An unverified family history may underestimate the importance of particular risk factors in epidemiologic studies.

Influence of apolipoprotein E polymorphism on the tracking of childhood levels of serum lipids and apolipoproteins over a 6-year period. The Bogalusa Heart Study

The influence of apolipoprotein (apo) E polymorphism on the tracking of serum lipoprotein variables over a 6-year follow-up period was examined in 442 individuals aged 5-15 years at baseline. The apo E phenotype-specific differences in total cholesterol and low-density lipoprotein (LDL) cholesterol levels persisted in the study cohort at baseline and follow-up examinations. However, the correlations of baseline versus follow-up levels of total cholesterol and LDL cholesterol varied according to the apo E phenotype group, with the apo E2 group, carrying E2/2 and E3/2 phenotypes, showing highest correlation for these variables (r = 0.73 - 0.74) and the apo E4 carrying E3/4 and E4/4 phenotypes the lowest (r = 0.48 - 0.59). The tracking correlation for LDL cholesterol in the apo E2 group was different form that of the other phenotype groups (P < 0.05). In terms of persistence in ranks over time, of the individuals who were in the highest quartile of LDL cholesterol at baseline none of those in the apo E2 group, 63% of those in the apo E3 group carrying E3/3 phenotype, and 60% of those in the apo E4 group maintained this high rank at follow-up; corresponding values for persistence in ranking at the lowest quartile over time were 82% for the apo E2 group, 57% for the apo E3 group, and 33% for the apo E4 group. Further, in a multiple regression model, apo E phenotype was retained as a predictor variable only in the case of LDL cholesterol. Thus, apo E polymorphism influences not only the level of LDL cholesterol in childhood, but also its tracking at least over a 6-year period.

Use of weight-for-height indices in children to predict adult overweight: the Bogalusa Heart Study

OBJECTIVE

To compare the body mass index (BMI) (weight/height2) and the Ponderal index (PI) (weight/height3) in childhood as predictors of adult overweight in a biracial group of children.

DESIGN

Prospective, 15-y follow-up.

SUBJECTS

835 children aged 10-15 y at baseline.

MEASUREMENTS

Weight in kg and height in m.

OUTCOME VARIABLE

Overweight, defined as a BMI greater than 27 kg/m2 in young adults.

RESULTS

Overall, the BMI and the PI at baseline were identically correlated with the BMI at follow-up (r = 0.64, p < 0.001). However, the predictions of overweight based on each index were distinctively affected by age, sex and race. The probability of adult overweight among 10-year old children was greater than 0.5 (50% overweight threshold) if their BMI exceeded 17 kg/m2 in black girls, 20 in white girls and 18 in boys of either race. Similarly, the 50% BMI overweight thresholds among 15-year-old children were 23 kg/m2 for black girls, 25 for white girls and 22 for boys of either race. The 50% PI overweight thresholds (in kg/m2) were 12 and 14 for 10-year-old black girls and white girls, respectively; and 14 and 16 for 15-year-old black girls and white girls, respectively. Among boys, the 50% PI threshold was 13 kg/m3 regardless of age or race.

CONCLUSION

The BMI and the PI in childhood were both useful in assessing sex-and race-specific risks of adult overweight. However, assessments based on the Ponderal index were less affected by age and race than those based on the BMI, particularly among boys. Hence, to establish general weight goals for children, aimed at preventing adult obesity, the PI could be a much better choice than the BMI.

Usefulness of childhood low-density lipoprotein cholesterol level in predicting adult dyslipidemia and other cardiovascular risks. The Bogalusa Heart Study

OBJECTIVE

To examine the usefulness of childhood low-density lipoprotein cholesterol (LDL-C) measurement for predicting future dyslipidemia and other cardiovascular risk in adulthood.

METHODS

A longitudinal cohort over 15 years was identified from a community study of the natural course of arteriosclerosis: 1169 individuals (34% black), aged 5 to 14 years, were included at initial study.

RESULTS

Levels of lipoprotein variables in childhood were associated with levels in adulthood, more strongly for total cholesterol (r = .4-.6) and LDL-C (r = .4-.6) than for high-density lipoprotein cholesterol (r = .2-.4) and triglycerides (r = .1-.4). In a stepwise multiple regression, the childhood level was most predictive of the adulthood level, followed by change in body mass index (weight in kilograms/height in meters squared) from childhood to adulthood, with explained variability (R2) of .29, .30, .27, and .19 for total cholesterol, LDL-C, high-density lipoprotein cholesterol, and triglycerides, respectively. Adulthood dyslipidemia, as defined by the National Cholesterol Education Program criterion, was best predicted by childhood LDL-C level among other lipoprotein variables. Compared with subjects with acceptable childhood risk (LDL-C level, < 2.84 mmol/L [< 110 md/dL]), those (6%) with high childhood risk (LDL-C level, > or = 3.36 mmol/L [> or = 130 mg/dL]) not only had a higher prevalence of dyslipidemic total cholesterol level (24%, 8.3-fold), LDL-C level (28%, 5.4-fold), triglyceride level (7%, sevenfold) and lower HDL-C level (14%, 2.1-fold), but also had a significantly higher (P < .05) prevalence of obesity (43%, 1.6-fold) and hypertension (19%, 2.4-fold). In addition, if the childhood LDL-C elevation (> 90th percentile) was persistent, the prevalence of adult dyslipidemia would be markedly increased (P < .001).

CONCLUSIONS

Adverse levels of LDL-C in childhood persist over time, progress to adult dyslipidemia, and relate to obesity and hypertension as well. National Cholesterol Education Program guidelines to classify cardiovascular risk on the basis of LDL-C level are helpful in targeting individuals at risk early in life.

The relation of apolipoprotein E polymorphism to multiple cardiovascular risk in children: the Bogalusa Heart Study

Apolipoprotein (apo) E is an important genetic determinant of serum lipoprotein concentrations and coronary artery disease risk. Multiple cardiovascular risk factors in addition to lipoproteins were examined by apoE phenotype in a random subsample (n = 746) of 8-17-year old children from a total community. The apoE2 group (n = 58) carrying E2/2 and E3/2 phenotypes showed lower age-, race- and sex-adjusted mean values of body mass index (BMI: weight/height2), percent body fat, fasting plasma insulin and LDL cholesterol, and a higher value of HDL cholesterol than the apoE3 group (n = 476) carrying the E3/3 phenotype (P < 0.01). In contrast, the apoE4 group (n = 212) carrying E4/4 and E3/4 phenotypes displayed higher values of total cholesterol and LDL cholesterol (P < 0.01). Both insulin and BMI, which correlated with each other, showed an association to triglycerides and systolic blood pressure in all three phenotype groups; whereas only BMI associated with LDL cholesterol, total cholesterol to HDL cholesterol ratio and diastolic blood pressure in all three phenotype groups (P < 0.05 to P < 0.0001). A marked increase in the prevalence of clustering of adverse (top tertile) total cholesterol to HDL cholesterol ratio with increased levels (top tertile) of one or two risk factors (BMI, insulin, and systolic blood pressure) occurred in the apoE3 and apoE4 groups, especially in the latter (P < 0.01 to P < 0.0001), but not in the apoE2 group. The prevalence of parental history of heart attack and diabetes mellitus among the three phenotype groups paralleled this trend. Thus, the risk status of apoE polymorphism may be associated with a constellation of cardiovascular risk factors in early life.

Utility of an automatic instrument for blood pressure measurement in children. The Bogalusa Heart Study

The Dinamap 845XT automatic blood pressure monitor, Dinamap 8100 (an update model), and two mercury sphygmomanometers were compared in 417 school-aged children examined in the spring of 1992 as part of the Bogalusa Heart Study. This study was conducted in the nearby community of Franklinton, Louisiana, to verify data obtained as part of a cross-sectional survey (1987 to 1988) of school-aged children in Bogalusa. Systolic blood pressure levels were on the average 3 mm Hg higher on the Dinamap instruments than on the sphygmomanometers. Mean levels of diastolic blood pressure using either Dinamap instrument were slightly higher until eight years of age and then were considerably lower than mercury sphygmomanometer fourth phase readings. Diastolic blood pressure levels on the Dinamap 8100 were 4 mm Hg lower than on the Dinamap 845XT. Height was identified as the predominant predictor variable of differences in diastolic blood pressure between the mercury sphygmomanometer and either Dinamap instrument. A 10% random sample of children was reexamined each screening day in the cross-sectional survey to estimate measurement errors. The diastolic readings of the Dinamap 845XT had a lower intraclass correlation (0.68) compared to the mercury sphygmomanometers (0.83 fourth phase and 0.76 fifth phase). The Dinamap offers the ease of measuring systolic blood pressure although the diastolic blood pressure appears to be biased and especially low, particularly on the new 8100 model.

Adolescent overweight is associated with adult overweight and related multiple cardiovascular risk factors: the Bogalusa Heart Study

Overweight in adolescence is considered an important predictor of long-term morbidity and mortality. The impact of adolescent overweight on adult overweight and related multiple cardiovascular risk factors was examined in a biracial (black-white) cohort (N = 783) who participated in two cross-sectional surveys as adolescents aged 13 to 17 years and as young adults aged 27 to 31 years. The cohort was categorized as adolescent-onset adult overweight (N = 110) or lean (N = 81) according to age-, race-, and sex-specific body mass index (BMI) greater than the 75th percentile or between the 25th and 50th percentiles on both surveys. The risk for overweight adolescents to remain overweight as young adults ranged from 52% in black males to 62% in black females. As young adults, the overweight cohort showed adverse levels of body fatness measures, systolic and diastolic blood pressure, lipoprotein cholesterol, insulin, and glucose as compared with the lean cohort (P < .01 to P < .0001). The prevalence of clinically recognized hypertension and dyslipidemia increased 8.5-fold and 3.1- to 8.3-fold, respectively, in the overweight cohort versus the lean cohort (P < .05 to P < .0001). The prevalence of parental history of diabetes mellitus and hypertension increased 2.4-fold (P < .01) and 1.3-fold (P < .05), respectively, in the overweight cohort. Clustering of adverse values (> 75th percentile) for the total cholesterol to high-density lipoprotein (HDL) cholesterol ratio, insulin level, and systolic blood pressure occurred only among the overweight cohort (P < .0001). Thus, excess weight in adolescence persists into young adulthood, and has a strong adverse impact on multiple cardiovascular risk factors, requiring primary prevention early in life.

Epidemiology of hypertension from childhood to young adulthood in black, white, and Hispanic population samples

RESEARCHERS RECORDED BLOOD PRESSURE LEVELS of children and adolescents in the Bogalusa Heart Study (black and white populations) and in the Brooks Country Study (Hispanic population). Hispanic children had smaller stature, while whites and Hispanics tended to be fatter than blacks in childhood. In Bogalusa, black boys showed higher blood pressure levels. Hispanic girls showed lower systolic blood pressure than the other ethnic groups. In cultures with a high prevalence of hypertension, such as blacks in the United States, it is important to understand the effect of environmental factors like dietary intake and electrolytes and obesity on the control of hypertension.

Obesity studies in Bogalusa

Obesity is a determinant of cardiovascular risk factors in childhood, adolescence, and adulthood. Since the inception of the Bogalusa Heart Study, various anthropometric measures of body size and mass have been obtained. Attention is given to identifying the distribution for various obesity measures, secular trends in obesity, clustering of obesity with other risk factors, and obesity during childhood as a predictor of risk factors during young adulthood. Race, gender, and age differences offer clues to etiology of future clinical disease and cardiovascular risk. Innovative programs are needed to alter the secular trend over the past 20 years toward increased obesity. General wellness must include a reduction in obesity.

Risk factors and atherosclerosis in youth autopsy findings of the Bogalusa Heart Study

The Collaborative Pathology Study is one of the most impressive programs of the Bogalusa Heart Study. Attempts are made to obtain complete and uniform necropsy coverage of all decreased young people who may have been examined in the Bogalusa Heart Study. Since 1978, autopsy specimens have been collected from 190 deaths, representing 65% of all known deaths in the study age category. The relation of antemortem risk factors for cardiovascular disease to early atherosclerotic lesions in the aorta and coronary arteries was assessed in those individuals previously examined in the Bogalusa Heart Study (N = 59). Aortic fatty streaks were strongly related to both total and low-density lipoprotein (LDL) cholesterol (r = 0.62, P < 0.0001 for each association), and were inversely correlated with the ratio of high-density lipoprotein (HDL) cholesterol to LDL plus very-low-density lipoprotein (VLDL) cholesterol (r = -0.29, P < 0.01). Coronary artery fatty streaks were associated with elevated total cholesterol, LDL cholesterol, VLDL cholesterol, and systolic blood pressure. Higher levels of LDL and VLDL cholesterol, triglycerides, systolic and diastolic blood pressure, and a lower ratio of HDL to LDL plus VLDL were found in those people with coronary artery fibrous plaques. Microscopy offered additional information about the characteristics of the aortic and coronary arterial intimal disease. Histologic observations have confirmed some of the relationships indicated with gross observations and show the complexity of this disease process. These findings emphasize the importance of an approach to preventive cardiology early in life.

Rationale to study the early natural history of heart disease: the Bogalusa Heart Study

The Bogalusa Heart Study now establishes that precursors of adult cardiovascular diseases begin in childhood. The clearest evidence comes from autopsy studies that show coronary atherosclerotic lesions occur in early life and are strongly associated with very-low-density lipoprotein cholesterol, systolic and diastolic blood pressure, and obesity, and have an inverse relationship with high-density lipoprotein cholesterol. Observations of cardiovascular risk factors span a period of life from birth to 31 years of age, and longitudinal studies span a 15-year period. Risk factor variables tend to persist over time, "track." Although tracking is best for height and weight, low-density lipoprotein cholesterol and serum total cholesterol track at a high order; blood pressure tends to track at a lower order. Obesity and body fatness have an adverse influence on risk factors in children, just as noted in adults, with central obesity becoming more obvious after puberty, and having a greater adverse effect on risk factors. The emergence of abnormal levels of risk factors by adult criteria begins to occur in young adults, and is not evident in childhood. Retrospective studies, interestingly, for obesity, higher blood pressure, and dyslipidemia reveal evidence of their presence already in childhood. These findings have strong implications for undertaking prevention in early life.

Comparison of fourth and fifth Korotkoff diastolic blood pressures in 5 to 30 year old individuals. The Bogalusa Heart Study

The use of fourth phase Korotkoff sound (K4) versus fifth phase Korotkoff sound (K5) for the determination of diastolic blood pressure (DBP) has been a subject of controversy since the indirect method of determining arterial blood pressure was described. Using data from the Bogalusa Heart Study, we evaluated the differences between K4 and K5 (K4-K5) from 4633 subjects 5 to 30 years of age examined between 1987 and 1991. The overall mean difference between K4 and K5 was 9.9 +/- 5.6 mm Hg (mean +/- SD). The average difference was highest in 5 to 8 year olds, where it measured 12.3 +/- 5.5 mm Hg. The average K4-K5 difference fell with increasing age and reached a value of 6.3 +/- 2.6 mm Hg by 25 years of age. For all race/sex groups, the youngest two age groups differed statistically from the oldest age groups in K4-K5 difference (P < .006). There were significant differences between blacks and whites (P < .015) and between men and women (P < .001) for subjects between 13 and 17 years of age. Additional analyses were performed with individuals having K5 = 0 added to yield an expanded population of 5117 persons. Overall, 9.5% had at least one of six measurements of K5 = 0 and most were young subjects: 27% of children 5 to 8 years and 13% of children 9 to 12 years. We conclude that by age 15 there may be no relevant clinical difference in K4-K5. However, in children, K4 and K5 should be recorded and K4 is a more reproducible measure of diastolic blood pressure.

The emergence of clinically abnormal levels of cardiovascular disease risk factor variables among young adults: the Bogalusa Heart Study

BACKGROUND

The Bogalusa Heart Study, a long-term epidemiologic investigation of the early natural history of atherosclerosis, was conducted for the first time in 1973-1974 on children from birth through the age of 14 in a biracial (black-white) population.

METHODS

The emergence of clinically recognizable abnormalities (obesity, hypertension, and hyperlipidemia) was studied in 1,928 young adults, ages 19-32 years, examined in the 1988-1991 survey.

RESULTS

The occurrence of morbid levels of cardiovascular disease risk factors varied by race and gender. The prevalence of severe overweight, body mass index > or = 31.1 kg/m2 for males and > or = 32.3 kg/m2 for females, was much higher for black women (20.1% than for white women (8.7%), black men (14.0%), or white men (11.7%). The frequency of hypertension [systolic blood pressure (BP) > or = 140 mm Hg, diastolic BP > or = 90 mm Hg, or treatment for high BP] was greatest for black women (13.9%) versus black men (10.1%), white men (6.2%), or white women (5.0%). Approximately 9.5% of the men and 6% of the women had elevated LDL cholesterol ( > or = 160 mg/dl), while elevated triglycerides ( > or = 250 mg/dl ranged from 0% in black females to 7.4% in white males. Dyslipoproteinemia related to HDL cholesterol ( < or = 35 mg/dl) was more marked among white men (16%) compared with other groups (approximately 4%). Correlations for risk factors in a subgroup of 1,587 individuals initially surveyed as children in 1973-1974 were examined as an indication of tracking over a 15-year period. Highly significant correlations were seen for obesity, blood pressure, and LDL cholesterol.

CONCLUSION

Early identification of adverse levels of cardiovascular disease risk factors defined by clinical experience should help to predict and prevent future cardiovascular disease morbidity and mortality.

Histologic features of atherosclerosis and hypertension from autopsies of young individuals in a defined geographic population: the Bogalusa Heart Study

Histologic features of arterial intima have been quantified at autopsy by morphometric methods in 66 individuals aged 6-30 years, in whom cardiovascular risk factors had been measured prospectively prior to death. Measures of serum cholesterol were found to correlate significantly with the extent of foam cell infiltration seen in paraffin sections and the intensity of lipid staining in frozen sections of the abdominal and thoracic segments of the aorta. A similar correlation in the coronary arteries was weak and inconsistent. Blood pressure was significantly correlated with foam cells and stainable lipid in the abdominal but not the thoracic segment of the aorta. A similar correlation in the coronary arteries was significant, but only in males, and most consistently in the black males. Intimal thickness of the coronary arteries showed sporadic and weak correlations with blood pressure and lipids; however, a strong and consistent correlation was seen between coronary intimal thickness and hyalinization of renal arterioles. With many statistical tests carried out on a limited data set, some particular details are, no doubt, spuriously significant; however, some persistent patterns are beginning to emerge. The reproducible findings support the concept that prospective measurements of blood pressure and serum lipids are associated with a degree of structural characteristics present in children and young adults. Moreover, the observed structural characteristics, specifically the deposition of lipids in the intima of coronary arteries and aorta, are likely to reflect variations in the rates of progression of atherosclerosis.

Association of fasting insulin level with serum lipid and lipoprotein levels in children, adolescents, and young adults: the Bogalusa Heart Study

OBJECTIVE

To assess whether circulating insulin is a major contributor to adverse lipid profiles during the transition from adolescence to young adulthood.

METHODS

The association between fasting insulin levels and serum lipid and lipoprotein levels was examined in a cross-sectional survey of 4136 young individuals aged 5 to 30 years from a biracial community.

RESULTS

Fasting insulin levels were strongly and positively correlated with serum triglyceride and very-low-density lipoprotein cholesterol levels and negatively correlated with high-density lipoprotein cholesterol levels in all age groups (5 to 11, 12 to 17, 19 to 24, and 25 to 30 years). An increasing impact of insulin level on low-density lipoprotein cholesterol level was observed in young adults aged 25 to 30 years. In multivariate analysis, fasting insulin level was associated with very-low-density lipoprotein cholesterol level for most of the age groups in both races independently of age, sex, glucose levels, obesity, cigarette smoking, and alcohol intake. The independent relationship to low-density lipoprotein cholesterol level persisted in young adults aged 25 to 30 years. The independent and negative association with high-density lipoprotein cholesterol level remained in whites aged 5 to 24 years and blacks aged 19 to 24 years. When individuals were divided into tertiles according to insulin concentration and subscapular skinfold thickness, the independent effect of insulin level and obesity on lipoprotein fractions was also noted. Furthermore, a stronger association of insulin level with lipoprotein fractions was observed in obese than in lean white males.

CONCLUSIONS

These data indicate that an increasing association of insulin levels with adverse lipoprotein levels in young adults, especially obese individuals, may have adverse consequence for adult cardiovascular diseases.

The relation of parental cardiovascular disease to risk factors in children and young adults. The Bogalusa Heart Study

BACKGROUND

Although cardiovascular risk factors relate to family history of cardiovascular disease, it is not clear how the relation changes from children to young adults.

METHODS AND RESULTS

As part of a community study for cardiovascular health, parental history of diseases was obtained from 8276 offspring 5 to 31 years old, 36% black and 64% white. Between 5- to 10-year-old children and 25- to 31-year-old young adults, prevalence of parental heart attack increased from 5% to 25%. More prevalent in blacks than in whites, parental stroke increased from 2% to 9% in whites versus 3% to 19% in blacks; parental diabetes rose from 7% to 19% in whites versus 9% to 33% in blacks; and parental hypertension increased from 26% to 59% in whites versus 40% to 72% in blacks. Offspring with parental heart attack history were significantly overweight after 10 years of age and showed elevated levels of total cholesterol, VLDL cholesterol, LDL cholesterol, insulin, and glucose after 17 years of age, irrespective of weight. Offspring of diabetic parents were significantly overweight, irrespective of age. They showed significant increases in levels of insulin, glucose, triglycerides, total cholesterol, VLDL cholesterol, and LDL cholesterol after age 24 years, independent of weight. Offspring of hypertensive parents displayed overweight regardless of age, higher levels of blood pressure after age 10 years, and elevations of triglycerides and VLDL cholesterol after age 24 years irrespective of weight. Analyzed by race and sex in young adults, parental heart attack related strongly to LDL cholesterol in the white offspring, especially white males, and to insulin in the black offspring. Parental diabetes showed a stronger association with overweight and glucose in black females. Also noted was the relation between parental hypertension and overweight in black females.

CONCLUSIONS

Parental history is an important surrogate measure for cardiovascular risk in the offspring. However, parental history information alone is not sufficient to designate younger children for selective screening for high cholesterol, because of the young age of parents.

Persistence of multiple cardiovascular risk clustering related to syndrome X from childhood to young adulthood. The Bogalusa Heart Study

BACKGROUND

Cardiovascular risk factors are known to persist over time and to cluster both in childhood and adulthood. Less is known about the persistence of clustering of multiple cardiovascular risk factors comprising adverse levels of systolic blood pressure, the ratio of total cholesterol to high-density lipoprotein cholesterol, and plasma insulin from childhood to young adulthood.

METHODS

In a community study of cardiovascular risk, 1176 individuals (52% female, 44% black) aged 5 through 17 years at baseline were followed up for 8 years.

RESULTS

Calculated as sum of the race-, sex-, and age-specific rankings of systolic blood pressure, insulin level, and total to high-density lipoprotein cholesterol ratio, the multiple risk index was shown to track in all four race-sex groups (year 1 vs year 8 correlations, .54 to .67). The magnitude of the overall multiple risk index tracking correlation (r = .64) was significantly stronger than that noted for individual risk factors (r = .34 to .57). Among subjects who were initially in the highest quintile of the multiple risk index, 61% remained there 8 years later. Tracking of the multiple risk index increased progressively with age and ponderal index (weight/[height3]). In a step-wise regression analysis, baseline multiple risk index score, baseline ponderal index, change in ponderal index, and change in height were predictive of the multiple risk index score on follow-up. These predictors explained 45% to 60% of the variability in multiple risk index scores among the race-sex groups.

CONCLUSIONS

The persistence of multiple cardiovascular risk clustering from childhood to adulthood and the impact of obesity in this regard point to the need for preventive measures aimed at developing healthy lifestyles early in life.

Epidemiology of early primary hypertension and implications for prevention: the Bogalusa Heart Study

Epidemiological studies of BPs in children and young adults over the past 20 years have contributed considerably to understanding the early onset of primary hypertension. Observations from autopsies and echocardiographic studies, together with long-term BP studies, of children clearly indicate that primary hypertension begins in early childhood. Although abnormal BP levels in children are much lower than the adult criteria used for clinical diagnosis of hypertension, essential hypertension is identifiable in early life. Complex haemodynamic and metabolic mechanisms related to essential hypertension are also being identified in childhood. The development of intervention programs in an attempt to prevent hypertension in its early phases suggests hypertensive cardiovascular disease is preventable. Environmental factors (improved dietary factors, altering electrolyte intake, prevention of obesity and increased activity levels) are critical elements to prevention. Children and young adults identified as high risk for hypertension need to be targeted for prevention of early cardiovascular renal disease. Also, as hypertension is so prevalent, attempts should be made to control environmental factors in the general public. Preventive programmes established by primary healthcare physicians, paediatricians and para-professionals can have a major impact on the reduction of hypertension and its complications of cardiovascular renal disease in the future.