Success and predictors of blood pressure control in diverse North American settings: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT).

CONTEXT: Blood pressure control (<140/90 mm Hg) rates for hypertension fall far short of the US national goal of 50% or more. Achievable control rates in varied practice settings and geographic regions and factors that predict improved blood pressure control are not well identified. OBJECTIVE: To determine the success and predictors of blood pressure control in a large hypertension trial involving a multiethnic population in diverse practice settings. DESIGN: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial is a randomized, double-blind, active-controlled clinical trial with a mean follow-up of 4.9 years. Participant enrollment began in February 1994 and follow-up was completed in March 2002. SETTING: A total of 623 centers in the United States, Canada, and the Caribbean. PARTICIPANTS: A total of 33,357 participants (aged > or =55 years) with hypertension and at least one other coronary heart disease risk factor. INTERVENTIONS: Participants were randomly assigned to receive (double-blind) chlorthalidone, 12.5-25 mg/d (n=15,255), amlodipine 2.5-10 mg/d (n=9048), or lisinopril 10-40 mg/d (n=9054) after other medication was discontinued. Doses were increased within these ranges and additional drugs from other classes were added as needed to achieve blood pressure control (<140/90 mm Hg). MAIN OUTCOME MEASURES: The outcome measures for this report are systolic and diastolic blood pressure, the proportion of participants achieving blood pressure control (<140/90 mm Hg), and the number of drugs required to achieve control in all three groups combined. RESULTS: Mean age was 67 years, 47% were women, 35% black, 36% diabetic; 90% were on antihypertensive drug treatment at entry. At the first of two pre-randomization visits, blood pressure was <140/90 mm Hg in only 27.4% of participants. After 5 years of follow-up, the percent controlled improved to 66%. Systolic blood pressure was <140 mm Hg in 67% of participants, diastolic blood pressure was <90 mm Hg in 92%, the mean number of drugs prescribed was 2.0+/-1.0, and the percent on > or =2 drugs was 63%. Blood pressure control varied by geographic regions, practice settings, and demographic and clinical characteristics of participants. CONCLUSIONS: These data demonstrate that blood pressure may be controlled in two thirds of a multiethnic hypertensive population in diverse practice settings. Systolic blood pressure is more difficult to control than diastolic blood pressure, and at least two antihypertensive medications are required for most patients to achieve blood pressure control. It is likely that the majority of people with hypertension could achieve a blood pressure <140/90 mm Hg with the antihypertensive medications available today.

Low birth weight: race and maternal nativity - impact of community income

BACKGROUND: The purpose of this article is to determine the effect of community income as a co-factor in the association of low birth weight, race, and maternal nativity in New York City. METHODS: New York City birth records, 1988 through 1994, provided data on maternal and infant characteristics. There were 274,121 white and 279,826 black mothers included in this study. Black mothers were classified as US-born (South and Northeast) and foreign-born (the Caribbean, South America, and Africa). Based on the 1990 US census income data, census tracts of the city were aggregated by tertile of per capita income as low-, middle-, and high-income communities. Incidence of low birth weight was estimated by race, maternal nativity in the city as a whole, and each income community. RESULTS: Overall, black women had a substantially higher risk of low birth weight infants (<2500 g) than did whites (13.1 percent vs 4.8 percent). Foreign-born black mothers had a birth weight advantage over US-born black mothers (10.0 percent vs 16.7 percent). After controlling for socioeconomic and medical characteristics, the risks of low birth weight for blacks compared with whites were 0.95 (95 percent confidence interval: 0.86-1.03) and 0.86 (0.69-1.02) for Caribbean- and African-born black mothers, respectively. Moreover, in low-income communities, compared with white mothers, the risks for Caribbean- and African-born black mothers were 0.88 (0.79-0.97) and 0.77 (0.61-0.96), respectively. By contrast, US and South American-born black mothers had a consistently higher risk of low birth weight infants, regardless of community income level. CONCLUSION: Low birth weight was significantly less frequent among whites than among blacks. However, this overall finding masked substantial variation among blacks, determined by maternal nativity and the income level of the community in which they lived. In fact, Caribbean- and African-born black mothers had birth outcomes generally similar to and, in poor communities, even more favorable than those for whites.(Au)

Influence of nativity on cancer mortality among black New Yorkers

BACKGROUND: Cancer is the second leading cause of death in U.S., and blacks have higher cancer death rates than whites. The authors conducted an analysis to determine the influence of birthplace on cancer mortality among blacks in New York City. METHODS: Death records for New York City from 1988 through 1992 were linked to the 1990 U.S. Census data. Age-adjusted cancer death rates by race and birthplace were computed. The experience of black residents born in the South and Northeast of the U.S. and in Caribbean countries were compared with that of New York City whites. RESULTS: The cancer mortality rate of blacks exceeded that of whites for males (512.6 vs 385.6 per 100,000 per year), but was similar for females (270.8 vs 270.6). However, cancer death rates of Southern-born black males (615.7) were substantially higher than those of black males born in the Northeast (419.1) or the Caribbean (352.4). Carcinomas of the lung, prostate, breast, and colon/rectum accounted for >50 percent of all cancer deaths. Lung carcinoma mortality varied greatly by birthplace, with Caribbean-born blacks (63.5 and 19.2 for males and females, respectively) having approximately one-third the death rates of Southern-born blacks (187.8 and 52.5 for males and females, respectively), and <50 percent that of New York City whites (108.7 and 53.2 for males and females, respectively). These differences were present in each age category, but were most pronounced among those age 45-64 years. In striking contrast, death rates from prostate carcinoma were highest in Caribbean-born black men, and this were especially apparent in persons age > or = 65 years. CONCLUSIONS: The generally higher cancer mortality of blacks compared with whites masks even greater intraracial heterogeneity revealed through stratification by birthplace. In general, Caribbean-born blacks are at lower risk of cancer mortality than other blacks, and whites, but their advantage does not hold for prostate carcinoma, for which Caribbean-born men had the highest mortality rate.(AU)

The impact of a family planning clinic in rural Jamaica

The impact of a family planning clinic functioning within a rural health centre has been evaluated through retrospective analysis of clinic records and a survey of women living in the communities served by the clinic. The results revealed a high degree of techniques, but rather poor patient adherence to therapy. During the period studied, there has not been a discernable reduction in the rate of fertility in this community as a result of the establishment of this clinic (AU)

The prevalence and persistence of lactose malabsorption among very young Jamaican children - abstract

Deficiency of intestinal lactase is widespread among otherwise healthy non-Caucasian adults. Limited available data suggest that very young children in some racial groups also may be affected. In a rural Jamaican district of Elderslie, where poverty, disease, and malnutrition are commonplace, dried skim milk was introduced as a food supplement for weanling children. These children, previously unaccustomed to milk-drinking responded to this new lactose source with frequent episodes of diarrhoea. To determine whether lactase deficiency might contribute to the apparent milk tolerance, a systematic study of lactose absorption was undertaken. Of the 600 children under 4 in the district, 94 were selected randomly for study. Capillary blood was drawn at 0, 15, 30, and 60 minutes after ingestion of 2 gms/kg of lactose. The Ames Reflection Meter/Dextrostix system was used to determine blood glucose. With a blood glucose rise of 25 mg percent or less as the criterion, 53 (56 percent) of the 94 children proved unable to absorb lactose. While two-thirds of the chilren under 12 months absorbed lactose, only one-third of those older enjoyed a similar capacity (p < .05). 9 of the 53 malbsorbers were being breast-fed at time of study. Similar tests in Kingston revealed 14 of 20 urban children were lactose malabsorbers. Neither sex, anthroponmetric status, milk consumption, symptoms of lactose intolerance, nor duration of breast-feeding correlated with lactose absorption. 52 of the original 53 malabsorbers at Elderslie were re-tested 6 months later and 11 (12 percent) displayed normal blood glucose rises. Particular important is the additional observation that this absorptive defect is at least sometimes reversible. Further study is required to relate these phenomena to other aspects of intestinal function and to determine their nutritional significance in children whose diet is marginal (AU)

A young-child nutrition programme in rural Jamaica

A programme to reduce the morbidity and mortality among young children in rural Jamaica has been developed. Locally recruited and trained health auxiliaries survey all children under five, diagnose malnutrition by application of anthropometric indices, and, according to a rigid protocol, treat the deficient children by education and demonstration at home. This economically feasible approach, relying entirely on local resources, has been followed for two years. The programme did not affect the prevalence of malnutrition, but did reduce young-child mortality by half.(AU)

A young child nutrition programme in rural Jamaica: the first year - abstract

At Elderslie, in rural Jamaica, 44 percent of all deaths occur among children not yet 5 years old, and 80 percent of these deaths are associated with malnutrition. A programme to improve young child nutrition was developed as part of a demonstration health project in which medical students play a significant role. The regular district health staff was augmented by five locally recruited and trained Community Health Aides (CHA). These aides obtained anthropometric and demographic data on all children under 5 (1160). Those weighing less than 75 percent of standard-for-age were identified for specific treatment. These youngsters are visited montly by a CHA to discuss and demonstrated sound dietary practice, Anthropometric follow-up and case-findings are carried out monthly in each village. The annual cost is less tha J$2.50 per child. Of the 68 malnourished children followed for 1 year, 63 percent are improved, 32 percent unchanged, and 5 percent declined (including 1 death). There were 12-13 deaths (age 5) in each of the past years, but only 6 deaths in the first year of the nutrition programme. The prevalence of Gomez Grades II & III malnutrition has fallen from 8.5 percent to 6.0 percent. Experience gained during the first year supports the thesis that Community Health Aides, operating within the context of a carefully defined protocol, can effectively influence young child nutrition with means locally available (AU)

A young child nutrition programme in rural Jamaica - abstract

An experimental approach to young child nutrition is described. This programme is part of a demonstration rural health project at Elderslie, Jamaica, sponsored by Cornell Medical College, the U.W.I. and the Jamaican Government. Information gained from experienced local health workers, vital statistic and a national nutrition survey had all suggested significant malnutrition among young children. Disease data obtained during the first year at Eldersile supported this preconception. In October, 1970, a child nutrition programme began. At first, demographic and anthropometric data were obtained on each child attending clinic. Then, in February, 1971 locally recruited and trained community health aides, supervised by nurses and medical students, applied this format in a field survey of the entire district. Examination of 716 children, 6 to 60 months old (80 percent of all eligible children) revealed, according to the Gomez Scale, that 33 percent suffered grade one, and 8 percent grade two or three malnutriton. The survey also showed that being a female, or having been breast fed for more than six months, significantly increased one's chances of becoming malnourished. In a third aspect of the programme, community health aides visit homes of "at risk" children to offer dietary advice and learn more about the home situations. A weekly review of these visits by the full clinic staff allows for direction of future patient care, in-service education of health aides, and constant programme evaluation. In this system, entry level health workers use rigid anthropometric and demographic criteria to "diagnose" malnutrition. They then administer "therapy", not by dispensing artificial food supplements or by grouping counselling, but rather by educating individuals according to a specific predetermined protocol. In the five months since introduction of this child nutrition programme, substantial reduction of young child morbidity and mortality has occurred (AU)