Associations between race, lifecourse socioeconomic position and prevalence of diabetes among US women and men: results from a population-based panel study.

BACKGROUND: Few studies have examined the degree to which racial disparities in the development of diabetes are accounted by differences in lifecourse socioeconomic position (SEP). We assessed the association between race, lifecourse SEP measures and prevalence of diabetes in a representative US sample of black and white adults. METHODS: A generalised estimating equations approach was used with a sample of 3497 adults from the Americans' Changing Lives study. Sex-specific models were calculated to compute prevalence ratios (PR) for associations of race and SEP with self-reported diagnoses of diabetes. RESULTS: For men, childhood and adult SEP were unrelated to diabetes, and adjustment for lifecourse SEP had little effect on the excess diabetes in blacks (PR=1.56, 95% CI 1.11 to 2.21). Adjustment for measures of lifecourse SEP reduced the PR for the association between race and diabetes in women from 1.96 (95% CI 1.52 to 2.54) to 1.40 (95% CI 1.04 to 1.87) with the respondent's education responsible for most of the reduction in the association. However, diabetes was also inversely associated with father's education, and low SEP throughout the lifecourse was associated with a nearly threefold increase in diabetes (PR=2.89, 95% CI 2.10 to 3.99). CONCLUSIONS: Racial disparities in diabetes existed among both men and women, but lifecourse SEP was related to diabetes only among women. The pathway and cumulative hypotheses for lifecourse SEP effects on diabetes may be especially salient for women.

Community measures of low-fat milk consumption: comparing store shelves with households.

OBJECTIVES: This study examined the relationship between the proportion of milk in food stores that is low-fat and consumption of low-fat milk in the community. METHODS: Data were gathered from 503 stores across 53 New York State zip codes. In 19 zip codes, a telephone survey measured household low-fat milk use. Census data were obtained to examine sociodemographic predictors of the percentage of low-fat milk in stores. RESULTS: The proportion of low-fat milk in stores was directly related to low-fat milk consumption in households and to the median income and urban level of the zip code. CONCLUSIONS: These results support using food store shelf-space observations to estimate low-fat milk consumption.

The contribution of baseline weight and weight gain to blood pressure change in African Americans: the Pitt County Study.

PURPOSE: The positive association between obesity and blood pressure has been less consistent in African Americans than whites. This is especially true for African American men. This study investigated the sex-specific associations between baseline body mass index (BMI), weight change (kilograms), and five-year hypertension incidence and changes in blood pressure in a cohort of African Americans ages 25-50 years at baseline. METHODS: The Pitt County Study is a longitudinal investigation of anthropometric, psychosocial, and behavioral predictors of hypertension in African Americans. Data were obtained through household interviews and physical examinations in 1988 and 1993. RESULTS: Baseline BMI was positively and independently associated with changes in blood pressure after controlling for weight change and other covariates. When participants were stratified by sex-specific overweight vs. nonoverweight status at baseline, weight gain was significantly associated with increases in blood pressure only among the initially nonoverweight. CONCLUSIONS: Baseline weight for all respondents, and weight gain among the nonoverweight at baseline, were independent predictors of blood pressure increases in this cohort of African Americans.

Physical activity and NIDDM in African-Americans. The Pitt County Study.

OBJECTIVE: Studies directly examining the association between physical activity and NIDDM in African-Americans are rare. Consequently, the strength of this association in this ethnic minority group remains unclear. The current study broadly characterizes the types of physical activity engaged in by a community sample of working-class African-Americans and then quantifies the association between physical activity and NIDDM risk in this population. RESEARCH DESIGN AND METHODS: During the 1993 reexamination of participants in the Pitt County Study in North Carolina, data on NIDDM history, current use of insulin or oral hypoglycemic drugs, and approximately 12-h overnight fasting blood glucose (FBG) were obtained from 598 women and 318 men, ages 30-55 years. The presence of NIDDM was determined by current insulin or medication use and FBG > or = 140 mg/dl. Study participants were assigned to one of four categories of physical activity: strenuous, moderate, low, or inactive. RESULTS: The weighted prevalence of NIDDM in the sample was 7.1%. After adjustment was made for age, sex, education, BMI, and waist-to-hip ratio, NIDDM risk for moderately active subjects was one-third that for the physically inactive subjects (odds ratio [OR], 0.35; 95% CI, 0.12-0.98). The ORs for low (OR, 0.51; 95% CI, 0.20-1.29) and strenuous (OR, 0.65; 95% CI, 0.26-1.63) activity also tended to be lower. A summary OR that contrasted any activity versus no activity was 0.51 (95% CI, 0.23-1.13). CONCLUSIONS: Moderate physical activity was strongly associated with reduced risk for NIDDM in this sample. While replication of these findings is needed, public health interventions designed to increase moderate (leisure-time) physical activity in black adults should be strongly encouraged.

Heterogeneous vasomotor responses of coronary conduit and resistance vessels in hypertension.

OBJECTIVES: The purpose of our study was to investigate the relation between conductance and resistance coronary vasomotor responsiveness in hypertensive patients without atherosclerosis. BACKGROUND: Although similar in morphology, conduit and resistance coronary vessels differ importantly in size, function and local environment and appear to be differentially affected in certain disease processes, such as atherosclerosis and hypertension. However, little is known about the effect of hypertension on contiguous coronary conduit and resistance vessels in humans. METHODS: Changes in coronary blood flow (a measure of resistance vessel reactivity) and coronary artery diameter (a measure of conduit vessel reactivity) were investigated in response to graded infusion of the endothelium-dependent agonist acetylcholine (ACh) in 98 patients with normal coronary arteries. RESULTS: In 31 normotensive, euglycemic patients, conduit and resistance coronary artery responses to intracoronary infusion of ACh were significantly correlated (r = 0.73, p = 1 x 10[-6]), although eight patients (26%) had constriction of conduit but dilation of resistance arteries at peak effect. In 28 hypertensive patients without left ventricular hypertrophy (LVH), conduit and resistance artery responses to ACh remained significantly correlated (r = 0.5, p = 0.006), although 12 patients (43%) had discordant findings. Finally, in 39 hypertensive patients with LVH, conduit and resistance artery responses to ACh displayed the lowest correlation (r = 0.38, p = 0.02), with 22 patients (56%) demonstrating conduit artery constriction and resistance artery dilation. CONCLUSIONS: Despite angiographically normal coronary arteries, heterogeneous vasomotor responses (dilation and constriction) were demonstrated in contiguous conduit and resistance arteries in normotensive and hypertensive patients referred for cardiac catheterization because of chest pain. In addition to more severe endothelial dysfunction among conduit and resistance arteries, a greater frequency of discordant conduit and resistance artery responses and resistance vessel constriction was found with increasing severity of hypertension. Our study suggests differing mechanisms of endothelium responsiveness to ACh among conduit and resistance coronary arteries.

Alcohol consumption and changes in blood pressure among African Americans. The Pitt County Study.

The Pitt County Study is a longitudinal investigation of anthropometric, psychosocial, and behavioral predictors of hypertension in African Americans who were aged 25-50 years at baseline in 1988. At baseline, a strong dose-response gradient was observed for alcohol consumption and blood pressure for both sexes. The current study investigated whether baseline alcohol consumption or, alternatively, changes in drinking status predicted 5-year changes in blood pressure among the 652 women and 318 men who satisfied all inclusion criteria for the longitudinal analyses. In multivariate regression analyses, baseline alcohol consumption was not significantly associated with changes in blood pressure or hypertension incidence (systolic/diastolic blood pressure > or = 160/95 mmHg) by 1993. Change in drinking status, however, was significantly associated with changes in systolic pressure. The systolic pressure increase among individuals who initiated alcohol consumption was 6.2 mmHg (95% confidence interval (CI) 1.1-6.4) greater than abstainers, while that for individuals who reported drinking at both time points was 3.8 mmHg (95% CI 1.3-11.1) greater. Blood pressure increases for persons who discontinued drinking were comparable to those of abstainers. Results were independent of baseline age, body mass index, blood pressure, and sex. Social and economic disadvantage in 1988 was significantly associated with continuation and initiation of alcohol consumption by 1993.

Social support, stress, and blood pressure in black adults.

Psychosocial factors arising from socioeconomic disadvantage and discrimination may contribute to the excess risk of elevated blood pressure in African-Americans. The purpose of this study was to assess the association of social support and stress with blood pressure in a community-based sample of 25-to 50-year-old black adults in Pitt County, NC. A stratified random sample of dwellings was selected in 1988, and 1,784 black adults (80% of those eligible) were interviewed. Analyses were sex specific and adjusted for age, obesity, and waist/hip ratio. In separate analyses of emotional support, instrumental support, and stress with blood pressure, all associations were in the predicted direction (inverse for support, direct for stress) but were stronger for systolic than for diastolic blood pressure. Differences in systolic blood pressure associated with low support or high stress ranged from 5.2 to 3.6 mmHg in women and 3.5 to 2.5 mmHg in men. In simultaneous regression analyses of support and stress, each of the separate effects was reduced for women, but a sizable aggregate effect of low support and high stress remained [+7.2 mmHg (95% confidence limits = +1.3, +13.1) for systolic blood pressure and +4.0 mmHg (95% confidence limits = +0.1, +7.9) for diastolic blood pressure.

Coronary vasomotor reactivity among normotensive African and white American subjects with chest pain.

BACKGROUND AND OBJECTIVES: Excess cardiovascular morbidity and mortality among African (black) Americans is the subject of intensive investigation but the etiology remains speculative. One hypothesis proposes that inherent, or intrinsic, differences in coronary vascular reactivity and endothelial function predispose African Americans to enhanced vasoconstriction and/or depressed vasodilation, resulting in excess ischemia. The objective of this study was to establish whether coronary vasoreactivity differs among normotensive, nondiabetic African and white Americans with normal arteries referred for coronary arteriography because of chest pain. PATIENTS AND METHODS: Eleven African American (8 female, 3 male) and 28 white American (9 female, 19 male) normotensive, euglycemic patients with normal coronary arteries were prospectively recruited for invasive testing of coronary artery and microvascular relaxation using the endothelium-dependent and -independent agents, acetylcholine and adenosine; a Doppler tipped intracoronary guidewire; and quantitative coronary angiography. RESULTS: The study cohort consisted of 17 women (44%) and 22 men (56%) with a mean age of 46 +/- 10 yrs. Of 8 African American women, 6 were premenopausal and 2 were postmenopausal on estrogen replacement therapy. Of 9 white American women, 2 were premenopausal, 1 was 46-year old with a previous history of hysterectomy without ovariectomy, 2 were postmenopausal on estrogen replacement therapy, 2 were perimenopausal and 44- and 54-year old, and 2 were postmenopausal without estrogen replacement therapy. In response to maximal infusion of acetylcholine, epicardial coronary arteries and resistance vessels dilated similarly in black and white subjects. Dose-response curves revealed no significant racial differences during submaximal graded infusion of acetylcholine. In response to peak effect of adenosine, there were no racial differences in dilation of the microcirculation. CONCLUSIONS: In the absence of hypertension, diabetes mellitus, and angiographic evidence of coronary artery disease, African American women demonstrate no evidence of intrinsic predisposition to enhanced coronary conduit vasoconstriction or depressed microcirculatory dilation in response to the endothelium-dependent and -independent vasodilator agonists-acetylcholine and adenosine-when compared with responses of similar white men and women. Because of low enrollment of black males, definitive conclusions cannot be drawn regarding this group.

Effect of African-American race and hypertensive left ventricular hypertrophy on coronary vascular reactivity and endothelial function.

Excess cardiovascular morbidity and mortality among African (black) Americans remains an important yet unexplained public health problem. One possible explanation proposes that intrinsic or acquired abnormalities in coronary vascular reactivity and endothelial function result in excess ischemia among black Americans. To examine this hypothesis, we subjected 80 individuals with normal coronary arteries to invasive testing of coronary artery and microvascular relaxation using intracoronary infusions of acetylcholine and adenosine, a Doppler tipped intracoronary guide wire, and quantitative coronary angiography. We measured the percent increase in coronary blood flow and epicardial diameter after graded infusion of intracoronary acetylcholine and in coronary blood flow after intracoronary adenosine in 31 normotensive subjects (10 black, 21 white) and 49 hypertensive subjects with left ventricular hypertrophy (25 black, 24 white). Categorical and multivariate analyses revealed that in response to intracoronary adenosine and acetylcholine, the depression in endothelium-independent and -dependent microvascular relaxation during peak agonist effect was largely related to the presence of chronic hypertension and left ventricular hypertrophy. Normotensive subjects demonstrated no intrinsic racial differences in conduit and resistance vessel vasoreactivity. In response to maximal infusion of acetylcholine, epicardial coronary arteries constricted similarly in black and white subjects with hypertensive left ventricular hypertrophy and dilated similarly in normotensive black and white subjects. Thus, our study shows that in a cohort of black and white subjects referred for coronary arteriography because of chest pain, African American race is not associated with excess intrinsic or acquired depression in coronary vascular relaxation during the peak effect of the endothelium-dependent and -independent agonists acetylcholine and adenosine, after adjustment for the presence of left ventricular hypertrophy.

Employment, job strain, and preterm delivery among women in North Carolina.

OBJECTIVES: A population-based case-control study was conducted in central North Carolina to assess the relationship between occupational stress and preterm delivery. METHODS: Four hundred twenty-one women delivering infants before 37 weeks' gestation and 612 women delivering infants at term were interviewed a median of 6 months after delivery. Exposure information was collected for all jobs held for at least 1 month during pregnancy. RESULTS: Work in a "high strain" job (i.e., high demand and low control) was not associated with increased risk of preterm delivery compared with work in "low strain" jobs (all other combinations of job demand and control). Narrowing the exposure window to the third trimester did not modify the results. However, women who worked at a high-strain job full-time (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 0.9, 2.0) or for 30 or more weeks (OR = 1.4, CI = 1.0, 2.2) had a modestly increased risk. Several analyses suggested that Black women were at greater risk from job strain than White women. CONCLUSIONS: This study suggests that chronic exposure during pregnancy to work characterized by high demand and low control may be modestly associated with preterm delivery.

Coronary vasomotor function in a normotensive, nondiabetic referral population with normal coronary arteriograms.

In a referral normal cardiac population, endothelium-independent coronary relaxation is nearly always normal, but endothelium-dependent relaxation may be depressed in a significant proportion of patients. Further study of the natural history of referral subjects with endothelial dysfunction is necessary to assess the potential cardiovascular risk of this finding in a presumed low-risk population.

Impact of institution size, staffing patterns, and infection control practices on communicable disease outbreaks in New York State nursing homes.

Institutional risk factors associated with the occurrence of nosocomial respiratory or gastrointestinal disease outbreaks in 1992 were examined in a case-cohort study of New York State nursing homes conducted in 1993. Facility size, staffing patterns, and employee sick leave policies were the principal effects found in an unconditional logistic regression model. The risk of having respiratory or gastrointestinal disease outbreaks was greater in larger nursing homes (adjusted risk ratio (RR) = 1.71 for each 100-bed increase in size, 95% confidence interval (CI) 1.20-2.42), for nursing homes with a single nursing unit (adjusted RR = 3.93, 95% CI 0.98-15.71), or those with multiple nursing units with shared staff (adjusted RR = 2.51, 95% CI 1.07-5.89). The risk was less for nursing homes with paid employee sick leave policies (adjusted RR = 0.38, 95% CI 0.15-0.99). Other potential risk factors examined in this study, such as the ratio of beds per unit, type of sponsorship, daily review of laboratory test results, and the proportion of private beds and patient-to-staff ratio, were not significantly associated with the risk of disease outbreaks. The results of this study have direct implications for control of nosocomial disease outbreaks in nursing homes.

Is the high ischemic heart disease mortality rate in New York State just an urban effect?

To determine whether New York State's high ischemic heart disease mortality rate was due primarily to an urban effect, rates for regions in the State were compared with each other and with national data. New York State mortality rates for the period 1980-87 were highest for New York City (344.5 per 100,000 residents), followed by upstate urban and rural areas (267.1-285.1), and New York City suburbs (272.5). However, the overall 1986 age-adjusted rate for the New York State region with the lowest mortality rate (265.7) exceeded that of 42 States. New York State's number one ischemic heart disease mortality ranking reflects the need for statewide intervention programs, because even regions with relatively low mortality rates are high when they are compared with national rates.

Impact of regulation on benzodiazepine prescribing to a low income elderly population, New York State.

On 1 January 1989, in an effort to reduce diversion of benzodiazepines for illicit use and reduce inappropriate prescribing, a regulation was implemented requiring the reporting of all benzodiazepine prescriptions to the New York State Department of Health. To assess the impact of the regulation on prescribing practices to the elderly, we followed the number of benzodiazepines and other central nervous system medications prescribed to a cohort of participants in an elderly pharmaceutical insurance program. Benzodiazepines were prescribed for 4652 (22%) of the 20,944 patients studied. By the last quarter of 1989, benzodiazepines were prescribed for 3120 (15%) patients, a decrease of 33%. The number of prescriptions of benzodiazepines decreased by 5010 (45%), from 11,123 to 6113. Decreases in the number of prescriptions were similar across benzodiazepine brands (range 40-56%). Statistically significant (p < 0.05) decreases were seen in all sex, age, race and marital status groups. Increases in number (and percent increases) of prescriptions for miscellaneous anxiolytics (i.e. hydroxyzine (399, 69%), meprobamate (299, 149%), buspirone (263, 111%), chloral hydrate (138, 265%), antidepressants (658, 19%), barbiturates (150, 29%), and tranquilizers (198, 19%), some of which may be more toxic or less effective, were noted. New York State's reporting regulation was effective in reducing both the number of patients being prescribed benzodiazepines and the number of prescriptions given to those who remain on benzodiazepines in the elderly population studies.

Association between maternal education and infant diarrhea in different household and community environments of Cebu, Philippines.

Maternal education is one of the strongest determinants of infant survival in developing countries, however, questions remain regarding the extent to which its effects vary as a function of contextual variables. In this study, a multi-level interactive model is used to assess whether the protective effect of maternal education on the risk of infant diarrhea is modified by three aspects of the mother's familial and community environment: household assets, community economic resources and the availability of mothers' clubs. 2484 study participants were interviewed in 1984 as part of the Cebu Longitudinal Infant Health and Nutrition Study. The findings suggest that the protective effect of maternal education on infant diarrhea varies according to the socio-economic environment in which the mother lives: maternal education protects against infant diarrhea in the more economically and socially advantaged communities but has no effect in the more disadvantaged communities. The results also indicate that the protective effect of maternal education is smaller in the wealthier households. These data suggest that improvement in maternal education level, alone, may not always have the expected beneficial effects on infant health. Corollary measures to improve access of mothers and children to basic community resources and efforts to help mothers be more effective in their various social roles may be necessary preconditions for higher levels of maternal education to result in improved infant health.

Self-reported physical activity in a rural county: a New York county health census.

OBJECTIVES: Few studies have described physical activity in rural populations. This study describes the frequency, types, and correlates of physical activity in 29,304 free-living adults in a rural county in New York State. METHODS: Self-reported responses about regular physical activity (maintained long enough to work up a sweat) were analyzed from a private household census of Otsego County with an 86.6% response rate. RESULTS: This survey categorized 46.2% of county residents as sedentary. Walking, the most frequent choice of activity (62% of the women, 36% of the men), increased in frequency with age of respondents whereas cycling, jogging, aerobics, team sports, and swimming (listed in rank order of frequency) generally tended to decrease in frequency with age. Farmers demonstrated an increased amount of "sweat activity" compared with persons in most other occupations. CONCLUSIONS: This descriptive study of physical activity in a rural county shows that sedentary lifestyle is of high prevalence. The high frequency of walking and the gender differences in both the levels and choice of activity suggest that further research and public policy recommendations focus on these issues.

The independent effects of obesity and body fat distribution on blood pressure in black adults: the Pitt County study.

The relationship of obesity measures to blood pressure and hypertension prevalence was assessed in a community probability sample of 25-50-year-old black adults (1101 women and 655 men) who were examined in 1988 in Pitt County, North Carolina. Among black women, both body mass index and waist-to-hip ratio had independent relationships with systolic and diastolic blood pressures and hypertension prevalence after controlling for the effects of age, socio-economic status, physical activity, alcohol, and the other obesity measure (P < 0.05). Body mass index also had independent relationships with blood pressure levels and hypertension prevalence in black men (P < 0.05), while waist-to-hip ratio was associated with hypertension prevalence (P = 0.05) and diastolic blood pressure (P < 0.05), but not with systolic blood pressure. The relationships of waist-to-hip ratio with blood pressure and hypertension prevalence were considerably reduced in both sex groups after controlling for body mass index. This study presents new evidence that waist-to-hip ratio is related to hypertension and blood pressure level independent of body mass index, in young to middle-aged black adult women and men.

Physician-based diet counseling for cholesterol reduction: current practices, determinants, and strategies for improvement.

BACKGROUND: Physicians face increasing pressure to counsel their hypercholesterolemic patients about diet. To design effective physician-based treatment programs, a better understanding of current dietary counseling practice and its determinants is needed. METHODS: Using a survey previously tested for reliability and validity, we examined the relationship of dietary knowledge, attitudes, beliefs, organizational barriers, and treatment practices for cholesterol management among 60 resident and attending physicians practicing in the general medicine clinic of a university medical center that serves primarily rural and disadvantaged patients. The survey was administered in October of 1988 prior to the release of the National Cholesterol Education Program Guidelines. RESULTS: The response rate was 100%. Ninety-two percent of physicians surveyed believe that dietary treatment effectively lowers cholesterol and 68% feel responsible for providing such therapy. However, most (72%) feel ill-prepared to give diet counseling, lack confidence in their ability to help patients make meaningful dietary changes (95%), and cite organizational barriers, such as limited time (72%) or inadequate educational materials (47%). Physicians were more likely to report behaviorally focused diet counseling practices if they felt prepared to counsel (r = 0.42, P < 0.001), were confident in their counseling skills (r = 0.39, P < 0.01), or reported personally following a prudent diet (r = 0.36, P < 0.01). We discuss the implications of these findings and how they should guide the design of physician-based dietary interventions for cholesterol reduction.

Education, race, and high-density lipoprotein cholesterol among US adults.

OBJECTIVES: Although educational achievement is positively related to levels of high-density lipoprotein cholesterol (HDL-C) among White adults, there is an inverse association among Blacks. We assessed whether this interaction could be attributed to differences in the relation of education to correlates of HDL-C. METHODS: Cross-sectional analyses were based on data from 8391 White and 995 Black adults who participated in the Second National Health and Nutrition Examination Survey. RESULTS: Associations between education and HDL-C levels varied from negative (Black men), to nearly nonexistent (White men and Black women), to positive (White women). Mean HDL-C levels were higher among Blacks than among Whites, but differences varied according to educational achievement. Among adults with less than 9 years of education, mean levels were 6 to 10 mg/dL higher among Blacks, but the radical difference was less than 1 mg/dL among adults with at least 16 years of education. About 20% to 40% of these differences could be accounted for by obesity, alcohol consumption, and other characteristics. CONCLUSIONS: Because of the implications for coronary heart disease risk, consideration should be given to behavioral characteristics associated with the interaction between race and educational achievement.

Socioeconomic and behavioral correlates of body mass index in black adults: the Pitt County Study.

BACKGROUND: Obesity is more prevalent among Black women than Black men, but there is little information on the correlates of obesity in Blacks. This study describes the relations of sociodemographic factors and health behaviors to body mass index in a southern, Black population. METHODS: In 1988, a community probability sample of 1784 Black adults, aged 25 to 50, was examined in Pitt County, NC. RESULTS: More women than men were at least 20% overweight (57% vs 36%). The relation of socioeconomic status (a composite of education and occupation) to age-adjusted body mass index level was inverse in women but not in men. Body mass index did not differ with either current energy intake or energy expenditure. Smokers and drinkers had lower age-adjusted levels than non-smokers and abstainers. CONCLUSIONS: Since the excess body mass index levels associated with low socioeconomic status in women could not be explained after controlling for adverse health behaviors, further epidemiologic study of risk factors for obesity in Black women is recommended.