Obesity management for cardiovascular disease prevention

Background: Obesity is a complex disease that leads to higher morbidity and mortality and its rate in the United States is rapidly rising. Targeting obesity management is one of the cornerstones of preventive medicine. Early intervention can significantly reduce the risk of developing cardiovascular disease. While it is well known that lifestyle interventions such as healthful nutrition and routine physical activity are the first and most important step in management, some do not achieve the desired results and require further therapies. Methods: A literature review was conducted, that included clinical documents, public scientific citations and peer review articles to evaluate anti-obesity medications, endoscopic procedures and bariatric surgeries in the management of obesity. We also included effects of these interventions on weight loss, cardiovascular disease risk reduction and side effects. Results: This clinical review summarizes recent evidence for the different approaches in obesity management including medications, common endoscopic procedures and bariatric surgeries. For more detailed review on the different management options discussed, we recommend reviewing Obesity Medicine Association Clinical Practice Statement [1]. Conclusion: Management of obesity reduces cardiovascular risk, improves metabolic parameters and other important health outcomes. Different management approaches are available, hence, a high level of awareness of the growing epidemic of obesity is needed to ensure timely referrals to obesity medicine specialists.</p

Mental Health and Access to Medical Care in Patients with Chronic Cardiovascular Conditions: An Analysis of the Behavior Risk Factor Surveillance System

Introduction. Poor mental health is associated with worse outcomes for chronic diseases. It is unclear whether mental illness predisposes to difficulties with healthcare access. Methods. Using a combined dataset of the 2016-2019 behavioral risk factor surveillance system, we included individuals who reported a chronic cardiovascular condition. Weighted multivariable logistic regression analyses were used to explore the association between domains of mental health and measures of healthcare access including delaying medical care, &gt; 1 year since last routine checkup, lack of a primary care physician (PCP), and cost-related medication nonadherence (CRMNA). Results. Among 1,747, 397 participants, 27% had a chronic cardiovascular condition, 12% had clinical depression, and 12% had poor mental health. Those with poor mental health (OR 3.20 [3.08 – 3.33]) and clinical depression (OR 2.43 [2.35 – 2.52]) were more likely to report delays in medical care.  Those with greater stress frequency (OR 8.47 [6.84 -10.49] stressed all of the time), lower levels of emotional support received (OR 3.07 [2.21 – 4.26] rarely get needed emotional support), and greater life dissatisfaction (6.66 [4.14 – 10.70] very dissatisfied) reported greater delays in medical care. Conclusions. Individuals with poor mental health have greater difficulty accessing medical care independent of socioeconomic variables

E-cigarette Use and Risk Behaviors among Lesbian, Gay, Bisexual, and Transgender Adults: The Behavioral Risk Factor Surveillance System (BRFSS) Survey

Introduction: We studied prevalence of e-cigarette use among lesbian, gay, bisexual, and transgender (LGBT) individuals and its association with risk behaviors. Methods: Using data from the Behavioral Risk Factor Surveillance System (BRFSS) survey, we assessed self-reported sexual orientation, e-cigarette use, cigarettes, marijuana, smokeless tobacco, and high-risk behavior (using non-prescribed drugs, treatment for sexually transmitted disease, or receiving monetary or drug compensation in exchange for sex in the previous year). We used multivariable-adjusted logistic regression models to study the association between LGBT and risk behaviors. Results: Prevalence of e-cigarette use among LGBT adults was 13%, nearly twice that of heterosexual adults. LGBT were more likely [Odds Ratio (95% Confidence Interval)] to report current use of e-cigarettes 1.84 (1.64,2.06), cigarettes 1.61 (1.49,1.73), marijuana 2.37 (1.99,2.82), and high-risk behavior 3.69 (3.40,4.01) compared to heterosexual adults. Results for smokeless tobacco were not significant. Conclusion: There are disparities in e-cigarette and other risk behaviors among LGBT adults, which may increase risk of adverse health effects in this vulnerable population

Racial/Ethnic Disparities and Determinants of Sufficient Physical Activity Levels

Introduction. It is important to identify racial/ethnic groups that may be less likely to achieve sufficient physical activity levels, and to address barriers to meeting physical activity requirements. Methods. Cross-sectional data from the 2006-2015 National Health Interview Survey (NHIS) was used to compare self-reported sufficient physical activity among different racial/ethnic groups: non-Hispanic (NH) Whites, NH Blacks, NH Asians, and Hispanics. Sufficient physical activity was defined as ≥150 minutes per week of moderate-intensity physical activity, ≥75 minutes per week of vigorous-intensity physical activity, or ≥150 minutes per week of moderate and vigorous physical activity. Results. The study sample consisted of 296,802 individuals, mean age ± standard error age 46.4 ± 0.10 years, 52% women, 70% NH White, 12% NH Black, 5% NH Asian, 14% Hispanic. The prevalence of sufficient physical activity in the overall population was 46%, while it was 48% among NH Whites, 39% among NH Blacks, 45% among NH Asians, and 40% among Hispanics. In multivariable-adjusted models (odds ratio; 95% confidence interval), NH Blacks (0.79; 0.64,0.97), NH Asians (0.72; 0.62,0.85) and Hispanics (0.71; 0.61,0.82) were significantly less likely to engage in sufficient physical activity compared with NH Whites. Older age, women, and low income were inversely associated with sufficient physical activity, while a college education or higher was directly associated with it. Conclusions. NH Black, NH Asian, and Hispanic adults are less likely to engage in sufficient physical activity levels compared with NH Whites. It is important to address barriers to meeting physical activity thresholds to help achieve optimal cardiovascular health

Evaluation of aspirin and statin therapy use and adherence in patients with premature atherosclerotic cardiovascular disease

Importance: Studies on the use of and adherence to secondary prevention therapies in patients with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD) are lacking.Objective: To evaluate and compare aspirin use, any statin use, high-intensity statin use, and statin adherence among patients with premature or extremely premature ASCVD compared with patients with nonpremature ASCVD.Design, setting, and participants: This multicenter cross-sectional study used the clinical and administrative data sets of the US Department of Veterans Affairs (VA) to identify adult patients with at least 1 primary care visit in the VA health care system between October 1, 2014, and September 30, 2015. The study cohort comprised patients with ASCVD (ischemic heart disease, peripheral arterial disease, or ischemic cerebrovascular disease) who were enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. Patients with missing data for date of birth or sex and those with limited life expectancy were excluded. Data were analyzed from November 1, 2019, to January 1, 2020.Exposures: Premature (the first ASCVD event occurred at age women) vs nonpremature (the first ASCVD event occurred at age ≥55 years for men or age ≥65 years for women) ASCVD and extremely premature (the first ASCVD event occurred at age \u3c40 \u3eyears) vs nonpremature ASCVD.Main outcomes and measures: The primary outcomes were aspirin use, any statin use, high-intensity statin use, and statin adherence (measured by proportion of days covered [PDC] ≥0.8).Results: Of the 1 248 158 patients identified, 135 703 (10.9%) had premature ASCVD (mean [SD] age, 49.6 [5.8] years; 116 739 men [86.0%]), 1 112 455 (89.1%) had nonpremature ASCVD (mean [SD] age, 69.6 [8.9] years; 1 104 318 men [99.3%]), and 7716 (0.6%) had extremely premature ASCVD (mean [SD] age, 34.2 [4.3] years; 6576 men [85.2%]). Patients with premature ASCVD vs those with nonpremature ASCVD had lower rates of aspirin use (96 468 [71.1%] vs 860 726 [77.4%]; P \u3c .001) and any statin use (98 908 [72.9%] vs 894 931 [80.5%]; P \u3c .001); had a statin PDC of 0.8 or higher (57 306 [57.9%] vs 644 357 [72.0%]; P \u3c .001); and a higher rate of high-intensity statin use (49 354 [36.4%] vs 332 820 [29.9%]; P \u3c .001). Similarly, patients with extremely premature ASCVD were less likely to use aspirin (odds ratio [OR], 0.27; 95% CI, 0.26-0.29), any statin (OR, 0.25; 95% CI, 0.24-0.27), or high-intensity statin (OR, 0.78; 95% CI, 0.74-0.82) and to be statin adherent (OR, 0.44; 95% CI, 0.41-0.47).Conclusions and relevance: In this study, patients with premature or extremely premature ASCVD appeared to be less likely to use aspirin or statins and to adhere to statin therapy. This finding warrants further investigation into premature ASCVD and initiatives, including clinician and patient education, to better understand and mitigate the disparities in medication use and adherence

Hypertension guidelines and coronary artery calcification among South Asians: Results from MASALA and MESA

Untreated hypertension may contribute to increased atherosclerotic cardiovascular disease (ASCVD) risk in South Asians (SA). We assessed HTN prevalence among untreated adults free of baseline ASCVD from the MASALA & MESA studies. The proportion of participants who received discordant recommendations regarding antihypertensive pharmacotherapy use by the 2017-ACC/AHA and JNC7 Guidelines across CAC score categories in each race/ethnic group was calculated. Compared with untreated MESA participants (n = 3896), untreated SA (n = 445) were younger (55±8 versus 59±10 years), had higher DBP (73±10 versus 70±10 mmHg), total cholesterol (199±34 versus 196±34 mg/dL), statin use (16% versus 9%) and CAC=0 prevalence (69% versus 58%), with fewer current smokers (3% versus 15%) and lower 10-year-ASCVD-risk (6.4% versus 9.9%) (all p\u3c0.001). A higher proportion of untreated MASALA and MESA participants were diagnosed with hypertension and recommended anti-hypertensive pharmacotherapy according to the ACC/AHA guideline compared to JNC7 (all p\u3c0.001). Overall, discordant BP treatment recommendations were observed in 9% SA, 11% Whites, 15% Blacks, 10% Hispanics, and 9% Chinese-American. In each race/ethnic group, the proportion of participants receiving discordant recommendation increased across CAC groups (all p\u3c0.05), however was highest among SA (40% of participants). Similar to other race/ethnicities, a higher proportion of SA are recommended anti-hypertensive pharmacotherapy by ACC/AHA as compared with JNC7 guidelines. The increase was higher among those with CAC\u3e100 and thus may be better at informing hypertension management in American South Asians

Identification and management of atherosclerotic cardiovascular disease risk in south Asian populations in the U.S.

South Asians (SAs, individuals with ancestry from Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) are among the fastest growing ethnic subgroups in the United States. SAs typically experience a high prevalence of diabetes, abdominal obesity, and hypertension, among other cardiovascular disease risk factors, which are often under recognized and undermanaged. The excess coronary heart disease risk in this growing population must be critically assessed and managed with culturally appropriate preventive services. Accordingly, this scientific document prepared by a multidisciplinary group of clinicians and investigators in cardiology, internal medicine, pharmacy, and SA-centric researchers describes key characteristics of traditional and nontraditional cardiovascular disease risk factors, compares and contrasts available risk assessment tools, discusses the role of blood-based biomarkers and coronary artery calcium to enhance risk assessment and prevention strategies, and provides evidenced-based approaches and interventions that may reduce coronary heart disease disparities in this higher-risk population

Healthcare Access Among Individuals of Asian Descent in the U.S.

Introduction. Some groups of Asian Americans, especially Asian Indians, experience higher rates of atherosclerotic cardiovascular disease (ASCVD) compared with other groups in the U.S. Barriers in accessing medical care partly may explain this higher risk as a result of delayed screening for cardiovascular risk factors and timely initiation of preventive treatment. Methods. Cross-sectional data were utilized from the 2006 to 2015 National Health Interview Survey (NHIS). Barriers to accessing medical care included no place to seek medical care when needed, no healthcare coverage, no care due to cost, delayed care due to cost, inability to afford medication, or not seeing a doctor in the past 12 months. Results. The study sample consisted of 18,150 Asian individuals, of whom 20.5% were Asian Indian, 20.5% were Chinese, 23.4% were Filipino, and 35.6% were classified as “Other Asians”. The mean (standard error) age was 43.8 (0.21) years and 53% were women. Among participants with history of hypertension, diabetes mellitus, or ASCVD (prevalence = 25%), Asian Indians were more likely to report delayed care due to cost (2.58 (1.14,5.85)), while Other Asians were more likely to report no care due to cost (2.43 (1.09,5.44)) or delayed care due to cost (2.35 (1.14,4.86)), compared with Chinese. Results among Filipinos were not statistically significant. Conclusions. Among Asians living in the U.S. with cardiovascular risk factors or ASCVD, Asian Indians and Other Asians are more likely to report delayed care or no care due to cost compared with Chinese

Cardiorespiratory Fitness and Incident Stroke Types: The FIT (Henry Ford ExercIse Testing) Project

OBJECTIVE: To study the association between cardiorespiratory fitness (CRF) and incident stroke types. PATIENTS AND METHODS: We studied a retrospective cohort of patients referred for treadmill stress testing in the Henry Ford Health System (Henry Ford ExercIse Testing Project) without history of stroke. CRF was expressed by metabolic equivalents of task (METs). Using appropriate International Classification of Diseases, Ninth Revision codes, incident stroke was ascertained through linkage with administrative claims files and classified as ischemic, hemorrhagic, and subarachnoid hemorrhage (SAH). Multivariable-adjusted Cox proportional hazards models examined the association between CRF and incident stroke. RESULTS: Among 67,550 patients, mean ± SD age was 54±13 years, 46% (n=31,089) were women, and 64% (n=43,274) were white. After a median follow-up of 5.4 (interquartile range 2.7-8.5) years, a total of 7512 incident strokes occurred (6320 ischemic, 2481 hemorrhagic, and 275 SAH). Overall, there was a graded lower incidence of stroke with higher MET categories. Patients with METs of 12 or more had lower risk of overall stroke [0.42 (95% CI, 0.36-0.49)], ischemic stroke [0.69 (95% CI, 0.58-0.82)], and hemorrhagic stroke [0.71 (95% CI, 0.52-0.95)]. CONCLUSION: In a large ethnically diverse cohort of patients referred for treadmill stress testing, CRF is inversely associated with risk for ischemic and hemorrhagic stroke

Determining Call-To-Entry Rate and Recruitment Barriers in Clinical Studies For Community Clinics Serving Low-income Populations: a Cohort Study

BACKGROUND: Recruitment for clinical studies is challenging. to overcome barriers, investigators have previously established call-to-entry rates to assist in planning. However, rates specific to low-income minority populations are needed to account for additional barriers to enrolment these individuals face. OBJECTIVE: to obtain a call-to-entry rate in a low-income uninsured Hispanic population with chronic disease. METHODS: We used data from four of our randomised clinical studies to determine the call-to-entry rate for individuals (n=1075) with or at risk for type 2 diabetes: participants needed/potential participants contacted=recruitment rate (yield). Research staff contacted potential participants to enrol in a study that evaluated 6 month diabetes programmes at community clinics from 2015 to 2020. We recorded call-to-entry rates, reasons for declining the study, show rates, and attrition. RESULTS: The call-to-entry rate was 14.5%. Forty per cent of potential participants could not be contacted, and 30.6%, 19.1%, and 5.4% responded CONCLUSIONS: We described a call-to-entry rate and detailed recruitment data, including reasons to decline the study. This valuable information can assist investigators in study planning and overcoming enrolment barriers in low-income populations. Telehealth-based or strategies that limit transportation needs may increase participant involvement. TRIAL REGISTRATION NUMBER: NCT03394456