Ten-Year Blood Pressure Trajectories, Cardiovascular Mortality, and Life Years Lost in 2 Extinction Cohorts: the Minnesota Business and Professional Men Study and the Zutphen Study

Background Blood pressure (BP) trajectories derived from measurements repeated over years have low measurement error and may improve cardiovascular disease prediction compared to single, average, and usual BP (single BP adjusted for regression dilution). We characterized 10-year BP trajectories and examined their association with cardiovascular mortality, all-cause mortality, and life years lost. Methods and Results Data from 2 prospective and nearly extinct cohorts of middle-aged men—the Minnesota Business and Professional Men Study (n=261) and the Zutphen Study (n=632)—were used. BP was measured annually during 1947–1957 in Minnesota and 1960–1970 in Zutphen. BP trajectories were identified by latent mixture modeling. Cox proportional hazards and linear regression models examined BP trajectories with cardiovascular mortality, all-cause mortality, and life years lost. Associations were adjusted for age, serum cholesterol, smoking, and diabetes mellitus. Mean initial age was about 50 years in both cohorts. After 10 years of BP measurements, men were followed until death on average 20 years later. All Minnesota men and 98% of Zutphen men died. Four BP trajectories were identified, in which mean systolic BP increased by 5 to 49 mm Hg in Minnesota and 5 to 20 mm Hg in Zutphen between age 50 and 60. The third systolic BP trajectories were associated with 2 to 4 times higher cardiovascular mortality risk, 2 times higher all-cause mortality risk, and 4 to 8 life years lost, compared to the first trajectory. Conclusions Ten-year BP trajectories were the strongest predictors, among different BP measures, of cardiovascular mortality, all-cause mortality, and life years lost in Minnesota. However, average BP was the strongest predictor in Zutphen

Dietary protein, blood pressure and mortality : the value of repeated measurements

Cardiovascular diseases (CVD) are the main cause of death worldwide. In 2012, about 17.5 million people died from CVD, accounting for 30% of all deaths. High blood pressure (BP) is a major cardiovascular risk factor, which was responsible for 10.4 million deaths in 2013. Diet and lifestyle play an important role in the etiology of hypertension. Maintenance of a desirable body weight, physical activity, and low intake of alcohol and salt are well-known measures to avoid high BP. Whether dietary protein, or more specifically plant and animal protein, could contribute to maintaining a healthy BP is less clear. The association between BP and CVD mortality has been extensively investigated. BP in prospective studies can be analyzed using different approaches, such as single BP (measured at one moment in time), single BP adjusted for regression dilution, average BP, and trajectories of BP. It is not yet clear which of these approaches is to be preferred for CVD risk prediction. This thesis is centered on BP as a major cardiovascular risk factor. In the first part (Chapter 2, 3 and 4), the relation of dietary protein intake with BP level and change was examined. In the second part (Chapter 5 and 6), various approaches for analyzing repeated BP measurements were compared in relation to CVD and all‑cause mortality risk. The final chapter discusses the main findings and their implications. Chapter 2 describes the association of 24-h urinary urea excretion, as a biomarker of total protein intake, with 9-year incidence of hypertension. We analyzed data of ~4000 men and women aged 28–75 years, who participated in the Prevention of Renal and Vascular Endstage Disease (PREVEND) study, a prospective cohort study. BP was measured four times during 1997–2009 and participants were followed for hypertension incidence, defined as BP ≥140/90mmHg or use of antihypertensive medication. Urea excretion was assessed in two consecutive 24-h urine collections at baseline and approximately 4 years later, from which total protein intake was estimated. Protein intake based on 24-h urinary urea excretion was not associated with incident hypertension. Chapter 3 presents findings for long-term total, animal and plant protein intake in relation to 5‑year BP change. Analyses were based on 702 observations of 272 men who participated in the Zutphen Elderly Study. Participants did not use antihypertensive medication and were initially free of CVD. Physical and dietary examinations were performed in 1985, 1990, 1995, and 2000. BP was measured twice at each examination and protein intake was assessed using the cross-check dietary history method. The upper tertiles of plant protein intake were associated with a mean 5‑year change in systolic BP of ‑2.9 mmHg (95% CI: ‑5.6, ‑0.2), compared with the bottom tertile. Total and animal protein intake was not associated with BP. Chapter 4 describes a meta‑analysis of 12 observational studies and 17 randomized controlled trials (RCTs) of dietary protein, including animal and plant protein, in relation to BP. Protein intake in prospective cohort studies was not associated with incident hypertension. For RCTs that used carbohydrate as a control treatment, the pooled BP effect was ‑2.1 mmHg systolic (95% CI: ‑2.9, ‑1.4) for a weighted mean contrast in protein intake of 41 grams per day. There was no differential effect of animal and plant protein on BP. Chapter 5 describes repeated BP measures and their association with CVD and all‑cause mortality and life years lost in two prospective and nearly extinct cohorts of middle-aged men, the Minnesota Business and Professional Men Study (n=261) and the Zutphen Study (n=632). BP was measured annually during 1947–1957 in Minnesota and 1960–1970 in Zutphen. After 10 years of BP measurements, men were followed until death on average 20 years later. Each 25-mmHg increase in average SBP was associated with a 49% to 72% greater CVD mortality risk, 34% to 46% greater all-cause mortality risk and 3 to 4 life years lost. Four systolic BP trajectories were identified, in which mean systolic BP increased by 5 to 49 mmHg in Minnesota and 5 to 20 mmHg in Zutphen between age 50 and 60. In Zutphen, a 2-times greater CVD and all-cause mortality risk and 4 life years lost were observed when comparing trajectories. In Minnesota, associations were twice as strong. BP trajectories were the strongest predictors of CVD mortality and life years lost in Minnesota men, whereas in Zutphen men, the average BP was superior to other measures. Chapter 6 presents findings for average BP and BP trajectories in relation to CVD and all-cause mortality, taking into account antihypertensive medication. A total of 762 participants aged ≥50 years of the Rancho Bernardo Study were examined five times from 1984 to 2002 and monitored for cause‑specific mortality from 2002 to 2013. Each 20‑mmHg increment in average systolic BP was associated with 35% greater CVD mortality and 25% greater all-cause mortality risk. We identified four trajectories for systolic BP for which BP increases ranged from 5 to 12 mmHg between age 60 and 70. In individuals who belonged to the higher trajectories, 2‑3 times greater CVD mortality and 1.5-times greater all-cause mortality risks were observed, compared to those who belonged to the lowest trajectory. Long-term systolic BP trajectories and average systolic BP were both significant predictors of CVD and all-cause mortality. The associations were not modified by antihypertensive medication. As described in Chapter 7, various approaches were used to study the relation between protein intake and BP. Findings from individual studies and a meta-analysis suggest that dietary protein per se does not affect BP within the range of intake generally consumed in the Netherlands. Replacing carbohydrates by protein, however, has a beneficial effect on BP. Moreover, this thesis showed that BP trajectories are not superior to average BP in predicting CVD and all-cause mortality. A few repeated BP measurements, e.g. three or four, are likely to be sufficient for obtaining a reliable average BP and had a similar predictive value for mortality compared to BP trajectories. Therefore, average BP can be considered the most practical tool for estimating mortality risk

Associations of plant and animal protein intake with 5-year changes in blood pressure: The Zutphen Elderly Study

Background and aim The aim of the present study was to investigate the association of plant and animal protein intake with 5-year changes in blood pressure (BP) level. Methods and results Analyses were based on 702 observations of 272 men participating in the Zutphen Elderly Study. Men did not use antihypertensive medication and were initially free of cardiovascular disease, diabetes mellitus and cancer. Physical and dietary examinations were performed in 1985, 1990, 1995, and 2000. Diet was assessed using the cross-check dietary history method. Men were categorised into tertiles according to their plant and animal protein intake. BP was measured twice at each examination. The associations of plant and animal protein intake with 5-year changes in BP level were investigated by a random intercept model with first-order autoregressive (AR [1]) serial correlation and a nugget effect. Adjustments were made for age, examination year, BMI, socioeconomic status, smoking, physical activity, prescribed diet, alcohol consumption and intake of energy and nutrients. In 1985, men were 70.1 ± 4.6 years old and had a mean BP of 147/84 mmHg. Mean protein intake was 15 en%, of which one-third consisted of plant protein. The higher-intake tertiles of plant protein intake were associated with a mean 5-year change of -2.9 mmHg (95% CI: -5.6, -0.2) systolic and -1.7 mmHg (95% CI: -3.2, -0.2) diastolic, compared with the lowest-intake tertile. No associations were observed for animal protein intake. Conclusion Intake of plant protein, but not animal protein, was inversely associated with 5-year changes in BP level in elderly men

Joint associations of alcohol consumption and physical activity with all-cause and cardiovascular mortality.

Individual associations of alcohol consumption and physical activity with cardiovascular disease are relatively established, but the joint associations are not clear. Therefore, the aim of this study was to examine prospectively the joint associations between alcohol consumption and physical activity with cardiovascular mortality (CVM) and all-cause mortality. Four population-based studies in the United Kingdom were included, the 1997 and 1998 Health Surveys for England and the 1998 and 2003 Scottish Health Surveys. In men and women, respectively, low physical activity was defined as 0.1 to 5 and 0.1 to 4 MET-hours/week and high physical activity as >= 5 and >= 4 MET-hours/week. Moderate or moderately high alcohol intake was defined as >0 to 35 and >0 to 21 units/week and high levels of alcohol intake as >35 and >21 units/week. In total, there were 17,410 adults without prevalent cardiovascular diseases and complete data on alcohol and physical activity (43% men, median age 55 years). During a median follow-up period of 9.7 years, 2,204 adults (12.7%) died, 638 (3.7%) with CVM. Cox proportional-hazards models were adjusted for potential confounders such as marital status, social class, education, ethnicity, and longstanding illness. In the joint associations analysis, low activity combined with high levels of alcohol (CVM: hazard ratio [HR] 1.95, 95% confidence interval [CI] 1.28 to 2.96, p = 0.002; all-cause mortality: HR 1.64, 95% CI 1.32 to 2.03,

Blood pressure trajectories in relation to cardiovascular mortality : The Rancho Bernardo Study

The added value of blood pressure (BP) trajectories for predicting cardiovascular disease (CVD) is currently unknown. We investigated the association of systolic BP (SBP) trajectories with CVD and all-cause mortality and compared these associations with those of average SBP, taking antihypertensive medication into account. Data from 762 participants of the Rancho Bernardo Study were used. SBP from five examinations (maximum) from 1984 to 2002 was used; mortality data were obtained from 2002 to 2013. SBP trajectories were derived using group-based trajectory modelling. Cox proportional hazards analysis was used to investigate associations of trajectories and average SBP with CVD and all-cause mortality, adjusted for age, sex, cholesterol, smoking, diabetes and antihypertensive medication. Mean baseline age was 65.7 years, and 67% were women. Four trajectories were identified, in which mean SBP increased by 5–12 mm Hg during 10 years. The highest trajectories were associated with two to three times greater CVD mortality and 1.5 times greater all-cause mortality risk, compared with the lowest trajectory. Each 20 mmHg increment in average SBP was associated with 1.4 times greater CVD mortality risk and 1.2 times all-cause mortality risk. Associations were not modified by antihypertensive medication (P-interaction>0.10). SBP trajectories were not superior to average SBP in predicting CVD and all-cause mortality. In the general middle-aged and older population of the Rancho Bernardo study, SBP trajectories provided no added value to average SBP in predicting CVD and all-cause mortality. Long-term average SBP levels and trajectories were significant predictors of CVD and all-cause mortality, irrespective of prescribed antihypertensive medication (which in the 1980s–1990s mainly were diuretics and β-blockers).Journal of Human Hypertension advance online publication, 23 March 2017; doi:10.1038/jhh.2017.20

Association of physical activity with all-cause mortality and incident and prevalent cardiovascular disease among patients with type 1 diabetes: the EURODIAB Prospective Complications Study

AIMS/HYPOTHESIS: The aim of this study was to examine the association of physical activity (PA) with all-cause mortality and incident and prevalent cardiovascular disease (CVD) among patients with type 1 diabetes. METHODS: The EURODIAB Prospective Complications Study is a cohort including 3,250 male and female patients with type 1 diabetes (mean age 32.7¿±¿10.2 years) from 16 European countries, of whom 1,880 participated in follow-up examinations. In analysis 1 (longitudinal), the association of baseline PA (based on the reported number of hours per week spent in mild, moderate and vigorous PA) with all-cause mortality and incident CVD was examined by performing survival analysis. In analysis 2 (cross-sectional), we focused on the association between PA at follow-up (data on sports, walking distance and regular bicycling) and prevalent CVD by performing logistic regression analysis. Adjustments were made for age, sex, BMI, smoking, consumption of alcohol, consumption of certain nutrients and diabetic complications. RESULTS: Analysis 1 (longitudinal): participation in moderate or vigorous PA once a week or more was borderline inversely associated with all-cause mortality (men and women combined) (HR 0.66, 95% CI 0.42, 1.03) and incident CVD (women only) (HR 0.66, 95% CI 0.40, 1.08). No association was found in men. Analysis 2 (cross-sectional): total PA (indexed by sports, walking, bicycling) and distance walked were inversely associated with prevalent CVD (OR(totalPA) 0.66, 95% CI 0.45, 0.97; and OR(walking) 0.61, 95% CI 0.42, 0.89). CONCLUSIONS/INTERPRETATION: PA showed a borderline inverse association with both all-cause mortality (both sexes) and incident CVD (women only) in patients with type 1 diabetes. Since this is an under-researched clinical population, future longitudinal studies with objective PA measurements are needed to expand on these results

Correction: Essential amino acids in the gluten-free diet and serum in relation to depression in patients with celiac disease

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