Faculty Bibliography

Purpose: Blacks are less likely to develop metabolic syndrome (MetS), a known cardiovascular risk factor. These findings should be interpreted cautiously because Blacks may not fit into the gold-standard diagnostic criteria and report lower lipid profiles levels. To resolve this issue, we suggest reclassifying the relative weighted effects of each MetS component in a diagnostic risk model. We argue that uncontrolled blood pressure is the strongest predictor of MetS in Blacks, because it causes obstructive sleep apnea (OSA), a known MetS risk factor. Method: Data were collected from 340 participants from the MetS Outcome study, a NIH-funded cohort study of 1,035 Blacks with MetS (mean age=62+/-13 years, 69% female, and 43% with annual family income <$10K). Patients with a BP <140/80 mm/Hg after several antihypertensive medications had uncontrolled BP and a score >6 on the Apnea Risk Evaluation System (ARES+/-) were considered high OSA risk. Results: 77.1% was at risk for OSA and 16.8% had uncontrolled BP. Mean systolic BP was 134.8+/-18.4; diastolic BP was 75.6+/-11.9; LDL cholesterol was 105.6+/-36.9; HDL cholesterol was 48.0+/-17.3; triglycerides were 135.8+/-81.2; glucose was 138.4+/-68.3; and HbA1c was 7.93+/-1.63. Uncontrolled BP increased the odds of OSA risk (OR=1.94, 95% CI=1.12-3.32, p<0.01) and was the strongest predictor of MetS in Blacks. Conclusion: Uncontrolled BP was associated with a twofold greater risk of OSA and the strongest predictor of MetS in Blacks. Blacks, therefore, with uncontrolled BP should be screened for the presence of OSA and MetS

Purpose: Resistant hypertension (RHTN) is an important condition affecting 3-29% of the US population, albeit more common among blacks. We evaluated associations of RHTN with short sleep among blacks. Method: Data came from the Metabolic Syndrome Outcome Study (MetSO), an NIH-funded cohort study characterizing metabolic syndrome (MetS) among blacks. Analysis was based on 883 patients (mean age: 62+/-14years; female: 69.2%). MetS was defined according to criteria from the Adult Treatment Panel (ATP III). RHTN was defined as failure to achieve blood pressure goal (BP) of <140/90 mm/Hg or <130/80 mm/Hg among patients with diabetes or kidney disease when on maximal doses of a three-drug regimen. This also includes patients requiring more medications to achieve BP goal. Short sleep, derived from subjective reports, was defined as <7hours nightly referenced to healthy sleep (7-8hours). OSA risk was assessed using the Apnea Risk Evaluation System (ARESTM); patients with a score >6 were considered at high OSA risk, based on validated studies. Results: Most (90.4%) were overweight/obese; 61.4% had diabetes; 74.8%, dyslipidemia; 30.2%, heart disease; and 48% were at OSA risk. Overall, 92.6% had HTN, and 20.8% met criteria for RHTN. Analyses showed no significant difference in HTN prevalence comparing short (93.1%), and healthy sleepers (91.4%) but those with RHTN were more likely to be short sleepers (26.8% vs. 14.9%, p<0.001). Based on logistic regression analysis, adjusting for effects of age, sex and medical comorbidities, patients with RHTN had increased odds of being short sleepers (OR=1.90, 95% CI: 1.27-2.90, p=0.002). Of interest, odds of being short sleepers among those at OSA risk were similar (OR=1.92, 95% CI: 1.38-2.68, p<0.001). Conclusion: Among blacks with metabolic syndrome, patients meeting criteria for RHTN showed a twofold greater likelihood of being short sleepers. Adjusted odds of short sleep were remarkably similar to those observed for patients at OSA risk

Purpose: Despite significant advances in the management of hypertension over the last 40 years, blacks are still disproportionately burdened by this condition. The aim of the present study was to assess the prevalence of hypertension between black and white adults in the United States over a forty-year span. Method: We used data from the National Health Interview Survey (NHIS) dataset beginning in 1983 and ending in 2013. NHIS dataset is an on-going, nationally representative, cross-sectional study of non-institutionalized US adults (> 18 years). This yielded data from 361,024 persons of different birthplaces from 54,612 households. Our sample represented a total of 357,342 adults (Whites = 302,730 and blacks = 58,294). Respondents provided sociodemographic and physician-diagnosed chronic conditions. Results: The average age of black and white adults was 43 years and 45 years, respectively. There were more black (56.0%) than white females (51.2%). Blacks were less likely to complete high school (56.3% vs. 64.4%), be employed in the past 12 months (27.6% vs. 6.1%), or be married (36.3% vs. 58.6%); all p < 0.05. Overall, prevalence of hypertension increased from 24.7% in 1983 to 32.5 in 2013. Over the 40 year period, Blacks consistently reported higher prevalence of hypertension than whites. The difference in adjusted prevalence rates blacks and whites increased from 11.6% in 1985 to 16% in 2010. Age and sex-adjusted logistic regressions showed that US black adults were 1.87 times [OR=1.87, 95% CI=1.76-1.99, p<.001] to report hypertension, compared to white adults. Adjustment for all sociodemographic factors reduced the odds ratio [OR=1.77, 95% CI=1.70-1.84, p<.001]. With further adjustment for health risk and chronic diseases, odds rations were further reduced [OR=1.56, 95% CI=1.50-1.62, p<.001]. Conclusion: Relative to whites, blacks reported higher rates of hypertension over time. The disparity in the prevalence of hypertension between black and white did not decline, and may have increased. More research on the mechanisms of hypertension disparities is needed

Introduction: Growing evidence supports a link of major depressive disorder and anxiety to cardiovascular disease outcome. The study evaluated whether individuals with hypertension are more likely to experience psychological distress. Methods: Data analysis was performed using the National Health Interview Survey (NHIS) dataset data (2004-2013), which applies a stratified multistage sample survey of the resident civilian non-institutionalized population. Respondents provided sociodemographic and physician-diagnosed chronic conditions. Hypertension was self-reported and the Kessler-6 (K6) scale was used to assess psychological distress; a score >13 indicated distress. The hypothesized relationship was tested using a multivariate logistic regression model. Results: Among the participants (N=403,621), 51% were female; overall the mean age (+/-SEM) was 35.3+/-0.02 years) and mean BMI was 27.5+/-0.01 Kg/m2. In the entire sample, the prevalence of hypertension was 28.4%. Hypertension was present among 9.7% of those reporting daily exercise, compared to 18.1% among those who did not (p<0.01). Hypertension was present among 7.5% of alcohol abstainers and 23.3% among current or former alcohol users. The mean age of participants with hypertension was 59.7+/-0.05 years versus 42.5+/-0.05 years for those without the condition. Hypertensives were characterized by a higher prevalence of dyslipidemia (51.4% versus 11.8%, p<0.01), diabetes mellitus (6.7% versus 3.8%, p<0.01), and weak/failing kidney (4.7% versus 0.8%, p<0.01). Multivariate logistic regression, adjusting for cardiovascular risk factors: age, race, BMI, diabetes, physical activity, sleep duration, marital status, educational level, and poverty status, indicated that individuals with hypertension were 30% more likely to experience psychological distress (OR = 1.30, 95% CI=1.16-1.46, p<0.01). There was significant interaction between psychological distress and race (beta=0.09, p<0.01). Conclusion: Results of this study characterized factors associated with the presence of hypertension. Consistent with our hypothesis, individuals with hypertension were more likely to experience psychological distress. Therefore, individuals with hypertension should be screened for the presence of psychological distress

Background: Despite expanding coverage under the Patient Protection and Affordable Care Act (PPACA) of 2010, health utilization and wellness disparities exist across racial and age groups. We hypothesized that rate of wellness assessment indexed by fasting blood sugar and blood lipid levels varied across race and age among individuals with hypertension, regardless of the status of their insurance coverage. Methods: To test our hypotheses, we used the 2010-2013 NHIS dataset. Hypertension was self-reported. Results: Of the sample, 52% were female; mean age (+/-SEM) was 59.5 +/- 0.05 years and mean BMI was 29.5 +/- 0.02 kg/m2. Analysis also showed 74% were white; 20%, black; and 4%, Asian. Ten percent reported no insurance coverage. Chi square analysis showed that there were 9% non-insured whites, 13% non-insured blacks, and 9% non-insured Asians (p<0.01). The rate of non-coverage was 30% for very young adults (18-25 years), 23% for young adults (26-34 years), 15% for middle age adults (35-64 years), and 1% for older adults (> 65 years) (p < 0.01). Among 18-25 years, assessment rates of fasting blood sugar level were 22.1% versus 35.5%, p<0.01; among 25-34 years, they were 25.1% versus 49.7%, p<0.01; among 35-64 years, they were 45.8% versus 68.0%, p<0.01; among those > 65 years, they were 58.6% versus 71.2%, p<0.01. Similarly, lower rates of fasting blood lipid were noted for non-insured hypertensives across the age groups. Among 18-25 years, 32.5% versus 50.1%, p<0.01; among 25-34 years, they were 35.2% versus 66.2%, p<0.01; among 35-64 years, they were 58.1% versus 86.1%, p<0.01; among those > 65 years, they were 73.1% versus 92.2%, p<0.01. Race-based wellness care contrasts between noninsured and insured hypertensives revealed that the rates of annual fasting blood sugar assessment rates were lower among the non-insured. Among Asians rates were (44.1% versus 68.3%, p<0.01); blacks (42.6% versus 66.4%, p<0.01); whites (40.6% versus 72.5%, p<0.01). The non-insured also had fewer assessment rates for fasting lipid. Among Asians rates were (57.2% versus 88.3%, p<0.01); blacks (61.7% versus 88.0%, p<0.01); whites (57.2% versus 87.3%%, p<0.01). Conclusion: Consistent with our hypotheses, individuals with hypertension had varying rates of wellness assessment for blood sugar and blood lipid levels. Results also suggested that the rates of health insurance coverage differed by individuals' age group and race

Background: Short sleep, resulting from sleep disorders or lifestyle choices, is increasingly recognized as an important factor in stroke prevention and management. Recent evidence also suggests that long sleep may also be associated with medical and comorbidities. In a cohort of patients with hypertension, we sought to evaluate whether sleep duration (short or long) is associated with increased stroke risk. Methods: Data from the National Health Interview Survey (2004-2013) were used. NHIS is an on-going nationally representative cross-sectional study of non-institutionalized US adults (> 18 years). Respondents provided sociodemographic and physician-diagnosed chronic conditions. Only those answering "yes" to the question "Have you EVER been told by a doctor or other health professional that you had hypertension, also called high blood pressure?" were included in the analysis. Sleep duration was categorized as very short (<5 hours), short (5-6 hours), healthy (7-8 hours), or long (>8 hours). Self-reported diagnosis of stroke was the main outcome of interest. Result: A total number of 203,794 self-reported hypertensive patients (mean age [+/-SEM] = 59.5 +/- 0.1 years and mean BMI = 29.7 +/- 0.1 kg/m²; 50.2% were female; 15.4%, Black; and 78.6%, White) were studied. Stroke prevalence was 11.2% among very short sleepers, 5.7% among short sleepers, 13.6% among long sleepers and 5.4% among healthy sleepers (p<0.05). Adjusted logistic regressions showed that hypertensive patients reporting very short sleep or long sleep had an increased odds of stroke, relative to healthy sleepers (OR = 1.83; 95% CI = 1.56-2.14), and (OR = 1.74; 95% CI =1.68 - 1.80), respectively. Analysis adjusted for demographic variables, medical comorbidities, smoking history, alcohol intake, and physical activity levels. Conclusion: Hypertensive patients with either very short sleep or long sleep duration had an almost twofold greater likelihood of having a stroke. Healthcare providers caring for hypertensive patients should incorporate a sleep history in their routine examination in order to optimize efforts to prevent or manage stroke

BACKGROUND: Globally, there is an increasing prevalence of high blood pressure (HBP) among adults and youth. However, the mechanisms of how the risk factors (physical inactivity and obesity) relate with blood pressure (BP) are not well known especially among the urban poor youth in low and middle income countries. Meanwhile childhood and adolescent physical inactivity and obesity, particularly in conditions of poverty, predispose individuals to cardiovascular diseases (CVDs) in later life. The aim of this study was to assess the BP levels and to examine its associations with physical activity (PA) and body mass index (BMI) amongst urban poor youth in Accra, Ghana. METHODS: We studied 201 youth aged 15-24 years in three urban poor communities in Accra, Ghana. Height, weight and BP were measured in all subjects. PA levels were assessed using the Edulink Urban Health and Poverty project questionnaire. Multiple linear regression analysis was used to determine the factors influencing BP levels. RESULTS: The proportion of pre-hypertension and hypertension among the youth was 32.3% and 4%, respectively. The rates of pre-hypertension (42.0 vs. 24.8) and hypertension (6.8 vs. 1.8) were higher in males than in females. More than three-quarters (84.1%) of the youth were not physically active. Females were more physically inactive compared to the males (94.7% vs. 70.5%). The average BMI was 22.8 kg/m(2). For overweight (17.7 vs. 6.8) and obesity (13.3 vs. 2.3), females had higher rates than males. BMI was positively related to systolic BP, and significantly associated with systolic BP (beta = 1.4, p < 0.000 and beta = 0.8, p < 0.000; respectively for male and female youth) compared to diastolic BP. Youth with low PA had raised BP. CONCLUSION: The positive association of BMI and BP in the study communities suggests the need for health measures to tackle their increase and related public health consequences. Further studies on BP and other risk factors among the youth of rural populations and other developing countries will be important to stall the rising prevalence and implications for adult morbidity and mortality.

BACKGROUND: Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites. This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these populations. Home blood pressure telemonitoring (HBPTM) and nurse case management (NCM) have proven efficacy in addressing the multilevel barriers to blood pressure (BP) control and reducing BP. However, the effectiveness of these interventions has not been evaluated in stroke patients. This study is designed to evaluate the comparative effectiveness, cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension. METHODS/DESIGN: A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are randomly assigned to one of two 12-month interventions: 1) HBPTM with wireless feedback to primary care providers or 2) HBPTM plus individualized, culturally-tailored, telephone-based NCM. Patients are recruited from stroke centers and primary care practices within the Health and Hospital Corporations (HHC) Network in New York City. Study visits occur at baseline, 6, 12 and 24 months. The primary outcomes are within-patient change in systolic BP at 12 months, and the rate of stroke recurrence at 24 months. The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months; and exploratory outcomes include changes in stroke risk factors, health behaviors and treatment intensification. Recruitment for the stroke telemonitoring hypertension trial is currently ongoing. DISCUSSION: The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation. Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension. If effective among Black and Hispanic stroke survivors, these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence. TRIAL REGISTRATION: ClinicalTrials.gov NCT02011685 . Registered 10 December 2013.

PURPOSE: Although the prevalence of mental health disorders in Nigeria is comparable to most developed countries, access to mental health care in Nigeria is limited. Improving access to care requires innovative approaches that deliver mental health interventions at the community level. The aim of this study was to determine the feasibility and acceptability of integrating mental health screening into an existing community-based program for prevention of mother-to-child transmission of HIV targeted at pregnant women and their male partners. METHODS: Pregnant women and their male partners from 117 churches enrolled in the healthy beginning initiative (HBI) in southeast Nigeria participated in the mental health screening project. Two members from each church were trained as church-based health advisors to administer the 12-item general health questionnaire. RESULTS: Ninety-three percent of the pregnant women and their male partners agreed to participate and fully completed the questionnaire. Overall, 21.7 % of the respondents scored above the threshold of 11 indicating significant psychological distress, with women having significantly higher scores than men. CONCLUSION: Mental health screening is feasible and well accepted among a cohort of pregnant women and their male partners. Church members can be trained as health advisors to administer mental health screening. Mental health interventions can be developed on the framework of the HBI.

BACKGROUND: The current Ebola Virus Disease (EVD) epidemic has ravaged the social fabric of three West African countries and affected people worldwide. We report key themes from an agenda-setting, multi-disciplinary roundtable convened to examine experiences and implications for health systems in Ghana, a nation without cases but where risk for spread is high and the economic, social and political impact of the impending threat is already felt. DISCUSSION: Participants' personal stories and the broader debates to define fundamental issues and opportunities for preparedness focused on three inter-related themes. First, the dangers of the fear response itself were highlighted as a threat to the integrity and continuity of quality care. Second, healthcare workers' fears were compounded by a demonstrable lack of societal and personal protections for infection prevention and control in communities and healthcare facilities, as evidenced by an ongoing cholera epidemic affecting over 20,000 patients in the capital Accra alone since June 2014. Third, a lack of coherent messaging and direction from leadership seems to have limited coordination and reinforced a level of mistrust in the government's ability and commitment to mobilize an adequate response. Initial recommendations include urgent investment in the needed supplies and infrastructure for basic, routine infection control in communities and healthcare facilities, provision of assurances with securities for frontline healthcare workers, establishment of a multi-sector, "all-hazards" outbreak surveillance system, and engaging directly with key community groups to co-produce contextually relevant educational messages that will help decrease stigma, fear, and the demoralizing perception that the disease defies remedy or control. The EVD epidemic provides an unprecedented opportunity for West African countries not yet affected by EVD cases to make progress on tackling long-standing health systems weaknesses. This roundtable discussion emphasized the urgent need to strengthen capacity for infection control, occupational health and safety, and leadership coordination. Significant commitment is needed to raise standards of hygiene in communities and health facilities, build mechanisms for collaboration across sectors, and engage community stakeholders in creating the needed solutions. It would be both devastating and irresponsible to waste the opportunity.