Faculty Bibliography

INTRODUCTION: Food insecurity is associated with diet-sensitive diseases and may be a barrier to successful chronic disease self-management. To evaluate the impact of food insecurity on blood pressure reduction in a pilot clinical trial, we tested the effectiveness of 2 behavioral interventions for hypertension in people with and without food security. METHODS: A group of 28 men and women with type 2 diabetes and uncontrolled hypertension were randomized to either 1) home blood pressure telemonitoring alone or 2) home blood pressure telemonitoring plus telephone-based nurse case management. The primary outcome was 6-month change in systolic blood pressure. RESULTS: The 2 interventions resulted in modest, nonsignificant blood pressure reductions. Food-secure patients experienced clinically and statistically significant reductions in blood pressure, whereas no significant change was seen among food-insecure patients. CONCLUSION: Screening for food insecurity may help identify patients in need of tailored disease management interventions.

Study Objectives: This study assessed knowledge and attitudes toward obstructive sleep apnea (OSA) among community physicians and explored factors that are associated with referrals for OSA evaluation. Methods: Medical students and residents collected data from a convenience sample of 105 physicians practicing at community-based clinics in a large metropolitan area. Average age was 48 +/- 14 years; 68% were male, 70% black, 24% white, and 6% identified as "other." Physicians completed the Obstructive Sleep Apnea Knowledge and Attitudes questionnaire. Results: The average year in physician practice was 18 +/- 19 years. Of the sample, 90% reported providing care to black patients. The overall OSA referral rate made by physicians was 75%. OSA knowledge and attitudes scores ranged from 5 to 18 (mean = 14 +/- 2) and from 7 to 20 (mean = 13 +/- 3), respectively. OSA knowledge was associated with white race/ethnicity (rp = 0.26, p < 0.05), fewer years in practice (rp = -0.38, p < 0.01), patients inquiring about OSA (rp = 0.31, p < 0.01), and number of OSA referrals made for OSA evaluation (rp = 0.30, p < 0.01). Positive attitude toward OSA was associated with patients inquiring about OSA (rp = 0.20, p < 0.05). Adjusting for OSA knowledge and attitudes showed that physicians whose patients inquired about OSA were nearly 10 times as likely to make a referral for OSA evaluation (OR = 9.38, 95% CI: 2.32 - 38.01, p < 0.01). Conclusion: Independent of physicians' knowledge and attitudes toward obstructive sleep apnea, the likelihood of making a referral for obstructive sleep apnea evaluation was influenced by whether patients inquired about the condition.

Introduction: Sleep duration has been inconsistently associated with elevated body mass index (BMI) in many populations. The Modeling the Epidemiologic Transition Study (METS), provides an excellent opportunity to assess these associations among populations of African origin at different levels of social and economic development. Methods: METS enrolled 500 young adults, 25-45 years, from each of 5 study sites: rural Ghana, urban South Africa, Seychelles, urban Jamaica and suburban U.S. Anthropometrics and self-reported sleep duration data were collected. Multivariate regression models were used to assess associations between habitual sleep duration and markers of obesity (BMI > 30 kg/m²) using aggregated data (using dummy site variables; n = 2,500), as well as with data from each site individually (n = 500 per analysis). Results: The mean (+/- SD) age was 34.7 (6.2) years. Among men, mean BMI ranged from 22.2 +/- 2.7 to 29.7 +/- 7.5 and among women it ranged from 25.5 +/- 5.2 and 34.1 +/- 8.8 in Ghana and the U.S., respectively. Percent body fat, fat mass, fat-free mass and waist and hip circumferences followed the same general pattern, lowest in Ghana and highest in the U.S. Mean sleep duration was shortest in the US (6.7 +/- 1.4 hours), intermediate in Seychelles (7.2 +/- 1.3), Jamaica (7.3 +/- 1.8), and Ghana (7.9 +/- 1.5) and longest in South Africa (10.3 +/- 1.7; p < 0.001), for both men and women. In multivariate regressions, adjusting for sex, age and site, sleep was significantly inversely associated with BMI, fat mass, fat-free mass, waist circumference and hip circumference (all p < 0.001). When site-specific regressions were conducted, results remained statistically significant across all sites only for fat-free mass (all sites p < 0.05). Conclusion: Sleep duration varied significantly between participants in South Africa and the other 4 METS study sites. In each and across all sites, fat-free mass was consistently more strongly associated with sleep duration than other indicators of obesity, warranting further investigation

Introduction: 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. Methods: 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 +/- 14 years; 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 < 7 hours, referenced to healthy sleep (7-8 hours). 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 (91.4%) and healthy sleepers (93.1%), 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

Introduction: The metabolic syndrome (MetS) and its components, which include hypertension, diabetes, dyslipidemia, and obesity, have been linked to obstructive sleep apnea (OSA). Blacks bear a greater burden of the metabolic syndrome risk factors and are generally at a greater risk for OSA than their white counterparts. This study aimed to determine whether Blacks with MetS are at a significantly increased risk for OSA than those without. It also ascertained which MetS component is the greatest predictor of OSA risk. Methods: A total of 1,035 participants with metabolic syndrome (ages 20-90, mean = 55.7 years; male/female ratio = 1:2.19) and 516 without metabolic syndrome (ages 20-91, mean = 62.4 years; male/female ratio = 1:2.57) were enrolled. They provided sociodemographic and anthropometric data. OSA risk was assessed using the Apnea Risk Evaluation System (ARESTM); patients with a score > 6 were considered at high OSA risk, based on validation studies. Multivariate-adjusted logistic regression was used to model OSA risk with MetS status as the primary outcome. The model also considered the contribution of hypertension, diabetes, dyslipidemia, and obesity, while controlling for differences in sex, birthplace, income, and education. Results: MetS was associated with an increased risk for OSA (OR = 3.85, 95% CI: 2.70-5.48). Diabetes (OR = 2.31, 95% CI: 1.77-3.01) and obesity (OR = 3.35, 95% CI: 2.12-5.28) were the strongest predictors of increased risk. Of note, the risk of OSA decreased slightly with increasing age (OR = 0.97, 95% CI: 0.96-0.98). Education, family income, birthplace and sex did not have significant effects on these associations (p > 0.05). Conclusion: These findings suggest that a diagnosis of MetS increases risks of OSA independent of the effects of MetS components (diabetes or obesity). Patients with metabolic syndrome, diabetes, or obesity should be routinely assessed for OSA risk and treated appropriately to improve overall health and quality of life

Introduction: This study ascertained whether inadequate sleep places unequal burden on blacks, relative to their white counterparts. Methods: Analysis was based on data obtained from adult Americans (age range: 18-85 years) who participated in the National Health Interview Survey, an important surveillance study of the health of the US population providing sociodemographic, health risk, and medical data from 1977-2009. Sleep duration was coded as either very short sleep [VSS] (< 5 hours), short sleep [SS] (5-6 hours), or long sleep [LS] (> 8 hours), referenced to 7-8 hour sleepers. Overweight was defined as BMI > 25.0 and < 29.9 kg/m² and obesity, BMI > 30 kg/m², referenced to normal weight (BMI = 18.5-24.9 kg/m²). Results: Multivariate-adjusted regression analyses indicated that among whites VSS was associated with a 10% increased likelihood of being overweight and 51% increased likelihood of being obese, relative to 7-8 hour sleepers. SS was associated with a 13%) increased likelihood of being overweight and 45% increased likelihood of being obese. LS was not a significant predictor of overweight, but it was associated with 21%o increased likelihood of being obese. Among blacks, VSS was associated with a 76% increased likelihood of being overweight and 81%o increased likelihood of being obese. SS was associated with a 16%o increased likelihood of being overweight and 32%o increased likelihood of being obese. As for whites, LS was not a significant predictor of overweight, but it was associated with a 25%o increased likelihood of being obese. Conclusion: Our investigation demonstrates strong linkages between inadequate sleep and overweight/obesity among both black and white Americans. While it cannot be said that insufficient sleep causes overweight or obesity, it is apparent that blacks sleeping 5 hours or less may be unequally burdened by sleep-related overweight/obesity

Mobile health may be an effective means of providing access and education to the millions of homeless Americans. We conducted semi-structured interviews with 50 homeless people from different shelters in New York City to evaluate their perceptions, attitudes, and experiences regarding mobile health. Participants' average age was 51.66 (SD = 11.34) years; duration of homelessness was 2.0 (SD = 3.10) years. The majority had a mobile phone with the ability to receive and send text messages. Most participants attempted to maintain the same phone number over time. The homeless were welcoming and supportive of text messaging regarding health care issues, including appointment reminders, health education, or management of diseases considering their barriers and mobility, and believed it would help them access necessary health care. Overwhelmingly they preferred text reminders that were short, positively framed, and directive in nature compared to lengthy or motivational texts. The majority believed that free cell phone plans would improve their engagement with, help them navigate, and ultimately improve their access to care. These positive attitudes and experience could be effectively used to improve health care for the homeless. Policies to improve access to mobile health and adapted text messaging strategies regarding the health care needs of this mobile population should be considered.

OBJECTIVES: African-Americans (AAs) have a high prevalence of hypertension and their blood pressure (BP) control on treatment still lags behind other groups. In 2004, NHLBI funded five projects that aimed to evaluate clinically feasible interventions to effect changes in medical care delivery leading to an increased proportion of AA patients with controlled BP. Three of the groups performed a pooled analysis of trial results to determine: 1) the magnitude of the combined intervention effect; and 2) how the pooled results could inform the methodology for future health-system level BP interventions. METHODS: Using a cluster randomized design; the trials enrolled AAs with uncontrolled hypertension to test interventions targeting a combination of patient and clinician behaviors. The 12-month Systolic BP (SBP) and Diastolic BP (DBP) effects of intervention or control cluster assignment were assessed using mixed effects longitudinal regression modeling. RESULTS: 2,015 patients representing 352 clusters participated across the three trials. Pooled BP slopes followed a quadratic pattern, with an initial decline, followed by a rise toward baseline, and did not differ significantly between intervention and control clusters: SBP linear coefficient = -2.60+/-0.21 mmHg per month, p<0.001; quadratic coefficient = 0.167+/- 0.02 mmHg/month, p<0.001; group by time interaction group by time group x linear time coefficient=0.145 +/- 0.293, p=0.622; group x quadratic time coefficient= -0.017 +/- 0.026, p=0.525). Results were similar for DBP. The individual sites did not have significant intervention effects when analyzed separately. CONCLUSION: Investigators planning behavioral trials to improve BP control in health systems serving AAs should plan for small effect sizes and employ a "run-in" period in which BP can be expected to improve in both experimental and control clusters.

OBJECTIVES: The objective of the study was to examine explanatory models of diabetes and diabetes complications among urban poor Ghanaians living with diabetes and implications for developing secondary prevention strategies. DESIGN: Twenty adults with type 2 diabetes were recruited from three poor communities in Accra. Qualitative data were obtained using interviews that run between 40 and 90 minutes. The interviews were audio-taped, transcribed and analysed thematically, informed by the 'explanatory model of disease' concept. RESULTS: Respondents associated diabetes and its complications with diet, family history, lifestyle factors (smoking, excessive alcohol consumption and physical inactivity), psychological stress and supernatural factors (witchcraft and sorcery). These associations were informed by biomedical and cultural models of diabetes and disease. Subjective experience, through a process of 'body-listening,' constituted a third model on which respondents drew to theorise diabetes complications. Poverty was an important mediator of poor self-care practices, including treatment non-adherence. CONCLUSIONS: The biomedical model of diabetes was a major source of legitimate information for self-care practices. However, this was understood and applied through a complex framework of cultural theories of chronic disease, the biopsychological impact of everyday illness experience and the disempowering effects of poverty. An integrated biopsychosocial approach is proposed for diabetes intervention in this research community.

INTRODUCTION: In sub-Saharan Africa (SSA), an estimated 74.7 million individuals are hypertensive. Reducing the growing burden of hypertension in sub-Saharan Africa will require a variety of strategies one of which is identifying the extent to which actions originating at the health systems level improves optimal management and control. METHODS AND RESULTS: We conducted a narrative synthesis of available papers examining health systems factors influencing optimal hypertension in SSA. Eligible studies included those that analyzed the impact of health systems on hypertension awareness, treatment, control and medication adherence. Twenty-five articles met the inclusion criteria and the narrative synthesis identified the following themes: 1) how physical resources influence mechanisms supportive of optimal hypertension control; 2) the role of human resources with enabling and/or inhibiting hypertension control goals; 3) the availability and/or use of intellectual resources; 4) how health systems financing facilitate and/or compromise access to products necessary for optimal hypertension control. CONCLUSION: The findings highlight the need for further research on the health systems factors that influence management and control of hypertension in the region.