Faculty Bibliography

Introduction: Studies have shown that decreased sleep duration and later sleep timing (midpoint of sleep) are associated with an increased body mass index (BMI). However, previous research has not determined which of these two sleep parameters is a better predictor of BMI. This study sought to determine whether sleep timing is a better predictor of the likelihood of being overweight/obese than insuficient sleep. Methods: Volunteers consisted of 459 postmenopausal women (mean age = 67.71 + 7.87 years) participating in the Women's Health Initiative study. Of the sample, 72% were non-Hispanic white; 14% Hispanic; 9% black; and 5% other. Volunteers wore an actigraph (Actillume) (ACT) and kept a seven-day sleep diary (SD) to estimate habitual sleep durations. ACT data were scored using a validated algorithm (Cole-Kripke) provided by the Actillume manufacturer. Subjective and actigraphic data were averaged over a period of 7 days to obtain an index of both objective and subjective sleep duration. Sleep timing was derived by calculating the midpoint of reported bedtimes and rise times. Results: Analysis revealed that 20.6% of the volunteers experienced short sleep (< 6 hours) based on subjective data; 47.7% experienced short sleep based on actigraphic estimates. The average sleep timing occured at 03:08. Of the sample, 62% were categorized as overweight or obese. Multivariate-adjusted linear regression showed that only ACTderived sleep duration was signiicantly associated with being overweight/ obese (OR = 2.46 (95% CI: 1.39-4.35, p < .001). There were no statistically signiicant associations between subjective sleep duration or sleep timing with overweight/obesity. The model adjusted for age, race, physical activity and sleep medications. Conclusion: Results suggest that insuficient sleep as measured by actigraphy is the single most important predictor of the likelihood of being overweight/obese among older women. Unlike previous research, sleep timing was not signiicantly associated with being overw!

Introduction: Many risk factors have been implicated in the pathophysiology of obstructive sleep apnea (OSA). Recent evidence suggests that medical risk factors, such as uncontrolled/high blood pressure (BP), high cholesterol, triglycerides, high body mass index, diabetes, and dyslipidemia (all indicators of metabolic syndrome) are highly comorbid with OSA. However, data on the relationships between these risk factors and OSA among blacks with metabolic syndrome are lacking. Methods: Data for the present study were collected from 340 participants from the Metabolic Syndrome Outcome (MetSO) study, a NIHfunded cohort study of 1,035 blacks with metabolic syndrome (mean age = 62 + 13 years, 69% female, and 43% with annual family income < $10K). During initial interviews, patients provided sociodemographic, health risks, and history of chronic diseases. Patients with a score > 6 on the Apnea Risk Evaluation System (ARES) were considered at high OSA risk. Logistic regression analyses were employed to investigate whether metabolic syndrome indicators, particularly uncontrolled blood pressure, increased the odds of OSA. Results: Of the sample, 77.1% was at risk for OSA and 16.8% had uncontrolled BP. Analysis also showed 60.4% were diabetic, 8.9% had a stroke history, 74.3% had dyslipidemia, 91.1% were either overweight or obese and 30.9% had heart disease. 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 was 135.8 + 81.2; glucose was 138.4 + 68.3; and HbA1c was 7.93 + 1.63. Logistic regression analysis showed that uncontrolled BP independently increased the odds of OSA risk (OR = 1.94, 95% CI = 1.12-3.32, p < 0.01). Conclusion: Our indings suggest that uncontrolled BP was associated with a twofold greater risk of OSA in blacks. The clinical implication of this inding is that blacks with metabolic syndrome and who have uncontrolled BP should be screened for the presence of OSA

Introduction: Identiication of risk factors for obstructive sleep apnea (OSA) is important to enable comprehensive intervention to reduce associated cardiovascular (CV) morbidity and mortality. The Metabolic Syndrome Outcome Study provides a unique opportunity to assess the presence of these factors among blacks, a group that is at high risk for adverse CV outcomes. The purpose of this study was to investigate risk of OSA among blacks with metabolic syndrome Methods: The present study utilized data from the Metabolic Syndrome Outcome (MetSO) study, an NIH-funded cohort study of blacks with metabolic syndrome. A total of 1,035 patients provided data for the present analysis. Patients were diagnosed with metabolic syndrome using criteria articulated in the joint interim statement for harmonizing the metabolic syndrome. OSA risks for all patients were assessed with the Apnea Risk Evaluation System (ARES). Those with an ARES score > 6 were considered at high OSA, based on previous validation studies. Data was coded and analyzed by an experienced statistician using SPSS 19.0. Results: The average age of the sample was 62 + 14 years (range: 20- 97); 71% were female. Of the sample, 93% were diagnosed with hypertension; 61%, diabetes; 72%, dyslipidemia; 90% were overweight/ obese; 33% had a history of heart disease and 10% had a stroke. ARES data indicated that 48% were at high OSA risk. Using multivariate logistic regression analysis, adjusting for age and gender, we observed that obesity was the strongest predictor of OSA risk (OR = 1.59, 95%CI = 1.24-2.04, p < 0.0001). This inding remained signiicant even after adjustment for blood pressure, LDL, HDL, and glucose levels (OR = 1.44, 95%CI = 1.11-1.86, p < 0.001). Conclusion: Of all of the markers of the metabolic syndrome, obesity is the most important predictor of increased risk of OSA among blacks. Our inding is consistent with previous research regarding the obesityapnea link

Introduction: Sleep among blacks with metabolic syndrome is not well characterized. Our study examined sleep characteristics of black men and women with a diagnosis of metabolic syndrome. Methods: The present study utilized data from the Metabolic Syndrome Outcome Study (MetSO), an NIH-funded cohort study of blacks with metabolic syndrome (N = 1,035). Patients [mean age = 62 + 14 years; female = 71%] were diagnosed with metabolic syndrome using criteria articulated in the joint interim statement for harmonizing the metabolic syndrome. They provided self-reported data including sleep habits and insomnia symptoms. They were administered the Apnea Risk Evaluation System (ARES) to ascertain risk of obstructive sleep apnea (OSA). Patients with a score of > 6 on the ARES scale were considered at high OSA risk, based on validation studies. Results: Of the sample, 60% were diagnosed with diabetes; stroke, 10%; heart disease, 31%; hypertension, 93%; overweight/obese, 90%. Based on ARES data, 48% were at risk for OSA. Analysis also showed that 53% reported feeling sleepy during the day, and 10% had an insomnia diagnosis. Speciic insomnia symptoms included dificulty falling asleep (38%), dificulty maintaining sleep (42%), early morning awakening (46%); 53% reported daytime naps, and 12% used sleep medication. Prevalence of short sleepers (< 6 hrs) and long sleepers (> 9 hrs), referenced to healthy sleepers (7-8 hrs), was 70% and 19%, respectively. Based on chi-squared analysis, there was signiicant difference between males and females in regard to reported daytime sleepiness (41% vs. 56%; x2 = 7.736, p < 0.05), dificulty falling asleep (34% vs. 41%; x2 = 5.252, p < 0.05), and daytime naps (60% vs. 50%, x2 = 8.338, p < 0.05). No other signiicant gender differences were observed. Conclusion: Our indings suggest that a large number of blacks with metabolic syndrome experience insomnia symptoms, use sleep aids, and are both short and long sleepers. These sleep-related problems are associated with a myriad of !

Introduction: Although the relationship between sleep duration and body mass index (BMI) has been well-characterized, the underlying mechanisms have not. Understanding which factors explain this relationship would provide important insights in developing effective public health interventions to reduce associated cardiometabolic risks. The present study investigated 5 potential mediators of the relationship between sleep duration and BMI. Methods: Data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) was used in our analysis. BRFSS is a CDC-sponsored project representing the world's largest ongoing, state-speciic, randomized telephone survey that measures behavioral risk factors among U.S. adults [mean age = 56 + 16 years, female = 63%]. Analysis focused on interviews conducted in six representative states, soliciting sociodemographic, medical, sleep, and health-risk data, yielding observations for n = 35,895 respondents. A bootstrapping method was employed to generate conidence intervals (BCCI) ascertaining total and unique mediation across all 5 hypothesized mediators simultaneously (using 1,000 bootstrap samples) of the sleep duration and BMI relationship. The hypothesized mediators included: alcohol use, diet, physical activity, general health status, and life satisfaction. Age and sex were adjusted in all tested models. Results: Analysis showed that for each additional hour of sleep BMI decreases by 0.15 unit. Evidence of unique mediation was noted for: physical activity (BCCI = 0.0017 to 0.0102; SE = 0.0022), diet (BCCI =-0.0138 to-0.0052; SE = 0.0022), and general health status (BCCI =-0.0379 to-0.0079; SE = 0.0423). However, there was no evidence of unique mediation for: alcohol use (BCCI =-0.0013 to 0.0019; SE = 0.0008) or life satisfaction (BCCI =-0.0057 to 0.0057; SE = 0.0028). Conclusion: These indings suggest that the sleep and BMI relationship may be partially mediated by physical activity, diet, and general health. This is consistent with previous hypotheses regard!

Introduction: Blacks are less likely to adhere to sleep apnea treatment compared with whites. This study explored the unique perspectives of blacks with metabolic syndrome who were referred for treatment of obstructive sleep apnea (OSA) at local sleep clinics. Methods: A total of 340 adults from the Metabolic Syndrome Outcome Study (MetSO), an NIH-funded cohort study of blacks, were randomly assigned to receive either Tailored-Telephone Intervention or regular standard of care. Prior to randomization, participants provided a detailed sleep history assessing sleep habits and OSA risk. The qualitative study involved 4 focus groups (mean age = years; 4 Males, 22 Females). A focus group guide was used to elicit responses from participants. Interviews were audio-taped and transcribed verbatim. Initial a priori codes were developed to guide initial coding. Analysis was guided by grounded theory. We explored 3 important questions: Q1) What are the potential barriers and facilitators of OSA evaluation? Q2) What are the potential barriers and facilitators of CPAP adherence? Q3) What are the experiences of blacks who participated in the intervention? Results: Themes for each question were as follows: Q1 a) general sleep disturbances, b) presence of other health conditions, c) encouragement from loved ones and d) rapport with medical provider plays a key role in adhering to OSA evaluation. Q2 a) improvement in sleep apnea, b) CPAP side effects, c) mistrust of the medical system, d) socio-economic factors limiting ability to participate and e) perception that CPAP device is not necessary were barriers and facilitators of CPAP adherence. Q3 a) having received meaningful information about sleep disorders, sleep hygiene b) increase in health information and c) rapport with the health educator were the experiences of participants in the intervention. Conclusion: To our knowledge, this is the irst study to describe qualitative indings of blacks with metabolic syndrome that participated in an OSA-related interve!

BACKGROUND: The rising burden of chronic non-communicable diseases in low and middle income countries has major implications on the ability of these countries to achieve universal health coverage. In this paper we discuss the impact of cardiovascular diseases (CVD) on primary healthcare services in urban poor communities in Accra, Ghana. METHODS: We review the evidence on the evolution of universal health coverage in Ghana and the central role of the community-based health planning services (CHPS) programme and the National Health Insurance Scheme in primary health care. We present preliminary findings from a study on community CVD knowledge, experiences, responses and access to services. RESULTS: The rising burden of NCDs in Ghana will affect the achievement of universal health coverage, particularly in urban areas. There is a significant unmet need for CVD care in the study communities. The provision of primary healthcare services for CVD is not accessible, equitable or responsive to the needs of target communities. CONCLUSIONS: We consider these findings in the context of the primary healthcare system and discuss the challenges and opportunities for strengthening health systems in low and middle-income countries.

BACKGROUND: Observational studies of patients with rheumatoid arthritis have suggested that racial and ethnic disparities exist for minority populations. We compared disease activity and clinical outcomes across racial and ethnic groups using data from a large, contemporary US registry. METHODS: We analyzed data from 2 time periods (2005-2007 and 2010-2012). The Clinical Disease Activity Index was examined as both a continuous measure and a dichotomous measure of disease activity states. Outcomes were compared in a series of cross-sectional and longitudinal multivariable regression models. RESULTS: For 2005-2007, significant differences of mean disease activity level (P < .001) were observed across racial and ethnic groups. Over the 5-year period, modest improvements in disease activity were observed across all groups, including whites (3.7; 95% confidence interval [CI], 3.2-4.1) compared with African Americans (4.3; 95% CI, 2.7-5.8) and Hispanics (2.7; 95% CI, 1.2-4.3). For 2010-2012, significant differences of mean disease activity level persisted (P < .046) across racial and ethnic groups, ranging from 11.6 (95% CI, 10.4-12.8) in Hispanics to 10.7 (95% CI, 9.6-11.7) in whites. Remission rates remained significantly different across racial/ethnic groups across all models for 2010-2012, ranging from 22.7 (95% CI, 19.5-25.8) in African Americans to 27.4 (95% CI, 24.9-29.8) in whites. CONCLUSIONS: Despite improvements in disease activity across racial and ethnic groups over a 5-year period, disparities persist in disease activity and clinical outcomes for minority groups versus white patients.

OBJECTIVE: Obesity is a pressing public health problem without proven population-wide solutions. Researchers sought to determine whether a city-mandated policy requiring calorie labeling at fast food restaurants was associated with consumer awareness of labels, calories purchased and fast food restaurant visits. DESIGN AND METHODS: Difference-in-differences design, with data collected from consumers outside fast food restaurants and via a random digit dial telephone survey, before (December 2009) and after (June 2010) labeling in Philadelphia (which implemented mandatory labeling) and Baltimore (matched comparison city). Measures included: self-reported use of calorie information, calories purchased determined via fast food receipts, and self-reported weekly fast-food visits. RESULTS: The consumer sample was predominantly Black (71%), and high school educated (62%). Postlabeling, 38% of Philadelphia consumers noticed the calorie labels for a 33% point (P < 0.001) increase relative to Baltimore. Calories purchased and number of fast food visits did not change in either city over time. CONCLUSIONS: While some consumers report noticing and using calorie information, no population level changes were noted in calories purchased or fast food visits. Other controlled studies are needed to examine the longer term impact of labeling as it becomes national law.

Global health (GH) spans every scientific, clinical and social science discipline. Cultural competency/ cross-cultural sensitivity has been identified as a GH priority for U.S. medical schools (Peluso 2013). As part of Curriculum for the 21st Century (C21), the Global Health Selective is prerequisite to the new Global Health Concentration at NYU School of Medicine (SoM). With special emphasis on cultural competency/ crosscultural sensitivity, its primary aim is to teach future physicians fund of knowledge and clinical skills that strengthen GH care. As a 4-week clinical clerkship, the GH Selective was first completed by 9 medical students in 2012, and again by 12 medical students in 2013. Activities included 18 ninety-minute patient case discussions in tropical medicine; related clinical assignments at NYU; literature review and journal clubs; and 9 half-day clinical skills simulation workshops covering 1) diarrhea in Haiti and Egypt, 2) tuberculosis in Peru 3) malaria in sub-Saharan Africa 4) hypertension screening by community health workers in Ghana 5) survivors of torture from central Africa 6) humanitarian response to tsunami in Indonesia 7) obstetrical emergencies in rural Liberia 8) interpreter exercise in Tibetan, and 9) smoking cessation via interpreters. Leadership is from NYU SoM Departments of Medicine and Population Health, and Center for Healthful Behavior Change. Over two years of the GH Selective, student feedback was overwhelmingly positive. Each year, at least 37 faculty volunteered from 11 departments at SoM to log at least 225 hours of direct contact teaching hours each offering. In its first two years, the GH Selective exceeded expectations. Its interdisciplinary curriculum is a particular strength, and its special emphasis on working with standardized patients in cross-cultural settings, focused on communication skills, health literacy, and health navigation, provided students with knowledge and clinical skills applicable for any clinical care provided locally, nationally,!