Faculty Bibliography

OBJECTIVE: To evaluate evidence from published randomised controlled trials (RCTs) for the use of task-shifting strategies for cardiovascular disease (CVD) risk reduction in low-income and middle-income countries (LMICs). DESIGN: Systematic review of RCTs that utilised a task-shifting strategy in the management of CVD in LMICs. DATA SOURCES: We searched the following databases for relevant RCTs: PubMed from the 1940s, EMBASE from 1974, Global Health from 1910, Ovid Health Star from 1966, Web of Knowledge from 1900, Scopus from 1823, CINAHL from 1937 and RCTs from ClinicalTrials.gov. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We focused on RCTs published in English, but without publication year. We included RCTs in which the intervention used task shifting (non-physician healthcare workers involved in prescribing of medications, treatment and/or medical testing) and non-physician healthcare providers in the management of CV risk factors and diseases (hypertension, diabetes, hyperlipidaemia, stroke, coronary artery disease or heart failure), as well as RCTs that were conducted in LMICs. We excluded studies that are not RCTs. RESULTS: Of the 2771 articles identified, only three met the predefined criteria. All three trials were conducted in practice-based settings among patients with hypertension (2 studies) and diabetes (1 study), with one study also incorporating home visits. The duration of the studies ranged from 3 to 12 months, and the task-shifting strategies included provision of medication prescriptions by nurses, community health workers and pharmacists and telephone follow-up posthospital discharge. Both hypertension studies reported a significant mean blood pressure reduction (2/1 mm Hg and 30/15 mm Hg), and the diabetes trial reported a reduction in the glycated haemoglobin levels of 1.87%. CONCLUSIONS: There is a dearth of evidence on the implementation of task-shifting strategies to reduce the burden of CVD in LMICs. Effective task-shifting interventions targeted at reducing the global CVD epidemic in LMICs are urgently needed.

OBJECTIVE: To compare bariatric surgery versus intensive medical weight management (MWM) in patients with type 2 diabetes mellitus (T2DM) who do not meet current National Institutes of Health criteria for bariatric surgery and to assess whether the soluble form of receptor for advanced glycation end products (sRAGE) is a biomarker to identify patients most likely to benefit from surgery. BACKGROUND: There are few studies comparing surgery to MWM for patients with T2DM and BMI less than 35. METHODS: Fifty-seven patients with T2DM and BMI 30 to 35, who otherwise met the criteria for bariatric surgery were randomized to MWM versus surgery (bypass, sleeve or band, based on patient preference). The primary outcomes assessed at 6 months were change in homeostatic model of insulin resistance (HOMA-IR) and diabetes remission. Secondary outcomes included changes in HbA1c, weight, and sRAGE. RESULTS: The surgery group had improved HOMA-IR (-4.6 vs +1.6; P = 0.0004) and higher diabetes remission (65% vs 0%, P < 0.0001) than the MWM group at 6 months. Compared to MWM, the surgery group had lower HbA1c (6.2 vs 7.8, P = 0.002), lower fasting glucose (99.5 vs 157; P = 0.0068), and fewer T2DM medication requirements (20% vs 88%; P < 0.0001) at 6 months. The surgery group lost more weight (7. vs 1.0 BMI decrease, P < 0.0001). Higher baseline sRAGE was associated with better weight loss outcomes (r = -0.641; P = 0.046). There were no mortalities. CONCLUSIONS: Surgery was very effective short-term in patients with T2DM and BMI 30 to 35. Baseline sRAGE may predict patients most likely to benefit from surgery. These findings need to be confirmed with larger studies.ClinicalTrials.gov ID: NCT01423877.

A growing body of research demonstrates that psychosocial factors play an important role in the development of hypertension. Previous reviews have identified several key factors (i.e., occupational stress) that contribute to the onset of hypertension; however, they are now outdated. In this review, we provide an updated synthesis of the literature from 2010 to April 2014. We identified 21 articles for inclusion in the review, of which there were six categories of psychosocial stressors: occupational stress, personality, mental health, housing instability, social support/isolation, and sleep quality. Sixteen of the studies reported an association between the psychosocial stressor and blood pressure. While several findings were consistent with previous literature, new findings regarding mediating and moderating factors underlying the psychosocial-hypertension association help to untangle inconsistencies reported in the literature. Moreover, sleep quality is a novel additional factor that should undergo further exploration. Areas for future research based on these findings are discussed.

BACKGROUND: We investigated ethnic differences in sleep duration, and the contribution of socio-economic status (SES) to the observed differences in Amsterdam, the Netherlands. METHODS: 6959 participants (aged 18-71 years) from the multi-ethnic HELIUS cohort were studied. Outcome variables were short sleep (<7 h/night) and long sleep (>/=9 h/night). Comparisons among groups were made using Prevalence Ratios (PRs). RESULTS: Ethnic minority groups were more likely than ethnic-Dutch to report short sleep, with prevalence ranging from 15.1% to 49.7% in men and 16.3% to 41.4% in women. Among men, the age-adjusted PRs ranged from 2.15 (95% CI 1.72-2.69) in Turkish to 3.31 (2.75-3.99) in Ghanaians; and among women, from 1.62 (1.30-2.01) in Turkish to 2.52 (2.15-2.95) in African-Surinamese, respectively. The prevalence of long sleep was significantly higher only in Moroccan men and all the ethnic minority women than in ethnic-Dutch women except for African-Surinamese. Adjustment for SES explains the ethnic difference in long sleep, but not for short sleep. CONCLUSION: Ethnic minority groups reported more short sleep than ethnic-Dutch, while there were no ethnic differences in long sleep. Further study is needed to investigate how this finding on short sleep may contribute to ethnic differences in health outcomes.

Introduction: Inadequate sleep duration is an important public health burden in the United States. However, there is a paucity of information on the relationships between psychological health and inadequate sleep. Our study examined the relationships between emotional distress and inadequate sleep. Methods: Data from the 2009 National Health Interview Survey (NHIS), N = 27,731 participants 18 years and older, were analyzed to investigate the associations of emotional distress with inadequate sleep duration, adjusting for socio-demographic factors, health risks, and chronic diseases. We deine inadequate sleep as less than 7 or greater than 8 hours sleep durations; compared to healthy sleep (7-8 hours). We measured emotional distress, based on Kessler's 6 scale, which assesses the frequency of feeling sad, nervous, restless, hopeless, worthless, and burdened over a 30-day period. Responses were used to generate a score ranging from 0 to 24. Scores of > 13 are considered likely to indicate serious mental illness. Results: Of the sample, 52% were female, 80% were white, 12% black, and 8% other; 30% hold a HS diploma and 31% reported a family income below 31K. Analysis also showed that 10.9% reported emotional distress and 37.2% reported inadequate sleep. Results of our logistic regression analysis revealed that individuals with emotional distress had 57% greater odd of reporting inadequate sleep (OR = 1.5795% C.I. 1.54, 1.61, p < 0.001); the model adjusted for age, sex, race/ethnicity, marital status, education, combined family income, body mass index, history of alcohol consumption, smoking status, and chronic diseases including, arthritis, hypertension, diabetes, cancer, coronary heart disease and heart conditions. Conclusion: Our indings showed that emotional distress, an important proxy for psychological health, was the strongest predictor of inadequate sleep. Other factors associated with inadequate sleep include demographic (age, education, sex, race/ethnicity, combined family income), health!

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 !