Faculty Bibliography

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: Studies have shown a significant association between long sleep (defined as > 8 hours) and various chronic conditions such as cardiovascular disease, obesity, cancer, and stroke. Moreover, research suggests that long sleep may be more detrimental to one's health than is short sleep. The purpose of this study was to determine the mediating role of body mass index (BMI), physical activity, and emotional distress on the relationship between long sleep and chronic conditions. Methods: The study utilized data from the National Health Interview Survey, an ongoing, nationally representative, cross-sectional study of noninstitutionalized U.S. adults (> 18 years) between 2003 and 2014 (n = 911,773). Structural equation modeling was employed to assess mediation of observed and latent factors using Path Coefficient Estimate (PCE). Physical activity was defined as 10+ minutes of either moderate or vigorous activity. We measured emotional distress with Kessler's 6 scale. Chronic diseases included hypertension, coronary heart disease, diabetes, stroke, kidney disease, cancer and history of heart attack. Results: Of the sample, 51.6% were female; 76.2%, White; and 15.6%, Black/African-American with a mean age of 35.79 +/- 22.4 yrs. Physical activity significantly mediated relationships between long sleep and presence of all chronic diseases (p < 0.001), while emotional distress only mediated relationships between long sleep and kidney disease, diabetes, stroke, and heart attack. Physical activity showed a negative relationship with long sleep (PCE = -0.012, p < 0.001), while emotional distress was positively associated with long sleep (PCE = 0.134, p < 0.01). Of interest, BMI did not significantly mediate relationships between long sleep and chronic conditions (PCE = -0.008, p = 0.322). Covariates included age, sex, income, race, and marital status. Conclusion: Our analysis revealed that the dynamic relationships between long sleep and chronic conditions were mediated by physical activity and emotional distress. Future research should explore the relationships between long sleep and BMI, which in our analyses did not prove significant

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

Introduction: Daily rhythmicity in locomotor activity has been studied in great detail in laboratory animals, but not in humans. We collected actigraphic data from individuals from five countries to explore the circadian organization of human physical activity. Methods: Physical activity was assessed using the Actical accelerometer in five countries differing in socioeconomic development as defined by the United Nations' Human Development Index (HDI): Ghana (HDI = 0.541) as a lower "medium" HDI country, South Africa (0.619) as "medium", Jamaica (0.727) and Seychelles (0.773) as "high", and the U.S.A. (0.910) as "very high". Participants (n = 2,213; ages 25-45 years; 50% were female) provided demographic and health data including body mass index. Individual activity records, lasting 7 days, were subjected to cosinor analysis to derive parameters of circadian activity rhythms: mesor (mean level), amplitude (half the range of excursion), acrophase (timing), and robustness (rhythm strength). Results: Activity records exhibited statistically significant 24-hour rhythmicity (p < 0.05). Averaged daily physical activity increased noticeably a few hours after sunrise and dropped off around sunset, peaking at 1:42 pm. Women and men did not differ significantly regarding the acrophase of the daily rhythm in each country, but the acrophase showed considerable between-country variation (~3 hours). In the United States, where there was substantial seasonal variation in photoperiod, acrophase followed local time, rather than the times of sunrise or sunset. Quantification of the socioeconomic stages of the five countries suggested that more developed countries have more obese residents (r = -0.83), who were less active (r = 0.69) and exhibited later activity timing (r = -0.69) than less developed countries (all p < 0.05). Conclusion: These results characterize human daily activity rhythm, revealing similarities and differences among five countries that differ in socioeconomic development. The results also document associations between individuals' activity rhythm, body mass index, and socioeconomic development of their respective country

BACKGROUND: Stroke is a leading cause of adult disability and mortality. Intravenous thrombolysis can minimize disability when patients present to the emergency department for treatment within the 3 - 4(1/2) h of symptom onset. Blacks and Hispanics are more likely to die and suffer disability from stroke than whites, due in part to delayed hospital arrival and ineligibility for intravenous thrombolysis for acute stroke. Low stroke literacy (poor knowledge of stroke symptoms and when to call 911) among Blacks and Hispanics compared to whites may contribute to disparities in acute stroke treatment and outcomes. Improving stroke literacy may be a critical step along the pathway to reducing stroke disparities. The aim of the current study is to test a novel intervention to increase stroke literacy in minority populations in New York City. DESIGN AND METHODS: In a two-arm cluster randomized trial, we will evaluate the effectiveness of two culturally tailored stroke education films - one in English and one in Spanish - on changing behavioral intent to call 911 for suspected stroke, compared to usual care. These films will target knowledge of stroke symptoms, the range of severity of symptoms and the therapeutic benefit of calling 911, as well as address barriers to timely presentation to the hospital. Given the success of previous church-based programs targeting behavior change in minority populations, this trial will be conducted with 250 congregants across 14 churches (125 intervention; 125 control). Our proposed outcomes are (1) recognition of stroke symptoms and (2) behavioral intent to call 911 for suspected stroke, measured using the Stroke Action Test at the 6-month and 1-year follow-up. DISCUSSION: This is the first randomized trial of a church-placed narrative intervention to improve stroke outcomes in urban Black and Hispanic populations. A film intervention has the potential to make a significant public health impact, as film is a highly scalable and disseminable medium. Since there is at least one church in almost every neighborhood in the USA, churches have the ability and reach to play an important role in the dissemination and translation of stroke prevention programs in minority communities. TRIAL REGISTRATION: NCT01909271 ; July 22, 2013.

Poor adherence to prescribed medication regimens remains an important challenge preventing successful treatment of cardiovascular diseases such as hypertension. While studies have documented differences in the time of day or weekday vs weekend on medication adherence, no study has examined whether having a medication-taking routine contributes to increased medication adherence. The purpose of this study was to: (1) identify patients' sociodemographic factors associated with consistent medication-taking routine; (2) examine associations between medication-taking consistency, medication adherence, and blood pressure (BP) control. The study included black patients with hypertension (n = 190; 22 men and 168 women; age, mean+/-standard deviation 54 +/- 12.08 years) who completed a practice-based randomized controlled trial. Findings showed that medication-taking consistency was significantly associated with better medication adherence (F = 9.54, P = .002). Associations with the consistency index were not statistically significant for diastolic BP control (odds ratio, 1.319; 95% confidence interval, 0.410-4.246; P = .642) and systolic BP control (odds ratio, 0.621; 95% confidence interval, 0.195-1.974; P = .419).

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.

INTRODUCTION: The association between sleep disturbances and cardiometabolic diseases has been understudied in blacks with metabolic syndrome. METHODS: This study is a cross-sectional analysis of the Metabolic Syndrome Outcome Study (MetSO) trial. We assessed insomnia symptoms, sleep duration, and risk for sleep apnea. Multivariate logistic regression models evaluated the association between sleep disturbances with diabetes mellitus (DM) and the combined outcomes of DM and hypertension as well as DM and dyslipidemia. RESULTS: The sample consisted of 1,013 participants, mean age of 62 +/- 14 years and 61% female. DM was diagnosed in 60% of the sample. Sleep apnea risk was observed in 48% of the sample, while 10% had insomnia symptoms and 65% reported short sleep duration (< 6 hours). Sleep apnea risk, but not insomnia or sleep duration, was associated with DM (OR 1.66; 95% CI 1.21-2.28), adjusting for age, sex, income, obesity (BMI >/= 30 kg/m2), tobacco use, alcohol use, hypertension, dyslipidemia, and depression. In fully adjusted models, sleep apnea risk was associated with the combined outcome of DM-hypertension (OR 1.95; 95% CI 1.42-2.69), but not with diabetes-dyslipidemia. CONCLUSION: We observed a strong association between sleep apnea risk and diabetes mellitus among blacks with metabolic syndrome.

Environmental factors, such as noise exposure and air pollution, are associated with hypertension. These environmental factors also affect sleep quality. Given the growing evidence linking sleep quality with hypertension, the purpose of this review is to investigate the role of sleep as a key mediator in the association between hypertension and environmental factors. Through this narrative review of the extant literature, we highlight that poor sleep quality mediates the relationship between environmental factors and hypertension. The conceptual model proposed in this review offers opportunities to address healthcare disparities in hypertension among African Americans by highlighting the disparate impact that the predictors (environmental factors) and mediator (sleep) have on the African-American community. Understanding the impact of these factors is crucial since the main outcome variable (hypertension) severely burdens the African-American community.

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.