Causal decomposition to evaluate movement behaviour changes on cardiovascular health inequalities

BackgroundTobacco advertising disproportionately targets low socio-economic position (SEP) groups, causing higher rates of tobacco use in this population. Anti-tobacco public health education campaigns persuade against use. This study measured real-time exposure of pro- and anti-tobacco messages from low SEP groups in two American cities.MethodsIndividuals in low SEP groups (N = 95), aged 18–34 years old, who were smokers and non-smokers, from the Boston and Houston areas, took part in a mobile health study. They submitted images of tobacco-related messages they encountered via a mobile application for a 7-week period. Two coders analyzed the images for message characteristics. Intercoder reliability was established using Krippendorff’s alpha and data were analyzed descriptively.ResultsOf the submitted images (N = 131), 83 were pro-tobacco and 53 were anti-tobacco. Of the pro-tobacco messages, the majority were cigarette ads (80.7%) seen outside (36.1%) or inside (30.1%) a convenience store or gas station and used conventional themes (e.g., price promotion; 53.2%). Of the anti-tobacco messages, 56.6% were sponsored by public health campaigns or were signage prohibiting smoking in a public area (39.6%). Most focused on the health harms of smoking (28.3%).ConclusionLow SEP groups in this study encountered more pro-tobacco than anti-tobacco messages at places that were point-of-sale using price promotions to appeal to this group. Anti-tobacco messages at point-of-sale and/or advertising regulations may help combat tobacco use.

Socioeconomic Inequalities in Intakes of Ultraprocessed and Minimally Processed Foods in Nationally Representative Samples of Adults in Canada: An Analysis of Trends between 2004 and 2015

Introduction: This study aimed to assess the within- and between-states inequality in hypertension management and cardiovascular disease (CVD) risk across sociodemographic groups in India and the correlation between states/UTs expenditure on health, hypertension management, and CVD risk. Methods: This study utilized cross-sectional data from 2017/2018 Longitudinal Aging Study in India (LASI), with a total sample of 58,848 respondents aged ≥45 years. Hypertension management was assessed based on hypertension awareness, treatment, and control, while 10-year CVD risk was measured using the 2019 WHO CVD risk. We used multilevel logistic regression models to estimate the socioeconomic inequality in hypertension management and 10-year CVD risk, measured by the relative index of inequality (RII). Results: Rural areas had a substantially poorer coverage of hypertension awareness, treatment, and control compared with urban areas. Richest socioeconomic groups were more likely to be aware of their hypertensive status (RII 1.28, 95% CI: 1.16–1.42), receive antihypertensive treatment (RII 1.47, 95% CI: 1.28–1.69), have their blood pressure controlled (RII 1.60, 95% CI: 1.34–1.90), and have 10-year CVD risk <10% (1.06, 95% CI: 1.01–1.12) compared to the poorest. The variance partition coefficient ranged from 1.5% for 10-year CVD risk to 9.9% for hypertension control. There was no significant correlation between socioeconomic inequality in hypertension management, 10-year CVD risk, and the per capita public health expenditure of states/UTs. Conclusion: Differences in state-level health system capacity may disproportionately affect socioeconomically disadvantaged populations, underscoring the need for more equitable hypertension management and cardiovascular health strategies across India.

The impact of nutritional policy on socioeconomic disparity in the unhealthy food intake among Korean adolescents

Risk assessment plays a central role in the primary prevention of cardiovascular disease. The 2017 High Blood Pressure Clinical Practice Guideline incorporated quantitative risk assessment for the first time to guide the initiation of antihypertensive drug therapy and recommended calculation of 10-year risk of atherosclerotic cardiovascular disease with the Pooled Cohort Equations. Although the 2025 High Blood Pressure Guideline reaffirmed this overarching paradigm for risk-based initiation of antihypertensive drug therapy, it updated the recommended risk model to the Predicting Risk of Cardiovascular Disease Events equations, which estimate 10-year risk of total cardiovascular disease (including atherosclerotic cardiovascular disease and heart failure), and defined a new risk threshold for initiation of antihypertensive therapy in patients with stage 1 hypertension. This American Heart Association/American College of Cardiology scientific statement summarizes the rationale to recommend the use of the Predicting Risk of Cardiovascular Disease Events equations, the evidence base for the new threshold of 10-year risk of cardiovascular disease of ≥7.5%, and the population-level implications of these revised recommendations. This scientific statement also offers practical advice for implementing risk assessment as the first step in the comprehensive approach to hypertension management with shared decision-making between patients and clinicians. Remaining gaps in awareness and treatment of hypertension underscore the need for innovative strategies to improve implementation of and adherence to risk-based guideline recommendations, including automation of risk assessment in electronic health records, decision-support aids, and refinement of risk assessment, to equitably improve the initiation of antihypertensive drug therapy, blood pressure control, and outcomes.

Informing a person of their individual risk of developing a disease in the future may be sufficient to provide the person with the impetus to adopt risk reducing behaviours. The aim of this study was to determine if a personalised 10-year cardiovascular disease (CVD) risk estimate can increase physical activity and other risk reduction behaviours in adults at high risk of CVD. Pilot 2 × 2 factorial randomised controlled trial conducted in Oxfordshire, UK including 194 adults at increased CVD risk (10-year CVD risk ≥ 20%) recruited from four general practices. Main outcome measure at one month was physical activity measured by accelerometer. Median (IQR) age was 62.3 (54.9, 66.1) years, 67% were men and 19% had known diabetes. Mean (SD) total accelerometer counts per day was 297 × 10(-3) (110 × 10(-3) ) and activity of moderate or greater intensity was undertaken for 53 (22) minutes per day. In the 185 (95%) participants attending follow-up an increase in physical activity was not seen. There was a non-significant 0.5% (p = 0.56) greater increase in accelerometer counts in those receiving personalised CVD risk estimates. No significant within or between group changes were seen at one month in estimated 10-year CVD risk. A net 7% decrease in mean LDL cholesterol (p = 0.004) was seen in the intervention group despite similar increases in new prescriptions for lipid lowering therapies. In adults at increased risk of CVD provision of personalised 10-year CVD risk estimates did not appear to increase physical activity or estimated CVD risk over a one-month period.

Background The Framingham Risk model estimates a person's 10-year cardiovascular disease (CVD) risk. Purpose We aimed to calculate the change in sex-age specific Framingham CVD risk in the Hong Kong Population Health Survey (PHS) 2014/15 in comparison with the survey in 2003–05 (PHS2003/2004 &amp; Heart Health Survey (HHS) 2004/2005). Methods Subjects aged 30–74 years from PHS2014/15 (n=1,662, n=4,445,869 after population weighing) and PHS2003/2004 &amp; HHS2004/2005 (n=818, n=3,495,074 after population weighing) with complete data for the calculation of Framingham CVD predicted risk were included. The sex-specific CVD risks of participants were calculated based on their age, total cholesterol and high-density lipoprotein, mean systolic blood pressure, smoking habits, diabetic status, and treatment for hypertension. The mean sex-age specific CVD risks were then calculated, and the differences in CVD risk between the two surveys were analysed using ANOVA. Results There was no significant difference in 10-year CVD risks between the 2003–2005 and 2014/15 study populations (10.2% vs. 10.6%, p=0.29). After adjusting to a standard population (US Census 2000), the age-standardized CVD risk was lower in 2014–2015 than in 2003–05 (10.0% vs. 10.7%, p=0.017). More participants aged 65–74 were classified as high risk during 2003/04 (PHS2003/2004 &amp; HHS2004/2005: 66.8% vs. PHS2014/15: 53.1%, p=0.026). This might be due to the decrease in the proportion of smokers among men (2003–2005: 30.5% vs. 24.0% in 2014–15, p&amp;lt;0.001). Conclusions Between 2003/04 and 2014/15, there was a small decrease in age-standardized 10-year CVD risk, which might be related to the reduction in smoking. However, more effort in targeting multiple CVD risk factors simultaneously is needed to achieve a greater reduction in CVD risk. Funding Acknowledgement Type of funding sources: None.

Early life stress (ELS) is associated with cardiovascular disease (CVD) risk in adulthood, but the underlying vascular mechanisms are poorly understood. Increased hemoglobin and heme have recently been implicated to mediate endothelial dysfunction in several vascular diseases. Chronic physiological stress is associated with alterations in the heme pathway that have been well‐described in the literature. However, very little is known about the heme pathway with exposure to ELS or chronic psychosocial stress. Utilizing a mouse model of ELS, maternal separation with early weaning (MSEW), we previously reported that MSEW induces endothelial dysfunction via increased superoxide production. We reasoned that heme dysregulation may be one of the culprits induced by MSEW and sustained throughout adulthood; thus, we hypothesized that MSEW induces heme dysfunction. We investigated whether circulating levels of heme, a circulating pro‐oxidant mediator, are increased by MSEW and examined the role of the heme metabolic pathway and heme homeostasis in this process. We found that circulating levels of heme are increased in mice exposed to MSEW and that plasma from MSEW mice stimulated higher superoxide production in cultured mouse aortic endothelial cells (MAECs) compared to plasma from normally reared mice. The heme scavenger hemopexin blunted this enhanced superoxide production. Splenic haptoglobin abundance was significantly lower and hemoglobin levels per red blood cell were significantly higher in MSEW versus control mice. These findings lead us to propose that ELS induces increased circulating heme through dysregulation of the haptoglobin‐hemoglobin system representing a mechanistic link between ELS and CVD risk in adulthood.

The aim of this study was to derive and validate the SCORE2-Older Persons (SCORE2-OP) risk model to estimate 5- and 10-year risk of cardiovascular disease (CVD) in individuals aged over 70 years in four geographical risk regions. Sex-specific competing risk-adjusted models for estimating CVD risk (CVD mortality, myocardial infarction, or stroke) were derived in individuals aged over 65 without pre-existing atherosclerotic CVD from the Cohort of Norway (28 503 individuals, 10 089 CVD events). Models included age, smoking status, diabetes, systolic blood pressure, and total- and high-density lipoprotein cholesterol. Four geographical risk regions were defined based on country-specific CVD mortality rates. Models were recalibrated to each region using region-specific estimated CVD incidence rates and risk factor distributions. For external validation, we analysed data from 6 additional study populations {338 615 individuals, 33 219 CVD validation cohorts, C-indices ranged between 0.63 [95% confidence interval (CI) 0.61-0.65] and 0.67 (0.64-0.69)}. Regional calibration of expected-vs.-observed risks was satisfactory. For given risk factor profiles, there was substantial variation across the four risk regions in the estimated 10-year CVD event risk. The competing risk-adjusted SCORE2-OP model was derived, recalibrated, and externally validated to estimate 5- and 10-year CVD risk in older adults (aged 70 years or older) in four geographical risk regions. These models can be used for communicating the risk of CVD and potential benefit from risk factor treatment and may facilitate shared decision-making between clinicians and patients in CVD risk management in older persons.

Introduction and Objective: The aim of this study was to examine the 9-year effects of structured lifestyle interventions on predicted 10-year CVD risk in Asian Indians with high risk for type 2 diabetes. Methods: The Kerala Diabetes Prevention Program (K-DPP) is a cluster-randomized controlled trial conducted in Kerala, India. The study involved 1,007 individuals at high risk for type 2 diabetes, based on Indian Diabetes Risk Score of ≥60. The intervention group participated in a 12-month lifestyle education program. The primary outcome of this study was the predicted 10-year cardiovascular disease (CVD) risk, assessed using the Framingham Risk Score. Results: The mean age at baseline was 46 years and 47.2% were female. The 10-year CVD risk at baseline was similar between study arms. The follow-up rate at 9 years was 85.5%. The difference in mean changes in predicted 10-year CVD risk between the intervention and control groups at 1 year was -0.64% (95% CI: -1.23, -0.04; P=0.030) and at 2 years was -0.68% (95% CI: -1.36, -0.01; P=0.050). However, at the 9 years, there was no difference in CVD risk between the intervention and the control group; 0.16% (95% CI: -1.17, 1.48; P=0.810). Conclusion: A community-based structured lifestyle intervention program reduced CVD risk among individuals at high risk for type 2 diabetes at 1 and 2 years but this was not maintained at 9 years. This was likely due to the profound effects of serious floods and the COVID-19 pandemic in this part of India in the intervening period. Disclosure G.D. Demissie: None. A. Shrestha: None. T. Haregu: None. S. Thirunavukkarasu: None. B. Oldenburg: None. Funding National Health and Medical Research Council (Grant ID: 1160283)

Pain is a significant burden within the U.S. adult population, but little is known regarding epidemiology of pain, particularly with respect to race, ethnicity, and socioeconomic position (SEP). The purpose of this study was to describe and evaluate prevalence and distribution of pain in the United States. With data from the population-based 2003-2004 National Health and Nutrition Examination Survey, prevalence of acute (<3 months) and chronic (≥ 3 months) pain was evaluated, including subgroup analyses of race, ethnicity, and SEP, with SEP defined by the poverty-to-income ratio, a ratio derived from the federal poverty level, accounting for household income and number of household members. Prevalence of acute pain was 12.2% (95% confidence interval: 11.2-13.3%). Non-Hispanic black as well as Hispanic and Mexican-American individuals had higher rates of acute pain than non-Hispanic white people, and a higher prevalence was noted in those with higher SEP. Chronic pain prevalence was 15.6% (13.4-17.7%), with non-Hispanic white people having a higher prevalence than those in other racial and ethnic groups. Trends of chronic pain by SEP were opposite of acute pain as those in the highest SEP group tended to have less chronic pain than those in lower SEP groups. These findings suggest that SEP, in addition to race and ethnicity, may play a role in the development of pain as well as its treatment and management.

Background Low socioeconomic position (SEP) is associated with cardiovascular disease (CVD) risk; yet, the underlying pathways are not fully clear and may affect sexes differently. We investigated sex differences in the relationship of SEP with prevalent CVD, cardiovascular risk factors (CRF) and estimated cardiovascular risk in a contemporaneous German population. Methods Data derived from the baseline examination of 204,780 participants in population-based German National Cohort (NAKO). Logistic, multinomial, and linear regression models were used to estimate sex-specific odds ratios (OR) and beta-coefficients with 95% confidence intervals (CI) of CVD, CRF and very high-risk score (SCORE2 ≥7.5% (age 40-49 years) or ≥ 10% (age 50-69 years)) associated with educational attainment and relative income. Women-to-men ratios of ORs (RORs) with 95%-CI were estimated. Results In women compared to men, low vs. high SEP was more strongly associated with obesity, overweight, self-reported myocardial infarction and hypertension, elevated blood pressure values, antihypertensive medication, and alcohol consumption, but less strongly related to smoking. In women with the lowest vs. highest educational level, the OR for a very high 10-year CVD risk was 3.61 (95%-CI 2.88; 4.53), compared to 1.72 (95%-CI 1.51; 1.96) in men. The women-to-men-ROR was 2.33 (95%-CI 1.78; 3.05), attenuated after age-adjustments. For the comparison of low vs. high relative income, the odds of having a very high 10-year CVD risk was 2.55 (95%-CI 2.04; 3.18) in women, and 2.25 (95%-CI 2.08; 2.42) in men (women-to-men ROR, 1.31 (95%-CI 1.05; 1.63). Conclusions In both sexes, there was an inverse graded relationship between SEP and the likelihood of prevalent CVD and CRF, with stronger associations in women than in men. Although women had a lower estimated 10-year CVD risk compared to men, the likelihood of having a very high CVD risk conferred by low SEP vs. a high one was higher in women than in men.

BackgroundAccurately defining obesity using anthropometric measures that best capture obesity-related risk is important for identifying high risk groups for intervention. The purpose of this study is to compare the association of different anthropometric measures of obesity with 10-year cardiovascular disease (CVD) risk in adults in the Eastern Caribbean.MethodsData from the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study (ECS) were analyzed. The ECS is comprised of adults aged 40 and older residing in the US Virgin Islands, Puerto Rico, Barbados, and Trinidad. 10-year CVD risk was calculated using the American Heart Association (ACC/AHA) ASCVD Risk Algorithm and categorized in the following high-risk groups: > 7.5, > 10, and > 20%. Logistic regression was used to examine associations between four anthropometric measures of obesity (BMI, waist circumference, waist-to-hip ratio, waist-to height ratio) and 10-year CVD risk.ResultsMean age (SD) of participants (n = 1617) was 56.6 years (±10.2), 64% were women, 74% were overweight/obese, and 24% had an ASCVD risk score above 10%. Elevated body mass index (BMI, > 30 kg/m2) and waist circumference were not associated with CVD risk. Elevated waist-to-hip ratio (WHR, > 0.9 men, > 0.85 women) and elevated waist-to-height ratio (> 0.5) were associated with all three categories of CVD risk. Area under the receiver curve was highest for WHR for each category of CVD risk. Elevated WHR demonstrated odds of 2.39, 2.58, and 3.32 (p < 0.0001) for CVD risk of > 7.5, > 10 and > 20% respectively.ConclusionFindings suggest that WHR is a better indicator than BMI of obesity-related CVD risk and should be used to target adults in the Caribbean, and of Caribbean-descent, for interventions.

The evaluation of the gender-specific prevalence of cardiovascular risk factors across socioeconomic position (SEP) categories may unravel mechanisms involved in the development of coronary heart disease. Using a sample of 1704 community dwellers of a Portuguese urban center aged 40 years or older, assessed in 1999–2003, we quantified the age-standardized prevalence of nine established cardiovascular risk factors (diabetes mellitus, hypertension, hypercholesterolemia, smoking, sedentariness, abdominal obesity, poor diet, excessive alcohol intake and depression) across SEP and gender categories. Data on individual education and occupation were collected by questionnaire and used to characterize SEP. The prevalence of seven out of nine well-established risk factors was higher in men. Among women, the prevalence of most of the studied risk factors was higher in lower SEP groups. The main exception was smoking, which increased with education and occupation levels. Among men, socioeconomic gradients were less clear, but lower SEP was associated with a higher prevalence of diabetes, excessive alcohol intake and depression in a graded mode. The historical cultural beliefs and practices captured throughout the lifecourse frame the wide socioeconomic gradients discernible in our study conducted in an unequal European developed population. While men were more exposed to most risk factors, the clearer associations between SEP and risk factors among women support that their adoption of particular healthy behaviors is more dependent on material and symbolic conditions. To fully address the issue of health inequalities, interventions within the health systems should be complemented with population-based policies specifically designed to reduce socioeconomic gradients.

ObjectivesTo investigate the predictors influencing the advancement of 10-year cardiovascular disease (CVD) risk after infection with Corona Virus Disease 2019 (COVID-19) in type 2 diabetes patients, and to provide a theoretical basis for an early intervention program for the cardiovascular dimension of the cardiovascular-kidney-metabolic syndrome (CKM syndrome).MethodsA cohort of 378 individuals diagnosed with type 2 diabetes was analyzed retrospectively. The progression of 10-year CVD risk was characterized by an elevation in the 10-year CVD risk category, as determined by the SCORE2-Diabetes scoring system, in type 2 diabetic infected with COVID-19. Factors influencing 10-year CVD risk progression were evaluated through univariate and multivariate stepwise logistic regression. Nonlinear relationships between predictors and 10-year CVD progression were assessed using restricted cubic spline (RCS) analysis, subsequently followed by an analysis of threshold effects. Finally, the predictive performance of various factor combinations for 10-year CVD risk progression during the post-acute COVID-19 phase in type 2 diabetes mellitus cohorts was measured by area under roc curve (AUC).ResultsAfter infection with COVID-19, 12.2% (n=46) experienced progression in their 10-year CVD risk category. In multifactorial stepwise logistic regression, alcohol consumption [odds ratio (OR) 2.10, 95% confidence interval (CI) 1.02-4.34], estimated glomerular filtration rate (eGFR) (OR 0.96, 95% CI 0.94-0.99) and high-sensitivity C-reactive protein (hs-CRP) (OR 1.33, 95% CI 1.13-1.57), were found to be significantly linked to the progression of 10-year CVD risk. Restricted cubic spline analysis (RCS) demonstrated a nonlinear correlation between hs-CRP and 10-year CVD risk progression with a threshold of 3.0 mg/L. 10-year CVD risk was significantly higher with increasing hs-CRP levels at hs-CRP < 3.0 mg/L (OR 2.28, 95% CI 1.48-3.55), and the two-stage model significantly superior to a single linear model (P = 0.028 for log-likelihood ratio). Among the different combinations of models for alcohol consumption, hs-CRP, and eGFR, the full model combination of all three had the best predictive effect (AUC = 0.749).ConclusionAlcohol consumption and elevated hs-CRP were associated with increased cardiovascular risk progression, while higher eGFR levels were inversely associated with risk progression.