The effect of modifiable risk factors on geographic mortality differentials : a modelling study

Background Australian mortality rates are higher in regional and remote areas than in major cities. The degree to which this is driven by variation in modifiable risk factors is unknown.

Methods We applied a risk prediction equation incorporating smoking, cholesterol and blood pressure to a national, population based survey to project all-causes mortality risk by geographic region. We then modelled life expectancies at different levels of mortality risk by geographic region using a risk percentiles model. Finally we set high values of each risk factor to a target level and modelled the subsequent shift in the population to lower levels of mortality risk and longer life expectancy.

Results Survival is poorer in both Inner Regional and Outer Regional/Remote areas compared to Major Cities for men and women at both high and low levels of predicted mortality risk. For men smoking, high cholesterol and high systolic blood pressure were each associated with the mortality difference between Major Cities and Outer Regional/Remote areas--accounting for 21.4%, 20.3% and 7.7% of the difference respectively. For women smoking and high cholesterol accounted for 29.4% and 24.0% of the difference respectively but high blood pressure did not contribute to the observed mortality differences. The three risk factors taken together accounted for 45.4% (men) and 35.6% (women) of the mortality difference. The contribution of risk factors to the corresponding differences for inner regional areas was smaller, with only high cholesterol and smoking contributing to the difference in men-- accounting for 8.8% and 6.3% respectively-- and only smoking contributing to the difference in women--accounting for 12.3%.

Conclusions These results suggest that health intervention programs aimed at smoking, blood pressure and total cholesterol could have a substantial impact on mortality inequities for Outer Regional/Remote areas. Background: Australian mortality rates are higher in regional and remote areas than in major cities. The degree to which this is driven by variation in modifiable risk factors is unknown. Methods. We applied a risk prediction equation incorporating smoking, cholesterol and blood pressure to a national, population based survey to project all-causes mortality risk by geographic region. We then modelled life expectancies at different levels of mortality risk by geographic region using a risk percentiles model. Finally we set high values of each risk factor to a target level and modelled the subsequent shift in the population to lower levels of mortality risk and longer life expectancy. Results: Survival is poorer in both Inner Regional and Outer Regional/Remote areas compared to Major Cities for men and women at both high and low levels of predicted mortality risk. For men smoking, high cholesterol and high systolic blood pressure were each associated with the mortality difference between Major Cities and Outer Regional/Remote areas - accounting for 21.4%, 20.3% and 7.7% of the difference respectively. For women smoking and high cholesterol accounted for 29.4% and 24.0% of the difference respectively but high blood pressure did not contribute to the observed mortality differences. The three risk factors taken together accounted for 45.4% (men) and 35.6% (women) of the mortality difference. The contribution of risk factors to the corresponding differences for inner regional areas was smaller, with only high cholesterol and smoking contributing to the difference in men - accounting for 8.8% and 6.3% respectively - and only smoking contributing to the difference in women - accounting for 12.3%. Conclusions: These results suggest that health intervention programs aimed at smoking, blood pressure and total cholesterol could have a substantial impact on mortality inequities for Outer Regional/Remote areas.

Chronic disease and impairment among Alaska native elders : the Alaska Education and Research Towards Health (EARTH) study

Background: Chronic diseases and impairments are prevalent among older Americans. However, prevalence data for Alaska Native (AN) elders are limited, with estimates usually extrapolated from national studies in which AN elders may not be well-represented. The aim of this study was to describe the prevalence of selected chronic diseases, impairments, and measured medical risk factors among a large community sample of AN elders.

Methods: Design, setting, and participants. A community-based cross-sectional study of baseline information from 656 AN elders aged 55 years or over who participated in the Alaska Education and Research Towards Health (EARTH) Study, March 2004 to August 2006. Measurements. Self-reported lifetime prevalence of 17 doctor-diagnosed chronic diseases, and point prevalence of vision, hearing, oral, and general health impairment were estimated from data collected using audio computer-assisted self-administered questionnaires. In addition, height, weight, blood pressure, fasting blood lipids, and fasting blood glucose levels were measured.

Results: The four most prevalent chronic diseases among AN elders were high blood pressure (55%), arthritis (49%), high cholesterol (42%), and adult bone fracture/break (35%). The median number of chronic diseases reported was three (inter-quartile range, 2 to 5). The prevalence of self-reported vision impairment was 15%, hearing impairment 18%, and having had all natural teeth removed 25%. Almost 50% were obese. High blood pressure (systolic ≥ 140 mm Hg and/or diastolic ≥ 90 mm Hg) was measured in 23%, high low density lipoprotein (LDL) cholesterol (≥ 130 mg/dL) in 39%, and high fasting plasma glucose (> 125 mg/dL) in 9%. Obesity was more prevalent among women than men. There were also significant regional differences in rates of obesity and high LDL cholesterol.

Conclusion: These data may be useful in public health programs and health services planning.

Coronary heart disease risk in volunteer firefighters in Victoria, Australia

Coronary heart disease (CHD) is a major problem for firefighters, even when considering the healthy worker effect (HWE). Although volunteer firefighters outnumber paid personnel, previous research has focused on paid US firefighters. By contrast, no CHD data for Australian firefighters exist. Risk factor data were collected from 2,943 Australian volunteer firefighters and CHD risk was compared with reference "low-risk" and Australian population data. Predicted CHD risk for male and female firefighter was 19.2% and 5.1%, respectively. Female firefighters high blood pressure and fasting glucose was significantly lower than the general population, whereas all other risk factors was similar to the general population. Firefighters' CHD risk was greater than other volunteer and paid emergency services, but the prevalence for most risk factors was similar to the general population. Therefore, Australian volunteer firefighters may not benefit from the HWE.

Risk factors for coronary heart disease among Asian Indians living in Australia

The aim of this study was to assess the coronary heart disease risk factors in the Asian Indian community living in a large city in Australia. A cross-sectional survey was conducted at the Australia India Friendship Fair in 2010. All people of Asian Indian descent who attended the Fair and visited the health promotion stall were eligible to participate in the study if they self-identified as of Asian Indian origin, were aged between 18 and 80 years, and were able to speak English. Blood pressure, blood glucose, waist circumference, height, and weight were measured by a health professional. Smoking, cholesterol levels, and physical activity status were obtained through self-reports. Data were analyzed for 169 participants. More than a third of the participants under the age of 65 years had high blood pressure. Prevalence of diabetes (16%) and obesity (61%) was significantly higher compared with the national average. Ten women identified themselves as smokers. Physical activity patterns were similar to that of the wider Australian population. The study has provided a platform for raising awareness among nurses and promoting advocacy on the cardiovascular risk among Asian Indians. Strategies involving Asian Indian nurses and other Asian Indian health professionals as well as support from the private and public sectors can assist in the reduction of the coronary heart disease risk factors among this extremely susceptible population.

Progress on salt reduction in the Pacific Islands: from strategies to action

BACKGROUND: Most populations are consuming too much salt which is the main contributor of high blood pressure, a leading risk factor of cardiovascular disease and stroke. The South Pacific Office of the World Health Organization has been facilitating the development of salt reduction strategies in Pacific Island Countries and areas (PICs). The objective of this analysis was to review progress to date and identify regional actions needed to support PICs and ensure they achieve the global target to reduce population salt intake by 30% by 2025.
METHODS: Relevant available national food, health and non-communicable disease (NCD) plans from all 22 PICs were reviewed. NCD co-ordinators provided updates and relayed experiences through semi-structured interviews. All activities were systematically categorised according to an existing salt reduction framework for the development of salt reduction strategies.
RESULTS: Salt reduction consultations had been held in 14 countries and final strategies or action plans developed in nine of these, with drafts available in a further three. Three other countries had integrated salt reduction into NCD strategic plans. Baseline monitoring of salt intake had been undertaken in three countries, salt levels in foods in nine countries and salt knowledge, attitude and behaviour surveys in four countries. Most countries were at early stages of implementation and identified limited resources as a barrier to action. Planned salt reduction strategies included work with food industry or importers, implementing regional salt reduction targets, reducing salt levels in school and hospital meals, behaviour change campaigns, and monitoring and evaluation.
CONCLUSIONS: There had been good progress on salt reduction planning in PICs. The need for increased capacity to effectively implement agreed activities, supported by regional standards and the establishment of improved monitoring systems, were identified as important steps to ensure the potential cardiovascular health benefits of salt reduction could be fully realised in the region.

The effect of modifiable risk factors on geographic mortality differentials: a modelling study

BACKGROUND: Australian mortality rates are higher in regional and remote areas than in major cities. The degree to which this is driven by variation in modifiable risk factors is unknown. METHODS: We applied a risk prediction equation incorporating smoking, cholesterol and blood pressure to a national, population based survey to project all-causes mortality risk by geographic region. We then modelled life expectancies at different levels of mortality risk by geographic region using a risk percentiles model. Finally we set high values of each risk factor to a target level and modelled the subsequent shift in the population to lower levels of mortality risk and longer life expectancy. RESULTS: Survival is poorer in both Inner Regional and Outer Regional/Remote areas compared to Major Cities for men and women at both high and low levels of predicted mortality risk. For men smoking, high cholesterol and high systolic blood pressure were each associated with the mortality difference between Major Cities and Outer Regional/Remote areas--accounting for 21.4%, 20.3% and 7.7% of the difference respectively. For women smoking and high cholesterol accounted for 29.4% and 24.0% of the difference respectively but high blood pressure did not contribute to the observed mortality differences. The three risk factors taken together accounted for 45.4% (men) and 35.6% (women) of the mortality difference. The contribution of risk factors to the corresponding differences for inner regional areas was smaller, with only high cholesterol and smoking contributing to the difference in men-- accounting for 8.8% and 6.3% respectively-- and only smoking contributing to the difference in women--accounting for 12.3%. CONCLUSIONS: These results suggest that health intervention programs aimed at smoking, blood pressure and total cholesterol could have a substantial impact on mortality inequities for Outer Regional/Remote areas.

The functional and clinical outcomes of exercise training following a very low energy diet for severely obese women: study protocol for a randomised controlled trial

BACKGROUND: Clinical practice guidelines globally recommend lifestyle modification including diet and exercise training as first-line treatment for obesity. The clinical benefits of exercise training in adults with obesity is well-documented; however, there is no strong evidence for the effectiveness of exercise training for weight loss in class II and class III obesity. The purpose of the randomised controlled trial described in this protocol article is to examine the effect of exercise training, in addition to a very low energy diet (VLED), in clinically severe obese women for changes in body composition, physical function, quality of life, and markers of cardiometabolic risk.

METHODS/DESIGN: Sixty women, aged 18-50 years with a body mass index (BMI) greater than 34.9 kg.m(2) and at least one obesity-related co-morbidity, will be recruited for this 12-month study. Participants will be randomised to either exercise plus energy restriction (n = 30), or energy restriction alone (n = 30). All participants will follow an energy-restricted individualised diet incorporating a VLED component. The exercise intervention group will also receive exercise by supervised aerobic and resistance training and a home-based exercise programme totalling 300 minutes per week. Primary outcome measures include body composition and aerobic fitness. Secondary outcome measures include: physical function, cardiometabolic risk factors, quality of life, physical activity, and mental health. All outcome measures will be conducted at baseline, 3, 6 and 12 months.

DISCUSSION: Previous research demonstrates various health benefits of including exercise training as part of a healthy lifestyle at all BMI ranges. Although clinical practice guidelines recommend exercise training as part of first-line treatment for overweight and obesity, there are few studies that demonstrate the effectiveness of exercise in class II and class III obesity. The study aims to determine whether the addition of exercise training to a VLED provides more favourable improvements in body composition, physical function, quality of life, and markers of cardiometabolic risk for women with clinically severe obesity, compared to VLED alone.

Unilateral bicep curl hemodynamics: low-pressure continuous vs high-pressure intermittent blood flow restriction

 Light-load exercise training with blood flow restriction (BFR) increases muscle strength and size. However, the hemodynamics of BFR exercise appear elevated compared with non-BFR exercise. This questions the suitability of BFR in special/clinical populations. Nevertheless, hemodynamics of standard prescription protocols for BFR and traditional heavy-load exercise have not been compared. We investigated the hemodynamics of two common BFR exercise methods and two traditional resistance exercises. Twelve young males completed four unilateral elbow flexion exercise trials in a balanced, randomized crossover design: (a) heavy load [HL; 80% one-repetition maximum (1-RM)]; (b) light load (LL; 20% 1-RM); and two other light-load trials with BFR applied (c) continuously at 80% resting systolic blood pressure (BFR-C) or (d) intermittently at 130% resting systolic blood pressure (BFR-I). Hemodynamics were measured at baseline, during exercise, and for 60-min post-exercise. Exercising heart rate, blood pressure, cardiac output, and rate–pressure product were significantly greater for HL and BFR-I compared with LL. The magnitude of hemodynamic stress for BFR-C was between that of HL and LL. These data show reduced hemodynamics for continuous low-pressure BFR exercise compared with intermittent high-pressure BFR in young healthy populations. BFR remains a potentially viable method to improve muscle mass and strength in special/clinical populations.

Pressure injury: an exploration of the relationship between risk factors and interface pressure

Pressure injuries are a serious risk for patients admitted to hospital and are thought to result from a number of forces operating on skin tissue (pressure, shear and friction). Most research on interface pressure (IP) has taken place using healthy volunteers or mannequins. Little is currently known about the relationship between pressure injury risk and IP for hospital patients. This relationship was investigated with a sample of 121 adult hospital patients. Pressure injury risk was evaluated using the Waterlow Risk Assessment Tool (WRAT) and IP was measured at the sacrum using a Tekscan ClinSeatTM IP sensor mat. Other factors considered were body mass index (BMI), blood pressure, reason for hospital admission, comorbidities and admission route to hospital. Patients were classified according to WRAT categories (‘low risk’, ‘at risk’, ‘high risk’, ‘very high risk’) and then remained still on a standard hospital mattress for 10 minutes while IP was measured. Participants in the ‘low risk’ group were significantly younger than all other groups (p<0.001) and there were some group differences in BMI. IP readings were compared between the ‘low risk’ group and all of the participants at greater risk. The ‘low risk’ group had significantly lower IP at the sacrum on a standard hospital mattress than those at greater risk (p=0.002). Those at greater risk tended to have IP readings at the low end of the compromised IP range. This study is significant because it describes a new, clinically relevant methodology and presents findings that challenge clinician assumptions about the relationships between pressure injury risk assessment and IP.

High-intensity resistance training improves glycemic control in older patients with type 2 diabetes

OBJECTIVE -- To examine the effect of high-intensity progressive resistance training combined with moderate weight loss on glycemic control and body composition in older patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS -- Sedentary, overweight men and women with type 2 diabetes, aged 60-80 years (n = 36), were randomized to high-intensity progressive resistance training plus moderate weight loss (RT & WL group) or moderate weight loss plus a control program (WL group). Clinical and laboratory measurements were assessed at 0, 3, and 6 months.

RESULTS -- HbA._1c fell significantly more in RT & WL than WL at 3 months (0.6 ± or -] 0.7 vs. 0.07 ± 0.8%, P < 0.05) and 6 months (1.2 ±1.0 vs. 0.4 ±0.8, P < 0.05). Similar reductions in body weight (RT & WL 2.5 ±2.9 vs. WL 3.1±2.1 kg) and fat mass (RT & WL 2.4 ± 2.7 vs. WL 2.7±2.5 kg) were observed after 6 months. In contrast, lean body mass (LBM) increased in the RT & WL group (0.5 ±1.1 kg) and decreased in the WL group (0.4±1.0) after 6 months (P < 0.05). There were no between-group differences for fasting glucose, insulin, serum lipids and lipoproteins, or resting blood pressure.

CONCLUSIONS -- High-intensity progressive resistance training, in combination with moderate weight loss, was effective in improving glycemic control in older patients with type 2 diabetes. Additional benefits of improved muscular strength and LBM identify high-intensity resistance training as a feasible and effective component in the management program for older patients with type 2 diabetes.

Numerical investigation of high and low pressure tube hydroforming

Hydroforming is one option to reduce vehicle weight while increasing component stiffness and rigidity. This typically involves using a fluid to form a component with high internal pressure. Tube hydroforming has gained increasing interest in the automotive and aerospace industries because of its many advantages such as part consolidation, good quality of the formed part etc. The main advantage is that the uniform pressure can be transferred to whole part at the same time. In low pressure hydroforming, the internal pressure is significantly and the hydroformed section length of line stays almost the same as the circumference of the blank tube. This paper details the comparison between high and low pressure hydroforming. It is shown that the internal pressure and holding force required for low pressure hydroforming process is much less than that of high pressure. Also stress and thickness distribution are more uniform and the process is highly suitable for the forming of advanced high strength steels.

Food patterns associated with blood lipids are predictive of coronary heart disease : the Whitehall II study

Analysis of the epidemiological effects of overall dietary patterns offers an alternative approach to the investigation of the role of diet in CHD. We analysed the role of blood lipid-related dietary patterns using a two-step method to confirm the prospective association of dietary pattern with incident CHD. Analysis is based on 7314 participants of the Whitehall II study. Dietary intake was measured using a 127-item FFQ. Reduced rank regression (RRR) was used to derive dietary pattern scores using baseline serum total and HDL-cholesterol, and TAG levels as dependent variables. Cox proportional hazard regression was used to confirm the association between dietary patterns and incident CHD (n 243) over 15 years of follow-up. Increased CHD risk (hazard ratio (HR) for top quartile: 2·01 (95 % CI 1·41, 2·85) adjusted for age, sex, ethnicity and energy misreporting) was observed with a diet characterised by high consumption of white bread, fried potatoes, sugar in tea and coffee, burgers and sausages, soft drinks, and low consumption of French dressing and vegetables. The diet-CHD relationship was attenuated after adjustment for employment grade and health behaviours (HR for top quartile: 1·81; 95 % CI 1·26, 2·62), and further adjustment for blood pressure and BMI (HR for top quartile: 1·57; 95 % CI 1·08, 2·27). Dietary patterns are associated with serum lipids and predict CHD risk after adjustment for confounders. RRR identifies dietary patterns using prior knowledge and focuses on the pathways through which diet may influence disease. The present study adds to the evidence that diet is an important risk factor for CHD.

Can the ABCD Score be dichotomised to identify high−risk patients with trainsient ischaemic attack in the emergency department?

Background: Recent evidence shows a substantial short-term risk of ischaemic stroke after transient ischaemic attack (TIA). Identification of patients with TIA with a high short-term risk of stroke is now possible through the use of the “ABCD Score”, which considers age, blood pressure, clinical features and duration of symptoms predictive of stroke.

Aim: To evaluate the ability of dichotomising the ABCD Score to predict stroke at 7 and 90 days in a population with TIA presenting to an emergency department.

Methods: A retrospective audit was conducted on all probable or definite TIAs presenting to the emergency department of a metropolitan hospital from July to December 2004. The ABCD Score was applied to 98 consecutive patients with TIA who were reviewed for subsequent strokes within 90 days. Patients obtaining an ABCD Score ≥5 were considered to be at high risk for stroke.

Results: Dichotomising the ABCD Score categorised 48 (49%) patients with TIA at high risk for stroke (ABCD Score ≥5). This high-risk group contained all four strokes that occurred within 7 days (sensitivity 100% (95% confidence interval (CI) 40% to 100%), specificity 53% (95% CI 43% to 63%), positive predictive value 8% (95% CI 3% to 21%) and negative predictive value 100% (95% CI 91% to 100%)), and six of seven occurring within 90 days (sensitivity 86% (95% CI 42% to 99%), specificity 54% (95% CI 43% to 64%), positive predictive value 12.5% (95% CI 5% to 26%) and negative predictive value 98% (95% CI 88% to 100%)). Removal of the “age” item from the ABCD Score halved the number of false-positive cases without changing its predictive value for stroke.

Conclusion: In this retrospective analysis, dichotomising the ABCD Score was overinclusive but highly predictive in identifying patients with TIA at a high short-term risk of stroke. Use of the ABCD Score in the emergency care of patients with TIA is simple, efficient and provides a unique opportunity to prevent stroke in this population of patients.

Rapid onset of renal sympathetic nerve activation in rabbits fed a high-fat diet

Hypertension and elevated sympathetic drive result from consumption of a high-calorie diet and deposition of abdominal fat, but the etiology and temporal characteristics are unknown. Rabbits instrumented for telemetric recording of arterial pressure and renal sympathetic nerve activity (RSNA) were fed a high-fat diet for 3 weeks then control diet for 1 week or control diet for 4 weeks. Baroreflexes and responses to air-jet stress and hypoxia were determined weekly. After 1 week of high-fat diet, caloric intake increased by 62%, accompanied by elevated body weight, blood glucose, plasma insulin, and leptin (8%, 14%, 134%, and 252%, respectively). Mean arterial pressure, heart rate, and RSNA also increased after 1 week (6%, 11%, and 57%, respectively). Whereas mean arterial pressure and body weight continued to rise over 3 weeks of high-fat diet, heart rate and RSNA did not change further. The RSNA baroreflex was attenuated from the first week of the diet. Excitatory responses to air-jet stress diminished over 3 weeks of high-fat diet, but responses to hypoxia were invariant. Resumption of a normal diet returned glucose, insulin, leptin, and heart rate to control levels, but body weight, mean arterial pressure, and RSNA remained elevated. In conclusion, elevated sympathetic drive and impaired baroreflex function, which occur within 1 week of consumption of a high-fat, high-calorie diet, appear integral to the rapid development of obesity-related hypertension. Increased plasma leptin and insulin may contribute to the initiation of hypertension but are not required for maintenance of mean arterial pressure, which likely lies in alterations in the response of neurons in the hypothalamus.