Publications by authors named "Scott A Lear"

154 Publications

Why do we keep asking, do we still need cardiac rehabilitation?

Eur J Prev Cardiol 2020 Feb 12. Epub 2020 Feb 12.

Institute for Physical Activity and Nutrition, Deakin University, Australia.

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http://dx.doi.org/10.1177/2047487320902745DOI Listing
February 2020

Association of bedtime with mortality and major cardiovascular events: an analysis of 112,198 individuals from 21 countries in the PURE study.

Sleep Med 2021 Feb 5;80:265-272. Epub 2021 Feb 5.

Population Health Research Institute, McMaster University, Hamilton, ON, Canada. Electronic address:

Objectives: This study aimed to examine the association of bedtime with mortality and major cardiovascular events.

Methods: Bedtime was recorded based on self-reported habitual time of going to bed in 112,198 participants from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study. Participants were prospectively followed for 9.2 years. We examined the association between bedtime and the composite outcome of all-cause mortality, non-fatal myocardial infarction, stroke and heart failure. Participants with a usual bedtime earlier than 10PM were categorized as 'earlier' sleepers and those who reported a bedtime after midnight as 'later' sleepers. Cox frailty models were applied with random intercepts to account for the clustering within centers.

Results: A total of 5633 deaths and 5346 major cardiovascular events were reported. A U-shaped association was observed between bedtime and the composite outcome. Using those going to bed between 10PM and midnight as the reference group, after adjustment for age and sex, both earlier and later sleepers had a higher risk of the composite outcome (HR of 1.29 [1.22, 1.35] and 1.11 [1.03, 1.20], respectively). In the fully adjusted model where demographic factors, lifestyle behaviors (including total sleep duration) and history of diseases were included, results were greatly attenuated, but the estimates indicated modestly higher risks in both earlier (HR of 1.09 [1.03-1.16]) and later sleepers (HR of 1.10 [1.02-1.20]).

Conclusion: Early (10 PM or earlier) or late (Midnight or later) bedtimes may be an indicator or risk factor of adverse health outcomes.
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http://dx.doi.org/10.1016/j.sleep.2021.01.057DOI Listing
February 2021

Associations of cereal grains intake with cardiovascular disease and mortality across 21 countries in Prospective Urban and Rural Epidemiology study: prospective cohort study.

BMJ 2021 02 3;372:m4948. Epub 2021 Feb 3.

Population Health Research Institute (PHRI), McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada.

Objective: To evaluate the association between intakes of refined grains, whole grains, and white rice with cardiovascular disease, total mortality, blood lipids, and blood pressure in the Prospective Urban and Rural Epidemiology (PURE) study.

Design: Prospective cohort study.

Setting: PURE study in 21 countries.

Participants: 148 858 participants with median follow-up of 9.5 years.

Exposures: Country specific validated food frequency questionnaires were used to assess intakes of refined grains, whole grains, and white rice.

Main Outcome Measure: Composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios were estimated for associations of grain intakes with mortality, major cardiovascular events, and their composite by using multivariable Cox frailty models with random intercepts to account for clustering by centre.

Results: Analyses were based on 137 130 participants after exclusion of those with baseline cardiovascular disease. During follow-up, 9.2% (n=12 668) of these participants had a composite outcome event. The highest category of intake of refined grains (≥350 g/day or about 7 servings/day) was associated with higher risk of total mortality (hazard ratio 1.27, 95% confidence interval 1.11 to 1.46; P for trend=0.004), major cardiovascular disease events (1.33, 1.16 to 1.52; P for trend<0.001), and their composite (1.28, 1.15 to 1.42; P for trend<0.001) compared with the lowest category of intake (<50 g/day). Higher intakes of refined grains were associated with higher systolic blood pressure. No significant associations were found between intakes of whole grains or white rice and health outcomes.

Conclusion: High intake of refined grains was associated with higher risk of mortality and major cardiovascular disease events. Globally, lower consumption of refined grains should be considered.
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http://dx.doi.org/10.1136/bmj.m4948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856570PMC
February 2021

Availability and affordability of medicines and cardiovascular outcomes in 21 high-income, middle-income and low-income countries.

BMJ Glob Health 2020 11;5(11)

Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.

Objectives: We aimed to examine the relationship between access to medicine for cardiovascular disease (CVD) and major adverse cardiovascular events (MACEs) among people at high risk of CVD in high-income countries (HICs), upper and lower middle-income countries (UMICs, LMICs) and low-income countries (LICs) participating in the Prospective Urban Rural Epidemiology (PURE) study.

Methods: We defined high CVD risk as the presence of any of the following: hypertension, coronary artery disease, stroke, smoker, diabetes or age >55 years. Availability and affordability of blood pressure lowering drugs, antiplatelets and statins were obtained from pharmacies. Participants were categorised: group 1-all three drug types were available and affordable, group 2-all three drugs were available but not affordable and group 3-all three drugs were not available. We used multivariable Cox proportional hazard models with nested clustering at country and community levels, adjusting for comorbidities, sociodemographic and economic factors.

Results: Of 163 466 participants, there were 93 200 with high CVD risk from 21 countries (mean age 54.7, 49% female). Of these, 44.9% were from group 1, 29.4% from group 2 and 25.7% from group 3. Compared with participants from group 1, the risk of MACEs was higher among participants in group 2 (HR 1.19, 95% CI 1.07 to 1.31), and among participants from group 3 (HR 1.25, 95% CI 1.08 to 1.50).

Conclusion: Lower availability and affordability of essential CVD medicines were associated with higher risk of MACEs and mortality. Improving access to CVD medicines should be a key part of the strategy to lower CVD globally.
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http://dx.doi.org/10.1136/bmjgh-2020-002640DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7640501PMC
November 2020

Contrasting Associations Between Diabetes and Cardiovascular Mortality Rates in Low-, Middle-, and High-Income Countries: Cohort Study Data From 143,567 Individuals in 21 Countries in the PURE Study.

Diabetes Care 2020 Dec 15;43(12):3094-3101. Epub 2020 Oct 15.

Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.

Objective: We aimed to compare cardiovascular (CV) events, all-cause mortality, and CV mortality rates among adults with and without diabetes in countries with differing levels of income.

Research Design And Methods: The Prospective Urban Rural Epidemiology (PURE) study enrolled 143,567 adults aged 35-70 years from 4 high-income countries (HIC), 12 middle-income countries (MIC), and 5 low-income countries (LIC). The mean follow-up was 9.0 ± 3.0 years.

Results: Among those with diabetes, CVD rates (LIC 10.3, MIC 9.2, HIC 8.3 per 1,000 person-years, < 0.001), all-cause mortality (LIC 13.8, MIC 7.2, HIC 4.2 per 1,000 person-years, < 0.001), and CV mortality (LIC 5.7, MIC 2.2, HIC 1.0 per 1,000 person-years, < 0.001) were considerably higher in LIC compared with MIC and HIC. Within LIC, mortality was higher in those in the lowest tertile of wealth index (low 14.7%, middle 10.8%, and high 6.5%). In contrast to HIC and MIC, the increased CV mortality in those with diabetes in LIC remained unchanged even after adjustment for behavioral risk factors and treatments (hazard ratio [95% CI] 1.89 [1.58-2.27] to 1.78 [1.36-2.34]).

Conclusions: CVD rates, all-cause mortality, and CV mortality were markedly higher among those with diabetes in LIC compared with MIC and HIC with mortality risk remaining unchanged even after adjustment for risk factors and treatments. There is an urgent need to improve access to care to those with diabetes in LIC to reduce the excess mortality rates, particularly among those in the poorer strata of society.
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http://dx.doi.org/10.2337/dc20-0886DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7770267PMC
December 2020

Global variations in the prevalence, treatment, and impact of atrial fibrillation in a multi-national cohort of 153,152 middle-aged individuals.

Cardiovasc Res 2020 Aug 10. Epub 2020 Aug 10.

Population Health Research Institute, McMaster University, Canada.

Aims: To compare the prevalence of electrocardiogram (ECG)-documented atrial fibrillation (or flutter) (AF) across eight regions of the world, and to examine anti-thrombotic use and clinical outcomes.

Methods And Results: Baseline ECGs were collected in 153,152 middle-aged participants (ages 35 to 70 years) to document AF in two community-based studies, spanning 20 countries. Medication use and clinical outcome data (mean follow up of 7.4 years) were available in one cohort. Cross sectional analyses were performed to document the prevalence of AF and medication use, and associations between AF and clinical events were examined prospectively. Mean age of participants was 52.1 years, and 57.7% were female. Age and sex-standardized prevalence of AF varied 12-fold between regions; with the highest in North America, Europe, China and Southeast Asia (270-360 cases per 100,000 persons); and lowest in the Middle East, Africa, and South Asia (30-60 cases per 100,000 persons)(p < 0.001). Compared with low-income countries (LICs), AF prevalence was 7-fold higher in middle-income countries (MICs) and 11-fold higher in high-income countries (HICs)(p < 0.001). Differences in AF prevalence remained significant after adjusting for traditional AF risk factors. In LICs/MICs, 24% of participants with AF and a CHADS2 score ≥1 received anti-thrombotic therapy, compared with 85% in HICs. AF was associated with an increased risk of stroke (hazard ratio [HR: 2.29; 95% confidence interval [CI] 1.49-3.52) and death (HR: 2.97; 95% CI 2.25-3.93); with similar rates in different country income levels.

Conclusions: Large variations in AF prevalence occur in different regions and country income settings, but this is only partially explained by traditional AF risk factors. Anti-thrombotic therapy is infrequently used in poorer countries despite the high risk of stroke associated with AF.

Translational Perspective: We examined atrial fibrillation (AF) prevalence in 153,152 middle-aged participants spanning 20 countries. Age and sex-standardized prevalence of AF varied by as much as 12-fold between regions; highest in North America, Europe, China and Southeast Asia (270-360 cases per 100,000 persons); and lowest in the Middle East, Africa, and South Asia (30-60 cases per 100,000 persons)(p < 0.001); and by as much as 11-fold between groups of countries at different income levels (p < 0.001). Global variations were poorly explained by traditional AF risk factors. Future studies are needed to understand the predominant determinants driving the variation in AF burden across different regions of the world.
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http://dx.doi.org/10.1093/cvr/cvaa241DOI Listing
August 2020

Exploring Knowledge and Perspectives of South Asian Children and Their Parents Regarding Healthy Cardiovascular Behaviors: A Qualitative Analysis.

Glob Pediatr Health 2020 1;7:2333794X20924505. Epub 2020 Jul 1.

Simon Fraser University, Burnaby, British Columbia, Canada.

South Asian children and parents have been shown to have a higher risk for cardiovascular disease (CVD) relative to white individuals. To design interventions aimed at addressing the comparatively higher burden in South Asians, a better understanding of attitudes and perspectives regarding CVD-associated behaviors is needed. As a result, we sought to understand knowledge about CVD risk in both children and parents, and attitudes toward physical activity and diet in both the children and parents, including potential cultural influences. In-depth interviews were conducted with 13 South Asian child-and-parent dyads representing a range of child body mass index (BMI) levels, ages, and with both sexes. South Asian children and parents demonstrated good knowledge about CVD prevention; however, knowledge did not always translate into behavior. The influence of social and cultural dynamics on behavior was also highlighted. To ensure that interventions aimed at this population are effective, an understanding of the unique social dynamics that influence diet and physical activity-related behaviors is needed.
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http://dx.doi.org/10.1177/2333794X20924505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7331759PMC
July 2020

Formative Evaluation of Consumer-Grade Activity Monitors Worn by Older Adults: Test-Retest Reliability and Criterion Validity of Step Counts.

JMIR Form Res 2020 Aug 18;4(8):e16537. Epub 2020 Aug 18.

Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada.

Background: To assess whether commercial-grade activity monitors are appropriate for measuring step counts in older adults, it is essential to evaluate their measurement properties in this population.

Objective: This study aimed to evaluate test-retest reliability and criterion validity of step counting in older adults with self-reported intact and limited mobility from 6 commercial-grade activity monitors: Fitbit Charge, Fitbit One, Garmin vívofit 2, Jawbone UP2, Misfit Shine, and New-Lifestyles NL-1000.

Methods: For test-retest reliability, participants completed two 100-step overground walks at a usual pace while wearing all monitors. We tested the effects of the activity monitor and mobility status on the absolute difference in step count error (%) and computed the standard error of measurement (SEM) between repeat trials. To assess criterion validity, participants completed two 400-meter overground walks at a usual pace while wearing all monitors. The first walk was continuous; the second walk incorporated interruptions to mimic the conditions of daily walking. Criterion step counts were from the researcher tally count. We estimated the effects of the activity monitor, mobility status, and walk interruptions on step count error (%). We also generated Bland-Altman plots and conducted equivalence tests.

Results: A total of 36 individuals participated (n=20 intact mobility and n=16 limited mobility; 19/36, 53% female) with a mean age of 71.4 (SD 4.7) years and BMI of 29.4 (SD 5.9) kg/m. Considering test-retest reliability, there was an effect of the activity monitor (P<.001). The Fitbit One (1.0%, 95% CI 0.6% to 1.3%), the New-Lifestyles NL-1000 (2.6%, 95% CI 1.3% to 3.9%), and the Garmin vívofit 2 (6.0%, 95 CI 3.2% to 8.8%) had the smallest mean absolute differences in step count errors. The SEM values ranged from 1.0% (Fitbit One) to 23.5% (Jawbone UP2). Regarding criterion validity, all monitors undercounted the steps. Step count error was affected by the activity monitor (P<.001) and walk interruptions (P=.02). Three monitors had small mean step count errors: Misfit Shine (-1.3%, 95% CI -19.5% to 16.8%), Fitbit One (-2.1%, 95% CI -6.1% to 2.0%), and New-Lifestyles NL-1000 (-4.3%, 95 CI -18.9% to 10.3%). Mean step count error was larger during interrupted walking than continuous walking (-5.5% vs -3.6%; P=.02). Bland-Altman plots illustrated nonsystematic bias and small limits of agreement for Fitbit One and Jawbone UP2. Mean step count error lay within an equivalence bound of ±5% for Fitbit One (P<.001) and Misfit Shine (P=.001).

Conclusions: Test-retest reliability and criterion validity of step counting varied across 6 consumer-grade activity monitors worn by older adults with self-reported intact and limited mobility. Walk interruptions increased the step count error for all monitors, whereas mobility status did not affect the step count error. The hip-worn Fitbit One was the only monitor with high test-retest reliability and criterion validity.
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http://dx.doi.org/10.2196/16537DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7463409PMC
August 2020

Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.

Lancet 2020 07 20;396(10244):97-109. Epub 2020 May 20.

Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.

Background: Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies.

Methods: In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death.

Findings: From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease.

Interpretation: Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men.

Funding: Full funding sources are listed at the end of the paper (see Acknowledgments).
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http://dx.doi.org/10.1016/S0140-6736(20)30543-2DOI Listing
July 2020

Association of nut intake with risk factors, cardiovascular disease, and mortality in 16 countries from 5 continents: analysis from the Prospective Urban and Rural Epidemiology (PURE) study.

Am J Clin Nutr 2020 07;112(1):208-219

Population Health Research Institute, Hamilton, ON, Canada.

Background: The association of nuts with cardiovascular disease and deaths has been investigated mostly in Europe, the USA, and East Asia, with few data available from other regions of the world or from low- and middle-income countries.

Objective: To assess the association of nuts with mortality and cardiovascular disease (CVD).

Methods: The Prospective Urban Rural Epidemiology study is a large multinational prospective cohort study of adults aged 35-70 y from 16 low-, middle-, and high-income countries on 5 continents. Nut intake (tree nuts and ground nuts) was measured at the baseline visit, using country-specific validated FFQs. The primary outcome was a composite of mortality or major cardiovascular event [nonfatal myocardial infarction (MI), stroke, or heart failure].

Results: We followed 124,329 participants (age = 50.7 y, SD = 10.2; 41.5% male) for a median of 9.5 y. We recorded 10,928 composite events [deaths (n = 8,662) or major cardiovascular events (n = 5,979)]. Higher nut intake (>120 g per wk compared with <30 g per mo) was associated with a lower risk of the primary composite outcome of mortality or major cardiovascular event [multivariate HR (mvHR): 0.88; 95% CI: 0.80, 0.96; P-trend = 0.0048]. Significant reductions in total (mvHR: 0.77; 95% CI: 0.69, 0.87; P-trend <0.0001), cardiovascular (mvHR: 0.72; 95% CI: 0.56, 0.92; P-trend = 0.048), and noncardiovascular mortality (mvHR: 0.82; 95% CI: 0.70, 0.96; P-trend = 0.0046) with a trend to reduced cancer mortality (mvHR: 0.81; 95% CI: 0.65, 1.00; P-trend = 0.081) were observed. No significant associations of nuts were seen with major CVD (mvHR: 0.91; 95% CI: 0.81, 1.02; P-trend = 0.14), stroke (mvHR: 0.98; 95% CI: 0.84, 1.14; P-trend = 0.76), or MI (mvHR: 0.86; 95% CI: 0.72, 1.04; P-trend = 0.29).

Conclusions: Higher nut intake was associated with lower mortality risk from both cardiovascular and noncardiovascular causes in low-, middle-, and high-income countries.
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http://dx.doi.org/10.1093/ajcn/nqaa108DOI Listing
July 2020

Long-term exposure to outdoor and household air pollution and blood pressure in the Prospective Urban and Rural Epidemiological (PURE) study.

Environ Pollut 2020 Jul 24;262:114197. Epub 2020 Feb 24.

School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA.

Exposure to air pollution has been linked to elevated blood pressure (BP) and hypertension, but most research has focused on short-term (hours, days, or months) exposures at relatively low concentrations. We examined the associations between long-term (3-year average) concentrations of outdoor PM and household air pollution (HAP) from cooking with solid fuels with BP and hypertension in the Prospective Urban and Rural Epidemiology (PURE) study. Outdoor PM exposures were estimated at year of enrollment for 137,809 adults aged 35-70 years from 640 urban and rural communities in 21 countries using satellite and ground-based methods. Primary use of solid fuel for cooking was used as an indicator of HAP exposure, with analyses restricted to rural participants (n = 43,313) in 27 study centers in 10 countries. BP was measured following a standardized procedure and associations with air pollution examined with mixed-effect regression models, after adjustment for a comprehensive set of potential confounding factors. Baseline outdoor PM exposure ranged from 3 to 97 μg/m across study communities and was associated with an increased odds ratio (OR) of 1.04 (95% CI: 1.01, 1.07) for hypertension, per 10 μg/m increase in concentration. This association demonstrated non-linearity and was strongest for the fourth (PM > 62 μg/m) compared to the first (PM < 14 μg/m) quartiles (OR = 1.36, 95% CI: 1.10, 1.69). Similar non-linear patterns were observed for systolic BP (β = 2.15 mmHg, 95% CI: -0.59, 4.89) and diastolic BP (β = 1.35, 95% CI: -0.20, 2.89), while there was no overall increase in ORs across the full exposure distribution. Individuals who used solid fuels for cooking had lower BP measures compared to clean fuel users (e.g. 34% of solid fuels users compared to 42% of clean fuel users had hypertension), and even in fully adjusted models had slightly decreased odds of hypertension (OR = 0.93; 95% CI: 0.88, 0.99) and reductions in systolic (-0.51 mmHg; 95% CI: -0.99, -0.03) and diastolic (-0.46 mmHg; 95% CI: -0.75, -0.18) BP. In this large international multi-center study, chronic exposures to outdoor PM was associated with increased BP and hypertension while there were small inverse associations with HAP.
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http://dx.doi.org/10.1016/j.envpol.2020.114197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7767575PMC
July 2020

The household economic burden of non-communicable diseases in 18 countries.

BMJ Glob Health 2020 11;5(2):e002040. Epub 2020 Feb 11.

London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK.

Background: Non-communicable diseases (NCDs) are the leading cause of death globally. In 2014, the United Nations committed to reducing premature mortality from NCDs, including by reducing the burden of healthcare costs. Since 2014, the Prospective Urban and Rural Epidemiology (PURE) Study has been collecting health expenditure data from households with NCDs in 18 countries.

Methods: Using data from the PURE Study, we estimated risk of catastrophic health spending and impoverishment among households with at least one person with NCDs (cardiovascular disease, diabetes, kidney disease, cancer and respiratory diseases; n=17 435), with hypertension only (a leading risk factor for NCDs; n=11 831) or with neither (n=22 654) by country income group: high-income countries (Canada and Sweden), upper middle income countries (UMICs: Brazil, Chile, Malaysia, Poland, South Africa and Turkey), lower middle income countries (LMICs: the Philippines, Colombia, India, Iran and the Occupied Palestinian Territory) and low-income countries (LICs: Bangladesh, Pakistan, Zimbabwe and Tanzania) and China.

Results: The prevalence of catastrophic spending and impoverishment is highest among households with NCDs in LMICs and China. After adjusting for covariates that might drive health expenditure, the absolute risk of catastrophic spending is higher in households with NCDs compared with no NCDs in LMICs (risk difference=1.71%; 95% CI 0.75 to 2.67), UMICs (0.82%; 95% CI 0.37 to 1.27) and China (7.52%; 95% CI 5.88 to 9.16). A similar pattern is observed in UMICs and China for impoverishment. A high proportion of those with NCDs in LICs, especially women (38.7% compared with 12.6% in men), reported not taking medication due to costs.

Conclusions: Our findings show that financial protection from healthcare costs for people with NCDs is inadequate, particularly in LMICs and China. While the burden of NCD care may appear greatest in LMICs and China, the burden in LICs may be masked by care foregone due to costs. The high proportion of women reporting foregone care due to cost may in part explain gender inequality in treatment of NCDs.
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http://dx.doi.org/10.1136/bmjgh-2019-002040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042605PMC
February 2020

Reduced Cognitive Assessment Scores Among Individuals With Magnetic Resonance Imaging-Detected Vascular Brain Injury.

Stroke 2020 04 4;51(4):1158-1165. Epub 2020 Mar 4.

Hotchkiss Brain Institute, Department of Clinical Neurosciences, University of Calgary, Alberta, Canada (E.E.S.).

Background and Purpose- Little is known about the association between covert vascular brain injury and cognitive impairment in middle-aged populations. We investigated if scores on a cognitive screen were lower in individuals with higher cardiovascular risk, and those with covert vascular brain injury. Methods- Seven thousand five hundred forty-seven adults, aged 35 to 69 years, free of cardiovascular disease underwent a cognitive assessment using the Digital Symbol Substitution test and Montreal Cognitive Assessment, and magnetic resonance imaging (MRI) to detect covert vascular brain injury (high white matter hyperintensities, lacunar, and nonlacunar brain infarctions). Cardiovascular risk factors were quantified using the INTERHEART (A Global Study of Risk Factors for Acute Myocardial Infarction) risk score. Multivariable mixed models tested for independent determinants of reduced cognitive scores. The population attributable risk of risk factors and MRI vascular brain injury on low cognitive scores was calculated. Results- The mean age of participants was 58 (SD, 9) years; 55% were women. Montreal Cognitive Assessment and Digital Symbol Substitution test scores decreased significantly with increasing age (<0.0001), INTERHEART risk score (<0.0001), and among individuals with high white matter hyperintensities, nonlacunar brain infarction, and individuals with 3+ silent brain infarctions. Adjusted for age, sex, education, ethnicity covariates, Digital Symbol Substitution test was significantly lowered by 1.0 (95% CI, -1.3 to -0.7) point per 5-point cardiovascular risk score increase, 1.9 (95% CI, -3.2 to -0.6) per high white matter hyperintensities, 3.5 (95% CI, -6.4 to -0.7) per nonlacunar stroke, and 6.8 (95% CI, -11.5 to -2.2) when 3+ silent brain infarctions were present. No postsecondary education accounted for 15% (95% CI, 12-17), moderate and high levels of cardiovascular risk factors accounted for 19% (95% CI, 8-30), and MRI vascular brain injury accounted for 10% (95% CI, -3 to 22) of low test scores. Conclusions- Among a middle-aged community-dwelling population, scores on a cognitive screen were lower in individuals with higher cardiovascular risk factors or MRI vascular brain injury. Much of the population attributable risk of low cognitive scores can be attributed to lower educational attainment, higher cardiovascular risk factors, and MRI vascular brain injury.
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http://dx.doi.org/10.1161/STROKEAHA.119.028179DOI Listing
April 2020

Why do we keep asking, do we still need cardiac rehabilitation?

Eur J Prev Cardiol 2020 Feb 11:2047487320902745. Epub 2020 Feb 11.

Institute for Physical Activity and Nutrition, Deakin University, Australia.

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http://dx.doi.org/10.1177/2047487320902745DOI Listing
February 2020

Ethnicity and Metabolic Syndrome: Implications for Assessment, Management and Prevention.

Nutrients 2019 Dec 19;12(1). Epub 2019 Dec 19.

School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.

The metabolic syndrome (MetS) is a constellation of cardiometabolic risk factors that identifies people at increased risk for type 2 diabetes and cardiovascular disease. While the global prevalence is 20%-25% of the adult population, the prevalence varies across different racial/ethnic populations. In this narrative review, evidence is reviewed regarding the assessment, management and prevention of MetS among people of different racial/ethnic groups. The most popular definition of MetS considers race/ethnicity for assessing waist circumference given differences in visceral adipose tissue and cardiometabolic risk. However, defining race/ethnicity may pose challenges in the clinical setting. Despite 80% of the world's population being of non-European descent, the majority of research on management and prevention has focused on European-derived populations. In these studies, lifestyle management has proven an effective therapy for reversal of MetS, and randomised studies are underway in specific racial/ethnic groups. Given the large number of people at risk for MetS, prevention efforts need to focus at community and population levels. Community-based interventions have begun to show promise, and efforts to improve lifestyle behaviours through alterations in the built environment may be another avenue. However, careful consideration needs to be given to take into account the unique cultural context of the target race/ethnic group.
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http://dx.doi.org/10.3390/nu12010015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019432PMC
December 2019

The Local Food Environment and Obesity: Evidence from Three Cities.

Obesity (Silver Spring) 2020 01 26;28(1):40-45. Epub 2019 Nov 26.

Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.

Objective: This study aimed to identify the association between the food environment and obesity.

Methods: BMI and waist circumference (WC) were measured in 8,076 participants from three cities. The number of fast-food restaurants, full-service restaurants, bars/pubs, markets, and liquor stores within 500 m of each participant was documented. The association between the food environment (ratio of fast-food to full-service restaurants, ratio of bars/pubs to liquor stores, and presence of markets) with obesity (BMI ≥ 30 kg/m ) and abdominal obesity (WC ≥ 102 cm for males or WC ≥ 88 cm for females) was investigated, adjusted for age, sex, education level, neighborhood deprivation, neighborhood type, and total hours per week of walking and taking into account city-level clustering.

Results: The ratios of fast-food to full-service restaurants and of bars/pubs to liquor stores were positively associated with obesity (OR = 1.05 [CI: 1.02-1.09] and OR = 1.08 [CI: 1.04-1.13], respectively). The ratio of bars/pubs to liquor stores was positively associated with abdominal obesity (OR = 1.10 [CI: 1.05-1.14]). There was no association between markets and either obesity or abdominal obesity.

Conclusions: Features of the food environment have varying associations with obesity. These features have an additive effect, and future studies should not focus on only one feature in isolation.
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http://dx.doi.org/10.1002/oby.22614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6972660PMC
January 2020

Relationship between diet and acculturation among South Asian children living in Canada.

Appetite 2020 04 20;147:104524. Epub 2019 Nov 20.

McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada. Electronic address:

Introduction: Diet and South Asian ethnicity are both associated with early onset of cardiovascular risk factors. Among youth of South Asian origin, little is known about the role of culture in determining healthy dietary patterns. We aimed to assess dietary patterns and their relationships with acculturation to Western and traditional lifestyles among South Asian youth in Canada.

Methods: The Research in Cardiovascular Health - Lifestyles, Environments and Genetic Attributes in Children and Youth (RICH LEGACY) study targeted South Asian children and adolescents aged 7-8 and 14-15 years in two Canadian cities. In this cross-sectional study, acculturation questionnaires and food frequency questionnaires were administered to assess the correlations between Western and traditional culture scores, immigration status (generation and length of residency) in Canada and intake frequency of various foods.

Results: Among 759 youth, those who ate fruits and vegetables more often consumed dairy and whole grains more often (all r = 0.17-0.22, all p < 0.001), while those who ate fast food more often consumed meat, sweets and sugared drinks more often (all r 0.24-0.38, all p < 0.001). Traditional culture scores were weakly positively correlated with whole grain intake frequency (r = 0.12, p = 0.001), and negatively with meat intake frequency (r = -0.14, p < 0.001). Western culture scores positively correlated with high intake frequency of meat (r = 0.23, p < 0.001), fast food (r = 0.14, p < 0.001) and sweets (r = 0.14, p < 0.001).

Discussion: Children who are more acculturated with Western lifestyle consumed foods associated with increased metabolic risk. However, whether this eating pattern translates into increased risk of obesity and cardiovascular diseases needs to be further explored.
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http://dx.doi.org/10.1016/j.appet.2019.104524DOI Listing
April 2020

Cardiovascular risk scoring and magnetic resonance imaging detected subclinical cerebrovascular disease.

Eur Heart J Cardiovasc Imaging 2020 06;21(6):692-700

Department of Medicine and Diagnostic Radiology, McGill University, 1001 Decarie Boulevard, Montreal, Quebec H4A 3J1, Canada.

Aims: Cardiovascular risk factors are used for risk stratification in primary prevention. We sought to determine if simple cardiac risk scores are associated with magnetic resonance imaging (MRI)-detected subclinical cerebrovascular disease including carotid wall volume (CWV), carotid intraplaque haemorrhage (IPH), and silent brain infarction (SBI).

Methods And Results: A total of 7594 adults with no history of cardiovascular disease (CVD) underwent risk factor assessment and a non-contrast enhanced MRI of the carotid arteries and brain using a standardized protocol in a population-based cohort recruited between 2014 and 2018. The non-lab-based INTERHEART risk score (IHRS) was calculated in all participants; the Framingham Risk Score was calculated in a subset who provided blood samples (n = 3889). The association between these risk scores and MRI measures of CWV, carotid IPH, and SBI was determined. The mean age of the cohort was 58 (8.9) years, 55% were women. Each 5-point increase (∼1 SD) in the IHRS was associated with a 9 mm3 increase in CWV, adjusted for sex (P < 0.0001), a 23% increase in IPH [95% confidence interval (CI) 9-38%], and a 32% (95% CI 20-45%) increase in SBI. These associations were consistent for lacunar and non-lacunar brain infarction. The Framingham Risk Score was also significantly associated with CWV, IPH, and SBI. CWV was additive and independent to the risk scores in its association with IPH and SBI.

Conclusion: Simple cardiovascular risk scores are significantly associated with the presence of MRI-detected subclinical cerebrovascular disease, including CWV, IPH, and SBI in an adult population without known clinical CVD.
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http://dx.doi.org/10.1093/ehjci/jez226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237958PMC
June 2020

Risk of myocardial infarction among people living with HIV: an updated systematic review and meta-analysis.

BMJ Open 2019 09 24;9(9):e025874. Epub 2019 Sep 24.

Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.

Objective: Cardiovascular disease (CVD) is one of the leading non-AIDS-defining causes of death among HIV-positive (HIV+) individuals. However, the evidence surrounding specific components of CVD risk remains inconclusive. We conducted a systematic review and meta-analysis to synthesise the available evidence and establish the risk of myocardial infarction (MI) among HIV+ compared with uninfected individuals. We also examined MI risk within subgroups of HIV+ individuals according to exposure to combination antiretroviral therapy (ART), ART class/regimen, CD4 cell count and plasma viral load (pVL) levels.

Design: Systematic review and meta-analysis.

Data Sources: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews until 18 July 2018. Furthermore, we scanned recent HIV conference abstracts (CROI, IAS/AIDS) and bibliographies of relevant articles.

Eligibility Criteria: Original studies published after December 1999 and reporting comparative data relating to the rate of MI among HIV+ individuals were included.

Data Extraction And Synthesis: Two reviewers working in duplicate, independently extracted data. Data were pooled using random-effects meta-analysis and reported as relative risk (RR) with 95% CI.

Results: Thirty-two of the 8130 identified records were included in the review. The pooled RR suggests that HIV+ individuals have a greater risk of MI compared with uninfected individuals (RR: 1.73; 95% CI 1.44 to 2.08). Depending on risk stratification, there was moderate variation according to ART uptake (RR, ART-treated=1.80; 95% CI 1.17 to 2.77; ART-untreated HIV+ individuals: 1.25; 95% CI 0.93 to 1.67, both relative to uninfected individuals). We found low CD4 count, high pVL and certain ART characteristics including cumulative ART exposure, any/cumulative use of protease inhibitors as a class, and exposure to specific ART drugs (eg, abacavir) to be importantly associated with a greater MI risk.

Conclusions: Our results indicate that HIV infection, low CD4, high pVL, cumulative ART use in general including certain exposure to specific ART class/regimen are associated with increased risk of MI. The association with cumulative ART may be an index of the duration of HIV infection with its attendant inflammation, and not entirely the effect of cumulative exposure to ART per se.

Prospero Registration Number: CRD42014012977.
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http://dx.doi.org/10.1136/bmjopen-2018-025874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773316PMC
September 2019

Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.

Lancet 2020 03 3;395(10226):795-808. Epub 2019 Sep 3.

Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, QC, Canada.

Background: Global estimates of the effect of common modifiable risk factors on cardiovascular disease and mortality are largely based on data from separate studies, using different methodologies. The Prospective Urban Rural Epidemiology (PURE) study overcomes these limitations by using similar methods to prospectively measure the effect of modifiable risk factors on cardiovascular disease and mortality across 21 countries (spanning five continents) grouped by different economic levels.

Methods: In this multinational, prospective cohort study, we examined associations for 14 potentially modifiable risk factors with mortality and cardiovascular disease in 155 722 participants without a prior history of cardiovascular disease from 21 high-income, middle-income, or low-income countries (HICs, MICs, or LICs). The primary outcomes for this paper were composites of cardiovascular disease events (defined as cardiovascular death, myocardial infarction, stroke, and heart failure) and mortality. We describe the prevalence, hazard ratios (HRs), and population-attributable fractions (PAFs) for cardiovascular disease and mortality associated with a cluster of behavioural factors (ie, tobacco use, alcohol, diet, physical activity, and sodium intake), metabolic factors (ie, lipids, blood pressure, diabetes, obesity), socioeconomic and psychosocial factors (ie, education, symptoms of depression), grip strength, and household and ambient pollution. Associations between risk factors and the outcomes were established using multivariable Cox frailty models and using PAFs for the entire cohort, and also by countries grouped by income level. Associations are presented as HRs and PAFs with 95% CIs.

Findings: Between Jan 6, 2005, and Dec 4, 2016, 155 722 participants were enrolled and followed up for measurement of risk factors. 17 249 (11·1%) participants were from HICs, 102 680 (65·9%) were from MICs, and 35 793 (23·0%) from LICs. Approximately 70% of cardiovascular disease cases and deaths in the overall study population were attributed to modifiable risk factors. Metabolic factors were the predominant risk factors for cardiovascular disease (41·2% of the PAF), with hypertension being the largest (22·3% of the PAF). As a cluster, behavioural risk factors contributed most to deaths (26·3% of the PAF), although the single largest risk factor was a low education level (12·5% of the PAF). Ambient air pollution was associated with 13·9% of the PAF for cardiovascular disease, although different statistical methods were used for this analysis. In MICs and LICs, household air pollution, poor diet, low education, and low grip strength had stronger effects on cardiovascular disease or mortality than in HICs.

Interpretation: Most cardiovascular disease cases and deaths can be attributed to a small number of common, modifiable risk factors. While some factors have extensive global effects (eg, hypertension and education), others (eg, household air pollution and poor diet) vary by a country's economic level. Health policies should focus on risk factors that have the greatest effects on averting cardiovascular disease and death globally, with additional emphasis on risk factors of greatest importance in specific groups of countries.

Funding: Full funding sources are listed at the end of the paper (see Acknowledgments).
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http://dx.doi.org/10.1016/S0140-6736(19)32008-2DOI Listing
March 2020

Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study.

Lancet Glob Health 2019 06 23;7(6):e748-e760. Epub 2019 Apr 23.

Population Health Research Institute, McMaster University, Hamilton Health Sciences Centre, Hamilton, ON, Canada.

Background: Socioeconomic status is associated with differences in risk factors for cardiovascular disease incidence and outcomes, including mortality. However, it is unclear whether the associations between cardiovascular disease and common measures of socioeconomic status-wealth and education-differ among high-income, middle-income, and low-income countries, and, if so, why these differences exist. We explored the association between education and household wealth and cardiovascular disease and mortality to assess which marker is the stronger predictor of outcomes, and examined whether any differences in cardiovascular disease by socioeconomic status parallel differences in risk factor levels or differences in management.

Methods: In this large-scale prospective cohort study, we recruited adults aged between 35 years and 70 years from 367 urban and 302 rural communities in 20 countries. We collected data on families and households in two questionnaires, and data on cardiovascular risk factors in a third questionnaire, which was supplemented with physical examination. We assessed socioeconomic status using education and a household wealth index. Education was categorised as no or primary school education only, secondary school education, or higher education, defined as completion of trade school, college, or university. Household wealth, calculated at the household level and with household data, was defined by an index on the basis of ownership of assets and housing characteristics. Primary outcomes were major cardiovascular disease (a composite of cardiovascular deaths, strokes, myocardial infarction, and heart failure), cardiovascular mortality, and all-cause mortality. Information on specific events was obtained from participants or their family.

Findings: Recruitment to the study began on Jan 12, 2001, with most participants enrolled between Jan 6, 2005, and Dec 4, 2014. 160 299 (87·9%) of 182 375 participants with baseline data had available follow-up event data and were eligible for inclusion. After exclusion of 6130 (3·8%) participants without complete baseline or follow-up data, 154 169 individuals remained for analysis, from five low-income, 11 middle-income, and four high-income countries. Participants were followed-up for a mean of 7·5 years. Major cardiovascular events were more common among those with low levels of education in all types of country studied, but much more so in low-income countries. After adjustment for wealth and other factors, the HR (low level of education vs high level of education) was 1·23 (95% CI 0·96-1·58) for high-income countries, 1·59 (1·42-1·78) in middle-income countries, and 2·23 (1·79-2·77) in low-income countries (p<0·0001). We observed similar results for all-cause mortality, with HRs of 1·50 (1·14-1·98) for high-income countries, 1·80 (1·58-2·06) in middle-income countries, and 2·76 (2·29-3·31) in low-income countries (p<0·0001). By contrast, we found no or weak associations between wealth and these two outcomes. Differences in outcomes between educational groups were not explained by differences in risk factors, which decreased as the level of education increased in high-income countries, but increased as the level of education increased in low-income countries (p<0·0001). Medical care (eg, management of hypertension, diabetes, and secondary prevention) seemed to play an important part in adverse cardiovascular disease outcomes because such care is likely to be poorer in people with the lowest levels of education compared to those with higher levels of education in low-income countries; however, we observed less marked differences in care based on level of education in middle-income countries and no or minor differences in high-income countries.

Interpretation: Although people with a lower level of education in low-income and middle-income countries have higher incidence of and mortality from cardiovascular disease, they have better overall risk factor profiles. However, these individuals have markedly poorer health care. Policies to reduce health inequities globally must include strategies to overcome barriers to care, especially for those with lower levels of education.

Funding: Full funding sources are listed at the end of the paper (see Acknowledgments).
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http://dx.doi.org/10.1016/S2214-109X(19)30045-2DOI Listing
June 2019

Joint association of urinary sodium and potassium excretion with cardiovascular events and mortality: prospective cohort study.

BMJ 2019 03 13;364:l772. Epub 2019 Mar 13.

Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada.

Objective: To evaluate the joint association of sodium and potassium urinary excretion (as surrogate measures of intake) with cardiovascular events and mortality, in the context of current World Health Organization recommendations for daily intake (<2.0 g sodium, >3.5 g potassium) in adults.

Design: International prospective cohort study.

Setting: 18 high, middle, and low income countries, sampled from urban and rural communities.

Participants: 103 570 people who provided morning fasting urine samples.

Main Outcome Measures: Association of estimated 24 hour urinary sodium and potassium excretion (surrogates for intake) with all cause mortality and major cardiovascular events, using multivariable Cox regression. A six category variable for joint sodium and potassium was generated: sodium excretion (low (<3 g/day), moderate (3-5 g/day), and high (>5 g/day) sodium intakes) by potassium excretion (greater/equal or less than median 2.1 g/day).

Results: Mean estimated sodium and potassium urinary excretion were 4.93 g/day and 2.12 g/day, respectively. After a median follow-up of 8.2 years, 7884 (6.1%) participants had died or experienced a major cardiovascular event. Increasing urinary sodium excretion was positively associated with increasing potassium excretion (unadjusted r=0.34), and only 0.002% had a concomitant urinary excretion of <2.0 g/day of sodium and >3.5 g/day of potassium. A J-shaped association was observed of sodium excretion and inverse association of potassium excretion with death and cardiovascular events. For joint sodium and potassium excretion categories, the lowest risk of death and cardiovascular events occurred in the group with moderate sodium excretion (3-5 g/day) and higher potassium excretion (21.9% of cohort). Compared with this reference group, the combinations of low potassium with low sodium excretion (hazard ratio 1.23, 1.11 to 1.37; 7.4% of cohort) and low potassium with high sodium excretion (1.21, 1.11 to 1.32; 13.8% of cohort) were associated with the highest risk, followed by low sodium excretion (1.19, 1.02 to 1.38; 3.3% of cohort) and high sodium excretion (1.10, 1.02 to 1.18; 29.6% of cohort) among those with potassium excretion greater than the median. Higher potassium excretion attenuated the increased cardiovascular risk associated with high sodium excretion (P for interaction=0.007).

Conclusions: These findings suggest that the simultaneous target of low sodium intake (<2 g/day) with high potassium intake (>3.5 g/day) is extremely uncommon. Combined moderate sodium intake (3-5 g/day) with high potassium intake is associated with the lowest risk of mortality and cardiovascular events.
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http://dx.doi.org/10.1136/bmj.l772DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6415648PMC
March 2019

Body composition, muscle function, and physical performance in fibrotic interstitial lung disease: a prospective cohort study.

Respir Res 2019 Mar 12;20(1):56. Epub 2019 Mar 12.

Department of Medicine, University of British Columbia, Vancouver, Canada.

Background: Patients with fibrotic interstitial lung disease (ILD) are frequently physically inactive and many ILD subtypes are characterized by risk factors for myopathy; however, the importance of body composition, muscle strength, and physical performance in this population is largely unknown.

Methods: Patients were prospectively recruited from a specialized ILD clinic, baseline characteristics were collected from the clinical record, pulmonary function tests were performed per established protocols, and dyspnea was measured using the University of California San Diego Shortness of Breath Questionnaire. Dual-energy X-ray absorptiometry (DXA) was used to assess body composition; handgrip strength to determine muscle strength, and 4-m gait speed to measure physical performance.

Results: One hundred and fifteen patients with fibrotic ILD including 40 patients with idiopathic pulmonary fibrosis were recruited. The mean age was 69+/- 10 years in men (62% of the cohort), and 66+/- 9 years in women, with mild and moderate reduction in FVC and DLCO, respectively, for both sexes. ILD severity (measured by FVC %-predicted, DLCO %-predicted, or the Composite Physiologic Index in separate models) significantly predicted muscle mass and percent body fat including with adjustment for age, sex, and weight. ILD severity was associated with grip strength and gait speed independent from body composition.

Conclusions: ILD severity has an important impact on body composition, particularly in men. Future studies are needed to confirm and further explore the possibility of additional pathways through which ILD directly impacts limb muscle function and physical performance.
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http://dx.doi.org/10.1186/s12931-019-1019-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6417197PMC
March 2019

Adiposity measures and their validity in estimating risk of hypertension in South Asian children: a cross-sectional study.

BMJ Open 2019 02 20;9(2):e024087. Epub 2019 Feb 20.

Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.

Objective: Given the South Asian phenotype of higher body fat at similar body mass index (BMI) relative to Caucasians, we sought to explore the association between prominent adiposity indicators with blood pressure (BP) and hypertension, to compare the accuracy of these indicators in estimating hypertension, and to provide cut-off values associated with adverse hypertension risk in South Asian children.

Design: Cross-sectional study.

Setting: Community-based recruitment in two Canadian cities (Hamilton and Surrey).

Participants: South Asian children (n=762) were recruited from two Canadian cities. Waist circumference, waist to height ratio and BMI were determined. Body fat percentage was assessed by bioelectrical impedance analysis and BP was assessed using an automated device. All variables (except body fat percentage) were transformed to z-scores using published standards.

Outcome Measures: Linear and Poisson regression was used to explore associations between the adiposity indicators with BP z-score and hypertension. Receiver operating curve (ROC) analysis was used to explore the strength of the adiposity indicators in estimating hypertension risk and sex-stratified optimal adiposity cut-off values associated with hypertension risk.

Results: Significant associations were detected in adjusted and unadjusted models between the adiposity indicators with BP z-score and hypertension (p<0.01 for all). The area under the curve (AUC) values for the adiposity indicators for boys and girls ranged from 0.74 to 0.80, suggesting that the adiposity indicators are fair measures of estimating hypertension risk. Sex-stratified cut-off associated with adverse risk of hypertension for girls and boys, respectively, were at the 92nd and 82nd percentile for BMI z-scores, 65th and 80th percentile for WC z-score, 63rd and 67th percentile for WHtR z-score and at 29.8% and 23.5% for body fat.

Conclusion: Our results show associations between adiposity indicators with BP and hypertension and suggests that South Asian children might be at adverse risk of hypertension at levels of adiposity considered normal.
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http://dx.doi.org/10.1136/bmjopen-2018-024087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398767PMC
February 2019

Delivery of Peer Support Through a Self-Management mHealth Intervention (Healing Circles) in Patients With Cardiovascular Disease: Protocol for a Randomized Controlled Trial.

JMIR Res Protoc 2019 Jan 11;8(1):e12322. Epub 2019 Jan 11.

Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada.

Background: Cardiovascular disease (CVD) is a leading cause of hospitalization and death around the world. The prevalence of CVD is increasing and, therefore, development and investigation of effective programs to help people better self-manage their CVD and prevent secondary complications are needed.

Objective: In this paper, we report on a protocol to evaluate Healing Circles-an evidence-based and patient-informed peer support mobile health program designed to facilitate self-management and support patients in their recovery from and management of CVD. We hypothesize that individuals with CVD who use Healing Circles will experience greater improvements to their self-management ability than individuals receiving usual care.

Methods: In this single-blinded (assessor) randomized controlled trial, 250 community-living individuals with CVD will be randomized on a 1:1 basis to either Healing Circles or Usual Care. The primary outcome of self-management will be measured using the Health Education Impact Questionnaire version 3.0. Secondary outcomes include self-efficacy with chronic disease management, health-related quality of life, health resource use and costs, and electronic health literacy. Measurements will be taken at the baseline and every 6 months for 24 months.

Results: The study started recruitment in September 2017. Individuals are currently being recruited for participation, and existing participants are currently on follow-up. Measurements will be taken every 6 months until the study end, which is anticipated in December 2019.

Conclusions: Healing Circles is a novel program aimed toward improving self-management through peer support. Given our real-world study design, our findings will be readily translatable into practice. If the results support our hypothesis, it will indicate that Healing Circles is an effective intervention for improving self-management and reducing health care use.

Trial Registration: ClinicalTrials.gov NCT03159325; https://clinicaltrials.gov/ct2/show/NCT03159325 (Archived by WebCite at http://www.webcitation.org/74DvxVKUd).

International Registered Report Identifier (irrid): DERR1-10.2196/12322.
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http://dx.doi.org/10.2196/12322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330197PMC
January 2019

Association of estimated sleep duration and naps with mortality and cardiovascular events: a study of 116 632 people from 21 countries.

Eur Heart J 2019 05;40(20):1620-1629

Department of Medicine, Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, Ontario, Canada.

Aims: To investigate the association of estimated total daily sleep duration and daytime nap duration with deaths and major cardiovascular events.

Methods And Results: We estimated the durations of total daily sleep and daytime naps based on the amount of time in bed and self-reported napping time and examined the associations between them and the composite outcome of deaths and major cardiovascular events in 116 632 participants from seven regions. After a median follow-up of 7.8 years, we recorded 4381 deaths and 4365 major cardiovascular events. It showed both shorter (≤6 h/day) and longer (>8 h/day) estimated total sleep durations were associated with an increased risk of the composite outcome when adjusted for age and sex. After adjustment for demographic characteristics, lifestyle behaviours and health status, a J-shaped association was observed. Compared with sleeping 6-8 h/day, those who slept ≤6 h/day had a non-significant trend for increased risk of the composite outcome [hazard ratio (HR), 1.09; 95% confidence interval, 0.99-1.20]. As estimated sleep duration increased, we also noticed a significant trend for a greater risk of the composite outcome [HR of 1.05 (0.99-1.12), 1.17 (1.09-1.25), and 1.41 (1.30-1.53) for 8-9 h/day, 9-10 h/day, and >10 h/day, Ptrend < 0.0001, respectively]. The results were similar for each of all-cause mortality and major cardiovascular events. Daytime nap duration was associated with an increased risk of the composite events in those with over 6 h of nocturnal sleep duration, but not in shorter nocturnal sleepers (≤6 h).

Conclusion: Estimated total sleep duration of 6-8 h per day is associated with the lowest risk of deaths and major cardiovascular events. Daytime napping is associated with increased risks of major cardiovascular events and deaths in those with >6 h of nighttime sleep but not in those sleeping ≤6 h/night.
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http://dx.doi.org/10.1093/eurheartj/ehy695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528160PMC
May 2019

Who is in the near market for bicycle sharing? Identifying current, potential, and unlikely users of a public bicycle share program in Vancouver, Canada.

BMC Public Health 2018 Nov 29;18(1):1326. Epub 2018 Nov 29.

Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A1S6, Canada.

Background: Public bicycle share programs in many cities are used by a small segment of the population. To better understand the market for public bicycle share, this study examined the socio-demographic and transportation characteristics of current, potential, and unlikely users of a public bicycle share program and identified specific motivators and deterrents to public bicycle share use.

Methods: We used cross-sectional data from a 2017 Vancouver public bicycle share (Mobi by Shaw Go) member survey (n = 1272) and a 2017 population-based survey of Vancouver residents (n = 792). We categorized non-users from the population survey as either potential or unlikely users based on their stated interest in using public bicycle share within the next year. We used descriptive statistics to compare the demographic and transportation characteristics of current users to non-users, and multiple logistic regression to compare the profiles of potential and unlikely users.

Results: Public bicycle share users in Vancouver tended to be male, employed, and have higher educations and incomes as compared to non-users, and were more likely to use active modes of transportation. The vast majority of non-users (74%) thought the public bicycle share program was a good idea for Vancouver. Of the non-users, 23% were identified as potential users. Potential users tended to be younger, have lower incomes, and were more likely to use public transit for their main mode of transportation, as compared to current and unlikely users. The most common motivators among potential users related to health benefits, not owning a bicycle, and stations near their home or destination. The deterrents among unlikely users were a preference for riding their own bicycle, perceived inconvenience compared to other modes, bad weather, and traffic. Cost was a deterrent to one-fifth of unlikely users, notable given they tended to have lower incomes than current users.

Conclusion: Findings can help inform targeted marketing and outreach to increase public bicycle share uptake in the population.
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http://dx.doi.org/10.1186/s12889-018-6246-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6267823PMC
November 2018

Patients in research: one step in a long path.

Authors:
Scott A Lear

BMJ 2018 10 24;363:k4386. Epub 2018 Oct 24.

Faculty of Health Sciences, Simon Fraser University, Vancouver, BC V6Z 1Y6, Canada.

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October 2018

Evaluation of the impact of a public bicycle share program on population bicycling in Vancouver, BC.

Prev Med Rep 2018 Dec 3;12:176-181. Epub 2018 Oct 3.

Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A1S6, Canada.

Public bicycle share programs have been implemented in cities around the world to encourage bicycling. However, there are limited evaluations of the impact of these programs on bicycling at the population level. This study examined the impact of a public bicycle share program on bicycling amongst residents of Vancouver, BC. Using an online panel, we surveyed a population-based sample of Vancouver residents three times: prior to the implementation of the public bicycle share program (T0, October 2015,  = 1111); in the early phase of implementation (T1, October 2016,  = 995); and one-year post implementation (T2, October 2017,  = 966). We used difference in differences estimation to assess whether there was an increase in bicycling amongst those living and/or working in close proximity (≤500 m) to Vancouver's public bicycle share program, compared to those living and working outside this area. Results suggest that only living or only working inside the bicycle share service area was not associated with increases in bicycling at T1 or T2 relative to those outside the service area. Both living and working inside the bicycle share service area was associated with increases in bicycling at T1 (OR: 2.26, 95% CI: 1.07, 4.80), however not at T2 (OR: 1.37, 95% CI: 0.67, 2.83). These findings indicate that the implementation of a public bicycle share program may have a greater effect on bicycling for residents who both live and work within the service area, although this effect may not be sustained over time.
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http://dx.doi.org/10.1016/j.pmedr.2018.09.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6174831PMC
December 2018

The Delivery of Cardiac Rehabilitation Using Communications Technologies: The "Virtual" Cardiac Rehabilitation Program.

Authors:
Scott A Lear

Can J Cardiol 2018 10 18;34(10 Suppl 2):S278-S283. Epub 2018 Jul 18.

Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada, Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada, and Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada. Electronic address:

Cardiac rehabilitation (CR) programs are a proven therapy for patients with cardiovascular disease, reducing future cardiac events and premature mortality. However, as little as 10% of eligible patients attend these programs, with a key reason being geographical inaccessibility. In Canada, more than 90% of Canadians have Internet access, and there are approximately 31 million cell phone subscribers, with these numbers expected to continue to increase. The proliferation of these affordable communications technologies has opened up opportunities for patient communication while bridging geographic distance. This has led to the development of "virtual" CR that can be remotely conducted, reaching patients in their homes and communities. These programs have used a range of technologies such as telephone, Internet, text messaging, and smartphones. Early research has focused on acceptance of use and feasibility in pilot studies, indicating patient willingness for use. More recently, a number of small, randomized trials have been conducted indicating potential positive effect on various clinical outcomes. This narrative review highlights the evidence to date on the use of virtual CR, using a variety of affordable communications technologies from early feasibility studies to modest randomized controlled trials. Finally, lessons from previous studies are discussed to help inform the development and testing of future virtual CR. This will be important if virtual CR is to become part of standard health care.
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http://dx.doi.org/10.1016/j.cjca.2018.07.009DOI Listing
October 2018