BACKGROUND:-Secular trend data on hypertension in children and adolescents are scarce and inconsistent. In the face of growing obesity, we sought to assess high blood pressure (HBP) secular trends in children and adolescents enrolled in national surveys and to determine whether the HBP trend reversed its course with the rise in obesity. Methods and Results-National survey data obtained from multistage probability sampling of the US noninstitutionalized population from 1963 to 2002 were examined; 8- to 17-year-old non-Hispanic blacks and whites and Mexican Americans were included. HBP ascertainment was based on age-, gender-, and height percentile-specific systolic and diastolic BPs. Weighted analyses were performed to account for the complex design. The BP, pre-HBP, and HBP trends were downward from 1963 to 1988 and upward thereafter. Pre-HBP and HBP increased 2.3%(P=0.0003) and 1%(P=0.17), respectively, between 1988 and 1999. Obesity increase, more so abdominal than general obesity, partially explained the rise in HBP and pre-HBP from 1988 to 1999. BP and HBP reversed their downward trends 10 years after the increase in the prevalence of obesity. Additionally, an ethnic and gender gap appeared in 1988 for pre-HBP and in 1999 for HBP; non-Hispanic blacks and Mexican Americans had a greater prevalence of HBP and pre-HBP than non-Hispanic whites, and males had a greater prevalence than females. Conclusions-HBP and pre-HBP in children and adolescents are on the rise. These new findings have implications for the cardiovascular disease public health burden, particularly the risk of a new cardiovascular disease transition. They reinforce the urgent call for early prevention of obesity and HBP and illustrate racial/ethnic disparities in this age group.

This paper examines the association between trait anger and subclinical carotid artery atherosclerosis among 14,098 Black or White men and women, aged 48-67 years, in the Atherosclerosis Risk in Communities Study cohort, 1990-1992. Trait anger was assessed using the 10-item Spielberger Trait Anger Scale. Carotid atherosclerosis was determined by an averaged measure of the wall intimal-medial thickness (IMT) of the carotid bifurcation and of the internal and common carotids, measured by high-resolution B-mode ultrasound. In the full study cohort, trait anger and carotid IMT were significantly and positively associated (p = 0.04). In race-gender stratified analysis, the association was strongest and independent only in Black men, among whom a significant trait anger-carotid IMT relation was observed for both the overall trait anger measure (p = 0.004) and the anger reaction dimension (p = 0.001). In Black men, carotid IMT levels increased across categories of overall trait anger and anger reaction, resulting in clinically significant differences (67 mum (95% confidence interval: 23, 110) and 82 mum (95% confidence interval: 40, 125), respectively) from low to high anger. Sociodemographic, lifestyle, anthropometric, and biologic cardiovascular disease risk factors appear to mediate the relation in Black women, White men, and White women. In conclusion, these findings document disparate race-gender patterns in the association of trait anger with subclinical carotid artery atherosclerosis.

The cross-sectional association between trait anger and stiffness of the left common carotid artery was examined in 10,285 black or white men or women, 48-67 years of age, from the Atherosclerosis Risk in Communities (ARIC) study cohort. Trait anger was assessed using the 10-item Spielberger Trait Anger Scale. Arterial stiffness was assessed by pulsatile arterial diameter change (PADC) derived from echo-tracking ultrasound methods; the smaller the PADC, the stiffer the common carotid artery. In men, trait anger was significantly associated with PADC, independent of the established cardiovascular disease risk factors (p=0.04). PADC decreased from the first (lowest anger group) to the second quintile of anger, but there was no progressive decrease thereafter. Also observed was a 13-mum (95% confidence interval [CI], 1-25) difference in the magnitude of PADC from the lowest to the uppermost quintile of anger (PADC [standard error], 421 [4] mum vs. 408 [5] mum). In women, the association was marginally significant (p=0.07). The low-high difference in the magnitude of PADC (PADC [standard error], 397 [3] mum vs. 406 [4] mum) was inverse (-9 mum 95% CI,-19 to 2). Conclusions indicate that very high trait anger is associated with arterial stiffness in men.

A continuous quality care improvement program (CQIP) was built into Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) to improve providers' patterns of diabetes care and patients' glycemic control. Project DIRECT consisted of a comprehensive program aimed at reducing the burden of diabetes in the vulnerable high-risk African-American population of southeast Raleigh, NC. Forty-seven providers caring for this target population of adult diabetes patients were included in this quasi-experimental study. At the initial session, providers learned about the CQIP components, completed a planning worksheet, and chose a CQIP coordinator. Educational events included continuing education in practices and through conferences by experts, and guideline distribution. Follow-up was accomplished through phone calls and visits. Effectiveness was measured by a change in prevalence of selected patterns of care abstracted from 1,006 medical charts. Appropriate statistical methods were used to account for the cluster design and repeated measures. At the fourth follow-up year, approximately 40% of providers still participated in the program. Among the providers who stayed in the program for the whole study period, most selected quality care patterns showed significant upward trends. Glycemic control indicators did not change, however, despite an increased number of hemoglobin A1c tests per year. A diabetes CQI program can be effectively implemented in a community setting. Improved performance measures were not associated with improved outcomes. These results suggest that a patient-centered component should reinforce the provider-centered component.

BACKGROUND: Impairment of arterial dilation is thought to occur earlier than arterial wall thickening in the atherosclerotic process. In comparison with whites, African Americans reportedly have a generalized attenuation of their vasodilation mechanisms. We set out to evaluate arterial stiffness and its correlates by ethnicity, hypothesizing that African Americans would have stiffer common carotid arteries (ie, lower arterial distension for a given systolic pressure) than their white counterparts. METHODS: The study population included 268 African Americans and 2459 whites, who were aged 45 to 64 years at baseline examination in 1986 to 1989, free of coronary heart disease and stroke/transient ischemic attack, from Forsyth County, North Carolina. The beta stiffness index and pulsatile arterial diameter change were derived from brachial blood pressure and from echo-tracked systolic and diastolic carotid arterial diameters. RESULTS: African Americans had stiffer carotid arteries than their white counterparts, with a right shift of the beta stiffness index distribution. After adjustment for selected cardiovascular risk factors, the mean beta stiffness index was 9% higher for African Americans (mean +/- SEM: 11.3 +/- 0.3) than for whites (mean +/- SEM: 10.3 +/- 0.1) among participants not taking antihypertensive medication. Socioeconomic status and comorbidities were differentially associated with arterial stiffness by ethnicity. Specifically, the association between these correlates and beta stiffness index was stronger in African Americans than in whites. CONCLUSIONS: This report on arterial mechanics in African Americans suggests that large artery stiffening either occurs earlier, or is more accelerated in African Americans than in whites in our sample, perhaps as a result of earlier exposure to multiple risk factors. This finding may have implications for hypertension prevention, as arterial stiffness is associated with the development of hypertension.

There is increasing evidence of an association between stress related to job strain and hypertension. However little data exist on stress from racism and race-based discrimination at work (RBDW). The objective of this study was to investigate whether blood pressure (BP) outcomes are positively associated with stressful racism towards African-Americans from non-African-Americans as well as RBDW from other African-Americans. The metro Atlanta heart disease study was a population-based study which included 356 African-American men and women, aged >/=21 years, residing in metropolitan Atlanta, Georgia during 1999-2001. Perceived stress was self-reported by 197 participants for racism from non-African-Americans and 95 for RBDW from other African-Americans. Sitting systolic (SBP) and diastolic (DBP) BP were taken at a clinic visit and was the average of the last two of three BP measures. Hypertension was self-reported as physician-diagnosed high BP on 2 or more visits. Logistic and least-squares linear regression models were fit accordingly and separately for each type of stress, adjusting for age, gender, body mass index, and coping abilities. The likelihood of hypertension significantly increased with higher levels of perceived stress following racism from non-African-Americans, but not from RBDW from other African-Americans; adjusted odd ratios (95% CI) were 1.4 (1.0, 1.9) and 1.2 (0.8, 1.5) per unit increment of stress. The adjusted magnitude of SBP and DBP increase between low and very high level of stress, conversely, was greater when RBDW originated from African-Americans than racism from non-African-Americans. Stressful racism and RBDW encounters are associated with increased SBP and DBP and increased likelihood of hypertension in African-Americans. Future studies with a larger sample size are warranted to further explore these findings for mechanistic understanding and occupational policy consideration regarding stress risk reduction.

Education is strongly inversely associated with common carotid artery intima-media thickness in the Atherosclerosis Risk in Communities (ARIC) Study. The authors extended the ARIC study of preclinical atherosclerosis by evaluating the cross-sectional association of education with common carotid artery elasticity. This study included 10,091 Black and White men and women aged 45-64 years who were free of clinical coronary heart disease and stroke/transient ischemic attack. Arterial elasticity was assessed by pulsatile arterial diameter change (PADC), derived from phase-locked echo-tracking. The smaller the PADC, the stiffer the artery. Education was categorized into grade school, high school without graduation, high school with graduation, vocational school, some college, and graduate/professional school. PADC was directly associated with educational attainment. The mean PADCs, adjusted for age, height, diastolic diameter, systolic blood pressure, pulse pressure (linear and squared), ethnicity, gender, and smoking status, in successively higher education strata were 402 (standard error (SE) 5), 403 (SE 4), 407 (SE 3), 413 (SE 4), 416 (SE 2), and 417 (SE 4) microm (p = 0.007). To the authors' knowledge, this is the first time such an association has been reported. If arterial dilation impairment precedes arterial wall thickening in the atherosclerotic process, as recent studies on endothelial dysfunction suggest, these results indicate that low socioeconomic status may be associated with early arterial pathophysiologic changes-an effect that appears to be mediated by established cardiovascular disease risk factors.

OBJECTIVES: Despite decreasing infant mortality in North Carolina, the gap between African Americans and Whites persists. This study examined how racial differences in infant mortality vary by maternal education. METHODS: Data came from Linked Birth and Infant Death files for 1988 through 1993. Multiple logistic regression models adjusted for confounders. RESULTS: Infant mortality risk ratios comparing African Americans and Whites increased with higher levels of maternal education. Education beyond high school reduced risk of infant mortality by 20% among Whites but had little effect among African Americans. CONCLUSIONS: Higher education magnifies racial differences in infant mortality on a multiplicative scale. Possible reasons include greater stress, fewer economic resources, and poorer quality of prenatal care among African Americans.

Comparisons of infant, perinatal, or neonatal mortality across populations with different birthweight or gestational age distributions are problematic. Summary measures with adjustment for birthweight or gestational age frequently are invalid or lack interpretability. We propose a percentile-based method of standardization for comparing infant, perinatal, or neonatal mortality across populations that have different distributions of birthweight and/or gestational age. The underlying concept is a simple one: comparable health for two population groups will be expressed as equal rates of disease or mortality at equal quantiles in the two distributions of birthweight or gestational age. We describe this method mathematically and present an example comparing mortality rates for African-American vs European-American infants in North Carolina. When gestational age is transformed to its rank, the well-known crossover in mortality rates, in which preterm African-American infants die at lower rates but term infants at higher rates, disappears: African-Americans show higher mortality rates at any percentile of gestational age. With homogeneous mortality rate ratios, a summary statistic becomes meaningful. We also demonstrate adjustment for percentile-transformed gestational age or birthweight in multiple logistic regression models. Percentile standardization is easily implemented, has advantages over other methods of internal standardization such as that of Wilcox and Russell, and communicates an intuitive public health-based concept of equality of mortality across populations.