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Introduction: While prior population-based cohorts have extensively described burden of coronary artery calcification (CAC) among asymptomatic individuals, there is paucity of occult coronary atherosclerotic disease (CAD) assessment with coronary computed tomography angiography (CCTA) in the general population. The aims were to determine prevalence, burden and coronary plaque characteristics in the ongoing prospective Miami Heart Study (MiHeart) using both CAC and CCTA. Methods: MiHeart enrolled 2,549 middle-aged 40-65 years free of clinical cardiovascular disease participants (49% females, mean age 53, 47% Hispanic/Latino) from general population of Greater Miami Area (Florida, USA). Final study consisted of 2491 (98%) among whom non- cardiac-gated CT for CAC testing and contrast-enhanced CCTA cardiac-gated were performed. Results: In this study 58% had CAC=0, 13% had CAC≥100, and 45% had detectable plaque on CCTA. 143 (6%) participants had significant (≥50%) stenosis and 44 (2%) had severe (≥70%) stenosis. Overall, 26% participants had exclusive non-calcified plaque whereas 7% demonstrated high-risk plaque features (HRP) with positive remodeling being most frequently observed (5%). Among participants with CAC=0, 15% had any plaque on CCTA (62% in 1 segment); 1% had obstructive CAD and 2% any HRP, respectively. Burden of CAD (plaque segmental score, subtype, stenosis) as well as HRP on CCTA was strongly associated with increasing CAC scores (table). Overall, 31% and 20% with CAC≥100 had significant stenosis and HRP, respectively. Conclusions: In the first US general population based CCTA study, we demonstrate high burden of diverse coronary atherosclerotic plaque features in a middle-aged general population free of established CVD. Future studies in MiHeart will focus on biological associations and clinical implications of of coronary atherosclerotic disease severity and features on CCTA among asymptomatic individuals.

Introduction: Psychological factors including stress are associated with adverse cardiovascular (CV) disease outcomes. Gender differences exist in both the perception of stress and the magnitude of the stress response. We hypothesize that self-perceived psychological stressors would have a greater impact on women compared to men as measured by the American Heart Association Life’s Simple Seven (LS7) health metrics. Methods: This was a cross-sectional study conducted among employees of BHSF. The LS7 metrics (smoking, physical activity, diet, body mass index, blood pressure, cholesterol and glucose) were each scored as ideal (2), intermediate (1), or poor (0), with composite scores ranging from 0 to 14. Total scores were categorized as optimal (11-14), average (9-10) and inadequate (0-8). We used multinomial logistic regression to compare psychological factors obtained by questionnaire (self-perceived stress, life satisfaction, hopelessness, sadness, depression, anxiety) with the LS7 score (inadequate score served as reference). The model was stratified by gender and adjusted for age, ethnicity, and education level. Results: Of the 9,056 participants, 74% were female, 17% white, 57% Hispanic, 16% black, with a mean age of 43±12 years. Self-perceived adverse psychological factors were associated with being less likely to achieve adequate and optimal LS7 scores (Table). For example both women and men, respectively, with self-perceived stress were less likely to have optimal LS7 metrics [OR 0.47 (95% CI 0.40-0.56) vs. 0.50 (0.36-0.69)]. There were some interactions by gender (P Conclusions: In an ethnically diverse population, participants with negative self-perceived psychological factors are more likely to have inadequate CV health as measured by LS7. Contrary to our hypothesis, in general, men and women were similarly affected by adverse psychological factors. Addressing psychological stressors may be one mechanism to improve CV health.

Background: Ethnic differences in obesity are well documented; however, the epidemiological evidence of the impact of socioeconomic and educational status on its relationship is sparse. We sought to assess the impact of educational attainment, as a proxy of socioeconomic status, on the association between ethnicity and morbid obesity (MO) among employees of Baptist Health South Florida (BHSF), a large nonprofit healthcare organization. Methods: Data was collected from employees participating in an annual Health Risk Assessment in 2014. Educational attainment was self-reported while weight, height and other biometric measures were measured in person. MO was categorized using eligibility criteria for bariatric surgery as outlined by the 1991 NIH consensus guidelines for surgery for the obese. Results: Data was collected for 9361 participants (mean age 42.8 ± 12.1 years, 74% females, 63% Hispanic). Overall, 7% meet criteria for MO (Non-Hispanic White [NHW]: 5%; Hispanics: 6%; Non-Hispanic Black [NHB]: 12%). A lower education was associated with a greater prevalence of morbid obesity (Post graduate/ professional: 4.2%; completed college: 5.2%; some college or lower: 9.8%) The highest (18%) and lowest (4%) prevalence of MO were observed in NHB with some college education or lower (SCL), and in Hispanics with post-graduate or professional educational (PG) attainment respectively. Among PG, compared to NHW, the odd ratios (95% CI) for presence of MO among NHB was 1.3 (0.6 - 2.5). Conversely, the respective MO risk for NHB vs. NHW was 4 fold higher (2.5 - 6.4) among those with SCL. Interaction of ethnicity and educational attainment for predicting MO was significant (p Conclusion: Underlying differences in educational status significantly impact ethnic disparities in morbid obesity. The co-existing influence of education and racial disparities should be jointly addressed to maximize yield of future wellness efforts aimed at optimizing CV health.

Background: Healthcare disparities are a major public health concern. It is known that ethnicity and educational status independently predict health outcomes. Higher numbers of the American Heart Association's (AHA) ideal Life’s Simple 7 metrics (LS7) are associated with better cardiovascular health. In this study, we investigated the interplay of ethnicity and education on the attainment of ideal cardiovascular health (ICH) among employees of Baptist Health South Florida (BHSF), a large nonprofit health care organization. Methods: The data collected during BHSF annual voluntary wellness examination included age, gender, race, ethnicity and education. We assessed cardiovascular health using the LS7 metrics. Components of the LS7 metrics (smoking, physical activity, body mass index, diet, total cholesterol, blood pressure, and blood glucose) were categorized into ideal, intermediate and poor, according to AHA criteria. Study participants who met 6-7 ideal metrics were considered to have attained ICH. Results: The study population consisted of 9056 individuals (Mean age 43 ± 12 years, 74% women). Among employees with postgraduate education, 12% of white employees met the ideal for 6-7 LS7 metrics, 15% for Hispanic and 4% for Black employees. For employees with college degrees, the prevalence of 6-7 ideal LS7 metrics was 14%, 16% and 8% for white, Hispanic and black employees respectively (Figure). Overall, the odds of meeting 6-7 ideal LS7 metrics was lower for Hispanic and black employees compared to white employees of similar education (Table). These differences were especially large in those with high school education or less. Conclusion: Minorities are at an increased risk of poor cardiovascular health particularly those with the lowest educational achievement. Comprehensive workplace wellness programs that target these groups will improve cardiovascular health and employee productivity, in addition to saving health care costs.

Introduction: There has been increased focus on the relationship between sleep duration and cardiovascular disease, however, there is limited understanding of the association of sleep duration with cardiovascular health (CVH). In this study we examine the relationship between sleep duration and the American Heart Association’s ideal CVH in a large employee population. Methods: Data for this study was collected from participants at the 2014 health risk assessment in which they reported their average hours of sleep, their dietary patterns. In person, participants were weighed and their heights were measured. They also had blood pressure, blood glucose, total cholesterol measurements as well as breath carbon monoxide tests for smoking. The ideal for each CVH metric was estimated for each of the 7 metrics. Sleep duration was grouped into less than 6 hours, 6 to 7.9 hours and 8 or more hours. Ideal CVH was classified as presence of 6-7 ideal metrics. Results: A total of 9700 participants (mean age 43yrs, 74% female) completed the 2014 health risk assessment and had complete data on the variables of interest. Overall, more females and persons without college degrees slept for less than 6 hours. Compared to those with less than 6 hours of sleep, those with 8 or more hours of sleep had 1.6 times the odds of ideal diet (95% CI: 1.1-2.6), 1.7 times the odds of having ideal BMI (95% CI: 1.4-2.1), 1.3 times the odds of having ideal BP (95% CI: 1.1-1.5) and 2.4 times the odds of achieving ideal physical activity (95% CI: 2.4 - 2.9) after controlling for age, sex and educational levels. Comparing to those with less than 6 hours of sleep and with a reference of 0-2 ideal metrics, participants with 8 or more hours of sleep were 2.7 times as likely to have ideal CVH (see figure). Conclusions: Our study findings underscore the importance of promoting sleep health for optimizing ideal CVH. Further studies are needed to determine generalizability of our results.

BACKGROUND: Obesity is strongly related to chronic health problems and concomitant increased healthcare costs for employers. The aim of the study is to explore the distribution of obesity categories and estimate associated health costs among self-insured employees of Baptist Health South Florida (BHSF), a large not-for-profit health care organization. METHODS: Distribution of BMI categories was determined among individuals participating in a voluntary health risk assessment (HRA) available to employees eligible for health benefits. The potential estimates of obesity related costs to BHSF were imputed using CDC's Obesity Cost Calculator based on data from NHIS and MEPS (http://www.cdc.gov/leanworks/costcalculator/disclaimer.html). RESULTS: Overall 9996 (aged 43.1±12.1 years, 75% females, 75% Hispanic, 35% hypertensive, 4% diabetic) employees participated in 2013 annual HRA and wellness fair. The age-adjusted mean BMI was 29.3 (95% CI, 29.1-29.5) for men and 28.3 (95% CI, 28.15-28.45) kg/m2 for women. The table describes distribution of BMI categories according to gender and age groups. The age-adjusted prevalence of obesity (BMI>30 kg/m2) was 36% (95% CI, 34%-37%) among men and 32% (95% CI, 31%-33 %) among women. In BHSF employee population, 6% (n=581) were classified as morbidly obese (BMI>=40) and 7% (n=748) individuals met criteria for bariatric surgery. Total annual estimated cost attributable to high BMI (>25) were $8.05 million (74% medical and 26% work lost) of which 41% were contributed by 14% employees with BMI>35. The average attributable cost per high BMI employee ranged from $598 among those with BMI 25-29.9 to $2695 with BMI>=40. CONCLUSIONS: One third of employees (predominantly female and Hispanic) in a large health care organization (BHSF) were obese. Given the significant financial burden imposed by obesity large self-insured organizations like BHSF have a lot to gain by introducing evidence-driven weight reduction programs, and tracking the success of these programs in the workforce.

Introduction: With the development of new health metrics to define ideal cardiovascular health (CVH), several studies have examined the distribution of the American Heart Association (AHA) 2020 ideal CVH metrics both within and outside the United States (US). In this meta-analysis of proportions, we synthesized available data on ideal CVH metrics distribution in US cohorts and compared them with non-US populations. Methods: A MEDLINE database search was conducted using relevant free text terms such as “life’s simple 7”, “AHA 2020”, “American Heart Association 2020” and “ideal cardiovascular health” between January 2000 and October 2014. Studies were included in the meta-analysis if the proportions achieving ideal for 0, 1, 2, 3, 4, 5 or ≥6 ideal CVH metrics were known or could be estimated. A meta-analysis of proportions was conducted for US and non-US studies using a random effect model (REM). REM models were chosen because of the significant heterogeneity among studies. Results: Overall the pooled data consisted of 10 US cohorts with a total population of 94,761 participants and 6 non-US cohorts with a total of 130,242 participants. The table shows the pooled prevalence of ideal CVH factors in this population. Overall the pooled estimates of US cohorts showed 15% had 0-1 ideal CVH metrics (inter-study range: 7-22%), while 3% (inter-study range: 1-10%) had 6-7 ideal CVH metrics. This is comparable to 12% (inter-study range 1-17%) and 2% (inter-study range: 1-12%) for 0-1 and 6-7 ideal CVH metrics in the non-US studies. Conclusion: The proportion of persons achieving 6 or more ideal CVH metrics in both US and non-US cohorts is very low and the distribution of CVH metrics is similar in both US and non-US populations. Considering the strong association with worse outcomes, a coordinated global effort at improving CVH should be considered a priority.

Introduction: Metabolic syndrome, the clustering of multiple cardiovascular risk factors, is established as a risk factor for CVD. Shorter or longer sleep duration has been reported to be associated with increased risk of metabolic syndrome (MS) and diabetes mellitus (DM) through increased insulin resistance (IR). However, it is not known if impaired sleep alters IR in a high-risk population with known MS/DM. Methods: The Baptist Employee Healthy Heart Study is an ongoing lifestyle intervention study examining the effects of web-based interventions on reducing CVD risk in individuals with MS/DM. Sleep duration was self reported by the participants. Daily sleep duration was categorized into sleep 8 hours (long). Homeostatic model assessment of insulin resistance (HOMA-IR) was calculated from fasting insulin and fasting glucose level. Results: The population consisted of 182 participants (74% women, 49% Hispanic, mean age 52 ± 9 years). In this study the mean sleep duration was 7±5 hours and mean HOMA-IR was 5.2 ± 5.6 units. Systolic and diastolic blood pressure, BMI, waist circumference, total cholesterol level and LDL cholesterol level did not apparently differ across the groups. Both short and long sleepers tended to have lower HDL cholesterol level and higher triglyceride level (p8hrs (9.52±10.7), p Conclusions: In this study of high metabolic risk individuals, sleep duration was associated with increased insulin resistance and highlights the importance of improving sleep hygiene in the clinical management of high risk individuals with MS and DM.

INTRODUCTION: A recent meta-analysis demonstrated that Lipoprotein-associated phospholipase A 2 (LpPLA 2 ) activity is associated with CVD events. However, the mechanisms which mediate this risk are poorly established. This study aims to assess the cross-sectional association between LpPLA 2 and components of an advanced lipid panel, subclinical CVD and markers of inflammation. METHODS: The Baptist Employee Healthy Heart Study (BEHHS) is an ongoing study examining the effect of web-based interventions on reducing CVD risk in individuals with metabolic syndrome & type II diabetes mellitus. Cardio IQ™ Ion Mobility lipoprotein fractionation was utilized for advanced lipid subclass measurement resulting in direct quantification of particles in each lipoprotein sub-class fraction. Endothelial function was assessed using endoPAT2000 (Itamar, Israel) and individuals older than 35 years had CT scan for coronary artery calcium (CAC). LpPLA 2 was measured by Enzyme-linked Immunosorbent Assay (ELISA). RESULTS: The population consisted of 182 individuals, 74% female with a mean age of 51±10 years (range 25 - 72). Overall the median plasma LpPLA 2 level was 199 ng/mL. In univariate analyses, there was a significant association with several lipid subclasses and with hs-CRP. After adjusting for risk factors, LpPLA 2 was independently associated with LDL-c and LDL particle size, Large LDL subclass A, small IDL, small, medium and large VLDL, and with hs-CRP. On the other hand there was no association between LpPLA 2 mass and HOMA-IR, reactive hyperemia index or presence of CAC. CONCLUSIONS: LpPLA 2 is significantly associated with several lipoprotein sub-classes and with systemic inflammation without affecting vascular endothelial function or atherosclerosis. Further studies are required to determine if lifestyle interventions affect LpPLA2 and how this may translate to reduced systemic inflammation and an improvement in cardiometabolic profile.

BACKGROUND: Bariatric surgery among the morbidly obese is recommended as an option to mitigate future risk of cardiovascular disease, diabetes and hypertension. To date there is little evidence on the effect of extensive lifestyle interventions among these high-risk groups in reducing the need for such procedures in extended periods. METHODS: The purpose of the present study is assess efficacy of an intensive lifestyle workplace intervention on significant body weight across the spectrum of obesity in a worksite wellness program, called “My Unlimited Potential (MyUP)” conducted at Baptist Health South Florida. Changes in BMI are being measured from baseline to 12 months follow up, along with corresponding improvements in cardio-metabolic risk. In addition, the decrease in participants meeting criteria for bariatric surgery over the study period is examined at 6 and 12 months. Bariatric surgery criteria were defined as BMI≥40 or BMI between 35 and 40 and at least one of the following co-morbidities: diabetes, hypertension, or high cholesterol. RESULTS: The study population consisted of 272 individuals (48±9 years, 78% female) with BMI≥27 at baseline. Complete data at 12-month follow up was available for 141 individuals (52%). A total of 21(14%) and 14 (10%) participants had lost at least 10 % of their body weight by 6 months and 12 months respectively. Forty-six participants (32%) initially met criteria for bariatric surgery. At six month follow-up 43% (20 of 46, p CONCLUSIONS: This worksite wellness program effectively obviated the need for bariatric surgery in approximately half of those who were initially eligible at 1 year of follow up. Replication of this program with a larger cohort with stricter attention to attrition is needed to asses the utility of our program and its implications as a larger corporate wellness strategy.

Introduction: Visceral adiposity is associated with increased CVD risk. Ectopic fat deposition is linked with lipotoxicity, metabolic derangement, insulin resistance, and atherosclerosis. The lipoprotein(LP) subclasses are established risk markers for CVD mortality. We evaluated for the association of ectopic visceral fat measures [pericardial (PCF), Epicardial (EPC)], traditional adiposity measures [waist: hip ratio (WHR), Body Mass index (BMI), waist circumference (WC)] and the LP subclasses. Methods: The Baptist Employee Healthy Heart Study (BEHHS) an ongoing study examines the effect of web based interventions on reducing CVD risk in subjects with metabolic syndrome and type II diabetes mellitus. We measured PCF and EPC adipose tissue volumes from the 16-slice multi-detector computed tomography (MDCT) (GE AWW 3D Workstation). Cardio IQ™ Ion Mobility LP fractionation was utilized for advanced lipid subclass measurement resulting in direct quantification of particles in each LP sub-class fraction. Results: The population had 182 participants, 74% women, 49% Hispanic, mean age of 52 ± 9 years. The median PCF volume was 130 (97-166) cc, EPC volume 112(78-265) cc, mean WC 105±15 cm, BMI 34±6 kg/m2 ,WHR was 0.94 (SD 0.09). There was no correlation between BMI, and WC with any of the LP. WHR was significantly correlated with LDL particle size LDL large (A), , IDL small, and HDL large, see table 1. These associations were not significant in multivariate regression analysis. On the other hand PCF and ECP were significantly correlated with a wide spectrum of the LPs. After an adjusted robust regression, they remained significantly associated with IDL(large), LDL(total), VLDL(small), VLDL(medium) and VLDL(large). Conclusion: This demonstrates association between the ectopic adiposity and LP subclasses compared to traditional obesity measures. Further follow-up is needed to assess the interplay of lifestyle intervention in improving cardiometabolic profile

Background: Studies have demonstrated that improving physical fitness is associated with weight loss and improvement in cardio-metabolic risk profile. However, the effect of improvement in aerobic fitness on metabolic risk in the absence of significant weight loss in a high risk working population is poorly understood. We examined efficacy of both weight reduction and increased aerobic fitness on metabolic syndrome in an ongoing multicomponent lifestyle intervention improvement program (My Unlimited Potential (myUP)), among employees of Baptist Health South Florida (BHSF). Methods: The study population included 158 participants who had at least 2 metabolic risk factors at baseline. An advanced nurse practitioner, registered dietician, exercise physiologist, certified diabetic educator, and registered nurse met with participants to provide one-on-one counseling and fitness training. During the first 12 weeks the multidisciplinary team rigorously supervised participants. Results: Over the 12 week period, there was a significant increase in METS (median difference 2.7; IQR 1.4 to 3.4 p Conclusion: Improvements in respiratory fitness as can be seen with exercise, even in the absence of significant weight loss, is associated with significant reduction in cardiometabolic risk. In an intensive lifestyle modification interventional program aimed at CVD risk reduction, emphasis should be placed at increasing physical fitness, not only on weight loss.

Introduction: The impact of physical fitness on heart rate recovery (HRR), a marker of cardiac parasympathetic activity, has rarely been studied across weight categories. We examined the effect of physical fitness across different weight categories on HRR at 2 minutes after exercise stress test in an asymptomatic cohort. Methods: This is a cross-sectional analysis of 525 Brazilian subjects, free of known cardiovascular disease that underwent exercise stress test. Metabolic equivalents at maximal exercise (METS) were calculated from the volume of oxygen consumed during maximal exercise (VO2max). HRR was defined as peak exercise HR minus HR after 2minutes rest. Weight was classified into obese (BMI ≥ 30), overweight (BMI 25 -29) and normal weight (BMI Results: The prevalence of overweight and obesity was 51% and 19% respectively. There was a positive significant correlation between METS and HRR (r= 0.34 p Conclusion: Our findings suggest that increasing fitness increases HRR, with greater benefit in the obese than other weight groups. Physical fitness, not simply weight loss, should be advocated in the obese. More studies are required to fully understand the temporal relationship between BMI, physical fitness and HRR.

Negative impact of CVD as the leading cause of death in the US is worsened by the significant burden of obesity and associated morbidity and concerns about the growing population inactivity. The American Heart Association has emphasized worksite-based interventions to improve CV health. We evaluated the benefits of improved physical activity(PA) and weight loss(WL) among employees of the Baptist Health South Florida enrolled in a wellness intervention program. Methods: Employees with two or more Cardio-metabolic risk factors , such as total cholesterol ≥ 200 mg/dl, systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg, hemoglobin A1C ≥ 6.5%, and body mass index (BMI) ≥ 30 were enrolled in an intervention program themed “My unlimited potential”. Interventions were focused on diet and PA modifications. We defined improved physical activity as the difference in the metabolic equivalents (METs) at 12 weeks follow-up and at baseline. WL (lbs) was the difference in weight at follow-up. The relationship between WL and changes in METs was explored in an ordered logistic regression. Results: Overall 203 (48±10 years, 78% females) employees were enrolled with a retention rate of 89% (n=181) at 12 weeks follow-up. At baseline the median weights was 211 lbs., and mean METs- 8.6, while at follow-up the median weight was 200 lbs, and the mean METs 11. At 12 weeks follow up 38% had significant WL (lost >5% of baseline weight). The median WL was 8.4 (IQR 4.8-13.0) lbs and the mean change in METs was 2.4±1.8. Median WL increased with increasing tertiles of METs change; tertile1- 6.5(4-11) lbs., tertile2- 9(6-13)lbs. tertile3- 11(7-15)lbs. Increased PA was related to increased WL across BMI categories adjusting for age, gender and baseline weight. Conclusion: This study points strongly toward the benefit of increasing PA among other lifestyle modification interventions in controlling weight. Although further follow-up of this population to evaluate sustainability of change is needed, our results clearly relate improved PA and health.

Background: Current recommendations support bariatric surgery among the morbidly obese as an option to mitigate future risk of cardiovascular disease, diabetes and hypertension. To date, there is little evidence on the effect of extensive lifestyle interventions among those high-risk individuals in reducing the need for such procedures. Methods: The purpose of the present study was to examine the efficacy of an intensive lifestyle workplace intervention on significant body weight and cardiovascular disease risk factors across the spectrum of obesity. Changes in BMI were measured from baseline to 12 week follow up, along with corresponding improvements in cardio-metabolic risk. In addition, the decrease in participants meeting criteria for bariatric surgery over the study period was examined. Bariatric surgery criteria were defined as BMI≥40 or BMI between 35 and 40 and at least one of the following co-morbidities: diabetes, hypertension, or high cholesterol. Results: The study population consisted of 169 individuals (49±10 years, 77% female) with BMI≥27 at baseline and complete data at follow-up. A total of 65 (39%) participants lost at least 5% of both their initial BMI and body weight. Additionally, 32% dropped an entire BMI category. Of note, 38%(18 of 48) who were classified as BMI>40 were in BMI 35-39 at follow-up, respectively 37%(13 of 55) of individuals in the BMI category 35-39 successfully moved to the BMI category 30-34 at 3 months follow-up. Sixty-three participants (37% of total) initially met criteria for bariatric surgery. At 12 weeks follow-up 35% (22 of 63) of these candidates no longer qualified. Conclusions: Worksites can be effective for achieving clinically important reductions in body weight and diminish the potential need for procedures among a small proportion of morbidly obese individuals. Further follow-up is needed to ascertain whether weight loss can be sustained long-term, and if the short term gains will translate to significant improvements in cardio-metabolic risk profile.