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Context Black adults experience more type 2 diabetes mellitus and higher inflammatory markers, including C-reactive protein (CRP), than White adults. Inflammatory markers are associated with risk of incident diabetes but the impact of inflammation on racial differences in incident diabetes is unknown. Objective We assessed whether CRP mediated the Black–White incident diabetes disparity. Methods The REasons for Geographic And Racial Differences in Stroke (REGARDS) study enrolled 30 239 US Black and White adults aged ≥45 years in 2003-2007 with a second visit approximately 10 years later. Among participants without baseline diabetes, adjusted sex- and race-stratified risk ratios for incident diabetes at the second visit by CRP level were calculated using modified Poisson regression. Inverse odds weighting estimated the percent mediation of the racial disparity by CRP. Results Of 11 073 participants without baseline diabetes (33% Black, 67% White), 1389 (12.5%) developed diabetes. Black participants had higher CRP at baseline and greater incident diabetes than White participants. Relative to CRP Conclusion Higher CRP is a risk factor for incident diabetes, but the excess burden of diabetes in Black adults was only seen in those with lower CRP, suggesting that inflammation is unlikely to be the main driver of this racial disparity.

Background Relative to White adults, Black adults have a substantially higher prevalence of hypertension and diabetes, both key risk factors for stroke, cardiovascular disease, cognitive impairment, and dementia. Blood biomarkers have shown promise in identifying contributors to racial disparities in many chronic diseases. Methods We outline the study design and related statistical considerations for a nested cohort study, the Biomarker Mediators of Racial Disparities in Risk Factors (BioMedioR) study, within the 30,239-person biracial REasons for Geographic And Racial Differences in Stroke (REGARDS) study (2003-present). Selected biomarkers will be assessed for contributions to racial disparities in risk factor development over median 9.4 years of follow-up, with initial focus on hypertension and diabetes. Here we outline study design decisions and statistical considerations for the sampling of 4,400 BioMedioR participants. Results The population for biomarker assessment was selected using a random sample study design balanced across race and sex to provide the optimal opportunity to describe association of biomarkers with the development of hypertension and diabetes. Descriptive characteristics of the BioMedioR sample and analytic plans are provided for this nested cohort study. Conclusions This nested biomarker study will examine pathways with the target to help explain racial differences in hypertension and diabetes incidence.

Low socioeconomic position (SEP) across the lifecourse is associated with Type 2 diabetes (T2DM). We examined whether these economic disparities differ by race and sex. We included 5448 African American (AA) and white participants aged ≥45 years from the national (United States) REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort without T2DM at baseline (2003–07). Incident T2DM was defined by fasting glucose ≥126 mg/dL, random glucose ≥200 mg/dL, or using T2DM medications at follow-up (2013–16). Derived SEP scores in childhood (CSEP) and adulthood (ASEP) were used to calculate a cumulative (CumSEP) score. Social mobility was defined as change in SEP. We fitted race-stratified logistic regression models to estimate the association between each lifecourse SEP indicator and T2DM, adjusting for covariates; additionally, we tested SEP-sex interactions. Over a median of 9.0 (range 7–14) years of follow-up, T2DM incidence was 167.1 per 1000 persons among AA and 89.9 per 1000 persons among white participants. Low CSEP was associated with T2DM incidence among AA (OR = 1.61; 95%CI 1.05–2.46) but not white (1.06; 0.74–2.33) participants; this was attenuated after adjustment for ASEP. In contrast, low CumSEP was associated with T2DM incidence for both racial groups. T2DM risk was similar for stable low SEP and increased for downward mobility when compared with stable high SEP in both groups, whereas upward mobility increased T2DM risk among AAs only. No differences by sex were observed. Among AAs, low CSEP was not independently associated with T2DM, but CSEP may shape later-life experiences and health risks.

Background and Purpose: In the general population, Black adults are less likely than White adults to have controlled blood pressure (BP), and when not controlled, they are at greater risk for stroke compared with White adults. High BP is a major modifiable risk factor for recurrent stroke, but few studies have examined racial differences in BP control among stroke survivors. Methods: We used data from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) to examine disparities in BP control between Black and White adults, with and without a history of stroke. We studied participants taking antihypertensive medication who did and did not experience an adjudicated stroke (n=306 and 7693 participants, respectively) between baseline (2003–2007) and a second study visit (2013–2016). BP control at the second study visit was defined as systolic BP Results: Among participants with a history of stroke, 50.3% of White compared with 39.3% of Black participants had controlled BP. Among participants without a history of stroke, 56.0% of White compared with 50.2% of Black participants had controlled BP. After multivariable adjustment, there was a tendency for Black participants to be less likely than White participants to have controlled BP (prevalence ratio, 0.77 [95% CI, 0.59–1.02] for those with a history of stroke and 0.92 [95% CI, 0.88–0.97] for those without a history of stroke). Conclusions: There was a lower proportion of controlled BP among Black compared with White adults with or without stroke, with no statistically significant differences after multivariable adjustment.

ObjectiveThe purpose of this study was to examine depressive symptoms as a risk factor for incident stroke and determine whether depressive symptomatology was differentially predictive of stroke among Black and White participants.MethodsThe study comprised 9,529 Black and 14,516 White stroke-free participants, aged 45 and older, enrolled in the REasons for Geographic and Racial Differences in Stroke (2003–2007). Incident stroke was the first occurrence of stroke. Association between baseline depressive symptoms (assessed via the 4-item Center for Epidemiologic Studies Depression Scale [CES-D-4]: 0, 1–3, or ≥4) and incident stroke was analyzed with Cox proportional hazards models adjusted for demographics, stroke risk factors, and social factors.ResultsThere were 1,262 strokes over an average follow-up of 9.21 (SD 4.0) years. Compared to participants with no depressive symptoms, after demographic adjustment, participants with CES-D-4 scores of 1–3 had 39% increased stroke risk (hazard ratio [HR] = 1.39, 95% confidence interval [CI] = 1.23–1.57), with slight attenuation after full adjustment (HR = 1.27, 95% CI = 1.11–1.43). Participants with CES-D-4 scores of ≥4 experienced 54% higher risk of stroke after demographic adjustment (HR = 1.54, 95% CI = 1.27–1.85), with risk attenuated in the full model similar to risk with 1–3 symptoms (HR = 1.25, 95% CI = 1.03–1.51). There was no evidence of a differential effect by race (p = 0.53).ConclusionsThe association of depressive symptoms with increased stroke risk was similar among a national sample of Black and White participants. These findings suggest that assessment of depressive symptoms should be considered in primary stroke prevention for both Black and White participants.

Purpose We previously described the magnitude of rural-urban differences in the prevalence of stroke risk factors and stroke mortality. In this report, we sought to extend the understanding of rural-urban differences in the prevalence of stroke risk factors by using an enhanced definition of rural-urban status and assessing the impact of neighborhood socioeconomic status (nSES) on risk factor differences. Methods This analysis included 28,242 participants without a history of stroke from the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort. Participants were categorized into the 6-level ordinal National Center for Health Statistics Urban-Rural Classification Scheme. The prevalence of stroke risk factors (hypertension, diabetes, smoking, atrial fibrillation, left ventricular hypertrophy, and heart disease) was assessed across the rural-urban scale with adjustment for demographic characteristics and further adjustment for nSES score. Findings Hypertension, diabetes, and heart disease were more prevalent in rural than urban regions. Higher odds were observed for these risk factors in the most rural compared to the most urban areas (odds ratios [95% CI]: 1.25 [1.11-1.42] for hypertension, 1.15 [0.99-1.33] for diabetes, and 1.19 [1.02-1.39] for heart disease). Adjustment for nSES score partially attenuated the odds of hypertension and heart disease with rurality, completely attenuated the odds of diabetes, and unmasked an association of current smoking. Conclusions Some of the higher stroke mortality in rural areas may be due to the higher burden of stroke risk factors in rural areas. Lower nSES contributed most notably to rural-urban differences for diabetes and smoking.

Background Retrospective studies have reported an association between cancer and arterial thromboembolic event (ATE) risk. Objectives We sought to confirm this in a prospective cohort with adjudicated outcomes. Methods We evaluated participants enrolled in the REGARDS (REasons for Geographic and Racial Differences in Stroke) study with Medicare coverage for 365 days before their baseline visit (2003-2007). Medicare claims were used to identify new cancer diagnoses during follow-up. Using incidence-density sampling, participants who developed cancer were matched by age, sex, race, and education 1:4 to control participants who had not developed cancer. Participants were prospectively followed through 2015 for an expert-adjudicated ATE, defined as acute myocardial infarction or ischemic stroke. Cox regression was performed to evaluate the association between incident cancer and subsequent ATE. Results In this analysis, 836 REGARDS participants with incident cancer were matched to 3339 control participants without cancer. In the 30 days after cancer diagnosis, 0.60% (n = 5) of the participants had an ATE; most of these events occurred near the time of cancer diagnosis. After adjustment for demographics, geographic region, and cardiovascular risk factors, compared to the noncancer controls, participants with incident cancer had an increased risk of ATE in the first 30 days after diagnosis (hazard ratio, 5.8; 95% confidence interval, 2.1-15.9). There was no association between cancer diagnosis and ATE beyond 30 days. Cancers with known metastases and types considered high risk for venous thromboembolism had the strongest associations with ATE. Conclusions Incident cancer is associated with an increased short-term risk of ATE independent of vascular risk factors.

BackgroundThere have been mixed findings regarding the relationship between walkability and level of physical activity in adults.MethodsParticipants from The REasons for Geographic and Racial Differences in Stroke (REGARDS) national cohort (N=7561) were used to examine the association between Walk Score and physical activity measured via accelerometry. The subsample included geographically diverse adults, who identified as black or white, and were over the age of 45. Linear regression was used to examine the direct effects, as well as the interaction, of Walk Score by sex, age and race.ResultsThe majority of participants lived in a ‘Very Car-Dependent’ location (N=4115). Only 527 lived in a location that was ‘Very Walkable/Walker’s Paradise’. Living in a location with a Walk Score of ‘Very Car-Dependent’ compared with ‘Very Walkable/Walker’s Paradise’ was associated with 19% (0.81; 95% CI 0.73 to 0.90) lower predicted minutes of moderate to vigorous physical activity per day, after adjustment for covariates. There was no evidence of statistically significant interactions between Walk Score and sex, age or race (p>0.05).ConclusionAccumulated daily time in moderate to vigorous physical activity was higher for participants living in neighbourhoods designated as ‘Very Walkable/Walker’s Paradise’. This effect was not moderated by sex, age or race of participants.

Objective: To describe the relationship between metabolic health parameters and depressive symptoms and perceived stress, and whether the co-occurrence of these two psychological stressors has an additive influence on metabolic dysregulation in adults at different levels of body mass index (BMI) without diabetes. Methods: Participants without diabetes (N=20,312) from the population-based REasons for Geographic And Racial Differences in Stroke (REGARDS) study (recruited between 2003–2007) who had a body mass index (BMI) ≥18.5 kg/m2 were included in this cross-sectional analysis. Mean age of sample was 64.4 years, with 36% African American, and 56% women. Depressive symptoms and perceived stress were measured using brief versions of the Center for Epidemiologic Studies Depression (CES-D-4 item) questionnaire and Cohen Perceived Stress Scale (PSS), respectively. Metabolic health parameters included waist circumference, blood pressure (systolic and diastolic), low- and high-density lipoprotein (LDL, HDL) cholesterol, triglycerides, fasting glucose, and high sensitivity C-reactive protein (hs-CRP). Sequentially adjusted General Linear Regression Models (GLM) for each metabolic parameter were used to assess the association between having both elevated depressive symptoms and stress, either of these psychological risk factors, or none with all analyses stratified by BMI category (i.e., normal, overweight, and obesity). Results: The presence of elevated depressive symptoms and/or perceived stress was generally associated with increased waist circumference, higher CRP, and lower HDL. The combination of depressive symptoms and perceived stress, compared to either alone, was typically associated with poorer metabolic health outcomes. However, sociodemographic and lifestyle factors generally attenuated the associations between psychological factors and metabolic parameters. Conclusions: Elevated depressive symptoms in conjunction with high levels of perceived stress were more strongly associated with several parameters of metabolic health than only one of these psychological constructs in a large, diverse cohort of adults. Findings suggest that healthy lifestyle factors may attenuate the association between psychological distress and metabolic health impairment.

Four seminal randomized controlled trials (RCTs) have investigated aspirin, aspirin plus extended-release dipyridamole, and clopidogrel for the prevention of recurrent vascular events. Despite studying over 32,000 patients with stroke in these trials, the decision on which antiplatelet agent to select for secondary stroke prevention remains controversial. Attempts to translate the results of these RCTs into clinical practice are complicated by each trial's selection of participants and choice of primary outcome. Herein, we argue that by examining RCT results with participant selection limited to patients with ischemic stroke or TIA and by focusing on recurrent stroke as our outcome, we can use the standard epidemiology 2 × 2 table to assist in selecting an antiplatelet agent for secondary stroke prevention.

ObjectiveNo systematic review of the literature has dedicated itself to looking at the management of symptomatic carotid stenosis in female patients. In this scoping review, we aimed to identify all randomised controlled trials (RCTs) that reported sex-specific outcomes for patients who underwent carotid revascularisation, and determine whether sufficient information is reported within these studies to assess short-term and long-term outcomes in female patients.Design, setting and participantsWe systematically searched Medline, Embase, Pubmed and Cochrane libraries for RCTs published between 1991 and 2020 that included female patients and compared either endarterectomy with stenting, or any revascularisation (endarterectomy or stenting) with medical therapy in patients with symptomatic high-grade (>50%) carotid stenosis.ResultsFrom 1537 references examined, 27 eligible studies were identified. Sex-specific outcomes were reported in 13 studies. Baseline patient characteristics of enrolled female patients were reported in 2 of those 13 studies. Common outcomes reported included stroke and death, however, there was significant heterogeneity in the reporting of both periprocedural and long-term outcomes. Sex-specific differences relating to the degree of stenosis and time from index event to treatment are largely limited to studies comparing endarterectomy to medical therapy. Adverse events were not reported by sex.ConclusionsOnly half of the previously published RCTs and systematic reviews report sex-specific outcomes. Detailed analyses on the results of carotid artery intervention for female patients with symptomatic stenosis are limited.

Background and Purpose: We examined differences in the volume and pattern of physical activity (PA) and sedentary behavior between adults with and without stroke. Methods: We studied cohort members with an adjudicated or self-reported stroke (n=401) and age-, sex-, race-, region of residence-, and body mass index-matched participants without a history of stroke (n=1203) from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). Sedentary behavior (total volume and bouts), light-intensity PA, and moderate-to-vigorous-intensity PA were objectively measured for 7 days via hip-worn accelerometer. Results: Sedentary time (790.5±80.4 versus 752.4±81.9 min/d) and mean sedentary bout duration (15.7±12.6 versus 11.9±8.1 min/d) were higher and PA (light-intensity PA: 160.5±74.6 versus 192.9±73.5 min/d and moderate-to-vigorous-intensity PA: 9.0±11.9 versus 14.7±17.0 min/d) lower for stroke survivors compared with controls ( P P Conclusions: Stroke survivors accrued a lower volume of PA, higher volume of sedentary time, and exhibited accrual patterns of more prolonged sedentary bouts and shorter, lower intensity activity breaks compared with persons without stroke.

Background The Life’s Simple 7 (LS7) metric incorporates health behaviors (body mass index, diet, smoking, physical activity) and health factors (blood pressure, cholesterol, glucose) to estimate an individual’s level of cardiovascular health. The association between cardiovascular health and incident hypertension is unresolved. Hypertension’s threshold was recently lowered and it is unclear if better cardiovascular health is associated with lower risk of incident hypertension with the updated threshold or in a multirace cohort. We sought to assess the association between better LS7 score and risk of incident hypertension among Black and White adults using a 130/80 mm Hg hypertension threshold. Methods and Results We determined the association between LS7 metric and incident hypertension in the REGARDS (Reasons for Geographic and Racial Disparities in Stroke) study, including participants free of baseline hypertension (2003–2007) who completed a second visit between 2013 and 2016. Hypertension was defined as systolic/diastolic blood pressure ≥130/80 mm Hg or antihypertensive medication use. Each LS7 component was assigned 0 (poor), 1 (intermediate), or 2 (ideal) points. We generated a 14‐point score by summing points. Among 2930 normotensive participants (20% Black, 80% White), the median (25th–75th percentiles) LS7 total score was 9 (8–10) points. Over a median follow‐up of 9 years, 42% developed hypertension. In the fully adjusted model, each 1‐point higher LS7 score had a 6% lower risk of incident hypertension (risk ratio, 0.94 per 1 point; 95% CI, 0.92–0.96). Conclusions Better cardiovascular health was associated with lower risk of incident hypertension using a 130/80 mm Hg hypertension threshold among Black and White adults.

OBJECTIVES: Short and long sleep duration are associated with poor health outcomes and are most prevalent among racial/ethnic minorities. Few studies have investigated the intersection of other sociodemographic characteristics with race/ethnicity on sleep duration prevalence. DESIGN: Longitudinal retrospective analysis of continental U.S. cohort, the REasons for Geographic And Racial Differences in Stroke (REGARDS) PARTICIPANTS: Black (n = 7,547) and white (n = 12,341) adults, 56% women, ≥45 years MEASUREMENTS: At baseline (2003–07), participants reported age, sex, race, education, income, marital status, U.S. region, and employment status. The weighted average of reported sleep duration on weekdays and weekends, assessed at follow-up (2008–10), was categorized as

Objectives Positive caregiver adaptation over time may be associated with reports of positive aspects of caregiving (PAC). We examined differences in PAC by caregiving duration and social engagement, controlling for measures of distress. Methods Participants included 283 African American or White caregivers from the Caregiving Transitions Study with a wide range of caregiving durations. PAC are defined as positive appraisals that caregivers report about their role, such as feeling appreciated or confident. We fit multivariable linear models with the total PAC score as the outcome to assess its association with years of caregiving and social engagement (social network, monthly social contact). Models were adjusted for age, sex, race, marital status, relationship to care recipient, care recipient's dementia status, perceived stress and caregiving strain. Results Caregivers with higher social engagement reported significantly higher PAC. A non-significant trend was found in most analytic models for caregivers with longer duration of care to report higher PAC. African American caregivers reported higher PAC compared to White caregivers. Dementia caregivers reported lower PAC than non-dementia caregivers in models adjusting for demographics and social network size, but the association was attenuated with the addition of caregiving strain. Discussion Higher social engagement and longer duration of care tend to be associated with higher PAC after adjusting for demographics and measures of distress. Future studies should aim to leverage longitudinal data to understand whether caregivers shift appraisal to positive aspects of their role and explore implementation of caregiving interventions targeting PAC in order to improve the caregiving experience.

Although education's protective effects on health have been well recognized, specific mechanisms through which higher education is associated with better health are still debated. Occupation, although strongly shaped by education, has rarely been examined as a mediating mechanism. Education attainment is patterned by race in the United States, and the same education does not lead to similar occupations for members of different racial/ethnic groups. Therefore, examining the link from education to jobs to mortality can illuminate potential mechanisms that create racial health disparities. Using a large U.S. national cohort of Black and White men and women, we examined if 2 occupational characteristics, substantive complexity of work and hazardous working conditions, mediate the effect of education on mortality. Data on occupation were collected between 2011 and 2013, and mortality follow-up data up to March 2018 were included in this analysis. The race- and gender-stratified analyses showed that among White men, the association between higher education and lower mortality was mediated by lower hazard on the job. Among Black men and White women, higher complexity of work explained the association between higher education and lower mortality. Among Black women, neither job characteristic mediated the association. These results suggest that occupational characteristics help explain health inequalities not only by education but also by race and gender. Investigating occupation explicitly in the causal chain of health disparities will help us better understand the mechanism of and potential solutions for health inequalities. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

OBJECTIVE Given temporal changes in diabetes prevalence and stroke incidence, this study investigated age, race, and sex differences in the diabetes–stroke association in a contemporary prospective cohort, the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. RESEARCH DESIGN AND METHODS We included 23,002 non-Hispanic black and white U.S. adults aged ≥45 years without prevalent stroke at baseline (2003–2007). Diabetes was defined as fasting glucose ≥126 mg/dL, random glucose ≥200 mg/dL, or use of glucose-lowering medication. Incident stroke events were expert adjudicated and available through September 2017. RESULTS The prevalence of diabetes was 19.1% at baseline. During follow-up, 1,018 stroke events occurred. Among adults aged CONCLUSIONS In this contemporary cohort, the diabetes–stroke association varied by age, race, and sex together, with a more pronounced effect observed among adults aged

ObjectivesWhile awareness of cigarette smoking’s harmful effects has increased, determinants associated with smoking status remain understudied, including potential racial differences. We aim to examine factors associated with former versus current smoking status and assess whether these associations differed by race.SettingWe performed a cross-sectional analysis using the population-based Reasons for Geographic and Racial Differences in Stroke(REGARDS)study.Outcome measuresLogistic regression was used to calculate the OR of former smoking status compared with current smoking status with risk factors of interest. Race interactions were tested using multiplicative interaction terms.Results16 463 participants reported smoking at least 100 cigarettes in their lifetime. Seventy-three per cent (n=12 067) self-reported former-smoker status. Physical activity (reference (REF) 3×/week: OR=1.26, 95% CI 1.11 to 1.43), adherence to Mediterranean diet (REF: low; medium: OR=1.46, 95% CI 1.27 to 1.67; high: OR=2.20, 95% CI 1.84 to 2.64), daily television viewing time (REF: >4 hours; ConclusionEfforts to promote tobacco cessation should consist of targeted behavioural interventions that incorporate racial differences.

This study examined the relationship between cognitive change and instrumental activities of daily living (IADL) in a large, national, population-based sample. Cognitive change was assessed via verbal fluency, word list learning (WLL), and word list delayed recall (WLD). Incident cognitive impairment was defined by change in Six-Item Screener (SIS) status over a period of 10 years. Impaired IADL was defined as self-reported difficulty or needing assistance performing any IADL at Year 10. A one-word decrease in WLL over a 10-year span increased the odds of impaired IADL by 16% (95% CI 1.08-1.24) and incident cognitive impairment increased the odds of impaired IADL by 59% (95% CI 1.36-1.85) when adjusting for demographic factors, health-related behaviors, vascular risk factors and disease, and depressive symptoms. Cognitive change most strongly predicted impairment in managing finances (OR 2.47, 95% CI 2.04-3.00) and driving (OR 2.06, 95% CI 1.73-2.44).

Background Up to date data on incidence, mortality, and case-fatality for stroke are important for setting the agenda for prevention and healthcare. Aims and/or hypothesis We aim to update the most current incidence and mortality data on stroke available by country, and to expand the scope to case-fatality and explore how registry data might be complementary. Methods Data were compiled using two approaches: (1) an updated literature review building from our previous review and (2) direct acquisition and analysis of stroke events in the World Health Organization (WHO) mortality database for each country providing these data. To assess new and/or updated data on incidence, we searched multiple databases to identify new original papers and review articles that met ideal criteria for stroke incidence studies and were published between 15 May 2013 and 31 May 2016. For data on case-fatality, we searched between 1980 and 31 May 2016. We further screened reference lists and citation history of papers to identify other studies not obtained from these sources. Mortality codes for ICD-8, ICD-9, and ICD-10 were extracted. Using population denominators provided for each country, we calculated both the crude mortality from stroke and mortality adjusted to the WHO world population. We used only the most recent year reported to the WHO for which both population and mortality data were available. Results Fifty-one countries had data on stroke incidence, some with data over many time periods, and some with data in more than one region. Since our last review, there were new incidence studies from 12 countries, with four meeting pre-determined quality criteria. In these four studies, the incidence of stroke, adjusted to the WHO World standard population, ranged from 76 per 100,000 population per year in Australia (2009–10) up to 119 per 100,000 population per year in New Zealand (2011–12), with the latter being in those aged at least 15 years. Only in Martinique (2011–12) was the incidence of stroke greater in women than men. In countries either lacking or with old data on stroke incidence, eight had national clinical registries of hospital based data. Of the 128 countries reporting mortality data to the WHO, crude mortality was greatest in Kazhakstan (in 2003), Bulgaria, and Greece. Crude mortality and crude incidence of stroke were both positively correlated with the proportion of the population aged ≥ 65 years, but not with time. Data on case-fatality were available in 42 studies in 22 countries, with large variations between regions. Conclusions In this updated review, we describe the current data on stroke incidence, case-fatality and mortality in different countries, and highlight the growing trend for national clinical registries to provide estimates in lieu of community-based incidence studies.

We used differences in state school policies as natural experiments to evaluate the joint influence of educational quantity and quality on late-life physical and mental health. Using US Census microsample data, historical measures of state compulsory schooling and school quality (term length, student-teacher ratio, and attendance rates) were combined via regression modeling on a scale corresponding to years of education (policy-predicted years of education (PPYEd)). PPYEd values were linked to individual-level records for 8,920 black and 14,605 white participants aged ≥45 years in the Reasons for Geographic and Racial Differences in Stroke study (2003–2007). Linear and quantile regression models estimated the association between PPYEd and Physical Component Summary (PCS) and Mental Component Summary (MCS) from the Short Form Health Survey. We examined interactions by race and adjusted for sex, birth year, state of residence at age 6 years, and year of study enrollment. Higher PPYEd was associated with better median PCS (β = 1.28, 95% confidence interval (CI): 0.40, 1.49) and possibly better median MCS (β = 0.46, 95% CI: –0.01, 0.94). Effect estimates were higher among black (vs. white) persons (PCS × race interaction, β = 0.22, 95% CI: –0.62, 1.05, and MCS × race interaction, β = 0.18; 95% CI: –0.08, 0.44). When incorporating both school quality and duration, this quasiexperimental analysis found mixed evidence for a causal effect of education on health decades later.

Importance Race-specific and sex-specific stroke risk varies across the lifespan, yet few reports describe sex differences in stroke risk separately in black individuals and white individuals. Objective To examine incidence and risk factors for ischemic stroke by sex for black and white individuals. Design, Setting, and Participants This prospective cohort study included participants 45 years and older who were stroke-free from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, enrolled from the continental United States 2003 through 2007 with follow-up through October 2016. Data were analyzed from March 2018 to September 2018. Exposures Sex and race. Main Outcomes and Measures Physician-adjudicated incident ischemic stroke, self-reported race/ethnicity, and measured and self-reported risk factors. Results A total of 25 789 participants (14 170 women [54.9%]; 10 301 black individuals [39.9%]) were included. Over 222 120 person-years of follow-up, 939 ischemic strokes occurred: 159 (16.9%) in black men, 326 in white men (34.7%), 217 in black women (23.1%), and 237 in white women (25.2%). Between 45 and 64 years of age, white women had 32% lower stroke risk than white men (incidence rate ratio [IRR], 0.68 [95% CI, 0.49-0.94]), and black women had a 28% lower risk than black men (IRR, 0.72 [95% CI, 0.52-0.99]). Lower stroke risk in women than men persisted at age 65 through 74 years in white individuals (IRR, 0.71 [95% CI, 0.55-0.94]) but not in black individuals (IRR, 0.94 [95% CI, 0.68-1.30]); however, the race-sex interaction was not significant. At 75 years and older, there was no sex difference in stroke risk for either race. For white individuals, associations of systolic blood pressure (women: hazard ratio [HR], 1.13 [95% CI, 1.05-1.22]; men: 1.04 [95% CI, 0.97-1.11];P = .099), diabetes (women: HR, 1.84 [95% CI, 1.35-2.52]; men: 1.13 [95% CI, 0.86-1.49];P = .02), and heart disease (women: HR, 1.76 [95% CI, 1.30-2.39]; men, 1.26 [95% CI, 0.99-1.60];P = .09) with stroke risk were larger for women than men, while antihypertensive medication use had a smaller association in women than men (women: HR, 1.17 [95% CI, 0.89-1.54]; men: 1.61 [95% CI, 1.29-2.03];P = .08). In black individuals, there was no evidence of a sex difference for any risk factors. Conclusions and Relevance For both races, at age 45 through 64 years, women were at lower stroke risk than men, and there was no sex difference at 75 years or older; however, the sex difference pattern may differ by race from age 65 through 74 years. The association of risk factors on stroke risk differed by race-sex groups. While the need for primordial prevention, optimal management, and control of risk factors is universal across all age, racial/ethnic, and sex groups, some demographic subgroups may require earlier and more aggressive strategies.

The REGARDS study enrolled 30,239 whites and blacks aged >45 from 2003 – 2007, with oversampling of blacks and residents of the Stroke Belt. Potential participants were mailed a letter/brochure followed by telephone call. After verbal consent, telephone interview assessed cardiovascular health and cognitive function. In a home visit, measurements of risk factors, biological samples, EKG, written consent were obtained; during the in-home visit, self-administrated questionnaires were left to be completed and returned. Participants are followed for hospitalizations via telephone at 6-month intervals. Annually and biennially, brief and more comprehensive assessments of global cognitive function are conducted. Medical records for suspected strokes are collected with adjudication by stroke experts. A 2nd in-home and telephone assessment was conducted 2013-2016, approximately 10 years after baseline. This presentation will describe the methodological details of REGARDS, progress on the specific aims of the current grant, and establish the context for the remaining presentations.

Maintaining social engagement is important for the health and well-being of older adults who become caregivers. We assessed the association between incident caregiving and leisure satisfaction as well as the 10-year change in social network size among 245 incident caregivers and 248 matched controls. Multiple linear regression analyses were used to adjust for age, gender, race, education level, income, and geographic region. Compared to controls, incident caregivers had significantly lower levels of leisure satisfaction (p

This study examines the association between inflammatory biomarkers and risk of cancer mortality by race. Data were obtained from 1,856 participants in the prospective REGARDS cohort who were cancer-free at baseline, and analyzed in relation to cancer mortality prospectively. Biomarkers were log-transformed and categorized into tertiles due to non-normal distributions, and Cox proportional hazard regression models were utilized to compute hazard ratios with 95% confidence intervals using robust sandwich methods. Individuals in the highest tertile of IL-6 had over a 12-fold increased risk of cancer mortality (HR: 12.97, 95% CI: 3.46-48.63); those in the highest tertile of IL-8 had over a 2-fold increased risk of cancer mortality (HR: 2.21, 95% CI: 0.86-5.71), while those in the highest tertile of IL-10 had over a 3-fold increased risk of cancer mortality (HR: 3.06, 95% CI: 1.35-6.89). In race-stratified analysis, each unit increase in IL-6 was associated with increased risk of cancer mortality among African-Americans (HR: 3.88, 95% CI: 1.17-12.88) and Whites (5.25, 95% CI: 1.24-22.31). If replicated in larger, racially diverse prospective cohorts, these results suggest that cancer patients may benefit from clinical or lifestyle approaches to regulate systemic inflammation as a cancer prevention strategy.

ObjectiveTo determine black-white differences in 1-year recurrent stroke and 30-day case fatality after a recurrent stroke in older US adults.MethodsWe conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries with fee-for-service health insurance coverage who were hospitalized for ischemic stroke between 1999 and 2013. Hazard ratios for recurrent ischemic stroke and risk ratios for 30-day case fatality comparing blacks to whites were calculated with adjustment for demographics, risk factors, and competing risk of death when appropriate.ResultsAmong 128,789 Medicare beneficiaries having an ischemic stroke (mean age 80 years [SD 8 years], 60.4% male), 11.1% were black. The incidence rate of recurrent ischemic stroke per 1,000 person-years for whites and blacks was 108 (95% confidence interval [CI], 106–111) and 154 (95% CI 147–162) , respectively. The multivariable-adjusted hazard ratio for recurrent stroke among blacks compared with whites was 1.36 (95% CI 1.29–1.44). The case fatality after recurrent stroke for blacks and whites was 21% (95% CI 21%–22%) and 16% (95% CI 15%–18%), respectively. The multivariable-adjusted relative risk for mortality within 30 days of a recurrent stroke among blacks compared with whites was 0.82 (95% CI 0.73–0.93).ConclusionThe risk of stroke recurrence among older Americans hospitalized for ischemic stroke is higher for blacks compared to whites, while 30-day case fatality after recurrent stroke remains lower for blacks.

ObjectiveTo determine whether patients who are dual eligible for Medicare and Medicaid benefits have outcomes after carotid endarterectomy (CEA) that are comparable to the outcomes of those eligible for Medicare alone.MethodsThe study cohort included fee-for-service Medicare beneficiaries ≥65 years of age who underwent CEA (ICD-9-CM code 38.12) between 2003 and 2010. Beneficiaries with ≥1 month of Medicaid coverage were considered dual eligible. We fit mixed models to assess the relationship between coverage (dual eligible vs Medicare only) and outcomes over time after adjustment for demographic and clinical characteristics.ResultsThere were 53,773 dual-eligible and 452,182 Medicare-only beneficiaries hospitalized for CEA. The percentage of dual-eligible patients receiving CEA increased from 10.1% in 2003 to 11.5% in 2010, with no change in geographic distribution across the country. In adjusted analyses, dual-eligible vs Medicare-only beneficiaries had a higher rate of 30-day ischemic stroke or death; higher in-hospital, 30-day, and 1-year all-cause mortality; and higher 30-day all-cause readmission. Relative annual reductions in outcomes from 2003 to 2010 ranged from 2% to 5%, but there was no significant interaction between dual-eligible status and time.ConclusionsDual-eligible beneficiaries had worse outcomes than those eligible for Medicare alone. Additional work is necessary to understand the reasons for this difference.