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Falls can have life-altering consequences for older adults, including extended recovery periods and compromised independence. Higher household income may mitigate the risk of falls by providing financial resources for mobility tools, remediation of environmental hazards, and needed supports, or it may buffer the impact of an initial fall on subsequent risk through improved assistance and care. Household income has not had a consistently observed association with falls in older adults; however, a segmented association may exist such that associations are attenuated above a certain income threshold. In this study, we utilized segmented negative binomial regression analysis to examine the association between household income and recurrent falls among 2,302 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study recruited between 2003 and 2007. Income-fall association segments separated by changes in slope were considered. Model results indicated a 2-segment association between household income and recurrent falls in the past year. In the range below the breakpoint, household income was negatively associated with the rate of recurrent falls across all age groups examined; in a higher income range (from $20,000–$49,999 to ≥$150,000), the association was attenuated (weaker negative trend) or reversed (positive trend). These findings point to potential benefits of ensuring that incomes for lower-income adults exceed the threshold needed to confer a reduced risk of recurrent falls. [ABSTRACT FROM AUTHOR]

Objectives Adiposity may have a role in the risk of dementia. Fewer studies have focused on the relationship between change in adiposity and cognitive decline. Our study aimed to explore the association between the change in adiposity and cognitive function in Black and White older adults. Methods The participants were 12,204 older adults without cognitive impairment (62.8 ± 8.0 years) in the United States. The percent body mass index change (%BMI change) and percent waist circumference change (%WC change) were measured at 2 in-home visits (first: 2003–2007, second: 2013–2016). Cognitive status was assessed by the Six-Item Screener annually. Memory and executive function were measured by word list learning, MOCA recall and orientation, and letter and animal fluency every 2 years. Logistic regression or linear regression models were used to estimate the relationship between percent change in adiposity and cognitive function. Results After 12.7 ± 1.7 years, a greater decrease in %BMI change or %WC change was significantly associated with a higher risk of cognitive impairment. Compared to older adults with −5% ≤ change ≤ 5% from baseline, a significantly higher risk of cognitive impairment and greater loss in memory and executive function were found among those who experienced more than a 10% decline in %BMI change or %WC change. Older adults who experienced a 5%–10% decrease in %BMI change had a higher risk of cognitive impairment and greater loss of memory compared to those with −5% ≤ change ≤ 5%. Discussion A greater decrease in %BMI (>5%) and %WC (>10%) change was associated with greater cognitive loss observed over time. [ABSTRACT FROM AUTHOR]

Neighborhood walkability—features of the built environment that promote pedestrian activity—has been associated with greater physical activity and lower body mass index (BMI; calculated as weight (kg)/height (m)2) among neighborhood residents. However, much of the literature has been cross-sectional and only a few cohort studies have assessed neighborhood features throughout follow-up. Using data from the Reasons for Geographic and Racial Differences in Stroke Study (2003–2016) and a neighborhood walkability index (NWI) measured annually during follow-up, we assessed whether the cumulative experience of neighborhood walkability (NWI-years) predicted BMI and waist circumference after approximately 10 years of follow-up, controlling for these anthropometric measures at enrollment. Analyses were adjusted for individual-level sociodemographic covariates and the cumulative experience of neighborhood poverty rate and neighborhood greenspace coverage. Almost a third (29%) of participants changed address at least once during follow-up. The first change of residence, on average, brought the participants to neighborhoods with higher home values and lower NWI scores than their originating neighborhoods. Compared with those having experienced the lowest quartile of cumulative NWI-years, those who experienced the highest quartile had 0.83 lower BMI (95% confidence interval, –1.5, −0.16) and 1.07-cm smaller waist circumference (95% confidence interval, –1.96, –0.19) at follow-up. These analyses provide additional longitudinal evidence that residential neighborhood features that support pedestrian activity are associated with lower adiposity. [ABSTRACT FROM AUTHOR]

Features of the physical environment may affect post-stroke recovery, but empirical evidence is limited. This study examines associations between features of the physical environment and post-stroke physical quality of life (PH-QOL). The study sample included stroke survivors enrolled in the Caring for Adults Recovering from the Effects of Stroke project, a prospective cohort. Features of the physical environment surrounding participants' home addresses were audited using Google Earth. Audits captured information about crossings (e.g. curb-cuts; range 0-4), street segments (e.g. sidewalks; range 0-17.5), and a route (e.g. parks; range 0-27) near participants' home. Summary scores were categorized into tertials representing "few," "some," and "many" pedestrian-friendly features. Post-stroke PH-QOL was measured by the SF-12 (range 0-100) around 6 to 12-, 18-, 27-, and 36-months post-stroke. Linear mixed models were used to estimate PH-QOL over time. Chained multiple imputation was used to account for missing data. Two hundred and seventy-five participants were eligible, among whom 210 had complete data. Most participants lived in areas with "few" features to promote outdoor mobility. Participants living in environments with "some" crossing features had a 4.90 (95% CI: 2.32, 7.48) higher PH-QOL score across the observation period in comparison to participants living in environments with "few" crossing features. Features of the physical environment along street segments and routes were not associated with post-stroke PH-QOL. Crossing features are associated with post-stroke PH-QOL. Modifying features of the physical environment at nearby crossings, such as curb-cuts, may be a promising strategy for increasing PH-QOL. [ABSTRACT FROM AUTHOR]

Background: Retirement represents a crucial transitional period for many adults with possible consequences for cognitive aging. We examined trajectories of cognitive change before and after retirement in Black and White adults. Methods: Longitudinal examination of up to 10 years (mean = 7.1 ± 2.2 years) using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study–a national, longitudinal study of Black and White adults ≥45 years of age. Data were from 2226 members of the REGARDS study who retired around the time when an occupational ancillary survey was administered. Cognitive function was an average of z‐scores for tests of verbal fluency, memory, and global function. Results: Cognitive functioning was stable before retirement (Estimate = 0.05, p = 0.322), followed by a significant decline after retirement (Estimate = −0.15, p < 0.001). The decline was particularly pronounced in White (Estimate = −0.19, p < 0.001) compared with Black (Estimate = −0.07, p = 0.077) participants, twice as large in men (Estimate = −0.20, p < 0.001) compared with women (Estimate = −0.11, p < 0.001), highest among White men (Estimate = −0.22, p < 0.001) and lowest in Black women (Estimate = −0.04, p = 0.457). Greater post‐retirement cognitive decline was also observed among participants who attended college (Estimate = −0.14, p = 0.016). While greater work complexity (Estimate = 0.92, p < 0.05) and higher income (Estimate = 1.03, p < 0.05) were related to better cognitive function at retirement, neither was significantly related to cognitive change after retirement. Conclusion: Cognitive functioning may decline at an accelerated rate immediately post‐retirement, more so in White adults and men than Black adults and women. Lifelong structural inequalities including occupational segregation and other social determinants of cognitive health may obscure the role of retirement in cognitive aging. [ABSTRACT FROM AUTHOR]

Dietary and lifestyle evolutionary discordance is hypothesised to play a role in the aetiology of CVD, including CHD and stroke. We aimed to investigate associations of a previously reported, total (dietary plus lifestyle) evolutionary-concordance (EC) pattern score with incident CVD, CHD and stroke. We used multivariable Cox proportional hazards regression to investigate associations of the EC score with CVD, CHD and stroke incidence among USA Black and White men and women ≥45 years old in the prospective REasons for Geographic and Racial Differences in Stroke study (2003–2017). The EC score comprised seven equally weighted components: a previously reported dietary EC score (using Block 98 FFQ data) and six lifestyle characteristics (alcohol intake, physical activity, sedentary behaviour, waist circumference, smoking history and social network size). A higher score indicates a more evolutionary-concordant dietary/lifestyle pattern. Of the 15 467 participants in the analytic cohort without a CVD diagnosis at baseline, 1563 were diagnosed with CVD (967 with CHD and 596 with stroke) during follow-up (median 11·0 years). Among participants in the highest relative to the lowest EC score quintile, the multivariable-adjusted hazards ratios and their 95 % CI for CVD, CHD and stroke were, respectively, 0·73 (0·62, 0·86; P trend < 0·001), 0·72 (0·59, 0·89; P trend < 0·001) and 0·76 (0·59, 0·98; P trend = 0·01). The results were similar by sex and race. Our findings support that a more evolutionary-concordant diet and lifestyle pattern may be associated with lower risk of CVD, CHD and stroke. [ABSTRACT FROM AUTHOR]

Socioeconomic status (SES) is a well‐established determinant of health. Disparities in stress are thought to partially account for SES‐health disparities. We tested whether multiple indicators of SES show similar associations with psychological stress and whether race, sex, and geographic region moderate associations. Participants (n = 26,451) are from a well‐characterized national cohort of Black and White US adults aged 45 years or older. Psychological stress was measured using the 4‐item perceived stress scale. Income was assessed as annual household income and education as highest level of education completed. Occupation was assessed during a structured interview and subsequently coded hierarchically. For all sex‐race‐region groups, the largest SES‐stress associations were for income and the smallest were for occupation. Race moderated SES‐stress associations, such that income and education were more closely associated with stress in Black adults than White adults. Additionally, education was more strongly associated with stress in individuals living in the stroke belt region. Black Americans with lower income and education reported greater psychological stress and may be at higher risk for disease through stress‐related pathways. Thus, which SES indicator is examined and for whom may alter the magnitude of the association between SES and psychological stress. [ABSTRACT FROM AUTHOR]

Objective: The current study aims to describe the Mediterranean diet (MD) adherence across the US regions, and explore the predictive factors of MD adherence among US adults.Design: Cross-sectional secondary data analysis. MD adherence score (0-9) was calculated using the Block 98 FFQ. Hot spot analysis was conducted to describe the geospatial distribution of MD adherence across the US regions. Logistic regression explored predictors of MD adherence.Setting: Nationwide community-dwelling residency in the USA.Participants: Adults aged ≥45 years (n 20 897) who participated in the REasons for Geographic and Racial Differences in Stroke study and completed baseline assessment during January 2003 and October 2007.Results: The mean of MD adherence score was 4·36 (sd 1·70), and 46·5 % of the sample had high MD adherence (score 5-9). Higher MD adherence clusters were primarily located in the western and northeastern coastal areas of the USA, whereas lower MD adherence clusters were majorly observed in south and east-north-central regions. Being older, black, not a current smoker, having a college degree or above, an annual household income ≥ $US 75K, exercising ≥4 times/week and watching TV/video <4 h/d were each associated with higher odds of high MD adherence.Conclusions: There were significant geospatial and population disparities in MD adherence across the US regions. Future studies are needed to explore the causes of MD adherence disparities and develop effective interventions for MD promotion in the USA. [ABSTRACT FROM AUTHOR]

Objective: To examine if the association between higher A1C and risk of cardiovascular disease (CVD) among adults with and without diabetes is modified by racial residential segregation.Research Design and Methods: The study used a case-cohort design, which included a random sample of 2,136 participants at baseline and 1,248 participants with incident CVD (i.e., stroke, coronary heart disease [CHD], and fatal CHD during 7-year follow-up) selected from 30,239 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants originally assessed between 2003 and 2007. The relationship of A1C with incident CVD, stratified by baseline diabetes status, was assessed using Cox proportional hazards models adjusting for demographics, CVD risk factors, and socioeconomic status. Effect modification by census tract-level residential segregation indices (dissimilarity, interaction, and isolation) was assessed using interaction terms.Results: The mean age of participants in the random sample was 64.2 years, with 44% African American, 59% female, and 19% with diabetes. In multivariable models, A1C was not associated with CVD risk among those without diabetes (hazard ratio [HR] per 1% [11 mmol/mol] increase, 0.94 [95% CI 0.76-1.16]). However, A1C was associated with an increased risk of CVD (HR per 1% increase, 1.23 [95% CI 1.08-1.40]) among those with diabetes. This A1C-CVD association was modified by the dissimilarity (P < 0.001) and interaction (P = 0.001) indices. The risk of CVD was increased at A1C levels between 7 and 9% (53-75 mmol/mol) for those in areas with higher residential segregation (i.e., lower interaction index). In race-stratified analyses, there was a more pronounced modifying effect of residential segregation among African American participants with diabetes.Conclusions: Higher A1C was associated with increased CVD risk among individuals with diabetes, and this relationship was more pronounced at higher levels of residential segregation among African American adults. Additional research on how structural determinants like segregation may modify health effects is needed. [ABSTRACT FROM AUTHOR]

Purpose: Rural cancer survivors (RCS) have poorer health outcomes and face multiple challenges-older age, and limited transportation, education, income, and healthcare access. Yet, RCS are understudied. The Reach-out to ENhancE Wellness(RENEW) trial, a home-based, diet and exercise intervention among 641 breast, prostate, and colorectal cancer survivors addressed many of these challenges.Methods: We examined whether rural and urban participants differed in their response to the RENEW intervention (e.g., physical functioning, quality-of-life, intakes of fruits and vegetables (F&V) and saturated fat, body mass index(BMI), physical activity, and adverse events).Results: Rural versus urban survivors report significantly more favorable mean (SE) changes in physical functioning [- 0.66 (1.47) v - 1.71 (1.00)], physical health [+ 0.14 (0.71) v - 0.74 (0.50)], and fewer adverse events [1.58 (0.08) v 1.64 (0.06)]. Rural versus urban survivors reported smaller increases in F&Vs [+ 1.47 (0.23) v + 1.56(0.16); p = 0.018], and lower percentages achieved goal behavior for endurance exercise and intakes of F&Vs and saturated fat.Conclusions: The RENEW intervention reduced declines in physical health and functioning among RCS to a significantly greater extent than for urban cancer survivors. All survivors significantly improved intakes of F&V and saturated fat, and endurance exercise; however, lower percentages of rural versus urban survivors met goal suggesting that more intensive interventions may be needed for RCS. [ABSTRACT FROM AUTHOR]

Objective: This study examined whether metabolic health status is associated with risk of cancer mortality and whether this varies by body mass index (BMI) category.Methods: A prospective study of 22,514 participants from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort was performed. Metabolically unhealthy status was defined as having three or more of the following: (1) elevated fasting glucose, (2) high triglycerides, (3) dyslipidemia, (4) hypertension, and (5) elevated waist circumference. Participants were categorized into normal weight (BMI 18.5-24.9 kg/m2 ), overweight (BMI 25.0-29.9 kg/m2 ), and obesity (BMI ≥ 30 kg/m2 ) groups. Cox proportional hazards regression was performed to estimate hazards ratios (HRs) and 95% confidence intervals (CIs) for cancer mortality during follow-up.Results: Among participants with normal weight, participants who were metabolically unhealthy had an increased risk of cancer mortality (HR: 1.65; 95% CI: 1.20-2.26) compared with metabolically healthy participants. The overall mortality risk for participants who were metabolically unhealthy and had normal weight was stronger for obesity-related cancers (HR: 2.40; 95% CI: 1.17-4.91). Compared with participants with normal weight, those who were metabolically healthy and overweight were at a reduced risk of any cancer mortality (adjusted HR: 0.79; 95% CI: 0.63-0.99).Conclusions: There was an increased risk of overall and obesity-related cancer mortality among metabolically unhealthy participants with normal weight. [ABSTRACT FROM AUTHOR]

Calcium intake has been consistently, modestly inversely associated with colorectal neoplasms, and supplemental calcium reduced adenoma recurrence in clinical trials. Milk products are the major source of dietary calcium in the United States, but their associations with colorectal neoplasms are unclear. Data pooled from three colonoscopy-based case-control studies of incident, sporadic colorectal adenoma (n= 807 cases, 2,185 controls) were analyzed using multivariable unconditional logistic regression. Residuals from linear regression models of milk with dietary calcium were estimated as the noncalcium, insulin-like growth factor 1-containing component of milk. For total, dietary, and supplemental calcium intakes, the adjusted odds ratios (ORs) comparing the highest to the lowest intake quintiles were 0.94 (95% confidence interval [CI] 0.69–1.30), 0.86 (CI 0.62–1.20), and 0.99 (CI 0.77–1.27), respectively. The corresponding ORs for consumption of total milk products, total milk, nonfat milk, total milk product residuals, and nonfat milk residuals were, respectively, 0.99, 0.90, 0.92, 0.94, and 0.95; all CIs included 1.0. For those who consumed any whole milk relative to those who consumed none, the OR was 1.15 (CI 0.89–1.49). These results are consistent with previous findings of modest inverse associations of calcium intakes with colorectal adenoma, but suggest that milk products may not be associated with adenoma. [ABSTRACT FROM PUBLISHER]

Background: Flavonoids are dietary polyphenolic compounds with a variety of proposed beneficial cardiovascular effects, but rigorous prospective studies that examine the association between flavonoid intake and incident coronary heart disease (CHD) in geographically and racially diverse US samples are limited. Objective: With the use of the new, expanded USDA flavonoid database, we assessed the association between total flavonoid and flavonoid subclass intakes with incident CHD in a biracial and geographically diverse cohort, as well as effect modification by age, sex, race, and region of residence. Design: Participants were 16,678 black and white men and women enrolled in the REGARDS (REasons for Geographic and Racial Differences in Stroke) study, a national prospective cohort study. All participants were without CHD at baseline, and all completed a Block98 food-frequency questionnaire. Flavonoid intakes were estimated from USDA flavonoid databases, which were recently improved to address missing values for cooked foods and to adjust for flavonoid losses due to processing. Incident CHD events were participant reported and adjudicated by experts. Quintiles of flavonoid intake were examined as predictors of incident CHD by using Cox proportional hazards regression to obtain HRs. Tests for trend used the quintile medians. Results: Over a mean ± SD follow-up of 6.0 ± 1.9 y, 589 CHD events occurred. High flavonoid intake was associated with selfidentified white race, exercise, not smoking, more education, and higher income. In models that adjusted for sociodemographic, health behavior, and dietary factors, there was an inverse association between anthocyanidin and proanthocyanidin intakes and incident CHD (HRs for quintile 5 compared with quintile 1--anthocyanidins: 0.71; 95% CI: 0.52, 0.98; P-trend = 0.04; proanthocyanidins: 0.63; 95% CI: 0.47, 0.84; P-trend = 0.02). There was no association between total flavonoid or other flavonoid subclass intakes and incident CHD. Conclusions: Reported anthocyanidin and proanthocyanidin intakes were inversely associated with incident CHD. There was no significant effect modification by age, sex, race, or region of residence. [ABSTRACT FROM AUTHOR]

Aims: To determine if the association between electrocardiographic left ventricular hypertrophy (ECG-LVH) and ischaemic stroke is partially explained by the concomitant presence of QT prolongation.Methods and Results: A total of 24 948 (mean age = 65 ± 9.4 years; 40% black; 55% women) participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study were included in this analysis. Electrocardiographic left ventricular hypertrophy was defined by the Sokolow-Lyon criteria. Heart rate-adjusted QT (QTa) was computed using a linear regression model. Adjudicated ischaemic stroke events were the outcome of interest. Cox regression was used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between ECG-LVH and prolonged QTa, in isolation and combined, with ischaemic stroke. There were 2422 (9.7%) participants with ECG-LVH, 820 (3.3%) with prolonged QTa, and 161 (0.6%) with both. Over a median follow-up of 7.6 years, 714 (2.9%) ischaemic stroke events occurred. After adjustment for stroke risk factors and potential confounders, an increased risk of ischaemic stroke was observed among participants with ECG-LVH and prolonged QTa (HR = 1.85, 95% CI = 1.04-3.30), isolated ECG-LVH (HR = 1.40, 95% CI = 1.13-1.75), and isolated prolonged QTa (HR = 1.45, 95% CI = 1.04-2.03) compared with participants without either condition. When ECG-LVH and prolonged QTa were examined as separate variables, the risk of ischaemic stroke for each condition remained statistically significant.Conclusion: The combination of ECG-LVH and prolonged QT is associated with a higher risk of ischaemic stroke compared with either condition in isolation, and the stroke risk for each condition does not depend on the presence of the other. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of comorbid depressive symptoms and/or stress on adverse cardiovascular (CV) outcomes in individuals with diabetes compared with those without diabetes.Research Design and Methods: Investigators examined the relationship between baseline depressive symptoms and/or stress in adults with and without diabetes and physician-adjudicated incident CV outcomes including stroke, myocardial infarction/acute coronary heart disease, and CV death over a median follow-up of 5.95 years in the national REGARDS cohort study.Results: Subjects included 22,003 adults (4,090 with diabetes) (mean age 64 years, 58% female, 42% black, and 56% living in the southeastern "Stroke Belt"). Elevated stress and/or depressive symptoms were more common in subjects with diabetes (36.8% vs. 29.5%; P < 0.001). In fully adjusted models, reporting either elevated stress or depressive symptoms was associated with a significantly increased incidence of stroke (HR 1.57 [95% CI 1.05, 2.33] vs. 1.01 [0.79, 1.30]) and CV death (1.53 [1.08, 2.17] vs. 1.12 [0.90, 1.38]) in subjects with diabetes but not in those without diabetes. The combination of both elevated stress and depressive symptoms in subjects with diabetes was associated with a higher incidence of CV death (2.15 [1.33, 3.47]) than either behavioral comorbidity alone (1.53 [1.08, 2.17]) and higher than in those with both elevated stress and depressive symptoms but without diabetes (1.27 [0.86, 1.88]).Conclusions: Comorbid stress and/or depressive symptoms are common in individuals with diabetes and together are associated with progressively increased risks for adverse CV outcomes. [ABSTRACT FROM AUTHOR]

Background: The oxidative balance score (OBS) is a composite estimate of the overall pro- and antioxidant exposure status in an individual. The aim of this study was to determine the association between OBS and renal disease.Methods: Using the Reasons for Geographic and Racial Differences in Stroke cohort study, OBS was calculated by combining 13 a priori-defined pro- and antioxidant factors by using baseline dietary and lifestyle assessment. OBS was divided into quartiles (Q1-Q4) with the lowest quartile, Q1 (predominance of pro-oxidants), as the reference. Multivariable logistic regression and Cox proportional hazards models were used to estimate adjusted ORs for albuminuria defined as urine albumin/creatinine ratio (ACR)>30 mg/g, macroalbuminuria defined as ACR>300 mg/g and chronic kidney disease (CKD) defined as estimated glomerular filtration rate<60 ml/min/1.73 m2 according to the Chronic Kidney Disease Epidemiology Collaboration and hazards ratios for end-stage renal disease (ESRD), respectively.Results: Of the 19,461 participants analyzed, 12.9% had albuminuria and 10.1% had CKD at baseline; over a median follow-up of 3.5 years (range 2.14-4.32 years), 0.46% developed ESRD. Higher OBS quartiles were associated with lower prevalence of CKD (OR vs. Q1: Q2=0.93 [95% CI 0.80-1.08]; Q3=0.90 [95% CI 0.77-1.04] and Q4=0.79 [95% CI 0.67-0.92], p for trend<.01). The associations between OBS and albuminuria (p for trend 0.31) and incident ESRD (p for trend 0.56) were not significant in the fully adjusted models.Conclusions: These findings suggest that higher OBS is associated with lower prevalence of CKD. Lack of association with ESRD incidence in the multivariable analyses indicates that temporal relation between OBS and renal damage remains unclear. [ABSTRACT FROM AUTHOR]

Background: Healthy obese individuals may be protected against adverse health outcomes. Diet and race might influence healthy obesity, but data on their roles and interactions on the phenotype are limited.Objective: We compared the food intake of metabolically healthy obese men to those of other weight status-metabolic health phenotypes.Methods: Men (n = 4855) aged ≥ 45 y with BMI ≥ 18.5 kg/m(2) and free of cardiovascular diseases, diabetes, and cancer were evaluated in a cross-sectional study of the REGARDS (REasons for Geographic And Racial Differences in Stroke) study cohort. Food intake was assessed with the use of a food frequency questionnaire. Weight status-metabolic health phenotypes were defined by using metabolic syndrome (MetS) and homeostasis model assessment of insulin resistance (HOMA-IR) criteria. Mean differences in food intake among weight status-metabolic health phenotypes were compared with the use of linear regression.Results: MetS-defined healthy obesity was present in 44% of white obese men and 58% of black obese men; the healthy obese phenotype, based on HOMA-IR, was equally prevalent in both white (20%) and black (21%) obese men. Among white men, MetS-defined healthy and unhealthy obesity were associated with lower wholegrain bread intake and higher consumption of red meat (P < 0.001), whereas HOMA-IR-defined healthy and unhealthy obesity were associated with lower red meat intake (P < 0.0001) compared with healthy normal weight in multivariable-adjusted analyses that adjusted for sociodemographic, lifestyle, and clinical confounders. However, results were attenuated and became nonsignificant after further adjustment for BMI. Healthy and unhealthy overweight, defined by both criteria, were associated with lower whole grain bread intake (P < 0.001) in all models. Among black men, weight status-metabolic health phenotypes were not associated with food intake in all models.Conclusion: Healthy obesity in men is not associated with a healthier diet. Future studies need to consider dietary patterns, which may better inform the holistic effect of diet on healthy obesity, in prospective analyses. [ABSTRACT FROM AUTHOR]

Objective: High dietary glycemic load (GL) has been associated with an increased risk for chronic diseases, including type 2 diabetes, coronary heart disease, and selected cancers. The aim of this study was to identify the main food and food group contributors to dietary GL in a representative sample of US adults to inform future interventions. Methods: Participants were from the REGARDS (REasons for Geographic and Racial Differences in Stroke) study, a longitudinal cohort of 30 239 community-dwelling black and white women and men ages >45 y from throughout the United States. Diet was assessed with a food frequency questionnaire. The amount of each carbohydrate food, and its glycemic index, were used to calculate GL values for each carbohydrate food reported. These were totaled to estimate the mean total daily GL for each participant. Individual carbohydrate foods also were collapsed into 18 carbohydrate food groups, and the portion of the total GL contributed by each carbohydrate food and food group was determined. Analyses were conducted overall, by race/sex groups, and by region. Results: Sweetened beverages were the main contributors to GL overall (12.14 median percentage [median %] of daily GL), by far the largest contributors in black men (17.79 median %) and black women (16.43 median %), and major contributors in white men (12.02 median %) and white women (11.22 median %). Other important contributors to GL overall and in all race/sex groups and regions included breads, starchy side dishes, and cereals. Conclusions: In this US cohort of white and black adults, sweetened beverages were major contributors to GL overall, especially in black participants. This information may help to inform future interventions targeting reduction in dietary GL. [ABSTRACT FROM AUTHOR]

Background: Whether elevated intakes of trans fatty acids (TFAs) increase the risk of stroke remains unclear. Except for the Women's Health Initiative-Observational Study, most studies that directly assessed the association between TFA intake and stroke yielded null results. Objective: The aim of this study was to investigate the association between TFA intake and stroke incidence. Design: We prospectively investigated the association between TFA intake and stroke incidence in black and white men and women (n = 17,107) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort. Participants were recruited between 2003 and 2007 from the continental United States and followed for incident stroke. Diet was assessed by using the Block 1998 food-frequency questionnaire. Cox regression was used to test whether energy-adjusted TFA intake in 1-SD increments was associated with incident stroke. Results: During a median follow-up of 7 y, 479 strokes were identified, including 401 ischemic strokes. Sex modified the association between TFA intake and stroke (P-interaction = 0.06), and thus the results were stratified by sex. In fully adjusted models, a 1-SD (2-g/d) increase in TFA intake was associated with an increased risk of any stroke in men (HR: 1.14; 95% CI: 1.02, 1.28) but not in women (HR: 0.93; 95% CI: 0.79, 1.11). Similarly, our results showed an increased risk of ischemic stroke in men (HR: 1.13; 95% CI: 1.00, 1.28) but not in women (HR: 0.93; 95% CI: 0.77, 1.12). Conclusions: We show that sex modifies the association between TFA intake and stroke; for every 2-g/d increase in TFA intake, there was a 14% increase in the risk of stroke in men but not in women. Our findings provide further evidence to support the concerted effort to minimize TFAs in the diet. [ABSTRACT FROM AUTHOR]

Background: The United States implemented mandatory folic acid fortification of enriched cereal grains in 1998. Although several studies have documented the resulting decrease in anemia and folate deficiency, to our knowledge, no one has determined the prevalence of folate-deficiency anemia after fortification. Objective: We determined the prevalence of folate deficiency and folate-deficiency anemia within a sample of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. Design: The REGARDS cohort is a prospective cohort of 30,239 black and white participants living in the contiguous United States. We measured serum folate concentrations in a random sample of 1546 REGARDS participants aged ≥50 y with baseline hemoglobin and red blood cell mean corpuscular volume measurements. Folate deficiency was defined as a serum folate concentration < 6.6 nmol/L (<3.0 ng/mL), and anemia was defined as a hemoglobin concentration,13 g/dL in men and <12 g/dL in nonpregnant women (WHO criteria). Folate-deiciency anemia was defined as the presence of both folate deficiency and anemia. Results: The mean hemoglobin concentration was 13.6 g/dL, and 15.9% of subjects had anemia. The median serum folate concentration was 34.2 nmol/L (15.1 ng/mL), and only 2 of 1546 participants 0.1%) were folate deficient. Both subjects were African American women with markedly elevated C-reactive protein concentrations, macrocytosis, and normal serum cobalamin concentrations; only one subject was anemic. Overall, the prevalence of folate-deficiency anemia was <0.1% (1 of 1546 subjects). Conclusion: Our data suggest that, after mandatory folic acid fortification, the prevalence of folate-deficiency anemia is nearly nonexistent in a community-dwelling population in the United States. [ABSTRACT FROM AUTHOR]

Background: A high intake of trans fatty acids decreases HDL cholesterol and is associated with increased LDL cholesterol, inflammation, diabetes, cancer, and mortality from cardiovascular disease. The relation between trans fat intake and all-cause mortality has not been established. Objective: The aim of this study was to determine the relation between trans fat intake and all-cause mortality. Design: We used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study--a prospective cohort study of white and black men and women residing in the continental United States. Energy-adjusted trans fat intake was categorized into quintiles, and Cox-regression was used to evaluate the association between trans fat intake and all-cause mortality. Results: During 7 y of follow-up, there were 1572 deaths in 18,513 participants included in REGARDS. From the first to the fifth quintile of trans fat intake, the mortality rates per 1000 person-years of follow-up (95% CIs) were 12.8 (11.3, 14.5), 14.3 (12.7, 16.2), 14.6 (13.0, 16.5), 19.0 (17.1, 21.1), and 23.6 (21.5, 25.9), respectively. After adjustment for demographic factors, education, and risk factors for mortality, the HRs (95% CIs) for all-cause mortality were 1.00, 1.03 (0.86, 1.23), 0.98 (0.82, 1.17), 1.25 (1.05, 1.48), and 1.24 (1.05, 1.48), respectively (P-trend = 0.004). The population attributable risk due to trans fat intake was 7% (95% CI: 5%, 8%). Conclusion: Higher trans fat intake is associated with an increased risk of all-cause mortality. [ABSTRACT FROM AUTHOR]

Longitudinal cohort studies normally identify and adjudicate incident events detected during follow-up by retrieving medical records. There are several reasons why the adjudication process may not be successfully completed for a suspected event including the inability to retrieve medical records from hospitals and an insufficient time between the suspected event and data analysis. These “incomplete adjudications” are normally assumed not to be events, an approach which may be associated with loss of precision and introduction of bias. In this article, the authors evaluate the use of multiple imputation methods designed to include incomplete adjudications in analysis. Using data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study, 2008−2009, they demonstrate that this approach may increase precision and reduce bias in estimates of the relations between risk factors and incident events. [ABSTRACT FROM PUBLISHER]

Inflammation biomarkers, including higher high-sensitivity C-reactive protein (hsCRP) levels, higher white blood cell (WBC) counts, and lower serum albumin levels, are associated with an increased risk of all-cause mortality. Many studies have examined these biomarkers individually, but less is known about their joint association with mortality. hsCRP, WBC count, and serum albumin were measured at baseline in the Reasons for Geographic and Racial Differences in Stroke Study cohort members, who were enrolled in 2003–2007. Over 4.5 years, there were 1,062 deaths in 17,845 participants. High-risk categories were defined as hsCRP or WBC levels above the 75th percentile (5.1 mg/L and 6.9 × 109 cells/L, respectively) and albumin levels below the 25th percentile (4.00 g/dL). The authors derived 4 groups that corresponded to 0 (n = 8,341), 1 (n = 6,277), 2 (n = 2,635), or 3 (n = 592) biomarkers in the high-risk category. After adjustment for age, sex, waist circumference, race, region, smoking, alcohol use, income, educational level, physical activity frequency, and medical history and compared with those with no biomarkers in the high-risk category, the hazard ratios for all-cause mortality for 1, 2, and 3 biomarkers in the high-risk category were 1.56 (95% confidence interval: 1.33, 1.82), 2.19 (95% confidence interval: 1.84, 2.62), and 2.96 (95% confidence interval: 2.30, 3.80), respectively (Ptrend < 0.0001). Adding the 3 inflammation biomarkers to a fully adjusted model improved risk discrimination by 23.7% (95% confidence interval: 9.3, 39.9). Measurement of more than 1 biomarker is more useful in risk prediction than single biomarkers. [ABSTRACT FROM AUTHOR]

Purpose: To examine the hypothesis that longer distance from home-to-hospital is associated with worse outcomes among hospitalizations for community-acquired sepsis.Methods: A secondary analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) prospective cohort of 30,239 white and Black US adults greater than or equal to 45 years old was conducted. Self-reported hospitalizations for serious infection between 2003 and 2012 fulfilling 2/4 systemic inflammatory response syndrome criteria were included. Estimated driving distance was derived from geocoded data and evaluated continuously and as quartiles of very close, close, far, very far (<3.1, 3.1-5.8, 5.9-11.5, and >11.5 miles respectively). The primary outcome was 30-day mortality while the secondary outcome was sequential organ failure assessment (SOFA) score on arrival.Results: Of the 912 hospitalizations for community-acquired sepsis had adequate data for analysis. The median (interquartile range) estimated driving distance was 5.8 miles (3.1,11.7), and 54 (5.9%) experienced the primary outcome. Compared to living very close, participants living very far had a mortality odds ratio of 1.30 (95% CI 0.64,2.62) and presenting SOFA score difference of 0.33 (95% CI -0.03,0.68).Conclusions: Among a national sample of community-acquired sepsis hospitalizations, there was no significant association between home-to-hospital distance and either 30-day mortality or SOFA score on hospital presentation. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to explore the relationship between TV/video viewing, as a measure of sedentary behavior, and risk of incident stroke in a large prospective cohort of men and women.Methods: This analysis involved 22,257 participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study who reported at baseline the amount of time spent watching TV/video daily. Suspected stroke events were identified at six-monthly telephone calls and were physician-adjudicated. Cox proportional hazards models were used to examine risk of stroke at follow-up.Results: During 7.1years of follow-up, 727 incident strokes occurred. After adjusting for demographic factors, watching TV/video ≥4h/day (30% of the sample) was associated with a hazard ratio of 1.37 increased risk of all stroke (95% confidence interval (CI), 1.10-1.71) and incident ischemic stroke (hazard ratio 1.35, CI 1.06-1.72). This association was attenuated by socioeconomic factors such as employment status, education and income.Conclusions: These results suggest that while TV/video viewing is associated with increased stroke risk, the effect of TV/video viewing on stroke risk may be explained through other risk factors. [ABSTRACT FROM AUTHOR]

It is unclear if patients who have atrial fibrillation (AF) have a greater fall risk compared with those in the general population and if falls increase mortality beyond that observed in AF. A total of 24,117 (mean age 65 ± 9.3 years; 55% women; 38% black) participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study were included. AF was identified from baseline electrocardiogram data and by self-reported history. Falls were considered present if participants reported ≥2 falls within the year before the baseline examination. Logistic regression was used to examine the relationship between prevalent AF and falls. Cox regression was used to examine the risk of death in those with AF and falls, separately and in combination, compared with those without either condition. A total of 2,007 participants (8.3%) had baseline AF and 1,655 (6.7%) reported falls. A higher prevalence of falls was reported in those with AF (n = 209; 10%) than those without AF (n = 1,446; 6.5%; p <0.0001). After adjustment for fall risk factors, AF was significantly associated with falls (odds ratio 1.22, 95% confidence interval [CI] 1.04 to 1.44). Compared with no history of AF or falls, the concomitant presence of AF and falls (hazard ratio [HR] 2.12, 95% CI 1.64 to 2.74) was associated with a greater risk of death than AF (HR 1.44, 95% CI 1.28 to 1.62) or falls (HR 1.61, 95% CI 1.42 to 1.82). In conclusion, patients with AF are more likely to report a history of falls in REGARDS. Additionally, participants with AF who report falls have an increased risk of death than those with either condition in isolation. [ABSTRACT FROM AUTHOR]

Introduction: Post-stroke physical activity has widespread health benefits. Environmental exposures may shape post-stroke physical activity behavior. This study investigates the relationships between environmental exposures and post-stroke physical activity.Methods: Stroke survivors (n=374) from a cohort of Black and White adults with post-stroke accelerometer data (2009-2013) were eligible for this study. Participants' home addresses were linked with secondary data to capture environmental characteristics, including annual density of neighborhood resources (e.g., parks, physical activity facilities, and intellectual stimulation destinations), 2010 neighborhood SES, 2010 neighborhood crime, and daily information on extremely cold days. Post-stroke light physical activity and moderate-to-vigorous physical activity were captured using accelerometers over a 7-day period. Linear regression and 2-part/hurdle models were used to estimate the relationship between the density of neighborhood resources with light physical activity and with moderate-to-vigorous physical activity, respectively. Analyses were conducted in 2021.Results: A 10% increase in the number of extremely cold days was associated with 6.37 fewer minutes of daily light physical activity (95% CI= -11.37, -1.37). A 1-SD increase in neighborhood SES was associated with greater odds (OR=1.10, 95% CI=1.02, 1.19) of doing any moderate-to-vigorous physical activity. Among participants obtaining any moderate-to-vigorous physical activity, a 1-unit (count/km2) increase in destinations for intellectual stimulation was associated with 0.99 (95% CI=0.02, 1.97) more minutes of daily moderate-to-vigorous physical activity. All other environmental exposures were not associated with post-stroke light physical activity or moderate-to-vigorous physical activity.Conclusions: Environmental exposures may facilitate physical activity participation among stroke survivors. This study found that weather, neighborhood SES, and proximity to destinations for intellectual stimulation were associated with physical activity over and above individual factors. [ABSTRACT FROM AUTHOR]

Objectives: Cognitive impairment is an important consequence of sepsis. We sought to determine long-term trajectories of cognitive function after sepsis.Design: Prospective study of the Reasons for Geographic and Racial Differences in Stroke cohort.Setting: United States.Patients: Twenty-one thousand eight-hundred twenty-three participants greater than or equal to 45 years, mean (sd) age 64.3 (9.2) years at first cognitive assessment, 30.9% men, and 27.1% Black.Measurements and Main Results: The main exposure was time-dependent sepsis hospitalization. The primary outcome was global cognitive function (Six-Item Screener range, 0-6). Secondary outcomes were incident cognitive impairment (Six-Item Screener score ≤ 4 [impaired] vs ≥5 [unimpaired]), new learning (Consortium to Establish a Registry for Alzheimer Disease Word List Learning range, 0-30), verbal memory (word list delayed recall range, 0-10), and executive function/semantic fluency (animal fluency test range, ≥ 30). Over a median follow-up of 10 years (interquartile range, 6-12 yr), 840 (3.8%) experienced sepsis (incidence 282 per 1,000 person-years). Sepsis was associated with faster long-term declines in Six-Item Screener (-0.02 points per year faster [95% CI, -0.01 to -0.03]; p < 0.001) and faster long-term rates of incident cognitive impairment (odds ratio 1.08 per year [95% CI, 1.02-1.15]; p = 0.008) compared with presepsis slopes. Although cognitive function acutely changed after sepsis (0.05 points [95% CI, 0.01-0.09]; p = 0.01), the odds of acute cognitive impairment (Six-Item Screener ≤ 4) immediately after sepsis was not significant (odds ratio, 0.81 [95% CI, 0.63-1.06]; p = 0.12). Sepsis hospitalization was not associated with acute changes or faster declines in word list learning, word list delayed recall, or animal fluency test.Conclusions: Sepsis is associated with accelerated long-term decline in global cognitive function. [ABSTRACT FROM AUTHOR]