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Abstract. This study investigated the association between microalbuminuria and the insulin resistance syndrome (IRS) among nondiabetic Native Americans. In a cross-sectional survey, age-stratified random samples were drawn from the Indian Health Service clinic lists for one Menominee and two Chippewa reservations. Information was collected from physical examinations, personal interviews, and blood and urine samples. The urinary albumin:creatinine ratio (ACR) was measured using a random spot urine sample. The IRS was defined by the number of composite traits: hypertension, impaired fasting glucose (IFG), high fasting insulin, low HDL cholesterol, and hypertriglyceridemia. Among the 934 eligible nondiabetic participants, 15.2% exhibited microalbuminuria. The prevalence of one, two, and three or more traits was 27.0, 16.6, and 7.4%, respectively. After controlling for age, sex, smoking, body mass index, education, and family histories of diabetes and kidney disease, the odds ratio (OR) for microalbuminuria was 1.8 (95% confidence interval [CI], 1.1 to 2.8) for one IRS trait, 1.8 (95% CI, 1.0 to 3.2) for two traits, and 2.3 (95% CI, 1.1 to 4.9) for three or more traits (versus no traits). The pattern of association appeared weaker among women compared with men. Of the individual IRS traits, only hypertension and IFG were associated with microalbuminuria. Among these nondiabetic Native Americans, the IRS was associated with a twofold increased prevalence of microalbuminuria. Health promotion efforts should focus on lowering the prevalence of hypertension, as well as glucose intolerance and obesity, in this population at high risk for renal and cardiovascular disease.Microalbuminuria is an early indicator of renal disease among individuals with type 1 and type 2 diabetes (1-4). Microalbuminuria in diabetic patients is associated with the insulin resistance syndrome (IRS), also known as the metabolic syndrome, syndrome X, and the multiple metabolic syndrome (5-7). The IRS is comprised of impaired glucose metabolism, insulin resistance, hypertriglyceridemia, low concentration of HDL cholesterol, high BP, and sometimes-central adiposity and obesity. In persons with diabetes, several of these factors, including high BP, dyslipidemia, central adiposity, and obesity, are associated with increased risk of microalbuminuria (8 -12).Although microalbuminuria has been associated with an increased rate of decline in creatinine clearance in nondiabetic hypertensive patients (13)(14), there is generally less information about its association with the IRS in persons without diabetes. If the metabolic and hemodynamic abnormalities characteristic of the IRS are causally related to microalbuminuria, we would expect to find an association between IRS and microalbuminuria in nondiabetic persons similar to that observed among patients with diabetes. We studied this possibility by examining the association between the IRS and prevalent microalbuminuria among nondiabetic members of a population of Native Americans.

Objective. To conceptualize and measure community contextual influences on population health and health disparities. Data Sources. We use traditional and nontraditional secondary sources of data comprising a comprehensive array of community characteristics. Study Design. Using a consultative process, we identify 12 overarching dimensions of contextual characteristics that may affect community health, as well as specific subcomponents relating to each dimension. Data Collection. An extensive geocoded library of data indicators relating to each dimension and subcomponent for metropolitan areas in the United States is assembled. Principal Findings. We describe the development of community contextual health profiles, present the rationale supporting each of the profile dimensions, and provide examples of relevant data sources. Conclusions. Our conceptual framework for community contextual characteristics, including a specified set of dimensions and components, can provide practical ways to monitor health-related aspects of the economic, social, and physical environments in which people live. We suggest several guiding principles useful for understanding how aspects of contextual characteristics can affect health and health disparities.Key Words. Health disparity, residence characteristics, contextual data, population health, socioeconomic factors Much has been accomplished to improve health and reduce disparities through understanding and intervening on individual-level risk factors for major causes of morbidity and mortality (U.S. Preventive Services Task Force 1996; Ketola, Sipila, and Makela 2000). However, far less attention has been paid to understanding the effect of community contextual characteristics on health outcomes and disparities. Although research interest in the role of socioenvironmental factors in the etiology of disease has surged over the past decade (for reviews see Pickett and Pearl 2001;Macintyre, Ellaway, and Cummins 2002;Yen and Syme 1999), a recurrent theme in this literature is the need for greater attention to the conceptualization and empirical assessment of 1645 ways in which contextual characteristics of places impact health (Pickett and Pearl 2001;Macintyre, Ellaway, and Cummins 2002;Lynch 1997, 2001;Yen and Syme 1999;Diez-Roux 1998). In addition, there has been great academic and policy interest in implementing interventions aimed at improving socioenvironmental factors that could produce wide-ranging health benefits (for example see articles in the April 2003 supplement to the American Journal of Preventive Medicine on this topic). Many in public health believe these represent a promising approach to reducing the marked health disparities that remain a high-priority public health concern (U.S. Department of Health and Human Services 2000). Furthermore, this approach provides critical data to ensure that decisions regarding the provision of health care services do not occur in a vacuum, but instead are integrated into the larger picture of health-promoting and health-endangering char...

The substantial proportion of persons with known multiple risk factors (25% of the population) suggests that increased CVD prevention and risk factor reduction efforts should focus on comprehensive risk reduction strategies.

Problem/ConditionHeart disease is the leading cause of death in the United States. In 2015, heart disease accounted for approximately 630,000 deaths, representing one in four deaths in the United States. Although heart disease death rates decreased 68% for the total population from 1968 to 2015, marked disparities in decreases exist by race and state.Period Covered1968–2015.Description of SystemThe National Vital Statistics System (NVSS) data on deaths in the United States were abstracted for heart disease using diagnosis codes from the eighth, ninth, and tenth revisions of the International Classification of Diseases (ICD-8, ICD-9, and ICD-10) for 1968–2015. Population estimates were obtained from NVSS files. National and state-specific heart disease death rates for the total population and by race for adults aged ≥35 years were calculated for 1968–2015. National and state-specific black-white heart disease mortality ratios also were calculated. Death rates were age standardized to the 2000 U.S. standard population. Joinpoint regression was used to perform time trend analyses.ResultsFrom 1968 to 2015, heart disease death rates decreased for the total U.S. population among adults aged ≥35 years, from 1,034.5 to 327.2 per 100,000 population, respectively, with variations in the magnitude of decreases by race and state. Rates decreased for the total population an average of 2.4% per year, with greater average decreases among whites (2.4% per year) than blacks (2.2% per year).At the national level, heart disease death rates for blacks and whites were similar at the start of the study period (1968) but began to diverge in the late 1970s, when rates for blacks plateaued while rates for whites continued to decrease. Heart disease death rates among blacks remained higher than among whites for the remainder of the study period. Nationwide, the black-white ratio of heart disease death rates increased from 1.04 in 1968 to 1.21 in 2015, with large increases occurring during the 1970s and 1980s followed by small but steady increases until approximately 2005. Since 2005, modest decreases have occurred in the black-white ratio of heart disease death rates at the national level. The majority of states had increases in black-white mortality ratios from 1968 to 2015. The number of states with black-white mortality ratios >1 increased from 16 (40%) to 27 (67.5%). InterpretationAlthough heart disease death rates decreased both for blacks and whites from 1968 to 2015, substantial differences in decreases were found by race and state. At the national level and in most states, blacks experienced smaller decreases in heart disease death rates than whites for the majority of the period. Overall, the black-white disparity in heart disease death rates increased from 1968 to 2005, with a modest decrease from 2005 to 2015.Public Health ActionSince 1968, substantial increases have occurred in black-white disparities of heart disease death rates in the United States at the national level and in many states. These increases appear to be due to...

Against the backdrop of late 20th century declines in heart disease mortality in the United States, race-specific rates diverged because of slower declines among blacks compared with whites. To characterize the temporal dynamics of emerging black-white racial disparities in heart disease mortality, we decomposed race-sex-specific trends in an age-period-cohort (APC) analysis of US mortality data for all diseases of the heart among adults aged ≥35 years from 1973 to 2010. The black-white gap was largest among adults aged 35-59 years (rate ratios ranged from 1.2 to 2.7 for men and from 2.3 to 4.0 for women) and widened with successive birth cohorts, particularly for men. APC model estimates suggested strong independent trends across generations ("cohort effects") but only modest period changes. Among men, cohort-specific black-white racial differences emerged in the 1920-1960 birth cohorts. The apparent strength of the cohort trends raises questions about life-course inequalities in the social and health environments experienced by blacks and whites which could have affected their biomedical and behavioral risk factors for heart disease. The APC results suggest that the genesis of racial disparities is neither static nor restricted to a single time scale such as age or period, and they support the importance of equity in life-course exposures for reducing racial disparities in heart disease.

Background Although many studies have documented the dramatic declines in heart disease mortality in the United States at the national level, little attention has been given to the temporal changes in the geographic patterns of heart disease mortality. Methods and Results Age-adjusted and spatially smoothed county-level heart disease death rates were calculated for 2-year intervals from 1973 to 1974 to 2009 to 2010 for those aged ≥35 years. Heart disease deaths were defined according to the International Classification of Diseases codes for diseases of the heart in the eighth, ninth, and tenth revisions of the International Classification of Diseases. A fully Bayesian spatiotemporal model was used to produce precise rate estimates, even in counties with small populations. A substantial shift in the concentration of high-rate counties from the Northeast to the Deep South was observed, along with a concentration of slow-decline counties in the South and a nearly 2-fold increase in the geographic inequality among counties. Conclusions The dramatic change in the geographic patterns of heart disease mortality during 40 years highlights the importance of small-area surveillance to reveal patterns that are hidden at the national level, gives communities the historical context for understanding their current burden of heart disease, and provides important clues for understanding the determinants of the geographic disparities in heart disease mortality.

Purpose Recent national trends show decelerating declines in heart disease mortality, especially among younger adults. National trends may mask variation by geography and age. We examined recent county-level trends in heart disease mortality by age group. Methods Using a Bayesian statistical model and National Vital Statistics Systems data, we estimated overall rates and percent change in heart disease mortality from 2010 through 2015 for four age groups (35–44, 45–54, 55–64, and 65–74 years) in 3098 US counties. Results Nationally, heart disease mortality declined in every age group except ages 55–64 years. County-level trends by age group showed geographically widespread increases, with 52.3%, 58.5%, 69.1%, and 42.0% of counties experiencing increases with median percent changes of 0.6%, 2.2%, 4.6%, and −1.5% for ages 35–44, 45–54, 55–64, and 65–74 years, respectively. Increases were more likely in counties with initially high heart disease mortality and outside large metropolitan areas. Conclusions Recent national trends have masked local increases in heart disease mortality. These increases, especially among adults younger than age 65 years, represent challenges to communities across the country. Reversing these trends may require intensification of primary and secondary prevention—focusing policies, strategies, and interventions on younger populations, especially those living in less urban counties.