Interventions For Modifiable Risk Factors Research Articles

Abstract WP276: Large Artery Atherosclerosis and Young Stroke

Introduction: It is known that past the age of 35, the prevalence of large artery atherosclerosis (LAA) related strokes increases with a cardiovascular risk factor (CVRF) profile beginning to resemble that of elderly patients. However, LAA-related strokes still only account for <10% of all young strokes over the age of 35. Further, there is limited data regarding the location, intracranial or extracranial, of LAA in this patient population. Methods: We conducted a retrospective review of stroke patients between the ages of 18 to 50 years presenting to our Young Stroke Center between April 2022 through August 2023. For each case, data including basic demographics and medical history were collected, and stroke etiology was determined by a vascular neurologist. Patients with LAA as the stoke etiology were compared to all non-LAA stroke etiologies. The two groups were analyzed with respect to baseline demographics and CVRFs. Analysis was performed with logistic regression adjusting for age, sex, and race. Results: Of 179 patients in the registry, 15 patients had LAA compared with 164 patients with non-LAA as their stroke etiology. Only one patient had extracranial carotid stenosis, with the rest of the LAA patients having intracranial atherosclerotic disease. There was a significant difference in age at time of stroke (42.9 ± 5.0 vs. 38.2 ± 8.0 years; OR [95% CI]: 1.11 [1.01-1.21]) between LAA and non-LAA groups, respectively. There was no significant difference in sex (66.7% vs. 62.8% female) and race (46.7% vs. 54.9% Black). A significantly larger proportion of patients with LAA had baseline CVRFs including hypertension (80.0% vs. 44.5%; 5.0 [1.2-20.3]), dyslipidemia (66.7% vs. 31.7%; 4.3 [1.3-14.1]), and obesity (33.3% vs. 12.2%; 5.6 [1.5-20.7]). There was also a trend toward increased rates of smoking (40.0% vs. 20.7%; 2.82 [0.9-9.0]) and diabetes (26.7% vs. 18.9%; 1.3 [0.3-4.7]). Conclusion: In the young stroke population, stroke due to LAA is more likely due to intracranial disease rather than extracranial disease and is associated with traditional CVRFs including hypertension, dyslipidemia, and obesity. These findings reinforce the importance of early intervention of modifiable risk factors for primary prevention of stroke in the young.

Willingness to institutionalize a relative with dementia: a web-platform assessment with the Portuguese adapted version of the Desire-to-Institutionalize Scale.

Older persons with dementia (PwD) are more likely to be institutionalized than their counterparts without dementia. The caregiver's desire to institutionalize has been suggested as the most important predictor of actual institutionalization. This cross-sectional study aimed to culturally adapt the Desire to Institutionalize Scale (DIS) to a country with a high prevalence of dementia (Portugal) and examine its psychometric properties. The reliability, structural validity, and criterion validity of the DIS-PT were assessed by applying the scale using a remote measurement web platform. A sample of 105 dementia caregivers completed the DIS-PT and several psychosocial measures, including caregiver burden, anxiety, depression, quality of life, PwD functional independence, and neuropsychiatric symptoms. The DIS-PT demonstrated good structural validity, with one factor explaining 75% of the total variance. The internal consistency of the scale was high (α = 0.802). Most caregivers (65.7%) endorsed at least one item on the DIS-PT (Mdn 2). The caregiver's desire to institutionalize was significantly associated with the caregiver, care recipient, and contextual variables previously known to affect institutional placement. These included the caregivers' occupational status, perceived burden, anxiety (but not depression), physical and psychological quality of life, care recipient education, severity of neuropsychiatric symptoms, and cohabitation with the caregiver. This study offers preliminary support for the psychometric quality of the DIS-PT. The scale has practical applications in the early identification of caregivers considering nursing home placement, providing room for intervention in modifiable risk factors that may otherwise lead to the institutionalization of PwD. Remote measurement tools may hold value in assessing caregiving dyads non-intrusively and inexpensively.

Blood DNA methylation biomarkers for cognitive decline in older adults with type 2 diabetes

AbstractBackgroundIndividuals with type 2 diabetes (T2D) are at particularly high risk for cognitive decline and dementia. Finding early, pre‐clinical biomarkers for detecting and tracking cognitive impairment and dementia in this population is important for personalized medicine approach. Our study aims to find blood DNA methylation biomarkers for cognitive decline among elderly T2D patients.MethodTwo groups of 30 T2D subjects each, from the Israel Diabetes and Cognitive Decline (IDCD) cohort, were included. One group (converters) was cognitively normal at baseline, yet at 36‐54 months follow‐up deteriorated from a Clinical Dementia Rating scale CDR = 0 (no dementia) to CDR≥0.5 (questionable dementia or frank dementia). The control group (non‐converters) was cognitively normal at baseline and maintained normal cognition during the follow‐up period (CDR = 0). We performed an epigenome‐wide association study, using the Illumina Infinium MethylationEPIC microarray, and searched for differentially methylated positions (DMPs) with significant methylation alterations (≥ 2 fold and FDR corrected p value <0.05) between the baseline and the follow‐up time points for each of the two groups.ResultParticipants were 65‐83 years of age (mean‐73.6 ± 4.1), 72% were men. The mean hemoglobin A1C value was 6.9 ± 0.8%, and T2D duration was 9.4 ± 4.7 years. Converters and non‐converters did not differ in any of these characteristics. Results show significant changes in multiple DMPs among the converters, but only in a few DMPs in the non‐converters. Gene ontology analyses indicates primarily involvement of central nervous system‐related pathways, mainly neurodevelopmental disorders.ConclusionThese preliminary results, employing a high‐throughput approach for methylation profile in blood, suggest methylomic alterations as a potential biomarker for cognitive decline in T2D elderly. A priori identification of patients at risk for cognitive decline may lead to early intervention in modifiable risk factors in this population, which is highly susceptible to dementia.

Health Prevention Interventions for Adults in the Community: A Scoping Review of Intervention Characteristics

This scoping review was designed to determine which adults receive preventative health interventions, the types of interventions for modifiable risk factors, the health professionals, including occupational therapy practitioners providing these interventions, and where they are delivered to adults in the community. The databases searched were PubMed, Ageline, and CINAHL and included research meeting the inclusion criteria and published between 2016–2021. All included studies addressed health prevention. 5,399 articles were screened with 83 of these included in the final review. Older adults, White and Black individuals, and females were the most prevalent individuals and groups to receive health prevention interventions and occupational therapy professionals were involved in 5% of the reviewed studies. As there is a need for preventative health interventions to help reduce negative health outcomes and occupational therapy professionals have important skills in health prevention this study illustrates the types of health prevention provided to adults receiving intervention in the community and points to areas of opportunity for occupational therapy professionals.

Preexisting mental health disorders and risk of opioid use disorder in young people: A case-control study.

Opioid use disorder (OUD) is a leading cause of preventable mortality amongst young people worldwide. Early identification and intervention of modifiable risk factors may reduce future OUD risk. The aim of this study was to explore whether the onset of OUD is associated with preexisting mental health conditions such as anxiety and depressive disorders in young people. A retrospective, population-based case-control study was conducted from 31 March 2018 until 01 January 2002. Provincial administrative health data were collected from Alberta, Canada. Individuals 18-25 years on 01 April 2018, with a previous record of OUD. Individuals without OUD were matched to cases, on age/sex/index date. Conditional logistic regression analysis was used to control for additional covariates (e.g., alcohol-related disorders, psychotropic medications, opioid analgesics, and social/material deprivation). We identified N= 1848 cases and N= 7392 matched controls. After adjustment, OUD was associated with the following preexisting mental health conditions: Anxiety disorders, aOR=2.53 (95% CI=2.16-2.96); depressive disorders, aOR=2.20 (95% CI=1.80-2.70); alcohol-related disorders, aOR=6.08 (95% CI, 4.86-7.61); anxiety and depressive disorders, aOR=1.94 (95% CI=1.56-2.40); anxiety and alcohol-related disorders, aOR=5.22 (95% CI=4.03-6.77); depressive and alcohol-related disorders, aOR=6.47 (95% CI=4.73-8.84); anxiety, depressive and alcohol-related disorders, aOR=6.09 (95% CI=4.41-8.42). Preexisting mental health conditions such as anxiety and depressive disorders are risk factors for future OUD in young people. Preexisting alcohol-related disorders showed the strongest association with future OUD and demonstrated an additive risk when concurrent with anxiety/depression. As not all plausible risk factors could be examined, more research is still needed.

Burden of kidney cancer and attributed risk factors in China from 1990 to 2019.

The changing trends and risk-attributed burdens of kidney cancer in China are unknown. Therefore, this study aimed to describe the latest status and trends of kidney cancer burden in China and its associated risk factors. The absolute numbers and rates of the incidence, deaths, and disability-adjusted life-years (DALYs) of kidney cancer in China were extracted from the Global Burden of Disease 2019 platform. Overall burden and burden attributed to smoking and high body mass index (BMI) were described. Average annual percent change (AAPC) was calculated to describe trend analyses from 1990 to 2019 using the Joinpoint regression program. In 2019, 59,827 new cases, 23,954 deaths, and 642,799 DALYs of kidney cancer occurred in China, of which men accounted for 71.1, 70.5, and 72.0%, and the population aged ≥55 years accounted for 58.9, 77.9, and 60.1%, of new cases, deaths, and DALYs, respectively. From 1990 to 2019, the age-standardized incidence rate (per 100,000 person-years) increased from 1.16 in 1990 to 3.21 in 2019, with an AAPC of 3.4% (95% confidence interval [CI]: 3.1-3.8%, p < 0.05); the mortality rate increased from 0.70 to 1.27, with an AAPC of 2.1% (1.5-2.3%, p < 0.05); and the DALY rate increased from 0.70 to 1.27, with an AAPC of 2.1% (1.5-2.3%, p < 0.05). In 2019, the proportions of DALYs attributed to smoking and high BMI were 18.0% and 11.1%, respectively, and the DALY rates attributed to both smoking and high BMI increased from 1990 to 2019, with AAPC of 2.9% (2.6-3.3%, p < 0.05) and 4.8% (4.2-5.4%, p < 0.05), respectively. The kidney cancer burden in China has continued to grow over the recent three decades, with a severe burden among older adults and men. Therefore, timely preventive interventions for modifiable risk factors are required.

Development of a Nomogram to Predict Postoperative Transfusion in the Elderly After Intramedullary Nail Fixation of Femoral Intertrochanteric Fractures.

PurposeThe aim of our study was to explore the risk factors related to blood transfusion after intramedullary nail fixation of elderly femoral intertrochanteric fracture (FTF) and establish a nomogram prediction model.Patients and MethodsWe conducted a retrospective study including elderly FTF patients treated by intramedullary nail between January 2017 and December 2019. Perioperative information was obtained retrospectively, uni- and multivariate regression analyses were performed to determine risk factors for blood transfusion. A nomogram model was established to predict the risk of blood transfusion, and consistency coefficient (C-index) and correction curve were used to evaluate the prediction performance and consistency of the model.ResultsOf 148 patients, 119 were finally enrolled in the study and and 46 patients (38.7%) received a blood transfusion after the operation. Logistic regression analysis the female, lower preoperative Hb, ASA score >2, general anesthesia, and higher intraoperative blood loss were independently associated with the blood transfusion. The accuracy of the contour map for predicting transfusion risk was 0.910.ConclusionThese risk factors are shown on the nomogram and verified. Through the assessment of the risk of blood transfusion and the intervention of modifiable risk factors, we may be able to reduce the blood transfusion rate to a certain extent, so as to further guarantee the safety of the elderly patients during the perioperative period.

Factors associated with health-related quality of life in PACE participants

Health-related quality of life (HRQoL) is an important measure of how health and illness affect the lives of older adults. This study aimed to determine the relationship between frailty, fear of falling, and depression with HRQoL in nursing home eligible community-dwelling older adults. A cross-sectional correlational design and chart review were conducted. Eighty four participants (mean age = 70.33 [SD = 6.33]) were surveyed on frailty, fear of falling, depression and physical and mental health measures of HRQoL. Increased frailty, fear of falling, and depression were associated with decreased physical and mental health and well-being. When controlling for sociodemographics, frailty and fear of falling were predictive of lower physical health and well-being whereas depression was independently predictive of lower mental health and well-being. The results of this study will assist in assessment and targeted interventions for modifiable risk factors that affect the HRQoL of nursing home eligible community-dwelling older adults.

Patient characteristics of smokers undergoing lumbar spine surgery: an analysis from the Quality Outcomes Database.

OBJECTIVE In this analysis the authors compare the characteristics of smokers to nonsmokers using demographic, socioeconomic, and comorbidity variables. They also investigate which of these characteristics are most strongly associated with smoking status. Finally, the authors investigate whether the association between known patient risk factors and disability outcome is differentially modified by patient smoking status for those who have undergone surgery for lumbar degeneration. METHODS A total of 7547 patients undergoing degenerative lumbar surgery were entered into a prospective multicenter registry (Quality Outcomes Database [QOD]). A retrospective analysis of the prospectively collected data was conducted. Patients were dichotomized as smokers (current smokers) and nonsmokers. Multivariable logistic regression analysis fitted for patient smoking status and subsequent measurement of variable importance was performed to identify the strongest patient characteristics associated with smoking status. Multivariable linear regression models fitted for 12-month Oswestry Disability Index (ODI) scores in subsets of smokers and nonsmokers was performed to investigate whether differential effects of risk factors by smoking status might be present. RESULTS In total, 18% (n = 1365) of patients were smokers and 82% (n = 6182) were nonsmokers. In a multivariable logistic regression analysis, the factors significantly associated with patients' smoking status were sex (p < 0.0001), age (p < 0.0001), body mass index (p < 0.0001), educational status (p < 0.0001), insurance status (p < 0.001), and employment/occupation (p = 0.0024). Patients with diabetes had lowers odds of being a smoker (p = 0.0008), while patients with coronary artery disease had greater odds of being a smoker (p = 0.044). Patients' propensity for smoking was also significantly associated with higher American Society of Anesthesiologists (ASA) class (p < 0.0001), anterior-alone surgical approach (p = 0.018), greater number of levels (p = 0.0246), decompression only (p = 0.0001), and higher baseline ODI score (p < 0.0001). In a multivariable proportional odds logistic regression model, the adjusted odds ratio of risk factors and direction of improvement in 12-month ODI scores remained similar between the subsets of smokers and nonsmokers. CONCLUSIONS Using a large, national, multiinstitutional registry, the authors described the profile of patients who undergo lumbar spine surgery and its association with their smoking status. Compared with nonsmokers, smokers were younger, male, nondiabetic, nonobese patients presenting with leg pain more so than back pain, with higher ASA classes, higher disability, less education, more likely to be unemployed, and with Medicaid/uninsured insurance status. Smoking status did not affect the association between these risk factors and 12-month ODI outcome, suggesting that interventions for modifiable risk factors are equally efficacious between smokers and nonsmokers.

Multi-Component Interventions and Cognitive Health: A Scoping Review.

Single-component interventions for modifiable risk factors to improve cognitive function in older adults have limited impacts. Multi-component interventions may be more effective. The current review describes randomized trials of multi-component interventions, and reports the state of the evidence to protect the cognitive health and reduce the risk of cognitive decline among middle-aged and older adults. Two hundred seventy-nine studies were found through electronic databases, 30 full-text reviews were completed, and six studies were identified for final selection. Findings suggest that a multi-component approach is promising compared to single-component interventions. Most multi-component intervention studies found improvement in at least one domain of cognitive function. However, the quality of multi-component studies was largely fair or poor primarily due to small samples and short trial durations. There is a need for more rigorous studies of multi-component interventions and to refine the knowledge on the specific interventions that optimize prevention domains. [Journal of Gerontological Nursing, 43(5), 39-48.].

Abstract 13486: Patient and Procedural Factors Are Associated With Autonomic and Endothelial Dysfunction in Adolescent and Young Adult Fontan Survivors

Introduction: Vascular dysfunction is associated with diminished functional capacity and quality of life in adolescent and young adult Fontan survivors. Patient and procedural factors associated with diminished endothelial and autonomic function have not been established. Methods: Cross-sectional single-institution study of Fontan survivors ages 8-25 years. Anthropometric characteristics were obtained. Endothelial function was assessed with brachial flow mediated dilation (FMD) and peripheral arterial tonometry reactive hyperemia index (lnRHI; EndoPAT). Autonomic function was assessed by heart rate variability (HRV; SphygmoCor). Records were reviewed for anatomic, hemodynamic and surgical characteristics, which served as predictor variables while vascular measures served as outcome variables. Bivariate predictors (p&lt;0.1) were candidates for inclusion in multivariable models. Model development utilized linear regression techniques. Results: Sixty patients (52% male, 90% Caucasian) completed the protocol with a mean age of 13.9 ± 4.1 years and duration of Fontan circulation of 9.9 ± 4.2 years. Median weight was 43.5 (IQR 31.4, 58.3) kg and BMI was 18.7 (16.1, 22.6) kg/m 2 . A single left ventricle was present in 65%. Mean FMD was 10.2 ± 5.5% and lnRHI was 0.236 ± 0.398. Median HRV was 41.2 (29.4, 52.0) ms. Major determinants of FMD included height, total # of surgeries and stage I palliation length of stay (LOS) (R 2 0.29, p&lt;0.001), whereas determinants of lnRHI included prior Norwood procedure, systolic blood pressure, resting heart rate and oxygen saturation (SaO 2 ), mixed venous SaO 2 and cardiac index (CI) at pre-Fontan catheterization (cath) and total # of hospitalizations (R 2 0.27, p=0.01). Major determinants of HRV included total duration of surgical circulatory arrest, CI at pre-Fontan cath and Fontan completion LOS (R 2 0.39, p=0.006). Traditional cardiovascular risk factors including weight and BMI were not independent determinants. Conclusions: Multiple patient and procedural factors are associated with diminished endothelial and autonomic function in adolescent and young adult Fontan survivors. Targeted intervention of modifiable risk factors may improve long-term vascular health and functional status.

The Heart Health Study - increasing cardiovascular risk assessment in family practice for first degree relatives of patients with premature ischaemic heart disease: a randomised controlled trial.

BackgroundThis study aimed to increase cardiovascular disease (CVD) risk assessment in adult first degree relatives of patients with premature ischaemic heart disease (PIHD) using written and verbal advice.MethodsDesign: A prospective, randomised controlled trial. Setting: Cardiovascular wards at three South Australian hospitals. Cardiovascular risk assessments were performed in general practice. Participants: Patients experiencing PIHD (heart disease in men aged <55 years or women aged < 65 years) and their first degree relatives. Intervention: Patients distributed either general information about heart disease and written advice to attend their general practitioner (GP) for CVD risk assessment or general information about heart disease only, to their first degrees relatives. Main outcome measure: The primary outcome was the proportion of relatives who attended their GP for CVD risk assessment within 6 months of the patients’ PIHD event.ResultsOne hundred forty four patients were recruited who had 541 eligible relatives; 97/541 (18 %) of relatives agreed to participate. A larger number of intervention 41/55 (75 %) than control group 9/42 (21 %) [difference 53 %, 95 % CI 36 % - 71 %] relatives attended their GP for a CVD assessment, and 34 % of these had moderate to very high 5-year absolute risk for CVD.ConclusionThis low cost intervention demonstrates that individuals who have a family history of PIHD and are at moderate or high risk of CVD can be targeted for early intervention of modifiable risk factors. Further research is required to improve the uptake of the intervention in relatives.Trial registrationThe trial was registered with the Australian Clinical Trials Registry (ACTRN), Registration ID 12613000557730.

Lupus anticoagulant: a marker for stroke and venous thrombosis in primary Sjögren’s syndrome

Antiphospholipid antibodies (aPL) and antiphospholipid syndrome (APS) have been described in primary Sjögren's syndrome (pSS) with controversial findings regarding aPL prevalence and their association with thrombotic events. We evaluated 100 consecutive pSS patients (American-European criteria) and 89 age-gender-ethnicity-matched healthy controls for IgG/IgM anticardiolipin (aCL), IgG/IgM anti-beta2-glycoprotein-I (aβ2GPI), and lupus anticoagulant (LA) (positivity according to APS Sydney's criteria). Clinical analysis followed standardized interview and physical examination assessing thrombotic and nonthrombotic APS manifestations and thrombosis risk factors. aPLs were detected in 16% patients and 5.6% controls (p = 0.035). LA was the most common aPL in patients (9%), followed by aβ2GPI (5%) and aCL (4%). Thrombotic events occurred in five patients [stroke in two, myocardial infarction in one and deep-vein thrombosis (DVT) in four], but in none of controls (p = 0.061). Mean age at time of stroke was 35years. Three patients with thrombotic events (including the two with stroke) had APS (Sydney's criteria) and were positive exclusively for LA. Comparison of patients with (n = 16) and without (n = 84) aPL revealed similar mean age, female predominance, and ethnicity (p > =0.387). Frequencies of livedo reticularis (25 vs. 4.8%, p = 0.021), stroke (12.5 vs. 0%, p = 0.024), and DVT (18.8 vs. 1.2%, p = 0.013) were significantly higher in APL + patients. Conversely, frequencies of hypertension, dyslipidemia, diabetes, obesity, smoking, sedentarism, and hormonal contraception were similar in patients with or without aPL (p ≥ 0.253). Our study identified LA as an important marker for APS in pSS, particularly for stroke in young patients, warranting routine evaluation of these antibodies and rigorous intervention in modifiable risk factors.

Major Risk Factors for Stillbirth in High-Income Countries: A Systematic Review and Meta-Analysis

Summary Background Stillbirth rates in high-income countries have shown little or no improvement over the past two decades. Prevention strategies that target risk factors could be important in rate reduction. This systematic review and meta-analysis was done to identify priority areas for stillbirth prevention relevant to those countries. Methods Population-based studies addressing risk factors for stillbirth were identified through database searches. The factors most frequently reported were identified and selected according to whether they could potentially be reduced through lifestyle or medical intervention. The numbers attributable to modifiable risk factors were calculated from data relating to the five high-income countries with the highest numbers of stillbirths and where all the data required for analysis were available. Odds ratios were calculated for selected risk factors, from which population-attributable risk (PAR) values were calculated. Findings Of 6963 studies initially identified, 96 population-based studies were included. Maternal overweight and obesity (body-mass index >25 kg/m 2 ) was the highest ranking modifiable risk factor, with PARs of 8–18% across the five countries and contributing to around 8000 stillbirths (≥22 weeks' gestation) annually across all high-income countries. Advanced maternal age (>35 years) and maternal smoking yielded PARs of 7–11% and 4–7%, respectively, and each year contribute to more than 4200 and 2800 stillbirths, respectively, across all high-income countries. In disadvantaged populations maternal smoking could contribute to 20% of stillbirths. Primiparity contributes to around 15% of stillbirths. Of the pregnancy disorders, small size for gestational age and abruption are the highest PARs (23% and 15%, respectively), which highlights the notable role of placental pathology in stillbirth. Pre-existing diabetes and hypertension remain important contributors to stillbirth in such countries. Interpretation The raising of awareness and implementation of effective interventions for modifiable risk factors, such as overweight, obesity, maternal age, and smoking, are priorities for stillbirth prevention in high-income countries. Funding The Stillbirth Foundation Australia, the Department of Health and Ageing, Canberra, Australia, and the Mater Foundation, Brisbane, Australia.

Metabolic syndrome and cardiovascular risk in survivors after hematopoietic cell transplantation

Increasing numbers of hematopoietic cell transplantations (HCTs) are being performed annually with a greater number of long-term survivors. There is increasing concern regarding the late complications and long-term effects that are secondary to treatment exposures before HCT as well as during the HCT conditioning therapy. In both the autologous as well as allogeneic transplant setting, transplant survivors experience mortality rates higher than the general population and the risk of premature cardiovascular (CV)-related death is increased 2.3-fold compared with the general population. The etiology of CV-related deaths in HCT survivors is multifactorial; however, increasing evidence suggests that HCT survivors are at higher risk of developing adverse CV risk factors leading to the development of the metabolic syndrome (a constellation high triglyceride levels, low high-density lipoprotein-cholesterol, hypertension, high fasting blood sugars and increased waist circumference), which then predisposes individuals to risk for early CV-related death. Resistance to insulin is the primary underlying pathophysiologic mechanism that contributes to the development of metabolic syndrome and HCT survivors have been shown to be more likely to develop hypertension, hyperlipidemia and to be insulin resistant. However, the relationship between HCT-related treatment exposures (total body irradiation, high dose chemotherapy, calcineurin inhibitors, steroids, etc) and transplant-related complications (such as GVHD) with the development of CV risk factors and insulin resistance is still in the early stages of investigation. Greater knowledge of the concern regarding CV risk in HCT survivors among both patients and care providers will provide the opportunity for appropriate screening as well as interventions for modifiable risk factors.

Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis

Stillbirth rates in high-income countries have shown little or no improvement over the past two decades. Prevention strategies that target risk factors could be important in rate reduction. This systematic review and meta-analysis was done to identify priority areas for stillbirth prevention relevant to those countries. Population-based studies addressing risk factors for stillbirth were identified through database searches. The factors most frequently reported were identified and selected according to whether they could potentially be reduced through lifestyle or medical intervention. The numbers attributable to modifiable risk factors were calculated from data relating to the five high-income countries with the highest numbers of stillbirths and where all the data required for analysis were available. Odds ratios were calculated for selected risk factors, from which population-attributable risk (PAR) values were calculated. Of 6963 studies initially identified, 96 population-based studies were included. Maternal overweight and obesity (body-mass index >25 kg/m(2)) was the highest ranking modifiable risk factor, with PARs of 8-18% across the five countries and contributing to around 8000 stillbirths (≥22 weeks' gestation) annually across all high-income countries. Advanced maternal age (>35 years) and maternal smoking yielded PARs of 7-11% and 4-7%, respectively, and each year contribute to more than 4200 and 2800 stillbirths, respectively, across all high-income countries. In disadvantaged populations maternal smoking could contribute to 20% of stillbirths. Primiparity contributes to around 15% of stillbirths. Of the pregnancy disorders, small size for gestational age and abruption are the highest PARs (23% and 15%, respectively), which highlights the notable role of placental pathology in stillbirth. Pre-existing diabetes and hypertension remain important contributors to stillbirth in such countries. The raising of awareness and implementation of effective interventions for modifiable risk factors, such as overweight, obesity, maternal age, and smoking, are priorities for stillbirth prevention in high-income countries. The Stillbirth Foundation Australia, the Department of Health and Ageing, Canberra, Australia, and the Mater Foundation, Brisbane, Australia.

Prevention of cardiovascular disease. Of what value are risk factor modification, exercise, fish consumption, and aspirin therapy?

PreviewAlthough on the decline, cardiovascular disease remains a major present and future threat to health in the United States. Family physicians, internists, and cardiologists face the dual challenge of impeding its progression and preventing its development. Intervention in modifiable risk factors, regular exercise, increased fish consumption, and daily aspirin therapy may each have an important role to play. In this article, Dr Lavie and coauthors discuss in detail the possible benefits of each.