Nutrition Examination Survey-III Research Articles

Do we underestimate risk of cardiovascular mortality due to lead exposure?

BackgroundStudies using data from the National Health and Nutrition Examination Survey-III (NHANES-III) have demonstrated significant prospective associations between blood lead levels and increased mortality. Bone lead represents cumulative lead burden and thus is a better biomarker for assessing chronic impacts, but its in vivo assessment requires special K-x-ray fluorescence (KXRF) instrumentation. Our team recently developed an algorithm predicting bone lead levels from a combination of blood lead levels, age and other socioeconomic and behavioral variables. We examined the associations of our algorithm-estimated bone lead levels and mortality in NHANES-III. MethodsWe included 11,628 adults followed up to December 31, 2019. Estimated tibia lead and patella lead levels were calculated using our prediction algorithms. We used survey-weighted Cox proportional hazards models to compute hazard ratios (HRs) and 95 % confidence intervals (CIs). ResultsDuring the median follow-up of 26.8 years, 4900 participants died (mortality rate = 1398 per 100,000 adults/year). Geometric means (95 % CIs) of blood lead, predicted tibia lead, and predicted patella lead were 2.69 μg/dL (2.54, 2.84), 6.73 μg/g (6.22, 7.25), and 16.3 μg/g (15.9, 16.8), respectively. The associations for all-cause mortality were similar between blood lead and bone lead. However, the associations for cardiovascular mortality were much greater with predicted bone lead markers compared to blood lead: for comparing participants at the 90th vs. 10th percentiles of exposure, HR = 3.32 (95 % CI: 1.93–5.73) for tibia lead, 2.42 (1.56–3.76) for patella lead, 1.63 (1.25–2.14) for blood lead. The population attributable fractions for cardiovascular disease mortality if everyone's lead concentrations were declined to the 10th percentiles were 45.8 % (95 % CI: 28.1–59.4) for tibia lead, 33.1 % (18.1–45.8) for patella lead, and 22.8 % (10.4–33.8) for blood lead. ConclusionsThese findings suggest that risk assessment for cardiovascular mortality based on blood lead levels may underestimate the true mortality risk of lead exposure.

Do We Underestimate Risk of Mortality due to Lead Exposure?

Background/Aim: Studies using data from the National Health and Nutrition Examination Survey-III (NHANES-III) have demonstrated significant associations between blood lead levels and increased mortality. However, blood lead reflects primarily recent exposure and lead mobilized from internal organs. Bone lead represents cumulative lead burden and thus is a better biomarker for assessing chronic impacts, but its in vivo assessment requires special K-x-ray fluorescence (KXRF) instrumentation. Our team used KXRF measurements of lead in bone and blood lead levels in participants of the Normative Aging Study to develop an algorithm predicting bone lead levels from a combination of blood lead levels and standard biochemical, hematologic, and questionnaire data. We examined the associations of our algorithm-estimated bone lead levels and mortality in NHANES-III.Methods: We included 11,065 adults followed up to December 31, 2015. Estimated tibia and patella bone lead levels were calculated using our prediction algorithm. We used survey-weighted Cox proportional hazards models to compute hazard ratios (HRs) and 95% confidence intervals (CIs).Results: During the median follow-up of 22.4 years (216,565 person-years), 4,103 participants died (mortality rate=1,895 per 100,000 adults/year). Means (95% CIs) of blood lead, tibia lead, and patella lead were 3.47 μg/dL (3.27-2.67), 2.98 μg/g (2.23-3.75), and 3.04 μg/g (1.94-4.14), respectively. After adjustment for potential confounders, the HRs comparing participants at the 90th vs. 10th percentiles of exposure with regards to all-cause mortality were 1.25 (95% CI: 1.05-1.50) for blood lead, 1.91 (1.36-2.68) for tibia lead, 2.00 (1.45-2.77) for patella lead; for CVD mortality, 1.67 (1.20-2.34) for blood lead, 1.89 (0.98-3.67) for tibia lead, 2.24 (1.26-4.00) for patella lead; and for cancer mortality, 1.35 (0.98-1.84) for blood lead, 2.52 (1.30-4.90) for tibia lead, 2.45 (1.29-4.66) for patella lead.Conclusions: These findings suggest that risk assessment based on blood lead levels may underestimate the true mortality risk of lead exposure.

1432-P: Association between Insulin Use and Long-Term Cardiovascular Disease Outcomes in Older Adults

Introduction: Exogenous insulin therapy has been the mainstay of treatment for those with uncontrolled type 2 diabetes; however, recent literature has pointed to a lack of risk reduction for cardiovascular disease (CVD). We sought to determine the association between insulin use and major adverse cardiovascular events (MACE) among older adults with type 2 diabetes with a long-term follow-up. Methods: A cohort of 1,084 participants >50 years with type 2 diabetes from the National Health and Nutrition Examination Survey-III (1988-1994) was followed for an average 22.4 years through 2015. Subjects were divided into two groups: 1) those using insulin therapy and 2) those using oral medications only. The primary outcome was major adverse cardiovascular events (MACE), a combination of self-reported myocardial infarction, stroke, or CVD mortality. We used multivariable logistic regression, adjusting for HbA1c, demographic, metabolic, and inflammatory factors and accounting for the survey design. Results: Among the participants, 227 (21%) regularly used insulin. Those using insulin were of similar age, more likely to be male, have similar BMI, waist circumference, blood pressure, and lipids, have higher HbA1c (8.2% vs. 7.3%, p<0.01), and have significantly higher serum insulin levels (mean[SD]: 51.1[4.2] vs. 18.5[0.7], p<0.001). Those taking insulin had nearly twice the adjusted odds of MACE relative to those only taking oral agents (aOR [95% CI]: 1.89 [1.11, 3.24]). When assessing individual conditions, those taking insulin had significantly increased odds of stroke, but not MI or CVD mortality (aOR [95% CI]: stroke = 3.69 [1.26, 10.78], MI = 1.41 [0.75, 2.65], CVD mortality = 1.19 [0.69, 2.06]). There was no significant dose-dependent association between insulin use and MACE. Conclusion: Long-term insulin use may be associated with increased stroke, although no dose-dependent association was present. Increased care and assessment may be warranted in patients taking insulin. Disclosure A. Visaria: None. T. Dharamdasani: None. K. Wickramasinghe: None. D. Lo: None. R. Malhotra: None.

Association of Parity in Patients with Chronic Liver Disease

Introduction and aim. The impact of type of liver disease on parity rates hasn’t been described. Our aim was to assess the parity rates among women with CLD.Material and methods. The National Health and Nutrition Examination Survey-III (19881994) data were used to identify adult female participants with a diagnosis of CLD. Participants were asked about their reproductive health status. Parity was defined as having at least one live birth. Hepatic ultrasound, serologic, medical examination and clinical data were available to determine the presence and type of CLD. Body mass index (kg/m2) was divided into 3 categories (< 30; 3035; 36+).Results. A total of 3,502 (865 NAFLD, 737 other CLD, 1,901 control) subjects were included. Patients with NAFLD were more likely to have at least one live birth than patients with other CLD and controls (77% in NAFLD vs. 72% in controls). Multivariate analysis revealed that presence of CLD other than NAFLD (OR: 0.46 [95% CI, 0.34-0.63]) and having a college or higher degree (OR: 0.48 [95% CI, 0.34-0.68]) were negatively associated while having low income (OR: 11.06 [95% CI, 6.86-17.82]) and being African American (OR: 3.93 [95% CI, 2.59-5.98]) were positively associated with having at least one live birth.Conclusions. This study revealed that patients with CLD other than NAFLD were less likely to have at least one live birth. NAFLD and obesity were associated with higher rates of live births which can potentially be explained by weight gain post live birth leading to obesity and its associated-NAFLD.

The impact of parental history on children's risk of asthma: a study based on the National Health and Nutrition Examination Survey-III.

PurposeThis study aimed to examine the separate effects of maternal and paternal history on the onset of asthma in children and evaluate the relationship between age of asthma onset in parents and risk of asthma in their children.MethodsWe used data from the third National Health and Nutrition Examination Survey. We developed new continuous standardized scores for survey data to quantify parental history that incorporated both the occurrence of asthma and the age at onset, and associated these scores with asthma risk in the children. The association analysis was adjusted for sex and obesity status.ResultsChildren with maternal history have elevated asthma risk (hazard ratio of 3.71, 95% CI: 1.19–11.60) than those without, and those whose mothers had earlier age of onset have increased risk of asthma compared to those whose mothers had later age of onset. On the contrary, paternal history had a relatively smaller effect that may be only detectable in larger samples (hazard ratio of 2.17, 95% CI: 0.69–6.79).ConclusionMaternal asthma history was strongly associated with the onset of asthma in the second generation, and children whose mother had an earlier age of onset had an increased risk of 3.71. For an approximately 10-year decrease in mother’s age at onset of asthma, the risk of asthma for the offspring increased by 1.37-fold. Using our new risk scores led to smaller standard errors and thus more precise estimates than using a binary indicator.

Association between neutrophil to lymphocyte ratio and atrial fibrillation

Neutrophil to lymphocyte ratio (NLR) is a ratio of subtypes of leukocyte and has been attracting attention as a significant biomarker of systemic inflammation [ [1] de Jager C.P. van Wijk P.T. Mathoera R.B. de Jongh-Leuvenink J. van der Poll T. Wever P.C. Lymphocytopenia and neutrophil–lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit. Crit. Care. 2010; 14 (England): R192 Crossref PubMed Scopus (369) Google Scholar ]. Inflammation has a significant role in atherosclerosis [ [2] Ross R. Atherosclerosis — an inflammatory disease. N. Engl. J. Med. 1999; 340: 115 Crossref PubMed Scopus (19066) Google Scholar ]. NLR has been shown to be related to adverse outcomes in patients with coronary heart disease (CHD) [ 3 Nunez J. Nunez E. Bodi V. Sanchis J. Minana G. Mainar L. et al. Usefulness of the neutrophil to lymphocyte ratio in predicting long-term mortality in ST segment elevation myocardial infarction. Am. J. Cardiol. 2008; 101 (United States): 747-752 Abstract Full Text Full Text PDF PubMed Scopus (360) Google Scholar , 4 Azab B. Zaher M. Weiserbs K.F. Torbey E. Lacossiere K. Gaddam S. et al. Usefulness of neutrophil to lymphocyte ratio in predicting short- and long-term mortality after non-ST-elevation myocardial infarction. Am. J. Cardiol. 2010; 106 (United States): 470-476 Abstract Full Text Full Text PDF PubMed Scopus (329) Google Scholar , 5 Tamhane U.U. Aneja S. Montgomery D. Rogers E.K. Eagle K.A. Gurm H.S. Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome. Am. J. Cardiol. 2008; 102 (United States): 653-657 Abstract Full Text Full Text PDF PubMed Scopus (605) Google Scholar , 6 Papa A. Emdin M. Passino C. Michelassi C. Battaglia D. Cocci F. Predictive value of elevated neutrophil–lymphocyte ratio on cardiac mortality in patients with stable coronary artery disease. Clin. Chim. Acta. 2008; 395 (Netherlands): 27-31 Crossref PubMed Scopus (272) Google Scholar , 7 Kaya M.G. Akpek M. Lam Y.Y. Yarlioglues M. Celik T. Gunebakmaz O. et al. Prognostic value of neutrophil/lymphocyte ratio in patients with ST-elevated myocardial infarction undergoing primary coronary intervention: a prospective, multicenter study. Int. J. Cardiol. 2013; 168 (Netherlands): 1154-1159 Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar , 8 Balta S. Demirkol S. Aparci M. Celik T. Ozturk C. The neutrophil lymphocyte ratio in coronary heart disease. Int. J. Cardiol. 2014; 176 (Netherlands): 267 Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar , 9 Shah N. Parikh V. Patel N. Patel N. Badheka A. Deshmukh A. et al. Neutrophil lymphocyte ratio significantly improves the Framingham risk score in prediction of coronary heart disease mortality: insights from the National Health and Nutrition Examination Survey-III. Int. J. Cardiol. 2014; 171: 390-397 Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar ] and can independently predict mortality of CHD in an asymptomatic population [ [9] Shah N. Parikh V. Patel N. Patel N. Badheka A. Deshmukh A. et al. Neutrophil lymphocyte ratio significantly improves the Framingham risk score in prediction of coronary heart disease mortality: insights from the National Health and Nutrition Examination Survey-III. Int. J. Cardiol. 2014; 171: 390-397 Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar ]. Atrial fibrillation (AF) is one of the most common cardiac arrhythmias and increases the risk of stroke and death. Inflammation, which is related to the initiation and maintenance of AF, plays a key role in AF [ 10 Aviles R.J. Martin D.O. Apperson-Hansen C. Houghtaling P.L. Rautaharju P. Kronmal R.A. et al. Inflammation as a risk factor for atrial fibrillation. Circulation. 2003; 108: 3006-3010 Crossref PubMed Scopus (1131) Google Scholar , 11 Aronson D. Boulos M. Suleiman A. Bidoosi S. Agmon Y. Kapeliovich M. et al. Relation of C-reactive protein and new-onset atrial fibrillation in patients with acute myocardial infarction. Am. J. Cardiol. 2007; 100 (United States): 753-757 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar , 12 Chung M.K. Martin D.O. Sprecher D. Wazni O. Kanderian A. Carnes C.A. et al. C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation. Circulation. 2001; 104 (United States): 2886-2891 Crossref PubMed Scopus (1130) Google Scholar ]. However, little is known about the association between NLR levels and AF.

Major electrocardiographic abnormalities and 25-hydroxy vitamin D deficiency: insights from National Health and Nutrition Examination Survey-III.

We explored the relationship between major electrocardiogram (ECG) abnormalities (mECG) and 25-hydroxy (25-OH) vitamin D deficiency (VDD) and the effect of mECG abnormalities on all-cause and cardiovascular mortality in a healthy cohort with 25-OH vitamin D insufficiency and deficiency. Lower levels of serum 25-OH vitamin D are associated with increased prevalence of mECG on resting ECG. We identified 5108 individuals from the National Health and Nutrition Examination Survey-III. mECG abnormalities included: major Q-QS wave abnormalities, ST depression/elevation, negative T waves, Wolff-Parkinson-White pattern, and ventricular conduction defect. Our cohort was divided into 3 groups based on 25-OH vitamin D levels: Group 1 (referent): > 40 ng/mL; group 2 (insufficient): ≥ 20.01 to ≤ 40 ng/mL; and group 3 (deficient): ≤ 20 ng/mL. Logistic regression and Cox proportional hazards regression models were built. The prevalence of major ECG abnormalities across 25-OH vitamin D sufficiency, insufficiency, and deficiency was .9%, 11%, and 13 %, respectively (P = 0.01). VDD was an independent predictor of mECG abnormalities after adjusting for traditional risk factors (continuous variable odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.97-0.99, P = 0.007; categorical variable group 3 vs group 1 OR: 2.36, 95% CI: 1.1-5.12, P = 0.03). Baseline major ECG abnormalities were predictive of long-term all-cause (hazard ratio [HR]:1.52, 95% CI: 1.23-1.89), composite cardiovascular (HR: 1.7, 95% CI: 1.34-2.15), cardiovascular (HR: 1.64, 95% CI: 1.27-2.12), and ischemic heart disease mortality (HR: 1.98, 95% CI: 1.46-2.69) in individuals with 25-OH vitamin D levels ≤ 40 ng/mL. VDD is associated with increased prevalence of major ECG abnormalities. Well-structured trials are needed to assess progression/resolution of mECG abnormalities with vitamin D supplementation in deficient individuals.

Neutrophil lymphocyte ratio significantly improves the Framingham risk score in prediction of coronary heart disease mortality: Insights from the National Health and Nutrition Examination Survey-III

BackgroundNeutrophil lymphocyte ratio (NLR) has been shown to predict cardiovascular events in several studies. We sought to study if NLR predicts coronary heart disease (CHD) in a healthy US cohort and if it reclassifies the traditional Framingham risk score (FRS) model. MethodsWe performed post hoc analysis of National Health and Nutrition Examination Survey-III (1998–94) including subjects aged 30–79years free from CHD or CHD equivalent at baseline. Primary endpoint was death from ischemic heart disease. NLR was divided into four categories: <1.5, ≥1.5 to <3.0, 3.0–4.5 and >4.5. Statistical analyses involved multivariate Cox proportional hazards models as well as discrimination, calibration and reclassification. ResultsWe included 7363 subjects with a mean follow up of 14.1years. There were 231 (3.1%) CHD deaths, more in those with NLR>4.5 (11%) compared to NLR<1.5 (2.4%), p<0.001. Adjusted hazard ratio of NLR>4.5 was 2.68 (95% CI 1.07–6.72, p=0.035). There was no significant improvement in C-index (0.8709 to 0.8713) or area under curve (0.8520 to 0.8531) with addition of NLR to FRS model. Model with NLR was well calibrated with Hosmer–Lemeshow chi-square of 8.57 (p=0.38). Overall net reclassification index (NRI) was 6.6% (p=0.003) with intermediate NRI of 10.1% (p<0.001) and net upward reclassification of 5.6%. Absolute integrated discrimination index (IDI) was 0.003 (p=0.039) with relative IDI of 4.3%. ConclusionsNLR can independently predict CHD mortality in an asymptomatic general population cohort. It reclassifies intermediate risk category of FRS, with significant upward reclassification. NLR should be considered as an inflammatory biomarker of CHD.

ST-T Wave Abnormality in Lead aVR and Reclassification of Cardiovascular Risk (from the National Health and Nutrition Examination Survey-III)

Electrocardiographic lead aVR is often ignored in clinical practice. The aim of this study was to investigate whether ST-T wave amplitude in lead aVR predicts cardiovascular (CV) mortality and if this variable adds value to a traditional risk prediction model. A total of 7,928 participants enrolled in the National Health and Nutrition Examination Survey (NHANES) III with electrocardiographic data available were included. Each participant had 13.5 ± 3.8 years of follow-up. The study sample was stratified according to ST-segment amplitude and T-wave amplitude in lead aVR. ST-segment elevation (>8 μV) in lead aVR was predictive of CV mortality in the multivariate analysis when not accounting for T-wave amplitude. The finding lost significance after including T-wave amplitude in the model. A positive T wave in lead aVR (>0 mV) was the strongest multivariate predictor of CV mortality (hazard ratio 3.37, p <0.01). The addition of T-wave amplitude in lead aVR to the Framingham risk score led to a net reclassification improvement of 2.7% of subjects with CV events and 2.3% of subjects with no events (p <0.01). Furthermore, in the intermediate-risk category, 20.0% of the subjects in the CV event group and 9.1% of subjects in the no-event group were appropriately reclassified. The absolute integrated discrimination improvement was 0.012 (p <0.01), and the relative integrated discrimination improvement was 11%. In conclusion, T-wave amplitude in lead aVR independently predicts CV mortality in a cross-sectional United States population. Adding T-wave abnormalities in lead aVR to the Framingham risk score improves model discrimination and calibration with better reclassification of intermediate-risk subjects.

Electrocardiographic Abnormalities and Reclassification of Cardiovascular Risk: Insights from NHANES-III

BackgroundWe aimed to assess the additive value of electrocardiogram (ECG) findings to risk prediction models for cardiovascular disease. MethodsOur dataset consisted of 6025 individuals with ECG data available from the National Health and Nutrition Examination Survey-III. This is a self-weighting sample with a follow-up of 79,046.84 person-years. The primary outcomes were cardiovascular mortality and all-cause mortality. We compared 2 models: Framingham Risk Score (FRS) covariates (Model A) and ECG abnormalities added to Model A (Model B), and calculated the net reclassification improvement index (NRI). ResultsMean age of our study population was 58.7 years; 45.6% were male and 91.7% were white. At baseline, 54.6% of individuals had ECG abnormalities, of which 545 (9%) died secondary to a cardiovascular event, compared with 194 individuals (3.2%) (P <.01) without ECG abnormalities. ECG abnormalities were significant predictors of cardiovascular mortality after adjusting for traditional cardiovascular risk factors (hazard ratio 1.44; 95% confidence interval, 1.13-1.83). Addition of ECG abnormalities led to an overall NRI of 3.6% subjects (P <.001) and 13.24% in the intermediate risk category. The absolute integrated discrimination index was 0.0001 (P <.001). ConclusionElectrocardiographic abnormalities are independent predictors of cardiovascular mortality, and their addition to the FRS improves model discrimination and calibration. Further studies are needed to assess the prospective application of ECG abnormalities in cardiovascular risk prediction in individual subjects.

In patients with non-alcoholic fatty liver disease, metabolically abnormal individuals are at a higher risk for mortality while metabolically normal individuals are not

Background and AimNon-alcoholic fatty liver disease (NAFLD) is a common cause of chronic liver disease and is strongly associated with metabolic syndrome. The aim of this study is to compare the clinical profile and long-term outcome in NAFLD patients with or without metabolic syndrome. MethodsThe initial cohort (N=6709) was identified from National Health and Nutrition Examination Survey-III (NHANES III, 1988–94) data. Laboratory profiles, body measurement examinations, and mortality data were linked to self-reported questionnaires of demographic and health risk information. NAFLD was defined as significant steatosis on hepatic ultrasound after exclusion of other chronic liver diseases (N=1448). NAFLD patients were classified according to presence or absence of metabolic syndrome. Mortality was determined through December 31, 2006. Cox models were used to estimate hazard ratios and 95% confidence intervals for all-cause, cardiovascular and liver-specific mortality differences between two sub-cohorts of NAFLD with and without metabolic syndrome. ResultsNAFLD participants with metabolic syndrome were more likely to be Non-Hispanic white, older, and have higher aminotransferase levels. All-cause mortality (P<.001) and cardiovascular mortality (P<.001) were higher in NAFLD patients with metabolic syndrome. Furthermore, the presence of metabolic syndrome was independently associated with overall mortality, liver-specific mortality, and cardiovascular mortality. Age was an independent predictor of both all-cause and cardiovascular mortality. Elevated liver enzymes and obesity were two other independent predictors of liver-specific mortality. There were no differences in all-cause, liver-related, or cardiovascular mortality between groups of individuals without liver disease and individuals with NAFLD without metabolic syndrome (metabolically-normal). ConclusionsDiagnosis of NAFLD with metabolic syndrome is an independent predictor of all-cause, liver-specific, and cardiovascular mortality. In contrast, mortality of metabolically-normal NAFLD patients is similar to the cohort without liver disease.

Cognitive Function and the Risk of Death in Chronic Kidney Disease

Background and Aims: Cognitive impairment is a risk factor for death in dialysis patients and the general population. We sought to determine if cognitive impairment is associated with death in people with non-dialysis-dependent chronic kidney disease (CKD), and if so, whether this relationship is greater in the CKD population compared to the general population. Methods: National Health and Nutrition Examination Survey-III participants older than 60 years were asked to subtract 3 from 20 five times and to perform immediate and delayed recall of three items. A cognitive score of 0–11 was assigned based on the number of correct responses. Participants were categorized according to cognitive score (11, 9–10, 6–9, and 0–5) and CKD status. Survival analyses were conducted using Cox models. Results: Within the CKD subpopulation, those in the lowest cognitive score group had a twofold increased hazard of death compared to those with maximum score. Within the non-CKD subpopulation, those in the lowest cognitive score group had a 46% increased hazard of death compared to those with maximum score. However, the difference in the hazards of death in the CKD and non-CKD subpopulations with the lowest cognitive score was not significant (p = 0.99). Conclusions: Low cognitive score is associated with an increased risk of death in elderly individuals with and without CKD; however, there was no interaction of CKD and low cognitive score in this analysis.

Diminishing efficacy of combination therapy, response-heterogeneity, and treatment intolerance limit the attainability of tight risk factor control in patients with diabetes.

To evaluate the attainability of tight risk factor control targets for three diabetes risk factors and to assess the degree of polypharmacy required. National Health and Nutrition Examination Survey-III. We simulated a strategy of "treating to targets," exposing subjects to a battery of treatments until low-density lipoprotein (LDL)-cholesterol (100 mg/dL), hemoglobin A1c (7 percent), and blood pressure (130/80 mm Hg) targets were achieved or until all treatments had been exhausted. Regimens included five statins of increasing potency, four A1c-lowering therapies, and eight steps of antihypertensive therapy. We selected parameter estimates from placebo-controlled trials and meta-analyses. Under ideal efficacy conditions, 77, 64, and 58 percent of subjects achieved the LDL, A1c, and blood pressure targets, respectively. Successful control depended highly on a subject's baseline number of treatments. Using the least favorable assumptions of treatment tolerance, success rates were 11-17 percentage points lower. Approximately 57 percent of subjects required five or more medication classes. A significant proportion of people with diabetes will fail to achieve targets despite using high doses of multiple, conventional treatments. These findings raise concerns about the feasibility and polypharmacy burden needed for tight risk factor control, and the use of measures of tight control to assess the quality of care for diabetes.

Racial/ethnic variations in associations between socioeconomic factors and tooth loss

To compare the associations between socioeconomic factors and tooth loss among White, Black, and Mexican-American people. Analyses were conducted on 16,821 adults, using data from the National Health and Nutrition Examination Survey-III. Age- and multivariate-adjusted negative binomial regressions were used to explore the relation of socioeconomic factors, region of residence, gender, and foreign birth with the number of missing teeth. Effect modification by race/ethnicity was assessed by the inclusion of interaction terms. In multivariate-adjusted analyses, non-Hispanic White people with 9-12 years of education exhibited 71% higher mean number of missing teeth than those with >12 years of education [incidence rate ratio (IRR) = 1.71, 95% confidence interval (CI): 1.52-1.92]. Education was unrelated to the number of teeth among non-Hispanic Black people (IRR = 1.16; 95% CI: 1.00-1.35) or Mexican-Americans (IRR = 1.10, 95% CI: 0.93-1.31). The poorest White people exhibited 39% more missing teeth, on average, than the most affluent White people, but no association between poverty and number of teeth was observed among Black or Mexican-American people. The associations between socioeconomic factors and tooth loss vary across race/ethnicity. This suggests that the health benefits associated with high socioeconomic status are not equally shared across racial/ethnic groups.