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Social and Biological Determinants of Blood Pressure in Afro-Caribbean Youth

Social and Biological Determinants of Blood Pressure in Afro-Caribbean Youth. Trevor S Ferguson, MBBS, DM, MSc, FACP Senior Lecturer (Epidemiology), Caribbean Institute for Health Research, UWI Honorary Consultant (General Internal Medicine), UHWI Caribbean Institute of Nephrology

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Social and Biological Determinants of Blood Pressure in Afro-Caribbean Youth

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  1. Social and Biological Determinants of Blood Pressure in Afro-Caribbean Youth Trevor S Ferguson, MBBS, DM, MSc, FACP Senior Lecturer (Epidemiology), Caribbean Institute for Health Research, UWI Honorary Consultant (General Internal Medicine), UHWI Caribbean Institute of Nephrology 10th Annual International Conference on Nephrology and Hypertension January 19 & 20, 2018

  2. GLOBAL BURDEN OF HYPERTENSION Source: A Global Brief on Hypertension. WHO/DCO/WHD/2013.2 WHO Global Health Observatory (Blood Pressure) http://www.who.int/gho/ncd/risk_factors/blood_pressure_text/en/ Hypertension is a global public problem causing ≈ 9.4 million deaths worldwide every year Causes at least 45% of deaths from heart disease and 51% of stroke deaths Globally, the overall prevalence of HTN in adults aged ≥18 yrswas around 22% in 2014 Prevalence was highest in Africa - 30% and lowest prevalence was in the Americas - 18% Prevalence is higher in low income countries

  3. MALES Jamaica = 24.5% Source: Global Status Report On Noncommunicable Diseases 2014

  4. FEMALES Jamaica = 19.2% Source: Global Status Report On Noncommunicable Diseases 2014

  5. Prevalence of hypertension by world regions in 1975-2015 • Overall prevalence of HTN decreasing • But # of adults with HTN  from 594 M in 1975 – 1.13 B in 2015 •  seen in high income and some middle income countries but unchanged in other regions • Some evidence for  prevalence in Sub-Saharan Africa and Southeast Asia Source: NCD Risk Factor Collaboration. Worldwide trends in blood pressure from 1975 to 2015; The Lancet; 2016. http://dx.doi.org/10.1016/S0140-6736(16)31919-5

  6. Hypertension is the leading risk factor for global disease burden Figure shows the burden of disease attributable to 20 leading risk factors in 2010, expressed as percent of global DALYs Hypertension accounted for 7% of global DALYs Source: The Lancet 2012; 380:2224-2260 (DOI:10.1016/S0140-6736(12)61766-8)

  7. Hypertension is a major cause of mortality in the Caribbean Leading causes of death in Jamaica and CAREC member countries in 2004 • Hypertensive diseases - 4th leading cause of death • Also major contributor to stroke & IHD deaths Ferguson & Tulloch-Reid. Curr Cardio Risk Rep (2010) 4:76–82

  8. Definition & Classification of High BP JNC 7 (2003) ACC/AHA 2017

  9. Hypertension Prevalence in Jamaica *Self-reports • Figueroa et al. West Indian Med J 1999; 48 (I): 9 -15 • Ferguson et al. West Indian Med J. 2011 Jul;60(4):422-8.

  10. Prehypertension in Jamaica Ferguson et al. BMC Cardiovascular Disorders 2008, 8:20 Ferguson et al. West Indian Med J 2011; 60 (4): 429 30% in JHLS-1 35% in JHLS-2 29% among youth 15-19 years old in JYRRBS 20% among young adults 18-20 years on in 1986 Birth Cohort Prevalence higher in men compared to women

  11. Consequences of hypertension Mortality– acute myocardial infarction, heart failure, ischaemic and haemorrhagic stroke, end stage renal disease Morbidity – ischaemic heart disease, hypertensive heart disease, non-fatal stroke, chronic kidney disease Social and economic – high health care costs, especially for treating complications; lost of income; increased dependency

  12. Aetiology of Hypertension

  13. Risk / Causal Factors in HypertensionMultifactorial Life Course Model Parental SES, Neighbourhood SES, Own SES, Environmental exposures Social factors across the life course Adult Blood Pressure Genetic & non-modifiable risk factors Intrauterine growth & early life factors Adult characteristics & behaviours Childhood growth • Body size & adiposity • Insulin resistance • Salt intake • Nutrition • Physical Inactivity • Alcohol consumption • Smoking • Stress • Single gene mutations • Familial genetic factors • Sex • Age • Race/Ethnicity • Maternal nutrition • Fetal nutrition • Fetal growth • Birth size • Prematurity • Rapid catch up growth • Childhood obesity and weight gain

  14. Early life influences on Hypertension

  15. Early life origins of chronic disease Early life factors are now recognised as important predictors of hypertension and other NCDs in adults Barker et al demonstrated an inverse relationship between measures of intra-uterine growth (chiefly birth weight) CVD, type 2 diabetes and dyslipidemia Initial studies focused on middle age and older adults in developed countries, but similar findings have now been replicated in several counties

  16. Early life origins of hypertension Early life influences identified include: Intrauterine growth Placental size Infant and postnatal growth Perinatal socioeconomic factors

  17. Birth weight and hypertension Data from Helsinki Birth Cohort – included 2003 persons examined at 62 years Eriksson et al. Childhood Growth and Hypertension in Later Life. Hypertension. 2007;49:1415-1421

  18. Parental social class and hypertension Data from Helsinki Birth Cohort – included 2003 persons examined at 62 years Barker et al. Maternal and Social Origins of Hypertension Hypertension. 2007;50:565-571

  19. Low Birth weight and subsequent blood pressure: a meta-analysis (OR for HTN for LBW vs. NBW) • Odds of hypertension was increased by 21% for persons with LBW compared to persons with NBW • Mean SBP was on average 2.3 mmHg higher among persons with LBW compared to those with NBW Mu et al. Archives of Cardiovascular Disease (2012) 105, 99—113

  20. Early life origins of hypertension: Studies from Jamaica • Previous studies examined associations between blood pressure and birth weight and other early life factors • Fetal growth and cardiovascular risk in Jamaican school children 6-16 years – Forrester et al BMJ 1996 • Birth weight and postnatal linear growth retardation on blood pressure at 11-12 years – Walker et al JECH 2001 • Limited data on the effect of early life or life-course factors in older adolescents or adults

  21. Social Determinants of Hypertension

  22. Socioeconomic status and hypertension Source: Leng et al. Socioeconomic status and hypertension: a meta-analysis; J Hypertens 33:221–229. DOI:10.1097/HJH.0000000000000428 • Several studies have documented associations between HTN and SES or other social factors, including neighbourhood characteristics • Recent meta-analysis of 51 studies published in 2015 • Overall increased risk of HTN with lower SES • Income - pooled OR 1.19, 95% CI 0.96–1.48 • Occupation - pooled OR 1.31, 95% CI 1.04–1.64 • Education - pooled OR 2.02, 95% CI 1.55–2.63 • Associations were significant in high-income countries • Association more consistent among women

  23. Knowledge Gaps Most studies done in developed countries Limited data for developing countries and for African origin populations Limited data for young adults

  24. Manuscript Series by ERU team Early life predictors of blood pressure in Afro-Caribbean young adults: the Jamaica 1986 Birth Cohort Study Effect of growth velocity and change in adiposity in childhood and adolescence on blood pressure in Afro-Caribbean youth: the Vulnerable Windows Cohort Study Factors associated with elevated blood pressure or hypertension in Afro-Caribbean youth

  25. Paper - 1: Early Life Social and Biological Determinants of Blood Pressure at 18-20 years old: The Jamaica 1986 Birth Cohort Study

  26. The 1986 Jamaica Birth Cohort Assembled from a subgroup of participants in the 1986 Jamaica Perinatal Mortality Survey Original survey enrolled consecutive births in all fourteen parishes in Jamaica during Sept – Oct 1986 Birth Cohort - sub-sample of participants from the parishes of Kingston and St. Andrew, and St. Catherine Last follow up - 902 participants enrolled; 794 participants included in analyses on birth weight and blood pressure

  27. Paper 1 - Objective To investigate how birth weight, parental socioeconomic circumstances (SEC), current SEC, and current body size, influence blood pressure in young adults at 18-20 years old

  28. Proportion (%) of male and female infants in 500 g birth weight categories

  29. Relationship between systolic blood pressure, birth weight and other characteristics in multi-level regression models2 1Coefficients represent change in systolic or diastolic blood pressure (mmHg) for each unit change in the various characteristics. 2Cluster variable for multilevel model was place of birth (29 clusters, usually a hospital or maternity centre) * p<0.05; ** p<0.01; *** p<0.001; BMI = body mass index Ferguson et al. (2015) Birth weight and maternal socioeconomic circumstances were inversely related to systolic blood pressure among Afro-Caribbean young adults. J ClinEpidemiol. 2015 Feb 12. doi: 10.1016/j.jclinepi.2015.01.026.

  30. Predicted systolic blood pressure by birth weight and mothers occupation category Male Female skilled/highly skilled semi-skilled/unskilled unemployed housewife Ferguson et al. (2015) Birth weight and maternal socioeconomic circumstances were inversely related to systolic blood pressure among Afro-Caribbean young adults. J ClinEpidemiol. 2015 Feb 12. doi: 10.1016/j.jclinepi.2015.01.026.

  31. CONCLUSIONS FROM PAPER 1 Intrauterine growth and early life SEC are important predictors of blood pressure in young adults Early life factors should be considered in the development of policies and interventions to reduce the burden of HTN and other NCDs

  32. Paper 2 Effect of linear growth rate and change in adiposity in childhood and adolescence on blood pressure in Afro-Caribbean youth Trevor Ferguson, Tamika Royal-Thomas, Lisa Chin-Harty, Minerva Thame, Terrence Forrester, Michael Boyne, Rainford Wilks Caribbean Institute for Health Research, The University of the West Indies, Jamaica Department of Medicine, The University of the West Indies, Jamaica Department of Child and Adolescent Health, The University of the West Indies, Jamaica UWI Solutions for Developing Countries, The University of the West Indies, Jamaica DOHAD Conference October 17, 2017

  33. Objectives To evaluate the effect of postnatal linear growth and change in body mass index from birth to adolescence on systolic and diastolic blood pressure in Afro-Caribbean youth

  34. Methods Participants from Vulnerable Windows Cohort Study in Jamaica Mothers recruited during 1st trimester of pregnancy in 1992 and 1993; children (singleton only) followed from birth at regular intervals (6 wks; 3mths; q3mths – 2yrs; then q6mths) This analysis included 366 persons age 15 years or older Growth and adiposity measurements calculated for four growth periods: early infancy (0-6 months), late infancy (6 months - 2 years), early childhood (2-8 years), and late childhood (8-15 years)

  35. Methods Growth rates were computed using conditional models which calculated how much body size at the end of a growth period differed from that predicted by the body size at the beginning of the period Calculated growth rates were standardized by converting them to z-scores Linear mixed models were used to estimate the effect of growth rates on SBP and DBP

  36. Participants and measurements Analyses included 162 males and 204 females Mean age 16.7 years (range 15.0, 21.2 years).  Each individual had on average 5.2 BP measurements (range 1-10)

  37. Final multivariable model with regression coefficients for the effect of linear growth on systolic BP at age ≥15 years

  38. Final multivariable model with regression coefficients for the effect of change in BMI on systolic BP at age ≥15 years

  39. Results for Diastolic BP Findings were generally similar for diastolic blood pressure, but were smaller in magnitude

  40. Conclusion Both faster linear growth and greater rate of increase in BMI were associated with higher BP Associations were stronger and more consistent for increase in BMI Findings suggest that postnatal growth trajectories should be closely monitored and faster than expected gain in adiposity should be discouraged

  41. Factors associated with elevated blood pressure or hypertension in Afro-Caribbean youth: a cross-sectional study Paper 3 Under review at PeerJ

  42. Paper 3 - Objectives • To evaluate the association between putative risk factors and elevated BP or hypertension (EBP/HTN), defined as BP ≥120/80 mmHg, among Afro-Caribbean youth. • To estimate the relative risk for having EBP/HTN among participants with putative CVD risk factors • To evaluate whether there were significant sex differences in risk factors for EBP/HTN

  43. Paper 3 - Methods Cross-sectional analysis from Jamaica 1986 Birth Cohort 898 young adults, 18-20 years old BP was measured with a mercury sphygmomanometer after participants had been seated for 5 min. Anthropometric measurements were done and venous blood obtained to measure fasting glucose, lipids and insulin.

  44. Paper 3 - Methods Data on socioeconomic status (SES) were obtained via questionnaire. CVD risk factor status was defined using standard cut-points or the upper quintile of the distribution. Relative risks were computed using odds ratios (OR) from logistic regression models. Multiple imputation by chained equations used to fill in missing values

  45. Distribution of BP Categories by 2017 ACC/AHA Criteria Prevalence HTN: Males 17% males; 8% females P<0.001 for male: female difference

  46. Prevalence of Elevated BP or HypertensionSBP ≥120 mmHg or DBP ≥80 mmHg

  47. Factors associated with elevated BP or HTN among MALES in multivariable logistic regression models Estimates derived from sex-specific models which included all variables in the table. N=409. Multiple imputation used to fill in missing values

  48. Factors associated with elevated BP or HTN among FEMALES in multivariable logistic regression models • Estimates derived from sex-specific models which included all variables in the table. N=489. Multiple imputation used to fill in missing values

  49. PAPER 3 - CONCLUSION Factors associated with elevated BP among Jamaican young adults include measures of obesity and insulin resistance, with some significant differences by sex Lower SES was associated with elevated BP among females only Reducing obesity and improving insulin sensitivity may reduce hypertension risk in Afro-Caribbean populations

  50. SUMMARY Hypertension remains a global public health problem Understanding the determinants of hypertension in youth can help in developing interventions to reduce the impact of hypertension on public health Early life factors including birth weight, postnatal growth and maternal SEC contribute to the risk of elevated blood pressure or hypertension in youth Obesity, measures of insulin resistance (glucose, triglycerides, HOMA-IR) and SES are associated with elevated BP in youth These factors should be considered in efforts to prevent hypertension

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