Publications

BACKGROUND: Low-carbohydrate diet (LCD) and low-fat diet (LFD) patterns are practiced by many in the United States, although their health effects, as well as the role of diet quality in the effects, are not fully understood.

OBJECTIVES: This study aimed to prospectively examine the associations of these diets, which emphasize different quantities and qualities of macronutrients, as well as their objective metabolomic indices, with coronary heart disease (CHD) risk in U.S.

METHODS: We followed 42,720 men in the Health Professionals Follow-Up Study (HPFS) (1986-2016), 64,164 women in the Nurses' Health Study (NHS) (1986-2018), and 91,589 women in NHSII (1991-2019) for CHD incidence. Five LCD and 5 LFD indices were derived based on food frequency questionnaire (FFQ) assessments, each emphasizing different sources and qualities of macronutrients (animal products vs plant-based foods, whole grains vs refined carbohydrates, etc). Multimetabolite scores of LCD and LFD indices assessed using FFQ assessments were developed through elastic net regressions among 1,146 healthy participants in the lifestyle validation studies (LVS), substudies embedded in the NHS/NHSII/HPFS.

RESULTS: During 5,248,916 person-years of follow-up, we documented 20,033 CHD cases. When comparing individuals with the highest LCD scores (emphasizing lower carbohydrate contents) and those with the lowest, the pooled multivariable-adjusted hazard ratios (95% CIs) for CHD were 1.05 (1.01-1.10) for overall LCD, 1.07 (1.02-1.12) for animal LCD, 0.94 (0.90-0.99) for vegetable LCD, 1.14 (1.09-1.20) for unhealthy LCD, and 0.85 (0.82-0.89) for healthy LCD. These estimates were 0.93 (0.89-0.98) for overall LFD, 0.94 (0.90-0.98) for animal LFD, 0.87 (0.83-0.91) for vegetable LFD, 1.12 (1.07-1.17) for unhealthy LFD, and 0.87 (0.83-0.91) for healthy LFD. The healthy versions of the LCD and LFD patterns were also linked to lower triglycerides, higher high-density lipoprotein cholesterol, and lower high-sensitivity C-reactive protein levels, as well as favorable metabolomic profiles, including increased 3-indolepropionic acid and decreased valine. Unhealthy patterns showed opposite associations. Multimetabolite scores of LCD and LFD indices were developed in the LVS (Spearman r = 0.57-0.68) and replicated in NHS, NHSII, and HPFS (r = 0.21-0.38). They showed associations with CHD risk highly consistent with those based on FFQ assessments.

CONCLUSIONS: These findings highlight the critical role of diet quality in determining health effects of low-carbohydrate and low-fat diets on CHD risk. The healthy versions of these diets may exert their health benefits through some common pathways that together entail favorable cardiovascular risk profile and lower CHD risk.

BACKGROUND: Home blood pressure (BP) monitoring (HBPM) is increasingly used as an alternative to office BP. However, factors influencing agreement between office and home BP among very old adults remain unclear.

METHODS: During ARIC (Atherosclerosis Risk in Communities) visit 10, participants underwent 3 automated office BP (AOBP) measurements using an Omron HEM-907XL and performed HBPM twice daily for 8 days using an Omron BP7450. Discordance was defined as a systolic BP difference of ±10 mm Hg between mean AOBP and HBPM. Multivariable regression models evaluated demographic, anthropometric, and clinical factors associated with discordance.

RESULTS: Among 792 participants (58% female; mean age, 84±3.7 years), mean systolic BP was 130.6 mm Hg (AOBP) and 129.6 mm Hg (HBPM). Despite a minimal average difference (1.0±15.7 mm Hg), 49% had ≥10 mm Hg systolic BP discordance. Higher AOBP was associated with greater discordance. Compared with females, males had lower AOBP relative to HBPM (-4.69 mm Hg [95% CI, -6.86 to -2.51]). Smaller arm circumference was associated with higher discordance (β=14.4 mm Hg [95% CI, 4.78-24.04]). Frail adults had lower AOBP relative to HBPM (β, -5.1 mm Hg [95% CI, -11.0 to 0.9]). Baseline AOBP systolic BP ≥140 mm Hg strongly predicted discordance ≥+10 mm Hg (odds ratio, 8.27 [95% CI, 5.52-12.40]). Participants aged 91 to 100 years had lower AOBP than those aged 78 to 80 years (β, -5.0 mm Hg [95% CI, -10.06 to 0.001]).

CONCLUSIONS: Among very old adults, substantial BP discordance between AOBP and HBPM was common and influenced by higher BP, age, male sex, arm circumference, and frailty.

Sankey diagram of agreement between dischareg summary, discharge instructions, and patient provided reasoning for chronic medication changes made during hospitalization.

BACKGROUND: Hypertension affects nearly half of U.S. adults. The 2025 American College of Cardiology/American Heart Association guideline adopts the Predicting Risk of Cardiovascular Disease Events (PREVENT) risk equations and updates treatment recommendations for stage 1 hypertension, potentially altering eligibility for antihypertensive therapy.

OBJECTIVES: The primary objective was to quantify changes in antihypertensive treatment eligibility under the 2025 vs 2017 guidelines. Secondary objectives were to characterize adults newly meeting treatment thresholds, assess concordance and discordance in eligibility, and evaluate robustness across PREVENT model variants.

METHODS: We conducted a simulation-based analysis using nationally representative National Health and Nutrition Examination Survey data (2017-2020) among adults aged 30 to 79 years. Treatment eligibility was assigned using 2017 and 2025 guideline criteria. Survey-weighted estimates quantified population-level eligibility, newly eligible adults, and concordance patterns. Analyses were repeated using PREVENT Base, Full, hemoglobin A1c, and albumin-to-creatinine ratio variants, and multivariable models identified predictors of eligibility.

RESULTS: Among 5,578 adults (weighted population 160 million), 36.4% were eligible for treatment under the 2017 guideline and 36.6% under the 2025 guideline, representing a minimal net increase of 0.7% (approximately 400,000 adults). Most adults were consistently ineligible (63.3%), whereas one-third were consistently eligible (36.3%). Newly eligible adults were predominantly older women with higher body mass index and borderline glycemic measures but without established cardiovascular disease. Eligibility patterns were stable across racial and ethnic groups. Analyses were repeated across all PREVENT risk equation variants, and multivariable models identified predictors of eligibility.

CONCLUSIONS: Adoption of the 2025 American College of Cardiology/American Heart Association guideline results in a minimal expansion of antihypertensive treatment eligibility. Results were robust across PREVENT model variants, supporting risk-based guideline implementation.

BACKGROUND: Delirium is a common complication of hospitalization with poor outcomes, but its underlying pathophysiology is poorly understood. We investigated the association of preoperative glial fibrillary acidic protein (GFAP), a biomarker of reactive astrocytosis, with delirium incidence and severity.

METHODS: Data were obtained from the ongoing prospective Successful Aging after Elective Surgery (SAGES) study. GFAP was measured in preoperative plasma (n = 529). Post-operative delirium incidence and severity were measured using the Confusion Assessment Method (CAM) and CAM-S (0-19, 19 worst), respectively. A multivariable generalized linear model (GLM) with log link and binary or Poisson error distribution was used to estimate the relative risk of delirium by GFAP quartile scale, and GLM with identity link was used to examine the association of preoperative GFAP and delirium severity.

RESULTS: Overall mean preoperative GFAP value was 289.6 ± 153.3 pg/ml; mean value by quartile (Q) was 148.1 ± 28.6 pg/ml for Q1, 220.5 ± 19.8 pg/ml for Q2, 298.2 ± 28.4 pg/ml for Q3, and 503.4 ± 128.3 pg/ml for Q4. Delirium incidence by GFAP level was 16% in Q1, 24% in Q2, 25% in Q3, and 28% in Q4 (Cochran Trend test P-value = 0.031; adjusted P-value = 0.205). Higher GFAP levels (4th vs. 1st quartile) were associated with greater risk of incident delirium (adjusted relative risk 1.70, 95% confidence interval (CI): 1.01-2.86) and greater delirium severity (adjusted mean difference 0.86, 95% CI: 0.004-1.71).

CONCLUSIONS: High preoperative plasma GFAP was associated with increased delirium incidence and severity, suggesting GFAP may serve as a risk marker for delirium. Brain vulnerability in the setting of astrocytosis may contribute to delirium pathophysiology.

PURPOSE OF REVIEW: Exercise is a recommended non-pharmacological approach to treat multiple sclerosis (MS) symptoms. Mind-body movement interventions (MBMIs) offer a multi-component exercise option that integrates movement, breathwork, and mindfulness. Using an umbrella review, we assessed the current best evidence on MBMIs (ai chi, dance, Pilates, qigong, tai chi, and yoga) for managing MS symptoms.

RECENT FINDINGS: MBMIs significantly improved balance, equal to or superior to active controls (AC) or usual care (UC). Ai chi/tai chi/qigong significantly improved depression. Analyzed with other mind-body therapies, yoga reduced pain compared to AC/UC. Mixed results were found for fatigue. Physical function and quality of life were comparable to AC/UC. The certainty of evidence was low to very low for most MBMIs. Most reviews were "critically low" quality. MBMIs are commonly included in MS exercise reviews and may improve balance, pain, and depression. However, larger trials with active comparators and comprehensive reporting are needed to improve quality and certainty.

IMPORTANCE: It is unclear whether and the extent to which subclinical myocardial injury or stress coexisting with prediabetes is associated with the risk of heart failure (HF).

OBJECTIVE: To evaluate the joint associations of prediabetes and subclinical myocardial injury or stress with incident HF risk.

DESIGN, SETTING, AND PARTICIPANTS: This post hoc prospective cohort study analyzed data from the Systolic Blood Pressure Intervention Trial (SPRINT). Two analytic samples were used: (1) adults with hypertension without diabetes or prior HF for the baseline biomarkers analysis and (2) participants with biomarker measurements at both baseline and 12 months for the longitudinal biomarkers' change. Prediabetes was defined as a fasting plasma glucose level of 100 to 125 mg/dL. Subclinical myocardial injury was defined as a high-sensitivity cardiac troponin I (hs-cTnI) level of 6 ng/L or higher in men and 4 ng/L or higher in women and subclinical myocardial stress defined as an N-terminal pro-B-type natriuretic peptide (NT-proBNP) level of 125 pg/mL or higher. A 25% or greater increase in any biomarker concentration from baseline to 12 months defined longitudinal change. Data were analyzed between January 1 and May 31, 2025.

MAIN OUTCOMES AND MEASURES: The primary outcome was adjudicated incident HF. Cox proportional hazards models were used to estimate hazard ratios (HRs) for HF across joint categories of prediabetes and biomarker elevation.

RESULTS: Of 8234 participants (mean [SD] age, 68 [9] years; 37.1% women), 3271 (39.7%) had prediabetes, 2942 (35.7%) had subclinical myocardial injury, and 3593 (43.6%) had subclinical myocardial stress. Over a median follow-up of 3.2 years (IQR, 2.8-3.8 years), 122 participants developed HF. Compared with normoglycemia and no myocardial injury, those with both prediabetes and injury had the highest HF risk (HR, 4.20; 95% CI, 2.31-7.63); similar findings were observed for myocardial stress (HR, 5.20; 95% CI, 2.52-10.70). In the longitudinal analysis (median follow-up, 2.3 years [IQR, 1.9-2-8 years]), 7449 participants with both prediabetes and a 25% or greater increase in hs-cTnI or NT-proBNP level had the highest risk of HF (for hs-cTnI: HR, 3.05; 95% CI, 1.58-5.88; for NT-proBNP: HR, 2.39; 95% CI, 1.28-4.46).

CONCLUSIONS AND RELEVANCE: These findings suggest that among adults with hypertension, prediabetes in combination with subclinical myocardial injury or stress is associated with a significantly elevated risk for HF. These findings support the integration of glycemic status and cardiac biomarkers profiling to improve HF risk stratification and guide prevention.