We introduce the concept of forcing factors, analogous to risk factors for population-wide health outcomes, that are attributes of the physical, social, legal, economic, or cultural environment that are common to all peo...We introduce the concept of forcing factors, analogous to risk factors for population-wide health outcomes, that are attributes of the physical, social, legal, economic, or cultural environment that are common to all people in an identified population and that promote or inhibit particular outcomes of health, wellness, and well-being. Examples include laws governing food or tobacco marketing, the built environment, and climate change. Culture also functions as a forcing factor of health outcomes. In contrast to past explanations of adverse health outcomes that have relied on cultural attributes of a specific sub-population, we draw on work of John McKinlay to make the point that it is the shared culture of a country or a region that influences health outcomes. Culture itself operates in a particular cultural context.
Low levels of physical activity (PA) and prolonged periods of sedentary time significantly increase the risk of developing non-communicable diseases. Individuals who minimally increase their PA levels can experience sign...Low levels of physical activity (PA) and prolonged periods of sedentary time significantly increase the risk of developing non-communicable diseases. Individuals who minimally increase their PA levels can experience significant reductions in risk of morbidity and mortality. Despite regular public messaging cycles and PA promotional campaigns highlighting these observations, the number of individuals meeting the PA recommendations has been underwhelming and stagnant for decades. Numerous studies have identified prominent barriers to becoming and staying physically active, in addition to a person's or people's cultural beliefs. Yet exercise professionals and other allied healthcare professionals may not consider one's cultural experiences when promoting PA. Recognizing the impact of culture on PA, whether it is positive or negative, can facilitate culturally sensitive discussions with individuals or groups and customizing PA recommendations in a way that facilitates its adoption. Accordingly, this paper aims to review relevant studies and examples of how culture can influence PA behaviors, as well as provide considerations for exercise professionals and allied healthcare providers to take when promoting PA in diverse populations.
BACKGROUND: Neighborhood median household income (NMHI), a key social determinant of health, is being recognized as a major source of inequity in healthcare. Its impact on patients with hypertrophic cardiomyopathy (HCM)...BACKGROUND: Neighborhood median household income (NMHI), a key social determinant of health, is being recognized as a major source of inequity in healthcare. Its impact on patients with hypertrophic cardiomyopathy (HCM) is uncertain. OBJECTIVE: We sought to study the association between NMHI and long-term outcomes of HCM patients. METHODS: This was an observation registry of 6368 HCM patients (median age 56 years, 58 % men, 83 % white, 32 % with ≥1 sudden death risk factor) who underwent a clinical evaluation at a tertiary care center between 2002 and 18. NMHI (US$) was calculated from each patient's zip code, using data from the US Census Bureau and Department of Housing & Urban Development. The primary outcome was death, appropriate internal cardioverter defibrillator (ICD) discharge or heart transplant in follow up. RESULTS: Patients were categorized as obstructive (oHCM, n = 3827 or 60 %, 65 % symptomatic, median NMHI $51,600) and nonobstructive (nHCM, n = 2541 or 40 %, 73 % asymptomatic, median NMHI $53,700) using echocardiography. At a median of 6 years (interquartile range or IQR 2.91, 9.74), there were 998 (16 %) primary events (deaths = 939), with breakdown as follows: 599/3827 (16 %) in oHCM and 399/2541 (16 %) in nHCM, respectively. On multivariable Cox survival analysis, a higher NMHI was independently associated with improved long-term freedom from primary events (oHCM [Hazard ratio or HR 0.84 95 % Confidence Interval or CI 0.80-0.88] and nHCM [HR 0.95 95 % CI 0.91-9.97]), both p < 0.01. On penalized spline analysis, the NMHI at which the hazard for primary events crossed 1 was ∼$52,000 for both oHCM and nHCM. In nHCM patients, NMHI greater than $52,000 was associated with improved longer-term freedom from primary events vs. those whose NMHI was lower than $52,000 (196/1398 [14 %] vs. 203/1143 [18 %], log-rank p-value<0.01). Similarly, oHCM patients with NMHI greater than $52,000 had significantly improved longer-term freedom from primary events vs. those whose NMHI was lower than $52,000 (186/2067 [9 %] vs. 413/1760 [23 %] vs., log-rank p-value<0.001). CONCLUSIONS: NMHI, a marker of socioeconomic status, is independently associated with outcomes in patients with HCM. oHCM patients below the NMHI cutoff had significantly worse long-term outcomes vs. the nHCM patients similarly below the NMHI cutoff.
AIMS: To assess if adiposity measures such as waist-to-hip ratio (WHR) modify the relationship of lipoprotein (a) [Lp(a)] with atherosclerotic cardiovascular disease (ASCVD). METHODS: 4652 participants from the Multi-Eth...AIMS: To assess if adiposity measures such as waist-to-hip ratio (WHR) modify the relationship of lipoprotein (a) [Lp(a)] with atherosclerotic cardiovascular disease (ASCVD). METHODS: 4652 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) were grouped as follows: Lp(a) < 50 mg/dl and WHR <90th percentile(pct) (reference); Lp(a) < 50 mg/dl and WHR ≥90th pct; Lp(a) ≥ 50 mg/dl and WHR <90th pct; and Lp(a) ≥50 mg/dl and WHR ≥90th pct. Cox proportional hazard models assessed the relationship of Lp(a) and WHR with time to ASCVD events. RESULTS: Compared to the reference group, isolated elevated Lp(a) ≥ 50 mg/dl or WHR ≥90th pct were not significantly associated with risk of ASCVD (hazard ratio (HR), 1.15, 95 % confidence interval (CI): 0.94-1.39) and (HR, 1.14, 95 % CI: 0.92-1.41), respectively. In contrast, the combination of elevated Lp(a) ≥50 mg/dl and WHR ≥90th pct was associated with ASCVD risk (HR, 2.34, 95 % CI: 1.61-3.40). Lp(a) ≥50 mg/dl was not significantly associated with ASCVD risk in the 1st and 2nd tertile of WHR (HR, 1.06, 95 % CI: 0.72-1.48and HR, 1.08, 95 % CI: 0.79-1.48, respectively). However, Lp(a) ≥50 mg/dl was significantly associated with ASCVD risk in the highest tertile of WHR (HR, 1.60, 95 % CI: 1.23-2.09). (Interaction p = 0.01). Body mass index (BMI) and Lp(a) combinations resulted in similar greater risks of ASCVD in the highest risk category (HR, 1.33, 95 % CI: 1.00-1.77), without a significant interaction (p = 0.99). CONCLUSIONS: In MESA, WHR significantly modifies the risk of ASCVD associated with Lp(a). Measures of abdominal adiposity may further refine the cardiovascular risk in individuals with elevated Lp(a).
While there is ongoing debate about the role of the 12‑lead Electrocardiogram (ECG) in the routine screening of young athletes during pre-participation evaluations, studies continue to support the use of ECG within prope...While there is ongoing debate about the role of the 12‑lead Electrocardiogram (ECG) in the routine screening of young athletes during pre-participation evaluations, studies continue to support the use of ECG within properly organized settings. This paper aims to offer considerations for enhancing the International ECG recommendations for the interpretation of the ECGs of young athletes through an emphasis on 1) percentile outliers, 2) computerized ECG technology and 3) clarification of terminology. We specifically highlight criteria for early repolarization, left atrial abnormality, right bundle branch block, ST shifts, and high and low voltage QRS.
With chronic diseases increasingly prevalent in the United States (U.S.), healthcare providers are in a unique position to promote healthy living behaviors, such as physical activity (PA) and nutrition, to patients. Howe...With chronic diseases increasingly prevalent in the United States (U.S.), healthcare providers are in a unique position to promote healthy living behaviors, such as physical activity (PA) and nutrition, to patients. However, many healthcare providers struggle with maintaining their own health, which negatively affects their ability to counsel patients effectively on these behaviors. This paper highlights the barriers healthcare providers face in adopting and promoting healthy behaviors, including individual habits, lack of training, and environmental factors within healthcare institutions. It also examines how these barriers, such as insufficient educational opportunities, inadequate work environments, and systemic obstacles like time constraints and reimbursement issues, hinder effective PA and nutritional counseling. The authors propose that improving the health of healthcare providers will enhance the quality of counseling they provide, ultimately benefiting patient care and population health.
Workplace settings, including hybrid, remote, and home-based environments, are key places to support employees and their families to live healthfully since so many adults spend significant amounts of time at work. Employ...Workplace settings, including hybrid, remote, and home-based environments, are key places to support employees and their families to live healthfully since so many adults spend significant amounts of time at work. Employers can create a culture of healthy living at their workplaces and do so intentionally through process and practice. They can establish organizational policies, systems, work processes, architectural design practices, and employment benefits designs to support healthy behaviors for their employees and their families. Employers also can ensure health insurance approaches that provide equitable access to quality health care. They can ensure livable wages for all staff and provide a host of other important healthy living support mechanisms, using incentives and communications. Organizational executives and upper managers play a critical role in modeling these shared values at the workplace and participatory approaches need to be implemented to give all workers opportunity to meaningfully engage. Corporate leaders can reinforce a healthy living culture with role modeling and by ensuring resources are available and accessible-to do so, a set of workplace factors should be implemented that, cumulatively, reach a tipping point toward the creation of a healthy workplace culture. Employers can both influence and be influenced by the communities in which they are located. Recognizing regional culture, participating in strategic relationships, investing in the community, and providing volunteer and civic engagement opportunities all contribute to the support of healthy living strategies in the workplace. When employers pursue a workplace culture of health, they not only do good by their employees, but they also increase the likelihood that their company may outperform their market competition.
Health education is more effective when the providers/educators are knowledgeable about the population in which the education is being disseminated in and cognizant of the cultural influences on these areas of health. Si...Health education is more effective when the providers/educators are knowledgeable about the population in which the education is being disseminated in and cognizant of the cultural influences on these areas of health. Simply put - "know your audience!" Because culture is who we are and what we are, it would be remis to ignore the richness of cultural foods, movement, and other health patterns. Embracing culture in its relationship to health is important. Health educators should be utilizing cultural variability and meeting the needs of specific populations. If lifestyle patterns are to be assimilated into daily practices, the behaviors must be meaningful and culturally relevant. When programs are tailored and implemented in youth and young adults, health education can take a proactive preventative role. This paper provides a perspective for approaching programming for youth, important components for tailoring educational programs, and a narrative review of educational health initiatives that seek to tailor their interventions towards youth. While programs do exist for youth, there is a need for improvement. If healthy living behaviors are to be assimilated into the cultural richness of the community in which the program is implemented, meeting the needs of youth through engaging relevant lessons is crucial.
Food choices and dietary behaviors are inherently complex and influenced by numerous interconnected factors including individual preferences such as taste, meal timing, and social interactions, alongside external element...Food choices and dietary behaviors are inherently complex and influenced by numerous interconnected factors including individual preferences such as taste, meal timing, and social interactions, alongside external elements like affordability, cultural norms, marketing, and policy environments. The physical contexts of food consumption - homes, schools, workplaces, and neighborhoods- further shape these behaviors, as do societal expectations and generational food literacy. Underpinning these dynamics are food systems, which are influenced by health, ethical, and sustainability considerations throughout the food production and consumption continuum. Cultural influences, encompassing traditions, rituals, and shared beliefs, play a pivotal role in shaping dietary practices. Distinctions between "cultural food" and "food culture" illustrate the deep integration of cuisine within identity and daily life. Historical events, globalization, and modernization have reshaped food traditions, leading to the adoption of new eating patterns and the erosion of others. Religion, socioeconomic status, and social networks also critically impact dietary behaviors, while contemporary challenges such as the nutrition transition and fast-food culture contribute to rising chronic disease burdens. Addressing these issues requires culturally tailored interventions and a focus on food environments, integrating modern tools like social media to promote healthier, community-oriented behaviors while recognizing the social and emotional roles of food.
A culture of health or healthy living can be envisioned as a society where well-being, including essential aspects like sleep, stress management, social connections, and leisure - is not merely an aspiration but a tangib...A culture of health or healthy living can be envisioned as a society where well-being, including essential aspects like sleep, stress management, social connections, and leisure - is not merely an aspiration but a tangible reality for diverse communities, free from systemic inequities. However, the concept of a healthy lifestyle, and by extension a culture of healthy living, varies widely across the globe, shaped by cultural norms, government policies, and social structures. Defining a universally acceptable "culture of healthy living" for every population or subgroup is inherently complex, making it more practical to focus on addressing the barriers and leveraging the enablers associated with leading a healthy life. At its core, discussing the foundational elements of a healthy life - such as diet and nutrition, physical activity, mental health, and access to healthcare - is crucial. To ensure the sustainability of healthy living practices, a multifaceted approach is needed, emphasizing these pillars alongside equity. Existing global initiatives offer promising frameworks to tackle these challenges, highlighting the importance of collaboration, innovation, and systemic change. By fostering mutual support and collective action, we can advance toward a global culture of healthy living that benefits all individuals and communities, leaving no one behind.
BACKGROUND: Resting Heart Rate (RHR) is commonly viewed as a reflection of underlying co-morbidities and not an independent risk factor. Here we compared whether high RHR (80-99 beats/min) and hypertension (blood pressur...BACKGROUND: Resting Heart Rate (RHR) is commonly viewed as a reflection of underlying co-morbidities and not an independent risk factor. Here we compared whether high RHR (80-99 beats/min) and hypertension (blood pressure, BP ≥140/90 mmHg) independently predict all-cause mortality in 692,217 adults from Asia and Europe. METHODS: Taiwan MJ cohort constituted of 636,064 adults (1994-2017) and the HUNT cohort of 56,153 Norwegian adults (1995-1997). Both cohorts were followed for about 25 years. We report adjusted hazard ratios (HRs) for all-cause mortality, and life expectancy were calculated. RESULTS: The prevalence of high RHR changed little between those aged 20-29 years (21.2 %) and ≥ 70 years (25.2 %, ns.), whereas hypertension prevalence increased from 4.5 % to 57.3 %, respectively. We observed similar all-cause mortality among those with a high RHR and a normal BP and those with hypertension and normal RHR of 60-69 beats/min. We observed higher all-cause mortality among those with normal BP (≤120/80 mmHg) but high RHR than among those with hypertension and normal RHR. All-cause mortality risk associated with hypertension was not significant for those <40 years of age, whereas risk associated with high RHR remained significant across all age groups. Reductions in life expectancy was larger among individuals with normal BP, but high RHR (10.29 years, 95 % CI 8.09-12.49) compared with those with hypertension but normal RHR (5.53 years, 95 % CI 3.57-7.59). CONCLUSIONS: Our data clearly demonstrate that elevated RHR should be considered as an independent risk factor for all-cause mortality. The observation that elevated RHR in young adulthood to middle age (20-50 years of age) served as better predictor of all-cause mortality than hypertension calls for a paradigm shift particularly among these age groups, and we suggest it is time that RHR should be regarded as a vital clinical sign measured and evaluated at all clinical visits.
Kim DS, Schuetz N, Johnson A
… +14 more, Tolas A, Mantena S, O'Sullivan JW, Hershman SG, Myers JN, Christle JW, Oppezzo M, Linos E, Rodriguez F, Mattsson CM, Wheeler MT, King AC, Taylor HA, Ashley EA
BACKGROUND: The six-minute walk test (6MWT) is a prognostic sub-maximal exercise test used clinically as a measure of functional capacity. With the emergence of advanced sensors, 6MWTs are being performed remotely via sm...BACKGROUND: The six-minute walk test (6MWT) is a prognostic sub-maximal exercise test used clinically as a measure of functional capacity. With the emergence of advanced sensors, 6MWTs are being performed remotely via smartphones and other devices. The My Heart Counts Cardiovascular Health Study is a smartphone application that serves as a digital platform for studies of human cardiovascular health, and has been used to perform 30,475 6MWTs on 8922 unique participants. OBJECTIVE: As our 30,475 6MWTs represent the largest such collection of data available, we sought to identify associations with measured demographic and clinical variables with 6MWT distance at enrollment and separately determine if use of the My Heart Counts smartphone application led to changes in 6MWT distance. METHODS AND RESULTS: We present the public data release of our 30,475 6MWTs and the launch of a webpage-based data viewer of summary-level statistics, to compare the functional capacity of an individual by their age, gender, height, weight, and disease status (https://mhc-6mwts.streamlit.app). Using multivariable regression, we report associations of demographic and clinical variables with baseline 6MWT distance (N = 3606), validating prior associations with age, male gender, height, and baseline physical activity level with 6MWT distance. We also report associations of 6MWT baseline distance with employment status (+12.4 m ±4.9 m, P = 0.011) and feeling depressed (-3.65 m, ±0.79 m, P < 0.001). We separately found that cardiovascular disease status was significantly associated with decreased 6MWT distance for atrial fibrillation (-24.9 m ±7.8 m, P = 0.0013), peripheral artery disease (-41.7 m ±12.5 m, P < 0.001), and pulmonary arterial hypertension (-76.3 m ±24.8 m, P = 0.0022). Heart failure was associated with decreased 6MWT distance but was not statistically significant (-25.5 m ±14.5 m, P = 0.078). In a subset of participants who conducted repeat 6MWTs separated by at least 1 week but no greater than 3 months (N = 1129), we found that use of the My Heart Counts app was associated with a statistically significant increase in 6MWT distance (+17.5 m ±7.85 m, P < 0.001). CONCLUSIONS: We validate previously identified associations from clinic-performed 6MWTs, demonstrating the utility of a mobile method in collecting 6MWT data for clinicians and researchers. We also demonstrate that use of the My Heart Counts app is associated with small, but significant increases in 6MWT distance. Given the importance of 6MWTs in assessment of functional capacity, our publicly-available data will serve an important purpose as a health and disease-specific reference for investigators worldwide.
Chaturvedi A, Gadela NV, Kalra K
… +12 more, Chandrika P, Toleva O, Alfonso F, Gonzalo N, Hashim H, Abusnina W, Chitturi KR, Ben-Dor I, Saw J, Pinilla-Echeverri N, Waksman R, Garcia-Garcia HM
Ischemic heart disease is the most common cardiovascular cause of death in women worldwide. Obstructive coronary atherosclerosis is the primary cause of myocardial infarction (MI), however, non-atherosclerotic mechanisms...Ischemic heart disease is the most common cardiovascular cause of death in women worldwide. Obstructive coronary atherosclerosis is the primary cause of myocardial infarction (MI), however, non-atherosclerotic mechanisms of MI, such as spontaneous coronary artery dissection, vasospasm, microvascular dysfunction, embolization, inflammation, coronary anomalies, infectious and infiltrative causes are increasingly being recognized. Emerging data suggest that women are two to five times more likely to have an MI in the absence of coronary atherosclerosis compared to men, but they continue to remain underdiagnosed and undertreated, partly due to underdiagnosis and limited understanding of these mechanisms. Recent advancements in invasive and noninvasive imaging techniques and physiological testing allow for distinguishing these mechanisms from each other, providing a definitive diagnosis and tailored treatment. This review summarizes the existing literature on the non-atherosclerotic coronary causes of MI with a focus on evidence pertaining to women, offering a basis for future studies.
Despite widespread attempts from governments and leading health organisations worldwide to promote equity in healthy living medicine, the evidence suggests that attempts to curb worsening public health have been almost e...Despite widespread attempts from governments and leading health organisations worldwide to promote equity in healthy living medicine, the evidence suggests that attempts to curb worsening public health have been almost entirely ineffective. Despite significant advancements in knowledge, medicine, and technology, as well as the promotion of guidelines and the implementation of numerous global initiatives aimed at addressing health disparities and mitigating the progression of non-communicable diseases (NCDs) worldwide, substantial work remains to be undertaken particularly in addressing inequalities in physical activity. Achieving equitable access to health resources and parity in health outcomes remains a critical and unresolved challenge. Whilst it is recognized that the public health paradigm is broad and complex, with many intersecting and interacting parts, the actions and considerations required to address the urgent and escalating scale of the problem appear at a crossroads of now or never. Throughout this narrative review, we describe the effectiveness of landmark physical activity-related guidelines, policies and national interventions that have been implemented since the turn of the century to address physical activity behaviour in the context of health inequalities.