James M. Shikany

Objective: To investigate the relationship between depressive symptoms and risk for COVID-19 hospitalization and death in a US general population-based sample. Methods: We studied participants enrolled in observational NIH-funded cohorts from 1971 to 2010 with ongoing follow-up through 2023. Prepandemic Centers for Epidemiologic Studies Depression (CES-D) 10-item scale scores ≥10 defined elevated depressive symptoms. Questionnaires, medical records, and death certificates classified incidents of COVID-19 as severe (hospitalized/fatal) or nonsevere from April 2020 through February 2023. Results: Of 33,565 participants, 633 (1.9%) had incident severe COVID-19 over a mean (SD) follow-up of 453 (207) days. Elevated prepandemic depressive symptoms were present in 4922 (16.3%) of participants. Elevated prepandemic depressive symptoms increased the hazard of severe COVID-19 in fully adjusted (aHR=1.27; 95% CI=1.03-1.57) models. In sex-stratified models ( p -interaction=.03), elevated depressive symptoms increased the hazard in women (aHR=1.49; 95% CI=1.17-1.90) but not in men (aHR=0.96; 95% CI=0.67-1.39). Conclusions: Prepandemic depressive symptoms were associated with increased risk of severe COVID-19 among women in a large US general population-based study of adults, and associations in men were neither confirmed nor ruled out. These results support current CDC recommendations that depression be considered an underlying medical condition associated with a higher risk for severe COVID-19 and suggest that increased clinical focus on risk mitigation for COVID-19 and other acute respiratory infections among patients with depressive symptoms is warranted.

Black Americans residing in rural communities are often excluded from clinical trials for hypertension, despite having a high prevalence of the disease and frequent complications. This report describes our research team’s experience to support recruitment and retention of rural Black patients with uncontrolled hypertension in the southeastern United States in a cluster-randomized clinical trial. While the focus of this report is on enrollment and engagement, the strategies employed were grounded in long-standing community-engaged research efforts and guided by principles of trust-building, transparency, and shared leadership. We share the challenges encountered and reflect on lessons learned to inform future approaches that authentically engage historically excluded and under-represented communities as active partners in research.

Background: Preconception diet and nutritional status are important determinants of reproductive and pregnancy health. As a comprehensive evaluation, this paper describes harmonization of diet data across multiple cohorts including over 50,000 participants and the differences between them. This information may be useful for developing targeted strategies to improve women’s diet prior to pregnancy for optimal prenatal health outcomes. Methods: The Preconception Period Analysis of Risks and Exposures influencing health and Development (PrePARED) consortium incorporates studies covering the preconception period and includes both couples planning pregnancy and studies covering the reproductive period but not focused on pregnancy. We harmonized data on 56,520 participants from seven cohort studies that collected data during the preconception period. We generated data on diet quality according to the International Federation of Gynecology and Obstetrics (FIGO) nutrition checklist to examine diet quality measures across the cohorts and compare estimates of diet quality across studies. Four studies used food frequency questionnaires; one used a study-specific diet history; one used two 24 h dietary recalls; and one used a short series of general diet questions. Positive responses on the six FIGO questions were tallied to calculate a total diet quality score. Results: Cohort samples varied in terms of age; socioeconomic status; race; ethnicity; and geographic region. Across the cohorts, participants met a median of three or four of the FIGO criteria for diet quality; those most commonly met were recommendations for consumption of meat and protein, while those least commonly met were recommendations for limiting consumption of processed foods and snacks. There was greater variation in meeting recommendations for the consumption of fruits and vegetables; dairy; fish; and whole grains. The percentage meeting ≤ 2 criteria ranged from 6.4% (Coronary Artery Risk Development in Young Adults) to 40.4% (Bogalusa Heart Study). Discussion: There was wide variability across preconception cohort studies in the extent to which participants met FIGO dietary guidelines. Although studies were conducted in populations that were not likely to be malnourished, it was rare for women to meet all the preconception dietary recommendations. These findings illustrate a need for strategies to promote meeting dietary guidelines prior to conception to improve health outcomes.

BACKGROUND: Increased burden of socially determined vulnerabilities (SDV), which include nonmedical conditions that contribute to patient health, is associated with incident heart failure (HF). Mediators of this association have not been examined. We aimed to determine if a healthy lifestyle mediates the association between SDV and HF. METHODS: We included adults aged 45 to 64 years old across the United States from the REGARDS cohort study (Reasons for Geographic and Racial Differences in Stroke) without evidence of HF at baseline. The primary exposure was a count of SDV based on the Healthy People 2030 framework. The primary outcome was incident HF. We assessed the role of a healthy behavior score (HBS range, 0–8) and its components (adherence to a Mediterranean diet, physical activity, lack of sedentary lifestyle, and smoking abstinence) as potential mediators of the association between SDV and incident HF. RESULTS: We included 13 on 525 participants. The median HBS was 4, with 16% with low HBS (0–2), 55% with moderate HBS (3–5), and 29% with high HBS (6–8). Increasing burden of SDV was associated with a stepwise increase in incident HF (adjusted hazard ratio, 1.84 [95% CI, 1.32–2.52] for 1 SDV, 2.59 [95% CI, 1.87–3.60] for 2 SDV, and 4.20 [95% CI, 3.08–5.73] for ≥3 SDV). There was no statistically significant mediation of HBS for the association of SDV count of 1 and incident HF. HBS score mediated 10.6% of the association between SDV count of 2 and incident HF and 11.1% of the association for those with ≥3 SDV. This increased to 10.8% and 18.3%, respectively, in the complete case analysis. Regarding individual components of HBS as mediators, only avoidance of a sedentary lifestyle was statistically significant (8.6% mediation) for the association of SDV count of 2 and incident HF. CONCLUSIONS: A healthy lifestyle plays a small role in mediating the association between high SDV count and incident HF.

Rationale: Robust COVID-19 outcomes classification is important for ongoing epidemiology research on acute and post-acute COVID-19 conditions. Protocolized medical record review is an established method to validate endpoints for clinical trials and cardiovascular epidemiology cohorts; however, a protocol to adjudicate hospitalizations for COVID-19 among epidemiology cohorts was lacking. Objectives: We developed a protocol to ascertain and adjudicate hospitalized COVID-19 across a meta-cohort of 14 US prospective cohort studies. This report describes the first three years of protocol implementation (October 1, 2020—October 1, 2023) and evaluates its repeatability and performance compared to classification by administrative codes. Methods: The protocol was adapted from cohort approaches to clinical cardiovascular events ascertainment and adjudication. Potential COVID-19 hospitalizations and deaths were identified by self-/proxy-report and, in some cases, active surveillance. Medical records were requested from hospitals and adjudicated for COVID-19 outcomes by clinically trained personnel according to a standardized rubric. Inter-rater agreement was assessed. The sensitivity and specificity of discharge diagnosis codes was compared to adjudicated diagnoses. Measurements and main results: The study obtained medical records for 1,167 potential COVID-19 hospitalizations, which underwent protocolized adjudication. Adjudication confirmed COVID-19 infection was present for 1,030 (88%) events, of which COVID-19 was not the cause of hospitalization for 78 (8%). Of 952 hospitalizations determined by adjudicators to be caused by COVID-19, 319 (34%) participants were critically ill and 210 (22%) died. Pneumonia was confirmed in 822 (86%) and acute kidney injury in 350 (37%); other cardiovascular and thrombotic complications were rare (2–5%). Interrater reliability among adjudicators was high (kappa = 0.85–1.00) except for myocardial infarction (kappa = 0.60). Compared to adjudication, sensitivity of discharge diagnosis codes was higher for pneumonia (84%) and pulmonary embolism (81%) than for other complications (48–70%). Conclusions: Protocolized adjudication confirmed four out of five COVID-19 hospitalizations in a US meta-cohort and confirmed cases of pneumonia, pulmonary embolism, and other conditions that were not indicated by discharge diagnosis codes. These results highlight the importance of validating health outcomes for use in research on COVID-19 and post-COVID-19 conditions, and some limitations of claims-based data.

BACKGROUND: Proximity to urban blue and green spaces has been associated with improved cardiovascular health; however, few studies have examined the role of race and socioeconomic status in these associations. METHODS: Data were from the CARDIA study (Coronary Artery Risk Development in Young Adults). We included longitudinal measurements (1985–1986 to 2010–2011) of blue and green spaces, including percentage of blue space cover, distance to the nearest river, green space cover, and distance to the nearest major park. Presence of coronary artery calcification (CAC) was measured with noncontrast cardiac computed tomography in 2010 to 2011. The associations of blue and green spaces with CAC were assessed with generalized estimating equation regression with adjustment for demographics, individual and neighborhood socioeconomic status, health-related behaviors, and other health conditions. We conducted stratified analyses by race and neighborhood deprivation score to investigate whether the association varied according to social determinants of health. RESULTS: The analytic sample included 1365 Black and 1555 White participants with a mean±SD age of 50.1±3.6 years. Among Black participants, shorter distance to a river and greater green space cover were associated with lower odds of CAC (per interquartile range decrease [1.45 km] to the river: odds ratio [OR], 0.90 [95% CI, 0.84–0.96]; per 10 percentage-point increase of green space cover: OR, 0.85 [95% CI, 0.75–0.95]). Among participants in deprived neighborhoods, greater green space cover was associated with lower odds of CAC (per a 10 percentage-point increase: OR, 0.89 [95% CI, 0.80–0.99]), whereas shorter distance to the park was associated with higher odds of CAC (per an interquartile range decrease [5.3 km]: OR, 1.07 [95% CI, 1.00–1.15]). Black participants in deprived neighborhoods had lower odds of CAC with shorter distance to a river (per an interquartile range decrease: OR, 0.90 [95% CI, 0.82–0.98]) and greater green space cover (per a 10 percentage-point increase: OR, 0.85 [95% CI, 0.75–0.97]). There was no statistical interaction between the blue and green spaces and race or neighborhood characteristics in association with CAC. CONCLUSIONS: Longitudinally, shorter distance to a river and greater green space cover were associated with less CAC among Black participants and those in deprived neighborhoods. Shorter distance to a park was associated with increased odds of CAC among participants in deprived neighborhoods. Black participants residing in more deprived neighborhoods showed lower odds of CAC in association with greater exposure to river and green space cover.