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Although persuasive work on the impact of shifts of small magnitude in the population distribution of blood pressure on the risk for CHD and stroke has been conducted93-95, little work of this kind has been reported to date to assess the
population impact of modest changes in adiposity, despite the dynamic nature of adiposity distributions in the young96.
Although only a few population-based prospective studies have examined the relationship between changes in BMI (measured as a continuous variable) and changes in cardio-metabolic risk factors (measured as continuous variables)11,
Droyvold et al.97 examined the association between BMI and blood pressure using
data from the Nord-Trondelag Health Study (HUNT). Among this group of 29,817 participants of mean age 50 years, changes in BMI had an independent effect on
changes in SBP in both sexes. Findings from the multicenter longitudinal bi-racial Coronary Artery Risk Development in Young Adults (CARDIA) study of 3,095 participants showed that the strongest predictor of both insulin resistance and
increase in glucose levels was an increase in BMI11. Increases in adiposity, whether
measured as BMI or % body fat were associated with adverse changes in blood pressure, lipids, and insulin levels regardless of initial weight, age, race or gender98.
A linear association has also been shown between weight gain and increased levels of C-reactive protein, a measure of systemic inflammation, thereby providing a mechanism to explain some of the association between adiposity and cardio- metabolic risk factors13.
Considering the marked temporal trends of increasing adiposity99, the
evidence that the cardio-metabolic risk factors associated with the detrimental health effects of adiposity can be reversed with weight loss15,100, and the growing burden of
CVD33, primary prevention strategies at a population level are an urgent and
important need. Associations between adiposity and cardio-metabolic risk factors extend beyond categorically defined obesity to adiposity in the modal region of the population distribution28,101. For this dissertation, we used methods already
described for blood pressure and CVD outcomes. A large proportion of blood pressure - related CVD events occur in individuals within the modal region of the population distribution where blood pressure falls below the threshold for
antihypertensive drug therapy. Three studies in particular highlighted the impact of small shifts in the population distribution of blood pressure on the risk of CHD events93-95. One study using data from the Third National Health and Examination
Survey (NHANES III) examined the impact on occurrence of CHD events associated with small shifts in the population distribution of SBP that would be seen through population-wide adoption of the Dietary Approaches to Stop Hypertension (DASH) diet95. After adjusting for race and baseline SBP, a population-wide SBP reduction of
5.5 mmHg was associated with a reduction of 416,514 CHD events. A greater relative reduction was observed for African Americans95.
Another study used data from the Framingham study and NHANES II to estimate the impact of small reductions in the population-wide distribution of diastolic blood pressure (DBP) through population-wide lifestyle modification on CHD and stroke. These authors found that a population-wide reduction of 2 mmHg in DBP would result in a 6% reduction in risk of CHD and a 15% reduction in risk of stroke and transient ischemic attacks (TIA)93. An overall upward shift in the population
distribution of BMI over time has been described across the NHANES and
Framingham data, suggesting the need to address the predictors of adverse health effects associated with adiposity at the population level and the health benefits of arresting current trends rather than focusing only on the individual99. Similar to blood
pressure, a large proportion of adiposity – related CVD events would likely occur in the modal region of the population distribution. The individuals in this region would not be classified as obese and would therefore fall below the threshold category for being classified as high-risk. For this dissertation, we hypothesized that small population-wide reductions in BMI and WC would be associated with significant reductions in CVD burden.
Further support for lifestyle modifications using population level strategies for reduction of cardio-metabolic risk factors was reported in a meta-analysis of 23 RCTs conducted between 1996 and 2011 in multiple countries102. These authors
examined the effects of low-carbohydrate diets versus low-fat diets on metabolic risk factors. Reductions in body weight, WC, and other metabolic risk factors were not significantly different between the two diets. Both diet intervention types showed that lifestyle modifications achieved small reductions in weight that were associated with reductions in cardio-metabolic risk factors including total cholesterol, LDL, HDL, triglycerides, SBP and DBP, FPG and insulin.
Recommendations for achieving the goal of the American Heart Association (AHA) to improve cardiovascular health 20% by 2020 include nationwide primordial prevention efforts at the population and individual level9. The paradigm of prevention
strategies proposed by Rose103,104 emphasized the importance of population
prevention strategies for risk factors and their associated chronic diseases since “high risk” prevention strategies that focus on the individual are limited in their ability to reduce burden of disease in the population. The individual-centered or “high-risk” strategy aims to truncate the risk distribution, whereas the population strategy aims to reduce disease outcomes by shifting the whole population distribution of a risk factor in a favorable direction. Because a large number of outcomes occur in the modal region of the distribution, a shift in the whole distribution of the risk factor would likely reduce outcomes more effectively than a truncation of the upper tail region of the distribution.
For this dissertation, we examined methods of prevention that move away from the individual-centered approach and towards a population-based approach. This would offer better measures of etiological outcome and public health
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