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Nocturnal Blood Pressure Dipping, Acculturation, and the Metabolic Syndrome in Hispanic Women

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Title: Nocturnal Blood Pressure Dipping, Acculturation, and the Metabolic Syndrome in Hispanic Women


1
Nocturnal Blood Pressure Dipping, Acculturation,
and the Metabolic Syndrome in Hispanic Women
  • Smriti Shivpuri, M.S.
  • Linda C. Gallo, Ph.D.
  • San Diego State University/
  • University of California San Diego
  • Joint Doctoral Program in Clinical Psychology

2
Nocturnal Blood Pressure (NBP) Dipping
  • NBP dipping defined as difference between diurnal
    and nocturnal levels of BP
  • Typical NBP dipping in adults 10-20
  • Classification
  • Non-dippers lt10
  • Dippers gt/ 10
  • Extreme Dippers gt20
  • Reverse Dippers higher nocturnal BP

3
NBP Dipping and Cardiovascular Disease (CVD)
Outcomes
  • Non-dipping linked to increased risk of a variety
    of CVD outcomes
  • Heart failure, Myocardial Infarction1
  • Stroke2
  • Sudden Death1
  • Target Organ damage3
  • Carotid IMT4
  • Left ventricular hypertrophy5
  • Mediating physiological mechanisms poorly
    understood

4
Metabolic Syndrome (MetSyn)
  • Syndrome characterized by constellation of risk
    factors of metabolic origin
  • Defined by NCEP ATPIIIa as 3 of following
    (women)

aNational Cholesterol Education Program Adult
Treatment Panel III
5
Metabolic Syndrome
  • MetSyn may be mediating mechanism between NBP
    dipping and CVD
  • Associated with almost three-fold increased risk
    of CVD6
  • Research addressing association between NBP
    dipping and the MetSyn is limited
  • Linked to NBP Dipping in some studies
  • Greater prevalence of MetSyn in non-dippers
    versus dippers7,8, 9
  • Higher mean score of MetSyn (when measured
    continuously) in non-dippers than dippers10
  • No association in other studies11

6
NBP Dipping in Hispanics
  • Evidence exists that NBP Dipping differs by race
  • African-Americans more likely to have blunted
    NBP Dipping than non-Hispanic Whites, and be
    classified as non-dippers12,13
  • Little to no work to date on NBP Dipping and CVD
    outcomes in Hispanics
  • Some evidence that Hispanic men may be more
    likely to be non-dippers than non-Hispanic
    Whites, but not true for Hispanic women14
  • One study found greater odds of stroke in
    nondippers versus dippers for African-Americans
    and non-Hispanic Whites, but not in Caribbean
    Hispanics15

7
NBP Dipping and MetSyn in Hispanics
  • Among ethnic minority groups in U.S.,
    Mexican-Americans have one of highest rates of
    MetSyn16
  • No studies have looked at link between NBP
    Dipping and MetSyn in Hispanics or non-diseased
    populations, or examined whether acculturation,
    which has been shown to affect the relationship
    between risk factors and CVD outcomes, moderates
    relationship

Note. Image courtesy http//img.medscape.com/slid
e/migrated/editorial/cmecircle/2006/5186/images/ca
ballero/slide032.gif
8
Current Study
  • Purpose To examine relationship between NBP
    dipping and MetSyn in Mexican-American women and
    explore whether association is modified by
    acculturation level
  • Sample 277 middle-aged (M49.56yrs) healthy
    Mexican-American women, recruited from South San
    Diego border community
  • Inclusion criteria age between 40-65 years,
    Mexican-American ethnicity, literate in English
    or Spanish, and free of major health conditions
    (e.g., CVD, cancer) and medications with
    autonomic effects
  • Methods Completed battery of questionnaires
    assessing sociodemographic, health
    history/behavior, and psychosocial factors, and
    next day underwent assessment of MetSyn
    components and completed 36hr ambulatory BP
    (AmBP) protocol

9
Assessment
  • NBP Dipping
  • AmBP monitor recorded participants BP every half
    hour during day, every hour during night
  • Resulted in an average of 60 BP readings per
    person over 36 hours
  • Calculated as (average diurnal BP - average
    NBP)/ average diurnal BP100
  • Acculturation
  • Measured using preferred language version of
    survey (commonly used proxy)
  • Low Acculturated (Spanish) 0 High Acculturated
    (English) 1
  • MetSyn (defined using NCEP ATP III criteria)
  • Waist circumference, height, weight measured by
    trained assessors
  • Average SBP, DBP recorded as mean of 3
    measurements while seated
  • Glucose, HDL, triglycerides obtained through
    fasting blood draw

10
Analyses
  • Hierarchical Linear Modeling (HLM) used to obtain
    average diurnal and nocturnal BP levels across
    repeated measurements while accounting for
    nesting of measurements within individuals
  • Logistic Regression used to test effects of NBP
    dipping (SBP and DBP), acculturation, and their
    interaction on probability of MetSyn
  • Covariates (identified from prior research)
    included
  • Average daytime BP
  • Age
  • Body Mass Index
  • Socioeconomic status (measured by educational
    attainment)

11
Results
  • No significant association between Diastolic BP
    dipping or Diastolic NBP dippingAcculturation
    interaction and MetSyn
  • Significant Systolic NBP (NSBP)
    dippingAcculturation interaction

12
Results
  • Decreased NSBP dipping associated with increased
    risk for MetSyn (i.e., increased NSBP dipping
    protective), but only for high acculturated women

Association between Gradations of Systolic NBP
(NSBP) Dipping and Odds of MetSyn in High
Acculturated women



Odds Ratios
p lt .05 plt.10
13
Conclusions
  • Systolic NBP dipping associated with MetSyn in
    high-acculturated but not low-acculturated
    Mexican-American women
  • Each 10 decrease in dipping associated with 3.67
    increased odds of MetSyn
  • Trend for non-dippers having three fold greater
    odds of MetSyn as compared to dippers (p.06)
  • Diastolic NBP dipping not associated with MetSyn
  • Finding suggests mechanisms by which NBP dipping
    relate to MetSyn may differ by acculturation
  • Less acculturated, more traditional women may be
    buffered against harmful metabolic effects of
    increased blood pressure load

14
Potential Buffering Mechanisms
  • Sociodemographic Factors
  • Marital Status, Income
  • Psychosocial Factors
  • Social support, Anger, Hostility, Chronic Stress,
    Racism
  • Behavioral Factors
  • Smoking, alcohol consumption, physical activity
  • Addition of these factors in exploratory
    follow-up analyses attenuated interaction effect,
    but it remained statistically significant
  • Interestingly, for high-acculturated women NSBP
    dipping associated with DBP, waist circumference
    and HDL components of MetSyn for
    low-acculturated, only waist circumference

15
Limitations/Future Directions
  • Limitations
  • Cross-sectional study
  • Ambulatory BP measurement for dipping only 36
    hour cycle
  • No gender or ethnic comparisons possible
  • Future directions
  • Explore whether NBP dipping association with CVD
    outcomes varies by acculturation status in
    Hispanics
  • Determine whether NBP dipping is related to
    other, non-metabolic factors in low-acculturated
    Hispanics (e.g., serum uric acid levels,
    hyperthyroidism, hyperaldosteronism)17
  • Cross-gender and cross-ethnic comparisons with
    Hispanics on association between NBP dipping and
    CVD outcomes

16
References
  1. Staessen, J., Thijs, L., Fagard, R., O'Brien, E.,
    Clement, D., de Leeuw, P., Webster, J. (1999).
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17
References
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18
References
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19
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