Racial/ethnic disparities in self-reported short sleep duration among US-born and foreign-born adults

OBJECTIVE

Racial/ethnic health disparities are infrequently considered by nativity status in the United States, although the immigrant population has practically doubled since 1990. We investigated the modifying role of nativity status (US- vs. foreign-born) on racial/ethnic disparities in short sleep duration (<7 h), which has serious health consequences.

DESIGN

Cross-sectional data from 23,505 US-born and 4,326 foreign-born adults aged ≥ 18 years from the 2012 National Health Interview Survey and multivariable log-linear regression were used to estimate prevalence ratios (PR) for reporting short sleep duration and their corresponding 95% confidence intervals (CI).

RESULTS

After controlling for sociodemographic covariates, short sleep was more prevalent among blacks (PR 1.29, 95% CI: 1.21-1.37), Hispanics (PR 1.18, 95% CI: 1.08, 1.29), and Asians (PR 1.37, 95% CI: 1.16-1.61) than whites among US-born adults. Short sleep was more prevalent among blacks (PR 1.71, 95% CI: 1.38, 2.13) and Asians (PR 1.23, 95% CI: 1.02, 1.47) than whites among the foreign-born.

CONCLUSION

Among both US- and foreign-born adults, blacks and Asians had a higher likelihood of short sleep compared to whites. US-born Hispanics, but not foreign-born Hispanics, had a higher likelihood than their white counterparts. Future research should aim to uncover mechanisms underlying these disparities.

Distribution of lifestyle and emerging risk factors by 10-year risk for coronary heart disease

BACKGROUND

The Framingham risk score has been used for coronary heart disease (CHD) risk assessment. Recently, additional risk factors not included in the Framingham algorithm have received much attention and may help improve risk assessment. We examined the distributions of lifestyle and emerging risk factors by 10-year risk of CHD.

METHODS

We calculated 10-year CHD risk (<10%, 10-20%, and >20%) for 8355 participants in the National Health and Nutrition Examination Survey (NHANES) 1999-2002 using the Framingham risk score as modified by the National Cholesterol Education Program Adult Treatment Panel III guidelines. We examined the prevalence of lifestyle risk factors [body mass index (BMI) and waist circumference] and various emerging risk factors [C-reactive protein (CRP), white blood cell count, fibrinogen, homocysteine, glycosylated hemoglobin, and albuminuria] as well as prevalence of high CHD risk by levels of these risk factors.

RESULTS

All examined CHD risk factors were significantly associated with increasing 10-year CHD risk among men and women. Odds of being in the highest CHD risk group were greater at higher levels of examined risk factors. Means for most risk factors were slightly higher for women than the means for men. Sizeable proportions of participants with lower 10-year CHD risk had high levels of lifestyle and emerging risk factors: 60.8% were overweight, 33.8% had high CRP concentrations, 24.1% had serum fibrinogen >400 mg/dl and 6% had an albumin/creatinine ratio >/=30.

CONCLUSIONS

Lifestyle and emerging risk factors, in addition to those included in the Framingham risk score, may be important in CHD risk assessment.

Camine Con Nosotros: Connecting Theory and Practice for Promoting Physical Activity among Hispanic Women

Despite the popularity and widespread use of theory in health education, practitioners still find it difficult to design and implement theory-based interventions. This is especially true when working with ethnic/racial minority groups, including Hispanic groups. Practitioners working with Hispanic communities face additional barriers that may often discourage them from using theories when planning interventions. These barriers include the diversity that exists within the Hispanic population, lack of reliable data, and issues related to cross-cultural applicability of current behavior theories. However, the use of theory constitutes a valuable tool for developing more effective programs, and theorist researchers should be more sensitive to practitioners’ needs. By explaining the processes for selecting and applying theory in the same detail as outcome results, researchers will contribute to increasing practitioners’ interest in theory. This article describes Camine con Nosotros, a theory-based physical activity program for Hispanic women, and explains the process of selecting the theoretical framework of the program and connecting theory and practice.

Trends in mortality from COPD among adults in the United States

BACKGROUND

COPD imposes a large public health burden internationally and in the United States. The objective of this study was to examine trends in mortality from COPD among US adults from 1968 to 2011.

METHODS

Data from the National Vital Statistics System from 1968 to 2011 for adults aged ≥ 25 years were accessed, and trends in mortality rates were examined with Joinpoint analysis.

RESULTS

Among all adults, age-adjusted mortality rate rose from 29.4 per 100,000 population in 1968 to 67.0 per 100,000 population in 1999 and then declined to 63.7 per 100,000 population in 2011 (annual percentage change [APC] 2000-2011, -0.2%; 95% CI, -0.6 to 0.2). The age-adjusted mortality rate among men peaked in 1999 and then declined (APC 1999-2011, -1.1%; 95% CI, -1.4 to -0.7), whereas the age-adjusted mortality rate among women increased from 2000 to 2011, peaking in 2008 (APC 2000-2011, 0.4%; 95% CI, 0.0-0.9). Despite a narrowing of the sex gap, mortality rates in men continued to exceed those in women. Evidence of a decline in the APC was noted for black men (1999-2011, -1.5%; 95% CI, -2.1 to -1.0) and white men (1999-2011, -0.9%; 95% CI, -1.3 to -0.6), adults aged 55 to 64 years (1989-2011, -1.0%; 95% CI, -1.2 to -0.8), and adults aged 65 to 74 years (1999-2011, -1.2%; 95% CI, -1.6 to -0.9).

CONCLUSIONS

In the United States, the mortality rate from COPD has declined since 1999 in men and some age groups but appears to be still rising in women, albeit at a reduced pace.

Cigarette Smoking, Tooth Loss, and Chronic Obstructive Pulmonary Disease: Findings From the Behavioral Risk Factor Surveillance System

BACKGROUND

Cigarette smoking and tooth loss are seldom considered concurrently as determinants of chronic obstructive pulmonary disease (COPD). This study examines the multiplicative effect of self-reported tooth loss and cigarette smoking on COPD among United States adults aged ≥18 years.

METHODS

Data were taken from the 2012 Behavioral Risk Factor Surveillance System (n = 439,637). Log-linear regression-estimated prevalence ratios (PRs) are reported for the interaction of combinations of tooth loss (0, 1 to 5, 6 to 31, or all) and cigarettes smoking status (never, former, or current) with COPD after adjusting for age, sex, race/ethnicity, marital status, educational attainment, employment, health insurance coverage, dental care utilization, and diabetes.

RESULTS

Overall, 45.7% respondents reported having ≥1 teeth removed from tooth decay or gum disease, 18.9% reported being current cigarette smokers, and 6.3% reported having COPD. Smoking and tooth loss from tooth decay or gum disease were associated with an increased likelihood of COPD. Compared with never smokers with no teeth removed, all combinations of smoking status categories and tooth loss had a higher likelihood of COPD, with adjusted PRs ranging from 1.5 (never smoker with 1 to 5 teeth removed) to 6.5 (current smoker with all teeth removed) (all P <0.05).

CONCLUSIONS

Tooth loss status significantly modifies the association between cigarette smoking and COPD. An increased understanding of causal mechanisms linking cigarette smoking, oral health, and COPD, particularly the role of tooth loss, infection, and subsequent inflammation, is essential to reduce the burden of COPD. Health providers should counsel their patients about cigarette smoking, preventive dental care, and COPD risk.

Are the Recent Secular Increases in Waist Circumference among Children and Adolescents Independent of Changes in BMI?

Background

Several studies have shown that the waist circumference of children and adolescents has increased over the last 25 years. However, given the strong correlation between waist circumference and BMI, it is uncertain if the secular trends in waist circumference are independent of those in BMI.

Methods

We analyzed data from 6- to 19-year-olds who participated in the 1988–1994 through 2011–2012 cycles of the National Health and Nutrition Examination Survey to assess whether the trends in waist circumference were independent of changes in BMI, race-ethnicity and age.

Results

Mean, unadjusted levels of waist circumference increased by 3.7 cm (boys) and 6.0 cm (girls) from 1988–94 through 2011–12, while mean BMI levels increased by 1.1 kg/m² (boys) and 1.6 kg/m² (girls). Overall, the proportional changes in mean levels of both waist circumference and BMI were fairly similar among boys (5.3%, waist vs. 5.6%, BMI) and girls (8.7%, waist vs. 7.7%, BMI). As assessed by the area under the curve, adjustment for BMI reduced the secular increases in waist circumference by about 75% (boys) and 50% (girls) beyond that attributable to age and race-ethnicity. There was also a race-ethnicity interaction (p < 0.001). Adjustment for BMI reduced the secular trend in waist circumference among non-Hispanic (NH) black children (boys and girls) to a greater extent (about 90%) than among other children.

Conclusions

Our results indicate that among children in the U.S., about 75% (boys) and 50% (girls) of the secular increases in waist circumference since 1988–94 can be accounted for by changes in BMI. The reasons for the larger independent effects among girls and among NH blacks are uncertain.

Gender- and race-specific metabolic score and cardiovascular disease mortality in adults: A structural equation modeling approach--United States, 1988-2006

OBJECTIVE

Consider all metabolic syndrome (MetS) components [systolic (SBP) and diastolic (DBP) blood pressures, waist circumference, HDL cholesterol, triglycerides (TG), and fasting glucose] and gender/race differential risk when assessing cardiovascular disease (CVD) risk.

METHODS

We estimated a gender- and race-specific continuous MetS score using structural equation modeling and tested its association with CVD mortality using data from National Health and Nutrition Examination Survey III linked with the National Death Index. Cox proportional hazard regression tested the association adjusted for sociodemographic and behavior characteristics.

RESULTS

For men, continuous MetS components associated with CVD mortality were SBP (hazard ratio = 1.50, 95% confidence interval = 1.14-1.96), DBP (1.48, 1.16-1.90), and TG (1.15, 1.12-1.16). In women, SBP (1.44, 1.27-1.63) and DBP (1.24, 1.02-1.51) were associated with CVD mortality. MetS score was not significantly associated with CVD mortality in men; but significant associations were found for all women (1.34, 1.06-1.68), non-Hispanic white women (1.29, 1.01-1.64), non-Hispanic black women (2.03, 1.12-3.69), and Mexican-American women (3.57, 2.21-5.76). Goodness-of-fit and concordance were overall better for models with the MetS score than MetS (yes/no).

CONCLUSIONS

When assessing CVD mortality risk, MetS score provided additional information than MetS (yes/no).

Coronary Heart Disease Mortality Declines in the United States From 1979 Through 2011: Evidence for Stagnation in Young Adults, Especially Women

BACKGROUND

Coronary heart disease (CHD) mortality rates have fallen dramatically over the past 4 decades in the Western world. However, recent data from the United States and elsewhere suggest a plateauing of CHD incidence and mortality among young women. We therefore examined recent trends in CHD mortality rates in the United States according to age and sex.

METHODS AND RESULTS

We analyzed mortality data between 1979 and 2011 for US adults ≥25 years of age. We calculated age-specific CHD mortality rates and compared estimated annual percentage changes during 3 approximate decades of data (1979-1989, 1990-1999, and 2000-2011). We then used Joinpoint regression modeling to assess changes in trends over time on the basis of inflection points of the mortality rates. Adults ≥65 years of age showed consistent mortality declines, which became even steeper after 2000 (women, -5.0%; men, -4.4%). In contrast, young men and women (<55 years of age) initially showed a clear decline in CHD mortality from 1979 until 1989 (estimated annual percentage change, -5.5% in men and -4.6% in women). However, the 2 subsequent decades saw stagnation with minimal improvement. Notably, young women demonstrated no improvements between 1990 and 1999 (estimated annual percentage change, 0.1%) and only -1% estimated annual percentage change since 2000. Joinpoint analyses provided consistent results.

CONCLUSIONS

The dramatic decline in CHD mortality since 1979 conceals major heterogeneities. CHD death rates in older groups are now falling steeply. However, young adults have experienced frustratingly small decreases in CHD mortality rates since 1990. The drivers of these major differences in CHD mortality trends by age and sex merit urgent study.

Trends in Outpatient Visits with Benzodiazepines among US Adults With and Without Bronchitis or Chronic Obstructive Pulmonary Disease from 1999 to 2010

Little is known about trends in prescriptions for benzodiazepines among patients with chronic obstructive pulmonary disease (COPD). Our objective was to examine trends of office/outpatient department visits with a mention of a benzodiazepine made by patients aged ≥40 years with COPD in the United States. We used data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1999-2010. From 1999 to 2010, the estimated numbers of office/outpatient department visits with a benzodiazepine mentioned increased from 20.7 million to 43.2 million among all patients, from 684,000 to 1.5 million among patients with COPD, and from 20.0 million to 41.7 million among patients without COPD. Using all 12-years of data, patients with COPD were more likely to have a visit with a mention of a benzodiazepine than patients without COPD (adjusted prevalence ratio = 1.48, 95% CI = 1.27-1.71).The unadjusted percentage of all office/outpatient department visits by patients with COPD with a mention of a benzodiazepine increased from 4.6% during 1999-2002 to 10.2% during 2007-2010 (P trend < 0.001). After adjustment for age, sex, and race, the adjusted prevalence ratio for 2007-2010 compared with 1999-2002 was 2.26 (95% confidence interval: 1.60-3.17). Since 1999, the number and percentage of office/outpatient department visits with a mention of a benzodiazepine by patients with COPD and all patients may have increased in the United States.

Independent and joint associations of race/ethnicity and educational attainment with sleep-related symptoms in a population-based US sample

OBJECTIVE

Prior studies have documented disparities in short and long sleep duration, excessive daytime sleepiness, and insomnia by educational attainment and race/ethnicity separately. We examined both independent and interactive effects of these factors with a broader range of sleep indicators in a racially/ethnically diverse sample.

METHODS

We analyzed 2012 National Health Interview Survey data from 33,865 adults aged ≥18years. Sleep-related symptomatology included short sleep duration (≤6h), long sleep duration (≥9h), fatigue >3days, excessive daytime sleepiness, and insomnia. Bivariate analyses with chi-square tests and log-linear regression were performed.

RESULTS

The overall age-adjusted prevalence was 29.1% for short sleep duration, 8.5% for long sleep duration, 15.1% for fatigue, 12.6% for excessive daytime sleepiness, and 18.8% for insomnia. Educational attainment and race/ethnicity were independently related to the five sleep-related symptoms. Among Whites, the likelihood of most sleep indicators increased as educational attainment decreased; relationships varied for the other racial/ethnic groups. For short sleep duration, the educational attainment-by-race/ethnicity interaction effect was significant for African Americans (p<0.0001), Hispanics (p<0.0001), and Asians (p=0.0233) compared to Whites. For long sleep duration, the interaction was significant for Hispanics only (p=0.0003).

CONCLUSIONS

Our results demonstrate the importance of examining both educational attainment and race/ethnicity simultaneously to more fully understand disparities in sleep health. Increased understanding of the mechanisms linking sociodemographic factors to sleep health is needed to determine whether policies and programs to increase educational attainment may also reduce these disparities within an increasingly diverse population.

Hospital discharges, readmissions, and ED visits for COPD or bronchiectasis among US adults: findings from the nationwide inpatient sample 2001-2012 and Nationwide Emergency Department Sample 2006-2011

BACKGROUND

Numbers and rates of hospitalizations and ED visits by patients with COPD are important metrics for surveillance purposes. The objective of this study was to examine trends in these rates from 2001 to 2012 among adults aged ≥ 18 years in the United States.

METHODS

Data from the Nationwide Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS) were examined for temporal trends in the numbers and rates of hospitalizations by patients with COPD or bronchiectasis, mean length of stay, in-hospital case-fatality rate, 30-day readmission rate, and numbers and rates of ED visits.

RESULTS

The national number of discharges with COPD or bronchiectasis as the principal diagnosis was about 88,000 higher in 2012 than in 2001, but the age-adjusted rate of discharges did not change significantly (range, 242.7-286.0 per 100,000 population, P trend = .554). In contrast, hospitalization rates for common cardiovascular disorders, pneumonia, and lung cancer decreased significantly by 27% to 68%, whereas the mean charge doubled and mean cost increased by 40%. From 2006 to 2011, the numbers of ED visits increased from 1,480,363 to 1,787,612. The age-adjusted rate increased nonsignificantly from 654 to 725 per 100,000 population (P trend = .072).

CONCLUSIONS

Despite many local and national efforts to reduce the burden of COPD, total hospitalizations and ED visits over the past decade have increased for COPD, and the age-adjusted rates of hospitalizations and ED visits for COPD or bronchiectasis have not changed significantly in the United States.

Trends in Self-Reported Sleep Duration among US Adults from 1985 to 2012

STUDY OBJECTIVE

The trend in sleep duration in the United States population remains uncertain. Our objective was to examine changes in sleep duration from 1985 to 2012 among US adults.

DESIGN

Trend analysis.

SETTING

Civilian noninstitutional population of the United States.

PARTICIPANTS

324,242 US adults aged ≥ 18 y of the National Health Interview Survey (1985, 1990, and 2004-2012).

MEASUREMENTS AND RESULTS

Sleep duration was defined on the basis of the question "On average, how many hours of sleep do you get in a 24-h period?" The age-adjusted mean sleep duration was 7.40 h (standard error [SE] 0.01) in 1985, 7.29 h (SE 0.01) in 1990, 7.18 h (SE 0.01) in 2004, and 7.18 h (SE 0.01) in 2012 (P 2012 versus 1985 < 0.001; P trend 2004-2012 = 0.982). The age-adjusted percentage of adults sleeping ≤ 6 h was 22.3% (SE 0.3) in 1985, 24.4% (SE 0.3) in 1990, 28.6% (SE 0.3) in 2004, and 29.2% (SE 0.3) in 2012 (P 2012 versus 1985 < 0.001; P trend 2004-2012 = 0.050). In 2012, approximately 70.1 million US adults reported sleeping ≤ 6 h.

CONCLUSIONS

Since 1985, age-adjusted mean sleep duration has decreased slightly and the percentage of adults sleeping ≤ 6 h increased by 31%. Since 2004, however, mean sleep duration and the percentage of adults sleeping ≤ 6 h have changed little.

Lung function, 25-hydroxyvitamin D concentrations and mortality in US adults

OBJECTIVE

To explore the associations between serum concentrations of vitamin D (25(OH)D) and all-cause mortality among US adults defined by lung function (LF) status, particularly among adults with obstructive LF (OLF).

METHODS

Data from 10,795 adults aged 20-79 years (685 with restrictive LF (RLF) and 1309 with OLF) who participated in the Third National Health and Nutrition Examination Survey (1988-1994), had a spirometric examination, and were followed through 2006 were included.

RESULTS

During 14.2 years of follow-up, 1792 participants died. Mean adjusted concentrations of 25(OH)D were 75.0 nmol/l (s.e. 0.7) for adults with normal LF (NLF), 70.4 nmol/l (s.e. 1.8) for adults with RLF, 75.5 nmol/l (s.e. 1.5) for adults with mild obstruction and 71.0 nmol/l (s.e. 1.9) among adults with moderate or worse obstruction (P=0.030). After adjustment for sociodemographic factors, lifestyle factors, clinical variables and prevalent chronic conditions, a concentration of <25 nmol/l compared with ⩾ 75 nmol//l was associated with mortality only among adults with NLF (hazard ratio (HR) 1.76; 95% confidence interval (CI) 1.03, 3.00). Among participants with OLF, adjusted HRs were 0.65 (95% CI 0.29, 1.48), 1.21 (95% CI 0.89, 1.66) and 0.97 (95% CI 0.78, 1.19) among those with concentrations <25, 25-<50 and 50-<75 nmol/l, respectively.

CONCLUSIONS

Baseline concentrations of 25(OH)D did not significantly predict mortality among US adults with impaired LF.

Employment and activity limitations among adults with chronic obstructive pulmonary disease--United States, 2013

Chronic obstructive pulmonary disease (COPD) is a group of progressive respiratory conditions, including emphysema and chronic bronchitis, characterized by airflow obstruction and symptoms such as shortness of breath, chronic cough, and sputum production. COPD is an important contributor to mortality and disability in the United States. Healthy People 2020 has several COPD-related objectives,* including to reduce activity limitations among adults with COPD. To assess the state-level prevalence of COPD and the association of COPD with various activity limitations among U.S. adults, CDC analyzed data from the 2013 Behavioral Risk Factor Surveillance System (BRFSS). Among U.S. adults in all 50 states, the District of Columbia (DC), and two U.S. territories, 6.4% (an estimated 15.7 million adults) had been told by a physician or other health professional that they have COPD. Adults who reported having COPD were more likely to report being unable to work (24.3% versus 5.3%), having an activity limitation caused by health problems (49.6% versus 16.9%), having difficulty walking or climbing stairs (38.4% versus 11.3%), or using special equipment to manage health problems (22.1% versus 6.7%), compared with adults without COPD. Smokers who have been diagnosed with COPD are encouraged to quit smoking, which can slow the progression of the disease and reduce mobility impairment. In addition, COPD patients should consider participation in a pulmonary rehabilitation program that combines patient education and exercise training to address barriers to physical activity, such as respiratory symptoms and muscle wasting.

Total and state-specific medical and absenteeism costs of COPD among adults aged ≥ 18 years in the United States for 2010 and projections through 2020

BACKGROUND

COPD remains a leading cause of morbidity and mortality. The objectives of this study were to estimate (1) national US COPD-attributable annual medical costs by payer (direct) and absenteeism (indirect) in 2010 and projected medical costs through 2020 and (2) state-specific COPD-attributable medical and absenteeism costs in 2010.

METHODS

We used the 2006-2010 Medical Expenditure Panel Survey, the 2004 National Nursing Home Survey, and 2010 Centers for Medicare and Medicaid Services data to generate cost estimates and 2010 census data to project medical costs through 2020.

RESULTS

In 2010, total national medical costs attributable to COPD and its sequelae were estimated at $32.1 billion, and total absenteeism costs were $3.9 billion, for a total burden of COPD-attributable costs of $36 billion. An estimated 16.4 million days of work were lost because of COPD. Of the medical costs, 18% was paid for by private insurance, 51% by Medicare, and 25% by Medicaid. National medical costs are projected to increase from $32.1 billion in 2010 to $49.0 billion in 2020. Total state-specific costs in 2010 ranged from $49.1 million in Wyoming to $2.8 billion in California: medical costs ranged from $42.5 million in Alaska to $2.5 billion in Florida and absenteeism costs ranged from $8.4 million in Wyoming to $434.0 million in California.

CONCLUSIONS

Costs attributable to COPD and its sequelae are substantial and are projected to increase through 2020. Evidence-based interventions that prevent tobacco use and reduce the clinical complications of COPD may result in potential decreased COPD-attributable costs.

Urinary albumin-creatinine ratio, estimated glomerular filtration rate, and all-cause mortality among US adults with obstructive lung function

BACKGROUND

Elevated urinary albumin-creatinine ratio (UACR) and decreased estimated glomerular filtration rate (eGFR) predict all-cause mortality, but whether these markers of kidney damage and function do so in adults with obstructive lung function (OLF) is unclear. The objective of this study was to examine the associations between UACR and eGFR and all-cause mortality in adults with OLF.

METHODS

Data of 5,711 US adults aged 40 to 79 years, including 1,390 adults with any OLF who participated in the National Health and Nutrition Examination Survey III (1988-1994), were analyzed. Mortality follow-up was conducted through 2006.

RESULTS

During the median follow-up of 13.7 years, 650 adults with OLF died. After maximal adjustment, mean levels of UACR were higher in adults with moderate-severe OLF (7.5 mg/g; 95% CI, 6.7-8.5) than in adults with normal pulmonary function (6.2 mg/g; 95% CI, 5.8-6.6) (P = .003) and mild OLF (6.2 mg/g; 95% CI, 5.5-6.9) (P = .014). Adjusted mean levels of eGFR were lower in adults with moderate-severe OLF (87.6 mL/min/1.73 m²; 95% CI, 86.0-89.1) than in adults with normal lung function (89.6 mL/min/1.73 m²; 95% CI, 88.9-90.3) (P = .015). Among adults with OLF, hazard ratios for all-cause mortality increased as levels of UACR, modeled as categorical or continuous variables, increased (maximally adjusted hazard ratio for quintile 5 vs 1: 2.23; 95% CI, 1.56-3.18). eGFR, modeled as a continuous variable but not as quintiles, was significantly associated with mortality.

CONCLUSIONS

UACR and eGFR, in continuous form, were associated with all-cause mortality among US adults with OLF.

Inflammatory markers and mortality among US adults with obstructive lung function

BACKGROUND AND OBJECTIVE

Chronic obstructive pulmonary disease is characterized by an inflammatory state of uncertain significance. The objective of this study was to examine the association between elevated inflammatory marker count (white blood cell count, C-reactive protein and fibrinogen) on all-cause mortality in a national sample of US adults with obstructive lung function (OLF).

METHODS

Data for 1144 adults aged 40-79 years in the National Health and Nutrition Examination Survey III Linked Mortality Study were analysed. Participants entered the study from 1988 to 1994, and mortality surveillance was conducted through 2006. White blood cell count and fibrinogen were dichotomized at their medians, and C-reactive protein was divided into >3 and ≤3 g/L. The number of elevated inflammatory markers was summed to create a score of 0-3.

RESULTS

The age-adjusted distribution of the number of elevated inflammatory markers differed significantly among participants with normal lung function, mild OLF, and moderate or worse OLF. Of the three dichotomized markers, only fibrinogen was significantly associated with mortality among adults with any OLF (maximally adjusted hazard ratio 1.49; 95% confidence interval (CI): 1.17-1.91). The maximally adjusted hazard ratios for having 1, 2 or 3 elevated markers were 1.17 (95% CI: 0.71-1.94), 1.44 (95% CI: 0.89-2.32) and 2.08 (95% CI: 1.29-3.37), respectively (P=0.003).

CONCLUSIONS

An index of elevated inflammatory markers predicted all-cause mortality among adults with OLF.

Are the recent secular increases in the waist circumference of adults independent of changes in BMI?

BACKGROUND

Several studies showed that the waist circumference of US adults has increased over the past 25 y. However, because of the high correlation between waist circumference and body mass index (BMI; in kg/m²) (r ∼ 0.9), it is uncertain if these trends in waist circumference exceed those expected on the basis of BMI changes over this time period.

OBJECTIVE

We assessed whether the recent trend in waist circumference was independent of changes in BMI, age, and race-ethnicity.

DESIGN

We analyzed data from the 1999-2000 through 2011-2012 cycles of the NHANES.

RESULTS

The mean waist circumference increased by ∼2 cm (in men) and ∼4 cm (in women) in adults in the United States over this 12-y period. In men, this increase was very close to what would be expected because of the 0.7 increase in mean BMI over this period. However, in women, most of the secular increase in waist circumference appeared to be independent of changes in BMI (mean: 0.6), age, and race-ethnicity over the 12-y period. We estimated that, independent of changes in these covariates, the mean waist circumference increased by 0.2 cm in men and 2.4 cm in women from 1999-2000 through 2011-2012; only the latter estimate was statistically significant.

CONCLUSIONS

Our results indicate that, in women but not men, the recent secular trend in waist circumference is greater than what would be expected on the basis of changes in BMI. Possible reasons for this secular increase, along with sex differences, are uncertain.

Trends in insomnia and excessive daytime sleepiness among U.S. adults from 2002 to 2012

OBJECTIVE

Insomnia is a prevalent disorder in the United States and elsewhere. It has been associated with a range of somatic and psychiatric conditions, and adversely affects quality of life, productivity at work, and school performance. The objective of this study was to examine the trend in self-reported insomnia and excessive daytime sleepiness among US adults.

METHODS

We used data of participants aged ≥18 years from the National Health Interview Survey for the years 2002 (30,970 participants), 2007 (23,344 participants), and 2012 (34,509 participants).

RESULTS

The unadjusted prevalence of insomnia or trouble sleeping increased from 17.5% (representing 37.5 million adults) in 2002 to 19.2% (representing 46.2 million adults) in 2012 (relative increase: +8.0%) (P trend <0.001). The age-adjusted prevalence increased from 17.4% to 18.8%. Significant increases were present among participants aged 18-24, 25-34, 55-64, and 65-74 years, men, women, whites, Hispanics, participants with diabetes, and participants with joint pain. Large relative increases occurred among participants aged 18-24 years (+30.9%) and participants with diabetes (+27.0%). The age-adjusted percentage of participants who reported regularly having excessive daytime sleepiness increased from 9.8% to 12.7% (P trend <0.001). Significant increases were present in most demographic groups. The largest relative increase was among participants aged 25-34 years (+49%). Increases were also found among participants with hypertension, chronic obstructive pulmonary disease, asthma, and joint pain.

CONCLUSIONS

Given the deleterious effects of insomnia on health and performance, the increasing prevalence of insomnia and excessive daytime sleepiness among US adults is a potentially troubling development.

Habitual sleep duration and predicted 10-year cardiovascular risk using the pooled cohort risk equations among US adults

Background

The association between sleep duration and predicted cardiovascular risk has been poorly characterized. The objective of this study was to examine the association between self‐reported sleep duration and predicted 10‐year cardiovascular risk among US adults.

Methods and Results

Data from 7690 men and nonpregnant women who were aged 40 to 79 years, who were free of self‐reported heart disease and stroke, and who participated in a National Health and Nutrition Examination Survey from 2005 to 2012 were analyzed. Sleep duration was self‐reported. Predicted 10‐year cardiovascular risk was calculated using the pooled cohort equations. Among the included participants, 13.1% reported sleeping ≤5 hours, 24.4% reported sleeping 6 hours, 31.9% reported sleeping 7 hours, 25.2% reported sleeping 8 hours, 4.0% reported sleeping 9 hours, and 1.3% reported sleeping ≥10 hours. After adjustment for covariates, geometric mean–predicted 10‐year cardiovascular risk was 4.0%, 3.6%, 3.4%, 3.5%, 3.7%, and 3.7% among participants who reported sleeping ≤5, 6, 7, 8, 9, and ≥10 hours per night, respectively (P_{Wald chi‐square}<0.001). The age‐adjusted percentages of predicted cardiovascular risk ≥20% for the 6 intervals of sleep duration were 14.5%, 11.9%, 11.0%, 11.4%, 11.8%, and 16.3% (P_{Wald chi‐square}=0.022). After maximal adjustment, however, sleep duration was not significantly associated with cardiovascular risk ≥20% (P_{Wald chi‐square}=0.698).

Conclusions

Mean‐predicted 10‐year cardiovascular risk was lowest among adults who reported sleeping 7 hours per night and increased as participants reported sleeping fewer and more hours.

Lung function and metabolic syndrome: Findings of National Health and Nutrition Examination Survey 2007–2010

BACKGROUND

Considerable uncertainty remains about obstructive lung function( OLF) in adults with metabolic syndrome (MetS). The aim of the present study was to examine pulmonary function status in adults with and without MetS.

METHODS

We used data from 3109 participants aged ≥20 years of the National Health and Nutrition Examination Survey 2007-2010. Subjects'MetS status was established on the basis of the 2009 harmonizing definition. Participants received spirometry.

RESULTS

After age adjustment, 79.3% (SE 1.1) of participants with MetS had normal lung function, 8.7% (0.9) had restrictive lung function (RLF), 7.1% (0.8) had mild OLF, and 4.8% (0.6) had moderate OLF or worse. Among participants without MetS, these estimates were 78.7% (1.2), 3.9% (0.6), 10.9%(1.1), and 6.4% (0.8), respectively. After multiple adjustment, participants with MetS were more likely to have RLF (adjusted prevalence ratio [aPR] 2.20; 95% confidence interval [CI] 1.67, 2.90) and less likely to have any OLF (aPR 0.73; 95% CI 0.62, 0.86) than those without MetS. Furthermore, participants with MetS had lower mean levels of forced expiratory volume in one second (FEV1), FEV1 % predicted, forced vital capacity (FVC), and FVC % predicted, but a higher FEV1/FVC ratio than participants without MetS. Mean levels of FEV1, FEV1 % predicted, FVC, and FVC % predicted declined significantly, but not the FEV1/FVC ratio, as the number of components increased.

CONCLUSIONS

Compared with adults without MetS, spirometry is more likely to show a restrictive pattern and less likely to show an obstructive pattern among adults with MetS.

Chronic obstructive pulmonary disease, hospital visits, and comorbidities: National Survey of Residential Care Facilities, 2010

OBJECTIVE

To characterize the prevalence of chronic obstructive pulmonary disease (COPD) among residential care facility (RCF) residents in the United States, and to compare patterns of hospital visits and comorbidities with residents without COPD.

METHOD

Resident data from the 2010 National Survey of Residential Care Facilities were analyzed. Medical history and information on past-year hospital visits for 8,089 adult residents were obtained from interviews with RCF staff.

RESULTS

COPD prevalence was 12.4%. Compared with residents without COPD, emergency department visits or overnight hospital stays in the previous year were more prevalent (p < .05) among residents with COPD. Less than 3% of residents with COPD had no comorbidities. Arthritis, depression, congestive heart failure (CHF), diabetes, coronary heart disease, and asthma were more common (p < .05) among residents with COPD than those without COPD, but Alzheimer's disease was less common.

DISCUSSION

COPD is associated with more emergency department visits, hospital stays, and comorbidities among RCF residents.

Sex-specific relationships between adverse childhood experiences and chronic obstructive pulmonary disease in five states

Purpose

Adverse childhood experiences (ACEs) before age 18 have been repeatedly associated with several chronic diseases in adulthood such as depression, heart disease, cancer, diabetes, and stroke. We examined sex-specific relationships between individual ACEs and the number of ACEs with chronic obstructive pulmonary disease (COPD) in the general population.

Materials and methods

Data from 26,546 women and 19,015 men aged ≥18 years in five states of the 2011 Behavioral Risk Factor Surveillance System were analyzed. We used log-linear regression to estimate prevalence ratios (PRs) and their corresponding 95% confidence intervals (CIs) for the relationship of eight ACEs with COPD after adjustment for age group, race/ethnicity, marital status, educational attainment, employment, asthma history, health insurance coverage, and smoking status.

Results

Some 63.8% of women and 62.2% of men reported ≥1 ACE. COPD was reported by 4.9% of women and 4.0% of men. In women, but not in men, there was a higher likelihood of COPD associated with verbal abuse (PR =1.30, 95% CI: 1.05, 1.61), sexual abuse (PR =1.69, 95% CI: 1.36, 2.10), living with a substance abusing household member (PR =1.49, 95% CI: 1.23, 1.81), witnessing domestic violence (PR =1.40, 95% CI: 1.14, 1.72), and parental separation/divorce (PR =1.47, 95% CI: 1.21, 1.80) during childhood compared to those with no individual ACEs. Reporting ≥5 ACEs (PR =2.08, 95% CI: 1.55, 2.80) compared to none was associated with a higher likelihood of COPD among women only.

Conclusion

ACEs are related to COPD, especially among women. These findings underscore the need for further research that examines sex-specific differences and the possible mechanisms linking ACEs and COPD. This work adds to a growing body of research suggesting that ACEs may contribute to health problems later in life and suggesting a need for program and policy solutions.

Associations of Self-Reported Cigarette Smoking with Chronic Obstructive Pulmonary Disease and Co-Morbid Chronic Conditions in the United States

BACKGROUND

The question of how smoking, COPD, and other chronic diseases are related remains unresolved. Therefore, we examined relationships between smoking, COPD, and 10 other chronic diseases and assessed the prevalence of co-morbid chronic conditions among people with COPD.

METHODS

We analyzed cross-sectional data from 405,856 US adults aged 18 years or older in the 2011 Behavioral Risk Factor Surveillance System. We used log-linear regression to estimate prevalence ratios (PRs) and their corresponding 95% confidence intervals (CIs) for these relationships adjusting for age, gender, race/ethnicity, marital status, educational attainment, annual household income, and health insurance coverage.

RESULTS

Overall, 17.5% reported being current cigarette smokers, 6.9% reported having COPD, and 71.2% reported another chronic condition. After age-adjustment, prevalence of COPD was 14.1% (adjusted PR = 3.9; 95% CI: 3.7, 4.1) among current smokers and 7.1% (adjusted PR = 2.5; 95% CI: 2.4, 2.7) among former smokers compared to 2.9% among never smokers. The most common chronic conditions among current smokers after age-adjustment were high cholesterol (36.7%), high blood pressure (34.6%), arthritis (29.4%), depression (27.4%), and asthma (16.9%). In separate multivariable models, smoking and COPD were associated with each of the 10 other chronic conditions (p < 0.05), which also included cancer, coronary heart disease, diabetes, kidney disease, and stroke; COPD modified associations between smoking and co-morbidities, while smoking did not modify associations between COPD and co-morbidities.

CONCLUSIONS

Our findings confirm previous evidence and highlight the continuing importance of comprehensive care coordination for people with COPD and co-morbid chronic conditions and also tobacco prevention and control strategies.

Age adjustment of diabetes prevalence: use of 2010 U.S. Census data

BACKGROUND

There is a growing interest in using the 2010 U.S. Census data for age adjustment after the Census data are officially released. This report discusses the rationale, procedures, demonstrations, and caveats of age adjustment using the 2010 U.S. Census data.

METHODS

Empirical data from the Behavioral Risk Factor Surveillance System and the 2010 U.S. Census age composition were used in demonstrations of computing the age-adjusted prevalence of diagnosed diabetes by race/ethnicity, across various geographic regions, and over time.

RESULTS

The use of the 2010 U.S. Census data yielded higher age-adjusted prevalence of diagnosed diabetes than using the 2000 projected US population data. The differences persisted across geographic regions, among racial/ethnic groups, and over time. Sixteen age compositions were generated to facilitate the use of the 2010 Census data in age adjustment. The SAS survey procedures and SUDAAN software programs yielded similar age-adjusted prevalence estimates of diagnosed diabetes.

CONCLUSIONS

Using the 2010 U.S. Census data tends to yield a higher age-adjusted measure than using the 2000 projected U.S. population data. Consistent use of a standard population and age composition is recommended once they are chosen for age adjustment.

Trends in outpatient visits for insomnia, sleep apnea, and prescriptions for sleep medications among US adults: findings from the National Ambulatory Medical Care survey 1999-2010

STUDY OBJECTIVE

To examine recent national trends in outpatient visits for sleep related difficulties in the United States and prescriptions for sleep medications.

DESIGN

Trend analysis.

SETTING

Data from the National Ambulatory Medical Care Survey from 1999 to 2010.

PARTICIPANTS

Patients age 20 y or older.

MEASUREMENTS AND RESULTS

The number of office visits with insomnia as the stated reason for visit increased from 4.9 million visits in 1999 to 5.5 million visits in 2010 (13% increase), whereas the number with any sleep disturbance ranged from 6,394,000 visits in 1999 to 8,237,000 visits in 2010 (29% increase). The number of office visits for which a diagnosis of sleep apnea was recorded increased from 1.1 million visits in 1999 to 5.8 million visits in 2010 (442% increase), whereas the number of office visits for which any sleep related diagnosis was recorded ranged from 3.3 million visits in 1999 to 12.1 million visits in 2010 (266% increase). The number of prescriptions for any sleep medication ranged from 5.3 in 1999 to 20.8 million in 2010 (293% increase). Strong increases in the percentage of office visits resulting in a prescription for nonbenzodiazepine sleep medications (∼350%), benzodiazepine receptor agonists (∼430%), and any sleep medication (∼200%) were noted.

CONCLUSIONS

Striking increases in the number and percentage of office visits for sleep related problems and in the number and percentage of office visits accompanied by a prescription for a sleep medication occurred from 1999-2010.

CITATION

Ford ES, Wheaton AG, Cunningham TJ, Giles WH, Chapman DP, Croft JB. Trends in outpatient visits for insomnia, sleep apnea, and prescriptions for sleep medications among US adults: findings from the National Ambulatory Medical Care Survey 1999-2010.

Drowsy driving and risk behaviors - 10 States and Puerto Rico, 2011-2012

Findings in published reports have suggested that drowsy driving is a factor each year in as many as 7,500 fatal motor vehicle crashes (approximately 25%) in the United States. CDC previously reported that, in 2009-2010, 4.2% of adult respondents in 19 states and the District of Columbia reported having fallen asleep while driving at least once during the previous 30 days. Adults who reported usually sleeping ≤6 hours per day, snoring, or unintentionally falling asleep during the day were more likely to report falling asleep while driving compared with adults who did not report these sleep patterns. However, limited information has been published on the association between drowsy driving and other risk behaviors that might contribute to crash injuries or fatalities. Therefore, CDC analyzed responses to survey questions regarding drowsy driving among 92,102 respondents in 10 states and Puerto Rico to the 2011-2012 Behavioral Risk Factor Surveillance System (BRFSS) surveys. The results showed that 4.0% reported falling asleep while driving during the previous 30 days. In addition to known risk factors, drowsy driving was more prevalent among binge drinkers than non-binge drinkers or abstainers and also more prevalent among drivers who sometimes, seldom, or never wear seatbelts while driving or riding in a car, compared with those who always or almost always wear seatbelts. Drowsy driving did not vary significantly by self-reported smoking status. Interventions designed to reduce binge drinking and alcohol-impaired driving, to increase enforcement of seatbelt use, and to encourage adequate sleep and seeking treatment for sleep disorders might contribute to reductions in drowsy driving crashes and related injuries.

Associations between self-reported sleep duration and sleeping disorder with concentrations of fasting and 2-h glucose, insulin, and glycosylated hemoglobin among adults without diagnosed diabetes

BACKGROUND

There is limited information from population-based investigations of the associations between sleep duration and sleep disorders and parameters of glucose homeostasis. The objective of the present study was to examine cross-sectional associations between sleep duration and sleep disordered breathing with concentrations of insulin, fasting and 2-h glucose, and HbA1c.

METHODS

Data from 11 815 adults aged ≥20 years without diagnosed diabetes (5002 with an oral glucose tolerance test) from the National Health and Nutrition Examination Survey 2005-2010 were used. Information about sleep duration (2005-2010) and sleep apnea and sleep-disordered breathing (2005-2008) was obtained via questionnaire.

RESULTS

An estimated 36.0% of participants reported sleeping ≤6 h/night, 62.0% reported sleeping 7-9 h/night, and 2.0% reported sleeping ≥10 h/night. In 2005-2008, 33.0% reported snoring ≥5 nights per week, 5.9% reported they snorted, gasped, or stopped breathing ≥5 nights/week, and 4.2% reported sleep apnea. Sleep duration was significantly associated with fasting concentrations of insulin and concentrations of HbA1c only in models that did not adjust for body mass index (BMI). Concentrations of fasting and 2-h glucose were significantly associated with sleep duration in models that adjusted only for age. Snoring frequency was positively associated with concentrations of insulin and HbA1c. Frequency of snorting or stopping breathing and sleep apnea status were associated with concentrations of insulin and of HbA1c only when BMI was not accounted for.

CONCLUSION

In a representative sample of US adults, concentrations of insulin and HbA1c were significantly associated with short sleep duration, possibly mediated by BMI.

Prescription practices for chronic obstructive pulmonary disease: findings from the national ambulatory medical care survey 1999-2010

Recent trends in prescriptions for medicines used to treat chronic obstructive pulmonary disease (COPD) in the United States have received little attention. Our objective was to examine trends in prescribing practices for medications used to treat COPD. We examined data from surveys of national samples of office visits to non-federal employed office-based physicians in the United States by patients aged ≥40 years with COPD recorded by the National Ambulatory Medical Care Survey from 1999 to 2010. From three diagnostic codes, office visits by patients with COPD were identified. Prescribed medications were identified from up to 8 recorded medications. The percentage of these visits during which a prescription for any medication used to treat COPD was issued increased from 27.0% in 1999 to 49.1% in 2010 (p trend < 0.001). Strong increases were noted for short-acting beta-2 agonists (17.6% in 1999 to 24.7% in 2010; p trend < 0.001), long-acting beta-2 agonists as single agents or combination products (6.2% in 1999 to 28.3% in 2010; p trend < 0.001), inhaled corticosteroids as single agents or combination products (10.9% in 1999 to 30.9% in 2010; p trend < 0.001), and tiotropium (3.8% in 2004 to 17.2% in 2010; p trend < 0.001). Since 1999, prescription patterns for medicines used to treat COPD have changed profoundly in the United States.

Trends in the use, sociodemographic correlates, and undertreatment of prescription medications for chronic obstructive pulmonary disease among adults with chronic obstructive pulmonary disease in the United States from 1999 to 2010

Background

The extent to which patients with COPD are receiving indicated treatment with medications to improve lung function and recent trends in the use of these medications is not well documented in the United States. The objective of this study was to examine trends in prescription medications for COPD among adults in the United States from 1999 to 2010.

Methods

We performed a trend analysis using data from up to 1426 participants aged ≥20 years with self-reported COPD from six national surveys (National Health and Nutrition Examination Survey 1999–2010).

Results

During 2009–2010, the age-adjusted percentage of participants who used any kind of medication was 44.2%. Also during 2009–2010, the most commonly used medications were short-acting agents (36.0%), inhaled corticosteroids (ICS) (18.3%), and LABAs (16.7%). The use of long-acting beta-2 agonists (LABAs) (p for trend <0.001), ICS (p for trend = 0.013) increased significantly over the 12-year period. Furthermore, the use of tiotropium increased rapidly during this period (p for trend <0.001). For the years 2005–2010, the use of LABAs, ICS and tiotropium increased with age. Compared with whites, Mexican Americans were less likely to use short-acting agents, LABAs, ICS, tiotropium, and any kind of COPD medication. Among participants aged 20–79 years with spirometry measurements during 2007–2010, the use of any medication was reported by 19.0% of those with a moderate/severe obstructive impairment and by 72.6% of those with self-reported COPD and any obstructive impairment.

Conclusion

The percentages of adults with COPD who reported having various classes of prescription medications that improve airflow limitations changed markedly from 1999–2000 to 2009–2010. However, many adults with COPD did not report having recommended prescription medications.

Multilevel regression and poststratification for small-area estimation of population health outcomes: a case study of chronic obstructive pulmonary disease prevalence using the behavioral risk factor surveillance system

A variety of small-area statistical models have been developed for health surveys, but none are sufficiently flexible to generate small-area estimates (SAEs) to meet data needs at different geographic levels. We developed a multilevel logistic model with both state- and nested county-level random effects for chronic obstructive pulmonary disease (COPD) using 2011 data from the Behavioral Risk Factor Surveillance System. We applied poststratification with the (decennial) US Census 2010 counts of census-block population to generate census-block-level SAEs of COPD prevalence which could be conveniently aggregated to all other census geographic units, such as census tracts, counties, and congressional districts. The model-based SAEs and direct survey estimates of COPD prevalence were quite consistent at both the county and state levels. The Pearson correlation coefficient was 0.99 at the state level and ranged from 0.88 to 0.95 at the county level. Our extended multilevel regression modeling and poststratification approach could be adapted for other geocoded national health surveys to generate reliable SAEs for population health outcomes at all administrative and legislative geographic levels of interest in a scalable framework.

Awareness of kidney disease among US adults: Findings from the 2011 behavioral risk factor surveillance system

BACKGROUND

The prevalence of chronic kidney disease as measured by biomarkers is increasing, but the recognition for this condition remains low in the USA. Little is known about the awareness of kidney disease at the state level.

METHODS

Data from 490,302 adults aged 18 years or older in all 50 states as well as the District of Columbia who participated in the 2011 Behavioral Risk Factor Surveillance System were analyzed. Kidney disease diagnosis, a measure of individual awareness, was ascertained by participants' self-report in the telephone survey. Prevalence ratios of self-reported kidney disease in subpopulations were estimated and tested using log-linear regression analyses with a robust variance estimator.

RESULTS

The unadjusted prevalence of self-reported kidney disease was estimated to be 2.5%. After adjustment for age and all other selected covariates, Hispanics had a higher prevalence than non-Hispanic whites (adjusted prevalence ratio 1.2, 95% CI 1.0-1.4). Persons who were unemployed (adjusted prevalence ratio 1.4, 95% CI 1.2-1.5) had a higher prevalence than those who were employed. Persons who had hypertension (adjusted prevalence ratio 1.9, 95% CI 1.7-2.1), diabetes (adjusted prevalence ratio 1.7, 95% CI 1.5-1.8), cardiovascular disease (coronary heart disease, myocardial infarction or stroke; adjusted prevalence ratio 1.5, 95% CI 1.4-1.6) or cancer (adjusted prevalence ratio 1.5, 95% CI 1.3-1.6) had a higher prevalence of self-reported kidney disease than those without these conditions.

CONCLUSION

The overall awareness of kidney disease was low in the general population. Efforts are needed to promote the awareness and early detection of kidney disease in public health services and clinical practice.

Leisure-time aerobic physical activity, muscle-strengthening activity and mortality risks among US adults: the NHANES linked mortality study

BACKGROUND

Regular physical activity elicits multiple health benefits in the prevention and management of chronic diseases. We examined the mortality risks associated with levels of leisure-time aerobic physical activity and muscle-strengthening activity based on the 2008 Physical Activity Guidelines for Americans among US adults.

METHODS

We analysed data from the 1999 to 2004 National Health and Nutrition Examination Survey with linked mortality data obtained through 2006. Cox proportional HRs with 95% CIs were estimated to assess risks for all-causes and cardiovascular disease (CVD) mortality associated with aerobic physical activity and muscle-strengthening activity.

RESULTS

Of 10 535 participants, 665 died (233 deaths from CVD) during an average of 4.8-year follow-up. Compared with participants who were physically inactive, the adjusted HR for all-cause mortality was 0.64 (95% CI 0.52 to 0.79) among those who were physically active (engaging in ≥150 min/week of the equivalent moderate-intensity physical activity) and 0.72 (95% CI 0.54 to 0.97) among those who were insufficiently active (engaging in >0 to <150 min/week of the equivalent moderate-intensity physical activity). The adjusted HR for CVD mortality was 0.57 (95% CI 0.34 to 0.97) among participants who were insufficiently active and 0.69 (95% CI 0.43 to 1.12) among those who were physically active. Among adults who were insufficiently active, the adjusted HR for all-cause mortality was 44% lower by engaging in muscle-strengthening activity ≥2 times/week.

CONCLUSIONS

Engaging in aerobic physical activity ranging from insufficient activity to meeting the 2008 Guidelines reduces the risk of premature mortality among US adults. Engaging in muscle-strengthening activity ≥2 times/week may provide additional benefits among insufficiently active adults.

Sleep duration and body mass index and waist circumference among U.S. adults

OBJECTIVE

To examine the form of the relationship between sleep duration and anthropometric measures and possible differences in these relationships by gender and race or ethnicity.

DESIGN AND METHODS

Data for 13,742 participants aged ≥20 years from the National Health and Nutrition Examination Survey 2005-2010 were used. Sleep duration was categorized as ≤6 (short sleepers), 7-9, and ≥10 hours (long sleepers).

RESULTS

Short sleepers were as much as 1.7 kg/m² (SE 0.4) heavier and had 3.4 cm (SE 1.0) more girth than long sleepers. Among participants without depression or a diagnosed sleep disorder, sleep duration was significantly associated with body mass index (BMI) and waist circumference in an inverse linear association in the entire sample, men, women, whites, African Americans, and participants aged 20-39 years. No evidence for statistical interaction by gender and race or ethnicity was observed. Regression coefficients were notably stronger among adults aged 20-39 years. Compared to participants who reported sleeping 7-9 hours per night, short sleepers were more likely to be obese and have abdominal obesity.

CONCLUSIONS

In this nationally representative sample of US adults, an inverse linear association most consistently characterized the association between sleep duration and BMI and waist circumference.

The association of chronic obstructive pulmonary disease, disability, engagement in social activities, and mortality among US adults aged 70 years or older, 1994-2006

PURPOSE

To assess associations among chronic obstructive pulmonary disease (COPD), disability as measured by activities of daily living (ADL) and instrumental ADL (IADL), engagement in social activities, and death among elderly noninstitutionalized US residents.

MATERIALS AND METHODS

A nationally representative sample of 9,415 adults who were aged ≥70 years and responded to the Second Supplement on Aging survey in 1994-1996 and mortality follow-up study through 2006 were assessed. Multiple logistic regression analyses were performed to assess the risk of all-cause mortality in participants with COPD after accounting for age, sex, race/ethnicity, and smoking status.

RESULTS

At baseline, approximately 9.6% of study participants reported having COPD. Compared with participants without COPD, those with COPD were significantly more likely (P<0.05) to have difficulty with at least one ADL (44.3% versus [vs] 27.5%) and with at least one IADL (59.9% vs 40.2%), significantly less likely to be engaged in social activities (32.6% vs 26.3%), and significantly more likely to die by 2006 (70.7% vs 60.4%; adjusted risk ratio 1.15, P<0.05). The association between COPD and risk for death was moderately attenuated by disability status.

CONCLUSION

COPD is positively associated with disability and mortality risk among US adults aged ≥70 years. The significant relationship between COPD and mortality risk was moderately attenuated, but was not completely explained by stages of ADL and IADL limitations and social activities.

Food security and cardiovascular disease risk among adults in the United States: findings from the National Health and Nutrition Examination Survey, 2003-2008

Introduction

Little is known about the relationship between food security status and predicted 10-year cardiovascular disease risk. The objective of this study was to examine the associations between food security status and cardiovascular disease risk factors and predicted 10-year risk in a national sample of US adults.

Methods

A cross-sectional analysis using data from 10,455 adults aged 20 years or older from the National Health and Nutrition Examination Survey 2003–2008 was conducted. Four levels of food security status were defined by using 10 questions.

Results

Among all participants, 83.9% had full food security, 6.7% had marginal food security, 5.8% had low food security, and 3.6% had very low food security. After adjustment, mean hemoglobin A1c was 0.15% greater and mean concentration of C-reactive protein was 0.8 mg/L greater among participants with very low food security than among those with full food security. The adjusted mean concentration of cotinine among participants with very low food security was almost double that of participants with full food security (112.8 vs 62.0 ng/mL, P < .001). No significant associations between food security status and systolic blood pressure or concentrations of total cholesterol, high-density lipoprotein cholesterol, or non-high-density lipoprotein cholesterol were observed. Participants aged 30 to 59 years with very low food security were more likely to have a predicted 10-year cardiovascular disease risk greater than 20% than fully food secure participants (adjusted prevalence ratio, 2.38; 95% CI, 1.31–4.31).

Conclusion

Adults aged 30 to 59 years with very low food security showed evidence of increased predicted 10-year cardiovascular disease risk.

COPD surveillance--United States, 1999-2011

This report updates surveillance results for COPD in the United States. For 1999 to 2011, data from national data systems for adults aged≥25 years were analyzed. In 2011, 6.5% of adults (approximately 13.7 million) reported having been diagnosed with COPD. From 1999 to 2011, the overall age-adjusted prevalence of having been diagnosed with COPD declined (P=.019). In 2010, there were 10.3 million (494.8 per 10,000) physician office visits, 1.5 million (72.0 per 10,000) ED visits, and 699,000 (32.2 per 10,000) hospital discharges for COPD. From 1999 to 2010, no significant overall trends were noted for physician office visits and ED visits; however, the age-adjusted hospital discharge rate for COPD declined significantly (P=.001). In 2010 there were 312,654 (11.2 per 1,000) Medicare hospital discharge claims submitted for COPD. Medicare claims (1999-2010) declined overall (P=.045), among men (P=.022) and among enrollees aged 65 to 74 years (P=.033). There were 133,575 deaths (63.1 per 100,000) from COPD in 2010. The overall age-adjusted death rate for COPD did not change during 1999 to 2010 (P=.163). Death rates (1999-2010) increased among adults aged 45 to 54 years (P<.001) and among American Indian/Alaska Natives (P=.008) but declined among those aged 55 to 64 years (P=.002) and 65 to 74 years (P<.001), Hispanics (P=.038), Asian/Pacific Islanders (P<.001), and men (P=.001). Geographic clustering of prevalence, Medicare hospitalizations, and deaths were observed. Declines in the age-adjusted prevalence, death rate in men, and hospitalizations for COPD since 1999 suggest progress in the prevention of COPD in the United States.

Prevalence of diagnosed cancer according to duration of diagnosed diabetes and current insulin use among U.S. adults with diagnosed diabetes: findings from the 2009 Behavioral Risk Factor Surveillance System

OBJECTIVE

To estimate the prevalence of diagnosed cancer according to duration of diagnosed diabetes and current insulin use among U.S. adults with diagnosed diabetes.

RESEARCH DESIGN AND METHODS

We analyzed data from 25,964 adults aged ≥ 18 years with diagnosed diabetes who participated in the 2009 Behavioral Risk Factor Surveillance System.

RESULTS

After adjustment for potential confounders, we found that the greater the duration of diagnosed diabetes, the higher the prevalence of diagnosed cancers (P < 0.0001 for linear trend). Among adults with diagnosed type 2 diabetes, the prevalence estimate for cancers of all sites was significantly higher among men (adjusted prevalence ratio 1.6 [95% CI 1.3-1.9]) and women (1.8 [1.5-2.1]) who reported being diagnosed with diabetes ≥ 15 years ago than among those reporting diabetes diagnosis <15 years ago. The prevalence estimate for cancers of all sites was ~1.3 times higher among type 2 diabetic adults who currently used insulin than among those who did not use insulin among both men (1.3 [1.1-1.6]) and women (1.3 [1.1-1.5]).

CONCLUSIONS

Our results suggest that there is an increased burden of diagnosed cancer among adults with a longer duration of diagnosed diabetes and among type 2 diabetic adults who currently use insulin.

Trends in total and low-density lipoprotein cholesterol among U.S. adults: contributions of changes in dietary fat intake and use of cholesterol-lowering medications

OBJECTIVE

Our aim was to examine the relative contributions of changes in dietary fat intake and use of cholesterol-lowering medications to changes in concentrations of total cholesterol among adults in the United States from 1988-1994 to 2007-2008.

METHOD

We used data from adults aged 20-74 years who participated in National Health and Nutrition Examination Surveys from 1988-1994 to 2007-2008. The effect of change in dietary fat intake on concentrations of total cholesterol was estimated by the use of equations developed by Keys, Hegsted, and successors.

RESULTS

Age-adjusted mean concentrations of total cholesterol were 5.60 mmol/L (216 mg/dl) during 1988-1994 falling to 5.09 mmol/L (197 mg/dl) in 2007-2008 (P<0.001). No significant changes in the intake of total fat, saturated fat, polyunsaturated fat, and dietary cholesterol were observed from 1988-1994 to 2007-2008. However, the age-adjusted use of cholesterol-lowering medications increased from 1.6% to 12.5% (P<0.001). The various equations suggested that changes in dietary fat made minimal contributions to the observed trend in mean concentrations of total cholesterol. The increased use of cholesterol-lowering medications was estimated to account for approximately 46% of the change.

DISCUSSION

Mean concentrations of total cholesterol among adults in the United States have declined by ∼4% since 1988-1994. The increased use of cholesterol-lowering medications has apparently accounted for about half of this small fall. Further substantial decreases in cholesterol might be potentially achievable by implementing effective and feasible public health interventions to promote the consumption of a more healthful diet by US adults.

DISCLAIMER

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Quantifying options for reducing coronary heart disease mortality by 2020

BACKGROUND

The American Heart Association (AHA) 2020 Strategic Impact Goal proposes a 20% improvement in cardiovascular health of all Americans. We aimed to estimate the potential reduction in coronary heart disease (CHD) deaths.

METHODS AND RESULTS

We used data on 40 373 adults free of cardiovascular disease from the National Health and Nutrition Examination Survey (NHANES; 1988-2010). We quantified recent trends for 6 metrics (total cholesterol, systolic blood pressure, physical inactivity, smoking, diabetes mellitus, and obesity) and generated linear projections to 2020. We projected the expected number of CHD deaths in 2020 if 2006 age- and sex-specific CHD death rates remained constant, which would result in ≈480 000 CHD deaths in 2020 (12% increase). We used the previously validated IMPACT CHD model to project numbers of CHD deaths in 2020 under 2 different scenarios: (1) Assuming a 20% improvement in each cardiovascular health metric, we project 365 000 CHD deaths in 2020 (range 327 000-403 000) a 24% decrease reflecting modest reductions in total cholesterol (-41 000), systolic blood pressure (-36 000), physical inactivity (-12 000), smoking (-10 000), diabetes mellitus (-10 000), and obesity (-5000); (2) Assuming that recent risk factor trends continue to 2020, we project 335 000 CHD deaths (range 274 000-386 000), a 30% decrease reflecting improvements in total cholesterol, systolic blood pressure, smoking, and physical activity (≈167 000 fewer deaths), offset by increases in diabetes mellitus and body mass index (≈24 000 more deaths).

CONCLUSIONS

Two contrasting scenarios of change in cardiovascular health metrics could prevent 24% to 30% of the CHD deaths expected in 2020, though with differing effects by age. Unfavorable continuing trends in obesity and diabetes mellitus would have substantial adverse effects. This analysis demonstrates the utility of modelling to inform health policy.

Trends in the prevalence of obstructive and restrictive lung function among adults in the United States: findings from the National Health and Nutrition Examination surveys from 1988-1994 to 2007-2010

BACKGROUND

National spirometric surveillance data in the United States were last collected during 1988-1994. The objective of this study was to provide current estimates for obstructive and restrictive impairment of lung function and to examine changes since 1988-1994.

METHODS

We used data from 14,360 participants aged 20 to 79 years from the National Health and Nutrition Examination Survey (NHANES) III (1988-1994) and 9,024 participants from NHANES 2007-2010. Spirometry was conducted using the same spirometers and generally similar protocols.

RESULTS

During 2007-2010, 13.5% (SE, 0.6) of participants had evidence of airway obstruction (FEV1/FVC < 0.70): 79.9% of adults had normal lung function, 6.5% had a restrictive impairment, 7.5% had mild obstruction, 5.4% had moderate obstruction, and 0.7% had severe obstruction. Although the overall age-adjusted prevalence of any obstruction did not change significantly from 1988-1994 (14.6%) to 2007-2010 (13.5%) (P = .178), significant decreases were noted for participants aged 60 to 79 years and for Mexican Americans. The prevalence of current smoking remained high among participants with moderate (48.4%) and severe (37.9%) obstructive impairments. A significant decline in current smoking occurred only among those with normal lung function (P < .05).

CONCLUSION

Spirometry revealed little change in the prevalence of any obstructive and restrictive impairment in lung function during 2007-2010, compared with 1988-1994.

Co-occurrence of leading lifestyle-related chronic conditions among adults in the United States, 2002-2009

INTRODUCTION

Public health and clinical strategies for meeting the emerging challenges of multiple chronic conditions must address the high prevalence of lifestyle-related causes. Our objective was to assess prevalence and trends in the chronic conditions that are leading causes of disease and death among adults in the United States that are amenable to preventive lifestyle interventions.

METHODS

We used self-reported data from 196,240 adults aged 25 years or older who participated in the National Health Interview Surveys from 2002 to 2009. We included data on cardiovascular disease (coronary heart disease, angina pectoris, heart attack, and stroke), cancer, chronic obstructive pulmonary disease (emphysema and chronic bronchitis), diabetes, and arthritis.

RESULTS

In 2002, an unadjusted 63.6% of participants did not have any of the 5 chronic conditions we assessed; 23.9% had 1, 9.0% had 2, 2.9% had 3, and 0.7% had 4 or 5. By 2009, the distribution of co-occurrence of the 5 chronic conditions had shifted subtly but significantly. From 2002 to 2009, the age-adjusted percentage with 2 or more chronic conditions increased from 12.7% to 14.7% (P < .001), and the number of adults with 2 or more conditions increased from approximately 23.4 million to 30.9 million.

CONCLUSION

The prevalence of having 1 or more or 2 or more of the leading lifestyle-related chronic conditions increased steadily from 2002 to 2009. If these increases continue, particularly among younger adults, managing patients with multiple chronic conditions in the aging population will continue to challenge public health and clinical practice.

Trends in energy intake among adults in the United States: findings from NHANES

BACKGROUND

Energy intake is a key determinant of weight.

OBJECTIVE

Our objective was to examine trends in energy intake in adults in the United States from 1971-1975 to 2009-2010.

DESIGN

The study was a trend analysis of 9 national surveys in the United States that included data from 63,761 adults aged 20-74 y.

RESULTS

Adjusted mean energy intake increased from 1955 kcal/d during 1971-1975 to 2269 kcal/d during 2003-2004 and then declined to 2195 kcal/d during 2009-2010 (P-linear trend < 0.001, P-nonlinear trend < 0.001). During the period from 1999-2000 to 2009-2010, no significant linear trend in energy intake was observed (P = 0.058), but a significant nonlinear trend was noted (P = 0.042), indicating a downward trend in energy intake. Significant decreases in energy intake from 1999-2000 to 2009-2010 were noted for participants aged 20-39 y, men, women, and participants with a BMI (in kg/m(2)) of 18.5 to <25 and ≥30.

CONCLUSION

After decades of increases, mean energy intake has decreased significantly since 2003-2004.