Health promotion data for state health departments: telephone versus in-person survey estimates of smoking and alcohol use

Abstract During 1988, more than 40 state health departments conducted telephone surveys to obtain state-specific population estimates of the prevalence of adult health behaviors and health practices. However, the comparability of estimates obtained from these telephone surveys with more expensive in-person surveys has not been assessed in an applied setting. This study compared the prevalence estimates of smoking and binge drinking obtained from a telephone survey (N = 1,492) with an in-person survey (N = 2,802) which were conducted by the state of Michigan during 1982-1983. Although the standard errors for the differences in the estimates for the two surveys were relatively large, the actual differences were consistently small within most age-, sex-, and education-specific groups. Despite certain limitations, telephone surveys provide a reasonable alternative to in-person surveys for estimating the prevalence of health behaviors. The data obtained from these surveys are being used to set state health objectives, to plan state-wide health promotion programs, and to support public health legislation.

Body weight and obesity in adults and self-reported abuse in childhood

BACKGROUND

Little is known about childhood factors and adult obesity. A previous study found a strong association between childhood neglect and obesity in young adults.

OBJECTIVE

To estimate associations between self-reported abuse in childhood (sexual, verbal, fear of physical abuse and physical) adult body weight, and risk of obesity.

DESIGN

Retrospective cohort study with surveys during 1995-1997.

PATIENTS

A total of 13,177 members of California health maintenance organization aged 19-92 y.

MEASUREMENTS

Body weight measured during clinical examination, followed by mailed survey to recall experiences during first 18 y of life. Estimates adjusted for adult demographic factors and health practices, and characteristics of the childhood household.

RESULTS

Some 66% of participants reported one or more type of abuse. Physical abuse and verbal abuse were most strongly associated with body weight and obesity. Compared with no physical abuse (55%), being 'often hit and injured' (2.5%) had a 4.0 kg (95% confidence interval: 2.4-5.6 kg) higher weight and a 1.4 (1.2-1.6) relative risk (RR) of body mass index (BMI) > or = 30. Compared with no verbal abuse (53%), being 'often verbally abused' (9.5%) had an RR of 1.9 (1.3-2.7) for BMI > or = 40. The abuse associations were not mutually independent, however, because the abuse types strongly co-occurred. Obesity risk increased with number and severity of each type of abuse. The population attributable fraction for 'any mention' of abuse (67%) was 8% (3.4-12.3%) for BMI > or = 30 and 17.3% (-1.0-32.4%) for BMI > or = 40.

CONCLUSIONS

Abuse in childhood is associated with adult obesity. If causal, preventing child abuse may modestly decrease adult obesity. Treatment of obese adults abused as children may benefit from identification of mechanisms that lead to maintenance of adult obesity.

Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study

CONTEXT

Suicide is a leading cause of death in the United States, but identifying persons at risk is difficult. Thus, the US surgeon general has made suicide prevention a national priority. An expanding body of research suggests that childhood trauma and adverse experiences can lead to a variety of negative health outcomes, including attempted suicide among adolescents and adults.

OBJECTIVE

To examine the relationship between the risk of suicide attempts and adverse childhood experiences and the number of such experiences (adverse childhood experiences [ACE] score).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of 17 337 adult health maintenance organization members (54% female; mean [SD] age, 57 [15.3] years) who attended a primary care clinic in San Diego, Calif, within a 3-year period (1995-1997) and completed a survey about childhood abuse and household dysfunction, suicide attempts (including age at first attempt), and multiple other health-related issues.

MAIN OUTCOME MEASURE

Self-reported suicide attempts, compared by number of adverse childhood experiences, including emotional, physical, and sexual abuse; household substance abuse, mental illness, and incarceration; and parental domestic violence, separation, or divorce.

RESULTS

The lifetime prevalence of having at least 1 suicide attempt was 3.8%. Adverse childhood experiences in any category increased the risk of attempted suicide 2- to 5-fold. The ACE score had a strong, graded relationship to attempted suicide during childhood/adolescence and adulthood (P<.001). Compared with persons with no such experiences (prevalence of attempted suicide, 1.1%), the adjusted odds ratio of ever attempting suicide among persons with 7 or more experiences (35.2%) was 31.1 (95% confidence interval, 20.6-47.1). Adjustment for illicit drug use, depressed affect, and self-reported alcoholism reduced the strength of the relationship between the ACE score and suicide attempts, suggesting partial mediation of the adverse childhood experience-suicide attempt relationship by these factors. The population-attributable risk fractions for 1 or more experiences were 67%, 64%, and 80% for lifetime, adult, and childhood/adolescent suicide attempts, respectively.

CONCLUSIONS

A powerful graded relationship exists between adverse childhood experiences and risk of attempted suicide throughout the life span. Alcoholism, depressed affect, and illicit drug use, which are strongly associated with such experiences, appear to partially mediate this relationship. Because estimates of the attributable risk fraction caused by these experiences were large, prevention of these experiences and the treatment of persons affected by them may lead to progress in suicide prevention.

Growing up with parental alcohol abuse: exposure to childhood abuse, neglect, and household dysfunction

OBJECTIVE

This study is a detailed examination of the association between parental alcohol abuse (mother only, father only, or both parents) and multiple forms of childhood abuse, neglect, and other household dysfunction, known as adverse childhood experiences (ACEs).

METHOD

A questionnaire about ACEs including child abuse, neglect, household dysfunction, and exposure to parental alcohol abuse was completed by 8629 adult HMO members to retrospectively assess the relationship of growing up with parental alcohol abuse to 10 ACEs and multiple ACEs (ACE score).

RESULTS

Compared to persons who grew up with no parental alcohol abuse, the adjusted odds ratio for each category of ACE was approximately 2 to 13 times higher if either the mother, father, or both parents abused alcohol (p < 0.05). For example, the likelihood of having a battered mother was increased 13-fold for men who grew up with both parents who abused alcohol (OR, 12.7; 95% CI: 8.4-19.1). For almost every ACE, those who grew up with both an alcohol-abusing mother and father had the highest likelihood of ACEs. The mean number of ACEs for persons with no parental alcohol abuse, father only, mother only, or both parents was 1.4, 2.6, 3.2, and 3.8, respectively (p < .001).

CONCLUSION

Although the retrospective reporting of these experiences cannot establish a causal association with certainty, exposure to parental alcohol abuse is highly associated with experiencing adverse childhood experiences. Improved coordination of adult and pediatric health care along with related social and substance abuse services may lead to earlier recognition, treatment, and prevention of both adult alcohol abuse and adverse childhood experiences, reducing the negative sequelae of ACEs in adolescents and adults.

Adverse childhood experiences and sexual risk behaviors in women: a retrospective cohort study

CONTEXT

Adverse childhood experiences such as physical abuse and sexual abuse have been shown to be related to subsequent unintended pregnancies and infection with sexually transmitted diseases. However, the extent to which sexual risk behaviors in women are associated with exposure to adverse experiences during childhood is not well-understood.

METHODS

A total of 5,060 female members of a managed care organization provided information about seven categories of adverse childhood experiences: having experienced emotional, physical or sexual abuse; or having had a battered mother or substance-abusing, mentally ill or criminal household members. Logistic regression was used to model the association between cumulative categories of up to seven adverse childhood experiences and such sexual risk behaviors as early onset of intercourse, 30 or more sexual partners and self-perception as being at risk for AIDS.

RESULTS

Each category of adverse childhood experiences was associated with an increased risk of intercourse by age 15 (odds ratios, 1.6-2.6), with perceiving oneself as being at risk of AIDS (odds ratios, 1.5-2.6) and with having had 30 or more partners (odds ratios, 1.6-3.8). After adjustment for the effects of age at interview and race, women who experienced rising numbers of types of adverse childhood experiences were increasingly likely to see themselves as being at risk of AIDS: Those with one such experience had a slightly elevated likelihood (odds ratio, 1.2), while those with 4-5 or 6-7 such experiences had substantially elevated odds (odds ratios, 1.8 and 4.9, respectively). Similarly, the number of types of adverse experiences was tied to the likelihood of having had 30 or more sexual partners, rising from odds of 1.6 for those with one type of adverse experience and 1.9 for those with two to odds of 8.2 among those with 6-7. Finally, the chances that a woman first had sex by age 15 also rose progressively with increasing numbers of such experiences, from odds of 1.8 among those with one type of adverse childhood experience to 7.0 among those with 6-7.

CONCLUSIONS

Among individuals with a history of adverse childhood experiences, risky sexual behavior may represent their attempts to achieve intimate interpersonal connections. Having grown up in families unable to provide needed protection, such individuals may be unprepared to protect themselves and may underestimate the risks they take in their attempts to achieve intimacy. If so, coping with such problems represents a serious public health challenge.

Abused boys, battered mothers, and male involvement in teen pregnancy

BACKGROUND

The relationship between boyhood exposure to physical abuse, sexual abuse, or to a battered mother and subsequent risk of impregnating a teenage girl has not previously been examined.

METHODS

In a retrospective cohort study set in a primary care clinic for adult members of a large health maintenance organization, questionnaire responses from 4127 men were analyzed. Respondents provided the age of the youngest female whom they had impregnated, their own ages at the time, and information regarding childhood exposure to physical or sexual abuse and battered mothers. We calculated the prevalence and adjusted odds ratio (OR) for having impregnated a teenage girl according to these 3 adverse childhood experiences, regardless of the male's age at the time of impregnation. Using logistic regression, ORs were adjusted for the male's age at time of survey, race, and education.

RESULTS

Nineteen percent of the men reported that they had ever impregnated a teenage girl. During childhood, 32% of respondents had been physically abused, 15% sexually abused, and 11% had battered mothers. Compared with respondents reporting no abuse, frequent physical abuse or battering of mothers increased the risk of involvement in teen pregnancy by 70% (OR: 1.7; 95% confidence interval [CI]: 1.2-2.5) and 140% (OR: 2.4; 95% CI: 1.1-5.0), respectively. Sexual abuse as a boy at age 10 years or younger increased the risk of impregnating a teenage girl by 80% (OR: 1.8; 95% CI: 1.3-2.4); sexual abuse with violence increased the risk by 110% (OR: 2.1; 95% CI: 1.2-3.4). We found a dose-response relationship between the number of types of exposures and the risk of impregnating a teenage girl; men who reported all 3 types of exposures were more than twice as likely to have been involved than those with no exposures (OR: 2.2; 95% CI: 1.4-3.5).

CONCLUSIONS

Boyhood exposure to physical or sexual abuse or to a battered mother is associated with an increased risk of involvement in a teen pregnancy-during both adolescence and adulthood. Because these exposures are common and interrelated, boys and adult men who have had these experiences should be identified via routine screening by pediatricians and other health care providers and counseled about sexual practices and contraception. Such efforts may prevent teen pregnancy and the intergenerational transmission of child abuse and domestic violence.

Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study

OBJECTIVE

Adverse childhood experiences (ACEs) may have long-term consequences on at-risk behaviors that lead to an increased risk of sexually transmitted diseases (STDs) during adulthood. Therefore, we examined the relationship between ACEs and subsequent STDs for both men and women.

METHODS

A total of 9323 (4263 men and 5060 women) adults >/=18 years of age participated in a retrospective cohort study evaluating the association between ACEs and self-reported STDs. Participants were adult members of a managed care organization who underwent routine medical evaluations and completed standardized questionnaires about 7 categories of ACEs, including emotional, physical, or sexual abuse; living with a battered mother; and living with a substance-abusing, mentally ill, or criminal household member. Logistic regression was used to model the association between the cumulative categories of ACEs (range: 0-7) and a history of STDs.

RESULTS

We found that 59% (2986) of women and 57% (2464) of men reported 1 or more categories of adverse experiences during childhood. Among those with 0, 1, 2, 3, 4 to 5, and 6 to 7 ACEs, the proportion with STDs was 4.1%, 6.9%, 8.0%, 11.6%, 13.5%, and 20.7% for women and 7.3%, 10.9%, 12.9%, 17.1%, 17.1%, and 39.1% for men. After adjustment for age and race, all odds ratios for reporting an STD had confidence intervals that excluded 1. Among those with 1, 2, 3, 4 to 5, and 6 to 7 ACEs, the odds ratios were 1.45, 1.54, 2.22, 2. 48, and 3.40 for women and 1.46, 1.67, 2.16, 2.07, and 5.3 for men.

CONCLUSIONS

We observed a strong graded relationship between ACEs and a self-reported history of STDs among adults.

Adverse childhood experiences and smoking during adolescence and adulthood

CONTEXT

In recent years, smoking among adolescents has increased and the decline of adult smoking has slowed to nearly a halt; new insights into tobacco dependency are needed to correct this situation. Long-term use of nicotine has been linked with self-medicating efforts to cope with negative emotional, neurobiological, and social effects of adverse childhood experiences.

OBJECTIVE

To assess the relationship between adverse childhood experiences and 5 smoking behaviors.

DESIGN

The ACE Study, a retrospective cohort survey including smoking and exposure to 8 categories of adverse childhood experiences (emotional, physical, and sexual abuse; a battered mother; parental separation or divorce; and growing up with a substance-abusing, mentally ill, or incarcerated household member), conducted from August to November 1995 and January to March 1996.

SETTING

A primary care clinic for adult members of a large health maintenance organization in San Diego, Calif.

PARTICIPANTS

A total of 9215 adults (4958 women and 4257 men with mean [SD] ages of 55.3 [15.7] and 58.1 [14.5] years, respectively) who responded to a survey questionnaire, which was mailed to all patients 1 week after a clinic visit.

MAIN OUTCOME MEASURES

Smoking initiation by age 14 years or after age 18 years, and status as ever, current, or heavy smoker.

RESULTS

At least 1 of 8 categories of adverse childhood experiences was reported by 63% of respondents. After adjusting for age, sex, race, and education, each category showed an increased risk for each smoking behavior, and these risks were comparable for each category of adverse childhood experiences. Compared with those reporting no adverse childhood experiences, persons reporting 5 or more categories had substantially higher risks of early smoking initiation (odds ratio [OR], 5.4; 95% confidence interval [CI], 4.1-7.1), ever smoking (OR, 3.1; 95% CI, 2.6-3.8), current smoking (OR, 2.1; 95% CI, 1.6-2.7), and heavy smoking (OR, 2.8; 95% CI, 1.9-4.2). Each relationship between smoking behavior and the number of adverse childhood experiences was strong and graded (P<.001). For any given number of adverse childhood experiences, recent problems with depressed affect were more common among smokers than among nonsmokers.

CONCLUSIONS

Smoking was strongly associated with adverse childhood experiences. Primary prevention of adverse childhood experiences and improved treatment of exposed children could reduce smoking among both adolescents and adults.

Unintended pregnancy among adult women exposed to abuse or household dysfunction during their childhood

CONTEXT

Studies have identified childhood sexual and physical abuse as a risk factor for adolescent pregnancy but the relationship between exposure to childhood abuse and unintended pregnancy in adulthood has, to our knowledge, not been studied.

OBJECTIVE

To assess whether unintended pregnancy during adulthood is associated with exposure to psychological, physical, or sexual abuse or household dysfunction during childhood.

DESIGN AND SETTING

Analysis of data from the Adverse Childhood Experiences Study, a survey mailed to members of a large health maintenance organization who visited a clinic in San Diego, Calif, between August and November 1995 and January and March 1996. The survey had a 63.4% response rate among the target population for this study.

PARTICIPANTS

A total of 1193 women aged 20 to 50 years whose first pregnancy occurred at or after age 20 years.

MAIN OUTCOME MEASURE

Risk of unintended first pregnancy by type of abuse (psychological, physical, or sexual abuse; peer sexual assault) and type of household dysfunction (physical abuse of mother by her partner, substance abuse by a household member, mental illness of a household member).

RESULTS

More than 45% of the women reported that their first pregnancy was unintended, and 65.8% reported exposure to 2 or more types of childhood abuse or household dysfunction. After adjustment for confounders (marital status at first pregnancy and age at first pregnancy), the strongest associations between childhood experiences and unintended first pregnancy included frequent psychological abuse (risk ratio [RR], 1.4; 95% confidence interval [CI], 1.2-1.6), frequent physical abuse of the mother by her partner (RR, 1.4; 95% CI, 1.1-1.7), and frequent physical abuse (RR, 1.5; 95% CI, 1.2-1.8). Women who experienced 4 or more types of abuse during their childhood were 1.5 times (95% CI, 1.2-1.8) more likely to have an unintended first pregnancy during adulthood than women who did not experience any abuse.

CONCLUSIONS

This study indicates that there may be a dose-response association between exposure to childhood abuse or household dysfunction and unintended first pregnancy in adulthood. Additional research is needed to fully understand the causal pathway of this association.

Heart failure survival among older adults in the United States: a poor prognosis for an emerging epidemic in the Medicare population

OBJECTIVE

To describe the 6-year probability of survival for older adults after their first hospitalization for heart failure.

SETTING

National Medicare hospital claims records for 1984 through 1986 and Medicare enrollment records from 1986 through 1992.

DESIGN

We identified a national cohort of 170 239 (9% black patients) Medicare patients, 67 years or older, with no evidence of heart failure in 1984 or 1985, who were hospitalized and discharged for the first time in 1986 with a principal diagnosis of heart failure. For groups defined by race, sex, age, Medicaid eligibility, and comorbid conditions, we compared the probability of survival with Cox proportional hazards regression.

RESULTS

Only 19% of black men, 16% of white men, 25% of black women, and 23% of white women survived 6 years. One third died within the first year. Men had lower median survival and 38% greater risk of mortality than did women (P<.05). White men had 10% greater risk of mortality than did black men (P<.05). Medicaid eligibility (white adults only) and diabetes were associated with increased mortality (P<.05).

CONCLUSIONS

The prognosis for older adults with heart failure underscores the importance of prevention strategies and early detection and treatment modalities that can prevent, improve, or reverse myocardial dysfunction, particularly for the growing number of adults who are at increased risk for developing heart failure because of hypertension, diabetes, or myocardial infarction.

Serum folate and risk for coronary heart disease: results from a cohort of US adults

PURPOSE

To assess the role of serum folate in the risk for coronary heart disease in a national cohort of US adults.

METHODS

Data from the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study (N = 1921) were used to determine whether a low serum folate concentration was associated with an increased risk for incident coronary heart disease (N = 284). The Cox proportional hazards model adjusted for age, sex, race, education, serum cholesterol, systolic blood pressure, body mass index, cigarette smoking, and alcohol consumption.

RESULTS

The association between folate and risk for coronary heart disease differed by age group (p = 0.03). Among persons aged 35-55 years, the relative risk for heart disease was 2.4 (95% confidence interval (CI), 1.1-5.2) for persons in the lowest quartile (< or = 9.9 nmol/L) when compared with those in the highest quartile (> or = 21.8 nmol/L). However, among persons > or = 55 years the relative risk was 0.5 (95% CI, 0.3-0.8) for comparisons of the lowest versus highest quartiles.

CONCLUSIONS

If the age differences in the risk for heart disease are confirmed, randomized clinical trials assessing the role of folic acid for the prevention of heart disease may need to include young adults in order to demonstrate benefits related to folate supplementation.

Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study

BACKGROUND

The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described.

METHODS

A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life.

RESULTS

More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life.

CONCLUSIONS

We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study

BACKGROUND

The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described.

METHODS

A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life.

RESULTS

More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life.

CONCLUSIONS

We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Impact of multiple risk factor profiles on determining cardiovascular disease risk

BACKGROUND

We examined the association between clustering of risk factors and the risk for coronary heart disease, stroke, and all-cause mortality.

METHODS

Data from the First National Health and Nutrition Examination Survey Epidemiologic Follow-Up Study (N = 12,932) were used to estimate the relative risk for coronary heart disease (N = 2,255), stroke (N = 929), and death from any cause (N = 4,506) by the number of cardiovascular disease risk factors present. Risk factors included current smoking, overweight, hypertension, high blood cholesterol, and diabetes.

RESULTS

The proportions of respondents with 0, 1, 2, 3, or > or = 4 risk factors were 25.0, 32.8, 27.8, 12.3, and 2.1%, respectively. Relative risks for coronary heart disease associated with having 1, 2, 3, and > or = 4 risk factors were 1.6 (95% confidence interval [CI] 1.4, 1.9), 2.2 (95% CI 1.9, 2.6), 3.1 (95% CI 2.6, 3.6), and 5.0 (95% CI 3.9, 6.3), respectively. Relative risks for stroke associated with the same risk levels were 1.4 (95% CI 1.1, 1.8), 1.9 (95% CI 1.5, 2.4), 2.3 (95% CI 1.7, 3.0), and 4.3 (95% CI 3.0, 6.3), respectively. Similar results were observed for all-cause mortality.

CONCLUSIONS

Risk for cardiovascular disease and all-cause mortality increased substantially with each additional risk factor. This supports the continued need for primary prevention of cardiovascular disease risk factors.

Pharmacologic management of heart failure among older adults by office-based physicians in the United States

BACKGROUND

Despite the recent availability of new classes of heart failure medications, little is known about national patterns in the actual physician utilization of these drugs.

METHODS

In the National Ambulatory Medical Care Survey, 2912 US physicians reported on 16,968 office visits in 1991-1992 with patients aged > or = 65 years. National estimates were obtained from weighted results that accounted for the complex sampling design.

RESULTS

An estimated 8.3 million (2.6%) office visits with older adults involved heart failure. This included 9.3% of visits to cardiologists, 4.3% to internists, 3.5% to general and family physicians, and 0.6% to other physicians. The most frequently prescribed medications during visits with these patients were diuretics (69%), digitalis compounds (46%), angiotensin-converting enzyme inhibitors (30%), and nitrates (19%). Internists and general and family physicians prescribed angiotensin-converting enzyme inhibitors, digitalis compounds, and loop diuretics for patients with heart failure less often than did cardiologists.

CONCLUSIONS

These are the first national surveillance estimates of physician practices in the management of heart failure. These data were collected during the same period in which heart failure clinical trial results were initially published, and they provide a baseline for monitoring the influence of recent clinical practice guidelines and professional education on changes in the management of heart failure by primary care physicians.

Socioeconomic status, race, and death from coronary heart disease

INTRODUCTION

Data to assess factors associated with differences in coronary heart disease mortality between Caucasians and African Americans are limited. We assessed risks for sudden, nonsudden, and other coronary death between Caucasians and African Americans in relation to known risk factors for coronary disease and socioeconomic status.

METHODS

We analyzed data from the 1986 National Mortality Followback Survey, the 1985 National Health Interview Survey, and the U.S. Bureau of the Census. Logistic regression methods were used to create multivariate models to assess the relationship of socioeconomic status and other known modifiable risk factors to death from each of the three coronary diseases for Caucasians and African Americans separately.

RESULTS

In an age- and gender-adjusted analysis of data on men 25-44 years old and women 25-54 years old, African Americans had about twice the risk for sudden, nonsudden, or other coronary death as did Caucasians. Adjusted risks for coronary death for Caucasians associated with modifiable risk factors (cigarette smoking, body weight, diabetes, and hypertension) either resembled or were slightly greater than those for African Americans. Half or more of all excess risks for African Americans in multivariate models could be explained by socioeconomic status. About 18% of excess sudden coronary death risk could be further explained by known modifiable coronary heart disease risk factors.

CONCLUSIONS

Broad public health efforts are needed to address these causes of excess mortality.

National trends in the initial hospitalization for heart failure

OBJECTIVES

Heart failure is a major health care burden among older adults, but information on recent trends has not been available. We compare rates, sociodemographic characteristics, and discharge outcomes of the initial hospitalization for heart failure in the Medicare populations of 1986 and 1993.

DESIGN

Information reported on the Medicare hospital claims record during initial hospitalization for heart failure was compared for patients aged 65 and older hospitalized in 1986 (N = 631,306) and those aged 65 and older hospitalized in 1993 (N = 803,506).

RESULTS

Age-standardized hospitalization rates (per 1000 person-years) for any diagnosis of heart failure were higher in 1993 than in 1986 (white: 24.6 vs 22.4, black: 26.1 vs 22.4, respectively). Age-specific results suggested an earlier onset of heart failure in black adults. In 1993, compared with 1986, higher proportions of heart failure patients were discharged to another care facility (white: 23.9% vs 16.8%, black: 17.6% vs 10.5%, respectively) or to health service care at home (white: 11.3% vs 6.0%, black: 12.4% vs 6.5%, respectively). In contrast, in-hospital mortality was lower in 1993 than in 1986 (white: 10.4% vs 13.3%, black: 8.9% vs 11.1%, respectively).

CONCLUSION

The increased numbers of hospitalizations for heart failure and the likelihood that these patients will require advanced nursing care after discharge have important implications for future national health care expenditures and resources.

Leisure-time physical activity among older adults. United States, 1990

OBJECTIVE

To investigate the prevalence and selected correlates of leisure-time physical activity in a nationally representative sample of persons aged 65 years or older.

METHODS

Data from 2783 older male and 5018 older female respondents to the 1990 National Health Interview Survey were used. Regular physical activity was defined as participation in leisure-time physical activities 3 times or more per week for 30 minutes or more during the previous 2 weeks. Odds ratios (ORs) were estimated from multivariate logistic regression analysis.

RESULTS

Prevalence of regular physical activity was 37% among older men and 24% among older women. Correlates of regular physical activity included the perception of excellent to good health (men: OR, 1.5; 95% confidence interval [CI], 1.1-1.9; women: OR, 1.6; 95% CI, 1.3-1.9), correct exercise knowledge (men: OR, 2.4; 95% CI, 1.9-3.1; women: OR, 2.7; 95% CI, 2.2-3.4), no activity limitations (men: OR, 1.3; 95% CI, 1.0-1.6; women: OR, 1.7; 95% CI, 1.4-2.0) and not perceiving "a lot" of stress during the previous 2 weeks (men: OR, 1.7; 95% CI, 1.2-2.4; women: OR, 1.3; 95% CI, 1.0-1.6). Among those who had been told at least twice that they had high blood pressure, physician's advice to exercise was associated with regular physical activity (men: OR, 1.6; 95% CI, 1.2-2.3; women: OR, 1.5; 95% CI, 1.2-1.9). The 2 major activities among active older adults were walking (men, 69%; women, 75%) and gardening (men, 45%; women, 35%).

CONCLUSIONS

Prevalence of regular physical activity is low among older Americans. Identifying the correlates of physical activity will help to formulate strategies to increase physical activity in this age group.

Evaluation of smoking on the physical activity and depressive symptoms relationship

Physical activity is inversely associated with depressive symptoms, and cigarette smoking is positively associated with depressive symptoms. Data from the first National Health and Nutrition Examination Survey (NHANES I) and the NHANES I Epidemiologic Follow-up study were analyzed to determine whether the relationship between physical activity and self-reported distress (depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale) was different for cigarette smokers and nonsmokers. Logistic regression was used to calculate odds ratios (adjusted for age, race, sex, education, alcohol use, and perceived health status) for depressive symptoms (> or = 16) associated with physical activity and smoking status among 2,054 respondents. At baseline, the odds ratio for depressive symptoms was about 2 times higher for moderately active smokers and nonsmokers, and 3 times higher for low active smokers and nonsmokers, compared with highly active nonsmokers. For 1,132 persons with a low number of depressive symptoms (< 16) at baseline, the incidence of depressive symptoms after 7-9 yr of follow-up was about 2 times higher for low/moderately active smokers and nonsmokers than for highly active nonsmokers. The association between physical activity and the prevalence and incidence of depressive symptoms is not significantly modified by smoking status.

Depression and smoking initiation among US Latinos

We assessed the relationship between depression and smoking initiation among people of Mexican, Puerto Rican and Cuban ancestry residing in specific geographic areas of the United States. Survey data were examined to calculate incidence of smoking initiation and prevalences and odds ratios for ever smoking by presence of depressed mood, a history of major depression or both conditions. Depressed mood, a history of major depression or both conditions were associated with smoking initiation risks during childhood, adolescence and young adulthood. These findings suggest that the relationship between depressive states and smoking initiation is established early in life. More definitive studies are needed to confirm these findings.

Serum folate and risk for ischemic stroke. First National Health and Nutrition Examination Survey epidemiologic follow-up study

BACKGROUND AND PURPOSE

A serum folate concentration < or = 9.2 nmol/L has been associated with elevated levels of plasma homocyst(e)ine. Elevated homocyst(e)ine levels have been associated with ischemic stroke in case-control studies; however, the results from prospective studies have been equivocal. We investigated whether a folate concentration < or = 9.2 nmol/L was associated with ischemic stroke in a national cohort.

METHODS

We used data from the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study (n = 2006). Cox proportional hazards analyses were used to adjust for differences in follow-up time and covariates. During the 13-year follow-up, 98 ischemic strokes occurred.

RESULTS

After adjusting for age, race, sex, education, diabetes, history of heart disease, systolic blood pressure, body mass index, hemoglobin level, cigarette smoking, and alcohol intake, participants with a folate concentration < or = 9.2 nmol/L were at slightly increased risk for ischemic stroke (relative risk [RR], 1.37; 95% confidence interval [CI], 0.82 to 2.29). There was a folate-race interaction (P = .11 for interaction term). Whites with a folate concentration < or = 9.2 nmol/L had a relative risk of 1.18 (95% CI, 0.67 to 2.08), whereas blacks had a relative risk of 3.60 (95% CI, 1.02 to 12.71).

CONCLUSIONS

These findings suggest that a folate concentration < or = 9.2 nmol/L may be a risk factor for ischemic stroke, especially in blacks. However, given the small number of stroke events, additional studies are needed to assess the role of folate in the epidemiology of ischemic stroke.

The shifting stroke belt. Changes in the geographic pattern of stroke mortality in the United States, 1962 to 1988

BACKGROUND AND PURPOSE

The factors that contribute to the Stroke Belt--a concentration of high stroke mortality rates in the southeastern United States--remain unidentified. Previous hypotheses that focused on physical properties of the area have not been confirmed. This study describes changes in the locations of areas with the highest rates of stroke mortality and the implications for new hypotheses regarding the Stroke Belt.

METHODS

We calculated annual, age-adjusted stroke mortality rates for black women, black men, white women, and white men for the years 1962 to 1988 using a three-piece log-linear regression model. Maps were produced with the state economic area (SEA) as the unit of analysis. The baseline Stroke Belt was defined as the area with the largest concentration of high-quintile SEAs in 1962.

RESULTS

The concentration of high-rate SEAs tended to shift away from the Piedmont region of the Southeast and toward the Mississippi River valley. For example, whereas among black women in 1962, 72% of SEAs in the baseline Stroke Belt were in the highest quintile, by 1988 this percentage had dropped to 48%. Similar patterns were observed for the other race/sex groups.

CONCLUSIONS

Temporal changes in the location of areas with the highest stroke mortality rates suggest that new hypotheses for understanding the geographic pattern of stroke mortality should consider temporal trends in a variety of medical, socioeconomic, and behavioral factors.

Alcohol intake and subsequent mortality: findings from the NHANES I Follow-up Study

OBJECTIVE

Because past research has focused primarily on populations of middle-aged men, the relationship between alcohol and mortality among women and the elderly has been less well substantiated

METHOD

We examined the relationship between alcohol intake and mortality using data from the NHANES I Epidemiologic Follow-Up Study. Total mortality was examined for both sexes (N = 4,614 women, 3,573 men), but ischemic heart disease (IHD) mortality was examined only for men because the number of deaths was too small in women. Proportional hazards modeling was used to adjust for the baseline characteristics of age, race, education, body weight, smoking and physical activity.

RESULTS

For men aged 40 to 64, the adjusted relative risks (RR) of death for drinking levels of .5 drinks/day, .5 to < 2 and > or = 2 (compared to the nondrinking reference group) were 0.8 (95% Confidence Interval: 0.6, 1.1), 0.9 (CI:0.6, 1.2) and 1.2 (CI: 0.9, 1.6); RRs of IHD mortality were 0.6 (CI: 0.4, 0.9), 0.5 (CI: 0.3, 0.9) and 0.7 (CI: 0.5, 1.2). For women aged 40 to 64, the RRs for death for the same exposure categories were 1.2 (CI: 0.9, 1.6), 0.9 (CI: 0.6, 1.4) and 1.9 (CI: 1.2, 3.0). Among both sexes 65 years and older, consumption of < 2 drinks/day was associated with about a 20% decrease in total mortality and IHD mortality (men only). However, this protective effect disappeared after exclusion of those with pre-existing disease.

CONCLUSIONS

Our findings support a protective effect of moderate alcohol intake on IHD mortality in middle-aged men. Among both men and women, there was little evidence of a protective association between moderate alcohol intake and total mortality after excluding those with pre-existing disease.

Race and sex differences in rates of invasive cardiac procedures in US hospitals. Data from the National Hospital Discharge Survey

BACKGROUND

Lower rates of invasive cardiac procedures have been reported for blacks and women than for white men. However, few studies have adjusted for differences in the type of hospital of admission, insurance status, and disease severity. SETTING, DESIGN, AND PARTICIPANTS: Data from the National Hospital Discharge Survey were used to investigate race and sex differences in rates of cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass surgery among 10,348 persons hospitalized for acute myocardial infarction.

RESULTS

White men consistently had the highest procedure rates, followed by white women, black men, and black women. After matching for the hospital of admission and adjusting for age, in-hospital mortality, health insurance, and hospital transfer rates (with white men as the referent), the odds ratios for cardiac catheterization were 0.67 (95% confidence interval [CI], 0.51 to 0.87) for black men, 0.72 (95% CI, 0.63 to 0.83) for white women, and 0.50 (95% CI, 0.37 to 0.68) for black women. Similar race-sex differences were noted for percutaneous transluminal coronary angioplasty and coronary artery bypass surgery.

CONCLUSIONS

Race and sex differentials in the rates of invasive cardiac procedures remained despite matching for the hospital of admission and controlling for other factors that influence procedure rates, suggesting that the race and sex of the patient influence the use of these procedures.

The association between alcohol use and health behaviors related to the risk of cardiovascular disease: the South Carolina Cardiovascular Disease Prevention Project

OBJECTIVE

This study examines the relationship between alcohol use and health behaviors related to the risk of cardiovascular disease (CVD). In particular, we examined the relationship between alcohol use and leisure time physical activity, participation in community physical activity programs and behaviors used for weight loss. Numerous studies have found a "protective" effect of moderate alcohol consumption on the risk of CVD. However, most of these studies have not adequately controlled for potential confounding by health behaviors associated with alcohol use.

METHOD

We used descriptive and logistic regression analyses to examine cross-sectional survey data from 2,072 participants in the South Carolina Cardiovascular Disease Prevention Project.

RESULTS

After controlling for age, race, education and preexisting CVD, moderate and heavy drinkers who do not smoke were more likely than nondrinkers to report engaging in regular leisure time physical activity. The relationship between other health behaviors and alcohol consumption was less clear. Among men, moderate and heavy drinkers were no more likely than nondrinkers to participate in community physical activity programs; among women, moderate and heavy drinkers were more likely than nondrinkers to report this activity. Moderate drinkers were more likely than nondrinkers to report that they were attempting to lose weight, however this difference was not statistically significant.

CONCLUSIONS

These data suggest that at least some of the apparent protective effect of moderate alcohol consumption found in other studies may be due to differences between nondrinkers and drinkers with respect to physical activity and other health practices.

Sedentary lifestyle and state variation in coronary heart disease mortality

Using linear regression, the authors demonstrated a strong association between State-specific coronary heart disease mortality rates and State prevalence of sedentary lifestyle (r2 = 0.34; P = 0.0002) that remained significant after controlling for the prevalence of diagnosed hypertension, smoking, and overweight among the State's population. This ecologic analysis suggests that sedentary lifestyle may explain State variation in coronary heart disease mortality and reinforces the need to include physical activity promotion as a part of programs in the States to prevent heart disease.

Weight control practices in adults: results of a multistate telephone survey

In this study, data collected in 1989 in a random-digit dialing telephone survey of 60,590 adults in 38 states and the District of Columbia were analyzed. Approximately 38% of women and 24% of men reported that they were currently trying to lose weight. Methods reported were counting calories (24% of women, 14% of men), participating in organized weight loss programs (10%, 3%), taking special supplements (10%, 7%), taking diet pills (4%, 2%), and fasting for 24 hours or longer (5%, 5%). Among both sexes, only half of those trying to lose weight reported using the recommended method of caloric restriction combined with physical activity.

Trends in oral contraceptive use and cigarette smoking. Behavioral Risk Factor Surveillance System, 1982 and 1988

OBJECTIVE

To investigate trends in oral contraceptive (OC) use and smoking among women of reproductive age and to determine factors related to smoking among OC users.

DESIGN, SETTING, AND PARTICIPANTS

Telephone interviews of women aged 18 through 45 years in 16 states and the District of Columbia who participated in the Behavioral Risk Factor Surveillance System in 1982 (N = 3553) and in 1988 (N = 7384).

RESULTS

Between 1982 and 1988, the prevalence of smoking decreased from 31% to 24% among OC users and from 32% to 28% among non-OC users. In both 1982 and 1988, more than half of the OC users who smoked were heavy smokers (smoked 15 or more cigarettes per day). Nearly one fourth of 35- to 45-year-old women who used OCs were smokers. After we standardized for age, race, and education, the decline in the prevalence of smoking among OC users did not differ substantially from the decline in smoking among non-OC users.

CONCLUSIONS

Despite the possible synergistic effects of smoking and OC use on the risk of cardiovascular disease, we found no accelerated decline in the prevalence of smoking among OC users. As of 1988, nearly one fourth of all OC users were smokers. These data emphasize the need to reduce the prevalence of smoking among women who use OCs before they reach the age at which their risk for cardiovascular disease increases substantially.

Trends in nonfatal coronary heart disease in the United States, 1980 through 1989

BACKGROUND

Although coronary heart disease mortality has been decreasing, little is known about trends in morbidity from coronary heart disease. We evaluated trends in nonfatal coronary heart disease in the United States during 1980 through 1989.

METHODS

We analyzed data from the National Health Interview Survey, an ongoing survey of representative samples of the civilian, noninstitutionalized population of the United States. Survey respondents were determined to have coronary heart disease if they reported ever having a myocardial infarction or heart attack, angina pectoris, or coronary heart disease. Incidence was defined as initial onset of a coronary heart disease condition during the year preceding the interview date.

RESULTS

About 6 million people were estimated to be living with coronary heart disease. The age-standardized prevalence was relatively constant at about 25 per 1000. Among white men, however, prevalence increased significantly over the 10-year period. Among 75- to 84-year-old men, prevalence increased from 100 per 1000 in 1980 to 179 per 1000 in 1989. Among men and women 45 to 54 years old, prevalence decreased. Overall, the incidence rate of nonfatal coronary heart disease was relatively flat (at about 3 per 1000 per year after 1983). Among white women, the incidence rate increased from 1.4 to 2.8 per 1000, and by the end of the decade it nearly equaled the incidence rate among white men.

CONCLUSIONS

Overall, the burden of nonfatal coronary heart disease remained fairly constant during the 1980s. The trends, however, were not uniform in all population groups. The apparent increasing incidence among women deserves continued monitoring. An encouraging trend is the decreasing prevalence in the younger age groups.

Weight control practices of U.S. adolescents and adults

OBJECTIVE

To estimate the prevalence of various weight-loss practices in U.S. adolescents and adults.

DESIGN

The Youth Risk Behavior Survey, a self-administered survey of a random sample of high school students in 1990 and the Behavioral Risk Factor Surveillance System, a random-digit dial survey in 1989.

SETTING

Thirty-eight states and the District of Columbia.

PARTICIPANTS

High school students (n = 11,467) and adults 18 years and older (n = 60,861).

RESULTS

Among high school students, 44% of female students and 15% of male students reported that they were trying to lose weight. An additional 26% of female students and 15% of male students reported that they were trying to keep from gaining more weight. Students reported that they had used the following weight control methods in the 7 days preceding the survey: exercise (51% of female students and 30% of male students); skipping meals (49% and 18%, respectively); taking diet pills (4% and 2%, respectively); and vomiting (3% and 1%, respectively). Among adults, 38% of women and 24% of men reported that they were trying to lose weight, whereas 28% of each sex reported that they were trying to maintain their weight.

CONCLUSIONS

Attempts to lose or maintain weight are very prevalent among both adolescents and adults, especially among females.

Recreational physical activity and ten-year weight change in a US national cohort

Clinical research has established that increases in physical activity cause weight loss among the obese, but less is known about the influence of physical activity on longer-term weight change in the general population. Data from the NHANES-I Epidemiologic Follow-up Study (1971-1975 to 1982-1984) were used to examine the relationship between self-reported recreational physical activity level (low, medium, high) and measured weight change after ten years among 3515 men and 5810 women aged 25-74 years. Cross-sectional analyses at both the baseline and follow-up surveys revealed that recreational physical activity was inversely related to body weight. Low recreational physical activity reported at the follow-up survey was strongly related to major weight gain (> 13 kg) that had occurred during the preceding ten years. The estimated relative risk of major weight gain for those in the low activity level at the follow-up survey compared to those in the high activity level was 3.1 (95% Cl = 1.6-6.0) in men and 3.8 (2.3-6.5) in women. In addition, the relative risk for persons whose activity level was low at both the baseline and follow-up surveys was 2.3 (0.9-5.8) in men and 7.1 (2.2-23.3) in women. However, no relationship was found between baseline physical activity level and subsequent weight gain among either men or women. The lack of a relationship may be due to mis-specification of physical activity because of changes in activity over time. These findings suggest that low physical activity may be both a cause and a consequence of weight gain.(ABSTRACT TRUNCATED AT 250 WORDS)

Dental disease and risk of coronary heart disease and mortality

OBJECTIVE

To investigate a reported association between dental disease and risk of coronary heart disease.

SETTING

National sample of American adults who participated in a health examination survey in the early 1970s.

DESIGN

Prospective cohort study in which participants underwent a standard dental examination at baseline and were followed up to 1987. Proportional hazards analysis was used to estimate relative risks adjusted for several covariates.

MAIN OUTCOME MEASURES

Incidence of mortality or admission to hospital because of coronary heart disease; total mortality.

RESULTS

Among all 9760 subjects included in the analysis those with periodontitis had a 25% increased risk of coronary heart disease relative to those with minimal periodontal disease. Poor oral hygiene, determined by the extent of dental debris and calculus, was also associated with an increased incidence of coronary heart disease. In men younger than 50 years at baseline periodontal disease was a stronger risk factor for coronary heart disease; men with periodontitis had a relative risk of 1.72. Both periodontal disease and poor oral hygiene showed stronger associations with total mortality than with coronary heart disease.

CONCLUSION

Dental disease is associated with an increased risk of coronary heart disease, particularly in young men. Whether this is a causal association is unclear. Dental health may be a more general indicator of personal hygiene and possibly health care practices.

Recent trends in the identification and treatment of high blood cholesterol by physicians. Progress and missed opportunities

OBJECTIVE

To investigate recent trends in the percentage and characteristics of patients being treated by a physician for high blood cholesterol (HBC) and to assess missed clinical opportunities to screen for HBC.

DESIGN, SETTING, PARTICIPANTS

Telephone interviews of 154,735 adults in 37 states that participated in the Behavioral Risk Factor Surveillance System during 1988-1990 to assess trends in the percentage of patients treated for HBC by a physician. An opportunity was considered missed if a person did not report being screened for HBC despite seeing a physician for preventive care in the last 2 years.

RESULTS

Between the first quarter of 1988 and the last quarter of 1990, the percentage of persons treated by a physician for HBC increased from 7.6% to 11.7% (P < .001). However, since an estimated 36% of US adults need treatment for HBC, fewer than one third of persons who need treatment are receiving it. Persons with two or more cardiac risk factors were more likely to be treated, while men, blacks, persons in lower socioeconomic groups, and persons between 20 and 34 years of age were less likely to be treated. Among the 126,571 persons who had seen a physician for preventive care within the last 2 years, missed opportunities to screen for HBC were most common among persons aged 20 through 34 years (59%) and among women who had seen obstetricians/gynecologists for preventive care (43%).

CONCLUSIONS

Fewer than one third of persons who need treatment for HBC as estimated by data from the second National Health and Nutrition and Nutrition Examination Survey are receiving treatment. Better use of clinical opportunities to screen for HBC could substantially accelerate the progress in identifying persons, young adults in particular, who are likely to benefit from cholesterol reduction.

Risk factors for coronary heart disease mortality among persons with diabetes

Although coronary heart disease is a leading cause of morbidity and mortality among persons with diabetes, the risk factors for coronary heart disease have not been well established for this population. The authors performed a case-control analysis by using data from two large population-based surveys. Cases of persons who died of coronary heart disease were identified from the 1986 National Mortality Followback Survey, and controls were taken from behavioral risk factor surveys conducted in 35 states in 1988. Diabetic women younger than 55 years with no other risk factors for coronary heart disease had a 16-fold higher risk of dying from coronary heart disease than did women without diabetes. About one-third of younger women who died of coronary heart disease had diabetes. Diabetic men less than 45 years old with no other risk factors for coronary heart disease had an eightfold higher risk of coronary heart disease mortality. Among older white men and women, diabetes increased the risk of mortality from coronary heart disease about twofold. In younger diabetics, current cigarette smoking was associated with a 50% increase in risk, and high blood pressure increased the risk more than threefold. In the older age group, risk factors for coronary heart disease mortality were similar among those with and those without diabetes: Cigarette smoking and high blood pressure each were associated with about a twofold increase in risk. Diabetes is a particularly strong risk factor for mortality from coronary heart disease in young adults. Smoking and blood pressure control represent major opportunities to reduce the risk of coronary heart disease among persons with diabetes.

Weight loss attempts in adults: goals, duration, and rate of weight loss

OBJECTIVES

Although attempted weight loss is common, little is known about the goals and durations of weight loss attempts and the rates of achieved weight loss in the general population.

METHODS

Data were collected by telephone in 1989 from adults aged 18 years and older in 39 states and the District of Columbia. Analyses were carried out separately for the 6758 men and 14,915 women who reported currently trying to lose weight.

RESULTS

Approximately 25% of the men respondents and 40% of the women respondents reported that they were currently trying to lose weight. Among men, a higher percentage of Hispanics (31%) than of Whites (25%) or Blacks (23%) reported trying to lose weight. Among women, however, there were no ethnic differences in prevalence. The average man wanted to lose 30 pounds and to weigh 178 pounds; the average woman wanted to lose 31 pounds and to weigh 133 pounds. Black women wanted to lose an average of 8 pounds more than did White women, but Black women's goal weight was 10 pounds heavier. The average rate of achieved weight loss was 1.4 pounds per week for men and 1.1 pounds per week for women; these averages, however, may reflect only the experience of those most successful at losing weight.

CONCLUSIONS

Attempted weight loss is a common behavior, regardless of age, gender, or ethnicity, and weight loss goals are substantial; however, obesity remains a major public health problem in the United States.

Self-perceived stress and the risk of peptic ulcer disease. A longitudinal study of US adults

BACKGROUND

Although many physicians and laypersons believe that stress plays a role in the occurrence of peptic ulcer disease, the importance of stress in the pathogenesis of peptic ulcers remains controversial.

METHODS

To investigate the relationship between perceived stress and peptic ulcer disease we used data from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study--a nationally representative cohort study of US adults. This analysis included 4511 persons who had not previously been diagnosed with peptic ulcer disease.

RESULTS

At baseline, 68% of the cohort perceived themselves as stressed. During 13 years of follow-up, 208 persons developed ulcers; the cumulative incidence of ulcers was 7.2% for persons who were stressed and 4.0% for persons who were not. After we adjusted for age, sex, education, smoking status, and regular aspirin use, persons who perceived themselves as stressed were 1.8 times more likely to develop ulcers than those who did not (95% confidence interval, 1.3 to 2.5). We also found a graded relationship between the perceived amount of stress and the incidence of peptic ulcers; relative to nonstressed persons, the relative risk of developing an ulcer was 1.4, 1.9, 2.3, 2.4, and 2.9 at five increasing levels of stress.

CONCLUSIONS

These findings suggest that persons who perceive their lives as stressful may be at increased risk for the development of peptic ulcer disease.

Emerging patterns of cocaine use and the epidemic of cocaine overdose deaths in Dade County, Florida

With the increasing use of cocaine in the United States, cocaine overdose deaths are being reported with increasing frequency. To describe patterns of cocaine use involved in cocaine overdose deaths, we reviewed the postmortem records from the Metropolitan Dade County Medical Examiner Department, Miami, Fla. We identified 239 cocaine overdose deaths from 1971 through 1987. During this period, the incidence of cocaine overdose deaths increased 20-fold, with the largest proportional increases occurring among persons aged older than 24 years, white persons, and men. The percentage of deaths that involved use of cocaine by nonparenteral routes, as well as newer and unknown preparations of cocaine (such as "crack" and "free-base" cocaine), increased. For example, the percentage of deaths that involved use of crack or free-base cocaine increased from 8% in 1981 to 20% in 1987. Persons who died after smoking crack or free-base cocaine had lower blood cocaine levels at autopsy (median level, 0.3 mg/L) than persons who died as a result of using cocaine hydrochloride (median level, 3.7 mg/L). Patterns of cocaine use involved in the epidemic of cocaine overdose deaths are changing. The data suggest that the newer preparations of cocaine, such as crack or free-base cocaine are playing an increasingly important role in this epidemic and that these preparations may be more toxic than cocaine hydrochloride.

Smoking cessation and severity of weight gain in a national cohort

BACKGROUND

Many believe that the prospect of weight gain discourages smokers from quitting. Accurate estimates of the weight gain related to the cessation of smoking in the general population are not available, however.

METHODS

We related changes in body weight to changes in smoking status in adults 25 to 74 years of age who were weighed in the First National Health and Nutrition Examination Survey (NHANES I, 1971 to 1975) and then weighed a second time in the NHANES I Epidemiologic Follow-up Study (1982 to 1984). The cohort included continuing smokers (748 men and 1137 women) and those who had quit smoking for a year or more (409 men and 359 women).

RESULTS

The mean weight gain attributable to the cessation of smoking, as adjusted for age, race, level of education, alcohol use, illnesses related to change in weight, base-line weight, and physical activity, was 2.8 kg in men and 3.8 kg in women. Major weight gain (greater than 13 kg) occurred in 9.8 percent of the men and 13.4 percent of the women who quit smoking. The relative risk of major weight gain in those who quit smoking (as compared with those who continued to smoke) was 8.1 (95 percent confidence interval, 4.4 to 14.9) in men and 5.8 (95 percent confidence interval, 3.7 to 9.1) in women, and it remained high regardless of the duration of cessation. For both sexes, blacks, people under the age of 55, and people who smoked 15 cigarettes or more per day were at higher risk of major weight gain after quitting smoking. Although at base line the smokers weighed less than those who had never smoked, they weighed nearly the same at follow-up.

CONCLUSIONS

Major weight gain is strongly related to smoking cessation, but it occurs in only a minority of those who stop smoking. Weight gain is not likely to negate the health benefits of smoking cessation, but its cosmetic effects may interfere with attempts to quit. Effective methods of weight control are therefore needed for smokers trying to quit.

Trends in alcohol consumption by pregnant women. 1985 through 1988

To examine trends in alcohol consumption among pregnant women, we examined data collected from 21 states participating in the Behavioral Risk Factor Surveillance System for 4 consecutive years: 1985 through 1988. Overall, 429 (25%) of 1712 pregnant women and 19,903 (55%) of 36,057 nonpregnant women 18 to 45 years of age reported using alcohol in the previous month. Pregnant women who used any alcohol reported consuming a median of four drinks per month, whereas nonpregnant women who used any alcohol reported nine. The prevalence of alcohol consumption among pregnant women declined steadily, from 32% in 1985 to 20% in 1988, but the median number of drinks per month for pregnant women who drank did not change. No decline was observed among the less educated or those under the age of 25 years. In 1988, the prevalence of alcohol use among pregnant women remained highest among smokers (37%) and the unmarried (28%). Although the overall consumption of alcohol by pregnant women in the United States appears to be declining, special efforts are needed to reduce alcohol use among pregnant women who are smokers, unmarried, less educated, or younger, women who may already be at high risk of a poor pregnancy outcome.

Sociodemographic characteristics of cigarette smoking initiation in the United States. Implications for smoking prevention policy

Cigarette smoking initiation greatly influences smoking prevalence in the United States. To understand better the initiation of cigarette smoking, we estimated the age-specific incidence of cigarette smoking initiation in relation to race/ethnicity, sex, and educational attainment, using the reported age at smoking onset for 18- to 35-year-old respondents in the 1987 National Health Interview Survey (N = 14764) and the Hispanic Health and Nutrition Examination Survey (N = 3123) conducted during 1982 to 1984. Among white, black, and Hispanic respondents the incidence of smoking initiation increased rapidly after 11 years of age, reaching a peak in groups 17 to 19 years of age, rapidly declining in groups through age 25 years, and gradually declining thereafter. Age-specific smoking initiation rates were generally lower among black than white respondents, similar between white and Hispanic respondents, and appreciably higher among black and Hispanic men than women. Compared with persons who graduated from high school, persons with less than high school education were consistently more likely to start smoking cigarettes during childhood and adolescence. These data indicate that age and educational attainment are the factors most consistently associated with cigarette smoking initiation among all race/ethnic groups in the United States. These data also emphasize the need for smoking-prevention education beginning at an early age, particularly among persons of low socioeconomic status.

Depression and the dynamics of smoking. A national perspective

Data from multiple studies suggest that depression plays a role in cigarette smoking. To obtain a national perspective on the role of depression in the dynamics of smoking, we analyzed data from the first National Health and Nutrition Examination Survey and the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. We used the Center for Epidemiologic Studies Depression Scale to assess symptoms of depression and used the standard cutoff (score, greater than or equal to 16) for defining persons as depressed. The cross-sectional analysis of the first National Health and Nutrition Examination Survey showed that the prevalence of current smokers increased as the Center for Epidemiologic Studies Depression Scale score increased, whereas the quit ratio (former smokers/ever smokers) decreased as the Center for Epidemiologic Studies Depression Scale score increased. Among the cohort of smokers in the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, the estimated incidence of quitting after 9 years of follow-up was 9.9% for depressed smokers and 17.7% for nondepressed smokers. When we adjusted for amount smoked, sex, age, and educational attainment by means of a Cox proportional hazards model, we found that depressed smokers were 40% less likely to have quit compared with nondepressed smokers (relative risk, 0.6). These findings suggest that depression plays an important role in the dynamics of cigarette smoking in the United States.

Smoking and the risk of peptic ulcer disease among women in the United States

Although multiple studies support a causal relationship between smoking and peptic ulcers in men, data for women are limited. Therefore, we used data from the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, a nationally representative prospective study of US adults, to evaluate the impact of smoking on the incidence of peptic ulcers in women. The study cohort included 2851 women who had not been diagnosed as having a peptic ulcer prior to the baseline interview. Among these women, 140 (4.9%) developed peptic ulcer disease. During 12.5 years of follow-up, the estimated cumulative incidence of ulcers was 10.0% for current smokers, 6.4% for former smokers, and 5.4% for never smokers. After adjusting for age, education, regular aspirin use, coffee consumption, and use of alcohol, current smokers were 1.8 times more likely to develop ulcers than never smokers (95% confidence interval, 1.2 to 2.6); the risk of peptic ulcer increased as the amount smoked increased. During the time of this study, we estimate that approximately 20% of incident peptic ulcer cases among US women were attributable to cigarette smoking.

Behavioral Risk Factor Surveillance, 1988

In 1988, 36 states (including the District of Columbia) participated in the Behavioral Risk Factor Surveillance System (BRFSS). This report provides state-specific estimates of the prevalence of certain health-risk behaviors and of the delivery of clinical preventive services as measured by the BRFSS during 1988. Because estimates vary considerably from state to state, national estimates are not always suitable for states to use in planning local programs. Therefore, the BRFSS will continue to provide state-specific data about health behaviors and the use of preventive health services. These data can be used to monitor trends in health behaviors that affect the burden of chronic diseases in the United States and to assess progress toward the year 2000 objectives for the nation.