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1.  "A Latino Advantage in Oral Health-Related Quality of Life is Modified by Nativity Status" 
Social science & medicine (1982)  2010;71(1):205-211.
Explanations for the social gradient in health status are informed by the rare exceptions. This cross-sectional observational study examined one such exception, the “Latino paradox” by investigating the presence of a Latino advantage in oral health-related quality of life and the effect of nativity status on this relationship. A nationally representative sample of adults (n = 4208) completed the National Health and Nutrition Examination Survey (NHANES) 2003–2004. The impact of oral disorders on oral health-related quality of life was evaluated using the NHANES Oral Health Impact Profile. Exposures of interest were race, ethnicity and nativity status. Covariates included sociodemographic characteristics, smoking status, self-rated health, access to dental care and number of teeth. Unconditional logistic regression models estimated odds of impaired oral health-related quality of life for racial/ethnic and nativity groups compared to the Non-Latino white population. Overall prevalence of impaired oral health-related quality of life was 15.1%. A protective effect of Latino ethnicity was modified by nativity status, such that Latino immigrants experienced substantially better outcomes than non-Latino whites. However the effect was limited to first-generation Latinos. U.S. born Latinos did not share the oral health-related quality of life advantage of their foreign-born counterparts. This advantage was not attributable to the healthy migrant phenomenon since immigrants of non-Latino origin did not differ from Non-Latino whites. The excess risk among Non-Hispanic Blacks was rendered non-significant after adjustment for socioeconomic position. A protective effect conferred by Latino nativity is unexpected given relatively disadvantaged socioeconomic position of this group, their language barrier and restrictions to needed dental care. As the Latino advantage in oral health-related quality of life is not explained by healthy immigrant selection, cultural explanations seem more likely than explanations based on characteristics of individuals.
doi:10.1016/j.socscimed.2010.03.031
PMCID: PMC2885514  PMID: 20434250
USA; Acculturation; Hispanic; Disparities; Epidemiology; Social Class; Oral Health; nativity; Latino paradox; ethnicity
2.  Impact of oral disease on quality of life in the US and Australian populations 
The US National Health and Nutrition Examination Survey (NHANES 2003–2004) evaluated oral health quality of life for the first time using a previously untested subset of seven Oral Health Impact Profile (OHIP) questions, i.e. the NHANES-OHIP.
Objectives
(i) To describe the impact of dental conditions on quality of life in the US adult population; (ii) to evaluate construct validity and adequacy of the NHANES-OHIP in NHANES 2003–2004 and a comparable Australian survey.
Methods
In the cross-sectional NHANES 2003–2004 survey of a nationally representative sample of US adults (n = 4907), prevalence was quantified as the proportion of adults who reported experiencing one or more impacts fairly often or very often within the past year. Construct validity was tested by comparing prevalence estimates across categories of sociodemographic, dental health and utilization characteristics known to vary in oral health. In 2002, Australian cross-sectional survey of a nationally representative sample of adults (n = 2644), adequacy of the NHANES-OHIP questions were tested with reference to a slightly modified version of the OHIP-14 questions.
Results
NHANES-OHIP prevalence estimates were markedly similar in the United States (15.3%) and Australia (15.7%). In the US construct, validity was evidenced by higher NHANES-OHIP scores among groups with greater levels of tooth loss, perceived treatment need and problem-oriented visiting and with lack of private dental insurance and low income. In Australia, prevalence for the NHANES-OHIP closely resembled prevalence estimates of the modified OHIP-14. Both varied to a similar degree across levels of tooth loss, perceived treatment need, problem-oriented visiting, and private dental insurance and income, demonstrating adequacy of the NHANES-OHIP as a brief independent instrument.
Conclusions
There was acceptable construct validity and adequacy of the NHANES-OHIP questionnaire. In the United States, the impact of oral disease disproportionately affected disadvantaged groups, a finding that supports application of the US Healthy People 2010 major goals of improved quality of life and reduced health disparities.
doi:10.1111/j.1600-0528.2008.00457.x
PMCID: PMC3760707  PMID: 19175659
adults; health policy; health surveys; NHANES; population groups
3.  The change in weight perception of weight status among the overweight: comparison of NHANES III (1988–1994) and 1999–2004 NHANES 
Objectives
This study seeks to determine whether perception of weight status among the overweight has changed with the increasing overweight/obesity prevalence.
Methods
The perception of weight status was compared between overweight participants (BMI between 25.0–29.9 kg/m2) from NHANES III (1988–1994) and overweight participants from NHANES 1999–2004. Perception of weight status was assessed by asking participants to classify their weight as about the right weight, underweight or overweight. Comparisons were made across age groups, genders, race/ethnicities and various income levels.
Results
Fewer overweight people during the NHANES 1999–2004 survey perceived themselves as overweight when compared to overweight people during the NHANES III survey. The change in distortion between the survey periods was greatest among persons with lower income, males and African-Americans.
Conclusion
The increase in overweight/obesity between the survey years (NHANES III and NHANES 1999–2004 has been accompanied with fewer overweight people perceiving themselves as overweight.
doi:10.1186/1479-5868-5-9
PMCID: PMC2275297  PMID: 18269748
4.  Ethnic variation in validity of classification of overweight and obesity using self-reported weight and height in American women and men: the Third National Health and Nutrition Examination Survey 
Nutrition Journal  2005;4:27.
Background
Few data have been published on the validity of classification of overweight and obesity based on self-reported weight in representative samples of Hispanic as compared to other American populations despite the wide use of such data.
Objective
To test the null hypothesis that ethnicity is unrelated to bias of mean body mass index (BMI) and to sensitivity of overweight or obesity (BMI >= 25 kg/m2) derived from self-reported (SR) versus measured weight and height using measured BMI as the gold standard.
Design
Cross-sectional survey of a large national sample, the Third National Health and Nutrition Examination Survey (NHANES III) conducted in 1988–1994.
Participants
American men and women aged 20 years and over (n = 15,025).
Measurements
SR height, weight, cigarette smoking, health status, and socio-demographic variables from home interview and measured weight and height.
Results
In women and Mexican American (MA) men SR BMI underestimated true prevalence rates of overweight or obesity. For other men, no consistent difference was seen. Sensitivity of SR was similar in non-Hispanic European Americans (EA) and non-Hispanic African Americans (AA) but much lower in MA. Prevalence of obesity (BMI >= 30 kg/m2) is consistently underestimated by self-report, the gap being greater for MA than for other women, but similar for MA and other men. The mean difference between self-reported and measured BMI was greater in MA (men -0.37, women -0.76 kg/m2) than in non-Hispanic EA (men -0.22, women -0.62 kg/m2). In a regression model with the difference between self-reported and measured BMI as the dependent variable, MA ethnicity was a significant (p < 0.01) predictor of the difference in men and in women. The effect of MA ethnicity could not be explained by socio-demographic variables, smoking or health status.
Conclusion
Under-estimation of the prevalence of overweight or obesity based on height and weight self-reported at interview varied significantly among ethnic groups independent of other variables.
doi:10.1186/1475-2891-4-27
PMCID: PMC1262765  PMID: 16209706
Overweight; Obesity; Hispanics; Mexican Americans; Body weight; Blacks
5.  Using the Edmonton obesity staging system to predict mortality in a population-representative cohort of people with overweight and obesity 
Background:
Anthropometric-based classification schemes for excess adiposity do not include direct assessment of obesity-related comorbidity and functional status and thus have limited clinical utility. We examined the ability of the Edmonton obesity staging system, a 5-point ordinal classification system that considers comorbidity and functional status, in predicting mortality in a nationally representative US sample.
Methods:
We analyzed data from the National Health and Human Nutrition Examination Surveys (NHANES) III (1988–1994) and the NHANES 1999–2004, with mortality follow-up through to the end of 2006. Adults (age ≥ 20 yr) with overweight or obesity who had been randomized to the morning session at the mobile examination centre were scored according to the Edmonton obesity staging system. We examined the relationship between staging system scores and mortality, and Cox proportional hazards models were adjusted for the presence of the metabolic syndrome or hypertriglyceridemic waist.
Results:
Over 75% of the cohort with overweight or obesity were given scores of 1 or 2. Scores of 4 could not be reliably assigned because specific data elements were lacking. Survival curves clearly diverged when stratified by scores of 0–3, but not when stratified by obesity class alone. Within the data from the NHANES 1988–1994, scores of 2 (hazard ratio [HR] 1.57; 95% confidence interval [CI] 1.16 to 2.13) and 3 (HR 2.69; 95% CI 1.98 to 3.67) were associated with increased mortality compared with scores of 0 or 1, even after adjustment for body mass index and the metabolic syndrome. We found similar results after adjusting for hypertriglyceridemic waist (i.e., waist circumference ≥ 90 cm and a triglyceride level ≥ 2 mmol/L for men; the corresponding values for women were ≥ 85 cm and ≥ 1.5 mmol/L), as well as in a cohort eligible for bariatric surgery.
Interpretation:
The Edmonton obesity staging system independently predicted increased mortality even after adjustment for contemporary methods of classifying adiposity. The Edmonton obesity staging system may offer improved clinical utility in assessing obesity-related risk and prioritizing treatment.
doi:10.1503/cmaj.110387
PMCID: PMC3185097  PMID: 21844111
6.  Racial/Ethnic- and Education-Related Disparities in the Control of Risk Factors for Cardiovascular Disease Among Individuals With Diabetes 
Diabetes Care  2012;35(2):305-312.
OBJECTIVE
There is limited information on whether recent improvements in the control of cardiovascular disease (CVD) risk factors among individuals with diabetes have been concentrated in particular sociodemographic groups. This article estimates racial/ethnic- and education-related disparities and examines trends in uncontrolled CVD risk factors among adults with diabetes. The main racial/ethnic comparisons made are with African Americans versus non-Latino whites and Mexican Americans versus non-Latino whites.
RESEARCH DESIGN AND METHODS
The analysis samples include adults aged ≥20 years from the National Health and Nutrition Examination Survey (NHANES) 1988–1994 and the NHANES 1999–2008 who self-reported having diabetes (n = 1,065, NHANES 1988–1994; n = 1,872, NHANES 1999–2008). By use of logistic regression models, we examined the correlates of binary indicators measuring 1) high blood glucose, 2) high blood pressure, 3) high cholesterol, and 4) smoking.
RESULTS
Control of blood glucose, blood pressure, and cholesterol improved among individuals with diabetes between the NHANES 1988–1994 and the NHANES 1999–2008, but there was no change in smoking prevalence. In the NHANES 1999–2008, racial/ethnic minorities and individuals without some college education were more likely to have poorly controlled blood glucose compared with non-Latino whites and those with some college education. In addition, individuals with diabetes who had at least some college education were less likely to smoke and had better blood pressure control compared with individuals with diabetes without at least some college education.
CONCLUSIONS
Trends in CVD risk factors among individuals with diabetes improved over the past 2 decades, but racial/ethnic- and education-related disparities have emerged in some areas.
doi:10.2337/dc11-1405
PMCID: PMC3263918  PMID: 22190677
7.  Respiratory Effects of Marijuana and Tobacco Use in a U.S. Sample 
OBJECTIVE
Although a number of studies have examined the respiratory impact of marijuana smoking, such studies have generally used convenience samples of marijuana and tobacco users. The current study examined respiratory effects of marijuana and tobacco use in a nationally representative sample while controlling for age, gender, and current asthma.
DESIGN
Analysis of the nationally representative third National Health and Nutrition Examination Survey (NHANES III).
SETTING
U.S. households.
PARTICIPANTS
A total of 6,728 adults age 20 to 59 who completed the drug, tobacco, and health sections of the NHANES III questionnaire in 1988 and 1994. Current marijuana use was defined as self-reported 100+ lifetime use and at least 1 day of use in the past month.
MEASUREMENTS AND MAIN RESULTS
Self-reported respiratory symptoms included chronic bronchitis, frequent phlegm, shortness of breath, frequent wheezing, chest sounds without a cold, and pneumonia. A medical exam also provided an overall chest finding and a measure of reduced pulmonary functioning. Marijuana use was associated with respiratory symptoms of chronic bronchitis (P =.02), coughing on most days (P =.001), phlegm production (P =.0005), wheezing (P <.0001), and chest sounds without a cold (P =.02).
CONCLUSION
The impact of marijuana smoking on respiratory health has some significant similarities to that of tobacco smoking. Efforts to prevent and reduce marijuana use, such as advising patients to quit and providing referrals for support and assistance, may have substantial public health benefits associated with decreased respiratory health problems.
doi:10.1111/j.1525-1497.2004.40081.x
PMCID: PMC1490047  PMID: 15693925
marijuana; tobacco; smoking; respiratory symptoms; epidemiology
8.  Does Dental Insurance Make a Difference in Type of Service Received by Iranian Dentate Adults? 
European Journal of Dentistry  2011;5(1):68-76.
Objectives:
To assess the relationship between insurance status and type of service received among dentate adults in a developing oral health care system.
Methods:
A cross-sectional survey based on phone interviews in Tehran, Iran. Four trained interviewers collected data using a structured questionnaire. Of 1,531 subjects answering the phone call, 224 were <18 years; of the remaining 1,307, 221 (17%) refused to participate, and 85 (6%) were excluded as edentate or reporting no dental visit, leaving 1,001 eligible subjects in the sample. The questionnaire covered insurance status, socio-demographics, frequency of tooth brushing, dental attendance as reasons for, and time since last dental visit, and dental service received then. Data analysis included the chi-square test and logistic regression.
Results:
Of the subjects, 71% had a dental insurance. Those with no insurance were more likely to report tooth extractions (OR=1.5) than those with an insurance coverage; for all other treatments no differences according to the insurance status appeared. Among the insured subjects, extractions were more likely for those reporting a problem-based dental visit (OR=6.0) or having a low level of education (OR=2.3).
Conclusions:
In Iran, with its developing oral health care system, dental insurance had only a minor impact on dental services reported.
PMCID: PMC3037191  PMID: 21311609
Adults’ dental care; Dental services; Dental insurance
9.  Comparing Oral Health Care Utilization Estimates in the United States Across Three Nationally Representative Surveys 
Health Services Research  2002;37(2):499-522.
Objective
To compare estimates of dental visits among adults using three national surveys.
Data Sources/Study Design
Cross-sectional data from the National Health Interview Survey (NHIS), National Health and Nutrition Examination Survey (NHANES), and National Health Expenditure surveys (NMCES, NMES, MEPS).
Study Design
This secondary data analysis assessed whether overall estimates and stratum-specific trends are different across surveys.
Data Collection
Dental visit data are age standardized via the direct method to the 1990 population of the United States. Point estimates, standard errors, and test statistics are generated using SUDAAN.
Principal Findings
Sociodemographic, stratum-specific trends are generally consistent across surveys; however, overall estimates differ (NHANES III [364-day estimate] versus 1993 NHIS: –17.5 percent difference, Z=7.27, p value < 0.001; NHANES III [365-day estimate] vs. 1993 NHIS: 5.4 percent difference, Z=–2.50, p value=0.006; MEPS vs. 1993 NHIS: –29.8 percent difference, Z=16.71, p value < 0.001). MEPS is the least susceptible to intrusion, telescoping, and social desirability.
Conclusions
Possible explanations for discrepancies include different reference periods, lead-in statements, question format, and social desirability of responses. Choice of survey should depend on the hypothesis. If trends are necessary, choice of survey should not matter; however, if health status or expenditure associations are necessary, then surveys that contain these variables should be used, and if accurate overall estimates are necessary, then MEPS should be used. A validation study should be conducted to establish “true” utilization estimates.
doi:10.1111/1475-6773.034
PMCID: PMC1430363  PMID: 12036005
Dental care/utilization; dental health surveys; United States epidemiology; adult
10.  Have Regulatory Efforts to Reduce Organophosphorus Insecticide Exposures Been Effective? 
Environmental Health Perspectives  2012;120(4):521-525.
Background: The Food Quality Protection Act (FQPA) was signed into law in 1996 to strengthen the regulation of pesticide tolerances in food. Organophosphorus (OP) insecticides were the first group of pesticides reviewed by the U.S. Environmental Protection Agency (EPA) under the new law.
Objective: Our goal was to determine whether urinary concentrations of dialkylphosphate (DAP) metabolites of OP pesticides declined between the National Health and Nutrition Examination Survey (NHANES) III and NHANES 1999–2004.
Methods: Using mass spectrometry–based methods, we analyzed urine samples from a nationally representative sample of 2,874 adults 20–59 years of age in NHANES 1999–2004 and samples from a non-nationally representative sample of 197 adult participants for NHANES III (1988–1994) for six common DAP metabolites of OP pesticides.
Results: Median urinary DAP concentrations decreased by more than half between NHANES III and NHANES 2003–2004. Reductions of about 50%–90% were also observed for 95th percentile concentrations of five of the six metabolites. Frequencies of detection (FODs) decreased in all six metabolites (< 50% reduction). On average, median and 95th percentile concentrations and FODs showed a larger decrease in diethylphosphate metabolites than dimethylphosphate metabolites.
Conclusions: Human exposure to OP insecticides as assessed by urinary DAP concentrations has decreased since the implementation of the FQPA, although we cannot be certain that U.S. EPA actions in response to the FQPA directly caused the decrease in DAP concentrations.
doi:10.1289/ehp.1104323
PMCID: PMC3339465  PMID: 22251442
biomonitoring; dialkylphosphate metabolite; FQPA; NHANES; organophosphorus insecticide
11.  Health professional's perceptions of and potential barriers to smoking cessation care: a survey study at a dental school hospital in Japan 
BMC Research Notes  2010;3:329.
Background
Smoking is currently accepted as a well-established risk factor for many oral diseases such as oral cancer and periodontal disease. Provision of smoking cessation care to patients with oral problems is a responsibility of health care professionals, particularly dentists and dental hygienists. This study examined the smoking-related perceptions and practices of dental school hospital-based health professionals in Japan.
Findings
A cross-sectional study design was used. The sample was formed from dentists, dental hygienists, physicians and nurses of a dental school hospital in Tokyo, Japan (n = 93, 72%). Participants were asked to complete an 11-item questionnaire assessing demographic variables and smoking history, provision of smoking cessation advice or care, attitudes about smoking cessation, and perceived barrier(s) to smoking cessation care. Eighteen percent of participants reported being current smokers and 15% reported being ex-smokers, with higher smoking rates reported by dentists compared with other health professionals (p = 0.0199). While recognizing the importance of asking patients about their smoking status, actual provision of smoking cessation advice or care by participants was relatively insufficient. Interventions such as 'assess willingness to make a quit attempt' and 'assist in quit attempt' were implemented for less than one-quarter of their patients who smoke. Non-smokers were more likely to acknowledge the need for increased provision in smoking cessation care by oral health professionals. 'Lack of knowledge and training' was identified as a central barrier to smoking cessation care, followed by 'few patients willing to quit'.
Conclusions
A need for further promotion of smoking cessation activities by the health professionals was identified. The findings also suggest that dentists and dental hygienists, while perceiving a role in smoking care, do require training in the provision of smoking cessation care to hospital patients. In order to overcome the potential barriers, it is necessary to provide staff with appropriate training and create an atmosphere supportive of smoking cessation activities.
doi:10.1186/1756-0500-3-329
PMCID: PMC3016266  PMID: 21138553
12.  Social relationships and health related behaviors among older US adults 
BMC Public Health  2014;14:533.
Background
Health behaviors are a key determinant of health and well-being that are influenced by the nature of the social environment. This study examined associations between social relationships and health-related behaviors among a nationally representative sample of older people.
Methods
We analyzed data from three waves (1999–2004) of the US National Health and Nutrition Examination Survey (NHANES). Participants were 4,014 older Americans aged 60 and over. Log-binomial regression models estimated prevalence ratios (PR) for the associations between social relationships and each of the following health behaviors: alcohol use, smoking, physical activity and dental attendance.
Results
Health-compromising behaviors (smoking, heavy drinking and less frequent dental visits) were related to marital status, while physical activity, a health-promoting behavior, was associated with the size of friendship networks. Smoking was more common among divorced/separated (PR = 2.1; 95% CI: 1.6, 2.7) and widowed (PR = 1.7; 95% CI: 1.3, 2.3) respondents than among those married or cohabiting, after adjusting for socio-demographic background. Heavy drinking was 2.6 times more common among divorced/separated and 1.7 times more common among widowed men compared to married/cohabiting men, while there was no such association among women. For women, heavy drinking was associated with being single (PR = 1.7; 95% CI: 1.0, 2.9). Being widowed was related to a lower prevalence of having visited a dentist compared to being married or living with a partner (PR = 0.92; 95% CI 0.86, 0.99). Those with a larger circle of friends were more likely to be physically active (PR = 1.17; 95% CI:1.06, 1.28 for 5–8 versus less than 5 friends).
Conclusions
Social relationships of older Americans were independently associated with different health-related behaviors, even after adjusting for demographic and socioeconomic determinants. Availability of emotional support did not however mediate these associations. More research is needed to assess if strengthening social relationships would have a significant impact on older people’s health behaviors and ultimately improve their health.
doi:10.1186/1471-2458-14-533
PMCID: PMC4046043  PMID: 24885507
Social relationships; Health behaviors; Aging
13.  Health Behaviors and All-Cause Mortality in African American Men 
American journal of men's health  2013;7(4 0):8S-18S.
Because of the excess burden of preventable chronic diseases and premature death among African American men, identifying health behaviors to enhance longevity is needed. We used data from the Third National Health and Nutrition Examination Survey 1988-1994 (NHANES III) and the NHANES III Linked Mortality Public-use File to determine the association between health behaviors and all-cause mortality and if these behaviors varied by age in 2029 African American men. Health behaviors included smoking, drinking, physical inactivity, obesity, and a healthy eating index score. Age was categorized as 25-44 years (n = 1,045), 45-64 years (n = 544), and 65 years and older (n = 440). Cox regression analyses were used to estimate the relationship between health behaviors and mortality within each age-group. All models were adjusted for marital status, education, poverty-to-income ratio, insurance status, and number of health conditions. Being a current smoker was associated with an increased risk of mortality in the 25- to 44-year age-group, whereas being physically inactive was associated with an increased risk of mortality in the 45- to 64-year age-group. For the 65 years and older age-group, being overweight or obese was associated with decreased mortality risk. Efforts to improve longevity should focus on developing age-tailored health promoting strategies and interventions aimed at smoking cessation and increasing physical activity in young and middle-aged African American men.
doi:10.1177/1557988313487552
PMCID: PMC4086642  PMID: 23649171
men's health; health behaviors; men; African Americans; mortality; health disparities
14.  Perceived dental treatment need among older Tanzanian adults – a cross-sectional study 
BMC Oral Health  2007;7:9.
Background
Need perceptions for dental care play a key role as to whether people in general will seek dental care. The aim was to assess the prevalence of perceived need of problem based dental care, dental check-ups and any type of dental care. Guided by the conceptual model of Wilson and Cleary, the relationship of perceived need for dental care with socio-demographic characteristics, clinically defined dental problems and self-reported oral health outcomes was investigated. Partial prosthetic treatment need was estimated using a socio-dental approach.
Method
A cross-sectional survey was conducted in Pwani region and in Dar es Salaam in 2004/2005. Information from interviews and clinical examination became available for 511 urban and 520 rural adults (mean age 62.9 yr).
Results
51.7% (95% CI 46.2, 57.0) urban and 62.5 % (95% CI 53.1, 70.9) rural inhabitants confirmed need for dental check-up, 42.9% (95% CI 36.9, 48.9) urban and 52.7% (95% CI 44.5, 60.6) rural subjects confirmed need for problem oriented care and 38.4% (95% CI 32.4, 44.6) urban versus 49.6% (95% CI 41.8, 57.4) rural residents reported need for any type of dental care. Binary and ordinal multiple logistic regression analyses revealed that adults who reported bad oral health and broken teeth were more likely to perceive need for dental care across the three outcome measures than their counterparts. Socio-demographic factors and clinically defined problems had less impact. Based on a normative and an integrated socio-dental approach respectively 39.5% and 4.7% were in need for partial dentures.
Conclusion
About half of the participants confirmed need for problem oriented care, dental check-ups and any type of dental care. Need perceptions were influenced by perceived oral health, clinically assessed oral problems and socio-demographic characteristics. Need estimates for partial denture was higher when based on clinical examination alone compared to an integrative socio-dental approach.
doi:10.1186/1472-6831-7-9
PMCID: PMC1939845  PMID: 17625014
15.  Self-rated dental health and dental insurance: modification by household income 
Background
Previous studies have reported that socioeconomically disadvantaged Australians have poorer self-rated dental health (SRDH), are less likely to be insured for dental services and are less likely to have regular dental visits than their more advantaged counterparts. However, less is known about the associations between dental insurance and SRDH. The aim of this study was to examine the associations between SRDH and dental insurance status and to test if the relationship was modified by household income.
Methods
A random sample of 3,000 adults aged 30–61 years was drawn from the Australian Electoral Roll and mailed a self-complete questionnaire. Analysis included dentate participants. Bivariate associations were assessed between SRDH and insurance stratified by household income group. A multiple variable model adjusting for covariates estimated prevalence ratios (PR) of having good to excellent SRDH and included an interaction term for insurance and household income group.
Results
The response rate was 39.1% (n = 1,093). More than half (53.9%) of the participants were insured and 72.5% had good to excellent SRDH. SRDH was associated with age group, brushing frequency, insurance status and income group. Amongst participants in the $40,000– < $80,000 income group, the insured had a higher proportion reporting good to excellent SRDH (80.8%) than the uninsured (66.5%); however, there was little difference in SRDH by insurance status for those in the $120,000+ income group. After adjusting for covariates, there was a significant interaction (p < 0.05) between having insurance and income; there was an association between insurance and SRDH for adults in the $40,000– < $80,000 income group, but not for adults in higher income groups.
Conclusions
For lower socio-economic groups being insured was associated with better SRDH, but there was no association for those in the highest income group. Insurance coverage may have the potential to improve dental health for low income groups.
doi:10.1186/1477-7525-12-67
PMCID: PMC4029830  PMID: 24886540
Self-rated dental health; Oral health; Dental insurance; Income
16.  The relationship between methamphetamine use and increased dental disease 
Background
Methamphetamine (MA) use has been linked anecdotally to rampant dental disease. The authors sought to determine the relative prevalence of dental comorbidities in MA users, verify whether MA users have more quantifiable dental disease and report having more dental problems than nonusers and establish the influence of mode of MA administration on oral health outcomes.
Methods
Participating physicians provided comprehensive medical and oral assessments for adults dependent on MA (n = 301). Trained interviewers collected patients' self-reports regarding oral health and substance-use behaviors. The authors used propensity score matching to create a matched comparison group of nonusers from participants in the the Third National Health and Nutrition Examination Survey (NHANES III).
Results
Dental or oral disease was one of the most prevalent (41.3 percent) medical cormorbidities in MA users who otherwise were generally healthy. On average, MA users had significantly more missing teeth than did matched NHANES III control participants (4.58 versus 1.96, P < .001) and were more likely to report having oral health problems (P < .001). Significant subsets of MA users expressed concerns with their dental appearance (28.6 percent), problems with broken or loose teeth (23.3 percent) and tooth grinding (bruxism) or erosion (22.3 percent). The intravenous use of MA was significantly more likely to be associated with missing teeth than was smoking MA (odds ratio = 2.47; 95 percent confidence interval = 1.3-4.8).
Conclusions
Overt dental disease is one of the key distinguishing comorbidities in MA users. MA users have demonstrably higher rates of dental disease and report long-term unmet oral health needs. Contrary to common perception, users who smoke or inhale MA have lower rates of dental disease than do those who inject the drug. Many MA users are concerned with the cosmetic aspects of their dental disease, and these concerns could be used as behavioral triggers for targeted interventions.
Clinical Implications
Dental disease may provide a temporally stable MA-specific medical marker with discriminant utility in identifying MA users. Dentists can play a crucial role in the early detection of MA use and participate in the collaborative care of MA users.
PMCID: PMC2947197  PMID: 20194387
Methamphetamine use; dental disease; oral health; general health; temporomandibular joint disorders
17.  Perceived oral health status and treatment needs of dental auxiliaries 
The Libyan Journal of Medicine  2010;5:10.3402/ljm.v5i0.4859.
Objective
To determine the perceived oral health status and treatment needs of Nigerian dental therapists in training and dental technology students.
Methods
A descriptive cross-sectional study of students from Federal School of Dental Therapy and Technology Enugu, Nigeria was conducted using self-administered questionnaire to obtain information on demography, self-reported oral health status, knowledge of impact of oral health on daily life activity, dental attendance and perceived dental need.
Results
The perception of oral health status and treatment need of the two groups of dental auxiliaries was the same. Fewer respondents (27.3%) rated their oral health as excellent, while 50.4% rated their oral health as good. Majority (95.5%) agreed that oral health is a part of general health and 94.6% agreed that oral health has a role in daily life.
Out of 81.4% that had previous dental treatment, scaling and polishing accounted for 66.1%. Presently, 48.8% think they need dental treatment ranging from scaling and polishing (33.9%), tooth restoration (10.3%), to extraction (1.2%).
Conclusion
This survey revealed that most of the students are aware that oral health is a component of general health and that it has an impact on an individual's daily life. More than half of the students perceived their oral health as good, but only a few knew that there is a need for a preventive approach to oral health as evident by the percentage that perceived scaling and polishing as a treatment need.
doi:10.3402/ljm.v5i0.4859
PMCID: PMC3071173  PMID: 21483589
oral health; status; dental auxiliaries
18.  Serum 25-hydroxyvitamin D status of the US population: 1988–1994 versus 2000–20041 
Background
Changes in serum 25-hydroxyvitamin D (25OHD) concentrations in the US population have not been described.
Objective
Use data from the National Health and Nutrition Examination Surveys (NHANES) to compare serum 25OHD concentrations in the US population in 2000–2004 versus 1988–1994, and to identify contributing factors.
Design
Serum 25OHD was measured with a radioimmunoassay kit in 20,289 participants in NHANES 2000–2004 and 18,158 participants in NHANES III (1988–1994). Body mass index (BMI) was calculated from measured height and weight. Milk intake and sun protection were assessed by questionnaire. Assay differences were assessed by re-analyzing 150 stored sera specimens from NHANES III with the current assay.
Results
Age-adjusted mean serum 25OHD concentrations were significantly lower by 5–20 nmol/L in NHANES 2000–2004 than in NHANES III. After accounting for assay shifts, age-adjusted means in NHANES 2000–2004 remained significantly lower (by 5–9 nmol/L) in most males, but not in most females. In a study subsample, accounting for the confounding effects of assay differences changed mean serum 25OHD by ~10 nmol/L, while accounting for changes in the factors likely related to real changes in vitamin D status (BMI, milk intake, and sun protection) changed means by 1–1.6 nmol/L.
Conclusions
Overall, mean serum 25OHD was lower in 2000–2004 than 1988–1994. Assay changes unrelated to changes in vitamin D status accounted for much of the difference in most population groups. In an adult subgroup, combined changes in BMI, milk intake and sun protection appeared to contribute to a real decline in vitamin D status.
doi:10.3945/ajcn.2008.26182
PMCID: PMC2745830  PMID: 19064511
Serum 25-hydroxyvitamin D; Vitamin D status; NHANES
19.  Impact of the population at risk of diabetes on projections of diabetes burden in the United States: an epidemic on the way 
Diabetologia  2006;50(5):934-940.
Aims/hypothesis
The aim of this study was to make projections of the future diabetes burden for the adult US population based in part on the prevalence of individuals at high risk of developing diabetes.
Materials and methods
Models were created from data in the nationally representative National Health and Nutrition Examination Survey (NHANES) II mortality survey (1976–1992), the NHANES III (1988–1994) and the NHANES 1999–2002. Population models for adults (>20 years of age) from NHANES III data were fitted to known diabetes prevalence in the NHANES 1999–2002 before making future projections. We used a multivariable diabetes risk score to estimate the likelihood of diabetes incidence in 10 years. Estimates of future diabetes (diagnosed and undiagnosed) prevalence in 2011, 2021, and 2031 were made under several assumptions.
Results
Based on the multivariable diabetes risk score, the number of adults at high risk of diabetes was 38.4 million in 1991 and 49.9 million in 2001. The total diabetes burden is anticipated to be 11.5% (25.4 million) in 2011, 13.5% (32.6 million) in 2021, and 14.5% (37.7 million) in 2031. Among individuals aged 30 to 39 years old who are not currently targeted for screening according to age, the prevalence of diabetes is expected to rise from 3.7% in 2001 to 5.2% in 2031. By 2031, 20.2% of adult Hispanic individuals are expected to have diabetes.
Conclusions/interpretation
The prevalence of diabetes is projected to rise to substantially greater levels than previously estimated. Diabetes prevalence within the Hispanic community is projected to be potentially overwhelming.
Electronic supplementary material
Supplementary material is available in the online version of this article at http://dx.doi.org/10.1007/s00125-006-0528-5 and is accessible to authorized users.
doi:10.1007/s00125-006-0528-5
PMCID: PMC1849422  PMID: 17119914
Diabetes; Epidemiology; Projection
20.  Associations between cadmium exposure and neurocognitive test scores in a cross-sectional study of US adults 
Environmental Health  2013;12:13.
Background
Low-level environmental cadmium exposure and neurotoxicity has not been well studied in adults. Our goal was to evaluate associations between neurocognitive exam scores and a biomarker of cumulative cadmium exposure among adults in the Third National Health and Nutrition Examination Survey (NHANES III).
Methods
NHANES III is a nationally representative cross-sectional survey of the U.S. population conducted between 1988 and 1994. We analyzed data from a subset of participants, age 20–59, who participated in a computer-based neurocognitive evaluation. There were four outcome measures: the Simple Reaction Time Test (SRTT: visual motor speed), the Symbol Digit Substitution Test (SDST: attention/perception), the Serial Digit Learning Test (SDLT) trials-to-criterion, and the SDLT total-error-score (SDLT-tests: learning recall/short-term memory). We fit multivariable-adjusted models to estimate associations between urinary cadmium concentrations and test scores.
Results
5662 participants underwent neurocognitive screening, and 5572 (98%) of these had a urinary cadmium level available. Prior to multivariable-adjustment, higher urinary cadmium concentration was associated with worse performance in each of the 4 outcomes. After multivariable-adjustment most of these relationships were not significant, and age was the most influential variable in reducing the association magnitudes. However among never-smokers with no known occupational cadmium exposure the relationship between urinary cadmium and SDST score (attention/perception) was significant: a 1 μg/L increase in urinary cadmium corresponded to a 1.93% (95%CI: 0.05, 3.81) decrement in performance.
Conclusions
These results suggest that higher cumulative cadmium exposure in adults may be related to subtly decreased performance in tasks requiring attention and perception, particularly among those adults whose cadmium exposure is primarily though diet (no smoking or work based cadmium exposure). This association was observed among exposure levels that have been considered to be without adverse effects and these levels are common in U.S. adults. Thus further research into the potential neurocognitive effects of cadmium exposure is warranted. Because cumulative cadmium exposure may mediate some of the effects of age and smoking on cognition, adjusting for these variables may result in the underestimation of associations with cumulative cadmium exposure. Prospective studies that include never-smokers and non-occupationally exposed individuals are needed to clarify these issues.
doi:10.1186/1476-069X-12-13
PMCID: PMC3599125  PMID: 23379984
Cadmium; Neurocognitive; Neuropsychological; NES2; NHANES; Attention; Smoking; Metals; Aging; Cognitive
21.  Growth Curves for Cardio-Metabolic Risk Factors in Children and Adolescents 
The Journal of pediatrics  2009;155(3):S6.e15-S6.e26.
Objective
This study developed percentile curves for anthropometric (waist circumference) and cardiovascular (lipid profile) risk factors for U.S. children and adolescents.
Study design
A representative sample of U.S. children and adolescents from the National Health and Nutrition Examination Survey from 1988–1994 (NHANES III) and the current national series (NHANES 1999–2006) were combined. Percentile curves were constructed, nationally weighted, and smoothed using the LMS method. The percentile curves included age- and sex-specific percentile values that correspond with and transition into the adult abnormal cut-off values for each of these anthropometric and cardiovascular components. To increase the sample size, a second series of percentile curves was also created from the combination of the 2 NHANES databases, along with cross-sectional data from the Bogalusa Heart Study, the Muscatine Study, the Fels Longitudinal Study and the Princeton Lipid Research Clinics Study.
Results
These analyses resulted in a series of growth curves for waist circumference, total cholesterol, LDL cholesterol, triglycerides and HDL cholesterol from a combination of pediatric data sets. The cutoff for abnormal waist circumference in adult males (102cm) was equivalent to the 94th (Table I, C) percentile line in 18 year olds, and the cut-off in adult females (88cm) was equivalent to the 84th (Table I, C) percentile line in 18 year olds. Triglycerides were found to have a bimodal pattern among females with an initial peak at age 11 and a second at age 20; the curve for males increased steadily with age. The HDL curve for females was relatively flat, but the male curve declined starting at age 9 years. Similar curves for Total and LDL cholesterol were constructed for both males and females. When data from the additional child studies were added to the national data, there was little difference in their patterns or rates of change from year to year.
Conclusions
These curves represent waist and lipid percentiles for U.S. children and adolescents, with identification of values that transition to adult abnormalities. They could be used conditionally for both epidemiological and possibly clinical applications, although they need to be validated against longitudinal data.
doi:10.1016/j.jpeds.2009.04.051
PMCID: PMC2789447  PMID: 19732566
22.  Longitudinal associations of blood markers of insulin and glucose concentrations and cancer mortality in the Third National Health and Nutrition Examination Survey 
Cancer causes & control : CCC  2010;21(4):10.1007/s10552-009-9492-y.
Insulin and glucose may influence cancer mortality via their proliferative and anti-apoptotic properties. Using longitudinal data from the nationally representative Third National Health and Nutrition Examination Survey (NHANES III;1988–1994), with an average follow-up of 8.5y to mortality, we evaluated markers of glucose and insulin concentrations, with cancer mortality, ascertained using death certificates using the National Death Index. Plasma glucose, insulin, C-peptide, and lipid concentrations were measured. Anthropometrics, lifestyle, medical and demographic information was obtained during in-person interviews. After adjusting for age, race, sex, smoking status, physical activity and body mass index, for every increase in 50 mg/dl of plasma glucose, there was a 22% increased risk of overall cancer mortality. Insulin resistance was associated with a 41% (95% confidence interval (CI)(1.07–1.87;p=0.01) increased risk of overall cancer mortality. These associations were stronger after excluding lung cancer deaths for insulin resistant individuals (HR:1.67; 95% CI:1.15–2.42;p=0.01), specifically among those with lower levels of physical activity (HR:2.06; 95% CI:1.4–3.0;p=0.0001). Similar associations were observed for other blood markers of glucose and insulin, albeit not statistically significant. In conclusions, hyperglycemia and insulin resistance may be ‘high-risk’ conditions for cancer mortality. Managing these conditions may be effective cancer control tools.
doi:10.1007/s10552-009-9492-y
PMCID: PMC3817266  PMID: 20094767
cancer mortality; insulin; glucose control; epidemiology; longitudinal study
23.  Exposure to Environmental Tobacco Smoke and Cognitive Abilities among U.S. Children and Adolescents 
Environmental Health Perspectives  2004;113(1):98-103.
We used the Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988 to 1994, to investigate the relationship between environmental tobacco smoke (ETS) exposure and cognitive abilities among U.S. children and adolescents 6–16 years of age. Serum cotinine was used as a biomarker of ETS exposure. Children were included in the sample if their serum cotinine levels were ≤15 ng/mL, a level consistent with ETS exposure, and if they denied using any tobacco products in the previous 5 days. Cognitive and academic abilities were assessed using the reading and math subtests of the Wide Range Achievement Test–Revised and the block design and digit span subtests of the Wechsler Intelligence Scale for Children–III. Analyses were conducted using SUDAAN software. Of the 5,365 6- to 16-year-olds included in NHANES III, 4,399 (82%) were included in this analysis. The geometric mean serum cotinine level was 0.23 ng/mL (range, 0.035–15 ng/mL); 80% of subjects had levels < 1 ng/mL. After adjustment for sex, race, region, poverty, parent education and marital status, ferritin, and blood lead concentration, there was a significant inverse relationship between serum cotinine and scores on reading (β= −2.69, p = 0.001), math (β= −1.93, p = 0.01), and block design (β= −0.55, p < 0.001) but not digit span (β= −0.08, p = 0.52). The estimated ETS-associated decrement in cognitive test scores was greater at lower cotinine levels. A log-linear analysis was selected as the best fit to characterize the increased slope in cognitive deficits at lower levels of exposure. These data, which indicate an inverse association between ETS exposure and cognitive deficits among children even at extremely low levels of exposure, support policy to further restrict children’s exposure.
doi:10.1289/ehp.7210
PMCID: PMC1253717  PMID: 15626655
children; cognition; environment; environmental tobacco smoke; epidemiology
24.  Insurance-Related Barriers to Accessing Dental Care Among African American Adults With Oral Health Symptoms in Harlem, New York City 
American journal of public health  2011;101(8):1420-1428.
Although ability to pay is associated with dental care utilization, provision of public or private dental insurance has not eliminated dental care disparities between African American and White adults. We examined insurance-related barriers to dental care in interviews with a street-intercept sample of 118 African American adults in Harlem, New York City, with recent oral health symptoms. Although most participants reported having dental insurance (21% private, 50% Medicaid), reported barriers included (1) lack of coverage, (2) insufficient coverage, (3) inability to find a dentist who accepts their insurance, (4) having to wait for coverage to take effect, and (5) perceived poor quality of care for the uninsured or underinsured. These findings provide insights into why disparities persist and suggest strategies to removing these barriers to dental care.
doi:10.2105/AJPH.2010.300076
PMCID: PMC3134506  PMID: 21680926
25.  Socioeconomic Differentials in Immune Response in the U.S. 
Epidemiology (Cambridge, Mass.)  2009;20(6):902-908.
Background
Lower socioeconomic status (SES) is strongly linked to health outcomes, though the mechanisms are poorly understood. Little is known about the role of the immune system in creating and sustaining health disparities. Here we test whether SES is related to cell-mediated immunity, as measured by the host’s ability to keep persistent cytomegalovirus (CMV) antibody levels in a quiescent state.
Methods
Censored regression models are used to test the cross-sectional relationship between education, income, race/ethnicity, and antibody response to CMV, using a nationally representative sample of 9721 respondents aged 25 years and older surveyed in the Third National Health and Nutrition Examination Survey (NHANES III, 1988–1994).
Results
Among CMV seropositive respondents, those with less education, income, and non-white race/ethnicity had significantly higher levels of antibodies to CMV at all ages. On average, each additional year of age was associated with CMV antibody levels that were 0.03 (95% CI 0.03–0.04) units higher, while each additional year of education was associated with antibody levels that were 0.05 (95% CI 0.02–0.09) units lower. A doubling of family income was associated with antibody levels that were 0.25 (95% CI 0.11–0.39) units lower, the equivalent of 8 fewer years of age-related CMV antibody response. These relationships remained strong after controlling for baseline health conditions, smoking status, and BMI.
Conclusions
This study reports for the first time a significant association between SES and an indirect marker of cell-mediated immunity in a nationally representative U.S. sample. SES differences in immune control over CMV may have fundamental implications for health disparities over the life course.
doi:10.1097/EDE.0b013e3181bb5302
PMCID: PMC2765221  PMID: 19797966
cytomegalovirus; socioeconomic status; immunity; aging; NHANES III

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