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1.  The Promise of Prevention: The Effects of Four Preventable Risk Factors on National Life Expectancy and Life Expectancy Disparities by Race and County in the United States 
PLoS Medicine  2010;7(3):e1000248.
Majid Ezzati and colleagues examine the contribution of a set of risk factors (smoking, high blood pressure, elevated blood glucose, and adiposity) to socioeconomic disparities in life expectancy in the US population.
Background
There has been substantial research on psychosocial and health care determinants of health disparities in the United States (US) but less on the role of modifiable risk factors. We estimated the effects of smoking, high blood pressure, elevated blood glucose, and adiposity on national life expectancy and on disparities in life expectancy and disease-specific mortality among eight subgroups of the US population (the “Eight Americas”) defined on the basis of race and the location and socioeconomic characteristics of county of residence, in 2005.
Methods and Findings
We combined data from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System to estimate unbiased risk factor levels for the Eight Americas. We used data from the National Center for Health Statistics to estimate age–sex–disease-specific number of deaths in 2005. We used systematic reviews and meta-analyses of epidemiologic studies to obtain risk factor effect sizes for disease-specific mortality. We used epidemiologic methods for multiple risk factors to estimate the effects of current exposure to these risk factors on death rates, and life table methods to estimate effects on life expectancy. Asians had the lowest mean body mass index, fasting plasma glucose, and smoking; whites had the lowest systolic blood pressure (SBP). SBP was highest in blacks, especially in the rural South—5–7 mmHg higher than whites. The other three risk factors were highest in Western Native Americans, Southern low-income rural blacks, and/or low-income whites in Appalachia and the Mississippi Valley. Nationally, these four risk factors reduced life expectancy at birth in 2005 by an estimated 4.9 y in men and 4.1 y in women. Life expectancy effects were smallest in Asians (M, 4.1 y; F, 3.6 y) and largest in Southern rural blacks (M, 6.7 y; F, 5.7 y). Standard deviation of life expectancies in the Eight Americas would decline by 0.50 y (18%) in men and 0.45 y (21%) in women if these risks had been reduced to optimal levels. Disparities in the probabilities of dying from cardiovascular diseases and diabetes at different ages would decline by 69%–80%; the corresponding reduction for probabilities of dying from cancers would be 29%–50%. Individually, smoking and high blood pressure had the largest effect on life expectancy disparities.
Conclusions
Disparities in smoking, blood pressure, blood glucose, and adiposity explain a significant proportion of disparities in mortality from cardiovascular diseases and cancers, and some of the life expectancy disparities in the US.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Life expectancy (a measure of longevity and premature death) and overall health have increased steadily in the United States over recent years. New drugs, new medical technologies, and better disease prevention have all helped Americans to lead longer, healthier lives. However, even now, some Americans live much longer and much healthier lives than others. Health disparities—differences in how often certain diseases occur and cause death in groups of people classified according to their ethnicity, geographical location, sex, or age—are extremely large and persistent in the US. On average, black men and women in the US live 6.3 and 4.5 years less, respectively, than their white counterparts; the gap between life expectancy in the US counties with the lowest and highest life expectancies is 18.4 years for men and 14.3 years for women. Disparities in deaths (mortality) from chronic diseases such as cardiovascular diseases (for example, heart attacks and stroke), cancers, and diabetes are known to be the main determinants of these life expectancy disparities.
Why Was This Study Done?
Preventable risk factors such as smoking, high blood pressure, excessive body fat (adiposity), and high blood sugar are responsible for many thousands of deaths from chronic diseases. Exposure to these risk factors varies widely by race, state of residence, and socioeconomic status. However, the effects of these observed disparities in exposure to modifiable risk factors on US life expectancy disparities have only been examined in selected groups of people and it is not known how multiple modifiable risk factors affect US health disparities. A better knowledge about how disparities in risk factor exposure contribute to health disparities is needed to ensure that prevention programs not only improve the average health status but also reduce health disparities. In this study, the researchers estimate the effects of smoking, high blood pressure, high blood sugar, and adiposity on US life expectancy and on disparities in life expectancy and disease-specific deaths among the “Eight Americas,” population groups defined by race and by the location and socioeconomic characteristics of their county of residence.
What Did the Researchers Do and Find?
The researchers extracted data on exposure to these risk factors from US national health surveys, information on deaths from different diseases in 2005 from the US National Center for Health Statistics, and estimates of how much each risk factor increases the risk of death from each disease from published studies. They then used modeling methods to estimate the effects of risk factor exposure on death rates and life expectancy. The Asian subgroup had the lowest adiposity, blood sugar, and smoking rates, they report, and the three white subgroups had the lowest blood pressure. Blood pressure was highest in the three black subgroups, whereas the other three risk factors were highest in Western Native Americans, Southern rural blacks, and whites living in Appalachia and the Mississippi Valley. The effects on life expectancy of these factors were smallest in Asians and largest in Southern rural blacks but, overall, these risk factors reduced the life expectancy for men and women born in 2005 by 4.9 and 4.1 years, respectively. Other calculations indicate that if these four risk factors were reduced to optimal levels, disparities among the subgroups in deaths from cardiovascular diseases and diabetes and from cancers would be reduced by up to 80% and 50%, respectively.
What Do These Findings Mean?
These findings suggest that disparities in smoking, blood pressure, blood sugar, and adiposity among US racial and geographical subgroups explain a substantial proportion of the disparities in deaths from cardiovascular diseases, diabetes, and cancers among these subgroups. The disparities in risk factor exposure also explain some of the disparities in life expectancy. The remaining disparities in deaths and life expectancy could be the result of preventable risk factors not included in this study—one of its limitations is that it does not consider the effect of dietary fat, alcohol use, and dietary salt, which are major contributors to different diseases. Thus, suggest the researchers, reduced exposure to preventable risk factors through the implementation of relevant policies and programs should reduce life expectancy and mortality disparities in the US and yield health benefits at a national scale.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000248.
The US Centers for Disease Control and Prevention, the US Office of Minority Health, and the US National Center on Minority Health and Health Disparities all provide information on health disparities in the US
MedlinePlus provides links to information on health disparities and on healthy living (in English and Spanish)
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living
The American Heart Association and the American Cancer Society provide information on modifiable risk factors for patients and caregivers
Healthy People 2010 is a national framework designed to improve the health of people living in the US
The US National Health and Nutrition Examination Survey (NHANES) and the Behavioral Risk Factor Surveillance System (BRFSS) collect information on risk factor exposures in the US
doi:10.1371/journal.pmed.1000248
PMCID: PMC2843596  PMID: 20351772
2.  Misinformation and misbeliefs in the Tuskegee Study of Untreated Syphilis fuel mistrust in the healthcare system. 
The Tuskegee Study of Untreated Syphilis (TSUS) is an important issue in research, healthcare, ethics and race relations. The assumed consequences of knowledge of this study on the African-American community include mistrust of the healthcare system. In the July 2005 issue of the Journal of the National Medical Association, Brandon, Isaac and LaVeist (the authors), who were at the Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, reported the results of black-white differences in awareness of and knowledge about the TSUS and the effect of that awareness and knowledge on medical mistrust. The study surveyed blacks, whites and others in the Baltimore, MD community about their knowledge of and attitudes about the TSUS. The respondents who were aware of the TSUS were asked survey items to assess specific factual information about the TSUS. The respondents who were not aware of the TSUS were read a brief description of the TSUS taken from the CDC website. Both groups were asked if a similar study was possible today. The authors performed a regression analysis of mistrust of medical care based on race, knowledge of the TSUS and demographic variables. The editorial identified and explained challenges in the article, i.e., challenges in calculations, demographic analysis by race, knowledge of TSUS, cultural sensitivity and methodology. The authors miscalculated the "similar proportions" of blacks and whites who were aware of the TSUS; the recalculated proportions, favoring whites, were different than reported by others. There was no demographic analysis by race in their article--also different than other published reports. Most respondents--blacks and whites--who were aware of the TSUS at baseline answered incorrectly the author-selected questions about the TSUS, particularly the fact-based question of whether the TSUS researchers gave syphilis to the men-not dissimilar to one other report. The source for TSUS information (the CDC website) that was used to educate respondents who were not aware of the TSUS at baseline had contradictions, errors and challenges in black history, medical and public health history, and women's studies. The content of what was actually read to respondents was unknown. Proportionally more whites who were not aware of the TSUS but who were read author-selected information about the TSUS believed that a similar study could happen today-a belief and possibly mistrust of medical care that appeared to be induced-compared to whites with prestudy awareness of the TSUS but not read information from the CDC website. Both black groups were not dissimilar from each other. The authors used a survey that measured a race difference in response to a medical event (TSUS) specific to only one racial group (blacks) when there were inclusive examples specific to other groups available. The authors used "Tuskegee" as a single-word sound bite for the TSUS--a misuse that was inappropriate in scientific and research discourse and that may fuel mistrust of medical care. Whether knowledge of the TSUS was a predictor of mistrust of the healthcare system was inconclusive based on the results in the authors' article. The core findings of the article made believing their case difficult. The editorial suggested that bias and misinformation in undertaking, analysis and reporting the study may in itself fuel mistrust in medical care in the community. Because of these challenges, the editorial urged caution with regard to any change in research direction or policy debate based on the results reported in the article.
PMCID: PMC2594917  PMID: 16334509
3.  Racial and ethnic differences in willingness to participate in psychiatric genetic research 
Psychiatric genetics  2009;19(4):186-194.
Objective
The National Institute of Mental Health’s effort to rectify the underrepresentation of American Blacks in the genetic studies of psychiatric disorders has met with mixed success. This study was designed to understand some of the barriers to recruitment.
Methods
Men and women, who were of Black, White or Hispanic race/ethnicity, aged 18–79 years (Nλ=λ353), were recruited from clinical and community settings in New York City Participants responded to a survey that was designed to measure willingness to participate and attitudes toward genetic research. Principal components analyses generated eight factors including perceived benefits, concerns about, and drawbacks of genetic research, and beliefs about genetic or environmental contributions to psychopathology. Analysis of variance assessed within-ethnic group differences on factor scores, as they related to willingness to participate in genetic research.
Results
Ethnic groups did not differ significantly in stated willingness to participate in genetic research; more than 70% in each group were willing to participate. Among Blacks and Hispanics, mistrust and wariness, and stigma were significantly increased in those unwilling to participate; for Whites, perceived benefit to society and perceived importance for knowledge/education were associated with willingness to participate. For Blacks and Hispanics, youth (aged 18–29 years) and college education reduced, but did not eliminate the association between wariness and mistrust and willingness to participate.
Conclusion
Findings suggest that recruitment efforts aimed at increasing the representation of Blacks should be aware of the barriers among those who are less educated, and involve interactive community collaborations, to fully address the mistrust in this population.
doi:10.1097/YPG.0b013e32832cec89
PMCID: PMC2742945  PMID: 19593860
attitudes; Blacks; depression; genomic; recruitment; mental illness
4.  Interrelationships of added sugars intake, socioeconomic status, and race/ethnicity in adults in the United States: National Health Interview Survey 2005 (ADAJ-D-08-00562R1) 
Background
The consumption of added sugars (e.g., white sugar, brown sugar, high-fructose corn syrup) displaces nutrient-dense foods in the diet. The intake of added sugars in the United States (US) is excessive. Little is known about the predictors of added sugars intake.
Objective
To examine the independent relationships of socioeconomic status and race/ethnicity with added sugars intake, and to evaluate the consistency of relationships using a short instrument to those from a different survey using more precise dietary assessment.
Design
Cross-sectional, nationally representative, interviewer-administered survey
Subjects/setting
Adults (≥18 years) participating in the 2005 US National Health Interview Survey (NHIS) Cancer Control Supplement responding to 4 added sugars questions (n=28,948)
Statistical analyses performed
The intake of added sugars was estimated using validated scoring algorithms. Multivariate analysis incorporating sample weights and design effects was conducted. Least squares means and confidence intervals, and significance tests using Wald F statistics are presented. Analyses were stratified by gender and controlled for potential confounders.
Results
The intake of added sugars was higher among males than females and inversely related to age, educational status, and family income. Asian-Americans had the lowest intake and Hispanics the next lowest intake. Among men, blacks had the highest intake, although whites and American Indians/Alaskan Natives (AI/ANs) also had high intakes. Among women, blacks and AI/ANs had the highest intakes. Intake of added sugars was inversely related to educational attainment in whites, blacks, Hispanic men, and AI/AN men, but was unrelated in Asian-Americans. These findings were generally consistent with relationships in NHANES 2003–04 (using one or two 24-hour dietary recalls).
Conclusions
Race/ethnicity, family income and educational status are independently associated with intake of added sugars. Groups with low income and education are particularly vulnerable to diets with high added sugars. Differences among race/ethnicity groups suggest that interventions to reduce intake of added sugars should be tailored. The NHIS added sugars questions with accompanying scoring algorithms appear to provide an affordable and useful means of assessing relationships between various factors and added sugars intake.
doi:10.1016/j.jada.2009.05.002
PMCID: PMC2743027  PMID: 19631043
5.  Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States 
PLoS Medicine  2006;3(9):e260.
Background
The gap between the highest and lowest life expectancies for race-county combinations in the United States is over 35 y. We divided the race-county combinations of the US population into eight distinct groups, referred to as the “eight Americas,” to explore the causes of the disparities that can inform specific public health intervention policies and programs.
Methods and Findings
The eight Americas were defined based on race, location of the county of residence, population density, race-specific county-level per capita income, and cumulative homicide rate. Data sources for population and mortality figures were the Bureau of the Census and the National Center for Health Statistics. We estimated life expectancy, the risk of mortality from specific diseases, health insurance, and health-care utilization for the eight Americas. The life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was 20.7 y in 2001. Within the sexes, the life expectancy gap between the best-off and the worst-off groups was 15.4 y for males (Asians versus high-risk urban blacks) and 12.8 y for females (Asians versus low-income southern rural blacks). Mortality disparities among the eight Americas were largest for young (15–44 y) and middle-aged (45–59 y) adults, especially for men. The disparities were caused primarily by a number of chronic diseases and injuries with well-established risk factors. Between 1982 and 2001, the ordering of life expectancy among the eight Americas and the absolute difference between the advantaged and disadvantaged groups remained largely unchanged. Self-reported health plan coverage was lowest for western Native Americans and low-income southern rural blacks. Crude self-reported health-care utilization, however, was slightly higher for the more disadvantaged populations.
Conclusions
Disparities in mortality across the eight Americas, each consisting of millions or tens of millions of Americans, are enormous by all international standards. The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries.
US mortality rates were calculated according to "race-county" units and divided into the "eight Americas", across which there are enormous disparities in life expectancy.
Editors' Summary
Background.
It has been recognized for a long time that the number of years that people in the United States can expect to live (“life expectancy”) varies enormously. For example, white Americans tend to live longer than black Americans, and life expectancy is much greater in some of the roughly 3,000 counties of the US than it is in others. However, there is a lack of information and understanding on how big a part is played in “health inequalities” by specific diseases and injuries, by risk factors (such as tobacco, alcohol, and obesity), and by variations in access to effective health care.
Why Was This Study Done?
The researchers wanted to find a way of dividing the people of the US into groups based on a small number of characteristics—such as location of county of residence, race, and income—that would help demonstrate the most important factors accounting for differences in life expectancy.
What Did the Researchers Do and Find?
The researchers used figures from the US Census Bureau and the National Center for Health Statistics to calculate mortality (death) rates for the years 1982–2001. They took note of the county of residence and of the race of all the people who died during that period of time. This enabled them to calculate the mortality rates for all 8,221 “race-county units” (all of the individuals of a given race in a given county). They experimented with different ways of combining the race-counties into a small and manageable number of groups. They eventually settled on the idea of there being “eight Americas,” defined on the basis of race-county, population density, income, and homicide rate. Each group contains millions or tens of millions of people. For each of the eight groups the researchers estimated life expectancy, the risk of mortality from specific diseases, the proportion of people who had health insurance, and people's routine encounters with health-care services. (The researchers also created maps of life expectancies for the US counties.) They describe their eight Americas as follows: Asians, northland low-income rural whites, Middle America, low-income whites in Appalachia and the Mississippi Valley, western Native Americans, black Middle America, low-income southern rural blacks, and high-risk urban blacks.
Many striking differences in life expectancy were found between the eight groups. For example, in 2001, the life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was nearly 21 years. Within the sexes, the life expectancy gap between the best-off and the worst-off groups was 15.4 years for males (Asians versus high-risk urban blacks) and 12.8 years for females (Asians versus low-income rural blacks in the South). The causes of death that were mainly responsible for these variations were various chronic diseases and injury. The gaps between best-off and worst-off were similar in 2001 to what they were in 1987.
What Do These Findings Mean?
Health inequalities in the US are large and are showing no sign of reducing. Social and economic reforms would certainly help change the situation. At the same time, the public health system should also improve the way in which it deals with risk factors for chronic diseases and injuries so that groups with the highest death rates receive larger benefits.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030260.
A Perspective article by Gregory Pappas in this issue of PLoS Medicine (DOI: 10.1371/journal.pmed.0030357) discusses the methods of this piece of research and the findings
The American Medical Students' Association deals with the question “What are Health Disparities?” on its web site
The National Institutes of Health's “Strategic Research Plan to Reduce and Ultimately Eliminate Health Disparities” may be seen at the NIH web site
The Office of Minority Health at the Centers for Disease Control and Prevention has a Web page called “Eliminating Racial and Ethnic Health Disparities”
The issue of health inequalities in the US has also been dealt with by the Robert Wood Johnson Foundation
doi:10.1371/journal.pmed.0030260
PMCID: PMC1564165  PMID: 16968116
6.  The publics' understanding of daily caloric recommendations and their perceptions of calorie posting in chain restaurants 
BMC Public Health  2010;10:121.
Background
Calorie posting in chain restaurants has received increasing attention as a policy lever to reduce energy intake. Little research has assessed consumer understanding of overall daily energy requirements or perceived effectiveness of calorie posting.
Methods
A phone survey was conducted from May 1 through 17, 2009 with 663 randomly selected, nationally-representative adults aged 18 and older, including an oversample of Blacks and Hispanics in the United States. To examine differences in responses by race and ethnicity (White, Black, and Hispanic) and gender, we compared responses by conducting chi-squared tests for differences in proportions.
Results
We found that most Americans were knowledgeable about energy requirements for moderately active men (78%) and women (69%), but underestimated energy requirements for inactive adults (60%). Whites had significantly higher caloric literacy and confidence about their caloric knowledge than Blacks and Hispanics (p < 0.05). As compared to their counterparts, Blacks, Hispanics and women reported a significantly higher likelihood of eating at a chain restaurant and of selecting lower calorie foods where caloric information was posted. Most Americans favored the government requiring chain restaurants to post calorie information on menus at the point of purchase (68%). Support for government mandated calorie posting in chain restaurants was significantly higher among Blacks, Hispanics and women as compared to their counterparts. The public was divided about the mode of caloric information that would best help them make a lower calorie decision; a third favored number of calories (35%) which is the current standard mode of presenting caloric information in chain restaurants, a third favored a physical activity equivalent (26%), and a third favored percentage of total energy intake (39%).
Conclusion
Mandating calorie posting in chain restaurants may be a useful policy tool for promoting energy balance, particularly among Blacks, Hispanics and women who have higher obesity risk.
doi:10.1186/1471-2458-10-121
PMCID: PMC2847976  PMID: 20214811
7.  Race and trust in the health care system. 
Public Health Reports  2003;118(4):358-365.
OBJECTIVE: A legacy of racial discrimination in medical research and the health care system has been linked to a low level of trust in medical research and medical care among African Americans. While racial differences in trust in physicians have been demonstrated, little is known about racial variation in trust of health insurance plans and hospitals. For the present study, the authors analyzed responses to a cross-sectional telephone survey to assess the independent relationship of self-reported race (non-Hispanic black or non-Hispanic white) with trust in physicians, hospitals, and health insurance plans. METHODS: Respondents ages 18-75 years were asked to rate their level of trust in physicians, health insurance plans, and hospitals. Items from the Medical Mistrust Index were used to assess fear and suspicion of hospitals. RESULTS: Responses were analyzed for 49 (42%) non-Hispanic black and 69 (58%) non-Hispanic white respondents (N=118; 94% of total survey population). A majority of respondents trusted physicians (71%) and hospitals (70%), but fewer trusted their health insurance plans (28%). After adjustment for potential confounders, non-Hispanic black respondents were less likely to trust their physicians than non-Hispanic white respondents (adjusted absolute difference 37%; p=0.01) and more likely to trust their health insurance plans (adjusted absolute difference 28%; p=0.04). The difference in trust of hospitals (adjusted absolute difference 13%) was not statistically significant. Non-Hispanic black respondents were more likely than non-Hispanic white respondents to be concerned about personal privacy and the potential for harmful experimentation in hospitals. CONCLUSIONS: Patterns of trust in components of our health care system differ by race. Differences in trust may reflect divergent cultural experiences of blacks and whites as well as differences in expectations for care. Improved understanding of these factors is needed if efforts to enhance patient access to and satisfaction with care are to be effective.
PMCID: PMC1497554  PMID: 12815085
8.  Racial and Ethnic Disparities in Cancer Screening 
Journal of General Internal Medicine  2003;18(12):1028-1035.
CONTEXT
Racial/ethnic groups comprised largely of foreign-born individuals have lower rates of cancer screening than white Americans. Little is known about whether these disparities are related primarily to their race/ethnicity or birthplace.
OBJECTIVE
To determine whether foreign birthplace explains some racial/ethnic disparities in cancer screening.
DESIGN, SETTING, AND SUBJECTS
Cross-sectional study using 1998 data from the National Health Interview Survey.
MAIN OUTCOME MEASURES
Completion of cervical, breast, or colorectal cancer screening.
RESULTS
Of respondents, 15% were foreign born. In analyses adjusted for sociodemographic characteristics and illness burden, black respondents were as or more likely to report cancer screening than white respondents; however, Hispanic and Asian-American and Pacific Islander (AAPI) respondents were significantly less likely to report screening for most cancers. When race/ethnicity and birthplace were considered together, U.S.-born Hispanic and AAPI respondents were as likely to report cancer screening as U.S.-born whites; however, foreign-born white (adjusted odds ratio [AOR], 0.58; 95% confidence interval [CI], 0.41 to 0.82), Hispanic (AOR, 0.65; 95% CI, 0.53 to 0.79), and AAPI respondents (AOR, 0.28; 95% CI, 0.19 to 0.39) were less likely than U.S.-born whites to report Pap smears. Foreign-born Hispanic and AAPI respondents were also less likely to report fecal occult blood testing (FOBT); AORs, 0.72; 95% CI, 0.53 to 0.98; and 0.61; 95% CI, 0.39 to 0.96, respectively); and sigmoidoscopy (AORs, 0.70; 95% CI, 0.51 to 0.97; and 0.63; 95% CI, 0.40 to 0.99, respectively). Furthermore, foreign-born AAPI respondents were less likely to report mammography (AOR, 0.49; 95% CI, 0.28 to 0.86). Adjusting for access to care partially attenuated disparities among foreign-born respondents.
CONCLUSION
Foreign birthplace may explain some disparities previously attributed to race or ethnicity, and is an important barrier to cancer screening, even after adjustment for other factors. Increasing access to health care may improve disparities among foreign-born persons to some degree, but further study is needed to understand other barriers to screening among the foreign-born.
doi:10.1111/j.1525-1497.2003.20807.x
PMCID: PMC1494963  PMID: 14687262
cervical cancer; breast cancer; colorectal cancer; cancer screening; race/ethnicity; immigrant status; health disparities
9.  Estimates of Outcomes Up to Ten Years after Stroke: Analysis from the Prospective South London Stroke Register 
PLoS Medicine  2011;8(5):e1001033.
Charles Wolfe and colleagues collected data from the South London Stroke Register on 3,373 first strokes registered between 1995 and 2006 and showed that between 20% and 30% of survivors have poor outcomes up to 10 years after stroke.
Background
Although stroke is acknowledged as a long-term condition, population estimates of outcomes longer term are lacking. Such estimates would be useful for planning health services and developing research that might ultimately improve outcomes. This burden of disease study provides population-based estimates of outcomes with a focus on disability, cognition, and psychological outcomes up to 10 y after initial stroke event in a multi-ethnic European population.
Methods and Findings
Data were collected from the population-based South London Stroke Register, a prospective population-based register documenting all first in a lifetime strokes since 1 January 1995 in a multi-ethnic inner city population. The outcomes assessed are reported as estimates of need and included disability (Barthel Index <15), inactivity (Frenchay Activities Index <15), cognitive impairment (Abbreviated Mental Test < 8 or Mini-Mental State Exam <24), anxiety and depression (Hospital Anxiety and Depression Scale >10), and mental and physical domain scores of the Medical Outcomes Study 12-item short form (SF-12) health survey. Estimates were stratified by age, gender, and ethnicity, and age-adjusted using the standard European population. Plots of outcome estimates over time were constructed to examine temporal trends and sociodemographic differences. Between 1995 and 2006, 3,373 first-ever strokes were registered: 20%–30% of survivors had a poor outcome over 10 y of follow-up. The highest rate of disability was observed 7 d after stroke and remained at around 110 per 1,000 stroke survivors from 3 mo to 10 y. Rates of inactivity and cognitive impairment both declined up to 1 y (280/1,000 and 180/1,000 survivors, respectively); thereafter rates of inactivity remained stable till year eight, then increased, whereas rates of cognitive impairment fluctuated till year eight, then increased. Anxiety and depression showed some fluctuation over time, with a rate of 350 and 310 per 1,000 stroke survivors, respectively. SF-12 scores showed little variation from 3 mo to 10 y after stroke. Inactivity was higher in males at all time points, and in white compared to black stroke survivors, although black survivors reported better outcomes in the SF-12 physical domain. No other major differences were observed by gender or ethnicity. Increased age was associated with higher rates of disability, inactivity, and cognitive impairment.
Conclusions
Between 20% and 30% of stroke survivors have a poor range of outcomes up to 10 y after stroke. Such epidemiological data demonstrate the sociodemographic groups that are most affected longer term and should be used to develop longer term management strategies that reduce the significant poor outcomes of this group, for whom effective interventions are currently elusive.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, 15 million people have a stroke. About 5 million of these people die within a few days, and another 5 million are left disabled. Stroke occurs when the brain's blood supply is suddenly interrupted by a blood clot blocking a blood vessel in the brain (ischemic stroke, the commonest type of stroke) or by a blood vessel in the brain bursting (hemorrhagic stroke). Deprived of the oxygen normally carried to them by the blood, the brain cells near the blockage die. The symptoms of stroke depend on which part of the brain is damaged but include sudden weakness or paralysis along one side of the body, vision loss in one or both eyes, and confusion or trouble speaking or understanding speech. Anyone experiencing these symptoms should seek immediate medical attention because prompt treatment can limit the damage to the brain. Risk factors for stroke include age (three-quarters of strokes occur in people over 65 years old), high blood pressure, and heart disease.
Why Was This Study Done?
Post-stroke rehabilitation can help individuals overcome the physical disabilities caused by stroke, and drugs and behavioral counseling can reduce the risk of a second stroke. However, people can also have problems with cognition (thinking, awareness, attention, learning, judgment, and memory) after a stroke, and they can become depressed or anxious. These “outcomes” can persist for many years, but although stroke is acknowledged as a long-term condition, most existing data on stroke outcomes are limited to a year after the stroke and often focus on disability alone. Longer term, more extensive information is needed to help plan services and to help develop research to improve outcomes. In this burden of disease analysis, the researchers use follow-up data collected by the prospective South London Stroke Register (SLSR) to provide long-term population-based estimates of disability, cognition, and psychological outcomes after a first stroke. The SLSR has recorded and followed all patients of all ages in an inner area of South London after their first-ever stroke since 1995.
What Did the Researchers Do and Find?
Between 1995 and 2006, the SLSR recorded 3,373 first-ever strokes. Patients were examined within 48 hours of referral to SLSR, their stroke diagnosis was verified, and their sociodemographic characteristics (including age, gender, and ethnic origin) were recorded. Study nurses and fieldworkers then assessed the patients at three months and annually after the stroke for disability (using the Barthel Index, which measures the ability to, for example, eat unaided), inactivity (using the Frenchay Activities Index, which measures participation in social activities), and cognitive impairment (using the Abbreviated Mental Test or the Mini-Mental State Exam). Anxiety and depression and the patients' perceptions of their mental and physical capabilities were also assessed. Using preset cut-offs for each outcome, 20%–30% of stroke survivors had a poor outcome over ten years of follow-up. So, for example, 110 individuals per 1,000 population were judged disabled from three months to ten years, rates of inactivity remained constant from year one to year eight, at 280 affected individuals per 1,000 survivors, and rates of anxiety and depression fluctuated over time but affected about a third of the population. Notably, levels of inactivity were higher among men than women at all time points and were higher in white than in black stroke survivors. Finally, increased age was associated with higher rates of disability, inactivity, and cognitive impairment.
What Do These Findings Mean?
Although the accuracy of these findings may be affected by the loss of some patients to follow-up, these population-based estimates of outcome measures for survivors of a first-ever stroke for up to ten years after the event provide concrete evidence that stroke is a lifelong condition with ongoing poor outcomes. They also identify the sociodemographic groups of patients that are most affected in the longer term. Importantly, most of the measured outcomes remain relatively constant (and worse than outcomes in an age-matched non-stroke-affected population) after 3–12 months, a result that needs to be considered when planning services for stroke survivors. In other words, these findings highlight the need for health and social services to provide long-term, ongoing assessment and rehabilitation for patients for many years after a stroke.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001033.
The US National Institute of Neurological Disorders and Stroke provides information about all aspects of stroke (in English and Spanish); the US National Institute of Health SeniorHealth Web site has additional information about stroke
The Internet Stroke Center provides detailed information about stroke for patients, families, and health professionals (in English and Spanish)
The UK National Health Service Choices Web site also provides information about stroke for patients and their families
MedlinePlus has links to additional resources about stroke (in English and Spanish)
More information about the South London Stroke Register is available
doi:10.1371/journal.pmed.1001033
PMCID: PMC3096613  PMID: 21610863
10.  Helicobacter pylori seropositivity and cognitive performance among US adults: evidence from a large national survey 
Psychosomatic medicine  2013;75(5):486-496.
Background
Helicobacter pylori (H. pylori) seropositivity is a potential risk for poor cognition among US adults.
Methods
Cross-sectional data from the National Health and Nutrition Examination Survey III, phase 1 (1988–91) were used. Measures included age-group specific neuropsychological test batteries and two measures of H. pylori seropositivity (IgG and IgG-CagA) (20–59yo:n=2,090–2,248; 60–90yo:n=2,123–2,388). We explored sex- and race-specific associations.
Results
On the basis of multiple OLS and zero-inflated Poisson regression models, we detected a poorer performance among those 60–90yo with H. pylori IgG+ vs. IgG− on a verbal memory test (story recall, correct items), overall (β=−0.04±0.01, p=0.010). NH blacks and women (20–59yo) performed worse on the serial digits learning errors (SDL-TE) when H. pylori IgG+(vs. IgG−), another verbal memory test (β=+0.94±0.40, p=0.029 and β=+1.19±0.44, p=0.012, respectively); (p<0.10 for interaction by sex and race). More trials to completion on this test (SDL-TTC) were also required among H. pylori IgG+ overall (20–59yo, β=+0.30±0.13, p=0.033). Other race-specific associations without significant interaction by race that were detected in the same direction of worse performance with seropositivity included H. pylori IgG+ in NH blacks with the symbol digits substitution test-number of errors (SDS-E) (20–59yo, p=0.038) and with the incorrect items on the orientation test (ORIENT-INC) (60–90yo, p=0.038). H. pylori IgG CagA+ was associated with poorer Word Recall test performance(WR-CORR) among Mexican Americans(60–90yo, p=0.048), WR-TRIALS among NH whites(60–90yo, p=0.047) and ORIENT-INC among NH blacks(60–90yo, p=0.025).
Conclusions
H. pylori seropositivity markers were associated with poor cognition among US adults. Longitudinal research is needed to extrapolote those findings to cognitive decline, incident dementia and Alzheimer’s Disease.
doi:10.1097/PSY.0b013e31829108c3
PMCID: PMC3679320  PMID: 23697465
Helicobacter pylori; seropositivity; cognitive function; adults; aging
11.  Mortality and Potential Years of Life Lost Attributable to Alcohol Consumption by Race and Sex in the United States in 2005 
PLoS ONE  2013;8(1):e51923.
Background
Alcohol has been linked to health disparities between races in the US; however, race-specific alcohol-attributable mortality has never been estimated. The objective of this article is to estimate premature mortality attributable to alcohol in the US in 2005, differentiated by race, age and sex for people 15 to 64 years of age.
Methods and Findings
Mortality attributable to alcohol was estimated based on alcohol-attributable fractions using indicators of exposure from the National Epidemiologic Survey on Alcohol and Related Conditions and risk relations from the Comparative Risk Assessment study. Consumption data were corrected for undercoverage (the observed underreporting of alcohol consumption when using survey as compared to sales data) using adult per capita consumption from WHO databases. Mortality data by cause of death were obtained from the US Department of Health and Human Services. For people 15 to 64 years of age in the US in 2005, alcohol was responsible for 55,974 deaths (46,461 for men; 9,513 for women) representing 9.0% of all deaths, and 1,288,700 PYLL (1,087,280 for men; 201,420 for women) representing 10.7% of all PYLL. Per 100,000 people, this represents 29 deaths (29 for White; 40 for Black; 82 for Native Americans; 6 for Asian/Pacific Islander) and 670 PYLL (673 for White; 808 for Black; 1,808 for Native American; 158 for Asian/Pacific Islander). Sensitivity analyses showed a lower but still substantial burden without adjusting for undercoverage.
Conclusions
The burden of mortality attributable to alcohol in the US is unequal among people of different races and between men and women. Racial differences in alcohol consumption and the resulting harms explain in part the observed disparities in the premature mortality burden between races, suggesting the need for interventions for specific subgroups of the population such as Native Americans.
doi:10.1371/journal.pone.0051923
PMCID: PMC3534703  PMID: 23300957
12.  Low income, race, and the use of mammography. 
Health Services Research  1999;34(1 Pt 2):229-239.
OBJECTIVE: To describe national trends in mammography use by race and income and to test whether higher use of mammography among low-income African American women than low-income white women can be explained by health insurance coverage, usual place of health care, or place of residence. DATA SOURCES/STUDY SETTING: Data from five years of the National Health Interview Survey spanning the period 1987-1994. STUDY DESIGN: Trends in the percentage of women 50-64 years of age with a mammogram within the past two years were analyzed by race and income. Data for 1993-1994 were pooled, and with logistic regression analysis, variation in use of recent mammography for low-income women was investigated. Independent variables are age, race, family income, education, health insurance coverage, place of usual source of health care, metropolitan residence, and geographic region. DATA COLLECTION/EXTRACTION METHODS: The National Health Interview Survey is a cross-sectional national survey conducted by the National Center for Health Statistics. Data are collected through household interviews. [Editor's note: in keeping with HSR policy, the term black is used to conform to its use in the surveys studied. In other references to race, the term African American is used.] PRINCIPAL FINDINGS: Among women 50-64 years of age use of recent mammograms increased rapidly between 1987 and 1991 for all groups of women, and between 1991 and 1994 the increases slowed. However, increases between 1991 and 1994 have been more rapid among low-income black women than among low-income white women. In 1993-1994, low-income black women were about one-third more likely than low-income white women to report mammography within the past two years. This difference could not be explained by health insurance coverage, usual source of health care, metropolitan status, or region of residence. CONCLUSIONS: These results, which provide some evidence of success for screening programs targeted to the poor, raise the question of why low-income black women appear to be to more likely than low-income white women to have benefited from recent efforts to promote mammography. Continued evaluation of mammography programs focused on women who are underserved as well as the monitoring of trends and variations in service use by race and income are needed.
PMCID: PMC1088997  PMID: 10199671
13.  The Social Patterns of a Biological Risk Factor for Disease: Race, Gender, Socioeconomic Position, and C-reactive Protein 
Objective.
Understand the links between race and C-reactive protein (CRP), with special attention to gender differences and the role of class and behavioral risk factors as mediators.
Method.
This study utilizes the National Social Life, Health, and Aging Project data, a nationally representative study of older Americans aged 57–85 to explore two research questions. First, what is the relative strength of socioeconomic versus behavioral risk factors in explaining race differences in CRP levels? Second, what role does gender play in understanding race differences? Does the relative role of socioeconomic and behavioral risk factors in explaining race differences vary when examining men and women separately?
Results.
When examining men and women separately, socioeconomic and behavioral risk factor mediators vary in their importance. Indeed, racial differences in CRP among men aged 57–74 are little changed after adjusting for both socioeconomic and behavioral risk factors with levels 35% higher for black men as compared to white men. For women aged 57–74, however, behavioral risk factors explain 30% of the relationship between race and CRP.
Discussion.
The limited explanatory power of socioeconomic position and, particularly, behavioral risk factors, in elucidating the relationship between race and CRP among men, signals the need for research to examine additional mediators, including more direct measures of stress and discrimination.
doi:10.1093/geronb/gbs048
PMCID: PMC3695599  PMID: 22588996
Behavioral risk factors; Gender; Inflammation; Race
14.  Understanding How Race/Ethnicity and Gender Define Age-Trajectories of Disability: An Intersectionality Approach 
Social science & medicine (1982)  2011;72(8):1236-1248.
A number of studies have demonstrated wide disparities in health among racial/ethnic groups and by gender, yet few have examined how race/ethnicity and gender intersect or combine to affect the health of older adults. The tendency of prior research to treat race/ethnicity and gender separately has potentially obscured important differences in how health is produced and maintained, undermining efforts to eliminate health disparities. The current study extends previous research by taking an intersectionality approach (Mullings & Schulz, 2006), grounded in life course theory, conceptualizing and modeling trajectories of functional limitations as dynamic life course processes that are jointly and simultaneously defined by race/ethnicity and gender. Data from the nationally representative 1994–2006 US Health and Retirement Study and growth curve models are utilized to examine racial/ethnic/gender differences in intra-individual change in functional limitations among White, Black and Mexican American Men and Women, and the extent to which differences in life course capital account for group disparities in initial health status and rates of change with age. Results support an intersectionality approach, with all demographic groups exhibiting worse functional limitation trajectories than White Men. Whereas White Men had the lowest disability levels at baseline, White Women and racial/ethnic minority Men had intermediate disability levels and Black and Hispanic Women had the highest disability levels. These health disparities remained stable with age—except among Black Women who experience a trajectory of accelerated disablement. Dissimilar early life social origins, adult socioeconomic status, marital status, and health behaviors explain the racial/ethnic disparities in functional limitations among Men but only partially explain the disparities among Women. Net of controls for life course capital, Women of all racial/ethnic groups have higher levels of functional limitations relative to White Men and Men of the same race/ethnicity. Findings highlight the utility of an intersectionality approach to understanding health disparities.
doi:10.1016/j.socscimed.2011.02.034
PMCID: PMC3087305  PMID: 21470737
Health Disparities; Functional Limitations; Race/Ethnicity; Gender; Intersectionality; Life Course; Older Adults; USA; disability
15.  Race/Ethnicity, Language, and Patients' Assessments of Care in Medicaid Managed Care 
Health Services Research  2003;38(3):789-808.
Objective
Consumer assessments of health care provide important information about how well health plans and clinicians meet the needs of the people they serve. The purpose of this study was to examine whether consumer reports and ratings of care in Medicaid managed care vary by race/ethnicity and language.
Data Sources
Data were derived from the National CAHPS ® Benchmarking Database (NCBD) 3.0 and consisted of 49,327 adults enrolled in Medicaid managed care plans in 14 states in 2000.
Data Collection
The CAHPS® data were collected by telephone and mail. Surveys were administered in Spanish and English. The response rate across plans was 38 percent.
Study Design
Data were analyzed using linear regression models. The dependent variables were CAHPS ® 2.0 global rating items (personal doctor, specialist, health care, health plan) and multi-item reports of care (getting needed care, timeliness of care, provider communication, staff helpfulness, plan service). The independent variables were race/ethnicity, language spoken at home (English, Spanish, Other), and survey language (English or Spanish). Survey respondents were assigned to one of nine racial/ethnic categories based on Hispanic ethnicity and race: White, Hispanic/Latino, Black/African American, Asian/Pacific Islanders, American Indian/Alaskan native, American Indian/White, Black/White, Other Multiracial, Other Race/Ethnicity. Whites, Asians, and Hispanics were further classified into language subgroups based on the survey language and based on the language primarily spoken at home. Covariates included gender, age, education, and self-rated health.
Principal Findings
Racial/ethnic and linguistic minorities tended to report worse care than did whites. Linguistic minorities reported worse care than did racial and ethnic minorities.
Conclusions
This study suggests that racial and ethnic minorities and persons with limited English proficiency face barriers to care, despite Medicaid-enabled financial access. Health care organizations should address the observed disparities in access to care for racial/ethnic and linguistic minorities as part of their quality improvement efforts.
doi:10.1111/1475-6773.00147
PMCID: PMC1360917  PMID: 12822913
Race/ethnicity; consumer assessments; CAHPS®; patient experiences; patient reports and ratings
16.  Trends in Back-White Differentials in Dietary Intakes of U.S. Adults, 1971–2002 
Background
Disparities in the health status of blacks and whites have persisted despite considerable gains in improved health of the U.S. population. Tracking changes in black-white differentials in dietary attributes over time may help in understanding the contribution of diet to these disparities.
Methods
Data were used from four National Health and Nutrition Examination Surveys conducted between 1971 and 2002 for trends in self-reported intakes of energy, macronutrients, micronutrients, fruits and vegetables, and the energy density of foods, among U.S. non-Hispanic black (n = 7099) and white (n = 23,314) men and women aged 25–74 years. Logistic and linear regression methods were used to adjust for multiple covariates and survey design.
Results
Energy intake, amount of food, and carbohydrate energy increased, whereas percentage of energy from protein, fat, and saturated fat decreased over time in all race-gender groups (p <0.001). In whites and in black women energy-density increased (p <0.001) in parallel to increases in obesity prevalence. In all surveys, black men and women reported lower intakes of vegetables, potassium, and calcium (p <0.001) than their white counterparts. In men, the race differential in calcium intake increased across surveys (p = 0.004).
Conclusions
Dietary intake trends in blacks and whites from 1971–2002 were similar—suggesting that previously identified dietary risk factors that differentially affect black Americans have not improved in a relative sense.
doi:10.1016/j.amepre.2006.12.011
PMCID: PMC2001255  PMID: 17383557
17.  Depressive Distress Among Homosexually Active African American Men and Women 
The American journal of psychiatry  1994;151(4):524-529.
Objective
Although early surveys of psychological adjustment among gay men and lesbians suggest only minor and not clinically relevant differences from heterosexual populations, concerns about psychiatric morbidity associated with HIV infection have renewed interest in the prevalence of psychological distress in this population, particularly among gay men. These later studies have focused primarily on white men. However, research indicates higher crude prevalence rates of psychological distress in community-drawn samples of African American subjects than in white subjects and also higher rates in women than in men. The authors examined rates of depressive distress and suicidal thoughts among homosexually active African American men and women who might be especially at risk for psychiatric morbidity due to multiple stigmatized social statuses.
Method
Two nationally recruited groups of homosexually active African Americans (829 men and 603 women) completed self-administered questionnaires, including the Center for Epidemiologic Studies Depression Scale.
Results
Homosexually active black women were as distressed as HIV-infected gay black men. Men with symptomatic HIV disease were significantly more distressed than men who were HIV infected but asymptomatic, HIV-antibody negative, or whose HIV status was unknown. Both men and women reported distress levels in excess of those previously reported in studies of blacks or primarily white gay men.
Conclusions
Further research is needed to identify specific predictors of life stressors and lack of social support among homosexually active African Americans who appear to be at higher risk for depressive distress.
PMCID: PMC3606487  PMID: 8147449
18.  Stroke literacy in Central Harlem 
Neurology  2009;73(23):1950-1956.
Background:
Awareness of stroke warning symptoms and risk factors (stroke literacy), as well as knowledge of available treatment options, may be poor in high-risk populations. We sought to evaluate stroke literacy among residents of Central Harlem, a predominantly African American population, in a cross-sectional study.
Methods:
Ten community-based sites in Central Harlem were identified between 2005 and 2006 for administration of a stroke knowledge survey. Trained volunteers administered in-person closed-ended questionnaires focused on stroke symptoms and risk factors.
Results:
A total of 1,023 respondents completed the survey. African Americans comprised 65.7% (n = 672) of the survey cohort. The brain was correctly identified as the site where a stroke occurs by 53.7% of respondents, whereas the heart was incorrectly identified by 20.8%. Chest pain was identified as a symptom of stroke by 39.7%. In multivariable analyses, African Americans (odds ratio [OR] 2.20, 95% confidence interval [CI] 1.09–4.45) and Hispanics (OR 5.27, 95% CI 2.46–11.30) were less likely to identify the brain as the damaged organ in stroke. Hispanics were more likely to incorrectly identify chest pain as a stroke symptom, compared with whites (OR 3.40, 95% CI 1.49–7.77). No associations were found between calling 911 and race/ethnicity and stroke knowledge, although women were more likely than men to call 911 (OR 0.50, 95% CI 0.30–0.80).
Conclusion:
Significant deficiencies in stroke literacy exist in this high-risk population, especially when compared with national means. Culturally tailored and sustainable educational campaigns should be tested in high-risk populations as part of stroke public health initiatives.
GLOSSARY
= Behavioral Risk Factor Surveillance Survey;
= confidence interval;
= Second Delay in Accessing Stroke Healthcare;
= emergency medical services;
= face, arm, speech, time;
= odds ratio.
doi:10.1212/WNL.0b013e3181c51a7d
PMCID: PMC2790229  PMID: 19890071
19.  Heterogeneity in the Relationship Between Ethnicity, BMI, and Fasting Insulin 
Diabetes care  2002;25(8):1351-1357.
OBJECTIVE
To determine whether the association of BMI and fasting insulin is modified by ethnicity.
RESEARCH DESIGN AND METHODS
Non-Hispanic black (black), non-Hispanic white (white), and Mexican-American men and women aged 20–80 years from the Third National Health and Nutrition Examination Survey (1988–1994) were included in this study. Linear regression models with an interaction term were used to test whether ethnicity modified the association between BMI and fasting insulin.
RESULTS
Fasting insulin was 19, 26, 20, and 19% higher in black women than white women with BMI levels of <22, 22–24, 25–27, and 28–30 kg/m2, respectively. These differences between black and white women converged at BMI levels >30 kg/m2. Mexican-American women had fasting insulin levels that were 17, 22, 20, and 16% higher than those of white women at BMI levels of 25–27, 28–30, 31–33, and >34 kg/m2, respectively, but were not different in individuals with BMI levels <25 kg/m2. Adjusting for established risk factors did not attenuate these associations in women. Differences in fasting insulin among men were not as apparent.
CONCLUSIONS
These findings suggest that the effect of obesity on insulin sensitivity is different for Americans in ethnic minorities. In black subjects, fasting insulin is higher at lean weight when compared with white and Mexican-American subjects. In Mexican-American subjects, fasting insulin is higher in overweight individuals when compared with white and black subjects. These findings are more pronounced in women than in men. This result reinforces the importance of designing prevention programs that are tailored to meet the needs of specific populations. Investigation of possible explanations for these differences seems warranted.
PMCID: PMC3121929  PMID: 12145234
20.  Bridging between two standards for collecting information on race and ethnicity: an application to Census 2000 and vital rates. 
Public Health Reports  2004;119(2):192-205.
OBJECTIVES: The 2000 Census, which provides denominators used in calculating vital statistics and other rates, allowed multiple-race responses. Many other data systems that provide numerators used in calculating rates collect only single-race data. Bridging is needed to make the numerators and denominators comparable. This report describes and evaluates the method used by the National Center for Health Statistics to bridge multiple-race responses obtained from Census 2000 to single-race categories, creating single-race population estimates that are available to the public. METHODS: The authors fitted logistic regression models to multiple-race data from the National Health Interview Survey (NHIS) for 1997-2000. These fitted models, and two bridging methods previously suggested by the Office of Management and Budget, were applied to the public-use Census Modified Race Data Summary file to create single-race population estimates for the U.S. The authors also compared death rates for single-race groups calculated using these three approaches. RESULTS: Parameter estimates differed between the NHIS models for the multiple-race groups. For example, as the percentage of multiple-race respondents in a county increased, the likelihood of stating black as a primary race increased among black/white respondents but decreased among American Indian or Alaska Native/black respondents. The inclusion of county-level contextual variables in the regression models as well as the underlying demographic differences across states led to variation in allocation percentages; for example, the allocation of black/white respondents to single-race white ranged from nearly zero to more than 50% across states. Death rates calculated using bridging via the NHIS models were similar to those calculated using other methods, except for the American Indian/Alaska Native group, which included a large proportion of multiple-race reporters. CONCLUSION: Many data systems do not currently allow multiple-race reporting. When such data systems are used with Census counts to produce race-specific rates, bridging methods that incorporate geographic and demographic factors may lead to better rates than methods that do not consider such factors.
PMCID: PMC1497618  PMID: 15192907
21.  Is Food Insecurity Associated with HIV Risk? Cross-Sectional Evidence from Sexually Active Women in Brazil 
PLoS Medicine  2012;9(4):e1001203.
Alexander Tsai and colleagues show that in sexually active women in Brazil severe food insecurity with hunger was positively associated with symptoms potentially indicative of sexually transmitted infection and with reduced odds of condom use.
Background
Understanding how food insecurity among women gives rise to differential patterning in HIV risks is critical for policy and programming in resource-limited settings. This is particularly the case in Brazil, which has undergone successive changes in the gender and socio-geographic composition of its complex epidemic over the past three decades. We used data from a national survey of Brazilian women to estimate the relationship between food insecurity and HIV risk.
Methods and Findings
We used data on 12,684 sexually active women from a national survey conducted in Brazil in 2006–2007. Self-reported outcomes were (a) consistent condom use, defined as using a condom at each occasion of sexual intercourse in the previous 12 mo; (b) recent condom use, less stringently defined as using a condom with the most recent sexual partner; and (c) itchy vaginal discharge in the previous 30 d, possibly indicating presence of a sexually transmitted infection. The primary explanatory variable of interest was food insecurity, measured using the culturally adapted and validated Escala Brasiliera de Segurança Alimentar. In multivariable logistic regression models, severe food insecurity with hunger was associated with a reduced odds of consistent condom use in the past 12 mo (adjusted odds ratio [AOR] = 0.67; 95% CI, 0.48–0.92) and condom use at last sexual intercourse (AOR = 0.75; 95% CI, 0.57–0.98). Self-reported itchy vaginal discharge was associated with all categories of food insecurity (with AORs ranging from 1.46 to 1.94). In absolute terms, the effect sizes were large in magnitude across all outcomes. Underweight and/or lack of control in sexual relations did not appear to mediate the observed associations.
Conclusions
Severe food insecurity with hunger was associated with reduced odds of condom use and increased odds of itchy vaginal discharge, which is potentially indicative of sexually transmitted infection, among sexually active women in Brazil. Interventions targeting food insecurity may have beneficial implications for HIV prevention in resource-limited settings.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
At the beginning of the AIDS epidemic, more men than women were infected with HIV, the virus that causes AIDS, but currently half of all HIV-positive adults are women. Most women become infected with HIV through unprotected sexual intercourse with an infected male partner. Biologically, women are twice as likely to become infected through unprotected heterosexual intercourse as men. Moreover, women are often unable to negotiate condom use because of unequal gender relations—men can insist on unprotected sexual intercourse in many relationships. Another factor often related to unequal gender relations that may shape women's risk of exposure to HIV is food insecurity—limited or uncertain access to enough nutritionally adequate and safe food for an active, healthy life. Recent studies done in sub-Saharan Africa suggest that food insecurity can affect women's engagement in risky sexual behaviors such as unprotected sex, transactional sex (sexual relationships that involve the giving of goods or services such as free lodgings), and commercial sex work.
Why Was This Study Done?
Policymakers planning HIV prevention strategies in resource-limited settings need to know whether food insecurity affects sexual risk taking among women. If it increases risk taking, then interventions that target food insecurity should improve the effectiveness of HIV prevention strategies. However, little is known about food insecurity and sexual risk taking outside sub-Saharan Africa. In this cross-sectional study (a study that characterizes a population at a single point in time), the researchers investigate whether food insecurity is associated with risky sexual behavior among sexually active women in Brazil, a country where the number of new heterosexually transmitted HIV infections among women is increasing. Condom promotion is the mainstay of Brazil's HIV prevention strategy, but less than half of the population reports the use of a condom whenever sexual intercourse occurs (consistent condom use) or at last sexual intercourse (recent condom use), and a greater proportion of men than women report condom use, possibly because of unequal power relations between men and women.
What Did the Researchers Do and Find?
The researchers obtained data on consistent condom use, recent condom use, and self-reported itchy vaginal discharge in the previous 30 days (used here as an indication that a woman may have a sexually transmitted infection) for 12,684 sexually active women from a national survey conducted in Brazil in 2006–2007. They then used multivariable logistic regression (a statistical method) to investigate the association between these outcomes and food insecurity, which was measured using the Escala Brasiliera de Insegurança Alimentar, an 18-item questionnaire that asks people to recall information about the quantity and quality of food available to them over the previous three months. Severe food insecurity with hunger (the most extreme category of food insecurity) was associated with an adjusted odds ratio (AOR) for consistent condom use of 0.67. That is, women who reported severe food insecurity were two-thirds as likely to use a condom whenever they had sexual intercourse as women who were food secure, after adjustment for other factors that might have affected condom use. The probability of consistent condom use was 15% among women who were food secure but only 10.5% among women who had the worst food security. Severe food insecurity with hunger was also associated with a reduced odds of recent condom use (AOR = 0.75), whereas all categories of food insecurity increased the odds of a recent itchy vaginal discharge.
What Do These Findings Mean?
These findings indicate that severe food insecurity with hunger is associated with reduced condom use and with increased occurrence of symptoms that may indicate sexually transmitted disease among sexually active women in Brazil. Because the study looked at women at only a single time point, these findings do not show that food insecurity causes risky sexual behavior. Moreover, these findings may not be generalizable to other settings, and they do not distinguish between regular condom use with a regular partner and regular condom use with casual partners. Also, although the researchers investigated two hypothesized explanations—lack of control in sexual relations and chronic energy deficiency—neither of these factors could explain why food insecurity is associated with risky sexual behavior. Nevertheless, these findings suggest that interventions that target sexual risk reduction behaviors are unlikely to be optimally effective if food insecurity is not taken into account, and, thus, the researchers conclude, HIV prevention strategies in Brazil should include interventions that target food insecurity.
Additional Information
Please access these web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001203.
Information is available from the US National Institute of Allergy and Infectious Diseases on all aspects of HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, and summaries of recent research findings on HIV care and treatment (in several languages)
Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including detailed information on HIV and AIDS prevention, women, HIV, and AIDS, and HIV and AIDS in Brazil (in English and Spanish); personal stories of women living with HIV are available
HIV InSite provides comprehensive and up-to-date information on all aspects of HIV/AIDS from the University of California at San Francisco
Additional patient stories about living with HIV/AIDS are available through the charity website Healthtalkonline
A primer on food security from the Food and Agriculture Organization of the United Nations is available
Information about the 2006–2007 Brazilian national survey on health in women and children is available in Portuguese; a profile of food security in Brazil is also available (some information in English but mainly in Portuguese)
doi:10.1371/journal.pmed.1001203
PMCID: PMC3323512  PMID: 22505852
22.  Race and Sex Differences in Bone Mineral Density and Geometry at the Femur 
Bone  2009;45(2):218-225.
Introduction
Differences in osteoporotic hip fracture incidence between American whites and blacks and between women and men are considered to result, in part, from differences in bone mineral density and geometry at the femur. The aim of this study was to quantify differences in femoral bone density and geometry between a large sample of healthy American white and black women and men.
Subjects and Methods
Healthy American white (n=612) and black (n=164) premenopausal women, aged 23 to 57 years, and healthy American white (n=492) and black (n=169) men, aged 20 to 63 years, had volumetric bone mineral density (vBMD) and geometry variables measured at the femur by computerized tomography (CT), and areal bone mineral density (aBMD) at femoral neck measured by dual x-ray absorptiometry (DXA).
Results
American blacks had higher vBMD at the femoral neck and femoral shaft cortex than American whites whereas femoral axis length and femoral neck area were not different. Men had lower vBMD at the femoral neck and femoral cortex than women but had greater femoral axis length and femoral neck area than women. The higher aBMD in American blacks than whites persisted after correction for measured area whereas the higher aBMD in men than women disappeared.
Conclusions
At the femoral neck, American whites have lower bone density than American blacks but similar geometry. Women have higher bone density than men in both races but have smaller geometry variables. The differences in bone density may account in part for the differences in hip fracture incidence between American blacks and whites, whereas the differences in femur size may account for the differences in hip fracture rates between men and women.
doi:10.1016/j.bone.2009.04.236
PMCID: PMC2754757  PMID: 19394455
sex; race; femur; bone mineral density; geometry
23.  Understanding Racial HIV/STI Disparities in Black and White Men Who Have Sex with Men: A Multilevel Approach 
PLoS ONE  2014;9(3):e90514.
Background
The reasons for black/white disparities in HIV epidemics among men who have sex with men have puzzled researchers for decades. Understanding reasons for these disparities requires looking beyond individual-level behavioral risk to a more comprehensive framework.
Methods and Findings
From July 2010-Decemeber 2012, 803 men (454 black, 349 white) were recruited through venue-based and online sampling; consenting men were provided HIV and STI testing, completed a behavioral survey and a sex partner inventory, and provided place of residence for geocoding. HIV prevalence was higher among black (43%) versus white (13% MSM (prevalence ratio (PR) 3.3, 95% confidence interval (CI): 2.5–4.4). Among HIV-positive men, the median CD4 count was significantly lower for black (490 cells/µL) than white (577 cells/µL) MSM; there was no difference in the HIV RNA viral load by race. Black men were younger, more likely to be bisexual and unemployed, had less educational attainment, and reported fewer male sex partners, fewer unprotected anal sex partners, and less non-injection drug use. Black MSM were significantly more likely than white MSM to have rectal chlamydia and gonorrhea, were more likely to have racially concordant partnerships, more likely to have casual (one-time) partners, and less likely to discuss serostatus with partners. The census tracts where black MSM lived had higher rates of poverty and unemployment, and lower median income. They also had lower proportions of male-male households, lower male to female sex ratios, and lower HIV diagnosis rates.
Conclusions
Among black and white MSM in Atlanta, disparities in HIV and STI prevalence by race are comparable to those observed nationally. We identified differences between black and white MSM at the individual, dyadic/sexual network, and community levels. The reasons for black/white disparities in HIV prevalence in Atlanta are complex, and will likely require a multilevel framework to understand comprehensively.
doi:10.1371/journal.pone.0090514
PMCID: PMC3946498  PMID: 24608176
24.  Temporomandibular Joint and Muscle Disorder (TMJMD) - type pain and Co-morbid Pains in a National US Sample 
Journal of orofacial pain  2011;25(3):190-198.
Aims
To compare prevalences of self-reported comorbid headaches, neck, back, and joint pains in respondents with temporomandibular joint and muscle disorder (TMJMD)-type pain in the 2000–2005 US National Health Interview Survey (NHIS), and to analyze these self-reported pains by gender and age for Non-Hispanic (NH) Whites (Caucasians), Hispanics and NH Blacks (African Americans).
Methods
Data from the 2000–2005 NHIS included information on gender, age, race, ethnicity, education, different common types of pain (specifically: TMJMD-type, severe headache/migraine, neck, and low back pains), changes in health status; and health care utilization. Estimates and test statistics (i.e. Pearson correlations, regressions and logistic models) were conducted using SAS survey analysis and SUDAAN software that take into account the complex sample design.
Results
A total of 189,977 people: 52% female and 48% males; 73% NH Whites, 12% Hispanic, 11% NH Blacks and 4% “Other” were included. A total of 4.6% reported TMJMD-type pain and only 0.77% overall reported it without any comorbid headache/migraine, neck, or low back pains; also 59% of the TMJMD-type pain (N = 8,964) reported ≥two comorbid pain. Females reported more comorbid pain than males (odds ratio (OR) = 1.41, p <0.001), Hispanic and NH Blacks reported more than NH Whites (OR = 1.56, p <0.001; OR = 1.38, p <0.001, respectively). In addition, 53% of those with TMJMD-type pain had severe headache/migraines; 54% had neck pain, 64% low back pain and 62% joint pain. Differences in gender, race by age patterns were detected. For females, headache/migraine pain with TMJMD-type pain peaked around age 40 and decreased thereafter regardless of race/ethnicity. Neck pain continued to increase up to about age 60, with higher prevalence for Hispanic women at younger ages, and more pronounced in males, being the highest in the non-Whites. Low back pain was higher in Black and Hispanic females across the age span and higher among non-White males after age 60. Joint pain demonstrated similar patterns by race/ethnicity, which higher rates for Black females, and increased with age regardless of gender.
Conclusions
TMJMD-type pain was most often associated with other common pains, and seldom existed alone. Two or more comorbid pains were common. Gender, race, and age patterns for pains with TMJMD-type pain resembled the specific underlying comorbid pain.
PMCID: PMC3807573  PMID: 21837286
age; back pain; chronic pain; headache/migraine; neck pain; prevalence; race/ethnicity; sample survey; self-report; temporomandibular joint and muscle disorders
25.  Inflammation gene variants and susceptibility to albuminuria in the U.S. population: analysis in the Third National Health and Nutrition Examination Survey (NHANES III), 1991-1994 
BMC Medical Genetics  2010;11:155.
Background
Albuminuria, a common marker of kidney damage, serves as an important predictive factor for the progression of kidney disease and for the development of cardiovascular disease. While the underlying etiology is unclear, chronic, low-grade inflammation is a suspected key factor. Genetic variants within genes involved in inflammatory processes may, therefore, contribute to the development of albuminuria.
Methods
We evaluated 60 polymorphisms within 27 inflammatory response genes in participants from the second phase (1991-1994) of the Third National Health and Nutrition Examination Survey (NHANES III), a population-based and nationally representative survey of the United States. Albuminuria was evaluated as logarithm-transformed albumin-to-creatinine ratio (ACR), as ACR ≥ 30 mg/g, and as ACR above sex-specific thresholds. Multivariable linear regression and haplotype trend analyses were conducted to test for genetic associations in 5321 participants aged 20 years or older. Differences in allele and genotype distributions among non-Hispanic whites, non-Hispanic blacks, and Mexican Americans were tested in additive and codominant genetic models.
Results
Variants in several genes were found to be marginally associated (uncorrected P value < 0.05) with log(ACR) in at least one race/ethnic group, but none remained significant in crude or fully-adjusted models when correcting for the false-discovery rate (FDR). In analyses of sex-specific albuminuria, IL1B (rs1143623) among Mexican Americans remained significantly associated with increased odds, while IL1B (rs1143623), CRP (rs1800947) and NOS3 (rs2070744) were significantly associated with ACR ≥ 30 mg/g in this population (additive models, FDR-P < 0.05). In contrast, no variants were found to be associated with albuminuria among non-Hispanic blacks after adjustment for multiple testing. The only variant among non-Hispanic whites significantly associated with any outcome was TNF rs1800750, which failed the test for Hardy-Weinberg proportions in this population. Haplotypes within MBL2, CRP, ADRB2, IL4R, NOS3, and VDR were significantly associated (FDR-P < 0.05) with log(ACR) or albuminuria in at least one race/ethnic group.
Conclusions
Our findings suggest a small role for genetic variation within inflammation-related genes to the susceptibility to albuminuria. Additional studies are needed to further assess whether genetic variation in these, and untested, inflammation genes alter the susceptibility to kidney damage.
doi:10.1186/1471-2350-11-155
PMCID: PMC2991302  PMID: 21054877

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