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1.  Sex-specific relationships between adverse childhood experiences and chronic obstructive pulmonary disease in five states 
Purpose
Adverse childhood experiences (ACEs) before age 18 have been repeatedly associated with several chronic diseases in adulthood such as depression, heart disease, cancer, diabetes, and stroke. We examined sex-specific relationships between individual ACEs and the number of ACEs with chronic obstructive pulmonary disease (COPD) in the general population.
Materials and methods
Data from 26,546 women and 19,015 men aged ≥18 years in five states of the 2011 Behavioral Risk Factor Surveillance System were analyzed. We used log-linear regression to estimate prevalence ratios (PRs) and their corresponding 95% confidence intervals (CIs) for the relationship of eight ACEs with COPD after adjustment for age group, race/ethnicity, marital status, educational attainment, employment, asthma history, health insurance coverage, and smoking status.
Results
Some 63.8% of women and 62.2% of men reported ≥1 ACE. COPD was reported by 4.9% of women and 4.0% of men. In women, but not in men, there was a higher likelihood of COPD associated with verbal abuse (PR =1.30, 95% CI: 1.05, 1.61), sexual abuse (PR =1.69, 95% CI: 1.36, 2.10), living with a substance abusing household member (PR =1.49, 95% CI: 1.23, 1.81), witnessing domestic violence (PR =1.40, 95% CI: 1.14, 1.72), and parental separation/divorce (PR =1.47, 95% CI: 1.21, 1.80) during childhood compared to those with no individual ACEs. Reporting ≥5 ACEs (PR =2.08, 95% CI: 1.55, 2.80) compared to none was associated with a higher likelihood of COPD among women only.
Conclusion
ACEs are related to COPD, especially among women. These findings underscore the need for further research that examines sex-specific differences and the possible mechanisms linking ACEs and COPD. This work adds to a growing body of research suggesting that ACEs may contribute to health problems later in life and suggesting a need for program and policy solutions.
doi:10.2147/COPD.S68226
PMCID: PMC4186575  PMID: 25298732
chronic obstructive pulmonary disease; childhood; abuse; sex
2.  Quantifying Options for Reducing Coronary Heart Disease Mortality By 2020 
Circulation  2013;127(25):2477-2484.
Introduction
The AHA 2020 Strategic Impact Goal proposes a 20% improvement in cardiovascular health of all Americans. We aimed to estimate the potential reduction in coronary heart disease (CHD) deaths.
Methods and Results
We used data on 40,373 CVD-free adults from NHANES (1988–2010). We quantified recent trends for six metrics (total cholesterol [TC]; systolic blood pressure [SBP]; physical inactivity; smoking; diabetes; obesity) and generated linear projections to 2020. We projected the expected number of CHD deaths in 2020 if 2006 age- and sex-specific CHD death rates remained constant, which would result in approximately 480,000 CHD deaths in 2020 (12% increase). We used the previously validated IMPACT CHD model to project numbers of CHD deaths in 2020 under two different scenarios.
A) Assuming a 20% improvement in each CVH metric, we project 365,000 CHD deaths in 2020, (range 327,000–403,000) a 24% decrease reflecting modest reductions in TC (−41,000), SBP (−36,000), physical inactivity (−12,000), smoking (−10,000), diabetes (−10,000), and obesity (−5,000). B) Assuming that recent risk factor trends continue to 2020, we project 335,000 CHD deaths (range 274,000–386,000), a 30% decrease reflecting improvements in TC, SBP, smoking and physical activity (~167,000 fewer deaths), offset by increases in diabetes and BMI (~24,000 more deaths).
Conclusions
Two contrasting scenarios of change in CVH metrics could prevent 24–30% of the CHD deaths expected in 2020, though with differing impacts by age. Unfavorable continuing trends in obesity and diabetes would have substantial adverse effects. This analysis demonstrates the utility of modelling to inform health policy.
doi:10.1161/CIRCULATIONAHA.112.000769
PMCID: PMC3795417  PMID: 23661723
heart disease; American Heart Association; epidemiology; risk factor
3.  Prevalence of Diagnosed Cancer According to Duration of Diagnosed Diabetes and Current Insulin Use Among U.S. Adults With Diagnosed Diabetes 
Diabetes Care  2013;36(6):1569-1576.
OBJECTIVE
To estimate the prevalence of diagnosed cancer according to duration of diagnosed diabetes and current insulin use among U.S. adults with diagnosed diabetes.
RESEARCH DESIGN AND METHODS
We analyzed data from 25,964 adults aged ≥18 years with diagnosed diabetes who participated in the 2009 Behavioral Risk Factor Surveillance System.
RESULTS
After adjustment for potential confounders, we found that the greater the duration of diagnosed diabetes, the higher the prevalence of diagnosed cancers (P < 0.0001 for linear trend). Among adults with diagnosed type 2 diabetes, the prevalence estimate for cancers of all sites was significantly higher among men (adjusted prevalence ratio 1.6 [95% CI 1.3–1.9]) and women (1.8 [1.5–2.1]) who reported being diagnosed with diabetes ≥15 years ago than among those reporting diabetes diagnosis <15 years ago. The prevalence estimate for cancers of all sites was ~1.3 times higher among type 2 diabetic adults who currently used insulin than among those who did not use insulin among both men (1.3 [1.1–1.6]) and women (1.3 [1.1–1.5]).
CONCLUSIONS
Our results suggest that there is an increased burden of diagnosed cancer among adults with a longer duration of diagnosed diabetes and among type 2 diabetic adults who currently use insulin.
doi:10.2337/dc12-1432
PMCID: PMC3661832  PMID: 23300288
4.  Trends in the Use, Sociodemographic Correlates, and Undertreatment of Prescription Medications for Chronic Obstructive Pulmonary Disease among Adults with Chronic Obstructive Pulmonary Disease in the United States from 1999 to 2010 
PLoS ONE  2014;9(4):e95305.
Background
The extent to which patients with COPD are receiving indicated treatment with medications to improve lung function and recent trends in the use of these medications is not well documented in the United States. The objective of this study was to examine trends in prescription medications for COPD among adults in the United States from 1999 to 2010.
Methods
We performed a trend analysis using data from up to 1426 participants aged ≥20 years with self-reported COPD from six national surveys (National Health and Nutrition Examination Survey 1999–2010).
Results
During 2009–2010, the age-adjusted percentage of participants who used any kind of medication was 44.2%. Also during 2009–2010, the most commonly used medications were short-acting agents (36.0%), inhaled corticosteroids (ICS) (18.3%), and LABAs (16.7%). The use of long-acting beta-2 agonists (LABAs) (p for trend <0.001), ICS (p for trend = 0.013) increased significantly over the 12-year period. Furthermore, the use of tiotropium increased rapidly during this period (p for trend <0.001). For the years 2005–2010, the use of LABAs, ICS and tiotropium increased with age. Compared with whites, Mexican Americans were less likely to use short-acting agents, LABAs, ICS, tiotropium, and any kind of COPD medication. Among participants aged 20–79 years with spirometry measurements during 2007–2010, the use of any medication was reported by 19.0% of those with a moderate/severe obstructive impairment and by 72.6% of those with self-reported COPD and any obstructive impairment.
Conclusion
The percentages of adults with COPD who reported having various classes of prescription medications that improve airflow limitations changed markedly from 1999–2000 to 2009–2010. However, many adults with COPD did not report having recommended prescription medications.
doi:10.1371/journal.pone.0095305
PMCID: PMC3994065  PMID: 24751857
5.  Patterns of Change in Cardiometabolic Risk Factors Associated with the Metabolic Syndrome among Children and Adolescents: The Fels Longitudinal Study 
The Journal of pediatrics  2009;155(3):S5.e9-S5.16.
Objectives
To examine the patterns of change in cardiometabolic risk factors associated with the metabolic syndrome in children and adolescents between the ages of 8 to 19 years.
Study Design
Data of children and adolescents who participated in the Fels Longitudinal Study were analyzed. Body mass index, waist circumference, fasting insulin, fasting glucose, triglycerides, high-density lipoprotein cholesterol, systolic blood pressure, and diastolic blood pressure were assessed annually with a standardized protocol.
Results
The proportion of participants having at least 1 change between states of high and normal risk ranged from of 11.0% for body mass index to 30.4% for triglycerides. Youth in the high-risk category at baseline had a higher proportion having changed their status for all risk factors (all P < .05) except waist circumference compared with those in the normal-risk category. There were significant time effects for all risk factors (all P < .01) except fasting glucose and triglyceride levels in metric scores, but insignificant time effects for all risk factors in Z-scores in growth curve analyses.
Conclusions
The cardiometabolic risk factors associated with the MetS were relatively stable among white children and adolescents in the normal risk category. Changes in status were common if the risk factor was elevated.
doi:10.1016/j.jpeds.2009.04.046
PMCID: PMC3988693  PMID: 19732564
6.  Cardiovascular Health Behavior and Health Factor Changes (1988 –2008) and Projections to 2020 
Circulation  2012;125(21):2595-2602.
Background
The American Heart Association’s 2020 Strategic Impact Goals target a 20% relative improvement in overall cardiovascular health with the use of 4 health behavior (smoking, diet, physical activity, body mass) and 3 health factor (plasma glucose, cholesterol, blood pressure) metrics. We sought to define current trends and forward projections to 2020 in cardiovascular health.
Methods and Results
We included 35 059 cardiovascular disease–free adults (aged ≥20 years) from the National Health and Nutrition Examination Survey 1988–1994 and subsequent 2-year cycles during 1999–2008. We calculated population prevalence of poor, intermediate, and ideal health behaviors and factors and also computed a composite, individual-level Cardiovascular Health Score for all 7 metrics (poor=0 points; intermediate=1 point; ideal=2 points; total range, 0–14 points). Prevalence of current and former smoking, hypercholesterolemia, and hypertension declined, whereas prevalence of obesity and dysglycemia increased through 2008. Physical activity levels and low diet quality scores changed minimally. Projections to 2020 suggest that obesity and impaired fasting glucose/diabetes mellitus could increase to affect 43% and 77% of US men and 42% and 53% of US women, respectively. Overall, population-level cardiovascular health is projected to improve by 6% overall by 2020 if current trends continue. Individual-level Cardiovascular Health Score projections to 2020 (men=7.4 [95% confidence interval, 5.7–9.1]; women=8.8 [95% confidence interval, 7.6–9.9]) fall well below the level needed to achieve a 20% improvement (men=9.4; women=10.1).
Conclusions
The American Heart Association 2020 target of improving cardiovascular health by 20% by 2020 will not be reached if current trends continue.
doi:10.1161/CIRCULATIONAHA.111.070722
PMCID: PMC3914399  PMID: 22547667
cardiovascular disease risk factors; epidemiology; risk factors; trends
7.  The association of chronic obstructive pulmonary disease, disability, engagement in social activities, and mortality among US adults aged 70 years or older, 1994–2006 
Purpose
To assess associations among chronic obstructive pulmonary disease (COPD), disability as measured by activities of daily living (ADL) and instrumental ADL (IADL), engagement in social activities, and death among elderly noninstitutionalized US residents.
Materials and methods
A nationally representative sample of 9,415 adults who were aged ≥70 years and responded to the Second Supplement on Aging survey in 1994–1996 and mortality follow-up study through 2006 were assessed. Multiple logistic regression analyses were performed to assess the risk of all-cause mortality in participants with COPD after accounting for age, sex, race/ethnicity, and smoking status.
Results
At baseline, approximately 9.6% of study participants reported having COPD. Compared with participants without COPD, those with COPD were significantly more likely (P<0.05) to have difficulty with at least one ADL (44.3% versus [vs] 27.5%) and with at least one IADL (59.9% vs 40.2%), significantly less likely to be engaged in social activities (32.6% vs 26.3%), and significantly more likely to die by 2006 (70.7% vs 60.4%; adjusted risk ratio 1.15, P<0.05). The association between COPD and risk for death was moderately attenuated by disability status.
Conclusion
COPD is positively associated with disability and mortality risk among US adults aged ≥70 years. The significant relationship between COPD and mortality risk was moderately attenuated, but was not completely explained by stages of ADL and IADL limitations and social activities.
doi:10.2147/COPD.S53676
PMCID: PMC3896280  PMID: 24477269
chronic obstructive pulmonary disease; mortality; activities of daily living; instrumental activities of daily living; disability
8.  Pulmonary function, chronic respiratory symptoms, and health-related quality of life among adults in the United States – National Health and Nutrition Examination Survey 2007–2010 
BMC Public Health  2013;13:854.
Background
We examined the association of impaired lung function and respiratory symptoms with measures of health status and health-related quality of life (HRQOL) among US adults.
Methods
The sample included 5139 participants aged 40–79 years in the National Health and Nutrition Examination Survey 2007–2010 who underwent spirometric testing and responded to questions about respiratory symptoms, health status, and number of physically unhealthy, mentally unhealthy, or activity limitation days in the prior 30 days.
Results
Among these adults, 7.2% had restrictive impairment (FEV1/FVC ≥ 70%; FVC < 80% of predicted), 10.9% had mild obstruction (FEV1/FVC < 70%; FEV1 ≥ 80% predicted), and 9.0% had moderate–severe obstruction (FEV1/FVC < 70%; FEV1 < 80% predicted). Individuals with restrictive impairment or moderate–severe obstruction were more likely to report fair/poor health compared to those with normal lung function (prevalence ratio (PR) =1.5 [95% CI: 1.2-1.9] and 1.5 [1.3-1.8]), after controlling for sociodemographics, non-respiratory chronic diseases, body mass index, smoking, and respiratory symptoms. Frequent mental distress (FMD; ≥14 mentally unhealthy days), frequent physical distress (FPD; ≥14 physically unhealthy days), and frequent activity limitation (FAL; ≥14 activity limitation days) did not differ by lung function status. Adults who reported any respiratory symptoms (frequent cough, frequent phlegm, or past year wheeze) were more likely to report fair/poor health (PR = 1.5 [1.3-1.7]), FPD (PR = 1.6 [1.4-1.9]), FMD (PR = 1.8 [1.4-2.2]), and FAL (PR = 1.4 [1.1-1.9]) than those with no symptoms.
Conclusions
These results suggest the importance of chronic respiratory symptoms as potential risk factors for poor HRQOL and suggest improved symptom treatment and prevention efforts would likely improve HRQOL.
doi:10.1186/1471-2458-13-854
PMCID: PMC3848467  PMID: 24040892
Chronic respiratory disease; Spirometry; FEV1; Activity limitation; Frequent mental distress; Wellbeing
9.  Stability of the Factor Structure of the Metabolic Syndrome across Pubertal Development: Confirmatory Factor Analyses of Three Alternative Models 
The Journal of pediatrics  2009;155(3):S5.e1-S5.e8.
Objective
To test the fit and stability of 3 alternative models of the metabolic syndrome’s factor structure across 3 developmental stages.
Study design
With data from the Fels Longitudinal Study, confirmatory factor analyses tested 3 alternative models of the factor structure underlying relationships among 8 metabolic syndrome-associated risks. Models tested were a 1-factor model (A), a 4-factor model (B), and a second-order latent factor model (C). Developmental stages assessed were prepuberty (ages 8–10), puberty (ages 11–15), and postpuberty (ages 16–20).
Results
Convergence was achieved for all developmental stages for model A, but the fit was poor throughout (root mean square error of approximation > 0.1). Standardized factor loadings for waist circumference and body mass index were much stronger than those for fasting insulin at all 3 time points. Although prepuberty and postpuberty models converged for models B and C, each model had problems with Heywood cases. The puberty model did not converge for either model B or C.
Conclusions
The hypothetical structures commonly used to support the metabolic syndrome concept do not provide adequate fit in a pediatric sample and may be variable by maturation stage. A components-based approach to cardiovascular risk reduction, with emphasis on obesity prevention and control, may be a more appropriate clinical strategy for children and youth than a syndromic approach.
doi:10.1016/j.jpeds.2009.04.045
PMCID: PMC3763727  PMID: 19732562
10.  Trends in Total and Low-Density Lipoprotein Cholesterol among U.S. Adults: Contributions of Changes in Dietary Fat Intake and Use of Cholesterol-Lowering Medications 
PLoS ONE  2013;8(5):e65228.
Objective
Our aim was to examine the relative contributions of changes in dietary fat intake and use of cholesterol-lowering medications to changes in concentrations of total cholesterol among adults in the United States from 1988–1994 to 2007–2008.
Method
We used data from adults aged 20–74 years who participated in National Health and Nutrition Examination Surveys from 1988–1994 to 2007–2008. The effect of change in dietary fat intake on concentrations of total cholesterol was estimated by the use of equations developed by Keys, Hegsted, and successors.
Results
Age-adjusted mean concentrations of total cholesterol were 5.60 mmol/L (216 mg/dl) during 1988–1994 falling to 5.09 mmol/L (197 mg/dl) in 2007–2008 (P<0.001). No significant changes in the intake of total fat, saturated fat, polyunsaturated fat, and dietary cholesterol were observed from 1988–1994 to 2007–2008. However, the age-adjusted use of cholesterol-lowering medications increased from 1.6% to 12.5% (P<0.001). The various equations suggested that changes in dietary fat made minimal contributions to the observed trend in mean concentrations of total cholesterol. The increased use of cholesterol-lowering medications was estimated to account for approximately 46% of the change.
Discussion
Mean concentrations of total cholesterol among adults in the United States have declined by ∼4% since 1988–1994. The increased use of cholesterol-lowering medications has apparently accounted for about half of this small fall. Further substantial decreases in cholesterol might be potentially achievable by implementing effective and feasible public health interventions to promote the consumption of a more healthful diet by US adults.
Disclaimer
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
doi:10.1371/journal.pone.0065228
PMCID: PMC3661527  PMID: 23717695
11.  COPD Surveillance—United States, 1999-2011 
Chest  2013;144(1):284-305.
This report updates surveillance results for COPD in the United States. For 1999 to 2011, data from national data systems for adults aged ≥ 25 years were analyzed. In 2011, 6.5% of adults (approximately 13.7 million) reported having been diagnosed with COPD. From 1999 to 2011, the overall age-adjusted prevalence of having been diagnosed with COPD declined (P = .019). In 2010, there were 10.3 million (494.8 per 10,000) physician office visits, 1.5 million (72.0 per 10,000) ED visits, and 699,000 (32.2 per 10,000) hospital discharges for COPD. From 1999 to 2010, no significant overall trends were noted for physician office visits and ED visits; however, the age-adjusted hospital discharge rate for COPD declined significantly (P = .001). In 2010 there were 312,654 (11.2 per 1,000) Medicare hospital discharge claims submitted for COPD. Medicare claims (1999-2010) declined overall (P = .045), among men (P = .022) and among enrollees aged 65 to 74 years (P = .033). There were 133,575 deaths (63.1 per 100,000) from COPD in 2010. The overall age-adjusted death rate for COPD did not change during 1999 to 2010 (P = .163). Death rates (1999-2010) increased among adults aged 45 to 54 years (P < .001) and among American Indian/Alaska Natives (P = .008) but declined among those aged 55 to 64 years (P = .002) and 65 to 74 years (P < .001), Hispanics (P = .038), Asian/Pacific Islanders (P < .001), and men (P = .001). Geographic clustering of prevalence, Medicare hospitalizations, and deaths were observed. Declines in the age-adjusted prevalence, death rate in men, and hospitalizations for COPD since 1999 suggest progress in the prevention of COPD in the United States.
doi:10.1378/chest.13-0809
PMCID: PMC3707177  PMID: 23619732
12.  The Independent Association of Serum Retinol and β-Carotene Levels with Hyperuricemia – A National Population Study 
Arthritis care & research  2012;64(3):389-396.
Objective
Use of synthetic vitamin A derivatives (e.g. isotretinoin used for severe acne) and high doses of preformed vitamin A have been implicated in the pathogenesis of hyperuricemia and gout, whereas a trial reported that β-carotene may lower serum uric acid (SUA) levels. We evaluated the potential population impact of these factors on SUA in a nationally representative sample of US adults.
Methods
Using data from 14,349 participants aged 20 years and older in the Third National Health and Nutrition Examination Survey (1988–1994), we examined the relation between serum retinol, β-carotene, and uric acid levels using weighted linear regression. Additionally, we examined the relation with hyperuricemia using weighted logistic regression.
Results
SUA levels increased linearly with increasing serum retinol levels, whereas SUA levels decreased with increasing serum β-carotene levels. After adjusting for age, sex, dietary factors, and other potential confounders, the SUA level differences from the bottom (referent) to top quintiles of serum retinol levels were 0, 0.16, 0.31, 0.43, 0.71mg/dL (P for trend < 0.001) and for β-carotene were 0, −0.15, −0.29, −0.27, −0.40 mg/dL (P for trend < 0.001). Similarly, the multivariate odds ratios of hyperuricemia from the bottom (referent) to top quintiles of serum retinol levels were 1.00, 1.30, 1.83, 2.09, and 3.22 (P for trend <0.001) and for β-carotene were 1.00, 0.85, 0.68, 0.73, and 0.54 (P for trend <0.001). The graded associations persisted across subgroups according to cross-classification by both serum retinol and β-carotene levels.
Conclusions
These nationally representative data raise concerns that vitamin A supplementation and food fortification may contribute to the high frequency of hyperuricemia in the US population, whereas β-carotene intake may be beneficial against hyperuricemia. The use of β-carotene as a novel preventive treatment for gout deserves further investigation.
doi:10.1002/acr.20692
PMCID: PMC3288639  PMID: 22076806
Uric acid; gout; vitamin A; retinol; β-carotene; NHANES III
13.  Excess Frequent Insufficient Sleep in American Indians/Alaska Natives 
Objective. Frequent insufficient sleep, defined as ≥14 days/past 30 days in which an adult did not get enough rest or sleep, is associated with adverse mental and physical health outcomes. Little is known about the prevalence of frequent insufficient sleep among American Indians/Alaska Natives (AI/AN). Methods. We assessed racial/ethnic differences in the prevalence of frequent insufficient sleep from the combined 2009-2010 Behavioral Risk Factor Surveillance Survey among 810,168 respondents who self-identified as non-Hispanic white (NHW, n = 671,448), non-Hispanic black (NHB, n = 67,685), Hispanic (n = 59,528), or AI/AN (n = 11,507). Results. We found significantly higher unadjusted prevalences (95% CI) of frequent insufficient sleep among AI/AN (34.2% [32.1–36.4]) compared to NHW (27.4% [27.1–27.6]). However, the age-adjusted excess prevalence of frequent insufficient sleep in AI/AN compared to NHW was decreased but remained significant with the addition of sex, education, and employment status; this latter relationship was further attenuated by the separate additions of obesity and lifestyle indicators, but was no longer significant with the addition of frequent mental distress to the model (PR  =  1.05; 95% CI : 0.99–1.13). This is the first report of a high prevalence of frequent insufficient sleep among AI/AN. These results further suggest that investigation of sleep health interventions addressing frequent mental distress may benefit AI/AN populations.
doi:10.1155/2013/259645
PMCID: PMC3595691  PMID: 23509471
14.  Temporal changes in concentrations of lipids and apolipoprotein B among adults with diagnosed and undiagnosed diabetes, prediabetes, and normoglycemia: findings from the National Health and Nutrition Examination Survey 1988–1991 to 2005–2008 
Background
Diabetes is characterized by profound lipid abnormalities. The objective of this study was to examine changes in concentrations of lipids and apolipoprotein B among participants stratified by glycemic status (diabetes, undiagnosed diabetes, prediabetes, and normoglycemia) in the United States from 1988–1991 to 2005–2008.
Methods
We used data from 3202 participants aged ≥20 years from the National Health and Nutrition Examination Survey (NHANES) III (1988–1991) and 3949 participants aged ≥20 years from NHANES 2005–2008.
Results
Among participants of all four groups, unadjusted and adjusted mean concentrations of total cholesterol, low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B, but not triglycerides, decreased significantly. Among participants with prediabetes and normoglycemia, unadjusted and adjusted mean concentrations of high-density lipoprotein cholesterol increased significantly. Adjusted mean log-transformed concentrations of triglycerides decreased in adults with undiagnosed diabetes and prediabetes. During 2005–2008, unadjusted concentrations of apolipoprotein B ≥80 mg/dl were observed in 72.8% of participants with diagnosed diabetes, 87.9% of participants with undiagnosed diabetes, 86.6% of participants with prediabetes, and 77.2% of participants with normoglycemia. The unadjusted use of cholesterol-lowering medications rose rapidly, especially among participants with diabetes (from ~1% to ~49%, P <0.001). The use of fenofibrate, gemfibrozil, and niacin rose significantly only among adults with diagnosed diabetes (from ~2% to ~8%, P = 0.011).
Conclusion
Lipid profiles of adults with diabetes improved during the approximately 16-year study period. Nevertheless, large percentages of adults continue to have elevated concentrations of apolipoprotein B.
doi:10.1186/1475-2840-12-26
PMCID: PMC3576331  PMID: 23360385
Apolipoprotein B; Cholesterol; Diabetes; High-density lipoprotein cholesterol; Lipids; Prediabetes; Triglycerides; Fenofibrate; Gemfibrozil; Niacin
15.  Co-Occurrence of Leading Lifestyle-Related Chronic Conditions Among Adults in the United States, 2002-2009 
Introduction
Public health and clinical strategies for meeting the emerging challenges of multiple chronic conditions must address the high prevalence of lifestyle-related causes. Our objective was to assess prevalence and trends in the chronic conditions that are leading causes of disease and death among adults in the United States that are amenable to preventive lifestyle interventions.
Methods
We used self-reported data from 196,240 adults aged 25 years or older who participated in the National Health Interview Surveys from 2002 to 2009. We included data on cardiovascular disease (coronary heart disease, angina pectoris, heart attack, and stroke), cancer, chronic obstructive pulmonary disease (emphysema and chronic bronchitis), diabetes, and arthritis.
Results
In 2002, an unadjusted 63.6% of participants did not have any of the 5 chronic conditions we assessed; 23.9% had 1, 9.0% had 2, 2.9% had 3, and 0.7% had 4 or 5. By 2009, the distribution of co-occurrence of the 5 chronic conditions had shifted subtly but significantly. From 2002 to 2009, the age-adjusted percentage with 2 or more chronic conditions increased from 12.7% to 14.7% (P < .001), and the number of adults with 2 or more conditions increased from approximately 23.4 million to 30.9 million.
Conclusion
The prevalence of having 1 or more or 2 or more of the leading lifestyle-related chronic conditions increased steadily from 2002 to 2009. If these increases continue, particularly among younger adults, managing patients with multiple chronic conditions in the aging population will continue to challenge public health and clinical practice.
doi:10.5888/pcd10.120316
PMCID: PMC3652715  PMID: 23618540
16.  Food Security and Cardiovascular Disease Risk Among Adults in the United States: Findings From the National Health and Nutrition Examination Survey, 2003–2008 
Introduction
Little is known about the relationship between food security status and predicted 10-year cardiovascular disease risk. The objective of this study was to examine the associations between food security status and cardiovascular disease risk factors and predicted 10-year risk in a national sample of US adults.
Methods
A cross-sectional analysis using data from 10,455 adults aged 20 years or older from the National Health and Nutrition Examination Survey 2003–2008 was conducted. Four levels of food security status were defined by using 10 questions.
Results
Among all participants, 83.9% had full food security, 6.7% had marginal food security, 5.8% had low food security, and 3.6% had very low food security. After adjustment, mean hemoglobin A1c was 0.15% greater and mean concentration of C-reactive protein was 0.8 mg/L greater among participants with very low food security than among those with full food security. The adjusted mean concentration of cotinine among participants with very low food security was almost double that of participants with full food security (112.8 vs 62.0 ng/mL, P < .001). No significant associations between food security status and systolic blood pressure or concentrations of total cholesterol, high-density lipoprotein cholesterol, or non-high-density lipoprotein cholesterol were observed. Participants aged 30 to 59 years with very low food security were more likely to have a predicted 10-year cardiovascular disease risk greater than 20% than fully food secure participants (adjusted prevalence ratio, 2.38; 95% CI, 1.31–4.31).
Conclusion
Adults aged 30 to 59 years with very low food security showed evidence of increased predicted 10-year cardiovascular disease risk.
doi:10.5888/pcd10.130244
PMCID: PMC3854876  PMID: 24309090
17.  Elevated cardiovascular risk among adults with obstructive and restrictive airway functioning in the United States: a cross-sectional study of the National Health and Nutrition Examination Survey from 2007–2010 
Respiratory Research  2012;13(1):115.
Background
Reasons for the excess risk for cardiovascular disease among people with chronic obstructive pulmonary disease remain unclear. Our objective was to examine the cardiovascular risk profile for adults with obstructive and restrictive impairments of lung functioning in a representative sample of adults from the United States.
Methods
We used data from adults aged 20–79 years who participated in the National Health and Nutrition Examination Survey from 2007 to 2010 and had a pulmonary function test. The severity of obstructive impairment was defined by adapting the Global Initiative for Chronic Obstructive Lung Disease criteria.
Results
Among 7249 participants, 80.9% had a normal pulmonary function test, 5.7% had a restrictive impairment, 7.9% had mild obstructive impairment, and 5.5% had moderate or severe/very severe obstructive impairment. Participants with obstructive impairment had high rates of smoking and increased serum concentrations of cotinine. Compared to participants with normal pulmonary functioning, participants with at least moderate obstructive impairment had elevated concentrations of C-reactive protein but lower concentrations of total cholesterol and non-high-density lipoprotein cholesterol. Among participants aged 50–74 years, participants with at least a moderate obstructive impairment or a restrictive impairment had an elevated predicted 10-year risk for cardiovascular disease.
Conclusions
The high rates of smoking among adults with impaired pulmonary functioning, particularly those with obstructive impairment, point to a need for aggressive efforts to promote smoking cessation in these adults. In addition, adults with restrictive impairment may require increased attention to and fine-tuning of their cardiovascular risk profile.
doi:10.1186/1465-9921-13-115
PMCID: PMC3546884  PMID: 23237325
Chronic obstructive pulmonary disease; Cardiovascular diseases; Risk factors; Spirometry
18.  Associations between Overall and Abdominal Obesity and Suicidal Ideation among US Adult Women 
Journal of Obesity  2012;2012:263142.
Obesity is associated with increased risks for mental disorders. This study examined associations of obesity indicators including body mass index (BMI), waist circumference, and waist-height ratio with suicidal ideation among U.S. women. We analyzed data from 3,732 nonpregnant women aged ≥20 years who participated in the 2005–2008 National Health and Nutrition Examination Survey. We used anthropometric measures of weight, height, and waist circumference to calculate BMI and waist-height ratio. Suicidal ideation was assessed using the Item 9 of the Patient Health Questionnaire-9. Odds ratios with 95% conference intervals were estimated using logistic regression analyses after controlling for potential confounders. The age-adjusted prevalence of suicidal ideation was 3.0%; the prevalence increased linearly across quartiles of BMI, waist circumference, and waist-height ratio (P for linear trend <0.01 for all). The positive associations of waist circumference and waist-height ratio with suicidal ideation remained significant (P < 0.05) after adjustment for sociodemographics, lifestyle-related behavioral factors, and having either chronic conditions or current depression. However, these associations were attenuated after both chronic conditions and depression were entered into the models. Thus, the previously reported association between obesity and suicidal ideation appears to be confounded by coexistence of chronic conditions and current depression among women of the United States.
doi:10.1155/2012/263142
PMCID: PMC3375088  PMID: 22720137
19.  Trends in the Risk for Coronary Heart Disease Among Adults With Diagnosed Diabetes in the U.S. 
Diabetes Care  2011;34(6):1337-1343.
OBJECTIVE
Coronary heart disease (CHD) is a major cause of mortality among people with diabetes. The objective of this study was to examine the trend in an estimated 10-year risk for developing CHD among adults with diagnosed diabetes in the U.S.
RESEARCH DESIGN AND METHODS
Data from 1,977 adults, aged 30–79 years, with diagnosed diabetes who participated in the National Health and Nutrition Examination Survey from 1999–2000 to 2007–2008 were used. Estimated risk was calculated using risk prediction algorithms from the UK Prospective Diabetes Study (UKPDS), the Atherosclerosis Risk in Communities study, and the Framingham Heart Study.
RESULTS
Significant improvements in mean HbA1c concentrations, systolic blood pressure, and the ratio of total cholesterol to HDL cholesterol occurred. No significant linear trend for current smoking status was observed. The estimated UKPDS 10-year risk for CHD was 21.1% in 1999–2000 and 16.4% in 2007–2008 (Plinear trend < 0.001). The risk decreased significantly among men, women, whites, African Americans, and Mexican Americans.
CONCLUSIONS
The estimated 10-year risk for CHD among adults with diabetes has improved significantly from 1999–2000 to 2007–2008. Sustained efforts in improving risk factors should further benefit the cardiovascular health of people with diabetes.
doi:10.2337/dc10-2251
PMCID: PMC3114334  PMID: 21505207
20.  Association Between Diagnosed Diabetes and Self-Reported Cancer Among U.S. Adults 
Diabetes Care  2011;34(6):1365-1368.
OBJECTIVE
To assess the association between diagnosed diabetes and self-reported cancer among U.S. adults.
RESEARCH DESIGN AND METHODS
We analyzed data for 397,783 adults who participated in the 2009 Behavioral Risk Factor Surveillance System and had valid data on diabetes and cancer.
RESULTS
After adjustment for potential confounders, diabetic men had higher adjusted prevalence ratios for cancers of the prostate (1.1 [95% CI 1.0–1.3]), colon (1.3 [1.0–1.7]), pancreas (4.6 [1.8–11.7]), rectum (2.2 [1.0–4.7]), urinary bladder (1.7 [1.2–2.2]), and kidney (1.9 [1.2–3.0]) than nondiabetic men (all P < 0.05). Diabetic women had higher adjusted prevalence ratios for cancers of the breast (1.1 [1.0–1.3]) and endometrium (1.6 [1.2–2.0]), and leukemia (2.3 [1.3–4.2]) than nondiabetic women (all P < 0.05).
CONCLUSIONS
Our results suggest that diabetic adults have higher prevalences of certain cancers than nondiabetic adults.
doi:10.2337/dc11-0020
PMCID: PMC3114364  PMID: 21505205
21.  Factors Associated with Vitamin D Deficiency and Inadequacy among Women of Childbearing Age in the United States 
ISRN Obstetrics and Gynecology  2012;2012:691486.
Objective. To examine the prevalence and correlates of vitamin D deficiency and inadequacy among US women of childbearing age. Methods. Data from 1,814 female participants (20–44 y) in the 2003–2006 NHANES were analyzed to estimate the age-adjusted prevalence and prevalence ratios with 95% confidence intervals (CIs) for vitamin D deficiency (defined as serum 25-hydroxyvitamin D [25(OH)D] <12.0 ng/mL) and inadequacy (defined as 25(OH)D: 12.0–<20.0 ng/mL). Results. The age-adjusted prevalence was 11.1% (95% CI: 8.8–14.0%) for vitamin D deficiency and 25.7% (95% CI: 22.3–29.5%) for vitamin D inadequacy. Race/ethnicity other than non-Hispanic white and obesity were associated with increased risks, whereas dietary supplement use, milk consumption of ≥1 time/day, and potential sunlight exposure during May-October were associated with decreased risks for both vitamin D deficiency and inadequacy (P < 0.05). Current smoking and having histories of diabetes and cardiovascular disease were also associated with an increased risk for vitamin D deficiency (P < 0.05). Conclusions. Among women of childbearing age, periconceptional intervention programs may focus on multiple risk factors for vitamin D deficiency and inadequacy to ultimately improve their vitamin D nutrition.
doi:10.5402/2012/691486
PMCID: PMC3317014  PMID: 22523695
22.  Associations Between Concentrations of Vitamin D and Concentrations of Insulin, Glucose, and HbA1c Among Adolescents in the United States 
Diabetes Care  2011;34(3):646-648.
OBJECTIVE
Our objective was to examine the associations between concentrations of vitamin D and concentrations of insulin, glucose, and HbA1c in a nationally representative sample of adolescents in the U.S.
RESEARCH DESIGN AND METHODS
We used data for 1,941 adolescents, aged 12–17 years, who participated in the National Health and Nutrition Examination Survey between 2001 and 2006.
RESULTS
Adjusted concentrations of insulin were ~24% lower among male subjects with a concentration of vitamin D ≥75 nmol/L than among male subjects with a concentration of vitamin D <50 nmol/L (P = 0.003). Concentrations of vitamin D were inversely associated with concentrations of glucose only among Mexican American male subjects (P = 0.007). No significant associations between concentrations of vitamin D and HbA1c were detected.
CONCLUSIONS
Our results support an inverse association between concentrations of vitamin D and insulin primarily in adolescent male subjects.
doi:10.2337/dc10-1754
PMCID: PMC3041198  PMID: 21273498
23.  Combined television viewing and computer use and mortality from all-causes and diseases of the circulatory system among adults in the United States 
BMC Public Health  2012;12:70.
Background
Watching television and using a computer are increasingly common sedentary behaviors. Whether or not prolonged screen time increases the risk for mortality remains uncertain.
Methods
Mortality for 7,350 adults aged ≥ 20 years who participated in the National Health and Nutrition Examination Survey during 1999-2002 and were followed through 2006 was examined. Participants were asked a single question about the amount of time they spent watching television or videos or using a computer during the past 30 days.
Results
During a median follow-up of 5.8 years, 542 participants died. At baseline, 12.7% of participants reported watching television or using a computer less than 1 h per day, 16.4% did so for 1 h, 27.8% for 2 h, 18.7% for 3 h, 10.9% for 4 h, and 13.5% for 5 or more h. After extensive adjustment, the hazard ratio for all-cause mortality for the top category of exposure was 1.30 (95% confidence interval: 0.82, 2.05). No significant trend across categories of exposure was noted. The amount of screen time was also not significantly related to mortality from diseases of the circulatory system.
Conclusions
In the present study, screen time did not significantly predict mortality from all-causes and diseases of the circulatory system.
doi:10.1186/1471-2458-12-70
PMCID: PMC3398267  PMID: 22269463
Mortality; Sedentary lifestyle; Television
24.  Use of folic acid and vitamin supplementation among adults with depression and anxiety: a cross-sectional, population-based survey 
Nutrition Journal  2011;10:102.
Background
Evidence suggests that folate deficiency may be causatively linked to depressive symptoms. However, little is known on the status of use of folic acid and vitamin supplements among people with mental disorders. This study examined the prevalence and the likelihood of use of folic acid or vitamin supplements among adults with depression and anxiety in comparison to those without these conditions.
Methods
Using data from 46, 119 participants (aged ≥ 18 years) in the 2006 Behavioral Risk Factor Surveillance System survey, we estimated the adjusted prevalence and odds ratios with 95% confidence intervals for taking folic acid and vitamin supplements among those with ever diagnosed depression (n = 8, 019), ever diagnosed anxiety (n = 5, 546) or elevated depressive symptoms (n = 3, 978, defined as having a depression severity score of ≥ 10 on the Patient Health Questionnaire-8 diagnostic algorithm).
Results
Overall, women were more likely than men to take folic acid supplements 1-4 times/day (50.2% versus 38.7%, P < 0.001) and vitamin supplements (62.5% versus 49.8%, P < 0.001). After multivariate adjustment, men with ever diagnosed depression or anxiety were 42% and 83%, respectively, more likely to take folic acid supplements < 1 time/day; 44% and 39%, respectively, more likely to take folic acid supplements 1-4 times/day; and 40% and 46%, respectively, more likely to take vitamin supplements compared to men without these conditions (P < 0.05 for all comparisons). Women with ever diagnosed depression were 13% more likely to take folic acid supplements 1-4 times/day and 15% more likely to take vitamin supplements than women without this condition (P < 0.05 for both comparisons). Use of folic acid and vitamin supplements did not differ significantly by elevated depressive symptoms in either sex.
Conclusion
The prevalence and the likelihood of taking folic acid and vitamin supplements varied substantially by a history of diagnosed depression among both men and women and by a history of diagnosed anxiety among men, but not by presence of elevated depressive symptoms in either sex.
doi:10.1186/1475-2891-10-102
PMCID: PMC3200167  PMID: 21962075
folic acid; vitamins; depression; anxiety; elevated depressive symptoms; BRFSS
25.  Waist circumference, abdominal obesity, and depression among overweight and obese U.S. adults: national health and nutrition examination survey 2005-2006 
BMC Psychiatry  2011;11:130.
Background
Obesity is associated with an increased risk of mental illness; however, evidence linking body mass index (BMI)-a measure of overall obesity, to mental illness is inconsistent. The objective of this study was to examine the association of depressive symptoms with waist circumference or abdominal obesity among overweight and obese U.S. adults.
Methods
A cross-sectional, nationally representative sample from the 2005-2006 National Health and Nutrition Examination Survey was used. We analyzed the data from 2,439 U.S. adults (1,325 men and 1,114 nonpregnant women) aged ≥ 20 years who were either overweight or obese with BMI of ≥ 25.0 kg/m2. Abdominal obesity was defined as waist circumference of > 102 cm for men and > 88 cm for women. Depressive symptoms (defined as having major depressive symptoms or moderate-to-severe depressive symptoms) were assessed by the Patient Health Questionnaire-9 diagnostic algorithm. The prevalence and the odds ratios (ORs) with 95% confidence intervals (CIs) for having major depressive symptoms and moderate-to-severe depressive symptoms were estimated using logistic regression analysis.
Results
After multivariate adjustment for demographics and lifestyle factors, waist circumference was significantly associated with both major depressive symptoms (OR: 1.03, 95% CI: 1.01-1.05) and moderate-to-severe depressive symptoms (OR: 1.02, 95% CI: 1.01-1.04), and adults with abdominal obesity were significantly more likely to have major depressive symptoms (OR: 2.18, 95% CI: 1.35-3.59) or have moderate-to-severe depressive symptoms (OR: 2.56, 95% CI: 1.34-4.90) than those without. These relationships persisted after further adjusting for coexistence of multiple chronic conditions and persisted in participants who were overweight (BMI: 25.0-< 30.0 kg/m2) when stratified analyses were conducted by BMI status.
Conclusion
Among overweight and obese U.S. adults, waist circumference or abdominal obesity was significantly associated with increased likelihoods of having major depressive symptoms or moderate-to-severe depressive symptoms. Thus, mental health status should be monitored and evaluated in adults with abdominal obesity, particularly in those who are overweight.
doi:10.1186/1471-244X-11-130
PMCID: PMC3163524  PMID: 21834955
abdominal obesity; depressive symptoms; PHQ-9 diagnostic algorithm; waist circumference

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