A method for estimating alcohol-related liver cirrhosis mortality in Japan.

In Japan, per capita alcohol consumption increased sharply during the post World War II period followed by an increase in cirrhosis mortality. The prevalence of alcoholic cirrhosis among hospitalized patients also increased, from 11% in 1969 to 18% in 1985. Despite an increase in the percentage of drinkers among young women, over 80% of women in Japan are still abstainers or light drinkers. Thus, female cirrhosis mortality rates can be used as a proxy measure of non-alcohol-related cirrhosis mortality rates to estimate alcohol-related cirrhosis deaths among Japanese men. Employing this method, we conclude that two-thirds of cirrhosis deaths among men between 24 and 85 years of age and half of all cirrhosis deaths were attributable to alcohol. Two factors are probably responsible for the differences in proportional morbidity and proportional mortality of alcohol-related cirrhosis: differences in survival rates between alcoholic and non-alcoholic cirrhosis patients and detection bias toward post-hepatic cirrhosis. The synergistic effect of alcohol on viral hepatitis may in part explain excess cirrhosis deaths among Japanese men.     

Acute and chronic liver toxicity resulting from exposure to chlorinated naphthalenes at a cable manufacturing plant during World War II

Historical records were used to reconstruct an outbreak of chloracne and acute liver toxicity due to chlorinated napthalene exposure at a New York State plant which manufactured “Navy cables” during World War II. A cohort mortality study was conducted of the population (n = 9.028) employed at the plant from 1940 to 1944. Vital status followed through December 31, 1985. The study found an excess of deaths from cirrhosis of the liver [observed (OBS) = 150; standardized mortality ratio (SMR) = 1.84; 95% confidence interval (CI) = 1.56-2.16]; cirrhosis deaths were elevated to a similar degree in the 460 individuals who had chloracne (OBS = 8; SMR = 1.51; CI = 0.65-2.98). The SMR for “non-alcoholic cirrhosis” (OBS = 83; SMR = 1.67; CI = 1.33-2.07) was similar to the SMR for “alcoholic cirrhosis” (OBS = 59; SMR = 1.96; CI = 1.49-2.53). There was no evidence for increased alcoholism in the overall cohort based on mortality from alcohol-related causes of death other than cirrhosis (SMR for esophageal cancel = 1.01 and for deaths from alcoholism = 0.99). We conclude that the excess mortality from cirrhosis of the liver observed in this cohort is due to the chronic effect of chlorinated naphthalene exposure. © 1996 Wiley-Liss, Inc.

1 This article is a US Government work and, as such, is in the public domain in the United States of America.

     

Cirrhosis and primary liver cancer amongst first generation migrants in England and Wales

Objective. To examine mortality from cirrhosis of the liver and primary liver cancer among first generation migrants to England and Wales. Design. Comparison of standardised mortality ratios (SMRs) for cirrhosis of the liver and primary liver cancer in men and women aged 20-69, by country of birth for the five year period 1988-1992. Setting. England and Wales. Results. There was a statistically significant two-fold excess of mortality from cirrhosis of the liver among male migrants from East Africa (SMR 286), India (SMR 261) and Bangladesh (SMR 254) as well as men born in Scotland (SMR 253) and Ireland (SMR252). Among women, only those born in Scotland (SMR 254) and Ireland (SMR 237) showed significant excess mortality. For liver cancer, significant excess mortality occurred among men born in the Caribbean (SMR 312), Bangladesh (910) and the African Commonwealth other than East Africa (1014), with Scottish and Irish born men showing more moderate excesses (136 and 170, respectively). SMRs were elevated also in all groups of foreign-born women but, probably owing to the small numbers of deaths, none of the findings reached statistical significance. Conclusions. Of public health concern is the excess mortality from cirrhosis in first generation immigrants to England and Wales from Scotland and Ireland (men and women) and in male migrants from India, Bangladesh and East Africa. Of equal concern is increased mortality from liver cancer in all foreign-born groups of both sexes, particularly among Bangladeshis, and African-Caribbeans. As well as promoting sensible drinking among immigrant men, specific preventive measures for those of Bangladeshi, African-Caribbean origin may include selective screening for hepatitis B and C and other tumour markers. Screening for liver cancer using imaging techniques needs further investigation. The benefit/cost ratio should be assessed by the Screening Committees of the UK Departments of Health. At local level, variation in incidence and prevalence of hepatic disease and feasible prevention programmes should be assessed within developing health improvement programmes.     

Respiratory tuberculosis in the potteries

A comparison of the notification rates for pulmonary tuberculosis from 1930 onwards between England and Wales and Stoke-on-Trent County Borough shows an excess for Stoke-on-Trent which lasted until the 1950s. A comparison of mortality rates, however, reveals an excess in Stoke-on-Trent which has lasted until the present day. This excess mortality is attributed to a difference in the age distribution of pulmonary tuberculosis in England and Wales compared with Stoke-on-Trent, where there is a striking peak in the incidence of the disease in elderly men and women from the 1950s onwards. It is suggested that this peak is due to reactivation of pulmonary tuberculosis in the cohort who were born in the early years of this century and experienced a severe epidemic of tuberculosis in early adult life which was worse in Stoke-on-Trent than in England and Wales as a whole. The severity of the epidemic in the Potteries may have been attributable to poor environmental conditions including exposure to silica dust among workers in the ceramics industry.     

Estimation of excess mortality associated with influenza epidemics specific for sex, age and cause of death in Japan during 1987-2005

OBJECTIVES: The aim of this study is to clarify the excess mortality associated with influenza epidemics in Japan during the period from 1987 to 2005. METHODS: Monthly data on the total number of deaths (excluding accidental deaths) and the numbers of deaths due to malignant neoplasms, heart disease, cerebrovascular disease, pneumonia, and renal failure were obtained from vital statistics from 1987-2005. The point estimates and range of excess mortality were evaluated using a model based on annual mortality and seasonal indices. Total mortality was analyzed for all ages, sex and for the following five age groups: 0-4, 5-24, 25-44, 45-64, and > or =65 yrs. RESULTS: The excess number of deaths showed almost no difference in each influenza season between men and women. During each influenza season, approximately 85-90% of the excess mortality was attributed to the > or =65 yrs age group. During the 1995 and 1999 seasons, mortality increased significantly across all age groups. The highest point estimate of excess mortality in the > or =65 yrs age group was observed in 1999. From a comparison of the range of excess mortality in the > or =65 yrs age group by year, the excess mortality in 1995 appeared to be the highest of the examined years. The highest point estimate of excess mortality in the 0-4 yrs age group was observed in 1995. From a comparison of the range of excess mortality in the 0-4 yrs age group by year, the excess mortality in 1998 or 1999 appeared to be the highest of the examined years. Excess mortality in the 45-64 yrs and > or =65 yrs age groups showed an increasing tendency in the 1990s and a stabilizing tendency beginning in 2000. In addition, excess mortality during each epidemic was occurred in persons with pneumonia, heart disease, cerebrovascular disease, malignant neoplasms, and renal failure, accounting for approximately 20-50%, 20-40%, 20%, 5%, and 2% of all the excess mortality, respectively. CONCLUSIONS: These results indicate that the majority of excess mortality occurred among the elderly and persons with pneumonia, heart disease, or cerebrovascular disease. Although it is unclear whether the increasing trend in the 1990s and the stabilizing trend beginning in 2000 were the result of vaccination measures, health measures for groups such as the elderly and heart disease patients are considered to be important for the future.     

Excess mortality from influenza epidemics in Japan, 1980-1994]

In 1973, WHO proposed that "excess mortality" be used for comparative assessment of the severity of influenza epidemics between countries. In this study, analysis of the data for deaths in Japan between 1980-1994 revealed excess mortality, which could be a useful indicator in Japan. There were six influenza epidemics, and statistically significant excess mortality rates were calculated in both deaths from acute respiratory diseases and all causes. The total number of excess deaths from acute respiratory diseases during influenza seasons for the 15 years was 13,931. Statistically significant excess mortality rates were also shown for other diseases, including ischemic heart disease, cerebro-vascular disease, diabetes, nephritis, chronic liver disease, malignant neoplasm, and chronic respiratory disease. Therefore, "excess mortality" is clearly present in recent years in Japan. In analyses of age-specific excess mortality rates, the epidemic was found to be most fatal to the aged. Further, the value of % excess (= excess rate divided by expected rate x 100) suggested that the number of deaths from all causes would be a more useful indicator than that from acute respiratory diseases. It was confirmed that excess mortality was applicable to regional surveillance of epidemic influenza.     

The reporting of HIV/AIDS deaths in women.

OBJECTIVE. This study was undertaken to assess the completeness of vital statistics and case reports of acquired immunodeficiency syndrome (AIDS) in measuring human immunodeficiency virus (HIV)-related mortality in women 15 through 44 years of age. METHODS. We used vital records to determine the number of deaths attributed to HIV infection and excess deaths due to causes that have increased in tandem with the HIV epidemic. RESULTS. In 1988, among women 15 through 44 years of age, there were 1365 deaths with HIV infection listed as the underlying cause, 202 deaths with HIV infection listed as an associated cause, and 149 excess deaths due to conditions highly associated with HIV infection (subtotal = 1716). In addition, there were 780 excess deaths due to causes that may be related to HIV infection or illicit drug use (maximum estimate of HIV-related deaths = 2496). Of the deaths that occurred in 1988, 1532 were reported through AIDS surveillance (1668 deaths when adjusted for reporting delays). CONCLUSIONS. Underlying-cause-of-death vital records and AIDS surveillance identified 55% to 80% and 67% to 97%, respectively, of HIV-related deaths in women 15 through 44 years of age in 1988. The wide ranges of these estimates reflect the potential role of both HIV infection and drug use in contributing to excess mortality.     

Estimation of excess mortality associated with influenza-epidemics by age and cause specific death in Japan, 1975-1999

OBJECTIVES: The purpose of this study was to assess the effects of recent influenza epidemics on mortality in Japan. METHODS: We applied a new definition of excess mortality associated with influenza epidemics and a new estimation method (new method) proposed in our previous paper to the national vital statistics for 1975-1999 (ICD8-ICD10 had been adopted) in Japan. This new method has the advantages of removing a source of random variations in excess mortality and of being applicable to shifting trends in mortality rates from different causes of death in response to the revision of ICD. The monthly rates of death from all causes other than accidents (all causes) and some cause-specific deaths such as pneumonia, malignant neoplasm, heart disease, cerebrovascular disease(C.V.D) and diabetes(D.M.) were analyzed by total and by five age groups: 0-4 years, 5-24 years, 25-44 years, 45-64 years, and 65 years old or older. RESULTS: The following findings were noted: 1. For each epidemic in every other year since 1993, large-scale excess mortality of over 10,000 deaths was observed and the effect of those epidemics could be frequently detected in mortality even among young persons, i.e., 0-4 years or 5-25 years. 2. Excess mortality associated with influenza epidemics influenced mortality by some chronic diseases such as pneumonia, heart disease, C.V.D., D.M., etc. For some epidemic years since 1978, excess mortality rates were detected even in mortality by malignant neoplasm. CONCLUSIONS: It has been definitely shown by applying the new method to the national vital statistics for 1975-1999 in Japan that influenza epidemics in recent years exerted an influence on overall mortality, increasing the number of deaths among the elderly and the younger generation. Monitoring of the trends in excess mortality associated with influenza epidemics should be continued.     

Cancer and other mortality patterns among United States furniture workers

Cause specific mortality was investigated among 36,622 members of a national furniture workers' union who were first employed in unionised shops between 1946 and 1962. Overall mortality for each race and sex group was less than expected when compared with United States death rates (white men SMR = 0.8, black men SMR = 0.7, white women SMR = 0.8, black women SMR = 0.5); however, raised risks were observed among white men employed in specific types of furniture industries and followed up for 20 or more years after first employment. Lymphatic and haematopoietic cancers were significantly raised (SMR = 1.8) among wood furniture workers followed up for at least 20 years due to excess deaths from leukaemia (SMR = 2.0) and non-Hodgkin's lymphoma (SMR = 2.0). Mortality from acute myeloid leukaemia was particularly high in this group (SMR = 4.7) based on six observed cases. Metal furniture workers followed up for at least 20 years experienced a significant excess of all cancers combined (SMR = 1.6), with non-significant increases in cancers of the lung, stomach, and colorectum. This group also had non-significant excesses of liver cirrhosis, arteriosclerotic heart disease, and cerebrovascular disease. Nasal cancer was not found to be significantly raised in this cohort, though the average follow up period may not have been sufficient to detect an excess risk for this uncommon tumour.     

Cancer and other mortality patterns among United States furniture workers.

Cause specific mortality was investigated among 36,622 members of a national furniture workers' union who were first employed in unionised shops between 1946 and 1962. Overall mortality for each race and sex group was less than expected when compared with United States death rates (white men SMR = 0.8, black men SMR = 0.7, white women SMR = 0.8, black women SMR = 0.5); however, raised risks were observed among white men employed in specific types of furniture industries and followed up for 20 or more years after first employment. Lymphatic and haematopoietic cancers were significantly raised (SMR = 1.8) among wood furniture workers followed up for at least 20 years due to excess deaths from leukaemia (SMR = 2.0) and non-Hodgkin's lymphoma (SMR = 2.0). Mortality from acute myeloid leukaemia was particularly high in this group (SMR = 4.7) based on six observed cases. Metal furniture workers followed up for at least 20 years experienced a significant excess of all cancers combined (SMR = 1.6), with non-significant increases in cancers of the lung, stomach, and colorectum. This group also had non-significant excesses of liver cirrhosis, arteriosclerotic heart disease, and cerebrovascular disease. Nasal cancer was not found to be significantly raised in this cohort, though the average follow up period may not have been sufficient to detect an excess risk for this uncommon tumour.     

A mortality study of workers manufacturing friction materials: 1941-86.

The mortality of workers employed at a factory producing friction materials has been studied from 1941 to 1986, extending a previous study by seven years. Apart from two periods before 1944, when crocidolite asbestos was used on one particular contract, only chrysotile asbestos has been used. Thirteen deaths were attributed to mesothelioma and of these, 11 were of subjects who had known contact with crocidolite asbestos. Of the remaining two, in one instance the diagnosis is uncertain and in the other the occupational history of the subject is not well established. There was no excess of deaths from lung cancer or other asbestos related tumours, or from chronic respiratory disease. After 1950 hygienic control was progressively improved and from 1970 levels of asbestos in air have not exceeded 0.5-1.0 f/ml. It is concluded that with good environmental control chrysotile asbestos may be used in manufacture without causing excess mortality.     

A mortality study of workers manufacturing friction materials: 1941-86

The mortality of workers employed at a factory producing friction materials has been studied from 1941 to 1986, extending a previous study by seven years. Apart from two periods before 1944, when crocidolite asbestos was used on one particular contract, only chrysotile asbestos has been used. Thirteen deaths were attributed to mesothelioma and of these, 11 were of subjects who had known contact with crocidolite asbestos. Of the remaining two, in one instance the diagnosis is uncertain and in the other the occupational history of the subject is not well established. There was no excess of deaths from lung cancer or other asbestos related tumours, or from chronic respiratory disease. After 1950 hygienic control was progressively improved and from 1970 levels of asbestos in air have not exceeded 0.5-1.0 f/ml. It is concluded that with good environmental control chrysotile asbestos may be used in manufacture without causing excess mortality.     

Material deprivation and leading causes of death by gender: evidence from a nationwide small area study

STUDY OBJECTIVE: To investigate the association between material deprivation and 10 leading causes of death by gender. DESIGN: Small area cross sectional ecological study using two dimensions of material deprivation (Index 1 and Index 2) drawn from 1991 census and cause specific mortality data aggregated for 1987-1995. SETTING: 2218 small areas in Spain. MAIN RESULTS: Strong detrimental associations of two deprivation indices were found with top six leading causes of death for men and top seven leading causes of death for women, except breast cancer. For men, the highest percentages of excess mortality (between 40% and 60%) were found for smoking and alcohol related causes of death such as lung cancer, chronic obstructive pulmonary diseases, and cirrhosis while for women the highest percentages of excess mortality (between 40% and 60%) were found for diet related causes such as diabetes and ischaemic heart disease. CONCLUSIONS: Health inequality is a widespread phenomenon in the majority of the top leading causes of deaths of the nation. Increasing levels of deprivation indices are associated with mortality risk differently by both cause and gender. Results suggest that deprivation effects mainly captured by Index 2 may manifest largely as unfavourable health behaviours leading to gender specific sets of causes of deaths. Findings of this study are consistent with the idea that material deprivation determines health inequality through both an increase of general susceptibility to ill health, leading to excess mortality in a wide range of causes, and a set of specific factors, resulting in an increased risk of death from a specific set of causes in each gender.     

Female mortality and occupational activity in France (a comparison, 1975-1982)

The study of the relationship between occupation and health in 1975, indicated a high excess mortality among inactive females. The decline of mortality and the increase in the number of working women recorded recently, have not changed the thrust of the relation. The analysis of the 1982 data shows a rise in the excess mortality of inactives, caused by an increase of the selection effect. The study of the mortality taking into account the marital status shows that it is the transition to working status of many married--therefore preselected--women that has increased the differences in the state of health between active and inactive women. The excess mortality of inactive women varies with the cause of death and it appears that the selection effect is stronger when death is caused by a chronic or slowly developing disease, and weaker when it is due to an accident or a cancer.     

The mortality of Royal Naval submariners 1960-89.

OBJECTIVES: To examine the mortality pattern of submariners in the Royal Navy to assess the long term effects on health of serving in submarines. Any specific cause of death which was increased was considered in advance to be of interest, but attention focused particularly on cancer mortality. METHOD: A mortality follow up study: 15 138 submariners who had conducted their first submarine training between 1960 and 1979 were followed up through their time in the Navy and into civilian life, up to the end of 1989. The main outcome measures were the numbers of deaths and standardised mortality ratios (SMRs) which indicate whether the mortality from all causes and specific causes, particularly cancers, exceeds that in men in England and Wales. RESULTS: Mortality in submariners was lower than that for men in England and Wales with an all cause SMR of 86; this was comparable with that found in other studies of armed forces personnel. Cancer mortality was particularly low with an SMR of 69 and there was no particular cancer site which showed an excess. Increased mortality from digestive diseases was found, the excess being attributable to cirrhosis of the liver, which had an SMR of 221 based on 12 deaths, alcohol being a contributory factor in eight. Deaths from accidents and violence were also higher than expected with an SMR of 115, but this was due to high levels of accidents occurring after discharge from the Navy. There was no apparent trend in mortality with time since starting submarine work. Likewise there was no pattern by calendar period, although the excess of cirrhosis of the liver was confined to the period 1970-9. CONCLUSION: The submariners seemed to be a healthy group with low mortality overall. Working in submarines was not associated with any increased cancer mortality. Excess deaths from cirrhosis of the liver, and from accidents and violence after leaving the Navy, were of some concern but they cannot be attributed directly to the submarine environment.     

Comparative study of new method and the Kawai and Fukutomi methods for estimating excess mortality associated with influenza-epidemics, based upon national vital statistics from 1975 to 1997]

PURPOSE: In our previous paper, we proposed a new definition and method for estimating excess mortality associated with influenza epidemics. In this paper, we applied this new method to the national vital statistics for 1975-1997 in Japan and compared the estimates obtained with those generated with the Kawai and Fukutomi method. METHODS: The monthly rates of death from all causes other than accidents (all-causes) and deaths attributed to pneumonia between 1975-1997 in Japan were analyzed using our new method. Epidemic periods were identified by examining the monthly rates for deaths attributable to influenza and associated excess mortality was then estimated for the 23-year period using defined criteria. Finally, the estimates obtained using the new method were compared with those obtained using the Kawai and Fukutomi method. RESULTS: 1) An increase in observed over expected mortality (i.e. excess mortality under the old definition) was detected even for months when influenza epidemics did not occur. 2) Estimates made using the Kawai and Fukutomi method were between 2,000-14,000 higher for deaths from all-causes and about 500-3,000 higher for those from pneumonia for each of the epidemic periods, compared to the relevant figures obtained using the new method. This finding provided a good indication of the methodological difference with the new method, which considers the range of random variation in seasonal mortality. Overall, the two methods differed in their estimates of which month had the highest excess monthly mortality rate for the year and which year had the highest excess annual mortality rate. CONCLUSIONS: By comparing estimates obtained using the new method and the Kawai and Fukutomi method, we demonstrated that the former provides a more reasonable estimate of excess mortality rates, regardless of whether or not the period in question occurred during an influenza epidemic.     

In utero exposure to famine and subsequent fertility: The Dutch Famine Birth Cohort Study.

OBJECTIVES: We hypothesized that if prenatal caloric restriction due to nutritional deprivation had affected development of the organs responsible for producing and regulating female reproductive hormones, a woman's fertility would be impaired. METHODS: Women born in Amsterdam from August 1, 1944, through April 15, 1946, a period encompassing a severe 5-month famine, were identified (n = 700; 85% response rate). Date of birth and vital status of all offspring were ascertained by home interview between 1987 and 1991. Famine exposure was inferred from the mother's date of birth. RESULTS: Of the study participants, 74 (10.6%) had no children. The remainder reported 1334 off-spring (1294 singletons, 20 pairs of twins), of whom 14 were stillborn and 22 died in the first 7 days of life. There was no detectable effect of famine exposure on age at menarche, the proportion having no children, age at first delivery, or family size. An excess of perinatal deaths occurred among offspring of famine-exposed women, particularly those exposed in their third trimester. CONCLUSIONS: Acute famine exposure in utero appears to have no adverse consequences for a woman's fertility. The excess perinatal mortality in the second generation is unexplained and should be confirmed by other studies.     

Unusually strong association between education and mortality in young adults in a community with a high rate of injection-drug users

BACKGROUND: To examine the association between education and mortality for various causes of death in young adults in a community with a high rate of injection-drug users. METHODS: Linked mortality study based on mortality records for 1996 and 1997 and on 1996 population census data from the Region of Madrid (Spain). The association between educational level and mortality was estimated by the mortality rate ratio. RESULTS: After adjustment for age and other socioeconomic variables the mortality rate in men and women aged 25-44 years with no education was, respectively, 4.7 and 3.7 times higher than in men and women with the highest educational level. The causes of death with the strongest association were chronic liver disease and cirrhosis, AIDS and diseases of the heart in both sexes and suicide in men. For these causes of death the mortality rate ratio between persons with the lowest and highest educational level ranged from 6.8 to 21.8 in men and from 4.1 to 16.9 in women. CONCLUSIONS: These causes of death are the leading specific causes of death in persons aged 25-44 years. Given that probably a substantial part of deaths from diseases of the heart in this age category are drug-related, the common denominator of the excess mortality related poor education seems to be drug injection.     

Temperature, housing, deprivation and their relationship to excess winter mortality in Great Britain, 1986-1996.

OBJECTIVES: To examine the associations between temperature, housing, deprivation and excess winter mortality using census variables as proxies for housing conditions. DESIGN: Small area ecological study at electoral ward level. Setting Great Britain between 1986 and 1996. PARTICIPANTS: Men and women aged 65 and over. MAIN OUTCOME MEASURES: Deaths from all causes (International Classification of Diseases, Ninth Revision [ICD-9] codes 0-999), coronary heart disease (ICD-9 410-414), stroke (ICD-9 430-438) and respiratory diseases (ICD-9 460-519). Odds of death occurring in winter period of the four months December to March compared to the rest of the year. RESULTS: During the study period (excluding the influenza epidemic year of 1989/90), a total of 1,682,687 deaths occurred in winter and 2,825,223 deaths occurred during the rest of the year among people aged > or =65 (around 30,000 excess winter deaths per year). A trend of higher excess winter mortality with age was apparent across all disease categories (P < 0.01). There was a significant association between winter mortality and temperature with a 1.5% higher odds of dying in winter for every 1 degrees C reduction in 24-h mean winter temperature. The amount of rain, wind and hours of sunshine were inversely associated with excess winter mortality. Selected housing variables derived from the English House Condition Survey showed little agreement with census-derived variables at electoral ward level. For all-cause mortality there was little association between deprivation and excess winter mortality, although lack of central heating was associated with a higher risk of dying in winter (odds ratio [OR] = 1.016, 95% CI : 1.009-1.022). CONCLUSIONS: Excess winter mortality continues to be an important public health problem in Great Britain. There was a strong inverse association with temperature. Lack of central heating was associated with higher excess winter mortality. Further work is needed to disentangle the complex relationships between different indicators of housing quality and other measures of socioeconomic deprivation and their relationship to the high number of excess winter deaths in Great Britain.     

Predictors and outcomes of excess gestational weight gain among low-income pregnant women

Low-income women were interviewed and their post-natal records were retrieved (n = 160) to assess prevalence of excess gestational weight gain and its socio-demographic predictors. More than half of the women (64%) gained excess weight during pregnancy, with an average of 10 lbs in excess of Institute of Medicine guidelines. Logistic regression indicated that women that started pregnancy at an obese body mass index; who were African American or having an unplanned pregnancy were at significant risk of gaining excess weight in pregnancy. Intervention to prevent excess weight gain during pregnancy is critical in addressing obesity epidemic in the United States and worldwide.