Peer Reviewed: A Cost-Benefit Analysis of Lipid Standardization in the United States

Introduction

By improving lipid standardization, the Centers for Disease Control and Prevention''s (CDC''s) Lipid Standardization Program and Cholesterol Reference Method Laboratory Network have contributed to the marked reduction in heart disease deaths since 1980. The objective of this study was to estimate the benefits (ie, the value of reductions in heart disease deaths) and costs attributable to these lipid standardization programs.

Methods

We developed a logic model that shows how the inputs and activities of the lipid standardization programs produce short- and medium-term outcomes that in turn lead to improvements in rates of cardiovascular disease and death. To calculate improvements in long-term outcomes, we applied previous estimates of the change in heart disease deaths between 1980 and 2000 that was attributable to statin treatment and to the reduction in total cholesterol during the period. Experts estimated the share of cholesterol reduction that could be attributed to lipid standardization. We applied alternative assumptions about the value of a life-year saved to estimate the value of life-years saved attributable to the programs.

Results

Assuming that 5% of the cholesterol-related benefits were attributable to the programs and a $113,000 value per life-year, the annual benefit attributable to the programs was $7.6 billion. With more conservative assumptions (0.5% of cholesterol-related benefits attributable to the programs and a $50,000 value per life-year), the benefit attributable to the programs was $338 million. In 2007, the CDC lipid standardization programs cost $1.7 million.

Conclusion

Our estimates suggest that the benefits of CDC''s lipid standardization programs greatly exceed their costs.     

Peer Reviewed: Enforcement of State Indoor Tanning Laws in the United States

Introduction

Twenty-eight US states have passed legislation for indoor tanning facilities. To our knowledge, whether these state laws are actually enforced has not been evaluated previously in all 28 states. Therefore, we interviewed key informants in these states to assess enforcement practices.

Methods

Two trained interviewers used a structured survey instrument to interview 28 key informants who were knowledgeable about enforcement practices for laws regarding indoor tanning. Respondents provided information specific to the most populous city in their states.

Results

Licensure for indoor tanning businesses was required in 22 of the 28 cities. Slightly less than half of the cities gave citations to tanning facilities that violated state law. Approximately 32% of the cities did not inspect indoor tanning facilities for compliance with state law, and another 32% conducted inspections less than annually. Of those cities that inspected at all, most conducted unannounced inspections.

Conclusion

The relatively low rates of annual inspections and citations are of concern. We recommend that future studies assess whether legislation, enforcement practices, or a combination of the 2 affects the practices of indoor tanning facilities or of consumers.     

Peer Reviewed: Cholesterol Screening by Marital Status and Sex in the United States

Introduction

Marital status may be a predisposing factor related to preventive health screenings, which may in part explain the "healthy marriage" effect. This study investigates differences in the likelihood of being screened for cholesterol by marital status for men and women.

Methods

Medical Expenditure Panel Surveys from 2003 through 2005 were used to calculate the likelihood of self-reported cholesterol screening in the past year by marital status and sex. Several rounds of interviews during a 2-year period resulted in a sample of 36,594 US adults.

Results

Most married, widowed, and divorced/separated people reported cholesterol screening in the past year. The highest percentages of people being screened for cholesterol were widowed men (75%) and women (81%). By contrast, 26% of single men and 38% of single women reported cholesterol screening. In multivariate models, being unmarried was associated with lower odds of cholesterol screening among men and women. The lowest likelihood of screening was associated with widowed status for both men (odds ratio, 0.56) and women (odds ratio, 0.53).

Conclusion

Marital status is a predisposing factor for cholesterol screening. Public health interventions aimed at improving preventive screening should focus on social networks, especially family members.     

Peer Reviewed: Hospice Use Among Cancer Decedents in Alabama, 2002-2005

Introduction

Most studies that describe hospice use among cancer patients use the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, which has known limitations. We used vital records data to describe patterns of hospice use among cancer decedents in Alabama.

Methods

To ascertain hospice use, we linked death certificates from 2002 through 2005 for people who died from cancer to listings of deaths reported by hospices. To evaluate accessibility of care, we calculated straight-line distances between decedent residence at death and the hospice providing care. We used these distances to estimate the reach of each hospice and identify the number of hospice nonusers residing in these areas.

Results

During the study period, 52.0% of cancer decedents in Alabama received hospice care from 165 hospices. Nearly two-thirds of Alabama counties contain at least 1 hospice. Whites (53.6%) used hospice at a significantly higher rate than blacks (47.0%), but the rate of use was similar for women (53.2%) and men (51.0%). For people who were eligible for Medicare, 53.0% received hospice care. The median distance between decedent’s residence and the hospice providing care was 9.8 miles. This distance was slightly shorter for blacks than whites and roughly equal by sex.

Conclusion

Alabamians use hospice at lower rates than observed elsewhere. Barriers to hospice care in Alabama must be identified and addressed.     

Update: Fusarium keratitis--United States, 2005-2006

In April 2006, CDC reported on an ongoing multistate investigation of Fusarium keratitis occurring predominantly among contact lens wearers. This update summarizes epidemiologic developments in this investigation, which indicate an association with Bausch & Lomb's ReNu with MoistureLoc contact lens solution.     

Peer Reviewed: BMI and Physical Activity Among at-Risk Sixth- and Ninth-Grade Students,Hillsborough County,Florida, 2005-2006

Introduction

During the past 3 decades, the number of overweight adolescents increased while adolescent engagement in physical activity decreased. We investigated the prevalence of overweight and physical activity levels among economically disadvantaged and minority middle- and high-school students in a school district in Florida. In particular, data on physical activity levels of middle-school students are limited and needed for prevention and intervention planning. In addition, because of state education policies, students in Florida are less likely than students nationally to enroll in physical education, placing them at a higher risk for decreased physical activity levels.

Methods

We used multivariate methodology to analyze physical activity levels among 526 students from 3 middle and 2 high schools in southwest Florida.

Results

Forty percent of students met criteria for overweight or obesity. Overall, less than 45% of students reported engaging in daily physical activity. Boys reported higher levels of physical activity than did girls, and a decline in physical activity levels was observed between grades 6 and 9, especially among minority girls (ie, African American and Latino). Lack of time was identified as the greatest barrier to engaging in physical activity.

Conclusion

This study documents health disparities among minority students from economically disadvantaged backgrounds in an urban school district. Participation in daily physical activity was below recommended guidelines across grades. We found numerous barriers to engaging in physical activity, which will enable local education agencies to evaluate their current physical activity policies and identify alternative physical activities for these youth.     

Peer Reviewed: Depression Screening and Treatment Among Nonpregnant Women of Reproductive Age in the United States, 1990-2010

Introduction

Whether routine screening for depression among nonpregnant women of reproductive age improves identification and treatment of the disorder remains unclear. We conducted a systematic review of the literature to address 5 key questions specific to this population: 1) What are the current national clinical practice recommendations and guidelines for depression screening; 2) What are the prevalence and predictors of screening; 3) How well do screening tools detect depression; 4) Does screening lead to diagnosis, treatment, and improved outcomes; and 5) What are the most effective treatment methods?

Methods

We searched bibliographic databases for full-length articles published in English between 1990 and 2010 that addressed at least 1 of our key questions.

Results

We identified 5 clinical practice guidelines pertinent to question 1, and 12 systematic reviews or post-hoc analyses of pooled data that addressed questions 3 through 5. No systematic reviews addressed question 2; however, we identified 4 individual studies addressing this question. Current guidelines do not recommend universal screening for depression in adults, unless staff supports are in place to diagnose, treat, and follow up patients. Reported screening rates ranged from 33% to 84% among women. Several validated screening tools for depression exist; however, their performance among this population is unknown. Screening in high-risk populations may improve the patient''s receipt of diagnosis and treatment. Effective treatments include exercise, psychotherapy, and pharmacotherapy.

Conclusion

More research is needed on whether routine screening for depression among women of reproductive age increases diagnosis and treatment of depression, improves preconception health, and reduces adverse outcomes.     

Peer Reviewed: Racial Disparities in Blood Pressure Control and Treatment Differences in a Medicaid Population, North Carolina, 2005-2006

Introduction

Racial disparities in prevalence and control of high blood pressure are well-documented. We studied blood pressure control and interventions received during the course of a year in a sample of black and white Medicaid recipients with high blood pressure and examined patient, provider, and treatment characteristics as potential explanatory factors for racial disparities in blood pressure control.

Methods

We retrospectively reviewed the charts of 2,078 black and 1,436 white North Carolina Medicaid recipients who had high blood pressure managed in primary care practices from July 2005 through June 2006. Documented provider responses to high blood pressure during office visits during the prior year were reviewed.

Results

Blacks were less likely than whites to have blood pressure at goal (43.6% compared with 50.9%, P = .001). Blacks above goal were more likely than whites above goal to have been prescribed 4 or more antihypertensive drug classes (24.7% compared with 13.4%, P < .001); to have had medication adjusted during the prior year (46.7% compared with 40.4%, P = .02); and to have a documented provider response to high blood pressure during office visits (35.7% compared with 30.0% of visits, P = .02). Many blacks (28.0%) and whites (34.3%) with blood pressure above goal had fewer than 2 antihypertensive drug classes prescribed.

Conclusion

In this population with Medicaid coverage and access to primary care, blacks were less likely than whites to have their blood pressure controlled. Blacks received more frequent intervention and had greater use of combination antihypertensive therapy. Care patterns observed in the usual management of high blood pressure were not sufficient to achieve treatment goals or eliminate disparities.     

Peer Reviewed: Trends in Incidence Rates of Tobacco-Related Cancer, Selected Areas, SEER Program, United States, 1992-2004

Introduction

Recent trends in incidence rates for tobacco-related cancers may vary geographically because of variation in socioeconomic status and in history of comprehensive state tobacco control programs (starting with California in 1989). Recent trends in risk factors are likely to affect cancer incidence rates at the youngest ages.

Methods

Trends in age-adjusted incidence rates for cancers most strongly associated with tobacco (ie, lung, oral cavity-pharynx, and bladder cancers) were analyzed for 1992 through 2004 in 11 areas (the states of Connecticut, Hawaii, Iowa, Utah, and New Mexico, and the metropolitan areas of Atlanta, Georgia; Detroit, Michigan; Los Angeles County, California; San Francisco-Oakland, California; San Jose-Monterey, California; and Seattle-Puget Sound, Washington) in the Surveillance, Epidemiology and End Results (SEER) Program. The 8 states differed in poverty rate of the population and in history of statewide tobacco control efforts as measured by an initial outcomes index (IOI) for the 1990s and a strength of tobacco control (SoTC) index for 1999 through 2000. Annual percentage change (APC) in incidence rate was calculated for whites and blacks separately and by sex for each SEER area.

Results

Among whites, the largest declines for lung cancer were in the 3 SEER areas of California, which were the only areas with significant (negative) APCs for oral cavity-pharynx cancer (but not for bladder cancer). For blacks, significant (negative) APCs for both lung and oral cavity-pharynx cancers were found in 4 of 5 areas with useful data but only 1 of 3 areas for bladder cancer. The strongest correlations of APCs for whites were for lung and oral cavity-pharynx cancers with the IOIs for the early 1990s and with the SoTC (due to the influence of California, which had the highest SoTC).

Conclusion

Lung and oral cavity-pharynx cancer incidence rates among whites aged 15 to 54 years declined more in California than in other areas, possibly because of comprehensive state tobacco control efforts. The different trends for bladder cancer vs other cancers could reflect the influence of risk factors other than tobacco. The greater geographic uniformity of trends among blacks than among whites for lung and oral cavity-pharynx cancers requires further study, particularly in relation to state tobacco control efforts.     

Peer Reviewed: Associations Between Severe Obesity and Depression: Results From the National Health and Nutrition Examination Survey, 2005-2006

Introduction

My objectives were to investigate the association between obesity and depression in a representative sample of American adults, investigate sex and severity of obesity as modifiers of the association between depression and body mass index, determine whether large waist circumference is associated with depression, and explore whether specific health behaviors and poor physical health are possible mediators of the association between obesity and depression, if found.

Methods

The sample consisted of 3,599 nonpregnant adults aged 20 years or older from the National Health and Nutrition Examination Survey, 2005-2006. I operationalized obesity as body mass index (BMI) and waist circumference from the anthropometric measurements of participants and current depression from Patient Health Questionnaire (PHQ-9) scores. I ran logistic regression models with depression as the dependent variable.

Results

In unadjusted analyses, large waist circumference (≥88 cm for women and ≥102 cm for men) and class III obesity (BMI ≥40 kg/m²) were associated with higher prevalence of depression in women only. All of these associations dramatically weakened after adjusting for demographic factors, self-rated health status, and number of chronic conditions.

Conclusion

These findings support an association between depression and obesity in women who are severely obese. Future studies should investigate poor physical health as a possible mediator of the association between obesity and depression in this population of women.     

Peer Reviewed: Physical Activity Patterns Among Latinos in the United States: Putting the Pieces Together

Introduction

Estimates of participation in physical activity among Latinos are inconsistent across studies. To obtain better estimates and examine possible reasons for inconsistencies, we assessed 1) patterns of participation in various categories of physical activity among Latino adults, 2) changes in their activity patterns with acculturation, and 3) variations in their activity patterns by region of origin.

Methods

Using data from four national surveillance systems (the National Health and Nutrition Examination Survey, 1999–2002; the Behavioral Risk Factor Surveillance System, 2003; the National Household Travel Survey, 2001; and the National Health Interview Survey Cancer Supplement, 2000), we estimated the percentage of Latinos who participated at least once per week in leisure-time, household, occupational, or transportation-related physical activity, as well as in an active pattern of usual daily activity. We reported prevalences by acculturation measures and region of origin.

Results

The percentage of Latinos who participated in the various types of physical activity ranged from 28.7% for having an active level of usual daily activity (usually walking most of the day and usually carrying or lifting objects) to 42.8% for participating in leisure-time physical activity at least once per week. The percentage who participated in leisure-time and household activities increased with acculturation, whereas the percentage who participated in occupational and transportation-related activities decreased with acculturation. Participation in an active level of usual daily activity did not change significantly. The prevalence of participation in transportation-related physical activity and of an active level of usual daily activity among Latino immigrants varied by region of origin.

Conclusion

Physical activity patterns among Latinos vary with acculturation and region of origin. To assess physical activity levels in Latino communities, researchers should measure all types of physical activity and the effects of acculturation on each type of activity.     

Peer Reviewed: Lifestyle Behaviors and Physician Advice for Change Among Overweight and Obese Adults With Prediabetes and Diabetes in the United States, 2006

Introduction

The objective of this study was to examine the lifestyle behaviors of overweight and obese people with prediabetes or diabetes and to determine whether an association exists between reported behaviors and physician advice for behavior change.

Methods

This investigation included overweight and obese people (body mass index ≥25.0 kg/m²) with prediabetes and diabetes aged 40 years or older identified from the 2006 National Health Interview Survey. Respondents reported attempts to control or lose weight, reduce the amount of fat or calories in their diet, and increase physical activity. Respondents also reported receipt of a physician recommendation for behavioral change in 1 or more of these areas. Data analysis included use of logistic regression stratified by sex and prediabetes/diabetes status to model odds of behavior by physician advice.

Results

Most people reported trying to control or lose weight (prediabetes, 82%; diabetes, 75%). Fewer identified efforts to reduce the amount of fat or calories in their diet (prediabetes, 62%; diabetes, 71%) or increase physical activity (prediabetes, 53%; diabetes, 57%). Approximately one-third reported not receiving physician advice for each of these behavior changes. In logistic regression, physician advice for reducing the amount of fat or calories in the diet and increasing physical activity was generally associated with the reported corresponding behavior.

Conclusion

Many respondents reported trying to control or lose weight, but fewer reported actually reducing fat or calories in their diet or increasing physical activity. Physician advice may influence attempts at behavior change among overweight and obese patients with prediabetes and diabetes.     

Peer Reviewed: Clinical Preventive Services for Patients at Risk for Cardiovascular Disease,National Ambulatory Medical Care Survey, 2005-2006

Introduction

Clinical preventive services can detect diseases early, when they are most treatable, but these services may not be provided as recommended. Assessing the provision of services to patients at risk for cardiovascular disease (CVD) could help identify disparities and areas for improvement.

Methods

We used data on patient visits (n = 21,261) from the National Ambulatory Medical Care Survey, 2005-2006, and classified patients with hypertension, hyperlipidemia, obesity, or diabetes as being at risk for CVD. We assessed differences in the provision of preventive services offered to patients who were and who were not at risk for CVD. Further, for those at risk, we compared the demographic characteristics of those who had and who had not been offered services.

Results

Patients at risk for CVD received significantly more preventive services compared with those not at risk. For patients at risk for CVD, aspirin therapy was more likely to be recommended to those aged 65 years or older than those aged 45 to 64 years and to men than women. Cholesterol screening was more likely for men and was less likely for patients with Medicare/Medicaid or no insurance than for patients who were insured. Rates of counseling for diet and nutrition, weight reduction, and exercise were low overall, but younger patients received these services more than older patients did.

Conclusion

Patients at risk for CVD are not all receiving the same level of preventive care, suggesting the need to clarify clinical practice guidelines and provide clinicians with education and support for more effective lifestyle counseling.     

Peer Reviewed: Differences in Patterns of Alcohol Consumption Among Hispanics in the United States,by Survey Language Preference,Behavioral Risk Factor Surveillance System, 2005

Introduction

Alcohol consumption is pervasive in the United States, and extent of alcohol consumption for the growing US Hispanic population needs further study. We examined the association between language chosen for a national health survey and alcohol use among Hispanic adults.

Methods

Hispanic participants aged 18 years and older (N = 20,234) from the 2005 Behavioral Risk Factor Surveillance System were stratified by choice of language (English, n = 13,035; Spanish, n = 7,199) for completing the survey. Differences for these 2 groups in current alcohol use, heavy alcohol use, and binge drinking were determined by using χ² analyses and logistic regression models.

Results

In bivariate associations, current drinking (P < .001), heavy drinking (P < .001), and binge drinking (P = .002) were significantly higher among participants who chose to complete the survey in English than among those who elected to complete the survey in Spanish. After controlling for demographic characteristics, associations between language choice and drinking behaviors were found to be greatest among women. Compared with women who chose to complete the survey in Spanish, women who chose to complete the survey in English were more than twice as likely to report current drinking (odds ratio [OR] = 2.42, 95% confidence interval [CI] = 2.02-2.91), heavy drinking (OR = 3.82, 95% CI = 1.44-10.10), and binge drinking (OR = 2.51, 95% CI = 1.64-3.84).

Conclusion

This study suggests that language choice when completing a health survey is a predictor of high levels of alcohol use among Hispanic adults in the United States and that differences in drinking behaviors based on language choice for a survey are more profound among women.     

Peer Reviewed: The Ethical Basis for Promoting Nutritional Health in Public Schools in the United States

Schools may have an ethical obligation to act in response to the precipitous increase in the incidence of obesity among children. Using a bioethics framework, we present a rationale for school programs to improve the nutritional quality of students'' diets. Because children are required to spend half their waking hours in school and because they consume a substantial portion of their daily food there, school is a logical focus for efforts to encourage healthy dietary behaviors to prevent obesity and its consequent individual and collective costs. We suggest that beyond strategic considerations, the concept of the common good justifies actions that may appear to conflict with freedom of choice of children, parents, and school staff, or with the interests of food and beverage companies.     

Dietary supplement use in the United States, 2003-2006

Dietary supplement use has steadily increased over time since the 1970s; however, no current data exist for the U.S. population. Therefore, the purpose of this analysis was to estimate dietary supplement use using the NHANES 2003-2006, a nationally representative, cross-sectional survey. Dietary supplement use was analyzed for the U.S. population (≥1 y of age) by the DRI age groupings. Supplement use was measured through a questionnaire and was reported by 49% of the U.S. population (44% of males, 53% of females). Multivitamin-multimineral use was the most frequently reported dietary supplement (33%). The majority of people reported taking only 1 dietary supplement and did so on a daily basis. Dietary supplement use was lowest in obese adults and highest among non-Hispanic whites, older adults, and those with more than a high-school education. Between 28 and 30% reported using dietary supplements containing vitamins B-6, B-12, C, A, and E; 18-19% reported using iron, selenium, and chromium; and 26-27% reported using zinc- and magnesium-containing supplements. Botanical supplement use was more common in older than in younger age groups and was lowest in those aged 1-13 y but was reported by ~20% of adults. About one-half of the U.S. population and 70% of adults ≥ 71 y use dietary supplements; one-third use multivitamin-multimineral dietary supplements. Given the widespread use of supplements, data should be included with nutrient intakes from foods to correctly determine total nutrient exposure.