COVID-19 Vaccine Policy Implementation and Differential Vaccine Uptake Trajectories in Chicago Communities.

BACKGROUND: Since the onset of the COVID-19 pandemic, multiple public health interventions have been implemented to respond to the rapidly evolving pandemic and community needs. This article describes the scope, timing, and impact of coordinated strategies for COVID-19 vaccine uptake in Chicago for the first year of vaccine distribution. METHODS: Using a series of interviews with public health officials and leaders of community-based organizations (CBOs) who participated in the implementation of the citywide COVID-19 vaccine outreach initiatives, we constructed a timeline of vaccine outreach initiatives. The timeline was matched to the vaccine uptake rates to explore the impact of the vaccine outreach initiatives by community area. Finally, we discussed the nature of policy initiatives and the level of vaccine uptake in relation to community characteristics. RESULTS: The Chicago Department of Public Health (CDPH) implemented myriad vaccine outreach strategies, including mass vaccination sites, improved access, and community-level vaccine campaigns. Protect Chicago+ was the primary vaccine outreach effort initiated by the CDPH, which identified 15 highly vulnerable community areas. More than 2.7 million (67%) Chicagoans completed the vaccine regimen by December 2021. Black (51.3%) Chicagoans were considerably less likely to be vaccinated than Asian (77.6%), White (69.8%), and Hispanic (63.6%) Chicago residents. In addition, there were significant spatial differences in the rate of COVID-19 vaccine completion: predominantly White and Hispanic communities, compared with Black communities, had higher rates of vaccine completion. CONCLUSIONS: The community outreach efforts to improve COVID-19 vaccine uptake in Chicago have shown the importance of community-engaged approaches in pandemic responses. Despite citywide efforts to build community infrastructure, Black communities had relatively lower levels of vaccine uptake than other communities. Broader social restructuring to mitigate disinvestment and residential segregation and to ameliorate medical mistrust will be needed to prepare for future pandemics and disasters.

Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report.

Cardiovascular disparities remain pervasive in the United States. Unequal disease burden is evident among population groups based on sex, race, ethnicity, socioeconomic status, educational attainment, nativity, or geography. Despite the significant declines in cardiovascular disease mortality rates in all demographic groups during the last 50 years, large disparities remain by sex, race, ethnicity, and geography. Recent data from modeling studies, linked micromap plots, and small-area analyses also demonstrate prominent variation in cardiovascular disease mortality rates across states and counties, with an especially high disease burden in the southeastern United States and Appalachia. Despite these continued disparities, few large-scale intervention studies have been conducted in these high-burden populations to examine the feasibility of reducing or eliminating cardiovascular disparities. To address this challenge, on June 22 and 23, 2017, the National Heart, Lung, and Blood Institute convened experts from a broad range of biomedical, behavioral, environmental, implementation, and social science backgrounds to summarize the current state of knowledge of cardiovascular disease disparities and propose intervention strategies aligned with the National Heart, Lung, and Blood Institute mission. This report presents the themes, challenges, opportunities, available resources, and recommended actions discussed at the workshop.

Vital Signs: Racial Disparities in Age-Specific Mortality Among Blacks or African Americans - United States, 1999-2015.

BACKGROUND: Although the overall life expectancy at birth has increased for both blacks and whites and the gap between these populations has narrowed, disparities in life expectancy and the leading causes of death for blacks compared with whites in the United States remain substantial. Understanding how factors that influence these disparities vary across the life span might enhance the targeting of appropriate interventions. METHODS: Trends during 1999-2015 in mortality rates for the leading causes of death were examined by black and white race and age group. Multiple 2014 and 2015 national data sources were analyzed to compare blacks with whites in selected age groups by sociodemographic characteristics, self-reported health behaviors, health-related quality of life indicators, use of health services, and chronic conditions. RESULTS: During 1999-2015, age-adjusted death rates decreased significantly in both populations, with rates declining more sharply among blacks for most leading causes of death. Thus, the disparity gap in all-cause mortality rates narrowed from 33% in 1999 to 16% in 2015. However, during 2015, blacks still had higher death rates than whites for all-cause mortality in all groups aged <65 years. Compared with whites, blacks in age groups <65 years had higher levels of some self-reported risk factors and chronic diseases and mortality from cardiovascular diseases and cancer, diseases that are most common among persons aged ≥65 years. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: To continue to reduce the gap in health disparities, these findings suggest an ongoing need for universal and targeted interventions that address the leading causes of deaths among blacks (especially cardiovascular disease and cancer and their risk factors) across the life span and create equal opportunities for health.

Clustering of Five Health-Related Behaviors for Chronic Disease Prevention Among Adults, United States, 2013.

INTRODUCTION: Five key health-related behaviors for chronic disease prevention are never smoking, getting regular physical activity, consuming no alcohol or only moderate amounts, maintaining a normal body weight, and obtaining daily sufficient sleep. The objective of this study was to estimate the clustering of these 5 health-related behaviors among adults aged 21 years or older in each state and the District of Columbia and to assess geographic variation in clustering. METHODS: We used data from the 2013 Behavioral Risk Factor Surveillance System (BRFSS) to assess the clustering of the 5 behaviors among 395,343 BRFSS respondents aged 21 years or older. The 5 behaviors were defined as currently not smoking cigarettes, meeting the aerobic physical activity recommendation, consuming no alcohol or only moderate amounts, maintaining a normal body mass index (BMI), and sleeping at least 7 hours per 24-hour period. Prevalence of having 4 or 5 of these behaviors, by state, was also examined. RESULTS: Among US adults, 81.6% were current nonsmokers, 63.9% obtained 7 hours or more sleep per day, 63.1% reported moderate or no alcohol consumption, 50.4% met physical activity recommendations, and 32.5% had a normal BMI. Only 1.4% of respondents engaged in none of the 5 behaviors; 8.4%, 1 behavior; 24.3%, 2 behaviors; 35.4%, 3 behaviors; and 24.3%, 4 behaviors; only 6.3% reported engaging in all 5 behaviors. The highest prevalence of engaging in 4 or 5 behaviors was clustered in the Pacific and Rocky Mountain states. Lowest prevalence was in the southern states and along the Ohio River. CONCLUSION: Additional efforts are needed to increase the proportion of the population that engages in all 5 health-related behaviors and to eliminate geographic variation. Collaborative efforts in health care systems, communities, work sites, and schools can promote all 5 behaviors and produce population-wide changes, especially among the socioeconomically disadvantaged.

Prescription practices for chronic obstructive pulmonary disease: findings from the national ambulatory medical care survey 1999-2010.

Recent trends in prescriptions for medicines used to treat chronic obstructive pulmonary disease (COPD) in the United States have received little attention. Our objective was to examine trends in prescribing practices for medications used to treat COPD. We examined data from surveys of national samples of office visits to non-federal employed office-based physicians in the United States by patients aged ≥40 years with COPD recorded by the National Ambulatory Medical Care Survey from 1999 to 2010. From three diagnostic codes, office visits by patients with COPD were identified. Prescribed medications were identified from up to 8 recorded medications. The percentage of these visits during which a prescription for any medication used to treat COPD was issued increased from 27.0% in 1999 to 49.1% in 2010 (p trend < 0.001). Strong increases were noted for short-acting beta-2 agonists (17.6% in 1999 to 24.7% in 2010; p trend < 0.001), long-acting beta-2 agonists as single agents or combination products (6.2% in 1999 to 28.3% in 2010; p trend < 0.001), inhaled corticosteroids as single agents or combination products (10.9% in 1999 to 30.9% in 2010; p trend < 0.001), and tiotropium (3.8% in 2004 to 17.2% in 2010; p trend < 0.001). Since 1999, prescription patterns for medicines used to treat COPD have changed profoundly in the United States.

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.

Developing an integrated strategy to reduce ethnic and racial disparities in the delivery of clinical preventive services for older Americans.

OBJECTIVES: To determine the optimum strategy for increasing up-to-date (UTD) levels in older Americans, while reducing disparities between White, Black, and Hispanic adults, aged 65 years and older. METHODS: Data were analyzed from the 2008 Behavioral Risk Factor Surveillance System, quantifying the proportion of older Americans UTD with influenza and pneumococcal vaccinations, mammograms, Papanicolaou tests, and colorectal cancer screening. A comparison of projected changes in UTD levels and disparities was ascertained by numerically accounting for UTD adults lacking 1 or more clinical preventive services (CPS). Analyses were performed by gender and race/ethnicity. RESULTS: Expanded provision of specific vaccinations and screenings each increased UTD levels. When those needing only vaccinations were immunized, there was a projected decrease in racial/ethnic disparities in UTD levels (2.3%-12.2%). When those needing only colorectal cancer screening, mammography, or Papanicolaou test were screened, there was an increase in UTD disparities (1.6%-4.5%). CONCLUSIONS: A primary care and public health focus on adult immunizations, in addition to other CPS, offers an effective strategy to reduce disparities while improving UTD levels.

Fifty communities putting prevention to work: accelerating chronic disease prevention through policy, systems and environmental change.

The burden of preventable chronic diseases is straining our nation's health and economy. Diseases caused by obesity and tobacco use account for the largest portions of this preventable burden. CDC funded 50 communities in 2010 to implement policy, systems, and environmental (PSE) interventions in a 2-year initiative. Funded communities developed PSE plans to reduce obesity, tobacco use, and second-hand smoke exposure for their combined 55 million residents. Community outcome objectives and milestones were categorized by PSE interventions as they related to media, access, promotion, pricing, and social support. Communities estimated population reach based on their jurisdiction's census data and target populations. The average proportion of each community's population that was reached was calculated for each intervention category. Outcome objectives that were achieved within 12 months of program initiation were identified from routine program records. The average proportion of a community's jurisdictional population reached by a specific intervention varied across interventions. Mean population reach for obesity-prevention interventions was estimated at 35%, with 14 (26%) interventions covering over 50% of the jurisdictional populations. For tobacco prevention, mean population reach was estimated at 67%, with 16 (84%) interventions covering more than 50% of the jurisdictional populations. Within 12 months, communities advanced over one-third of their obesity and tobacco-use prevention strategies. Tobacco interventions appeared to have higher potential population reach than obesity interventions within this initiative. Findings on the progress and potential reach of this major initiative may help inform future chronic disease prevention efforts.

Explaining the decrease in U.S. deaths from coronary disease, 1980-2000.

BACKGROUND: Mortality from coronary heart disease in the United States has decreased substantially in recent decades. We conducted a study to determine how much of this decrease could be explained by the use of medical and surgical treatments as opposed to changes in cardiovascular risk factors. METHODS: We applied a previously validated statistical model, IMPACT, to data on the use and effectiveness of specific cardiac treatments and on changes in risk factors between 1980 and 2000 among U.S. adults 25 to 84 years old. The difference between the observed and expected number of deaths from coronary heart disease in 2000 was distributed among the treatments and risk factors included in the analyses. RESULTS: From 1980 through 2000, the age-adjusted death rate for coronary heart disease fell from 542.9 to 266.8 deaths per 100,000 population among men and from 263.3 to 134.4 deaths per 100,000 population among women, resulting in 341,745 fewer deaths from coronary heart disease in 2000. Approximately 47% of this decrease was attributed to treatments, including secondary preventive therapies after myocardial infarction or revascularization (11%), initial treatments for acute myocardial infarction or unstable angina (10%), treatments for heart failure (9%), revascularization for chronic angina (5%), and other therapies (12%). Approximately 44% was attributed to changes in risk factors, including reductions in total cholesterol (24%), systolic blood pressure (20%), smoking prevalence (12%), and physical inactivity (5%), although these reductions were partially offset by increases in the body-mass index and the prevalence of diabetes, which accounted for an increased number of deaths (8% and 10%, respectively). CONCLUSIONS: Approximately half the decline in U.S. deaths from coronary heart disease from 1980 through 2000 may be attributable to reductions in major risk factors and approximately half to evidence-based medical therapies.

Decreases in smoking prevalence in Asian communities served by the Racial and Ethnic Approaches to Community Health (REACH) project.

OBJECTIVES: We examined trends in smoking prevalence from 2002 through 2006 in 4 Asian communities served by the Racial and Ethnic Approaches to Community Health (REACH) intervention. METHODS: Annual survey data from 2002 through 2006 were gathered in 4 REACH Asian communities. Trends in the age-standardized prevalence of current smoking for men in 2 Vietnamese communities, 1 Cambodian community, and 1 Asian American/Pacific Islander (API) community were examined and compared with nationwide US and state-specific data from the Behavioral Risk Factor Surveillance System. RESULTS: Prevalence of current smoking decreased dramatically among men in REACH communities. The reduction rate was significantly greater than that observed in the general US or API male population, and it was greater than reduction rates observed in the states in which REACH communities were located. There was little change in the quit ratio of men at the state and national levels, but there was a significant increase in quit ratios in the REACH communities, indicating increases in the proportions of smokers who had quit smoking. CONCLUSIONS: Smoking prevalence decreased in Asian communities served by the REACH project, and these decreases were larger than nationwide decreases in smoking prevalence observed for the same period. However, disparities in smoking prevalence remain a concern among Cambodian men and non-English-speaking Vietnamese men; these subgroups continue to smoke at a higher rate than do men nationwide.

Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study.

BACKGROUND: Strong relationships between exposure to childhood traumatic stressors and smoking behaviours inspire the question whether these adverse childhood experiences (ACEs) are associated with an increased risk of lung cancer during adulthood. METHODS: Baseline survey data on health behaviours, health status and exposure to adverse childhood experiences (ACEs) were collected from 17,337 adults during 1995-1997. ACEs included abuse (emotional, physical, sexual), witnessing domestic violence, parental separation or divorce, or growing up in a household where members with mentally ill, substance abusers, or sent to prison. We used the ACE score (an integer count of the 8 categories of ACEs) as a measure of cumulative exposure to traumatic stress during childhood. Two methods of case ascertainment were used to identify incident lung cancer through 2005 follow-up: 1) hospital discharge records and 2) mortality records obtained from the National Death Index. RESULTS: The ACE score showed a graded relationship to smoking behaviors. We identified 64 cases of lung cancer through hospital discharge records (age-standardized risk = 201 x 100,000(-1) population) and 111 cases of lung cancer through mortality records (age-standardized mortality rate = 31.1 x 100,000(-1) person-years). The ACE score also showed a graded relationship to the incidence of lung cancer for cases identified through hospital discharge (P = 0.0004), mortality (P = 0.025), and both methods combined (P = 0.001). Compared to persons without ACEs, the risk of lung cancer for those with >or= 6 ACEs was increased approximately 3-fold (hospital records: RR = 3.18, 95%CI = 0.71-14.15; mortality records: RR = 3.55, 95%CI = 1.25-10.09; hospital or mortality records: RR = 2.70, 95%CI = 0.94-7.72). After a priori consideration of a causal pathway (i.e., ACEs --> smoking --> lung cancer), risk ratios were attenuated toward the null, although not completely. For lung cancer identified through hospital or mortality records, persons with >or= 6 ACEs were roughly 13 years younger on average at presentation than those without ACEs. CONCLUSIONS: Adverse childhood experiences may be associated with an increased risk of lung cancer, particularly premature death from lung cancer. The increase in risk may only be partly explained by smoking suggesting other possible mechanisms by which ACEs may contribute to the occurrence of lung cancer.

Trends in hospitalization with chronic obstructive pulmonary disease-United States, 1990-2005.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and a major cause of morbidity and disability. To update national estimates and examine trends for hospitalization with COPD between 1990 and 2005, we analyzed data from the National Hospital Discharge Survey (NHDS). The results indicated that an estimated 715,000 hospitalizations with COPD, or 23.6 per 10,000 population, occurred during 2005, an increase in the number and the rate of COPD hospitalizations since 1990 (370,000 hospitalizations; rate = 15.9 per 10,000 population). To reverse increases in the number of COPD hospitalizations and decrease the burden of COPD, public health programs should continue focused efforts to reduce total personal exposure to tobacco smoke, including passive smoke exposure; to occupational dusts and chemicals; and to other indoor and outdoor air pollutants linked to COPD.

Factors explaining excess stroke prevalence in the US Stroke Belt.

BACKGROUND AND PURPOSE: Higher risk and burden of stroke have been observed within the southeastern states (the Stroke Belt) compared with elsewhere in the United States. We examined reasons for these disparities using a large data set from a nationwide cross-sectional study. METHODS: Self-reported data from the 2005 and 2007 Behavioral Risk Factor Surveillance System were used (n=765,368). The potential contributors for self-reported stroke prevalence (n=27 962) were demographics (age, sex, geography, and race/ethnicity), socioeconomic status (education and income), common risk factors (smoking and obesity), and chronic diseases (hypertension, diabetes, and coronary heart disease). Multivariate logistic regression was used in the analysis. RESULTS: The age- and sex-adjusted OR comparing self-reported stroke prevalence in the 11-state Stroke Belt versus non-Stroke Belt region was 1.25 (95% CI, 1.19 to 1.31). Unequal black/white distribution by region accounted for 20% of the excess prevalence in the Stroke Belt (OR reduced to 1.20; 1.15 to 1.26). Approximately one third (32%) of the excess prevalence was accounted either by socioeconomic status alone or by risk factors and chronic disease alone (OR, 1.12). The OR was further reduced to 1.07 (1.02 to 1.13) in the fully adjusted logistic model, a 72% reduction. CONCLUSIONS: Differences in socioeconomic status, risk factors, and prevalence of common chronic diseases account for most of the regional differences in stroke prevalence.

Relation of candidate genes that encode for endothelial function to migraine and stroke: the Stroke Prevention in Young Women study.

BACKGROUND AND PURPOSE: Migraine with aura is a risk factor for ischemic stroke, but the mechanism by which these disorders are associated remains unclear. Both disorders exhibit familial clustering, which may imply a genetic influence on migraine and stroke risk. Genes encoding for endothelial function are promising candidate genes for migraine and stroke susceptibility because of the importance of endothelial function in regulating vascular tone and cerebral blood flow. METHODS: Using data from the Stroke Prevention in Young Women study, a population-based case-control study including 297 women aged 15 to 49 years with ischemic stroke and 422 women without stroke, we evaluated whether polymorphisms in genes regulating endothelial function, including endothelin-1 (EDN), endothelin receptor type B (EDNRB), and nitric oxide synthase-3 (NOS3), confer susceptibility to migraine and stroke. RESULTS: EDN SNP rs1800542 and rs10478723 were associated with increased stroke susceptibility in whites (OR, 2.1; 95% CI, 1.1-4.2 and OR, 2.2; 95% CI, 1.1-4.4; P=0.02 and 0.02, respectively), as were EDNRB SNP rs4885493 and rs10507875, (OR, 1.7; 95% CI, 1.1-2.7 and OR, 2.4; 95% CI, 1.4-4.3; P=0.01 and 0.002, respectively). Only 1 of the tested SNP (NOS3 rs3918166) was associated with both migraine and stroke. CONCLUSIONS: In our study population, variants in EDN and EDNRB were associated with stroke susceptibility in white but not in black women. We found no evidence that these genes mediate the association between migraine and stroke.

The relationship of adverse childhood experiences to a history of premature death of family members.

BACKGROUND: To assess the association between adverse childhood experiences (ACEs), including childhood abuse and neglect, and serious household dysfunction, and premature death of a family member. Because ACEs increase the risk for many of the leading causes of death in adults and tend to be familial and intergenerational, we hypothesized that persons who report having more ACEs would be more likely to have family members at risk of premature death. METHODS: We used data from 17,337 adult health plan members who completed a survey about 10 types of ACEs and whether a family member died before age 65. The prevalence of family member premature death and its association with ACEs were assessed. RESULTS: Family members of respondents who experienced any type of ACEs were more likely to have elevated prevalence for premature death relative to those of respondents without such experience (p < 0.01). The highest risk occurred among those who reported having been physically neglected and living with substance abusing or criminal family members during childhood. A powerful graded relationship between the number of ACEs and premature mortality in the family was observed for all age groups, and comparison between groups reporting 0 ACE and >or= 4 ACEs yielded an OR of 1.8 (95%CI, 1.6-2.0). CONCLUSION: Adverse childhood experiences may be an indicator of a chaotic family environment that results in an increased risk of premature death among family members.

Average age at death from COPD in the United States: 1980-85, 1990-95, 2000-05.

COPD represents an important public health challenge, in the US and globally, that is both preventable and treatable. We describe the average age at death from COPD, a leading cause of death in the US, using data from the National Vital Statistics System for the periods 1980-85, 1990-95, and 2000-05. Average age at death from COPD increased 3-4 years between 1980-85 and 2000-05 for men and women as well as for Whites and Blacks.

Dose-response relationship between cigarette smoking and risk of ischemic stroke in young women.

BACKGROUND AND PURPOSE: Although cigarette smoking is known to be a risk factor for ischemic stroke, there are few data on the dose-response relationship between smoking and stroke risk in a young ethnically diverse population. METHODS: We used data from the Stroke Prevention in Young Women Study, a population-based case-control study of risk factors for ischemic stroke in women aged 15 to 49 years to examine the relationship between cigarette smoking and ischemic stroke. Historical data, including smoking history, was obtained through standardized interviews. Odds ratios (OR) were estimated using logistic regression. Cases (n=466) were women with stroke in the greater Baltimore-Washington area, and controls (n=604) were women free of a stroke history identified by random digit dialing. RESULTS: After multivariable adjustment, the OR comparing current smokers to never smokers was 2.6 (P<0.0001); no difference in stroke risk was observed between former smokers and never smokers. Adjusted OR increased with increasing number of cigarettes smoked per day (OR=2.2 for 1 to 10 cigs/d; 2.5 for 11 to 20 cigs/d; 4.3 for 21 to 39 cigs/d; 9.1 for 40 or more cigs/d). CONCLUSIONS: These results suggest a strong dose-response relationship between cigarette smoking and ischemic stroke risk in young women and reinforce the need for aggressive smoking cessation efforts in young adults.

Trends in hospitalization for the implantation of cardioverter-defibrillators in the United States, 1990-2005.

Implantable cardioverter-defibrillators were first approved for use in the United States in 1985. Their efficacy in improving the survival of patients at risk for sudden cardiac death has been shown, and the number of patients eligible for ICDs has increased. Using data from the National Hospital Discharge Survey (NHDS), hospitalizations for the implantation of ICDs were identified and age- and gender-specific rates and trends in hospitalizations for ICDs during the period from 1990 to 2005 were estimated. From 1990 to 2005, the estimated number of hospitalizations for the implantation of ICDs increased from 5,600 to >108,000 for the total United States population, and the estimated annual rate of hospitalizations for the implantation of ICDs increased 10-fold. The rate of ICD procedures was substantially greater in men than women, and the rate increased significantly with age, although there was no increase in ICD use in patients aged >or=75 years. In conclusion, as the list of clinical indications and insurance coverage for ICD use expand, continued surveillance to monitor trends in the use of ICDs is warranted.

Adverse childhood experiences and chronic obstructive pulmonary disease in adults.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality in the U.S. However, little is known about the influence of childhood stressors on its occurrence. METHODS: Data were from 15,472 adult HMO members enrolled in the Adverse Childhood Experiences (ACE) Study from 1995 to 1997 and eligible for the prospective phase. Eight ACEs were assessed: abuse (emotional, physical, sexual); witnessing domestic violence; growing up with substance-abusing, mentally ill, or criminal household members; and parental separation or divorce. The number of ACEs (ACE Score) was used to examine the relationship of childhood stressors to the risk of COPD. Three methods of case ascertainment were used to define COPD: baseline reports of prevalent COPD, incident hospitalizations with COPD as a discharge diagnosis, and rates of prescription medications to treat COPD during follow-up. Follow-up data were available through 2004. RESULTS: The ACE Score had a graded relationship to each of three measures of the occurrence of COPD. Compared to people with an ACE Score of 0, those with an ACE Score of > or =5 had 2.6 times the risk of prevalent COPD, 2.0 times the risk of incident hospitalizations, and 1.6 times the rates of prescriptions (p<0.01 for all comparisons). These associations were only modestly reduced by adjustment for smoking. The mean age at hospitalization decreased as the ACE Score increased (p<0.01). CONCLUSIONS: Decades after they occur, adverse childhood experiences increase the risk of COPD. Because this increased risk is only partially mediated by cigarette smoking, other mechanisms by which ACEs may contribute to the occurrence of COPD merit consideration.

Clustering of cardiovascular disease risk factors and health-related quality of life among US adults.

OBJECTIVE: To assess the association of clusters of multiple cardiovascular disease (CVD) risk factors with health-related quality of life (HRQOL) among US adults aged 18 years or older in 2003. METHODS: Data from the 2003 Behavioral Risk Factor Surveillance System were analyzed. The four HRQOL questions developed by the Centers for Disease Control and Prevention were used. The CVD risk factors included diabetes, hypertension, high cholesterol, obesity, and current smoking. RESULTS: The adjusted odds ratios of having four or more CVD risk factors were 14.0 (95% confidence interval [CI] 12.4-16.0) for poor or fair health, 6.4 (95% CI 5.6-7.3) for 14 or more physically unhealthy days, 4.8 (95% CI 4.2-5.6) for 14 or more mentally unhealthy days, and 8.0 (95% CI6.8-9.3) for 14 or more impaired activity days compared to having none of the five risk factors. A greater number of CVD risk factors was significantly associated with an increasing likelihood of having poor or fair health (P(1) < 0.0001 for linear trend, P(2) < 0.0001 for quadratic trend), 14 or more physically unhealthy days (P(1) < 0.0001, P(2) < 0.0001), 14 or more mentally unhealthy days (P(1) < 0.0001, P(2) = 0.02), and 14 or more impaired activity days (P(1) < 0.0001, P(2) < 0.0001). CONCLUSIONS: A greater number of multiple CVD risk factors may be associated with more detrimental impairment of HRQOL. Preventing or reducing the clustering of multiple CVD risk factors to improve HRQOL is needed among adults.