Results of a 2-year randomized, controlled obesity prevention trial: Effects on diet, activity and sleep behaviors in an at-risk young adult population.

Excess weight gain tends to occur in young adulthood. However, research examining effective weight-related interventions for this age group has been limited. As one of seven trials in the EARLY Trials consortium (Early Adult Reduction of weight through LifestYle intervention), the CHOICES Study (Choosing Healthy Options in College Environments and Settings) tested effects of a technology-integrated, young adult weight gain prevention intervention. It was a randomized controlled trial with assessments at baseline (2011) and 4-, 12- and 24-months post-intervention initiation and included 441 participants (ages 18-35) who were students at three Minnesota community colleges. The 24-month intervention included a 1-credit academic course and social networking and support online intervention. This analysis examined effects on 12 secondary behavioral outcomes across three domains: diet (fast food, sugary beverages, breakfast, at-home meal preparation), physical activity/screen time (minutes and energy expenditure in leisure time physical activity, television viewing, leisure time computer use) and sleep (hours of sleep, time required to fall asleep, days not getting enough rest, difficulty staying awake). The intervention resulted in significant reductions in fast food (p=0.007) but increases in difficulty staying awake (p=0.015). There was limited evidence of other behavior changes at 4months (0.05

Body dissatisfaction: Do associations with disordered eating and psychological well-being differ across race/ethnicity in adolescent girls and boys?

OBJECTIVE: This study examined whether body dissatisfaction, and its associations with disordered eating and psychological well-being, differ significantly across racial/ethnic groups of adolescents. METHOD: Cross-sectional analysis using data from a large, population-based study of adolescents participating in Eating and Activity in Teens, 2010 (EAT 2010) (N = 2,793; Mage = 14.4 years). The sample was socioeconomically and racially/ethnically diverse (81% racial/ethnic minority; 54% low or low-middle income). RESULTS: Body dissatisfaction differed significantly across racial/ethnic groups; Asian American girls and boys reported the most dissatisfaction with their bodies. Among boys, the relationship between body dissatisfaction and unhealthy weight control behaviors was moderated by race/ethnicity (p < .01), with a significantly weaker association for African American boys compared with those in other groups. Otherwise, the associations between body dissatisfaction and dieting and disordered eating did not vary significantly across racial/ethnic groups. Associations between body dissatisfaction and depressive symptoms and (boys') self-esteem differed significantly across racial/ethnic groups. CONCLUSION: In this study, with the exception of boys' unhealthy weight control behaviors, body dissatisfaction was associated with measures of dieting and disordered eating for youth across racial/ethnic groups. In addition, the association between body dissatisfaction and psychological well-being interacted significantly with adolescents' racial/ethnic backgrounds (with the exception of girls' self-esteem). Findings highlight specific racial/ethnic differences in the associations between body dissatisfaction and psychological well-being, and underscore the importance of addressing body dissatisfaction in youth of all racial/ethnic backgrounds.

Campus Sexual Violence Resources and Emotional Health of College Women Who Have Experienced Sexual Assault.

Institutional characteristics may help mitigate trauma associated with sexual assault. This study examines associations between resources on college campuses for sexual violence prevention and the emotional well-being of female students who have experienced sexual assault. There were 495 female college students who have experienced sexual assault who provided survey data in 2010-2011. Sexual violence resource data from 28 college campuses were combined with student survey data in multilevel analysis. Dependent variables include diagnosis with anxiety, depression, panic attacks, and PTSD, and models adjust for covariates and clustering of students within colleges. Participants attending colleges with more sexual violence resources had lower rates of mental health conditions than those attending colleges with fewer resources. Colleges are encouraged to expand their array of sexual violence resources to create a supportive environment for victims of sexual assault and to connect affected students with appropriate services.

Smoking patterns, quit behaviors, and smoking environment of workers in small manufacturing companies.

BACKGROUND: This study describes smokers employed at 47 small manufacturing companies in Minnesota, USA. METHODS: Smokers (n = 713) participating in a group-randomized trial completed a baseline survey on their smoking patterns, quit behaviors, smoking environment, workplace attitudes about smoking, and correlates of smoking. These characteristics were examined by job type and a latent class analysis (LCA) was performed to group workers with similar characteristics. RESULTS: Production workers had the highest prevalence of daily smoking (88% vs. 68% among managers), and addiction (61% vs. 26% among managers), and the highest mean level of perceived stress (6.4 vs. 4.9 among managers). The LCA identified three subgroups of smokers that differed in levels of barriers to cessation. Production workers were most likely to be in the group with greater barriers (P = 0.01). CONCLUSIONS: These results underscore the importance of targeting interventions to production workers and those who exhibit the greatest barriers to cessation.

Secular trends in fast-food restaurant use among adolescents and maternal caregivers from 1999 to 2010.

OBJECTIVES: We examined trends from 1999 to 2010 in adolescents' self-reported fast-food restaurant use alongside maternal reports of fast-food consumption and purchasing from restaurants for family meals. METHODS: Middle- and high-school student participants from Minneapolis-St Paul, Minnesota, represented diverse ethnic/racial and socioeconomic backgrounds. Adolescents completed classroom-administered surveys and maternal caregivers responded by phone or mail. RESULTS: The overall prevalence of frequent fast-food consumption, defined as 3 or more times per week, decreased from 1999 to 2010 among adolescents (1999: 25%; 2010: 19%; P < .001) and maternal caregivers (1999: 17%; 2010: 11%; P < .001), but sociodemographic disparities were apparent. For example, the prevalence of frequent fast-food consumption remained highest and did not significantly decrease among Black or Native American youths. The overall prevalence of frequent fast-food purchases for family meals did not significantly decrease; large decreases were observed only among Hispanic families (1999: 18%; 2010: 6%; P < .001). CONCLUSIONS: In light of previous findings linking frequent fast-food consumption to greater weight gain and poor nutrition, the observed decreases in consumption are encouraging and interventions are needed to address observed disparities.

Associations of home food availability, dietary intake, screen time and physical activity with BMI in young American-Indian children.

OBJECTIVE: To evaluate associations between home environmental factors and BMI of young American-Indian children. DESIGN: Cross-sectional and prospective study. SETTING: School-based obesity prevention trial (Bright Start) on a Northern Plains Indian reservation in South Dakota. Mixed model multivariable analysis was used to examine associations between child BMI categories (normal, overweight and obese) and home food availability, children's dietary intake and physical activity. Analyses were adjusted for age, gender, socio-economic status, parent BMI and school; prospective analyses also adjusted for study condition and baseline predictor and outcome variables. SUBJECTS: Kindergarten children (n = 424, 51 % male; mean age = 5.8 years, 30 % overweight/obese) and parents/caregivers (89 % female; 86 % overweight/obese) had their height and weight measured and parents/caregivers completed surveys on home environmental factors (baseline and 2 years later). RESULTS: Higher fast-food intake and parent-perceived barriers to physical activity were marginally associated with higher probabilities of a child being overweight and obese. Vegetable availability was marginally associated with lower probabilities of being overweight and obese. The associations between home environmental factors and child weight status at follow-up were not significant. CONCLUSIONS: Findings indicate that selected aspects of the home environment are associated with weight status of American-Indian children. Obesity interventions with this population should consider helping parents to engage and model healthful behaviours and to increase availability of healthful foods at home.

High food insecurity and its correlates among families living on a rural American Indian Reservation.

OBJECTIVES: We sought to better understand the prevalence and consequences of food insecurity among American Indian families with young children. METHODS: Parents or caregivers of kindergarten-age children enrolled in the Bright Start study (dyad n=432) living on the Pine Ridge Reservation in South Dakota completed a questionnaire on their child's dietary intake, the home food environment, and food security. We assessed food security with a standard 6-item scale and examined associations of food insecurity with family sociodemographic characteristics, parents' and children's weight, children's dietary patterns, and the home food environment. RESULTS: Almost 40% of families reported experiencing food insecurity. Children from food-insecure households were more likely to eat some less healthful types of foods, including items purchased at convenience stores (P= .002), and food-insecure parents reported experiencing many barriers to accessing healthful food. Food security status was not associated with differences in home food availability or children's or parents' weight status. CONCLUSIONS: Food insecurity is prevalent among families living on the Pine Ridge Reservation. Increasing reservation access to food that is high quality, reasonably priced, and healthful should be a public health goal.

Secular trends in weight status and weight-related attitudes and behaviors in adolescents from 1999 to 2010.

OBJECTIVE: To examine secular trends from 1999 to 2010 in weight status and weight-related attitudes and behaviors among adolescents. METHODS: A repeated cross-sectional design was used. Participants were from Minneapolis/St. Paul middle schools and high schools and included 3072 adolescents in 1999 (mean age 14.6 ± 1.8) and 2793 adolescents in 2010 (mean age 14.4 ± 2.0). Trends in weight-related variables were examined using inverse probability weighting to control for changes in socio-demographics over time. RESULTS: The prevalence of obesity among boys increased by 7.8% from 1999 to 2010, with large ethnic/racial disparities. In black boys the prevalence of obesity increased from 14.4% to 21.5% and among Hispanic boys, obesity prevalence increased from 19.7% to 33.6%. Trends were more positive among girls: weight status did not significantly increase, perceptions of overweight status were more accurate, the use of healthy weight control behaviors remained high, dieting decreased by 6.7%, unhealthy weight control behaviors decreased by 8.2% and extreme weight control behaviors decreased by 4.5%. CONCLUSIONS: Trends indicate a need to intensify efforts to prevent obesity and other weight-related problems, particularly for boys from ethnic/racial minorities. The decreases in unhealthy weight control behaviors among girls are encouraging.

Association between major patterns of dietary intake and weight status in adolescents.

The relationship between dietary intake and obesity is complex, and dietary pattern analysis may offer new insight. We examined associations between dietary patterns identified in a diverse cohort of adolescents and weight status cross-sectionally and over a 5-year period. Project EAT (Eating Among Teens) (Time 1) collected data on 4746 middle (younger cohort) and high school (older cohort) students in 1998-9. EAT-II (Time 2) resurveyed 2516 of the original cohort in 2003-4. All analyses were run separately by age cohort and sex. The relationship between dietary patterns identified previously (vegetable, fruit, vegetable & fruit, starchy food, sweet & salty snack food, and fast food) and weight status was examined using logistic regression. All analyses were adjusted for socioeconomic status, race/ethnicity and activity level (longitudinal analyses were also adjusted for baseline weight status). In cross-sectional analyses, higher adherence to dietary patterns loading heavily on vegetables was associated with lower risk of overweight/obese weight status in older and younger girls, whereas higher adherence to a 'sweet & salty snack food' pattern was associated with lower risk in older and younger boys. These associations were found prospectively in older boys and girls, but were no longer significant in analyses adjusting for baseline weight status. We did not find consistent or intuitive associations between dietary patterns and weight status. Identified patterns may not capture the elements of diet that are truly important in determining adolescent weight, or diet may not be the primary driver in determining weight status at this age. Methodological difficulties in assessing diet must also be taken into consideration.

American Indian parents' assessment of and concern about their kindergarten child's weight status, South Dakota, 2005-2006.

INTRODUCTION: Obesity is highly prevalent among American Indians, and effective prevention efforts require caregiver involvement. We examined American Indian (AI) parents' assessment of and level of concern about their kindergarten child's weight status. METHODS: We collected baseline data (fall of 2005 and fall of 2006) on children and their parents or caregivers for a school-based obesity prevention trial (Bright Start) on an AI reservation in South Dakota. The current study uses 413 parent-child pairs. Age- and sex-adjusted body mass index percentiles were categorized as very underweight (<5th percentile), slightly underweight (5th to <15th percentile), normal weight (15th to <85th percentile), overweight (85th to <95th percentile), and obese (≥ 95th percentile). Parents or caregivers reported their assessment of and concerns about their child's weight status as well as sociodemographic characteristics. We used mixed-model multivariable analysis to examine associations between sociodemographic characteristics and the probability of parents underclassifying or overclassifying their child's weight status; analyses were adjusted for school as a random effect. RESULTS: Children were evenly divided by sex and had a mean age of 5.8 years. Twenty-nine percent of children and 86% of parents were overweight or obese. Approximately 33% (n = 138) of parents underclassified and 7% (n = 29) of parents overclassified their child's weight status. Higher parental weight status and higher concern about their child's weight status increased the probability of underclassification (P for trend = .02 for both). CONCLUSION: In this sample of at-risk children, one-third of parents underclassified their child's weight status. Childhood obesity prevention programs need to increase awareness and recognition of childhood obesity and address parental weight issues.

Familial correlates of adolescent girls' physical activity, television use, dietary intake, weight, and body composition.

BACKGROUND: The family environment offers several opportunities through which to improve adolescents' weight and weight-related behaviors. This study aims to examine the cross-sectional relationships between multiple factors in the family environment and physical activity (PA), television use (TV), soft drink intake, fruit and vegetable (FV) intake, body mass index (BMI), and body composition among a sample of sociodemographically-diverse adolescent girls. METHODS: Subjects included girls (mean age=15.7), 71% of whom identified as a racial/ethnic minority, and one of their parents (dyad n=253). Parents completed surveys assessing factors in the family environment including familial support for adolescents' PA, healthful dietary intake, and limiting TV use; parental modeling of behavior; and resources in the home such as availability of healthful food. Girls' PA and TV use were measured by 3-Day Physical Activity Recall (3DPAR) and dietary intake by survey measures. BMI was measured by study staff, and body fat by dual-energy X-ray absorptiometry (DXA). Hierarchical linear regression models tested individual and mutually-adjusted relationships between family environment factors and girls' outcomes. RESULTS: In the individual models, positive associations were observed between family support for PA and girls' total PA (p=.011) and moderate-to-vigorous PA (p=.016), home food availability and girls' soft drink (p<.001) and FV (p<.001) intake, and family meal frequency and girls' FV intake (p=.023). Across the individual and mutually-adjusted models, parental modeling of PA, TV, and soft drink and FV intake was consistently associated with girls' behavior. CONCLUSIONS: Helping parents improve their physical activity and dietary intake, as well as reduce time watching television, may be an effective way to promote healthful behaviors and weight among adolescent girls.

Growing into obesity: patterns of height growth in those who become normal weight, overweight, or obese as young adults.

OBJECTIVES: To study whether patterns of height growth differ by adult obesity status, and determine the contribution of subcutaneous fatness as an explanatory variable for any differences. STUDY DESIGN: A multicenter, prospective longitudinal cohort assessed in 3rd grade (8.8 years), 5th grade (11.1 years), 8th grade (14.1 years), and 12th grade (18.3 years). Exposures were young adult obesity status classified by CDC adult BMI categories at 12th grade. Skinfolds were measured in third, fifth, and eighth grades. Outcome was mean height (cm) at the four measurements using repeated-measures ANCOVA for young adult obesity status, and height increments between grades by adult obesity status in sequential models including initial height and, secondarily, initial skinfolds. RESULTS: Adjusted for age, and race/ethnicity, young adult obesity status explained a small, but statistically significant amount of height growth among both females and males within each of the three intervals. Compared with normal weight young adults, overweight or obese young adults stood taller in childhood, but had relatively less growth in height throughout the teenage years. There was no association between adult height and weight status. Skinfolds explained only a small amount of the height patterns in the three weight groups. CONCLUSION: Childhood and adolescent height growth patterns differ between those who become young adults who are normal weight and those who become overweight or obese. Since differences in fatness explain only a small amount of these height growth patterns, research is needed to identify other determinants.

Body fat is differentially related to body mass index in U.S.-born African-American and East African immigrant girls.

OBJECTIVE: To examine ethnic differences in adiposity at a given body mass index (BMI) in a sample of U.S.-born African-American and East African immigrant adolescent girls. METHODS: In a sample of black adolescent girls (n = 79; ages 14-20) we compared measures of adiposity across the range of BMI-for-age among 55 U.S.-born African-American (mean BMI: 30.4; age: 15.4) and 24 East African immigrant girls (mean BMI: 21.8; age: 16.7). Fat and fat-free mass were assessed with dual-energy X-ray absorptiometry (DXA). We used spline regression to examine the distributions of fat mass index and percent body fat across the range of BMI-for-age z-scores. RESULTS: Compared with African-American girls, East African girls were smaller on all body measures, but appeared to have higher fat mass index and percent body fat at the same BMI-for-age. CONCLUSIONS: Our findings indicate that at a given BMI East African immigrants may have greater adiposity than African-American girls. If corroborated in larger samples, our data suggest that the cardiometabolic risks attendant to elevated adiposity may affect East African girls at a lower BMI than in African-American girls.

Substance use and dietary practices among students attending alternative high schools: results from a pilot study.

BACKGROUND: Substance use and poor dietary practices are prevalent among adolescents. The purpose of this study was to examine frequency of substance use and associations between cigarette, alcohol and marijuana use and selected dietary practices, such as sugar-sweetened beverages, high-fat foods, fruits and vegetables, and frequency of fast food restaurant use among alternative high school students. Associations between multi-substance use and the same dietary practices were also examined. METHODS: A convenience sample of adolescents (n = 145; 61% minority, 52% male) attending six alternative high schools in the St Paul/Minneapolis metropolitan area completed baseline surveys. Students were participants in the Team COOL (Controlling Overweight and Obesity for Life) pilot study, a group randomized obesity prevention pilot trial. Mixed model multivariate analyses procedures were used to assess associations of interest. RESULTS: Daily cigarette smoking was reported by 36% of students. Cigarette smoking was positively associated with consumption of regular soda (p = 0.019), high-fat foods (p = 0.037), and fast food restaurant use (p = 0.002). Alcohol (p = 0.005) and marijuana use (p = 0.035) were positively associated with high-fat food intake. With increasing numbers of substances, a positive trend was observed in high-fat food intake (p = 0.0003). There were no significant associations between substance use and fruit and vegetable intake. CONCLUSIONS: Alternative high school students who use individual substances as well as multiple substances may be at high risk of unhealthful dietary practices. Comprehensive health interventions in alternative high schools have the potential of reducing health-compromising behaviors that are prevalent among this group of students. This study adds to the limited research examining substance use and diet among at-risk youth. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT01315743.

Summer effects on body mass index (BMI) gain and growth patterns of American Indian children from kindergarten to first grade: a prospective study.

BACKGROUND: Overweight and obesity are highly prevalent among American Indian children, especially those living on reservations. There is little scientific evidence about the effects of summer vacation on obesity development in children. The purpose of this study was to investigate the effects of summer vacation between kindergarten and first grade on growth in height, weight, and body mass index (BMI) for a sample of American Indian children. METHODS: Children had their height and weight measured in four rounds of data collection (yielded three intervals: kindergarten, summer vacation, and first grade) as part of a school-based obesity prevention trial (Bright Start) in a Northern Plains Indian Reservation. Demographic variables were collected at baseline from parent surveys. Growth velocities (Z-score units/year) for BMI, weight, and height were estimated and compared for each interval using generalized linear mixed models. RESULTS: The children were taller and heavier than median of same age counterparts. Height Z-scores were positively associated with increasing weight status category. The mean weight velocity during summer was significantly less than during the school year. More rapid growth velocity in height during summer than during school year was observed. Obese children gained less adjusted-BMI in the first grade after gaining more than their counterparts during the previous two intervals. No statistically significant interval effects were found for height and BMI velocities. CONCLUSIONS: There was no indication of a significant summer effect on children's BMI. Rather than seasonal or school-related patterns, the predominant pattern indicated by weight-Z and BMI-Z velocities might be related to age or maturation. TRIAL REGISTRATION: Bright Start: Obesity Prevention in American Indian Children Clinical Trial Govt ID# NCT00123032.

Associations of American Indian children's screen-time behavior with parental television behavior, parental perceptions of children's screen time, and media-related resources in the home.

INTRODUCTION: American Indian children have high rates of overweight and obesity, which may be partially attributable to screen-time behavior. Young children's screen-time behavior is strongly influenced by their environment and their parents' behavior. We explored whether parental television watching time, parental perceptions of children's screen time, and media-related resources in the home are related to screen time (ie, television, DVD/video, video game, and computer use) among Oglala Lakota youth residing on or near the Pine Ridge Reservation in South Dakota. METHODS: We collected baseline data from 431 child and parent/caregiver pairs who participated in Bright Start, a group-randomized, controlled, school-based obesity prevention trial to reduce excess weight gain. Controlling for demographic characteristics, we used linear regression analysis to assess associations between children's screen time and parental television watching time, parental perceptions of children's screen time, and availability of media-related household resources. RESULTS: The most parsimonious model for explaining child screen time included the children's sex, parental body mass index, parental television watching time, how often the child watched television after school or in the evening, parental perception that the child spent too much time playing video games, how often the parent limited the child's television time, and the presence of a VCR/DVD player or video game player in the home (F(7,367) = 14.67; P < .001; adjusted R(2) = .37). The presence of a television in the bedroom did not contribute significantly to the model. CONCLUSION: Changes in parental television watching time, parental influence over children's screen-time behavior, and availability of media-related resources in the home could decrease screen time and may be used as a strategy for reducing overweight and obesity in American Indian children.

Effects of policies to restrict malt liquor sales on neighborhood crime.

We examined the effectiveness of malt liquor sales restrictions adopted in 2005 in three liquor stores in a large Midwestern U.S. city. We hypothesized that the restrictions would be associated with crime reductions in adjacent neighborhoods. Using Poisson regression modeling, we compared crime rates two years prior to, and two years following policy adoption. Findings were mixed; malt liquor restrictions were associated with reductions in disorderly conduct citations, but increases in larceny/theft, beyond citywide trends. Limitations and implications of our study are discussed, and further research suggested. The study was funded by the U.S. Centers for Disease Control and Prevention.

Reproductive history, hormone replacement, and incidence of venous thromboembolism: the Longitudinal Investigation of Thromboembolism Etiology.

Numerous studies have established that hormone replacement therapy increases the risk of venous thromboembolism (VTE), but an association of endogenous oestrogen exposure with the incidence of VTE is not fully established. Using a prospective design combining the Atherosclerosis Risk in Communities and the Cardiovascular Health Study cohort, we studied the 12-year risk of VTE in relation to hormone replacement therapy use, age at menopause, parity number, and type of menopause in 8236 post-menopausal women. There were no significant associations of age at menopause, parity number, or type of menopause with incidence of VTE. Women currently using hormone replacement had a 1.6-times higher multivariate-adjusted rate ratio (RR) of VTE compared with those without hormone use in the time-dependent model (RR=1.60, 95% confidence interval [CI], 1.06-2.36; Population attributable fraction=6.7%, 95%CI, 1.0-10.3). When we excluded women with 1-year or more duration of hormone therapy at baseline, the association was stronger (RR=2.02, 95%CI, 1.31-3.12). The multivariate-adjusted RRs of VTE for current users tended to be higher in those with idiopathic VTE (RR=2.40, 95%CI, 1.40-4.12) than those with secondary VTE (RR=1.08, 95%CI, 0.63-1.85). Hormone replacement therapy is associated with increased risk of VTE, but reproductive history markers of endogenous oestrogen exposure were not associated with VTE.

Work hours, weight status, and weight-related behaviors: a study of metro transit workers.

BACKGROUND: Associations between hours worked per week and Body Mass Index (BMI), food intake, physical activity, and perceptions of eating healthy at work were examined in a sample of transit workers. METHODS: Survey data were collected from 1086 transit workers. Participants reported hours worked per week, food choices, leisure-time physical activity and perceptions of the work environment with regard to healthy eating. Height and weight were measured for each participant. Multivariate linear and logistic regressions were conducted to examine associations between work hours and behavioral variables. Associations were examined in the full sample and stratified by gender. RESULTS: Transit workers working in the highest work hour categories had higher BMI and poorer dietary habits, with results differing by gender. Working 50 or more hours per week was associated with higher BMI among men but not women. Additionally, working 50 or more hours per week was significantly associated with higher frequency of accessing cold beverage, cold food, and snack vending machines among men. Working 40 or more hours per week was associated with higher frequency of accessing cold food vending machines among women. Reported frequency of fruit and vegetable intake was highest among women working 50 or more hours per week. Intake of sweets, sugar sweetened beverages, and fast food did not vary with work hours in men or women. Physical activity and perception of ease of eating healthy at work were not associated with work hours in men or women. CONCLUSIONS: Long work hours were associated with more frequent use of garage vending machines and higher BMI in transit workers, with associations found primarily among men. Long work hours may increase dependence upon food availability at the worksite, which highlights the importance of availability of healthy food choices.

Novel hemostatic factor levels and risk of ischemic stroke: the Atherosclerosis Risk in Communities (ARIC) Study.

BACKGROUND AND OBJECTIVE: The role of hemostatic factor levels in cerebral infarction remains uncertain. We studied the association of levels of several under-studied hemostatic factors with ischemic stroke in a population-based cohort. METHODS: The Atherosclerosis Risk in Communities (ARIC) study includes 15,792 individuals aged 45-54 years at intake. Hemostatic factors II, V, IX, X, XI, XII, plasminogen and alpha(2)-antiplasmin were measured on frozen citrate plasma samples from 1990 to 1992. A case-cohort design was used, including all incident ischemic strokes (n = 89) over a median of 7.5 years and a stratified cohort random sample (n = 412). To determine the association of hemostatic factors with incident ischemic stroke, we computed hazard ratios (HRs) using multivariate proportional hazard regression analyses adjusted for demographic and other cardiovascular risk factors. RESULTS: The cohort random sample had a mean age (SD) of 56.9 (5.4) years and 42% were men. The age-, sex- and race-adjusted HRs for highest versus lowest quartiles were: factor XI (2.74, 95% CI 1.42-5.29), factor IX (1.92, 95% CI 0.99-3.73), and alpha(2)-antiplasmin (2.24, 95% CI 1.16-4.33). Correspondingly, the HRs of ischemic stroke per SD increment of factors XI, IX, and alpha(2)-antiplasmin were 1.64, 1.46 and 1.52, respectively (all p < 0.05). After multivariate adjustment including other clinical variables, the standardized HR remained significant for factor XI (1.50, 95% CI 1.10-2.05), but no other factor. CONCLUSION: A greater level of factor XI was associated with an increased risk of ischemic stroke. Higher factor XI levels might help identify patients at elevated ischemic stroke risk.