Epidemiologic Follow-up Study Research Articles

The Color of Hospitalization Over the Adult Life Course: Cumulative Disadvantage in Black and White?

Drawing from cumulative disadvantage theory, this research addresses the following questions: Do hospital admission and discharge rates differ for White and Black adults? If yes, do the differences amplify in later life? This study made use of hospital records abstracted from a long-term prospective study of adults in the National Health and Nutrition Examination Survey I: Epidemiologic Follow-up Study (N = 6,833). Semi-Markov models were specified to examine the likelihood of hospital admission and discharge for Black and White adults aged 25 to 74 years old at baseline. Black adults were less likely than White adults to be admitted to the hospital, but they had longer lengths of stay. The risk of death in the hospital was greater for both Black men and women than for White men and women. In addition, the observed racial differences in hospitalization experiences amplified in later life. Health inequality in America is manifest in how White and Black adults enter and exit hospitals. The findings demonstrate growing heterogeneity in later life by race.

Correcting Biases in Estimates of Mortality Attributable to Obesity

To assess whether a recent study that found a relatively small number of excess deaths attributable to obesity may have underestimated by not correcting for statistical biases. This prospective cohort study used data from the First National Health and Nutrition Examination Survey Epidemiologic Follow-Up Study. Survival analyses were conducted using 9690 individuals 32 to 87 years of age and 1886 all-cause deaths during a 9.1-year follow-up. Corrections were made for the reputed regression-dilution bias by using the average BMI during the decade before follow-up as predictor. Corrections for the reputed reverse-causation bias were made by excluding participants with a history of serious illness. Attributable fractions were calculated and used to estimate excess deaths. The uncorrected estimate of excess deaths attributable to obesity (BMI > or =30) was 41.9, using 18.5 to 25 kg/m(2) as ideal-weight category. Using average BMI as predictor increased the estimate to 93.3. Correcting for reverse-causation effects increased the estimate further to 131.1 (range, 93.3 to 169.0). The uncorrected hazard ratio, 1.25, was increased to 1.41 by using average BMI as predictor, and then to 2.40 by correcting for reverse causation. Using BMI 21 to 25 kg/m(2) and 23 to 25 kg/m(2) as ideal-weight categories increased the corrected estimates to 144.6 (range, 80.5 to 177.2) and 164.1 (range, 103.8 to 194.9), respectively. Larger increases were found for overweight and Grade 2 to 4 obesity (BMI > or =35 kg/m(2)). For overweight, the uncorrected estimate using 18.5 to 25 kg/m(2) as ideal-weight category was -88.3 and the corrected estimate using 23 to 25 kg/m(2) as ideal-weight category was 205.4 (range, 114.5 to 296.3). Correcting for statistical biases and using higher ideal-weight categories increased the estimate of excess deaths attributable to obesity by approximately 400% and changed the negative estimate for overweight to a large positive estimate.

Effect of depression on all-cause mortality in adults with cancer and differential effects by cancer site

Objective The objective of this study was to compare the effect of depression on the risk of death in adults with and without cancer and by specific cancer site among those with cancer. Research Design and Methods We analyzed data on 10,025 participants in the population-based National Health and Nutrition Examination Survey (NHANES) 1 Epidemiologic Follow-up Study. Four groups were created based on cancer and depression status in 1982: (a) no cancer, no depression (reference group; no CA, no DEP); (b) depression but no cancer (DEP, no CA); (c) cancer but no depression (CA, no DEP); and (d) cancer and depression (CA+DEP). Six CA sites were defined: lung, breast, gastrointestinal (GI), genitourinary (GU), skin and other. Cox proportional models were used to calculate adjusted hazard for death for each group compared with the reference group and by cancer site. Results Over 8 years (78,433 person-years of follow-up), 1925 deaths were documented. The mortality rate per 1000 person-years of follow-up was highest in the CA+DEP group. Compared to the reference group, the hazard ratios (HRs) for all-cause mortality were as follows: CA, no DEP: 1.43 [95% confidence interval (95% CI)=1.23–1.67]; DEP, no CA: 1.44 (95% CI=1.28–1.63); CA+DEP: 1.87 (95% CI=1.49–2.34). HRs for depression by site were as follows: lung: 1.30 (95% CI=0.49–3.99); breast: 1.27 (95% CI=0.58–2.79); GI: 1.47 (95% CI=0.58–3.75); GU: 0.93 (95% CI=0.50–1.74); skin: 1.07 (95% CI=0.67–1.69); other: 2.13 (95% CI=0.55–8.25). Conclusion The coexistence of cancer and depression is associated with a significantly increased risk of death, and the effect of depression on the risk of death differs by cancer site.

Are Blood Pressure Predictors of Cardiovascular Disease Mortality Different for Prehypertensives Than for Hypertensives?

The ability of diastolic, systolic, mean arterial, and pulse pressures to predict cardiovascular disease (CVD) morality has not been assessed for persons with prehypertension (diastolic pressure 80 to 89 mm Hg or systolic pressure 120 to 139 mm Hg). Cox's regression analyses were conducted using 4849 subjects aged 33 to 87 years from the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. A correction was made for the regression-dilution bias. There were 327 cardiovascular disease and 258 coronary heart-disease deaths during an average follow-up of 8.6 years. For nonelderly prehypertensives, systolic blood pressure (BP) was a stronger predictor than diastolic BP. The multivariate single predictor hazard ratios (95% confidence interval) for CVD mortality were 1.43 (0.65-3.14) and 2.11 (1.28-3.49), for a 10 mm Hg increment diastolic and systolic BP, respectively. For elderly prehypertensives, it was reversed. The equivalent results were 1.53 (1.10-2.13) and 1.25 (0.89-1.60), respectively. For nonelderly hypertensives, diastolic BP was a stronger predictor than systolic BP, and for elderly hypertensives it was reversed. Diastolic and systolic BP provided as much as or more predictive information than pulse and mean arterial pressure in all analyses. For nonelderly prehypertensives, systolic BP was the strongest predictor, whereas for hypertensives the strongest predictor was diastolic BP. For elderly subjects this pattern was reversed.

Section 5: Management of Asymptomatic Patients With Reduced Left Ventricular Ejection Fraction

Section 5: Management of Asymptomatic Patients With Reduced Left Ventricular Ejection Fraction

131st ENMC International workshop: Selection of Outcome Measures for Peripheral Neuropathy Clinical Trials: 10–12 December 2004, Naarden, The Netherlands

131st ENMC International workshop: Selection of Outcome Measures for Peripheral Neuropathy Clinical Trials: 10–12 December 2004, Naarden, The Netherlands

Eat your fruit and vegetables

Your parents were smart when they told you to eat all of your vegetables, and encouraged you to eat your fruit, but they probably did not know that eating more fruit and vegetables would lower the risk of stroke. 1 He FJ Nowson CA MacGregor GA Fruit and vegetable consumption and stroke: a meta-analysis of cohort studies. Lancet. 2006; 367: 320-326 Summary Full Text Full Text PDF PubMed Scopus (792) Google Scholar , 2 Ness AR Maynard M Frankel S et al. Diet in childhood and adult cardiovascular and all cause mortality: the Boyd Orr cohort. Heart. 2005; 91: 894-898 Crossref PubMed Scopus (135) Google Scholar Results of epidemiological studies of the relation between intakes of nutrients in fruit and vegetables, such as vitamin C or beta-carotene, and risk of stroke have been inconsistent. 3 Ness AR Powles JW Fruit and vegetables, and cardiovascular disease: a review. Int J Epidemiol. 1997; 26: 1-13 Crossref PubMed Scopus (1083) Google Scholar , 4 Leppala JM Virtamo J Fogelholm R et al. Controlled trial of alpha-tocopherol and beta-carotene supplements on stroke incidence and mortality in male smokers. Arterioscler Thromb Vasc Biol. 2000; 20: 230-235 Crossref PubMed Scopus (158) Google Scholar However, disease prevention might not be attributable to single nutrients, but to the interaction of nutrient and non-nutritive components in whole foods. Fruit and vegetables are rich in many health-promoting nutrients and food compounds, including antioxidants such as vitamin C and folate, potassium, phytochemicals, dietary fibre, and plant proteins that have been inversely related to high blood pressure and stroke. 3 Ness AR Powles JW Fruit and vegetables, and cardiovascular disease: a review. Int J Epidemiol. 1997; 26: 1-13 Crossref PubMed Scopus (1083) Google Scholar , 4 Leppala JM Virtamo J Fogelholm R et al. Controlled trial of alpha-tocopherol and beta-carotene supplements on stroke incidence and mortality in male smokers. Arterioscler Thromb Vasc Biol. 2000; 20: 230-235 Crossref PubMed Scopus (158) Google Scholar , 5 Appel LJ Moore TJ Obarzanek E et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med. 1997; 336: 1117-1124 Crossref PubMed Scopus (4242) Google Scholar , 6 Steffen LM Kroenke CH Yu X et al. Associations of plant foods, dairy products, and meat consumption with fifteen-year incidence of elevated blood pressure in young black and white adults: The CARDIA Study. Am J Clin Nutr. 2005; 82: 1169-1177 PubMed Google Scholar , 7 John JH Ziebland S Yudkin P Roe LS Neil HA for the Oxford Fruit and Vegetable Study GroupEffects of fruit and vegetable consumption on plasma antioxidant concentrations and blood pressure: a randomised controlled trial. Lancet. 2002; 359: 1969-1974 Summary Full Text Full Text PDF PubMed Scopus (405) Google Scholar , 8 Bazzano LA He J Ogden LG et al. Dietary intake of folate and risk of stroke in US men and women: NHANES I epidemiologic follow-up study. National health and nutrition examination survey. Stroke. 2002; 33: 1183-1188 Crossref PubMed Scopus (133) Google Scholar It is likely that the combination of nutrients and compounds in foods has greater health benefits than the individual nutrient alone. 9 Jacobs DR Steffen LM Nutrients, foods, and dietary patterns as exposures in research: a framework for food synergy. Am J Clin Nutr. 2003; 78: 508S-513S PubMed Google Scholar In this week's Lancet, a meta-analysis by Feng He and colleagues provides strong evidence of an inverse relation between fruit and vegetable intake and risk of stroke. 1 He FJ Nowson CA MacGregor GA Fruit and vegetable consumption and stroke: a meta-analysis of cohort studies. Lancet. 2006; 367: 320-326 Summary Full Text Full Text PDF PubMed Scopus (792) Google Scholar Compared with individuals who consumed less than 3 servings of fruit and vegetables per day, those who ate more than 5 daily servings of fruit and vegetables had a 26% lower risk of stroke, while 3–5 servings per day conferred a 9% lower risk. Less than a quarter of adults in the USA eat 5 or more servings of fruit and vegetables per day, and there is therefore a serious need to develop and implement public-health strategies to achieve this dietary goal. Fruit and vegetable consumption and stroke: meta-analysis of cohort studiesIncreased fruit and vegetable intake in the range commonly consumed is associated with a reduced risk of stroke. Our results provide strong support for the recommendations to consume more than five servings of fruit and vegetables per day, which is likely to cause a major reduction in strokes. Full-Text PDF

Coffee and Tea Consumption Are Associated With a Lower Incidence of Chronic Liver Disease in the United States

Coffee drinking has been suggested to protect against liver injury, but it is uncertain whether this is of clinical significance. We examined the relationship of coffee and tea consumption with the incidence of hospitalization or death from chronic liver disease (CLD). Participants in the population-based, first National Health and Nutrition Examination Survey, 1971-1975, were asked about coffee and tea consumption, which was categorized as <1 cup (mean, 0.2 cups), 1 to 2 cups, and >2 cups per day (mean, 4.0 cups). A second analysis included persons who, in 1982-1984, were asked more detailed questions on coffee and tea drinking. Participants were followed through 1992-1993 for a hospital or death certificate diagnosis of CLD or cirrhosis (ICD-9-CM 571). Hazard rate ratios for CLD according to coffee and tea intake were calculated using Cox proportional hazards analysis. Among 9849 persons followed for a median of 19.0 years (range, 0.02-22.1), the cumulative incidence of CLD was 1.4%. In multivariate analysis, participants who drank >2 cups per day had less than half the rate of CLD as those who drank <1 cup per day (hazard ratio, 0.43, 95% confidence interval: 0.24-0.78). Protection by coffee and tea was limited to persons at higher risk for liver diseases from heavier alcohol intake, overweight, diabetes, or high iron saturation. Among 9650 participants who provided detailed drink information in 1982-1984, intake of regular ground coffee and of caffeine was associated with lower incidence of CLD. Coffee and tea drinking decreases the risk of clinically significant CLD.

Need to Educate Primary Caregivers About the Risk Factor Profile of Smokeless Tobacco Users

Many cancer risk factors are correlated with one another, and the presence of 1 risk factor may be a marker for other unhealthy behaviors. In this article, we focus on smokeless tobacco (ST), a known risk factor for oral leukoplakia and oral cancer, and the cancer risk factors associated with its use. We analyzed cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) I and the 1982-1984 NHANES I Epidemiologic Follow-up Study. Risk factor information was available on individuals 25-74 years of age, most of whom would be middle age or elderly today. Older subjects, Black males, and those living in the Southern Unite States had the highest prevalence of ST use. ST use was associated with current smoking (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.5), former smoking (OR, 1.6; 95% CI, 1.4-2.0), low fruit and vegetable intake, low SES, increased alcohol consumption (among nonsmoking ST users), and increased body mass index, all of which elevate cancer risk. CONCLUSION. Physicians and dentists should ask their patients about current or former ST use. Identification of ST users should prompt the physician or dentist to inquire about other chronic disease risk factors that the patient may have and to educate the ST using patient about ways to reduce their risk of cancer.

Independent effect and population impact of obesity on fatal coronary heart disease in adults

Background. It is unclear whether the coronary heart disease (CHD) mortality risk associated with obesity is mediated only through traditional CHD risk factors. This analysis evaluated the independent CHD mortality risk due to obesity and determined its population attributable risk (PAR). Methods. Using the NHANES I Epidemiologic Follow-up Study (1971–1992, n = 10,582), a diabetes-body mass index (BMI) variable was constructed. The hazard ratios (HR) for fatal CHD in the diabetes-BMI categories (adjusting for age, sex, race, exercise, education level, smoking, hypertension, cholesterol, and alcohol use) were determined and the PARs subsequently estimated. Results. Compared to lean non-diabetics, the HR (95% CI) for fatal CHD is 0.8 (0.7, 1.1) in overweight non-diabetics, 1.4 (1.3, 2.0) in obese non-diabetics, 2.2 (1.2, 4.0) in lean diabetics, 2.3 (1.4, 3.9) in overweight diabetics, and 3.3 (1.9, 8.9) in obese diabetics. The PAR% is −6.8 (−15.7, 1.8) in overweight non-diabetics, 6.1 (1.7, 11.1) in obese non-diabetics, 2.0 (0.3, 4.0) in lean diabetics, 2.2 (0.6, 4.3) in overweight diabetics, and 2.2 (0.8, 3.8) in obese diabetics. Conclusions. Obesity is an independent risk factor for CHD mortality even after controlling for traditional CHD risk factors. The PAR for CHD death in obese non-diabetics is significant. Obesity should be aggressively treated in those without traditional CHD risk factors.

Building prediction models for coronary heart disease by synthesizing multiple longitudinal research findings

No methodology is currently available to allow the combining of individual risk factor information derived from different longitudinal studies for a chronic disease in a multivariate fashion. This paper introduces such a methodology, named Synthesis Analysis, which is essentially a multivariate meta-analytic technique. The construction and validation of statistical models using available data sets. Two analyses are presented. (1) With the same data, Synthesis Analysis produced a similar prediction model to the conventional regression approach when using the same risk variables. Synthesis Analysis produced better prediction models when additional risk variables were added. (2) A four-variable empirical logistic model for death from coronary heart disease was developed with data from the Framingham Heart Study. A synthesized prediction model with five new variables added to this empirical model was developed using Synthesis Analysis and literature information. This model was then compared with the four-variable empirical model using the first National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study data set. The synthesized model had significantly improved predictive power (chi = 43.8, P<0.00001). Synthesis Analysis provides a new means of developing complex disease predictive models from the medical literature.

Cigarette Smoking Among Spouses

It is well known that passive exposure to cigarette smoking increases the risk of coronary events, but the effect on the risk of stroke is not well defined. We performed this study to determine the effect of cigarette smoking among spouses on the risk of developing stroke and ischemic stroke among a nationally representative sample of women. We examined the association between history of smoking among spouses with the incidence of stroke in a national cohort of 5379 women who participated in the First National Health and Nutrition Examination Survey Epidemiologic Follow-Up Study. During a mean follow-up of 8.5 years, the risk was significantly increased for all strokes (relative risk, 5.7; 95% CI, 1.4 to 24) and ischemic stroke (relative risk, 4.8; 95% CI, 1.2 to 20) among cigarette-smoking women with a cigarette-smoking spouse compared with those with a nonsmoking spouse after adjusting for other cardiovascular risk factors. The study provides new evidence linking spousal smoking to stroke.

Erleben der Sexualität nach Schwangerschaft und Entbindung

Background: To date there is only a limited number of study data.an the changes in the perceived quality of sexuality and relationships of women that occur with pregnancy and childbirth. Apart from prevalence issues predictors for those changes are important. These questions were addressed with this epidemiological follow-up study. Methods: The study sample consisted of 236 women who gave birth to a child between November 2000 and May 2001 at Bonn University Hospital in Germany. A first visit took place at the hospital a few days after childbirth. Data included sociodemographic data, medical and gynecological data as well as personality traits using the NEO-FFI. A second visit took place 6.6±0.8 months after childbirth. It included the BSPS (Bonn Scale for Post-Partum Sexuality) and psychiatric symptoms using the SCL-90-R. Results: Approximately six months after childbirth 40.6% of women perceived a diminished quality of sexual life compared to the time before pregnancy. 23.2% indicated a diminished relationship quality. The potentially relevant co-variables regarding the changes in sexual quality were age, breast feeding, fertilization, use of contraceptives and presence of psychiatric symptoms. With the changes in relationship quality there were correlations with marital status, conscientiousness, and psychiatric symptom load. Discussion: The majority of women six months after childbirth did not return to a perceived sexual life comparable to the time before pregnancy. In addition to the high presence of symptoms of sexual dysfunction, the high psychosocial pressure is of special importance. Therefore the information of patients about the potential development of sexuality after childbirth and an integrative approach by the gynecologist seem important. Particularly the correlation between psychiatric symptom load and their predictive potential regarding satisfaction with sexuality should be accounted for in further epidemiological research.

Hospitalizations, Nursing Home Admissions, and Deaths Attributable to Diabetes

To estimate all-cause hospitalizations, nursing home admissions, and deaths attributable to diabetes using a new methodology based on longitudinal data for a representative sample of older U.S. adults. A simulation model, based on data from the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Followup Study, was used to represent the natural history of diabetes and control for a variety of baseline risk factors. The model was applied to 6,265 NHANES III adults aged 45-74 years. The prevalence of risk factors in NHANES III, fielded in 1988-1994, better represents today's adults. For all NHANES III adults aged 45-74 years, a diagnosis of diabetes accounted for 8.6% of hospitalizations, 12.3% of nursing home admissions, and 10.3% of deaths in 1988-1994. For people with diabetes, diabetes alone was responsible for 43.4% of hospitalizations, 52.1% of nursing home admissions, and 47% of deaths. Adjusting for related cardiovascular conditions, which may provide more accurate estimates of attributable risks for people with diabetes, increased these estimates to 51.4, 57.1, and 56.8%, respectively. Risks of institutionalization and death attributable to diabetes are large. Efforts to translate recent trials of primary prevention into practice and continued efforts to prevent complications of diabetes could have a substantial impact on hospitalizations, nursing home admissions, and deaths and their societal costs.

THE ASSOCIATION BETWEEN WEIGHT FLUCTUATION AND MORTALITY: RESULTS FROM A POPULATION-BASED COHORT STUDY

Previous studies evaluating the association between weight fluctuation and mortality are limited and have conflicting results. This study will further evaluate the association between weight fluctuation and mortality in a nationally representative cohort by performing survival analysis of NHANES I and NHANES I Epidemiologic Follow-up Study (n = 8479; weighted sample = 68,200,905). This cohort was followed from 1971 to 1992 and categorized using weight change over five time points into stable non-obese, stable obese, weight gain, weight loss and weight fluctuation groups. All-cause mortality (ACM) and cardiovascular mortality (CM) were evaluated. Respondents with weight fluctuation had higher ACM (HR: 1.83, 95% CI: 1.25-2.69) and CM hazards ratios (HR: 1.86, 95% CI: 1.10-3.15) than the stable non-obese group, even after controlling for pre-existing disease, initial BMI and excluding those in poor health or incapacitated. Increased mortality was also seen in the weight loss group (ACM HR: 3.36, 95% CI: 2.47-4.55), (CM HR 4.22, 95% CI: 2.60-6.84). The stable obese group did not have increased ACM, but did have increased CM prior to the exclusion of those in poor health or incapacitated. (HR: 2.17, 95% CI: 1.10-4.28). Weight fluctuation is associated with a higher risk of all-cause and cardiovascular disease mortality in the US population, even after adjustment for pre-existing disease, initial BMI and the exclusion of those in poor health or incapacitated. Thus, health care providers should promote a commitment to maintaining weight loss to avoid weight fluctuation and consider patients' weight histories when assessing their risk status.

FLEGAL ET AL. RESPOND

Hu et al. speculate that the number of deaths attributable to obesity in the United States may be underestimated when relative risks are calculated on the basis of current body mass index (BMI). They cite no data to support their speculations, but instead invoke the notion of “reverse causality.” They hypothesize that relative risks are lowered by obese people who become ill, lose weight because of this illness to become normal weight, and die shortly thereafter of the underlying illness, surviving just long enough to be included in the study. However, this reverse-causation hypothesis is unlikely to be the correct explanation for the lower relative risks in the elderly for 2 reasons: first because data show that exclusion of preexisting illness has little effect on relative risk estimates,1 and second because weight loss from obesity to normal weight is relatively uncommon. Nationally representative data on measured weight change in US adults comes from the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow-up Study (NHEFS), in which body weight was measured on 2 occasions, approximately 10 years apart. Our analyses of these data show that among older adults (aged 65 years and older) with normal BMIs (18.5–24.9) in the early 1980s, only 2% had been obese (BMI ≥30) 10 years previously. Of older adults who were obese in the early 1970s, only 4% had normal BMIs 10 years later. The probability of large weight loss among obese adults is likely to be even lower today.2 Our analyses of NHANES 1999–2002 self-reported past-weight data for adults 65 years of age and older show that only 6% of non-obese older adults (BMI < 30) were obese 10 years previously and 2% of normal-weight older adults were obese 10 years previously. Hu et al. raise the same specter of reverse causation to assert that individuals with pre-existing illness should be excluded from cohorts used to derive relative risks applicable to the whole US population. However, these and other common exclusions (such as exclusion of the older elderly and of current or former smokers) not only make the remaining cohort less representative of the US population but in fact exclude the people more likely to die, thus making the deaths in the cohort even less representative of mortality in the US population. Relative risks based only on a subgroup of the US population defined by exclusions are not necessarily valid for inference to deaths outside that subgroup.

The Relationship Between Reduced Lung Function and Cardiovascular Mortality: A Population-Based Study and a Systematic Review of the Literature

Conditions that give rise to reduced lung function are frequently associated with low-grade systemic inflammation, which may lead to poor cardiovascular outcomes. We sought to determine the relationship between reduced FEV1 and cardiovascular mortality, independent of smoking. Longitudinal population-based study and a meta-analysis of literature. Representative sample of the general population. Participants of the first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study who were 40 to 60 years of age at baseline assessment (n = 1,861). We compared the risk of cardiovascular mortality across quintiles of FEV1. Individuals in the lowest FEV1 quintile had the highest risk of cardiovascular mortality (relative risk [RR], 3.36; 95% confidence interval [CI], 1.54 to 7.34). Compared to FEV1 quintile 1, individuals in quintile 5 had a fivefold increase in the risk of death from ischemic heart disease (RR, 5.65; 95% CI, 2.26 to 14.13). We also performed a systematic review of large cohort studies (> 500 participants) that reported on the relationship between FEV1 and cardiovascular mortality (12 studies; n = 83,880 participants). Compared to participants in the highest FEV1 category, those with reduced FEV1 had a higher risk of cardiovascular mortality (pooled RR, 1.77; 95% CI, 1.56 to 1.97). There is strong epidemiologic evidence to indicate that reduced FEV1 is a marker for cardiovascular mortality independent of age, gender, and smoking history.

Incidence of Primary Headache: A Danish Epidemiologic Follow-up Study

The incidence of migraine in a general population has been assessed in few longitudinal studies, and the incidence of tension-type headache has never been assessed. The authors aimed to assess the incidence of migraine and tension-type headache in Denmark by conducting a 12-year follow-up study of a general population (1989-2001). The design and methods of follow-up replicated the baseline study exactly, including use of the International Headache Society's diagnostic criteria and administration of headache diagnostic interviews by a physician. Of 740 persons aged 25-64 years examined in 1989, 673 were eligible in 2001 and 549 (81.6%) participated. The incidence of migraine was 8.1 per 1,000 person-years (male:female ratio, 1:6), and the incidence of frequent tension-type headache was 14.2 per 1,000 person-years (male:female ratio, 1:3). Both rates decreased with age. The incidence of migraine was higher than that previously calculated from cross-sectional studies. Risk factors for migraine were familial disposition, no vocational education, a high work load, and frequent tension-type headache. For tension-type headache, risk factors were poor self-rated health, inability to relax after work, and sleeping few hours per night. The gender difference for tension-type headache differed from that for migraine, and no association with educational level was observed.

Exercise and Cardiovascular Outcomes by Hypertensive Status: NHANES I Epidemiological Follow-up Study, 1971–1992

A favorable effect of exercise on cardiovascular longevity has been repeatedly demonstrated in the general population. The association of exercise and cardiovascular disease (CVD) outcome among persons with different blood pressure (BP) status is less well known. We examined the epidemiologic follow-up of the First National Health and Nutrition Examination Survey (NHANES I) (1971-1992). Of 14,407 participants, 9791 subjects aged 25 to 74 years met inclusion criteria. All cause, CVD, and non-CVD mortality rates, as well as CVD incidence rates were determined. The associations of levels of exercise and outcomes by BP status were examined. Age- and gender-adjusted rates, as well as Cox proportional hazard models were determined. During 17 years of follow-up, there were 3069 deaths, 1465 of which were CVD. In addition, 2808 subjects had incident CVD events. Overall, CVD incidence and mortality rates increased as BP rose. The association of exercise with CVD events differed by BP status (normal, prehypertension, and hypertension). Age- and gender-adjusted CVD mortality rate per 1000 person-years for least, moderate, and most exercise were 5.0, 3.6, and 2.4 among normotensive subjects (P > .05), 6.3, 4.7, and 5.2 among prehypertensive subjects (P > .05), and 11.8, 9.8, and 8.7 among hypertensive subjects (P < .01), respectively. In fact, exercise was a significant independent predictor of reduced CVD event only among hypertensive subjects, after adjusting for other CVD risk factors. Among prehypertensive and normotensive subjects, where events were fewer, those who exercise more vigorously also had lower mortality, but these differences did not reach statistical significance. This study, consistent with previous observational data, demonstrates that increased exercise is associated with decreased CVD event. Interestingly, this effect is most robust among hypertensive subjects, whereas for prehypertensive and normotensive subjects, a significant benefit of exercise on CVD outcome, perhaps because of lack of power, was not found.

Depression and All-Cause and Coronary Heart Disease Mortality Among Adults With and Without Diabetes

The aim of this study was to evaluate the effect of depression on all-cause and coronary heart disease (CHD) mortality among adults with and without diabetes. We studied 10,025 participants in the population-based National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study who were alive and interviewed in 1982 and had complete data for the Center for Epidemiologic Studies Depression Scale. Four groups were created based on diabetes and depression status in 1982: 1) no diabetes, no depression (reference group); 2) no diabetes, depression present; 3) diabetes present, no depression; and i4) diabetes present, depression present. Cox proportional hazards regression models were used to calculate multivariate-adjusted hazard ratios (HRs) of death for each group compared with the reference group. Over 8 years (83,624 person-years of follow-up), 1,925 deaths were documented, including 522 deaths from CHD. Mortality rate per 1,000 person-years of follow-up was highest in the group with both diabetes and depression. Compared with the reference group, HRs for all-cause mortality were no diabetes, depression present, 1.20 (95% CI 1.03-1.40); diabetes present, no depression 1.88 (1.55-2.27); and diabetes present, depression present, 2.50 (2.04-3.08). HRs for CHD mortality were no diabetes, depression present, 1.29 (0.96-1.74); diabetes present, no depression 2.26 (1.60-3.21); and diabetes present, depression present, 2.43 (1.66-3.56). The coexistence of diabetes and depression is associated with a significantly increased risk of death from all causes, beyond that due to having either diabetes or depression alone.