David F. Williamson

Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.

BACKGROUND The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. METHODS A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. RESULTS More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. CONCLUSIONS We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Original ArticlesRelationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study

BACKGROUND The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. METHODS A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. RESULTS More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. CONCLUSIONS We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

The Effect of Age on the Association between Body-Mass Index and Mortality

BACKGROUND The effect of age on optimal body weight is controversial, and few studies have had adequate numbers of subjects to analyze mortality as a function of body-mass index across age groups. METHODS We studied mortality over 12 years among white men and women who participated in the American Cancer Societys Cancer Prevention Study I (from 1960 through 1972). The 62,116 men and 262,019 women included in this analysis had never smoked cigarettes, had no history of heart disease, stroke, or cancer (other than skin cancer) at base line in 1959-1960, and had no history of recent unintentional weight loss. The date and cause of death for subjects who died were determined from death certificates. The associations between body-mass index (defined as the weight in kilograms divided by the square of the height in meters) and mortality were examined for six age groups in analyses in which we adjusted for age, educational level, physical activity, and alcohol consumption. RESULTS Greater body-mass index was associated with higher mortality from all causes and from cardiovascular disease in men and women up to 75 years of age. However, the relative risk associated with greater body-mass index declined with age. For example, for mortality from cardiovascular disease, the relative risk associated with an increment of 1 in the body-mass index was 1.10 (95 percent confidence interval, 1.04 to 1.16) for 30-to-44-year-old men and 1.03 (95 percent confidence interval, 1.02 to 1.05) for 65-to-74-year-old men. For women, the corresponding relative risk estimates were 1.08 (95 percent confidence interval, 1.05 to 1.11) and 1.02 (95 percent confidence interval, 1.02 to 1.03). CONCLUSIONS Excess body weight increases the risk of death from any cause and from cardiovascular disease in adults between 30 and 74 years of age. The relative risk associated with greater body weight is higher among younger subjects.

Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes

BACKGROUND Weight loss is recommended for overweight or obese patients with type 2 diabetes on the basis of short-term studies, but long-term effects on cardiovascular disease remain unknown. We examined whether an intensive lifestyle intervention for weight loss would decrease cardiovascular morbidity and mortality among such patients. METHODS In 16 study centers in the United States, we randomly assigned 5145 overweight or obese patients with type 2 diabetes to participate in an intensive lifestyle intervention that promoted weight loss through decreased caloric intake and increased physical activity (intervention group) or to receive diabetes support and education (control group). The primary outcome was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for angina during a maximum follow-up of 13.5 years. RESULTS The trial was stopped early on the basis of a futility analysis when the median follow-up was 9.6 years. Weight loss was greater in the intervention group than in the control group throughout the study (8.6% vs. 0.7% at 1 year; 6.0% vs. 3.5% at study end). The intensive lifestyle intervention also produced greater reductions in glycated hemoglobin and greater initial improvements in fitness and all cardiovascular risk factors, except for low-density-lipoprotein cholesterol levels. The primary outcome occurred in 403 patients in the intervention group and in 418 in the control group (1.83 and 1.92 events per 100 person-years, respectively; hazard ratio in the intervention group, 0.95; 95% confidence interval, 0.83 to 1.09; P=0.51). CONCLUSIONS An intensive lifestyle intervention focusing on weight loss did not reduce the rate of cardiovascular events in overweight or obese adults with type 2 diabetes. (Funded by the National Institutes of Health and others; Look AHEAD ClinicalTrials.gov number, NCT00017953.).

Dental disease and risk of coronary heart disease and mortality.

OBJECTIVE--To investigate a reported association between dental disease and risk of coronary heart disease. SETTING--National sample of American adults who participated in a health examination survey in the early 1970s. DESIGN--Prospective cohort study in which participants underwent a standard dental examination at baseline and were followed up to 1987. Proportional hazards analysis was used to estimate relative risks adjusted for several covariates. MAIN OUTCOME MEASURES--Incidence of mortality or admission to hospital because of coronary heart disease; total mortality. RESULTS--Among all 9760 subjects included in the analysis those with periodontitis had a 25% increased risk of coronary heart disease relative to those with minimal periodontal disease. Poor oral hygiene, determined by the extent of dental debris and calculus, was also associated with an increased incidence of coronary heart disease. In men younger than 50 years at baseline periodontal disease was a stronger risk factor for coronary heart disease; men with periodontitis had a relative risk of 1.72. Both periodontal disease and poor oral hygiene showed stronger associations with total mortality than with coronary heart disease. CONCLUSION--Dental disease is associated with an increased risk of coronary heart disease, particularly in young men. Whether this is a causal association is unclear. Dental health may be a more general indicator of personal hygiene and possibly health care practices.

Smoking Cessation and Severity of Weight Gain in a National Cohort

BACKGROUND Many believe that the prospect of weight gain discourages smokers from quitting. Accurate estimates of the weight gain related to the cessation of smoking in the general population are not available, however. METHODS We related changes in body weight to changes in smoking status in adults 25 to 74 years of age who were weighed in the First National Health and Nutrition Examination Survey (NHANES I, 1971 to 1975) and then weighed a second time in the NHANES I Epidemiologic Follow-up Study (1982 to 1984). The cohort included continuing smokers (748 men and 1137 women) and those who had quit smoking for a year or more (409 men and 359 women). RESULTS The mean weight gain attributable to the cessation of smoking, as adjusted for age, race, level of education, alcohol use, illnesses related to change in weight, base-line weight, and physical activity, was 2.8 kg in men and 3.8 kg in women. Major weight gain (greater than 13 kg) occurred in 9.8 percent of the men and 13.4 percent of the women who quit smoking. The relative risk of major weight gain in those who quit smoking (as compared with those who continued to smoke) was 8.1 (95 percent confidence interval, 4.4 to 14.9) in men and 5.8 (95 percent confidence interval, 3.7 to 9.1) in women, and it remained high regardless of the duration of cessation. For both sexes, blacks, people under the age of 55, and people who smoked 15 cigarettes or more per day were at higher risk of major weight gain after quitting smoking. Although at base line the smokers weighed less than those who had never smoked, they weighed nearly the same at follow-up. CONCLUSIONS Major weight gain is strongly related to smoking cessation, but it occurs in only a minority of those who stop smoking. Weight gain is not likely to negate the health benefits of smoking cessation, but its cosmetic effects may interfere with attempts to quit. Effective methods of weight control are therefore needed for smokers trying to quit.

Depressed affect, hopelessness, and the risk of ischemic heart disease in a cohort of U.S. adults.

Major depression has been associated with mortality from ischemic heart disease (IHD). In addition, a symptom of depression—hopelessness—has been suggested as a determinant of health status. We studied the relation of both depressed affect and hopelessness to IHD incidence using data from a cohort of 2,832 U.S. adults age 45–77 years who participated in the National Health Examination Follow-up Study (mean follow-up = 12.4 years) and had no history of IHD or serious illness at baseline. We used the depression subscale of the General Well-Being Schedule to define depressed affect and a single item from the scale to define hopelessness. At baseline, 11.1% of the cohort had depressed affect; 10.8% reported moderate hopelessness, and 2.9% reported severe hopelessness. Depressed affect and hopelessness were more common among women, blacks, and persons who were less educated, unmarried, smokers, or physically inactive. There were 189 cases of fatal IHD during the follow-up period. After we adjusted for demographic and risk factors, depressed affect was related to fatal IHD [relative risk = 1.5; 95% confidence interval (CI) = 1.0–2.3]; the relative risks of fatal IHD for moderate and severe levels of hopelessness were 1.6 (95% CI = 1.0–2.5) and 2.1 (95% CI = 1.1–3.9), respectively. Depressed affect and hopelessness were also associated with an increased risk of nonfatal IHD. These data indicate that depressed affect and hopelessness may play a causal role in the occurrence of both fatal and nonfatal IHD. (Epidemiology 1993;4:285–294)

Systematic review of long-term weight loss studies in obese adults : clinical significance and applicability to clinical practice

BACKGROUND:Obesity is a common health problem that requires a long-term care approach. We systematically reviewed long-term (≥2 y) studies investigating dietary/lifestyle, pharmacologic, and surgical weight loss methods to assess (1) weight loss efficacy, defined by absolute weight loss and the proportion of subjects with ≥5% weight loss, (2) effects of weight loss on cardiovascular risk factors, and (3) applicability of findings from studies to everyday clinical practice.METHODS:The MEDLINE, HealthSTAR, and the Cochrane Controlled Trials databases were searched for studies investigating the long-term efficacy of weight loss methods in overweight and obese adults. Data were extracted for (i) weight loss after 1 y (pharmacologic studies only), 2 y, 3 y, and 4 y, (ii) proportion of subjects with ≥5% weight loss at the end of follow-up, and (iii) changes (end-of follow-up minus baseline values) in blood lipids, fasting blood glucose, and systolic and diastolic blood pressure.RESULTS:Dietary/lifestyle therapy provides <5 kg weight loss after 2–4 y, pharmacologic therapy provides 5–10 kg weight loss after 1–2 y, and surgical therapy provides 25–75 kg weight loss after 2–4 y. Weight loss of ≥5% baseline weight is not consistently associated with improvements in cardiovascular risk factors and these benefits appear to be intervention specific and occur mainly in people with concomitant cardiovascular risk factors. Weight loss studies have methodologic limitations that restrict the applicability of findings to unselected obese people assessed in everyday clinical practice. These limitations include an inadequate study duration, large proportions of subjects lost to follow-up, a lack of an appropriate usual care group, and a lack of reporting of outcomes in high-risk subgroups.CONCLUSIONS:Dietary/lifestyle and pharmacologic weight loss interventions provide modest weight loss, and may improve markers of cardiovascular risk factors although these benefits occur mainly in patients with cardiovascular risks. Studies investigating weight loss have methodologic limitations that restrict the applicability of findings to obese patients assessed in clinical practice.

Body weight and obesity in adults and self-reported abuse in childhood

BACKGROUND: Little is known about childhood factors and adult obesity. A previous study found a strong association between childhood neglect and obesity in young adults.OBJECTIVE: To estimate associations between self-reported abuse in childhood (sexual, verbal, fear of physical abuse and physical) adult body weight, and risk of obesity.DESIGN: Retrospective cohort study with surveys during 1995–1997.PATIENTS: A total of 13 177 members of California health maintenance organization aged 19–92 y.MEASUREMENTS: Body weight measured during clinical examination, followed by mailed survey to recall experiences during first 18 y of life. Estimates adjusted for adult demographic factors and health practices, and characteristics of the childhood household.RESULTS: Some 66% of participants reported one or more type of abuse. Physical abuse and verbal abuse were most strongly associated with body weight and obesity. Compared with no physical abuse (55%), being ‘often hit and injured’ (2.5%) had a 4.0 kg (95% confidence interval: 2.4–5.6 kg) higher weight and a 1.4 (1.2–1.6) relative risk (RR) of body mass index (BMI)≥30. Compared with no verbal abuse (53%), being ‘often verbally abused’ (9.5%) had an RR of 1.9 (1.3–2.7) for BMI≥40. The abuse associations were not mutually independent, however, because the abuse types strongly co-occurred. Obesity risk increased with number and severity of each type of abuse. The population attributable fraction for ‘any mention’ of abuse (67%) was 8% (3.4–12.3%) for BMI≥30 and 17.3% (−1.0–32.4%) for BMI≥40.CONCLUSIONS: Abuse in childhood is associated with adult obesity. If causal, preventing child abuse may modestly decrease adult obesity. Treatment of obese adults abused as children may benefit from identification of mechanisms that lead to maintenance of adult obesity.

Descriptive Epidemiology of Body Weight and Weight Change in U.S. Adults

This review examines published articles on body weight and weight change from nationally representative data on U.S. adults. These articles were identified both by computer search and by the authors perusal of the literature. Distribution of Body Mass Index The most recently available national data on height and weight of U.S. adults 18 to 74 years old comes from the Second National Health and Nutrition Examination Survey (NHANES II), which was conducted between 1976 and 1980 [1]. Men were found to have an average height slightly more than 1.75 m (59) and an average weight of approximately 77 kg (170 pounds). Nonpregnant women had an average height of nearly 1.63 m (54) and an average weight of slightly less than 63 kg (138 pounds). These height and weight data are expressed in terms of the body mass index (weight [kg]/height [m2]), which tends to have a low correlation with height and thus allows comparison of body weights among persons of differing heights. For persons of average height, one BMI unit is equivalent to approximately 3.1 kg (6.8 pounds) in men and 2.6 kg (5.8 pounds) in women. Figure 1 compares the percentile distribution of BMI for men and women. If men and women had identical BMI distributions, all percentiles would lie on the 45 degrees line. Because women generally have smaller bones and less muscle tissue than do men, womens BMI would be expected to be less than that of men for any given percentile; that is, the percentile curve would lie consistently below the 45 degrees line. This theory holds true below the 75th percentile of the BMI distribution. In the upper quarter of the distribution, however, womens BMIs are higher than mens. For example, at the 95th percentile of the two distributions, the BMI of women (36.0) is nearly 3.5 units higher than that of men (32.6). This finding indicates that the distribution of body weight in women is more variable and skewed toward heavier body weights than that in men. Figure 1. Comparison of the body mass index percentiles between men and women between 18 and 74 years old. Prevalence of Overweight The National Center for Health Statistics has defined overweight as a BMI of 27.8 or more in men and of 27.3 or more in women. Severe overweight was defined as a BMI of 31.1 or more in men and of 32.3 or more in women. The lower cutoffs correspond to approximately 20% above desirable body weight in the 1983 Metropolitan Life Insurance Company mortality tables, whereas the upper cutoffs correspond to 40% above desirable body weight [1]. For persons of average height (men, 59; women, 54), overweight is equivalent to a body weight greater than 85 kg (187 pounds) in men and greater than 72 kg (158 pounds) in women, whereas severe overweight is equivalent to a body weight greater than 95 kg (210 pounds in men) and greater than 85 kg (188 pounds) in women. In adults 20 to 74 years old, the prevalence of overweight is 24.2% in men (15.4 million) and 27.1% in nonpregnant women (18.6 million), yielding 34 million overweight Americans [1, 2] (Table 1). Table 1. Mean Body Mass Index, Percentage Overweight, and Percentage Severely Overweight by Age and Ethnicity in U.S. Adults* For both men and women, the prevalence of overweight has its greatest increase at the ages between the early twenties and the early thirties. In men, the peak prevalence of overweight occurs between 45 and 54 years of age when it reaches a level of 31.0%; subsequently, the prevalence of overweight decreases with increasing age. In women, however, the prevalence of overweight continues to increase throughout the entire age range, reaching a peak of 38.5% in 65- to 74-year-old women. Kuczmarski [2] has summarized the estimated prevalences of severe overweight for adults 20 to 74 years old. Eight percent of men (5.1 million persons) and 10.8% of women (7.4 million persons) are estimated to be severely overweight, yielding a total of 12.5 million Americans. Kuczmarski has defined morbid obesity as a BMI of 39.0 or more for both sexes [2]. According to this definition, a man of average height (59) would weigh 120 kg (265 pounds) or more, and a woman of average height (54) would weigh 103 kg (226 pounds) or more. The prevalence of morbid obesity is estimated to be 0.6% (327 000 persons) in men and 2.5% (1 676 000 persons) in women, yielding a total of more than 3 million Americans [2]. Modest ethnic variation exists in the prevalence of overweight among men, with the greatest prevalence difference between whites (24.4%) and Mexican-Americans (31.2%) [3]. The prevalence of overweight in black men (26.3%) is similar to that of their white counterparts. Among women, the ethnic variation in overweight is much greater. The prevalence of overweight in whites is 24.6% compared with 45.1% in blacks. Mexican- and Puerto Rican-American women have a prevalence of overweight approximately 15 percentage points higher than that of white women [3]. Secular Trend in Overweight Kuczmarski has estimated the age-adjusted prevalences of overweight in black and white adults 20 to 74 years old in three nationally representative surveys conducted from 1960 to 1962, 1971 to 1974, and 1976 to 1980 [2]. Although the prevalence of overweight appears to have increased by only about 1 percentage point among white adults over these three surveys, it has increased by 5.1 percentage points among black adults. The most striking increase occurred in black men, who experienced a 6.0-percentage-point increase (a relative change of 28%) during the 20-year period. Among black women, the increase in the prevalence of overweight was 3.2 percentage points (a relative increase of 7%). Flegal and colleagues [4, 5] have analyzed these data for evidence of a secular trend in mean BMI (rather than overweight) and limited their analysis to adults aged 18 to 34 years. They found little evidence of any secular trend in mean BMI in black or white men but found strong evidence of an increasing trend in BMI for women of both races: The mean annual increase in BMI ranged from 0.07 to 0.25 units, depending on the race-education subgroup examined. Shah and colleagues [6] have analyzed data collected between 1980 and 1987 in three communities in the upper midwestern United States. In this sample of predominantly white adults 25 to 74 years old, they found strong evidence of a secular trend in both mean BMI and in the prevalence of overweight in both sexes, with the strongest trends observed in women. The results of these reports on secular trends are somewhat inconsistent, possibly owing to differences in age groups studied or to differences in the covariates used for statistical adjustment over time. Weight Change Associated with Aging Williamson and colleagues [7] have analyzed data on weight change from the First National Health and Nutrition Examination Survey Follow-up Study (NHEFS). In this nationally representative cohort of approximately 10 000 U.S. adults 25 to 74 years old, body weights were measured an average of 10 years apart from 1971 to 1975 and from 1982 to 1984. At the first weighing, patients wore a disposable paper uniform and foam rubber slippers and were weighed on a self-balancing scale. At the second weighing, patients wore light indoor clothing without shoes, and 1.6 kg was subtracted from the weight to adjust for indoor clothing. A portable spring scale was used for weight measurements. In both sexes, the net change in weight during a 10-year period was a modest gain of 2 pounds. However, substantial heterogeneity was noted in weight change across age groups: On average, both men and women younger than 55 years tended to gain weight, whereas those 55 years or older tended to lose weight. The magnitude of weight gain for both sexes decreased with increasing age, whereas the magnitude of weight loss increased with increasing age. At all ages, however, the magnitude of weight change was substantially greater for women than for men. Although data were inadequate to examine ethnic differences in weight change with age in men, white and black women were compared [8]. Among women 30 to 55 years old, the average 10-year change in weight was virtually identical in black (+ 2.0 kg) and white (+ 2.1 kg) women. This average, however, masked substantial heterogeneity between black and white women in their distributions of 10-year weight change. At the 5th (loss) and 95th (gain) percentiles of the weight-change distribution, black women had about twice the magnitude of weight change as did their white counterparts. Sex Differences in Variability of Weight Change The question of whether women have greater variability in weight change than do men has been raised with regard to the interpretation of epidemiologic studies of weight cycling [9]. Using data from eight biennial examinations in the Framingham heart study, Lissner and colleagues [10] reported that body weight had a coefficient of variation of 6.7% in women compared with 5.7% in men. Table 2 shows the distribution of weight change over 10 years in three age groups of men and women as estimated from NHEFS data. Women in all three age groups tended to have a higher probability of being in the extremes of weight change. For example, among adults 25 to 44 years old, 2.9% of men gained 25% or more of their starting body weight during the 10-year period. In women, however, the proportion was 6.5%, indicating that they were more than twice as likely as men to have gained this much weight. Table 2. Distribution of U.S. Men and Women by Percentage Change in Body Weight over a 10-Year Period* These data can be formally tested to determine whether the variance of weight change among women differs statistically from that among men. Table 2 indicates that in all three age groups the female-to-male ratio of the variances (F ratio) is significantly higher in women than in men. For example, in the 65- to 74-year age group, the variability in 10-year weight change among women is 90% greater than th