Joel C. Kleinman

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.

Racial Differences in Low Birth Weight

Abstract To identify the risk factors responsible for differences in birth weight between blacks and whites, we investigated the effects of four maternal characteristics (age, parity, marital statu...

Reduction of cardiovascular disease—related mortality among postmenopausal women who use hormones: Evidence from a national cohort

A national sample of 1944 white menopausal women greater than or equal to 55 years old from the epidemiologic follow-up of participants in the National Health and Nutrition Examination Survey was reviewed to investigate the role of hormone therapy in altering the risk of death from cardiovascular disease. Women in the study were observed for up to 16 years after the baseline survey in 1971 to 1975. By 1987 631 women had died; 347 of these deaths were due to cardiovascular disease. History of diabetes (relative risk, 2.38; 95% confidence interval 1.73 to 3.26), previous myocardial infarction (relative risk, 2.12; 95% confidence interval 1.56 to 2.86), smoking (relative risk, 2.18; 95% confidence interval, 1.69 to 2.81), and elevated blood pressure (relative risk, 1.49; 95% confidence interval, 1.14 to 1.94) were strong predictors of cardiovascular disease-related death in this cohort. After adjusting for known cardiovascular disease risk factors (smoking, cholesterol, body mass index, blood pressure, previous myocardial infarction, history of diabetes, age) and education, the use of postmenopausal hormones was associated with a reduced risk of death from cardiovascular disease (relative risk, 0.66; 95% confidence interval, 0.48 to 0.90). The same protective effect provided by postmenopausal hormone therapy was seen in women who experienced natural menopause (relative risk, 0.69; 95% confidence interval, 0.45 to 1.06).

Representativeness of the Framingham risk model for coronary heart disease mortality: A comparison with a national cohort study

The Framingham Heart Study has been the foundation upon which several national policies regarding risk factors for coronary heart disease mortality are based. The NHANES I Epidemiologic Followup Study is the first national cohort study based upon a comprehensive medical examination of a probability sample of United States adults. The average follow-up time was 10 years. This study afforded an opportunity to evaluate the generalizability of the Framingham risk model, using systolic blood pressure, total cholesterol, and cigarette smoking, to the U.S. population with respect to predicting death from coronary heart disease. The Framingham model predicts remarkably well for this national sample. The major risk factors for coronary heart disease mortality described in previous Framingham analyses are applicable to the United States white adult population.

Use of ambulatory medical care by the poor: another look at equity.

Access to health services by the poor and other disadvantaged groups has improved considerably over the past 15 years. These circumstances have led some to question whether the poor now have equal access to health care. This article presents recent evidence from the 1976-78 National Health Interview Surveys (NHIS) comparing utilization among age, race, and income groups. Without adjustment for health status, the poor have more physician visits than those with higher incomes. After adjusting for age and health status, however, these differences are reversed. Depending on which measure is used, the poor have between 7 per cent and 44 per cent fewer visits than those with income above twice the poverty level. Furthermore, the age- and health-adjusted data show blacks have significantly fewer visits than their white counterparts. In addition, there are large differences among race and income groups in the characteristics of the ambulatory care obtained. Blacks and the poor are much more likely to use hospital clinics and less likely to use private physician offices or telephone consultations. The poor also receive less preventive care. It would appear from the present evidence that still further progress is required to achieve the goal of equity in the distribution of medical care services.

The low cholesterol-mortality association in a national cohort

The relationship of low serum cholesterol and mortality was examined in data from the NHANES I Epidemiologic Followup Study (NHEFS) for 10,295 persons aged 35-74, 5833 women with 1281 deaths and 4462 men with 1748 deaths (mean (followup = 14.1 years). Serum cholesterol below 4.1 mmol/l was associated with increased risk of death in comparison with serum cholesterol of 4.1-5.1 mmol/l (relative risk (RR) for women = 1.7, 95% confidence interval (CI) = (1.2, 2.3); for men RR = 1.4, CI = (1.1, 1.7)). However, the low serum cholesterol-mortality relationship was modified by time, age, and among older persons, activity level. The low serum cholesterol-mortality association was strongest in the first 10 years of followup. Moreover, this relationship occurred primarily among older persons (RR for low serum cholesterol for women 35-59 = 1.0 (0.6, 1.8), for women 70-74, RR = 2.1 (1.2, 3.7); RR for low serum cholesterol for men 35-59 = 1.2 (0.8, 2.0), for men 70-74, RR = 1.9 (1.3, 2.7)). Among older persons, however, the low serum cholesterol-mortality association was confined only to those with low activity at baseline. Factors related to underlying health status, rather than a mortality-enhancing effect of low cholesterol, likely accounts for the excess risk of death among persons with low cholesterol. The observed low cholesterol-mortality association therefore should not discourage public health programs directed at lowering serum cholesterol.

Double jeopardy: Twin infant mortality in the United States, 1983 and 1984

The United States Linked Birth/Infant Death Data Sets: 1983 and 1984 Birth Cohorts from the National Center for Health Statistics were used to identify maternal and infant characteristics related to twin infant mortality; 41,554 white and 10,062 black live-born matched twin pairs were evaluated. Twin birth weight distribution was skewed with 48% of white and 63% of black twins born weighing less than 2500 gm. Overall infant mortality rates were 47.1 and 79.3 deaths per 1000 live births for white and black twins, respectively (five times the rates for singletons). Three fourths of deaths were among twins weighing less than 1500 gm. White like-gender twins had about twice the risk of both twins dying compared with unlike-gender twins. Likewise, white twin pairs with greater than 25% birth weight disparity had a 40% to 80% increased risk of both twins dying, compared with twins whose weights were within 10% of each other. Twins born to high-risk women (on the basis of demographic factors) were twice as likely to die as twins born to low-risk women. Thus strategies to decrease twin infant mortality must address both maternal and infant risk factors.

Travel for ambulatory medical care.

This article describes travel patterns for ambulatory care based on the 1978 National Health Interview Survey. The county where a physician visit occurs has been compared with the county of patients residence. Nearly 20 per cent of physician visits occur outside the county of residence, with substantial variation according to metropolitan status and proximity to an SMSA. Visits by nonmetropolitan residents are twice as likely to occur in another county as visits by metropolitan residents. The proportion of visits that occur outside the county of residence increases with decreasing population density, both among metropolitan and nonmetropolitan areas. Travel patterns for the usual source of care are similar to those for primary care physician visits. The results are used to estimate adjusted physician-population ratios by allocating physicians to each county type in proportion to their use by residents. These adjusted ratios exhibit substantially less variation than the unadjusted ratios.

Foreign medical graduates and the medical underground.

Abstract A written questionnaire was distributed by the Educational Council for Foreign Medical Graduates to 4035 foreign medical graduates taking the January, 1973, examination in centers in the United States. Forty-eight per cent of the 3935 respondents were working in the health field at the time of the examination. In general, married males on permanent visas who entered the United States before 1970 had the highest rate of employment in the health field. Those working in the health field had a lower passing rate on the examination than those not working (15 vs. 26 per cent). The questionnaire was followed by telephone interviews of a sample of 850 respondents designed to obtain more detailed information about job duties. Seventy-three per cent of the 513 who reported working in the health field were involved in direct patient care, and 64 per cent of these were employed in hospitals. Analyses of specific job duties revealed large numbers functioning independently and in unsupervised settings. The res...

Mortality among children and youth.

All of the US mortality data in this report are for the 50 States and the District of Columbia and are based on data from death certificates provided by State and city vital statistics offices to the National Center for Health Statistics (NCHS) (or to its predecessor agencies). Data for eight other industrialized nations are also included, based on tabulations provided by the World Health Organization individual country reports, and selected detailed studies