William S. Pearson

Cumulative Childhood Stress and Autoimmune Diseases in Adults

Objective: To examine whether childhood traumatic stress increased the risk of developing autoimmune diseases as an adult. Methods: Retrospective cohort study of 15,357 adult health maintenance organization members enrolled in the Adverse Childhood Experiences (ACEs) Study from 1995 to 1997 in San Diego, California, and eligible for follow-up through 2005. ACEs included childhood physical, emotional, or sexual abuse; witnessing domestic violence; growing up with household substance abuse, mental illness, parental divorce, and/or an incarcerated household member. The total number of ACEs (ACE Score range = 0-8) was used as a measure of cumulative childhood stress. The outcome was hospitalizations for any of 21 selected autoimmune diseases and 4 immunopathology groupings: T- helper 1 (Th1) (e.g., idiopathic myocarditis); T-helper 2 (Th2) (e.g., myasthenia gravis); Th2 rheumatic (e.g., rheumatoid arthritis); and mixed Th1/Th2 (e.g., autoimmune hemolytic anemia). Results: Sixty-four percent reported at least one ACE. The event rate (per 10,000 person-years) for a first hospitalization with any autoimmune disease was 31.4 in women and 34.4 in men. First hospitalizations for any autoimmune disease increased with increasing number of ACEs (p < .05). Compared with persons with no ACEs, persons with ≥2 ACEs were at a 70% increased risk for hospitalizations with Th1, 80% increased risk for Th2, and 100% increased risk for rheumatic diseases (p < .05). Conclusions: Childhood traumatic stress increased the likelihood of hospitalization with a diagnosed autoimmune disease decades into adulthood. These findings are consistent with recent biological studies on the impact of early life stress on subsequent inflammatory responses. ACE = adverse childhood experience; AD = autoimmune disease; Th1 = T-helper 1; Th2 = T-helper 2; CRP = C-reactive protein; CRH = corticoid releasing hormone.

Trends in hypercholesterolemia, treatment and control among United States adults.

BACKGROUND Control of hypercholesterolemia is an important clinical and public health objective, yet it is generally poor. The objective of this study was to examine trends in the prevalence of hypercholesterolemia, having a cholesterol check, awareness, treatment, and control among United States adults. METHODS We examined data for 18053 participants aged > or =20 years of the National Health and Nutrition Examination Surveys from 1999 to 2006. RESULTS The unadjusted prevalence of hypercholesterolemia ranged from 53.2% to 56.1% and changed little over the study period. Significant increases were evident in the percentage of United States adults who had their concentration of cholesterol checked (from 68.6% to 74.8%), who reported being told that they had high hypercholesterolemia (from 42.0% to 50.4%), who reported using cholesterol-lowering medications (from 39.1% to 54.4%), and who had their hypercholesterolemia controlled (from 47.0 to 64.3%). Among all participants with hypercholesterolemia control of hypercholesterolemia increased from 7.2% to 17.1%. Disparities related to gender and race or ethnicity existed, notably a lower rate of control among women than men and lower rates of having a cholesterol check and reporting being told about hypercholesterolemia among African Americans and Mexican Americans than whites. CONCLUSIONS Encouraging increases in awareness, treatment, and control of hypercholesterolemia occurred from 1999 through 2006. Nevertheless, control of hypercholesterolemia remains poor.

Trends in the Prevalence of Low Risk Factor Burden for Cardiovascular Disease Among United States Adults

Background— Cohorts consistently show that individuals with low levels of cardiovascular risk factors experience low rates of subsequent cardiovascular events. Our objective was to examine the prevalence and trends in low risk factor burden for cardiovascular disease among adults in the US population. Methods and Results— We used data from adults 25 to 74 years of age who participated in 4 national surveys. We created an index of low risk from the following variables: not currently smoking, total cholesterol <5.17 mmol/L (<200 mg/dL) and not using cholesterol-lowering medications, systolic blood pressure <120 mm Hg and diastolic blood pressure <80 mm Hg and not using antihypertensive medications, body mass index <25 kg/m2, and not having been previously diagnosed with diabetes mellitus. The age-adjusted prevalence of low risk factor burden increased from 4.4% during 1971 to 1975 to 10.5% during 1988 to 1994 before decreasing to 7.5% during 1999 to 2004 (P for nonlinear trend <0.001). The patterns were similar for men and women, although the prevalence among women exceeded that among men in each survey (P<0.001 for each survey). In addition, whites had a significantly higher prevalence of low risk factor burden than blacks during each survey except during 1976 to 1980 (1971 to 1975, 1988 to 1994, 1999 to 2004: P<0.001; 1976 to 1980: P=0.154). Furthermore, a larger percentage of whites had a low risk factor burden than Mexican Americans during 1988 to 1994 (P<0.001) and 1999 to 2004 (P=0.001). Conclusions— The prevalence of low risk factor burden for cardiovascular disease is low. The progress that had been made during the 1970s and 1980s reversed in recent decades.

PREVALENCE AND CORRELATES OF UNDIAGNOSED DEPRESSION AMONG U.S. ADULTS WITH DIABETES: THE BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM, 2006

AIMS Many people with depression may be undiagnosed and thus untreated. We sought to assess the prevalence and correlates of undiagnosed depression among adults with diabetes. METHODS Data of U.S. adults from the Behavioral Risk Factor Surveillance System in 2006 were analyzed. Cox proportional hazard regression analysis was used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) of correlates for undiagnosed depression. RESULTS The unadjusted and age-adjusted prevalences of undiagnosed depression were 8.7% and 9.2%. About 45% of diabetes patients with depression were undiagnosed. After adjustments for all correlates, female gender (PR, 1.4; 95% CI: 1.1-1.8), poor or fair health (PR, 2.8; 95% CI: 2.1-3.6), lack of social and emotional support (PR, 2.5; 95% CI: 1.8-3.3), life dissatisfaction (PR, 3.5; 95% CI: 2.2-5.5), use of special equipment (PR, 1.4; 95% CI: 1.1-1.8), no leisure-time physical activity (PR, 1.5; 95% CI: 1.2-1.9), and comorbid cardiovascular disease (PR, 1.5; 95% CI: 1.2-1.9) were associated with undiagnosed depression. CONCLUSIONS Undiagnosed depression among people with diabetes was common. Because depression is associated with increased risk of diabetes-related complications, early detection of depression is needed in clinical settings.

Body mass index and headaches: findings from a national sample of US adults

The objective was to study the cross-sectional association between body mass index (BMI) and the prevalence of severe headaches or migraines in a national sample of US adults. We used data from 7601 men and women aged ≥ 20 years who participated in the National Health and Nutrition Examination Survey 1999-2002. The age-adjusted prevalence of severe headaches or migraines during the previous 3 months was 34.0, 18.9, 20.7 and 25.9± among participants with a BMI< 18.5, 18.5 to< 25, 25 to< 30 and ≥ 30 kg/m2, respectively. After adjusting for a variety of covariates in a logistic regression model, those with a BMI< 18.5 kg/m2 [odds ratio (OR) 2.01; 95± confidence interval (CI) 1.34, 3.02] or ≥ 30 kg/m2 (OR 1.37; 95± CI 1.09, 1.72) had a significantly elevated OR for having a headache compared with participants with a BMI of 18.5-< 25 kg/m2. BMI is associated with the prevalence of severe headaches or migraines in a non-linear manner.

Trends in the prevalence and comorbidities of diabetes mellitus in nursing home residents in the United States: 1995-2004.

OBJECTIVES: To estimate trends in the prevalence and comorbidities of diabetes mellitus (DM) in U.S. nursing homes from 1995 to 2004.

Multiple healthy behaviors and optimal self-rated health: Findings from the 2007 Behavioral Risk Factor Surveillance System Survey ☆

OBJECTIVE The aim of this study was to examine the association between the number of healthy behaviors (i.e., not currently smoking, not currently drinking excessively, physically active, and consuming fruits and vegetables five or more times per day) and optimal self-rated health (SRH) among U.S. adults or adults with cardiovascular diseases (CVDs) or diabetes. METHODS We estimated the age-standardized prevalence of optimal SRH among a total of 430,912 adults who participated in the 2007 Behavioral Risk Factor Surveillance System (BRFSS). Prevalence ratios were produced with multivariate Cox regression models using number of healthy behaviors as a predictor; status of optimal SRH was used as an outcome variable while controlling for sociodemographic and health risk factors. RESULTS The age-standardized prevalence of reporting optimal SRH was 83.5%, 55.6%, and 56.3% among adults overall, and adults with CVDs or diabetes, respectively. Also in the aforementioned order, adults who reported having four healthy behaviors had 33%, 85%, and 87% increased likelihoods of reporting optimal SRH, when compared to their counterparts who reported none of these behaviors. CONCLUSION The findings of this study indicate that number of healthy behaviors is associated with optimal SRH among adults, especially adults with CVDs or diabetes. These findings reinforce the support for identifying and implementing clinical and population-based intervention strategies that effectively promote multiple healthier lifestyle behaviors among adults.

Sedentary behavior, physical activity, and concentrations of insulin among US adults

Time spent watching television has been linked to obesity, metabolic syndrome, and diabetes, all conditions characterized to some degree by hyperinsulinemia and insulin resistance. However, limited evidence relates screen time (watching television or using a computer) directly to concentrations of insulin. We examined the cross-sectional associations between time spent watching television or using a computer, physical activity, and serum concentrations of insulin using data from 2800 participants aged at least 20 years of the 2003-2006 National Health and Nutrition Examination Survey. The amount of time spent watching television and using a computer as well as physical activity was self-reported. The unadjusted geometric mean concentration of insulin increased from 6.2 microU/mL among participants who did not watch television to 10.0 microU/mL among those who watched television for 5 or more hours per day (P = .001). After adjustment for age, sex, race or ethnicity, educational status, concentration of cotinine, alcohol intake, physical activity, waist circumference, and body mass index using multiple linear regression analysis, the log-transformed concentrations of insulin were significantly and positively associated with time spent watching television (P = < .001). Reported time spent using a computer was significantly associated with log-transformed concentrations of insulin before but not after accounting for waist circumference and body mass index. Leisure-time physical activity but not transportation or household physical activity was significantly and inversely associated with log-transformed concentrations of insulin. Sedentary behavior, particularly the amount of time spent watching television, may be an important modifiable determinant of concentrations of insulin.

Trends in obesity and abdominal obesity among hypertensive and nonhypertensive adults in the United States.

BACKGROUND As the prevalence of obesity has increased in the United States, it is likely that the prevalence of obesity among people with hypertension has increased as well. Because little is known about this issue, our objective was to compare secular trends in the prevalence of obesity and abdominal obesity among hypertensive and nonhypertensive adults in the United States. METHODS We used data from adults aged 18-74 years who participated in National Health and Nutrition Examination Surveys (NHANESs) during 1976-1980, 1988-1994, and 1999-2004. RESULTS Among adults with hypertension, the age-adjusted mean body mass index increased from 27.5 kg/m2 during 1976-1980 to 31.2 kg/m2 during 1999-2004 (P < 0.001), and the age-adjusted prevalence of obesity increased from 25.7-50.8% (P < 0.001). Among adults without hypertension, mean body mass index increased from 24.2-27.1 kg/m2 (P < 0.001), and the prevalence of obesity increased from 8.4-25.1% (P < 0.001). The prevalence of obesity among women with hypertension exceeded that among men with hypertension during all three surveys (P < 0.05 for all three surveys). During 1999-2004, 56.4% (s.e. 3.4) of women with hypertension were obese compared with 46.9% (s.e. 2.1) of men. During this same time period, the prevalence of obesity was highest among Mexican-American women with hypertension (63.8%; s.e. 4.2) and lowest among African-American men with hypertension (43.8%; s.e. 2.5). CONCLUSIONS Over half of people with hypertension are currently obese. The large increase in obesity among people with hypertension presents clinicians with a serious challenge in the management of hypertension.

Utilization of emergency department in patients with non-urgent medical problems: patient preference and emergency department convenience.

BACKGROUND/PURPOSE We investigated the factors associated with emergency department (ED) use among patients with non-urgent medical problems, with a focus on convenience and preference to use the ED instead of primary care clinics. METHODS A five-level triage system was adopted by research nurses to decide each patients triage level and the maximum time to physician interview. Patients who had a maximum time to physician interview of more than 60 minutes were assumed to be non-urgent in this study. RESULTS More than half of ED visits were considered to be non-urgent. Non-urgent patients were more likely to be unmarried, government employees, visit the ED due to trauma, have a history of chronic illness, and present in the day time or at the weekend. ED visits were also more likely to occur in patients who took less than 15 minutes to reach the ED, chose the ED for its convenience, agreed that they could have chosen another facility for their visit, did not agree that the ED was convenient for receiving medical care. Multivariate logistic regression showed that marital status, time of presentation, time needed to get to the ED, and occupation were associated with non-urgent ED visits. CONCLUSION Preference for using EDs for medical care and their convenience might contribute to non-urgent ED visits. A five-level triage system reliably stratified patients with different admission rates and utilization of medical resources, and could be helpful for reserving limited medical resources for more urgent patients.