Ziona Haklai

Body-Mass Index in 2.3 Million Adolescents and Cardiovascular Death in Adulthood

BACKGROUND In light of the worldwide increase in childhood obesity, we examined the association between body-mass index (BMI) in late adolescence and death from cardiovascular causes in adulthood. METHODS We grouped data on BMI, as measured from 1967 through 2010 in 2.3 million Israeli adolescents (mean age, 17.3±0.4 years), according to age- and sex-specific percentiles from the U.S. Centers for Disease Control and Prevention. Primary outcomes were the number of deaths attributed to coronary heart disease, stroke, sudden death from an unknown cause, or a combination of all three categories (total cardiovascular causes) by mid-2011. Cox proportional-hazards models were used. RESULTS During 42,297,007 person-years of follow-up, 2918 of 32,127 deaths (9.1%) were from cardiovascular causes, including 1497 from coronary heart disease, 528 from stroke, and 893 from sudden death. On multivariable analysis, there was a graded increase in the risk of death from cardiovascular causes and all causes that started among participants in the group that was in the 50th to 74th percentiles of BMI (i.e., within the accepted normal range). Hazard ratios in the obese group (≥95th percentile for BMI), as compared with the reference group in the 5th to 24th percentiles, were 4.9 (95% confidence interval [CI], 3.9 to 6.1) for death from coronary heart disease, 2.6 (95% CI, 1.7 to 4.1) for death from stroke, 2.1 (95% CI, 1.5 to 2.9) for sudden death, and 3.5 (95% CI, 2.9 to 4.1) for death from total cardiovascular causes, after adjustment for sex, age, birth year, sociodemographic characteristics, and height. Hazard ratios for death from cardiovascular causes in the same percentile groups increased from 2.0 (95% CI, 1.1 to 3.9) during follow-up for 0 to 10 years to 4.1 (95% CI, 3.1 to 5.4) during follow-up for 30 to 40 years; during both periods, hazard ratios were consistently high for death from coronary heart disease. Findings persisted in extensive sensitivity analyses. CONCLUSIONS A BMI in the 50th to 74th percentiles, within the accepted normal range, during adolescence was associated with increased cardiovascular and all-cause mortality during 40 years of follow-up. Overweight and obesity were strongly associated with increased cardiovascular mortality in adulthood. (Funded by the Environment and Health Fund.).

Effect of interpregnancy interval on adverse perinatal outcomes — a national study

BACKGROUND The interpregnancy interval (IPI) has been reported to influence the outcome of pregnancy and birth. We performed a national study in Israel to determine the impact of IPI on multiple adverse perinatal outcomes. STUDY DESIGN This longitudinal cohort study used birth certificates of siblings born to the same biological mother, with at least one previous birth and a subsequent singleton pregnancy. Adverse pregnancy outcomes included preterm delivery, very preterm birth, small for gestational age (SGA), very SGA (VSGA), early neonatal death and major congenital malformations. Multivariate logistic regression was performed for each outcome. RESULTS The study included 440,838 of a total of 846,845 reported live births in Israel over 5 years; excluded were primiparas (32%), multifetal births (4.9%) and those with incomplete data (10.9%). For IPIs shorter than 6 months, there were significantly increased risks for preterm birth (OR=1.23), SGA (OR=1.14), VSGA (OR=1.15), early neonatal death (OR=1.62) and congenital malformations (OR=1.14). Intervals of 60 months or longer had higher risks for preterm birth (OR=1.39) and VSGA (OR=1.16). CONCLUSION Optimal IPI recommendation of >11 months is an accessible and low-cost means to improve multiple adverse perinatal outcomes.

Coronary heart disease mortality among Arab and Jewish residents of Jerusalem

Information on coronary heart disease (CHD) in the Palestinian population is sparse. We compared mortality rates in the largely Palestinian Arab population of Jerusalem with the Jewish population of the district between 1984 and 1997 based on official Israeli statistics. CHD mortality and all-cause mortality rates were significantly higher among Arab residents than among Jewish residents aged 35-74 years. Whether the excess CHD mortality reflects increased incidence of events, higher case fatality, or both remains to be established. Possible explanations include a higher prevalence of conventional risk factors such as diabetes, obesity, and smoking in Palestinians, stress effects related to the complex political situation and socioeconomic inequalities, and suspected differences in medical care.

Chronic physical conditions and use of health services among persons with mental disorders — results from the Israel National Health Survey

OBJECTIVE This study aimed to determine the association between common mental disorders and common chronic physical conditions and the contribution of mental disorders to the likelihood of being a higher user of health services. METHOD A representative sample extracted from the National Population Register of noninstitutionalized residents of Israel aged 21 or older were interviewed at their homes between May 2003 and April 2004. Mental disorders were assessed using a revised version of the World Mental Health Composite International Diagnostic Interview. Chronic physical conditions were measured via a checklist of chronic physical disorders. RESULTS Current mood or anxiety disorders were found to be associated with higher likelihood of chronic pain, cardiovascular conditions, diabetes and respiratory conditions beyond the sociodemographic characteristics and the risk factors (BMI or smoking). Current mood or anxiety disorders increased the likelihood of being a higher user of primary care beyond the effects of gender, population group, self-evaluation of general health, chronic pain or chronic conditions. CONCLUSION The results regarding the prevalence of mental-physical comorbidity emphasize the need for integration in the physical and mental care of people with mental disorders.

Mortality and causes of death among users of methadone maintenance treatment in Israel, 1999–2008

OBJECTIVES To determine all-cause and specific-causes mortality, in the years 1999-2008, among opioid-dependent users treated at methadone maintenance treatment (MMT) clinics in Israel and to compare the obtained results with data from relevant studies worldwide. METHOD The records of patients treated at MMT units were linked to the nationwide database of causes of death. Information about the Israeli general population from the Central Bureau of Statistics was used for comparison to match sex and age to the cohort under study. Crude mortality rates (CMRs) per 100 persons per year (PY) and standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated. RESULTS The overall CMR for MMT users was 1.49/100 PY (CI 1.40-1.59) and was not associated with gender, age at entering MMT, ethnicity, and immigrant status. The leading causes of mortality were sudden/undefined death (0.31/100 PY, CI 0.26-0.35), overdose (0.22/100 PY, CI 0.17-0.27), and cancer (0.15/100 PY, CI 0.12-0.18). The MMT users were 12.2 times more likely to die from all causes than people from the general population. Overall, our estimates were comparable with the figures pooled from relevant studies. CONCLUSIONS The results suggest that the excess mortality of MMT users is associated with an increased morbidity, which alone or in combination with service-related risks, lead to worse outcomes.

BMI at Age 17 Years and Diabetes Mortality in Midlife: A Nationwide Cohort of 2.3 Million Adolescents

OBJECTIVE The sequelae of increasing childhood obesity are of major concern. We assessed the association of BMI in late adolescence with diabetes mortality in midlife. RESEARCH DESIGN AND METHODS The BMI values of 2,294,139 Israeli adolescents (age 17.4 ± 0.3 years), measured between 1967 and 2010, were grouped by U.S. Centers for Disease Control and Prevention age/sex percentiles and by ordinary BMI values. The outcome, obtained by linkage with official national records, was death attributed to diabetes mellitus (DM) as the underlying cause. Cox proportional hazards models were applied. RESULTS During 42,297,007 person-years of follow-up (median, 18.4 years; range <1–44 years) there were 481 deaths from DM (mean age at death, 50.6 ± 6.6 years). There was a graded increase in DM mortality evident from the 25th to the 49th BMI percentile group onward and from a BMI of 20.0–22.4 kg/m2 onward. Overweight (85th to 94th percentiles) and obesity (the 95th percentile or higher), compared with the 5th to 24th percentiles, were associated with hazard ratios (HRs) of 8.0 (95% CI 5.7–11.3) and 17.2 (11.9–24.8) for DM mortality, respectively, after adjusting for sex, age, birth year, height, and sociodemographic variables. The HR for the 50th through 74th percentiles was 1.6 (95% CI 1.1–2.3). Findings persisted in a series of sensitivity analyses. The estimated population-attributable fraction for DM mortality, 31.2% (95% CI 26.6–36.1%) for the 1967–1977 prevalence of overweight and obesity at age 17, rose to a projected 52.1% (95% CI 46.4–57.4%) for the 2012–2014 prevalence. CONCLUSIONS Adolescent BMI, including values within the currently accepted “normal” range, strongly predicts DM mortality up to the seventh decade. The increasing prevalence of childhood and adolescent overweight and obesity points to a substantially increased future adult DM burden.

Suicidal behavior among Muslim Arabs in Israel

PurposeCountries with Muslim populations report relatively lower rates of suicide. However, authors have noted methodological flaws in the data. This study examined reliable rates of completed suicide, suicide ideation, planning and attempts among Muslims as compared to Jews in Israel.MethodsFor completed suicide, information was extracted from death certificates (2003–2007); the National Emergency Room Admissions Database (NERAD) provided data on suicide attempts (2003–2007); and the Israel National Health Survey (INHS) (2003–2004) was used for self reports on lifetime suicide ideation, planning and attempts.ResultsCompleted suicide rates among Muslim-Israelis (3.0 per 100,000) were lower compared to Jewish-Israelis (8.2 per 100,000). Based on NERAD, attempted suicide rates among men were lower for Muslims compared to Jews, while among women aged 15–44 no differences were found. In the INHS, the rate of self-reported lifetime suicide attempts was significantly higher among Muslims (2.8%) compared to Jews (1.2%), while lifetime prevalence rates of suicide ideation (6.6%) and planning (2.1%) in Muslims did not differ from Jews (5.2 and 1.9%, respectively).ConclusionsConceivably, the lower rate of completed suicide among Muslim-Israelis might be explained by the strenuous proscription of suicide by the Koran. However, its extension to suicide attempts is equivocal: attempts were higher among Muslims than among Jews according to self-reports but lower in the NERAD records. Social pressures exerted on the reporting agents may bias the diagnosis of self-harm in both the latter data source and in the death certificates.

Mortality rates in Israel from causes amenable to health care, regional and international comparison

BackgroundMortality from causes amenable to health care is a valuable indicator of quality of the health care system, which can be used to assess inter-regional differences and trends over time. This study investigates these mortality rates in Israel over time, and compares inter-regional and international rates in recent years.ResultsAge-adjusted amenable mortality rates have been decreasing steadily in Israel, by 31% for males and 28% for females between 1998–2000 and 2007–2009. Amenable mortality was lower in the center of the country than in the Northern, Southern, and Haifa districts. The proportion of mortality from circulatory diseases was highest in the North and Haifa districts and from cancer in the Tel-Aviv and Central districts. A higher proportion of infectious diseases was seen in the Southern district.In comparison with amenable mortality rates in 20 European countries, Israel ranked 8th lowest for males and 12th lowest for females, in 2008. The rate was lower than in Britain, Ireland, and Portugal; lower than in Germany, Spain, Austria, and Finland for males; and higher than France, Netherlands, Sweden, Norway, and Italy. But Israel ranked higher in the decrease in amenable mortality rates between 2001 and 2007 for females than males in a 19 country comparison. Genitourinary diseases were a larger component in Israel than other countries and circulatory diseases were smaller.ConclusionThe indicator of amenable mortality shows improvement in health outcomes over the years, but continuing improvement is needed in health care and education, in particular in the periphery of Israel and for females.

Female physicians: trends and likely impacts on healthcare in Israel

BackgroundFemale physicians have become an increasing proportion of the medical workforce in Israel. This study investigates this trend and discusses its likely impact on the quantity and quality of medical care available.MethodData on licensed physicians and new licenses issued to physicians were taken from a Ministry of Health database, and analyzed by gender, age, academic origin (Israeli graduates, immigrants, Israeli-born who studied abroad), and specialty for the years 1999–2011.Data on employed physicians, their population group, and work hours were taken from the Central Bureau of Statistics (CBS) annual Labour Force Survey for the years 2009–2011.ResultsThe proportion of women amongst physicians aged under 65 rose from 38% in 1999 to 42% in 2011, and was even higher for younger physicians. The highest proportion of females is found amongst new immigrant physicians who studied abroad. The corresponding proportion has been rising steadily amongst Israeli-educated physicians, and is lowest amongst Israeli-born physicians who studied abroad.Similarly, among newly licensed physicians, the proportion of females has traditionally been highest among immigrants who studied abroad and lowest among Israeli-born graduates who studied abroad. Among newly-licensed physicians who studied in Israel, the proportion of females has historically been intermediate between the other two groups, but it has recently risen to 54% and now parallels the proportion of females among immigrants who studied abroad. In recent years, the mix of academic origins among newly licensed physicians has changed dramatically, with important implications for the proportion of women among newly licensed physicians.The highest percentage of females was found in family medicine followed by oncology, pediatrics and psychiatry. The greatest increase over the years in this percentage was for gynecology and internal medicine.Female physicians worked shorter hours than males, particularly at younger ages. The proportion of females among employed Arab physicians is much lower than among Jewish physicians.ConclusionsThe proportion of female physicians has been steadily rising, although in recent years the increase has leveled off. This has been due, in part, to the decline in the flow of immigrant physicians and the increase in the number of Israelis studying abroad. Future developments in medical education options and immigration will determine whether their proportion will continue rising. Planning for future medical personnel must take these results into consideration.

Trends in acute non-variceal bleeding in Israel in 1996–2007: A significant decrease in the rates of bleeding peptic ulcers

BACKGROUND A decrease in the incidence of hospital admissions for acute non-variceal upper GI bleeding (AUGIB) has been reported in regions with a low prevalence of Helicobacter pylori (HP) infection. AIM To investigate trends in hospital admissions for AUGIB in Israel, where the prevalence of HP infection is intermediate. METHODS We have searched the National Hospital Discharge Database of the Israeli Ministry of Health, where all admissions to acute care hospitals for the period January 1, 1996 through December 31, 2007 are compiled. Using a validated strategy, we identified all admissions for AUGIB according to ICD-9-CM codes. Incidence rates were calculated and adjusted to reflect the age and gender distribution of the Israeli population. RESULTS The overall rates of hospital admissions for AUGIB decreased significantly from 29.3 to 16.8 cases/10(5)population/year (p<0.0001). The decreases were similar in both genders. This decrease was due to decreased rates of bleeding from duodenal ulcers (from 13.6 to 5 cases/10(5)population/year) and gastric ulcers (from 4.3 to 2.4 cases/10(5)population/year). The rates of bleeding from other causes remained unchanged. The rates of surgical interventions bleeding control decreased significantly (overall from 11 to 4%). The in-hospital mortality rate varied between 7.6 and 7%, did not change significantly in both genders but increased significantly with age during the study period. CONCLUSIONS A decline in the overall incidence of AUGIB during the study period was due to a significant decrease in the rate of bleeding peptic ulcers.