Health Matters for Women^™
Fall 2002

Fall 2002 PDF   INSIDE THIS ISSUE Highlight - CDC's New Director Cover Story - Asthma News You Can Use - DES - Contraceptive - STD - Seniors - Youth Campaign - Youth Web Site - Hysterectomy - COPD - Environmental Health Prevention Works - Project Joy - Flu Shot - Uninsured Women - HRT Dates That Matter CDC Resources RELATED LINKS Newsletter Archive Order a copy

HIGHLIGHT

CDC's New Director
Julie L. Gerberding, MD, MPH, is the new director of the Centers for Disease Control and Prevention and administrator for the Agency for Toxic Substances and Disease Registry.

Gerberding has been acting principal deputy director of CDC and part of the interim team that directed the agency after former director Jeffrey Koplan, MD, MPH. She played a major role in leading CDC's response to anthrax bioterrorism attacks in the fall of 2001.

Gerberding, 47, joined CDC in 1998 as director of the Division of Healthcare Quality Promotion, where she developed patient safety initiatives to prevent infections, antimicrobial resistance, and medical errors. Before that, she headed the Prevention Epicenter at the University of California, San Francisco.

COVER STORY

Asthma: A Heavy Burden for Women
Climbing asthma rates among children have generated popular notice in recent years, but it is adult women who actually suffer most often from the disease. And it is older women who are dying from asthma, at rates considerably higher than men, driving the overall increase in death rates from 10 to 17 people per million between 1979 and 1996.

In 2001, 9.1 percent of adult U.S. women -- 9.6 million women -- had asthma. In men, the rate was 5.1 percent, or 5 million men.

Why? There is evidence that estrogen level is related to asthma - rates in girls jump during adolescence, asthma severity often shifts during pregnancy, and episodes may fluctuate with women's monthly estrogen levels. In addition, women tend to have smaller airways than men. Obesity and asthma are often found together, raising questions about the relationship between these two conditions.

1999 Asthma Morbidity & Mortality

Source: "Surveillance for Asthma – United States, 1980-1999." MMWR Surveillance Summaries, March 29, 2002 / 51(SS01); 1-13.

But right now, there are no easy answers.

"We just don't know," said Jeanne Moorman, MS, a CDC environmental health researcher. "All of these questions are raised, but there's very little research that shows us what is different about asthma for women."

What the numbers make clear, though, is that efforts to reduce asthma deaths must focus on middle-aged and elderly women. As Moorman and CDC's David Mannino, MD, write in their evaluation of asthma deaths, "The single subgroup most responsible for the increase in the asthma mortality rate between 1979 and 1996 is white females aged 65 years and older. Black females aged 65 years and older had the highest asthma mortality rate in 1996 and experienced the most rapid increase in rates between 1979 and 1996."

Other medical problems can complicate the management of asthma in older women. Medicines for conditions such as high blood pressure can aggravate asthma, for example, and medicines for asthma can complicate heart conditions and osteoporosis.

CDC's Asthma Control Program
CDC's goal, through its asthma control program, is to reduce the burden of asthma: deaths, hospitalizations, emergency department visits, work and school days missed, and limitations on activity. The program's three-pronged approach: improve tracking to help focus policy; translate science into proven programs to ease asthma; and forge partnerships to put good local asthma programs to work.

Tracking
Surveillance for asthma is complicated by several factors. Asthma onset can be difficult to pinpoint. Doctors are not required to report cases of the disease. And as a cause of death, asthma may be under- or over-reported. Even defining a case of asthma is a problem.

"There's no perfect test for asthma," said Mannino. "Diagnoses are based on symptoms, and different doctors may use different definitions."

CDC's strategy is to collect, analyze and make available more information at the state and local levels. The Behavioral Risk Factors Surveillance Survey, the telephone survey from which the primary local asthma numbers come, added questions on asthma in adults beginning in 1999. Now, CDC is field testing a National Asthma Survey to collect data on prevalence, knowledge, and attitudes. CDC's asthma program also funds 13 asthma tracking projects in states around the country.

Interventions
Many of the 45 asthma interventions CDC funds focus on children, especially those living in inner cities. But two CDC-funded projects with Kaiser Permanente are focusing on the disease in women.

A study at Kaiser Permanente Georgia has found that women report more severe attacks and use more asthma-control medications than men, according to Dennis Tolsma, MPH, the primary investigator at Kaiser.

Now that project is evaluating a group visit intervention. About a dozen women met with their primary care doctor and a nurse educator three times in three months. Each got one-on-one time with her doctor for a vital signs check and a medication review. Then they came together for an educational talk from the nurse and support and learning from one another.

Both the doctors and the patients were very positive about the group visit, Tolsma said. "The doctors felt it was very productive, and the women said it benefits them in all their health problems to have this kind of group structure."

The second study, this one at Kaiser Northwest, is looking at women and men with asthma to find out how the disease might be different in women – in severity and treatment. An intervention will encourage patients and doctors to follow National Asthma Education and Prevention Program guidelines.

Partnerships
CDC helps forge coalitions to treat asthma as a public health problem. The wide range of partners includes the U.S. Environmental Protection Agency, the National Association of School Nurses, the American Lung Association, the National Heart, Lung, and Blood Institute, and the National Institute of Allergy and Infectious Diseases. CDC funds 30 asthma projects with state health departments working to develop comprehensive, statewide asthma control plans.

Asthma Resources
"Surveillance for Asthma – United States, 1980-1999." CDC MMWR Surveillance Summaries, March 29, 2002 / 51(SS01); 1-13. www.cdc.gov/mmwr/preview/mmwrhtml/ss5101a1.htm.

"Surveillance for Asthma – United States, 1960-1995." CDC MMWR Surveillance Summaries, April 24, 1998 / 47(SS-1); 1-28. www.cdc.gov/epo/mmwr/preview/mmwrhtml/00052262.htm.

"Increasing U.S. Asthma Mortality Rates: Who Is Really Dying?" Jeanne E. Moorman and David M. Mannino. Journal of Asthma, 38(1), 65-71 (2001).

CDC's National Asthma Control Program. www.cdc.gov/nceh/airpollution/asthma.

CDC National Center for Health Statistics. www.cdc.gov/nchs/fastats/asthma.htm.

NEWS YOU CAN USE

DES
Campaign Updates Patients and Providers
This winter, CDC unveils a range of educational materials about DES (diethylstilbestrol) for health-care providers and patients.

From 1938 to 1971, 5 to 10 million individuals were exposed to DES, a synthetic estrogen prescribed to help women avoid miscarriage and premature delivery. Considered safe at the time, DES was discontinued in 1971 when it was linked to vaginal cancer in the daughters of women who took the drug.

Thirty years of research has confirmed that DES daughters exposed in the womb are at increased risk for a type of cancer of the vagina and cervix, reproductive tract structural differences, pregnancy complications, and infertility. DES sons are at increased risk for non-cancerous cysts of the epidymis, behind the testicles. And the women who took DES while they were pregnant have a modestly increased risk of breast cancer.

Patients and their physicians have not always had access to the latest and most accurate information about DES. Now, CDC aims to help them make the right choices with the most up-to-date and comprehensive information on the topic.

See the DES Update site at www.cdc.gov/des. To learn more, call Marsha Vanderford at 770-488-4552.

Contraceptive
Good News About the Pill
Women who have taken oral contraceptives are no more likely to develop breast cancer than women their age who have never taken the pill, says a study by the National Institute of Child Health and Human Development and the CDC. About 80 percent of U.S. women born since 1945 have used oral contraceptives at some point in their lives, and women in that first generation to use them were interviewed for the study.

"The results are good news," said lead author Polly A. Marchbanks, PhD, of CDC's chronic disease program. "For women 35 to 64 years old, this study provides reassurance that oral contraceptives do not increase the risk of breast cancer."

The article was published in the New England Journal of Medicine in June: content.nejm.org/cgi/content/short/346/26/2025.

STD
Updated Treatment Guidelines
CDC has updated its guidelines for treatment of patients with sexually transmitted diseases (STD). Among the new recommendations:

• recommendations against nonoxynol-9 for STD prevention.
• alternative treatment regimen for gonorrhea to combat antibiotic-resistant strains
• expanded risk assessment and screening among gay and bisexual men
• a new test for genital herpes
• rescreening for chlamydia several months after treatment

The 2002 Guidelines for the Treatment of Sexually Transmitted Diseases bring together recommendations on the most effective treatment, screening and prevention strategies for STDs, which infect 15 million people each year in the United States. CDC revises the guidelines about every four years, after a scientific evidence-based review process.

Find the recommendations at www.cdc.gov/std/treatment or contact CDC at (404) 639-8895.

Seniors
Falls are a Serious Hazard
Falls are a serious health hazard for older adults, and women suffer the majority of injuries related to falls.

As many as 40 percent of people 65 and older fall each year. In 2000, 1.6 million seniors were treated in emergency departments for falls.

• Women sustain about 80
  percent of all hip fractures. Only half of relatively healthy older adults who suffer hip fractures can live independently one year later.
• Seniors with osteoporosis are especially susceptible to fractures if they fall.
• The growing U.S. older population fuels a total annual cost of hip fractures that may reach $240 billion by 2040.

U.S. Fall Prevention Programs for Seniors: Selected Programs Using Home Assessment and Modification, describes successful programs that use education and exercise as well as evaluate seniors' homes for problems and help fix the hazards they find.

Learn more about falls and fall prevention at www.cdc.gov/ncip/cmprfact.htm or in the CDC Injury Fact Book at www.cdc.gov/ncipc/fact_book.

Youth Campaign
Verb: It's What You Do
Find your verb: run, paint, sing, bowl, volunteer, dance, kick...

CDC's new national media campaign to get kids active kicked off this summer with TV and radio ads to create a buzz for the VERB™ brand. Now, TV, Internet, print, billboard, and radio ads are encouraging 9- to 13-year olds (tweens) to be positively active – physically and pro-socially.

The $190 million campaign was created in response to Congress' concern about U.S. youth's physical inactivity, poor nutrition, obesity, mental health, and use of drugs, alcohol, and tobacco.

"Too many of our children are sitting around, and their inactivity is leading to serious health problems such as obesity and diabetes," said U.S. Health and Human Services Secretary Tommy G. Thompson. "We need to get our children away from the Play Station and onto the playground."

Extensive research drives the content and tone of the campaign, which is being tested along the way with its audiences to be sure the ads are on target. VERB includes specific messages and strategies to reach American Indian and Alaska Natives, African Americans, Asian American and Pacific Islanders, and Hispanics/Latinos.

To extend its reach, VERB is partnering with organizations ranging from Disney and Viacom to celebrity endorsers to local churches to other government agencies. A toolkit for partners will be available later this fall.

An AOL site -- www.verbnow.com/ -- is geared toward tweens, while www.cdc.gov/youthcampaign/ introduces the site to potential partners and others. For more information, e-mail
youthcampaign@cdc.gov.

Youth
BAM! Body and Mind
What's lurking in the locker room? Is "No pain, no gain" a good motto for physical activity? Can kids with asthma exercise?

Children can find the answers in BAM!, CDC's new e-zine for kids. The first edition gives kids a cool way to learn about ways to be active and health issues related to physical activity - like germs and fungi, asthma, safety, and disability.

BAM! is targeted to "tweens" aged 9 to 13 and their teachers. Quarterly new editions will address different interrelated health issues, but kids will be able to access past content, too. Plans include topics for parents, teens, and younger children.

A teacher's corner includes pre-assessment questions and activities linked to national curriculum standards. Health and science teachers will find interactive ways for their students to learn about health topics.

The "Head Strong" section will help kids see the truth behind "stuff that plays with your head from the outside, like TV and magazines." The goal: help them learn skills to respond to peer pressure, manage conflict, and build self-esteem.

Take a look at www.bam.gov.

Hysterectomy
Rates are Up
Hysterectomy rates climbed minimally during the late 1990s, according to a recent report, "Hysterectomy Surveillance – United States, 1994-1999."

The overall U.S. hysterectomy rate was 5.5 per 1,000 women. The data show limited but significant increases in hysterectomy rates from 1994 (5.1) through 1998 (5.8), then a decrease in 1999 (5.5).

Benign, fibroid tumors (uterine leiomyoma), endometriosis, and uterine prolapse were the diagnoses that most often led to hysterectomy. More than half of women who had a hysterectomy during the study period also had their ovaries removed during the surgery.

• Women 40 to 44 years old had the highest rate of hysterectomy. More than half of all hysterectomies were on women in this age group.
• Black women 35 to 44 years old were more likely to have a hysterectomy than white women.
• Rates were highest in the South.

For U.S. women of reproductive age, hysterectomy is the second most frequent surgery, after cesarean section. About 600,000 hysterectomies are performed each year in the United States.

See the report at
www.cdc.gov/mmwr/preview/mmwrhtml/ss5105a1.htm.

Women Surpass Men in COPD Deaths
Deaths from chronic obstructive pulmonary disease (COPD) grew much faster in women than in men over the past 20 years. In 2000, for the first time, more women than men died from COPD.

COPD is a group of airflow obstruction conditions, including chronic bronchitis and emphysema, that usually cause chronic cough, shortness of breath, expectoration, or wheezing.

In 2000, the age-adjusted death rate for women grew from 20.1 per 100,000 in 1980 to 56.7 per 100,000 in 2000. During the same period, COPD death rates in men grew from 73.0 per 100,000 to 82.6 per 100,000. (Because women die at an older mean age, their age-adjusted death rate is lower than men's.) The data show that 59,936 women and 59,118 men died from COPD in 2000.

COPD death rates parallel smoking rates to some degree. As the number of women who have smoked age, more women are dying from chronic lung disease. The good news: The percentage of the population 55 years or older with COPD decreased, which may signal an end to the upward trend in COPD hospitalizations and deaths.

Read more in CDC's "Chronic Obstructive Pulmonary Disease Surveillance – United States, 1971-2000" at www.cdc.gov/mmwr/preview/mmwrhtml/ss5106a1.htm.

CDC's National Center for Environmental Health
Watching Exposures in the World Around Us
Researchers in CDC's National Center for Environmental Health (NCEH) have a job that spans the life cycle and is as big as the world around us. For CDC, the environment includes the air we breathe, the water we drink, the food we eat, and the chemicals, radiation, microbes, and physical forces with which we come into contact. So the work of NCEH covers issues as diverse as air pollution, lead poisoning, mold, noise, genetics, chemical weapons, and earthquakes. Here are a few examples of particular interest to women's health.

Asthma
CDC's asthma control program now tracks asthma and has documented that adult women are driving the high rates of asthma and death for the disease. The program works with partners to bring a public-health approach to controlling asthma. (Please see related Cover Story.)

Osteoporosis
CDC's environmental health lab helped improve the diagnosis and management of osteoporosis with a new lab to standardize how bone resorption markers are measured and used. Bone markers allow scientists to investigate what affects bone development and monitor how treatment is working.

Secondhand Smoke
CDC researchers have measured exposure to secondhand tobacco smoke in pregnant women and their babies. One study found that women with the most passive smoke exposure were almost two and a half times more likely to have a low-birth-weight baby than women with the least exposure. Another found that babies exposed prenatally to nicotine are at higher risk for SIDS (Sudden Infant Death Syndrome).

Micronutrients
CDC has supported studies to gauge the nutritional status of people in countries around the world, measuring, for instance, iodine, folate, and iron levels in Micronesia; anemia in Mongolia; and vitamin A in Brazil. CDC established a network of international iodine labs to help standardize how iodine is measured. Iodine deficiency disorders are the main cause of preventable retardation.

Chemical Exposure
CDC's scientists have been measuring chemicals in people for at least 25 years, and in 2001, the agency's National Report on Human Exposure to Environmental Chemicals (www.cdc.gov/exposurereport) gave Americans a glimpse of what they're being exposed to – as measured in people rather than out in the environment.

CDC lab scientists studied DDT in women and found a greater risk for premature babies; showed a significant association between levels of dioxin and breast cancer; and are studying children exposed in utero to PCBs and mercury.

Genetics and Molecular Biology
"The Genetic Basis of Cancer" (www.oup.com/us/catalog/general/
subject/?view=usa&ci=0195126750) CD-ROM educates doctors about risk assessment, genetic testing, and care for cancer, focusing on breast and colon cancer.

The genomics and disease prevention branch makes available studies on topics related to birth defects and cancer risk. Visit www.cdc.gov/genomics for details.

For more information about CDC's work in environmental health, visit http://www.cdc.gov/nceh/.

PREVENTION WORKS

Project Joy
Church Program Lowers African-American Women's Heart Risk
Church-based nutrition and exercise programs can move African-American women to adopt healthier habits, according to a CDC-funded study by Johns Hopkins researchers. Project Joy programs in 16 inner-city Baltimore churches encouraged more than 500 participants to lose weight and choose healthier foods over a year-long period, according to a report of the study in Public Health Reports.

Women who participated in on-site exercise and dietary activities did much better than those assigned to self-help groups. One year after the program's start, researchers found a statistically significant reduction in 11 of 13 risk factors for heart disease in the intervention group.

"Urban African-American women age 40 and up bear a marked excess risk of obesity and death from heart disease," said Diane M. Becker, ScD, MPH, an author of the study and director of Johns Hopkins' Center for Health Promotion. "This study demonstrates that church-based interventions can greatly improve their cardiovascular health."

Women who weighed the most at the study's start lost an average of nearly 20 pounds during the program, compared to the biggest weight loss among the self-help group of seven pounds. Overall, participants lost two-thirds of an inch from their waistlines and reduced systolic blood pressure (the upper number), daily calories, daily fat, and daily salt intake.

In some of the churches, female African-American health educators, assisted by church lay leaders with health training, led weekly nutrition and physical activity sessions at the church. Each session included a weigh-in and group discussion, a taste test or cooking demonstration, and 30 to 45 minutes of moderate aerobic activity such as brisk walking, water aerobics, or kick-boxing. Many groups included spiritual content and prayer, with aerobics to gospel music or worship dance.

In other churches, participants were simply given self-help handouts and other materials tailored to their needs on diet, exercise, and smoking cessation. They attended no support groups or education sessions but had a hotline number for guidance.

After a full health screening, women were encouraged to exercise at least 30 minutes five to seven days a week. They were urged to eat 1,200 to 1,800 calories per day, including at least five servings of fruits and vegetables, 25 grams of fiber, less than 40 grams of fat, and less than 2,400 milligrams of sodium. If they smoked, they were encouraged to quit.

Project Joy was named from a Bible verse (Nehemiah 8:10b), "... for Joy of the Lord is your strength." In many communities, the church remains a prime source of social support and community leadership among older African-American women.

Yanek, L.R., Becker, D.M., et al., "Project Joy: Faith- Based Cardiovascular Health Promotion for African American Women," Public Health Reports, Summer 2001, Vol. 116: pp. 68-82.

Uninsured Women
WISEWOMAN Screens, Counsels, Refers
To combat the No. 1 killer of women, CDC's WISEWOMAN™ targets early detection of heart disease in low-income and uninsured women. Under WISEWOMAN (Well-Integrated Screening and Evaluation for Women Across the Nation):

1. Women receive free screening for heart disease and stroke risk factors such as high blood pressure and high cholesterol. Some projects also offer screenings for diet and physical activity patterns, diabetes, and osteoporosis.
2. If screenings point to problems, women are referred to physicians.
3. Women are encouraged to adopt healthier behaviors to reduce the chances of heart disease — quitting smoking, improving their diets, and increasing their physical activity. Interventions such as stress-reduction classes, counseling sessions, walking groups, stop-smoking programs, and nutrition tips make it easier.

More than 12,000 women have been screened through WISEWOMAN.

WISEWOMAN is a sister program to CDC's National Breast and Cervical Cancer Early Detection Program, which funds free mammogram and Pap screenings for low-income and uninsured women. Since uninsured women are more likely to have risk factors for cardiovascular and other chronic disease, Congress authorized CDC to explore the benefits of additional preventive services.

In the first three demonstration projects, 50 to 75 percent of participants had either high blood pressure or high cholesterol. CDC now supports 12 WISEWOMAN projects in 11 states: Alaska, California, Connecticut, Illinois, Iowa, Massachusetts, Michigan, Nebraska, North Carolina, South Dakota, and Vermont.

The Massachusetts Department of Public Health, for instance, provides WISEWOMAN services at 10 sites. Each woman receives education to help her reduce her risk for heart disease. Based on the results of their screenings for blood pressure, cholesterol, and blood sugar, women are referred to nutrition and physical activity programs.

On WISEWOMAN's Web site, women will find risk calculators, health quizzes, nutrition tips and recipes, and links to science-based yet practical information. Health professionals will find a comprehensive set of links on related topics as well as a description of each of the 12 WISEWOMAN projects around the country. Check out http://www.cdc.gov/wisewoman/.

HRT
NIH Halts Trial of Estrogen Plus Progestin
Women and their health-care providers are reassessing hormone replacement therapy after an early halt to a major clinical trial.

An increased risk of invasive breast cancer caused the National Heart, Lung, and Blood Institute to stop its trial on combined estrogen plus progestin therapy in healthy postmenopausal women in July, three years early. The large, randomized trial of the Women's Health Initiative concluded after an average follow-up of 5.2 years that long-term combined estrogen-progestin caused more harm than good. In addition to a small but significant increase in breast cancer, the study documented increases in heart disease, stroke, and blood clots among those taking estrogen-progestin. Benefits of estrogen-progestin therapy were fewer hip fractures, total fractures, and cases of colorectal cancer.

The study did not address the short-term risks and benefits of hormones to treat menopausal symptoms such as hot flashes.

An accompanying editorial in the Journal of the American Medical Association emphasizes that "the absolute risk of harm to an individual woman is very small," but that the results provide "an important health answer for generations of healthy postmenopausal women to come – do not use estrogen/progestin to prevent chronic disease." A study on estrogen-only therapy for women who have had hysterectomies continues. Read the details in the Journal of the American Medical Association: jama.ama-assn.org/content/vol288/issue3/index.dtl and www.nih.gov/PHTindex.htm.

To encourage testing among those at risk, CDC posters highlight the many ways people might have contracted hepatitis C, including blood transfusions before July 1992 or illegal injected drug use. New infections are down from 240,000 per year in the 1980s to about 34,000 in 2000. Most new cases are now due to illegal injection drug use.

For posters, other educational materials, statistics, and recommendations, visit http://www.cdc.gov/hepatitis or call (888) 4-HEP-CDC.

DATES THAT MATTER

December

World Aids Day
December 1

National Hand-Washing Awareness Week
December 8-14

National Stress-Free Family Holidays Month

Colorectal Cancer Education and Awareness Month

January

National Birth Defects Prevention Month

Cervical Health Awareness Month

February

American Heart Month

Sinus Pain Awareness Month

Wise Health Consumer Month

CDC RESOURCES

We want to hear from you, so please let us know what you think.
— Yvonne Green, Director CDC/ATSDR Office of Women's Health

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