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Scientific Observations: Reducing Risk Factors for Chronic Disease

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Adolescent and School Health

Reliability and Validity of Self-Reported Height and Weight Among High School Students

CDC researchers assessed the reliability and validity of the self-reported height and weight of 4,619 high school students. On two separate occasions, the students were asked their height and weight, and results showed that self-reports were highly reliable. However, when the students were measured by a third party, results differed from the self-reported measurements. On average, body mass indexes (BMIs) calculated on the basis of self-reported height and weight were lower than BMIs calculated on the basis of measured height and weight. Therefore, BMIs based on self-reports underestimate the prevalence of overweight in adolescent populations. However, BMIs based on self-reports can be used to track trends in BMI over time.

Brener N, McManus T, Galuska DA, Lowry R, Wechsler H. Reliability and validity of self-reported height and weight among high school students. Journal of Adolescent Health 2003;32:281–7.

Source of Firearms Used by Students in School-Associated Violent Deaths: United States, 1992–1999

CDC researchers examined school-associated firearm homicides and suicides committed by students in elementary and secondary schools in the United States and determined the sources of the firearms used in these events. They found that the firearms used by students in school-associated homicides and suicides came primarily from perpetrators’ homes or from friends or relatives. Students who committed a school-associated suicide or a multiple-victim homicide were more likely to have obtained firearms from their homes than from any other source. Parents with teenaged children were found to be less likely to store firearms safely than parents with younger children, even though older children are at greater risk for firearm death. The results of this study indicate that it is not enough for parents to eliminate unsupervised access to firearms in their home; approximately 25% of the firearms used in school-associated homicides were obtained from friends or relatives. The report recommends that parents consider discussing access to firearms and safe-storage practices with their relatives and the parents of their children’s friends.

Reza, A, Modzeleski W, Feucht T, Anderson, M, Simon TR, Barrios, L. Source of firearms used by students in school-associated violent deaths—United States, 1992–1999. MMWR 2003;51:169–72.

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Adverse Childhood Experiences and Self- Reported Liver Disease: New Insights into the Causal Pathway

To assess whether adverse childhood experiences increase the risk of liver disease, a retrospective study of 17,337 adult health plan members was conducted. The results supported the assertion that childhood abuse, neglect, and forms of household dysfunction are significantly associated with the risk of liver disease. This association appears to be mediated substantially by unhealthy behaviors such as substance abuse and high-risk sexual activity, which increase the risk of viral and alcohol-induced liver disease.

Dong M, Dube SR, Giles WH, Felitti VJ. Anda, RF. Adverse childhood experiences and self-reported liver disease: new insights into the causal pathway. Archives of Internal Medicine 2003;163:1949–56.

Binge Drinking Among U.S. Adults, 1993–1999

Binge drinking is a harmful and increasingly common pattern of alcohol use in the United States; however, there is limited information on the frequency and distribution of binge drinking among U.S. adults. CDC researchers used Behavioral Risk Factor Surveillance System data on binge drinking (defined as 5 or more drinks on one or more occasion) to estimate total binge drinking episodes, episodes per respondent per year, per capita binge drinking in states, and the relationship between binge drinking and alcohol-impaired driving. CDC found that, from 1993 through 2001, there were approximately 1 billion episodes of binge drinking annually in the United States, and the rate of binge drinking episodes per person per year increased 17.5%. Binge drinking rates were highest among those aged 18–25 years; however, 70% of binge drinking episodes occurred among those 25 years of age or younger. Binge drinking varied considerably by state and region. Binge drinkers were also 14 times more likely to report alcohol-impaired driving than non-binge drinkers. In summary, binge drinking is extremely common among U.S. adults, and is strongly associated with impaired driving.

Naimi TS, Brewer RD, Mokdad AH, Denny C, Serdula MK, Marks JS. Binge drinking among United States adults, 1993–1999. JAMA 2002;289:70–5.

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Complications of Screening Flexible Sigmoidoscopy

Flexible sigmoidoscopy (FS) is recommended for mass screening for colorectal cancer (CRC), yet little is known about the risk of adverse events when FS is used in general clinical practice. CDC aimed to determine the incidence of gastrointestinal complications and acute myocardial infarction (MI) after screening FS. Northern California Kaiser Permanente Medical Care Program members of average risk for CRC underwent screening FS during 1994 to 1996, as part of the Colorectal Cancer Prevention program. The main outcome measure was hospitalization for gastrointestinal complications or acute MI within 4 weeks of FS. Overall, 24 persons were hospitalized for a gastrointestinal complication. Of these, 7 were serious (2 perforations, 2 episodes of diverticulitis requiring surgery, 2 cases of bleeding requiring transfusion, and 1 episode of unexplained colitis). In multivariate models, complications were significantly more common in men than in women. The risk of serious complications after screening FS in this setting appears to be modest. Although MI occurs after FS, the risk during the 4 weeks after the procedure appears to be similar to the risk for all persons of screening age.

Levin TR, Conell C, Shapiro JA, Chazan SG, Nadel MR, Selby JE. Complications of screening flexible sigmoidoscopy. Gastroenterology 2002;123:1786–92.

Progress in Cancer Screening Practices in the United States: Results from the National Health Interview Survey

Understanding differences in cancer screening between population groups in 2000 and successes or failures in reducing disparities over time among groups is important for planning a public health strategy to reduce or eliminate health disparities, a major goal of Healthy People 2010 national cancer screening objectives. In 2000, the new cancer control module added to the National Health Interview Survey (NHIS) collected more detailed information on cancer screening compared with previous surveys. Data from the 2000 NHIS and earlier surveys were analyzed to discern patterns and trends in cancer screening practices, including Pap tests, mammography, prostate specific antigen (PSA) screening, and colorectal screening. The data are reported for population subgroups that were defined by a number of demographic and socioeconomic characteristics. Women who were least likely to have had a mammogram within the last 2 years were those with no usual source of health care (61%), women with no health insurance (67%), and women who immigrated to the United States within the last 10 years (61%). Results for Pap tests within the last 3 years were similar. Among both men and women, those least likely to have had a fecal occult blood test or endoscopy within the recommended screening interval had no usual source of care (14% for men and 18% for women), no health insurance (20% for men and 18% for women), or were recent immigrants (20% for men and 18% for women). An analysis of changes in test use since the 1987 survey indicated that the disparities are widening among groups with no usual source of care. No striking improvements have been observed for the groups with greatest need. Although screening use for most groups has increased since 1987, major disparities remain. Some groups, notably individuals with no usual source of care and the uninsured, are falling further behind; and, according to the 2000 data, recent immigrants also experience a significant gap in screening use. The publication suggests that more attention is needed to overcome screening barriers for these groups if the population benefits of cancer screening are to be achieved.

Swan J, Breen N, Coates RJ, Rimer BK, Lee NC. Progress in cancer screening practices in the United States: results from the National Health Interview Survey. Cancer 2003;97:1528–40.

United States Cancer Statistics: 1999 Incidence

CDC and the National Cancer Institute (NCI) worked together to produce a set of official federal cancer incidence statistics from each state that has high-quality cancer registry data. United States Cancer Statistics: 1999 Incidence was produced in collaboration with the North American Association of Central Cancer Registries. States provided data for cancer cases diagnosed in 1999, the most recent year for which data were available. Data were provided from 37 states, 6 metropolitan areas, and the District of Columbia. These geographic areas represent about 78% of the U.S. population. Findings showed that the leading cancer in men, regardless of race, is prostate cancer, followed by lung/bronchus and colon/ rectal. Prostate cancer rates were 1.5 times higher in black men than in white men. The leading cancer in women, regardless of race, was breast cancer, followed by lung/bronchus and colon/ rectal in white women, and colon/rectal and lung/bronchus in black women. Breast cancer rates were about 20% higher in white women than in black women. This new report exemplifies the progress achieved in creating a national system of cancer surveillance. Data are now available at regional and state levels for monitoring cancer, planning and evaluating cancer control programs, and conducting research. This information is critical for directing effective cancer prevention and control programs or other interventions.

U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999 Incidence. Atlanta, GA: CDC and National Cancer Institute; 2003.

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Costs of a Screening for Pre-Diabetes Among U.S. Adults: A Comparison of Different Screening Strategies

CDC researchers evaluated various strategies to identify individuals aged 45–74 years with pre-diabetes (either impaired glucose tolerance or impaired fasting glucose). Researchers conducted a cost analysis to evaluate the effectiveness (proportion of cases identified), total costs, and efficiency (cost per case identified) of five detection strategies: an oral glucose tolerance test (OGTT), a fasting plasma glucose (FPG) test, an HbA(1c) test, a capillary blood glucose (CBG) test, and a risk assessment questionnaire. For the first strategy, all individuals received an OGTT. For the last four strategies, only those with a positive screening test received an OGTT. Data were from the Third U.S. National Health and Nutrition Examination Survey, 2000 census, Medicare, and published literature. One-time screening costs were estimated from both a single-payer perspective and a societal perspective. The proportion of pre-diabetes and undiagnosed diabetes identified ranged from 69% to 100% (12.1–17.5 million). The cost per case identified ranged from U.S. dollars 176 to U.S. dollars 236 from a singlepayer perspective and from U.S. dollars 247 to U.S. dollars 332 from a societal perspective. Testing all with OGTT was the most effective strategy, but the CBG test and risk assessment questionnaire were the most efficient. If people are substantially less willing to take an OGTT than a FPG test, then the FPG testing strategy was the most effective strategy. The study showed that there is a tradeoff between effectiveness and efficiency in choosing a strategy. The most favorable strategy depends on if the goal of the screening program is to identify more cases or to pursue the lowest cost per case. The expected percentage of the population willing to take an OGTT is also a consideration.

Zhang P, Engelgau MM, Valdez R, Benjamin SM, Cadwell B, Venkat Narayan KM. Costs a of screening for pre-diabetes among U.S. adults: a comparison of different screening strategies. Diabetes Care 2003;26(9):2536–42.

Estimated Number of Adults with Pre-Diabetes in the US in 2000: Opportunities for Prevention

CDC researchers analyzed data from the Third National Health and Nutrition Examination Survey (NHANES III; 1988–1994) and projected the estimates to the year 2000. Researchers defined impaired glucose tolerance (IGT; 2-h glucose 140–199 mg/dl), impaired fasting glucose (IFG; fasting glucose 110–125 mg/dl), and prediabetes (IGT or IFG) per American Diabetes Association (ADA) criteria. The ADA recently recommended that all overweight people (BMI ≥kg/m(2)) who are ≥45 years of age with pre-diabetes could be potential candidates for diabetes prevention, as could pre-diabetic people aged >25 years with risk factors. In NHANES III, 2-h postload glucose concentrations were done only among subjects aged 40–74 years. Because researchers were interested in overweight people who had both the 2-h glucose and fasting glucose tests, researchers limited their estimates of IGT, IFG, and pre-diabetes to those aged 45–74 years. Overall, 17.1% of overweight adults aged 45–74 years had IGT, 11.9% had IFG, 22.6% had pre-diabetes, and 5.6% had both IGT and IFG. Based on those data, researchers estimated that in the year 2000, 9.1 million overweight adults aged 45–74 had IGT, 5.8 million had IFG, 11.9 million had pre-diabetes, and 3.0 million had IGT and IFG. Almost 12 million overweight individuals aged 45–74 years in the U.S. may benefit from diabetes prevention interventions. The number will be substantially higher if estimation is extended to individuals aged >75 and 25–44 years.

Benjamin SM, Valdez R, Geiss LS, Rolka DB, Venkat Narayan KM. Estimated number of adults with pre-diabetes in the United States in 2000: opportunities for prevention. Diabetes Care 2003;26(3):645–9.

Excess Physical Limitations Among Adults with Diabetes in the U.S. Population, 1997–1999

To estimate the prevalence of physical limitations associated with diabetes among U.S. adults aged 18 years or older, CDC researchers conducted a cross-sectional analysis of the association between diabetes status and physical limitations using data from the 1997–1999 National Health Interview Survey (NHIS). Physical limitation was defined from self-reported degree of difficulty with nine tasks. The results showed that people with diabetes had a higher proportion of any physical limitation than did people without diabetes overall (66% vs. 29%, P<0.001), for both men (59% vs. 24%, P<0.001) and women (72% vs. 34%, P<0.001). Compared with people without diabetes, a higher proportion of people with diabetes had some physical limitation among all age groups, and the difference declined (all P<0.001) with increasing age (46% vs. 18% for 18- to 44-year-olds; 63% vs. 35% for 45- to 64- year-olds; 74% vs. 53% for 65- to 74-year-olds; and 85% vs. 70% for those 75 years old or older). After controlling for demographic characteristics and several other confounders, the odds ratio of physical limitation among adults with diabetes versus those without diabetes was 1.9 (95% CI: 1.8 –2.1). People with diabetes are much more likely to have a physical limitation than those without diabetes. Interventions are needed to reduce progression from impairment to physical limitation and from physical limitation to disability, especially because the prevalence of diabetes is projected to increase dramatically in the next several decades.

Ryerson B, Tierney EF, Thompson TJ, Engelgau MM, Wang J, Gregg EW, Geiss LS. Excess Physical Limitations Among Adults With Diabetes in the U.S. Population, 1997–1999 Diabetes Care 2003;26:206–210.

Lifetime Risk for Diabetes Mellitus in the United States

Although diabetes mellitus is one of the most prevalent and costly chronic diseases in the United States, no estimates have been published of individuals’ average lifetime risk of developing diabetes. To estimate age-, sex-, and race/ethnicity specific lifetime risk of diabetes in the cohort born in 2000 in the United States. Data from the National Health Interview Survey (1984–2000) were used to estimate age-, sex-, and race/ethnicity-specific prevalence and incidence in 2000. U.S. Census Bureau data and data from a previous study of diabetes as a cause of death were used to estimate age-, sex-, and race/ethnicity-specific mortality rates for diabetic and non-diabetic populations. Residual (remaining) lifetime risk of diabetes (from birth to 80 years in 1-year intervals), duration with diabetes, and life-years and quality-adjusted life-years lost from diabetes. The estimated lifetime risk of developing diabetes for individuals born in 2000 is 32.8% for males and 38.5% for females. Females have higher residual lifetime risks at all ages. The highest estimated lifetime risk for diabetes is among Hispanics (males, 45.4% and females, 52.5%). Individuals diagnosed as having diabetes have large reductions in life expectancy. For example, CDC researchers estimated that if an individual is diagnosed at age 40 years, men will lose 11.6 life-years and 18.6 quality-adjusted life-years and women will lose 14.3 life-years and 22.0 quality-adjusted life years. For individuals born in the United States in 2000, the lifetime probability of being diagnosed with diabetes mellitus is substantial. Primary prevention of diabetes and its complications are important public health priorities.

Narayan KMV, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the United States. JAMA 2003;8;290(14):1884–90.

Relationship of Walking to Mortality Among U.S. Adults with Diabetes

Walking is associated with reduced diabetes incidence, but few studies have examined whether it reduces mortality among those who already have diabetes. To estimate the association between walking and the risk for all-cause and cardiovascular disease (CVD) mortality among persons with diabetes, CDC researchers conducted a prospective cohort study of a representative sample of the U.S. population. Researchers sampled 2896 adults 18 years and older with diabetes as part of the 1990 and 1991 National Health Interview Survey, looking at all-cause and CVD mortality for 8 years. Compared with inactive individuals, those who walked at least 2 h/wk had a 39% lower all-cause mortality rate (hazard rate ratio [HRR], 0.61; 95% confidence interval [CI], 0.48-0.78; 2.8% vs 4.4% per year) and a 34% lower CVD mortality rate (HRR, 0.66; 95% CI, 0.45-0.96; 1.4% vs 2.1% per year). Researchers controlled for sex, age, race, body mass index (calculated as weight in kilograms divided by the square of height in meters), smoking, and co-morbid conditions. The mortality rates were lowest for persons who walked 3 to 4 hours/week (all-cause mortality HRR, 0.46; 95% CI, 0.29-0.71; CVD mortality HRR, 0.47; 95% CI, 0.24-0.91) and for those who reported that their walking involved moderate increases in heart and breathing rates (all-cause mortality HRR, 0.57; 95% CI, 0.41-0.80; CVD mortality HRR, 0.69; 95% CI, 0.43-1.09). The protective association of physical activity was observed for persons of varying sex, age, race, body mass index, diabetes duration, comorbid conditions, and physical limitations. Walking was associated with lower mortality across a diverse spectrum of adults with diabetes. One death per year may be preventable for every 61 people who could be persuaded to walk at least 2 hours/week.

Gregg EW, Gerzoff RB, Caspersen CJ, Williamson DF, Narayan KMV. Relationship of walking to mortality among U.S. adults with diabetes. Archives of Internal Medicine 2003;163:1440–47.

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Global Health

Evidence in Support of Foster Care During Acute Refugee Crises

The United Nations High Commissioner on Refugees (UNHCR) and the United Nations International Children’s Emergency Fund (UNICEF) encourage foster care during refugee emergencies. CDC examined evidence to support this policy using data from the 1994 Rwandan refugee crisis. The association of weight gain and acute illness with family status (foster children versus children living with their biological families) was examined using latent growth curve and repeated measures logistic regression analysis. The results indicated that weight gain for all children averaged 0.40 kilograms per month and was associated with the child’s age but not with family status, child’s or caregiver’s sex, caregiver’s marital status, possession of blankets or plastic sheeting, severe malnutrition, month of enrollment, or acute illness. Illness was not more common among foster children than among children living with their biological families. Therefore, this analysis supports the UNHCR/UNICEF recommendation of fostering for unaccompanied children during an acute refugee crisis.

Duerr A, Posner SF, Gilbert M. Evidence in support of foster care during acute refugee crises. American Journal of Public Health 2003;93:1904–9.

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Heart Disease and Stroke

Public Health and Aging: Hospitalizations for Stroke Among Adults Aged 65 Years or Older—United States, 2000

In 2003, stroke cost the United States an estimated $51 billion in lost productivity and health care costs, including $12 billion in nursing home costs. As the U.S. population ages, the impact of stroke may increase. CDC analyzed Medicare hospital claims for persons with stroke who were 65 or older during 2000 for the 50 states and the District of Columbia. In 2000, there were a total of 445,452 hospitalizations among Medicare enrollees that were attributed to stroke (age-adjusted rate of 16.3 per 1,000 enrollees). Stroke hospitalization rates increased with age and were higher among men than among women and among blacks than among whites. Overall, half of the stroke hospitalizations resulted in discharge to home, but more than half of persons aged 85 or older were discharged to a skilled nursing facility. Hospitalizations and discharge outcomes also varied by state. Reducing the burden of stroke in the United States will require primary prevention and control of risk factors, public education, early evaluation and treatment of persons with acute stroke, and effective secondary prevention among persons living with stroke.

Davis HF, Croft JB, Malarcher AM, Ayala C, Antoine TL, Hyduk A, Mensah GA. Public health and aging: hospitalizations for stroke among adults aged >65 years—United States, 2000. MMWR 2003;52(25):586–9.

Serum Total Cholesterol Concentrations and Awareness, Treatment, and Control of Hypercholesterolemia Among U.S. Adults

Whether serum total cholesterol concentrations in the U.S. population continued to decline in the 1990s was unknown. Using data from 4,148 adult participants (aged 20 years and older) in the National Health and Nutrition Examination Survey, 1999–2000, CDC showed that the age-adjusted mean total cholesterol concentration was 5.27 mmol/L (203 mg/dL) among all adults (men, 5.25 mmol/L (203 mg/dL); women, 5.28 mmol/L (204 mg/dL). These cholesterol concentrations have changed little since the period from 1988 through 1994. The low percentage (18%) of adults with controlled blood cholesterol concentrations suggests the need for a renewed commitment to the prevention, treatment, and control of hypercholesterolemia.

Ford ES, Mokdad AH, Giles WH, Mensah GA. Serum total cholesterol concentrations and awareness, treatment, and control of hypercholesterolemia among US adults: findings from the National Health and Nutrition Examination Survey, 1999 to 2000. Circulation 2003;107(17):2185–9.

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HFE Genotype and Transferrin Saturation in the United States

Hemochromatosis, often considered the most common genetic defect in humans, is characterized by lifelong excessive absorption of iron. Iron accumulates in body organs, eventually causing inflammation, cirrhosis of the liver, liver cancer, heart failure, diabetes, impotence, arthritis, or other disorders. Recently, two mutations of the HFE gene, denoted C282Y and H63D, were identified as being responsible for hemochromatosis. However, the percentage of those with a genetic condition who will ultimately develop hemochromatosis is not yet well understood. To further such understanding, CDC arranged for the genetic testing of samples from the Third National Health and Nutrition Examination Survey. In a study published this year in Genetics and Medicine, CDC documented the relationship between the genetic mutations and a screening test for hemochromatosis, elevated transferrin saturation. Among those homozygous for C282Y, 69% screened positive for hemochromatosis and, among those homozygous for H63D, 25% screened positive. Within the C282Y homozygous group, men were at higher risk than women. The associations of H63D homozygosity with hemochromatosis were stronger in people aged 50 years or older than in younger persons. Among Mexican Americans, simple H63D heterozygosity was associated with hemochromatosis. This ground-breaking study will be critical in helping us understand the natural history of hemochromatosis and its resulting iron overload.

Cogswell ME, Gallagher ML, Steinberg KK, Caudill SP, Looker AC, Bowman BA, Gunter EW, Franks AL, Satten GA, Khoury MJ, Grummer-Strawn LM. HFE genotype and transferrin saturation in the United States. Genetics in Medicine 2003;5:304–10.

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Nutrition, Physical Activity and Obesity

Does Overweight in Infancy Persist Through the Preschool Years? An Analysis of CDC Pediatric Nutrition Surveillance System Data

This study was designed to determine whether overweight in infancy (0–11 months) and young childhood (12–35 months) persists through the preschool years. CDC researchers analyzed prospective longitudinal surveillance data from the CDC Pediatric Nutrition Surveillance System. The study included 380,518 low-income children from birth to age 59 months who were born between 1985 and 1990. Overweight was defined as weight-for-height greater than or equal to the 95th percentile based on the 2000 CDC growth reference. Among overweight infants, 35.6% remained overweight at age 1, 27.7% at age 2, 25.1% at age 3, and 23.7% at age 4. In contrast, 8.2% of non-overweight infants became overweight by age 1, 7.9% by age 2, 7.7% by age 3, and 8.3% by age 4. Nearly 63% of overweight 3-year-olds were still overweight a year later, but only 4.1% of non-overweight 3-year-olds became overweight a year later. High-birth-weight children remained in the high percentile of weight-for-height and had the highest prevalence of overweight during all preschool years. However, low-birth-weight children had the highest relative risk of remaining overweight after they became overweight compared with normal and high-birth-weight children. This study is important because no previous studies tracked overweight annually from birth through early childhood using such a large, ethnically diverse sample from birth to less than 5 years of age. Researchers examined children’s risk of remaining or becoming overweight in their later preschool years based on their previous relative weight status. Because of known problems with pediatric overweight and overweight continuing into adulthood, this study suggests that monitoring preschoolers’ height and weight status should be a strategy for preventing obesity in adolescence and adulthood.

Mei Z, Grummer-Strawn LM, Scanlon KS. Does overweight in infancy persist through the preschool years? An analysis of CDC Pediatric Nutrition Surveillance System data. Sozial-und Praventivmedizin 2003; 48:161–7.

Local Ordinances That Promote Physical Activity: A Survey of Municipal Policies

This Utah-based study had three objectives: 1) to identify the types of municipal employees responsible for physical activity policies, 2) to identify municipal ordinances that may influence physical activity, and 3) to determine local government’s intentions to implement such policies. Researchers surveyed all of Utah’s municipalities to measure six physical activity domains: sidewalks, bicycle lanes, shared-use paths, worksites, greenways, and recreational facilities. Data from 74 municipalities revealed that planners made up a small proportion of municipal staff. Relative to cities experiencing slow or medium growth, high-growth cities reported more ordinances encouraging physical activity. Results indicate that states can collect information related to the prevalence of physical activity policies at low cost. These data can be used to develop objectives for community-level physical activity initiatives.

Librett JJ, Yore MM, Schmid TL. Local ordinances that promote physical activity: a survey of municipal policies. American Journal of Public Health 2003;93:1399–403.

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Oral Health

Challenges in Oral Health Surveillance

This review summarizes efforts in the United States to collect oral health data, principally on dental caries (tooth decay) and periodontal diseases, at national, state, and local levels. The review used the definition of surveillance in public health (the ongoing and systematic collection, analysis, and interpretation of outcome- specific data for use in planning, implementing, and evaluating public health practice) to make a case for the need to develop new techniques for surveillance of oral diseases, conditions, and behaviors at the national, state, and local levels. The review also contains information on alternative techniques developed in the past 10 years to collect oral health data. Such alternative means include focusing on secondary data collected at the state and local levels, conducting visual screenings based on the Basic Screening Survey protocol, collecting programmatic and administrative data, accepting self-reports or parental reports, integrating oral health questions into existing national surveys (e.g., Behavioral Risk Factor Surveillance System, Youth Risk Behavior Surveillance System, Pregnancy Risk Assessment Monitoring System), and establishing sentinel surveillance.

Beltrán-Aguilar EB, Malvitz, DM, Lockwood S, Rozier GR, Tomar SL. Oral health surveillance: past, present, and future challenges. Journal of Public Health Dentistry 2003;63(3):141–9.

Use of Postexposure Prophylaxis for HIV by Dental Health Care Personnel

This study analyzed 208 occupational exposures to blood reported by dental health care personnel. CDC researchers concluded that the risk of HIV transmission in dental settings is low, and that using rapid HIV tests may reduce unnecessary use of post-exposure prophylaxis (PEP). It also recommends that dental practices develop comprehensive written procedures for preventing and managing occupational exposures to blood.

Cleveland JL, Barker L, Gooch BF, Beltrami EM, Cardo D. Use of postexposure prophylaxis by dental health care personnel: an overview and updated recommendations. Journal of the American Dental Association 2002;133(12):1619–30.

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Safe Motherhood

Alcohol Use Before and During Pregnancy and the Risk of Small-for-Gestational-Age Birth

Few studies have examined the effect of binge drinking on human fetal growth. The authors studied the effect of binge drinking 3 months before pregnancy and during the last 3 months of pregnancy on small-for-gestational-age (SGA) birth, using data from the Pregnancy Risk Assessment Monitoring System (PRAMS), an ongoing U.S. survey of women who recently gave birth to a live infant. This study included 50,461 women who delivered at term from 1996 to 1999. Overall, binge drinkers before pregnancy were less likely than nondrinkers to have an SGA infant, but moderate or heavy drinkers (4 or more drinks per week) who also binged were 2.2 times more likely to have an SGA infant. Moderate and heavy drinkers in late pregnancy were also more likely to have an SGA infant, but there were only 46 women in these categories, so estimates are imprecise. Vascular effects of alcohol or dietary differences between drinkers and non-drinkers may explain the lower risk of SGA births among some drinkers; however, the relationship between diet, the vascular effects of alcohol, and fetal growth needs more research.

Whitehead N, Lipscomb L. Patterns of alcohol use before and during pregnancy and the risk of small-for-gestationalage birth. American Journal of Epidemiology 2003;158(7):654–62.

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Tobacco Control

Cigarette Smoking Among Adults: United States, 2001

According to this study, 46.2 million adults (22.8%) in the United States were smokers in 2001, down from 25.0% in 1993. From 1965 through 2001, smoking declined faster for non- Hispanic blacks aged 18 or older than for non- Hispanic whites of the same age. Smoking among black women is now lower than among white women; and from 2000 to 2001, for the first time, smoking prevalence among black men was similar to that among white men. Although the decline in the overall prevalence of cigarette smoking in the adult U.S. population is encouraging, it is not occurring at a rate that will result in meeting the 2010 national health objective of 12% overall smoking prevalence. Meeting the CDC-recommended funding levels for implementing and sustaining comprehensive tobacco-control programs will be an important step in reaching the 2010 national objective.

Woolley T, Trosclair A, Husten C, Caraballo RC, Kahende J. Cigarette smoking among adults, United States, 2001. MMWR 2003;52(40):953–6.

Cigarette Smoking-Attributable Morbidity: United States, 2000

This study was conducted by researchers at Roswell Park Research Institute and CDC to estimate the prevalence of people who are alive with diseases caused by smoking. This report includes the first smoking-related morbidity data released by CDC and provides a national estimate of people living with smoking-attributable illness. The study findings showed that at least 8.6 million persons in the United States are living with one or more serious smoking-attributed illnesses. For every one person who dies from a smoking-attributable disease, 20 more people are suffering with serious illness caused by smoking. The cost of smoking-attributable diseases is a major contributor to the $75 billion per year in direct medical costs from smoking. Many more people are harmed by tobacco use than indicated by death rates alone, and more people will experience serious chronic diseases attributed to smoking if they continue to smoke.

Hyland A, Vena C, Bauer J, Li Q, Giovino GA, Yang J, Cummings KM, Mowery P, Fellows J, Pechacek T, Pederson L. Cigarette smoking-attributable morbidity: United States, 2000. MMWR 2003;52(35):842–4.

Differences in Worldwide Tobacco Use by Gender: Findings from the Global Youth Tobacco Survey

The Global Youth Tobacco Survey (GYTS) is the largest survey of its kind in the world, surveying more than one million adolescents from more than 150 countries. It is a collaborative effort of CDC, the World Health Organization and its regional offices, the Canadian Public Health Association, other international agencies, and individual countries. Recent GYTS findings showed that among young people who smoke cigarettes, few differences exist between the sexes. Results from the 2003 study showed that girls and boys are using non-cigarette tobacco products— such as spit tobacco, bidis, and water pipes— at similar rates, and that these rates are often as high or higher than cigarette smoking rates.

Global Youth Tobacco Survey Collaborating Group. Differences in worldwide tobacco use by gender: findings from the Global Youth Tobacco Survey. Journal of School Health 2003;73(6):207–15.

Tobacco-Specific Nitrosamines in Tobacco from U.S. Brand and Non-U.S. Brand Cigarettes

CDC conducted this study to evaluate a variety of chemicals in international cigarettes. This research is done to better understand risk factors that result in adverse health effects from smoking so that public health officials and consumers will be more aware of which chemicals and factors lead to greatest risk. The study results showed that levels of tobacco-specific nitrosamines (TSNAs) in cigarette tobacco vary widely around the world. In most cases, the top-selling U.S. cigarette brand in other countries has significantly higher TSNA levels than the popular local brands. In 11 of 13 countries studied, TSNA levels were significantly higher in Marlboros than in the non-U.S. brands, ranging from 1.3 times higher in Marlboros from the Russian Federation to up to 22 times higher in Marlboros from China. Higher TSNA levels were not found in Marlboros sold in Brazil and Mexico. No significant difference was found between TSNA levels in foreign-manufactured Marlboros and levels in U.S.-manufactured Marlboros exported to the country where they were purchased. Findings also showed that levels of TSNAs in Doral cigarettes purchased in the United States were not significantly different from TSNA levels in Marlboros purchased in the United States.

Ashley D, Beeson MD, Johnson DR, McCraw JM, Richter P, Pirkle JL, Pechacek T, Song S, Watson CH. Tobaccospecific nitrosamines in tobacco from US brand and non-US brand cigarettes. Nicotine & Tobacco Research 2003;5(3):323–31.

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Page last reviewed: November 18, 2005
Page last modified: November 18, 2005
Content source: National Center for Chronic Disease Prevention and Health Promotion

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