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Objective: Diabetes is the sixth leading cause of death in U.S adults, which may be an underestimate because of under-reporting on death certificates. In this study we examined death certificate sensitivity and specificity for diabetes, as well as the factors related to better reporting, in a community-based sample.Research Design and Methods: Death certificates were obtained for 3,209 decedents who were enrolled in the Rancho Bernardo cohort in 1972-1974 and followed through 2003. Diabetes status was reassessed at periodic clinic visits and annual mailed surveys during an average follow-up of 15.2 +/- 7.6 years. Diabetes reported anywhere on death certificates was abstracted. Sensitivity and specificity calculations among diabetic participants were stratified by age, sex, year, place, cause of death, and diabetes medication use.Results: Among 1,641 men and 1,568 women, 378 decedents had a history of diabetes, 168 of whom had diabetes listed anywhere on their death certificates. The sensitivity and specificity were 34.7 and 98.1%. Diabetes reporting on death certificates did not improve over time or vary significantly by age and sex, but sensitivity for diabetes reporting was better for recent (1992-2003) cardiovascular disease (CVD) deaths compared with any other causes of death (48.9 vs. 28.6%, respectively, P < 0.05).Conclusions: Although diabetes reporting on death certificates did not improve over time, sensitivity was better for diabetes in the context of CVD deaths, probably reflecting the increasing recognition that diabetes is a major cardiovascular risk factor. [ABSTRACT FROM AUTHOR]

Objective: To examine whether parental beliefs about routine checkups are associated with children's receipt of timely preventive care.Data Sources: The 2001 United Way Outcomes and Community Impact Program telephone survey of San Diego County, including 918 households with children between 3 and 19 years of age, where the respondent was the parent.Study Design: Cross-sectional analyses examined the relationship between parental beliefs and children's receipt of routine checkups in the past year, using the expanded behavioral model of health services utilization.Results: Approximately 81 percent of children received routine visits as recommended during the prior year. Parents' beliefs about the timing of routine checkups were strongly associated with their children's receipt of recommended routine care, after controlling for important covariates (odds ratio=2.85, 95 percent confidence interval=1.7-4.8). Other significant factors included the parent's educational level, whether the child had a regular source of care, and whether the child was sick in the past year.Conclusions: Multiple factors, including parental beliefs, influence whether children receive recommended routine care. Understanding the role of these factors may help explain why even insured children do not receive preventive health care as recommended, and can be used to target children most likely to lack regular preventive care. [ABSTRACT FROM AUTHOR]

PURPOSE: Studies researching service members' health after deployment have relied on self-reported deployment history, although validity of these data remains unknown. This study compared self-reported and electronic deployment data and explored differences in functional health. METHODS: Self-reported and military deployment data were compared for more than 51,000 participants enrolled in the Millennium Cohort Study (2004-2006). Kappa statistics were used to measure agreement. Analysis of variance was used to assess functional health, as measured by the Medical Outcomes Study Short Form 36-Item Health Survey for Veterans (SF-36V). RESULTS: Of 51,741 participants who completed the initial deployment question, objective records and self-report agreed in 47,355 (92%). Agreement was substantial for deployment status, frequency, and number of deployments (kappa = 0.81, 0.71, and 0.61, respectively). Deployment start dates agreed within 1 month for 82% of participants confirmed as deployed once. Participants' Mental and Physical Component Summary scores from the SF-36V did not differ by agreement level. CONCLUSIONS: These findings indicate substantial agreement between self-reported and objective deployment information and no clinically meaningful differences in functional health for the small proportion with inconsistent deployment information. These findings should be reassuring to investigators who examine military deployment as a determinant of future health. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The authors report the association of balding or graying with BMD in older adults. METHOD: BMD was measured at the spine, hip, and total body in 1,207 participants. Of these, 508 women and 380 men responded to a 1986 survey about balding patterns; in 1994, all participants answered questions about graying. RESULTS: Among men, 10.7% reported graying, and 51.1%, balding; 9.9% of women reported graying, and 9.5%, balding. Models were adjusted for age, body mass index, alcohol consumption, smoking, exercise, calcium supplements, diuretics, glucocorticoids, thyroid hormone, and estrogen. CONCLUSION: Graying was not significantly associated with BMD in either group. Balding men averaged 5% lower total body BMD (p

Insulin resistance is closely associated with both aging and overweight; yet in old age, weight loss is common, although insulin resistance increases. To study this paradox, the authors evaluated the role of insulin resistance in weight change among older adults from the Rancho Bernardo Study cohort. Participants were 725 nondiabetic men and women who were aged 50-89 years when weight and insulin were measured at baseline (1984-1987). The participants were evaluated again in 1992-1996, at which time weight was remeasured. Fasting insulin and homeostasis model assessment (HOMA) measurements were evaluated in separate but parallel statistical models as surrogates for insulin resistance. Insulin resistance, when defined as the top quartile of fasting insulin level or HOMA value, was significantly associated with weight loss before and after adjustment for baseline weight and age (fasting insulin: beta = -1.30 kg, p = 0.01; HOMA: beta = -1.18 kg, p = 0.01). Results were the same for men versus women, for the overweight (body mass index (weight (kg)/height (m)(2)) < or =26.6) versus the normal weight (body mass index >26.6), and for younger persons (age <70 years) versus older persons (age > or =70 years). Insulin-resistant individuals had a threefold increased likelihood of losing 10 or more kg compared with those without insulin resistance. The authors conclude that hyperinsulinemia, independently of age and baseline weight, may have a catabolic effect in the elderly. [ABSTRACT FROM AUTHOR]

Objectives. The purpose of the study was to determine whether breast-feeding is associated with increased longevity or cause-specific survival. Methods. Teachers throughout California identified intellectually gifted children as part of a prospective study begun in the 1920s by Lewis Terman. Information on breast-feeding was available on 1170 subjects, who have been followed for more than 65 years. Results. Survival analysis (Cox proportional hazards model) indicated that breast-feeding was associated with increased longevity, even after adjustment for age at baseline, birthweight, infant health, and childhood socioeconomic status, but only among men, and the association was not significant (P=.15). Neither cardiovascular disease nor cancer survival was significantly associated with duration of breast-feeding for either sex. Survival from deaths due to injuries was positively associated with breast-feeding after adjustment (P=.03) and demonstrate a clear gradient with duration, but only among men. Conclusions. Overall, the present study does not provide strong evidence that breast-feeding is associated with adult longevity. The reduced risk of death from injury may reflect chance, in that the association was significant only for men, or it may reflect psychosocial correlates of breast-feeding practices. [ABSTRACT FROM AUTHOR]

Introduction: Pre-existing chronic conditions (PECs) pose a unique problem for the care of aging trauma populations. However, the relationships between specific conditions and outcomes after injury are relatively unknown. Evaluation of trauma patients is further complicated by their discharge to care facilities, where mortality risk remains high. Traditional approaches for evaluating in-hospital mortality do not account for the discharge of at-risk patients, which constitutes a competing risk event to death. The objective of this study was to evaluate associations between 40 PECs and two clinical outcomes in the context of competing risks among older trauma patients., Methods: This retrospective study evaluated blunt-injured patients aged 55 years and older admitted to a level I trauma centre in 2006-2012. Outcomes were hospital length of stay (HLOS) and in-hospital mortality. Survivors were classified as discharges home or discharges to care facilities. Competing risks regression was used to evaluate each PEC with in-hospital mortality, accounting for discharges to care facilities as competing events. Competing risk estimates were compared to Cox model estimates, for which all survivors to discharge were non-events. Analyses were stratified using injury-based mortality risk at a 50% cutpoint (high versus low)., Results: Among 4653 patients, 176 died in-hospital, 3059 were discharged home, and 1418 were discharged to a care facility. Most patients (98%) were classified with a low mortality risk. Only haemophilia and coagulopathy were consistently associated with longer HLOS. In the low-risk subgroup, in-hospital mortality was most strongly associated with liver diseases, haemophilia, and coagulopathy. In the high-risk group, Parkinson's disease, depression, and cancers showed the strongest associations. Accounting for the competing event altered estimates for 12 of 19 significant conditions., Conclusions: Excess mortality among patients expected to survive their injuries may be attributable to complications resulting from PECs. Discharges to care facilities constitute a bias in the evaluation of in-hospital mortality and should be considered for the accurate calculation of risk. In conjunction with injury measures, consideration of PECs provides physicians with a foundation to plan clinical decisions in older trauma patients., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: To determine the effect of rheumatoid arthritis (RA) disease severity on pregnancy outcomes in pregnant women with and without autoimmune diseases., Methods: A prospective cohort study was conducted using the Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project. Pregnant women with RA enrolled between 2005 and 2013 were selected if they (1) delivered a live-born singleton infant; and (2) completed 3 telephone-based measures of RA disease severity prior to 20 weeks' gestation, including the Health Assessment Questionnaire Disability Index (HAQ-DI), pain score, and patient's global scale. Associations between RA disease severity and preterm delivery, small for gestational age (SGA), or cesarean delivery were tested in unadjusted and multivariate analyses using modified Poisson regression models., Results: The sample consisted of 440 women with RA. Several unadjusted comparisons yielded significant associations. After adjustment for covariates, increasing disease severity was associated with risk for preterm delivery and SGA. For each unit increase in HAQ-DI (0-1), the adjusted relative risk (aRR) for preterm delivery increased by 58% (aRR 1.58, 95% CI 1.17-2.15). Among those with HAQ-DI > 0.5, the aRR for SGA was 1.81 (95% CI 1.01-3.33)., Conclusion: RA disease severity in early pregnancy, as measured in this study, was predictive of preterm delivery and SGA. These findings suggest that the risk of preterm delivery and SGA in women with RA might be lowered if RA is well controlled early in pregnancy.

The association between self-reported smoking and overuse injury in a cohort of young men (n = 900) and women (n = 597) undergoing 12 weeks of standardized military instruction, after adjustment for physical activity, health history, and incoming fitness tests was examined. The outcome includes all International Classification of Diseases, 9th Revision codes related to injuries resulting from cumulative microtrauma (overuse injuries). The short survey asked about the subject's demographics, smoking habits, prior injuries sustained, physical activity level, self-perceived fitness, and (for women) menstrual history. From the survey, 4 questions established smoking behavior: smoked at least 100 cigarettes in lifetime, age smoked a whole cigarette for the first time, how many cigarettes smoked during the last 30 days, and how many cigarettes smoked per day during the last 30 days. None of the adjusted hazard ratios for the smoking questions were associated with an increased risk of overuse injury for either sex. Furthermore, this study did not find a significant association with respect to smoking and all injuries in either men or women. In conclusion, smoking does not appear to be an independent risk factor for overuse injury in either young men or women during 12 weeks of standardized military instruction., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

Objective: Studies examining the association of dairy consumption with incident CHD have yielded inconsistent results. The current prospective study examined the association between dairy consumption and CHD in a population-based sample of older community-dwelling adults., Design: Baseline CHD risk factors were assessed and an FFQ was self-administered. Participants were followed for morbidity and mortality with periodic clinic visits and annual mailed questionnaires for an average of 16?2 years, with a 96% follow-up rate for fatal and non-fatal CHD., Setting: Community., Subjects: Participants were 751 men and 1008 women aged 50–93 years who attended a clinic visit in 1984–1987., Results: At baseline the mean age was 70.6 (SD 9.8) years for men and 70.1 (SD 9.3) years for women. Participants who developed CHD during follow-up were significantly older (P < 0.001), had higher BMI (P = 0.035) and higher total cholesterol (P = 0.050), and were more likely to be male (P < 0.001), diabetic (P = 0.011) and hypertensive (P < 0.001), than those who did not develop CHD. Multivariate regression analyses adjusting for age, BMI, diabetes, hypertension, LDL-cholesterol and oestrogen use (in women) indicated that women who consumed low-fat cheese ‘sometimes/often’ and women who consumed non-fat milk ‘sometimes/often’ had an increased risk of incident CHD (hazard ratio 52.32; 95% CI 1.57, 3.41) and CHD (hazard ratio 51.48; 95% CI 1.02, 2.16) compared with women who ‘never/rarely’ ate these dairy products., Conclusions: Woman with higher intake of low-fat cheese and non-fat milk seem to have a higher risk of incident CHD. This needs further investigation considering recent evidence of cardiovascular benefits from certain dairy fat.

Purpose: The objective of this study was to ascertain whether a relationship exists between pre-diagnostic serum levels of 25-hydroxyvitamin D (25(OH)D) and risk of breast cancer in young women., Methods: About 600 incident cases of breast cancer were matched to 600 controls as part of a nested case-control study that utilized pre-diagnostic sera. Logistic regression was used to assess the relationship between serum 25(OH)D concentration and breast cancer risk, controlling for race and age., Results: According to the conditional logistic regression for all subjects, odds ratios for breast cancer by quintile of serum 25(OH)D from lowest to highest were 1.2, 1.0, 0.9, 1.1, and 1.0 (reference) (p trend = 0.72). After multivariate regression for subjects whose blood had been collected within 90 days preceding diagnosis, odds ratios for breast cancer by quintile of serum 25(OH)D from lowest to highest were 3.3, 1.9, 1.7, 2.6, and 1.0 (reference) (p trend = 0.09)., Conclusions: An inverse association between serum 25(OH)D concentration and risk of breast cancer was not present in the principal analysis, although an inverse association was present in a small subgroup analysis of subjects whose blood had been collected within 90 days preceding diagnosis. Further prospective studies of 25(OH)D and breast cancer risk are needed.

This prospective study evaluated the association of self-reported health habits and behaviors in 2,930 Navy recruits with poor training outcomes, defined as graduating late or separating from training. Although 17% of the men and 21% of the women had a poor training outcome, results suggest that some self-reported measures were associated with poor training outcomes. Men who did not run or jog at least 1 month before basic training or had a previous lower limb injury without complete recovery and women reporting the same or less physical activity compared with their same-age counterparts were more likely to have a poor training outcome. An important first step in decreasing poor training outcomes is encouraging incoming recruits to participate in physical activity and taking steps to identify and rehabilitate recruits who are not completely healed from a lower limb musculoskeletal injury before reporting to basic training.

A wide range of epidemiologic and laboratory studies combined provide compelling evidence of a protective role of vitamin D on risk of breast cancer. This review evaluates the scientific evidence for such a role in the context of the A.B. Hill criteria for causality, in order to assess the presence of a causal, inverse relationship, between vitamin D status and breast cancer risk. After evaluation of this evidence in the context of Hill's criteria, it was found that the criteria for a causal relationship were largely satisfied. Studies in human populations and the laboratory have consistently demonstrated that vitamin D plays an important role in the prevention of breast cancer. Vitamin D supplementation is an urgently needed, low cost, effective, and safe intervention strategy for breast cancer prevention that should be implemented without delay. In the meantime, randomized controlled trials of high doses of vitamin D(3) for prevention of breast cancer should be undertaken to provide the necessary evidence to guide national health policy.

Objective: To examine associations of gravidity and parity with all-cause, cardiovascular disease (CVD), and coronary heart disease (CHD) mortality in postmenopausal women., Design: Prospective cohort study., Setting: Rancho Bernardo, a southern California community., Patient(s): One thousand two hundred ninety-four postmenopausal women ages 50-96 who attended a 1984-87 research clinic visit at which reproductive and medical histories were obtained and who were followed through 2007., Intervention(s): None., Main Outcome Measure(s): All-cause, CVD, CHD, and non-CHD CVD mortality, determined by nosologist-coded death certificates., Result(s): Average baseline age was 70.6 ± 9.2. Numbers of pregnancies ranged from 0 to 13 (median = 2); births ranged from 0 to 11 (median = 2). During a median of 19.3 years of follow-up, 707 women (54.6%) died, with 46.5% attributed to CVD, 20.5% to CHD, and 26.0% to non-CHD CVD. Trend analyses showed inverse associations of gravidity with CVD mortality and non-CHD CVD mortality. Women with four or more pregnancies were less likely than nulligravidas to have fatal CVD (hazard ratio [HR] = 0.63, 95% confidence interval [CI] = 0.40-0.99) and non-CHD CVD (HR = 0.48, 95% CI = 0.26-0.91) independent of age, years postmenopause, obesity, and HDL. Associations increased after the first decade of follow-up. Parity and gravidity were not associated with overall or CHD mortality., Conclusion(s): High gravidity was associated with reduced CVD and non-CHD CVD mortality in postmenopausal women. Protective associations could reflect biological mechanisms that occur with repeated pregnancy or greater social support related to family size among multiparous women., (Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Low serum levels of 25-hydroxyvitamin D [25(OH)D] have been associated with a high risk of breast cancer. Since publication of the most current meta-analysis of 25(OH)D and breast cancer risk, two new nested case-control studies have emerged., Materials and Methods: A PubMed search for all case-control studies on risk of breast cancer by 25(OH)D concentration identified 11 eligible studies. Data from all 11 studies were combined in order to calculate the pooled odds ratio of the highest vs. lowest quantile of 25(OH)D across all studies., Results: The overall Peto odds ratio summarizing the estimated risk in the highest compared to the lowest quantile across all 11 studies was 0.61 (95% confidence interval 0.47, 0.80)., Conclusion: This study supports the hypothesis that higher serum 25(OH)D levels reduce the risk of breast cancer. According to the review of observational studies, a serum 25(OH)D level of 47 ng/ml was associated with a 50% lower risk of breast cancer.

Objective: To examine whether dietary self-monitoring is related to weight loss in overweight children and whether perceived social support or dietary self-efficacy affects this relation. Design. Longitudinal, behavioral intervention study., Subjects: The study population included 153 children, aged 7-12 years, with daily food records from a 20-week weight loss program in San Diego, California, USA, conducted between 1999 and 2002. Methods. Self-monitoring was assessed using two methods: a weekly index as a measure of competency (possible range -7 to +35) and recording sufficiency for total compliance (percentage of days)., Results: Significantly greater decreases in percentage overweight were found for children with recording competency at or above the median (mean change: -13.4% vs. -8.6%; p < 0.001) or who were compliant in recording -50% of the days (mean change: -13.0% vs. ?8.4%; p < 0.001). Using hierarchical linear regression, children who had a higher average weekly monitoring index or recorded sufficiently on more days had significantly greater decreases in percent overweight, after adjusting for age, sex, SES, race/ethnicity and baseline percent overweight (p < 0.001). Perceived social support at baseline and dietary self-efficacy were not related to self-monitoring or change in percent overweight in this sample., Conclusion: As has been demonstrated with adults and adolescents, self-monitoring in children was associated with greater decreases in percent overweight. However, dietary self-efficacy and perceived social support were not related to how frequently or thoroughly they monitored dietary intake.

Objective: Assess age and sex differences in the association of obesity and other CVD risk factors with osteoarthritis (OA) in Southern California American Indian/Alaska Native (AIAN) adults., Design: Cross-sectional study., Setting: Southern California., Participants: 6,299 AIAN adults aged 35+ years from health clinic system., Main Outcome Measures: Osteoarthritis prevalence., Results: Age-adjusted OA prevalence was 16.5% in women and 11.5% in men. OA prevalence increased with age and was higher in women. Very and morbid levels of obesity were associated with higher OA prevalence in some age groups. Hypertension was strongly associated with increased OA and current smoking tended to be associated with increased OA. For men, we found no association between diabetes and OA; however, diabetes was associated with more OA for women aged 35-54 years., Conclusions: Southern California AIANs may have lower OA prevalence than the US population as a whole. Comparisons of OA prevalence with other AIAN communities were not possible due to lack of other similar published results. Further studies are needed to determine the impact of OA within this understudied minority population.

Objective: To study the sex-specific association of angina pectoris with mortality in community-dwelling older adults with and without diabetes., Methods: Baseline prevalence of angina was evaluated in 822 men and 1184 postmenopausal women aged 50-89 years at the 1984-1987 Rancho Bernardo Study clinic visit, when an oral glucose tolerance test (OGTT) and the Rose angina questionnaire were administered. All-cause and coronary heart disease (CHD) mortality were assessed after an average follow-up period of 13.2 years. Sex-specific Cox proportional hazard models were used to examine the independent association of angina with mortality by glucose tolerance category., Results: At baseline, average age was 71 years for both sexes; 61 men (7.4%) and 142 women (12.0%) had angina. Overall, 129 men (15.9%) and 130 women (11.0%) had type 2 diabetes; 228 men (27.7%) and 357 women (30.2%) had impaired glucose tolerance (IGT). During follow-up, 485 men (59%) and 557 women (47%) died, of whom 103 men (21.2%) and 104 women (18.7%) had fatal CHD. Women with diabetes and angina had a 3-4-fold greater risk of dying from CHD than women with diabetes but without angina, independent of covariates. Women with angina and IGT had twice the risk of CHD mortality compared with women with IGT but without angina. A smaller increased risk of fatal CHD in men was not statistically significant., Conclusions: Angina was associated with an increased risk of dying from CHD among women, especially among those who also had IGT or diabetes.

Low birth weight is associated with poorer cognitive function from infancy through early adulthood, but little is known about low birth weight and cognitive performance in the elderly. This study examines the association of birth weight with cognitive function in community-dwelling older women. Participants were 292 community-dwelling women aged 55-89 (median = 71 years) who attended a 1988-91 clinic visit when cognitive function was assessed, and responded to a 1991 mailed questionnaire assessing birth weight. All analyses were adjusted for age and education. Birth weight ranged from 2 to 12 pounds (lbs; mean = 7.4 +/- 1.9). When birth weight was categorized into tertiles (2-6.9 lbs, 7-8 lbs, and 8.1-12.4 lbs), women in the lowest tertile had significantly lower ("poorer") scores on Serial 7's, a test of concentration and calculation (p < 0.05). Other birth weight categorizations (lowest quartile or quintile, or birth weight <5.5 lbs vs. 5.6-8.9 lbs and >or=9 lbs) did not improve the prediction of poor performance on Serial 7's. Birth weight as a continuous variable was significantly and positively associated with Serial 7's test scores (p = 0.04). Results suggest that small decrements in cognitive function tasks involving calculation may persist throughout life in women who were of relatively low birth weight. Although this association could be spurious, it deserves further evaluation.

Context: Although numerous studies have explored the relation of IGF-I with cancer incidence, few have investigated the association between IGF-I and cancer mortality., Objective: This study examined the association of serum IGF-I levels with cancer mortality in older community-dwelling men., Design, Setting, and Participants: We conducted a prospective, population-based study of 633 men aged 50 yr and older (mean = 73) who attended a 1988-1991 research clinic visit when blood was obtained for measurement of IGF-I. Participants were followed for vital status through July 2006., Main Outcome Measure: All-cancer mortality was assessed., Results: Median IGF-I was 96 ng/ml. During the 18-yr follow-up, 368 deaths occurred; 74 (20%) were due to cancer. Cox regression analyses showed a significant quadratic association between IGF-I and all-cancer mortality (P = 0.039). Higher levels of IGF-I were associated with progressively higher risk of cancer death after adjusting for age, IGF-binding protein-1, adiposity, exercise, current smoking, and previous cancer. The adjusted risk of cancer death was statistically significant for IGF-I levels above 120 ng/ml, with magnitudes of effect ranging from 1.61 [95% confidence interval (CI) = 1.28-2.02] to 2.61 (95% CI = 1.46-4.64). For the 46% of men with IGF-I above 100 ng/ml, the risk of fatal cancer was 1.82 (95% CI = 1.11-2.96) compared to the risk with lower levels., Conclusions: Higher serum IGF-I in older men is associated with increased risk of cancer death, independent of age, adiposity, lifestyle, and cancer history. These results suggest caution in the use of IGF-I-enhancing therapies to slow the adverse effects of aging.

Results of studies comparing overall obesity and abdominal adiposity or body fat distribution with risk of mortality have varied considerably. We compared the relative importance and joint association of overall obesity and body fat distribution in predicting risk of mortality. Participants included 5,799 men and 6,429 women aged 30-102 years enrolled in the third National Health and Nutrition Examination Survey who completed a baseline health examination during 1988-1994. During a 12-year follow-up (102,172 person-years), 1,188 men and 925 women died. In multivariable-adjusted analyses, waist-to-thigh ratio (WTR) in both sexes (Ptrend<0.01 for both) and waist-to-hip ratio (WHR) in women (Ptrend 0.001) were positively associated with mortality in middle-aged adults (30-64 years), while BMI and waist circumference (WC) exhibited U- or J-shaped associations. Risk of mortality increased with a higher WHR and WTR among normal weight (BMI 18.5-24.9 kg/m2) and obese (BMI>or=30.0 kg/m2) adults. In older adults (65-102 years), a higher BMI in both sexes (Ptrend<0.05) and WC in men (Ptrend 0.001) were associated with increased survival, while remaining measures of body fat distribution exhibited either no association or an inverse relation with mortality. In conclusion, ratio measures of body fat distribution are strongly and positively associated with mortality and offer additional prognostic information beyond BMI and WC in middle-aged adults. A higher BMI in both sexes and WC in men were associated with increased survival in older adults, while a higher WHR or WTR either decreased or did not influence risk of death.

Objective: To evaluate the association of thyroid stimulating hormone levels with cognitive function and depressed mood in a community-based sample., Design: Cross-sectional study., Setting: Clinic visit in 1999- 2003., Participants: Community-dwelling men (N=447) and women (N=663) aged 42-99 years., Measurement: Cognitive function was assessed with the Buschke-Fuld Selective Reminding Test, the Modified Mini-Mental State Examination, Trails B, and category fluency. Depressed mood was assessed with the Beck Depression Inventory (BDI). A fasting blood sample was obtained for thyroid stimulating hormone (TSH) measurement., Results: Mean age was 73.6 +/- 10.0 in men and 74.3 +/- 10.4 in women. Mean TSH was 1.9 mu IU/ml in both sexes; 9.0% of men and 24% of women reported thyroid medication use. Mean BDI scores were 4.6 +/- 4.1 in men and 5.2 +/- 4.3 in women; 9% of men and 11% of women used antidepressants. Before and after adjustment for covariates or exclusion of participants taking thyroid hormones, no associations were observed between TSH and cognitive function (ps > 0.10). TSH was inversely associated with BDI (p=0.03) in men, but not women., Conclusions: Thyroid stimulating hormone level was unrelated to cognitive function in men and women, and was inversely associated with depressed mood in men only, possibly reflecting the greater use of both thyroid medications and antidepressants by women.

Purpose: The association of overall obesity and abdominal adiposity in predicting risk of all-cause mortality in white and black adults was compared., Methods: This prospective study included a national sample of 3219 non-Hispanic white and 2,561 non-Hispanic black adults 30 to 64 years of age enrolled in the third National Health and Nutrition Examination Survey during 1988-1994. Multiple measures of adiposity were measured and calculated, including body mass index (BMI), waist circumference, waist-to-hip ratio (WHR), and waist-to-thigh ratio (WTR). Vital status was ascertained with the National Death Index through 2000., Results: During 12 years of follow-up (51,133 person-years), 188 white and 222 black adults died. After adjustment for age, education, smoking, and existing disease, positive dose-response associations between WTR and mortality in both sexes and races, and WHR in white and black women were observed (p(trend) < 0.05 for all). These results were unchanged after additional adjustment for BMI. In contrast, BMI and waist circumference alone exhibited curvilinear-shaped associations with mortality. A higher WTR was associated with a higher risk of mortality among normal weight (BMI: 18.5-24.9 kg/m(2)) and obese (BMI: > or =30.0 kg/m(2)) white and black adults., Conclusions: These results suggest ratio measures of abdominal adiposity, particularly WTR in both sexes and WHR in women, strongly and positively predict mortality, independent of BMI, among white and black adults. Furthermore, WTR offers additional prognostic information beyond that provided by BMI alone.

Objectives: Posttraumatic stress disorder (PTSD) results from experiencing or witnessing traumatic, life-threatening events including combat-related experiences. The purpose of this study was to investigate the prevalence of PTSD symptoms and diagnosis, self-reported exposures, and functional health in a large cross-section of the U.S. military., Methods: This study used baseline Millennium Cohort data (July 2001 to June 2003) of 75,156 U.S. military members to assess the population-based prevalence of PTSD symptoms, self-reported exposures, and functional health as measured by the Medical Outcomes Study Short Form 36-Item Health Survey for Veterans (SF-36V)., Results: PTSD diagnosis without current symptoms was reported by 953 respondents (1.2%, weighted), 1,490 respondents (2.1%, weighted) reported no diagnosis but reported PTSD symptoms, and 287 respondents (0.4%, weighted) reported diagnosis and current symptoms. Self-reported exposure to chemical or biological warfare agents, protective countermeasures, or hearing alarms were associated with PTSD symptoms independent of other combat-like exposures. Physical health was similar among those with PTSD diagnosis and current PTSD symptoms. However, compared with the overall cohort, lower mental health summary means for those reporting current PTSD symptoms (mean = 27.8), current symptoms and diagnosis (mean = 24.6), and diagnosis without current symptoms (mean = 47.5) were found., Conclusions: Results suggest a 2.0% prevalence of PTSD symptoms without diagnosis and that self-reported threatening exposures were significantly associated with PTSD symptoms. Mental and physical health scores of those with current PTSD symptoms appear diminished, but suggest a return to cohort levels with resolution of PTSD symptoms.

Objectives: The purpose of this study was to examine the association of progressive versus stable peripheral arterial disease (PAD) with the risk of future cardiovascular disease (CVD) events., Background: An independent association between PAD, defined by low values of the ankle-brachial index (ABI), and future CVD risk has been demonstrated. However, the prognostic significance of declining versus stable ABI has not been studied., Methods: We recruited 508 subjects (59 women, 449 men) from 2 hospital vascular laboratories in San Diego, California. ABI and CVD risk factors were measured at Visit 2 (1990 to 1994). ABI values from each subject's earliest vascular laboratory examination (Visit 1) were abstracted from medical records. Mortality and morbidity were tracked for 6 years after Visit 2 using vital statistics and hospitalization data., Results: In multivariate models adjusted for CVD risk factors, very low (<0.70) and, in some cases, low (0.70 < or = ABI <0.90) Visit 2 ABIs were associated with significantly elevated all-cause mortality, CVD mortality, and combined CVD morbidity/mortality at 3 and 6 years. Decreases in ABI of more than 0.15 between Visit 1 and Visit 2 were significantly associated with an increased risk of all-cause mortality (risk ratio [RR]: 2.4) and CVD mortality (RR: 2.8) at 3 years, and CVD morbidity/mortality (RR: 1.9) at 6 years, independent of Visit 2 ABI and other risk factors., Conclusions: Progressive PAD (ABI decline >0.15) was significantly and independently associated with increased CVD risk. Patients with decreasing ABI may be candidates for more intensive cardiovascular risk factor management.

The authors developed a three-week faculty development program, "Addressing the Health Needs of the Underserved" (funded by Title VII), and later incorporated a year long Fellowship in Underserved Medicine. This article describes these programs from 1999 to 2007, focusing on participants, curricula, outcomes, and potential impact.Participants (n = 107) in the three-week faculty development program came from 29 states and Puerto Rico, with more than 25% from underrepresented minorities in the health professions. The program focused on three skill sets: creating and sustaining community programs and partnerships; core faculty development/academic skills; and personal and professional renewal. Outcomes measured with follow-up surveys and interviews in 2003 revealed that since their participation, the first 53 participants to complete the program had created 30 new or modified residency curricula, 19 new student curricula, and 7 new student-run free clinic projects. Pre-post measures from 2003 to 2007 identified an overall 46% increase in skill confidence, with the greatest increase reported for designing a promotora (community lay health promoter) program. Participants expressed particular satisfaction with becoming part of a national community of scholars in the field of underserved medicine.For the year long, on-site Fellowship in Underserved Medicine, four of the first six fellows who completed the fellowship were former University of California-San Diego Student-Run Free Clinic Project student leaders who left San Diego to complete family medicine residency and returned to complete the fellowship. All six currently work with underserved communities as their primary focus, five in the United States and one internationally with Doctors Without Borders.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Objective: Case series suggest that nonalcoholic fatty liver disease (NAFLD) is associated with increased all-cause and cardiovascular mortality. The current study compared the survival of subjects with and without suspected NAFLD in a population-based cohort, and placed the finding in the context of previously published case series., Methods: Primary analysis assessed mortality for NHANES-III participants with and without suspected NAFLD using the National Death Index. Suspected NAFLD was based upon unexplained ALT elevation. The Olmsted County and Cleveland Clinic case series were also used for comparison. Survivals were compared using Proportional Hazards Model and direct age standardization., Results: The NHANES cohort included 980 with and 6,594 subjects without suspected NAFLD. Over a mean of 8.7 yr, suspected NAFLD had a hazards ratio of 1.37 (95% CI 0.98-1.91) for all-cause mortality. In the 45-54 age group, suspected NAFLD had significantly higher all-cause (4.40 95% CI 1.27-13.23) and cardiovascular mortality (8.15, 95% CI 2.00-33.20) after adjusting for conventional cardiovascular risk factors. The age-standardized rate per 10,000 per year was 129 (95% CI 118-140) for the NHANES non-NAFLD cohort, 154 (95% CI 116-198) for the NHANES suspected NAFLD cohort, 214 (95% CI 157-279) for the Olmsted County series, and 426 (95% CI 298-573) for the Cleveland Clinic series., Conclusion: The magnitude of mortality risk in NAFLD depends on the setting and method of ascertainment. Suspected NAFLD in the 45-54 age group is a strong independent risk factor for cardiovascular death and warrants further cardiovascular risk management guidelines.

Previous studies of leptin with cardiovascular disease (CVD) risk factors have been limited by clinical samples or lack of representation of the general population. This cross-sectional study, designed to examine whether leptin or insulin may mediate the endogenous relation of obesity with metabolic, inflammatory, and thrombogenic cardiovascular risk factors, included 522 men and 514 women aged >or=40 years who completed a physical examination during the third National Health and Nutrition Examination Survey. Participants were free of existing CVD, cancer (except non-melanoma skin cancer), diabetes, or respiratory disease. In multivariable analyses adjusted for race/ethnicity and lifestyle factors, waist circumference (WC) was positively associated with blood pressure, triglyceride, LDL cholesterol, total cholesterol:HDL ratio, apolipoprotein B, C-reactive protein (CRP), and fibrinogen concentrations, and negatively associated with HDL cholesterol and apolipoprotein A1 levels. The associations of WC with the metabolic CVD risk factors were largely attenuated after adjustment for insulin levels, while the associations of WC with the inflammatory and thrombogenic factors (CRP and fibrinogen, respectively) were largely explained by adjustment for leptin concentrations. However, leptin levels were not independently associated with CRP and fibrinogen in men and CRP in women when adjusted for WC. Positive associations of leptin and insulin with fibrinogen in women, independent of WC, were noted. These results suggest that insulin may be an important mediator of the association of obesity with metabolic but not inflammatory or thrombogenic CVD risk factors, while leptin does not appear to influence cardiovascular risk through a shared association with these risk factors. However, we cannot rule out the possibility that leptin and insulin influence cardiovascular risk in women through independent effects on fibrinogen concentrations.

Background: Although studies have outlined the benefit of diversity in academic medicine, the number of underrepresented minority (URM) faculty remains low. In 1998, University of California, San Diego (UCSD) School of Medicine with the Hispanic Center of Excellence began a formalized proactive faculty development program. Over the past 10 years, recruitment and retention of URM junior faculty have increased. We undertook a study to explore factors associated with this improvement., Methods: Semistructured interviews were conducted with 18 out of 26 URM and 12 out of 26 randomly chosen non-URM assistant and associate faculty members throughout 2005. Interview content, based on a conceptual framework from Joanne Moody, included career path, knowledge and experience with faculty development programs and perceived faculty standing., Results: URM faculty were more likely than majority faculty (44% vs. 8%, p = 0.04) to mention the importance of a role model in choosing their career path. URM faculty participated in faculty development programs at a higher rate than majority faculty (78% vs. 17%, p < 0.001), were more likely to find out about programs through personal contact (94% vs. 42%, p = 0.001) and reported more personal contacts prior to participation (78% vs. 33%, p = 0.02). URM faculty were older, graduated earlier and were more likely hired into a staff position prior to faculty appointment (61% vs. 17%, p = 0.02)., Conclusions: Academic medical centers may find competitive URM candidates in staff positions and alternative faculty tracks within their institution. Informing URM faculty often and personally about opportunities for faculty development may increase their participation in career development programs and improve retention.