Virginia W Chang
Associate Professor of Social and Behavioral Sciences
Virginia W. Chang, MD, PhD is Associate Professor of Global Public Health at NYU School of Global Public Health, Associate Professor of Population Health at NYU School of Medicine, and Affiliated Associate Professor in the Department of Sociology at NYU. Dr. Chang is a graduate of the Inteflex Program at the University of Michigan, where she received her BS and MD degrees. She then completed a residency in internal medicine, fellowship training with the Robert Wood Johnson Foundation Clinical Scholars Program, and a PhD in sociology, all at the University of Chicago. Prior to joining NYU, Dr. Chang was in the Division of General Internal Medicine at the Perelman School of Medicine at the University of Pennsylvania and a staff physician at the Philadelphia Veterans Administration Medical Center.
As a physician and sociologist, Dr. Chang integrates perspectives from medicine, epidemiology, sociology, and demography in her research. Much of her work has focused on obesity and health disparities, engaging topics such as the influence of socially structured context (e.g., racial segregation, income inequality, neighborhood social/physical disorder) on obesity; the relationship of obesity to mortality and disability; the influence of weight status on the quality of medical care; socioeconomic disparities in health and mortality; and the inter-relationships between health, medical technologies, and stratification.
Her research program has been funded by the NICHD, NHLBI, and NIA of the National Institutes of Health, the Veterans Health Administration, the Robert Wood Johnson Foundation, the Measy Foundation, the American Diabetes Association, and the Russell Sage Foundation. She is the recipient of numerous awards, including the Society of General Internal Medicine Award for Outstanding Junior Investigator of the Year and the Marjorie A. Bowman Award from the University of Pennsylvania School of Medicine for achievement in the health evaluation sciences. Dr. Chang is also a Diplomate of the American Board of Internal Medicine.
Dr. Chang’s publications span a variety of disciplines, including journals such as JAMA, Annals of Internal Medicine, JAMA Internal Medicine, Health Affairs, American Journal of Public Health, American Journal of Epidemiology, Journal of Health & Social Behavior, Social Science & Medicine, Demography, and Social Forces. She was recently an Associate Editor of the Journal of Health & Social Behavior.
BS, Biomedical Sciences and Philosophy, University of Michigan, Ann Arbor, MIMD, Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MIMA, Sociology, University of Chicago, Chicago, ILPhD, Sociology, University of Chicago, Chicago, IL-Fellow, Robert Wood Johnson Clinical Scholars Program, University of Chicago, Chicago, ILResident, Department of Medicine, University of Chicago, Chicago, ILIntern, Department of Medicine, University of Chicago, Chicago, IL-Diplomate, American Board of Internal MedicineLicensed Medical Physician, Commonwealth of Pennsylvania
Majorie A. Bowman Research Award, University of Pennsylvania School of Medicine (2010)Outstanding Junior Investigator of the Year, Society of General Internal Medicine (2008)Robert Austrian Faculty Award for Health Evaluation Reserach, Department of Medicine, University of Pennsylvania School of Medicine (2008)Physician Faculty Scholars Award, Robert Wood Johnson Foundation (2007)Finalist, Hamolsky Junior Facutly Award, Society of General Internal Medicine (2004)Finalist, Richard Saller Prize for Best Dissertation in the Division of the Social Sciences, University of Chicago (2003)Graduate University Fellowship, University of Chicago (2001)Eli G. Rochelson Memorial Award for Excellence in Pulmonary and Critical Care Medicine, University of Michigan Medical School (1994)Biomedical Research Program Scholarship, University of Michigan Medical School (1991)James B. Angell Scholar, University of Michigan (1988)William J. Branstrom Freshman Prize, University of Michigan (1986)
Global HealthHealth DisparitiesInternal MedicineObesityPopulation HealthSocial Behaviors
Patient-Provider Communication Quality, 2002-2016: A Population-based Study of Trends and Racial DifferencesCho, G., & Chang, V. W.
Journal titleMedical care
Page(s)324-331AbstractBackground: Effective patient-provider communication (PPC) can improve clinical outcomes and therapeutic alliance. While PPC may have improved over time due to the implementation of various policies for patient-centered care, its nationwide trend remains unclear. Objective: The objective of this study was to examine trends in PPC quality among US adults and whether trends vary with race-ethnicity. Research Design: A repeated cross-sectional study. Participants: We examine noninstitutionalized civilian adults who made 1 or more health care visits in the last 12 months and self-completed the mail-back questionnaire in the Medical Expenditure Panel Survey, 2002-2016. Measures: Outcomes include 4 top-box measures, each representing the odds of patients reporting that their providers always (vs. never, sometimes, usually) used a given communication behavior in the past 12 months regarding listening carefully, explaining things understandably, showing respect, and spending enough time. A linear mean composite score (the average of ordinal responses for the behaviors above) is also examined as an outcome. Exposures include time period and race-ethnicity. Results: Among 124,158 adults (181,864 observations), the quality of PPC increases monotonically between 2002 and 2016 for all outcomes. Between the first and last periods, the odds of high-quality PPC increase by 37% [95% confidence interval (CI)=32%-43%] for listen, 25% (95% CI=20%-30%) for explain, 41% (95% CI=35%-47%) for respect, and 37% (95% CI=31%-43%) for time. The composite score increases by 3.24 (95% CI=2.87-3.60) points. While increasing trends are found among all racial groups, differences exist at each period. Asians report the lowest quality throughout the study period for all outcomes, while Blacks report the highest quality. Although racial differences narrow over time, most changes are not significant. Conclusions: Our findings suggest that providers are increasingly likely to use patient-centered communication strategies. While racial differences have narrowed, Asians report the lowest quality throughout the study period, warranting future research.
Trends in Prescription Opioid and Nonopioid Analgesic Use by Race, 1996–2017Cho, G., & Chang, V. W.
Journal titleAmerican journal of preventive medicine
Page(s)422-426AbstractIntroduction: Identifying racial differences in trends in prescription opioid use (POU) is essential for formulating evidence-based responses to the opioid epidemic. This study analyzes trends in the prevalence of POU and exclusive nonopioid analgesic use (ENA) by race–ethnicity. Methods: The Medical Expenditure Panel Survey was used to examine analgesic use among civilian adults without cancer (age ≥18 years) between 1996 and 2017. The outcome classified individuals into 3 mutually exclusive categories of prescription analgesic use: no prescription analgesic, POU, and ENA. Analyses were conducted between December 2020 and April 2021. Results: Among 250,596 adults, baseline analgesic usage varied with race–ethnicity, where non-Hispanic Whites had the highest POU (11.9%), and it was as prevalent as ENA (11.3%). Non-Hispanic Blacks and Hispanics had lower POU at baseline (9.3% and 9.6%, respectively), and ENA exceeded POU. Subsequently, POU increased across race–ethnicity with concomitant decreases in ENA, eventually eclipsing ENA in Whites and Blacks but not among Hispanics. Although POU among Blacks became as prevalent as it was among Whites in the 2000s–2010s, POU among Hispanics remained lower than the other groups throughout the 2000s–2010s. After the adoption of prescribing limits, POU declined across race–ethnicity by comparable levels in 2016–2017. Conclusions: Blacks and Hispanics were less likely to use opioids when they first became widely available for noncancer pain. Subsequently, POU displaced ENA among Whites and Blacks. Although POU is often associated with Whites, a significant proportion of the Black population may also be at risk. Finally, although lower POU among Hispanics may be protective of misuse, it could represent undertreatment.
Ultra-processed food consumption among US adults from 2001 to 2018Juul, F., Parekh, N., Martinez-Steele, E., Monteiro, C. A., & Chang, V. W.
Journal titleAmerican Journal of Clinical Nutrition
Page(s)211-221AbstractBACKGROUND: Accumulating evidence links ultra-processed foods to poor diet quality and chronic diseases. Understanding dietary trends is essential to inform priorities and policies to improve diet quality and prevent diet-related chronic diseases. Data are lacking, however, for trends in ultra-processed food intake. OBJECTIVES: We examined US secular trends in food consumption according to processing level from 2001 to 2018. METHODS: We analyzed dietary data collected by 24-h recalls from adult participants (aged >19 y; N = 40,937) in 9 cross-sectional waves of the NHANES (2001-2002 to 2017-2018). We calculated participants' intake of minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods as the relative contribution to daily energy intake (%kcal) using the NOVA framework. Trends analyses were performed using linear regression, testing for linear trends by modeling the 9 surveys as an ordinal independent variable. Models were adjusted for age, sex, race/ethnicity, education level, and income. Consumption trends were reported for the full sample and stratified by sex, age groups, race/ethnicity, education level, and income level. RESULTS: Adjusting for changes in population characteristics, the consumption of ultra-processed foods increased among all US adults from 2001-2002 to 2017-2018 (from 53.5 to 57.0 %kcal; P-trend < 0.001). The trend was consistent among all sociodemographic subgroups, except Hispanics, in stratified analyses. In contrast, the consumption of minimally processed foods decreased significantly over the study period (from 32.7 to 27.4 %kcal; P-trend < 0.001) and across all sociodemographic strata. The consumption of processed culinary ingredients increased from 3.9 to 5.4 %kcal (P-trend < 0.001), whereas the intake of processed foods remained stable at ∼10 %kcal throughout the study period (P-trend = 0.052). CONCLUSIONS: The current findings highlight the high consumption of ultra-processed foods in all parts of the US population and demonstrate that intake has continuously increased in the majority of the population in the past 2 decades.
Behavioral correlates of COVID-19 worry: Stigma, knowledge, and news sourceMeltzer, G. Y., Chang, V. W., Lieff, S. A., Grivel, M. M., Yang, L. H., & Des Jarlais, D. C.
Journal titleInternational journal of environmental research and public health
Issue21AbstractNon-adherence to COVID-19 guidelines may be attributable to low levels of worry. This study assessed whether endorsing COVID-19-stigmatizing restrictions, COVID-19 knowledge, and preferred news source were associated with being ‘very worried’ versus ‘not at all’ or ‘somewhat’ worried about contracting COVID-19. Survey data were collected in July–August 2020 from N = 547 New York State (NYS) and N = 504 national Amazon MTurk workers. Respondents who endorsed COVID-19 stigmatizing restrictions (NYS OR 1.96; 95% CI 1.31, 2.92; national OR 1.80; 95% CI 1.06, 3.08) and consumed commercial news (NYS OR 1.89; 95% CI 1.21, 2.96; national OR 1.93; 95% CI 1.24, 3.00) were more likely to be very worried. National respondents who consumed The New York Times (OR 1.52; 95% CI 1.00, 2.29) were more likely to be very worried, while those with little knowledge (OR 0.24; 95% CI 0.13, 0.43) were less likely to be very worried. NYS (OR 2.66; 95% CI 1.77, 4.00) and national (OR 3.17; 95% CI 1.95, 5.16) respondents with probable depression were also more likely to be very worried. These characteristics can help identify those requiring intervention to maximize perceived threat to COVID-19 and encourage uptake of protective behaviors while protecting psychological wellbeing.
Obesity and the Receipt of Prescription Pain Medications in the USCho, G., & Chang, V. W.
Journal titleJournal of general internal medicine
Page(s)2631-2638AbstractBackground: Little is known about disparities in pain treatment associated with weight status despite prior research on weight-based discrepancies in other realms of healthcare and stigma among clinicians. Objective: To investigate the association between weight status and the receipt of prescription analgesics in a nationally representative sample of adults with back pain, adjusting for the burden of pain. Design: Cross-sectional analyses using the Medical Expenditure Panel Survey (2010–2017). Participants: Five thousand seven hundred ninety-one civilian adults age ≥ 18 with back pain. Main measures: We examine the odds of receiving prescription analgesics for back pain by weight status using logistic regression. We study the odds of receiving (1) any pain prescription, (2) three pain prescription categories (opioid only, non-opioid only, the combination of both), and (3) opioids conditional on having a pain prescription. Key Results: The odds of receiving pain prescriptions increase monotonically across weight categories, when going from normal weight to obesity II/III, despite adjustments for the burden of pain. Relative to normal weight, higher odds of receiving any pain prescription is associated with obesity I (OR = 1.30 [95% CI = 1.04–1.63]) and obesity II/III (OR = 1.72 [95% CI = 1.36–2.18]). Obesity II/III is also associated with higher odds of receiving opioids only (OR = 1.53 [95% CI = 1.16–2.02]), non-opioids only (OR = 1.77 [95% CI = 1.21–2.60]), and a combination of both (OR = 2.48 [95% CI = 1.44–4.29]). Obesity I is associated with increased receipt of non-opioids only (OR = 1.55 [95% CI = 1.07–2.23]). Conditional on having a pain prescription, the odds of receiving opioids are comparable across weight categories. Conclusions: This study suggests that, relative to those with normal weight, adults with obesity are more likely to receive prescription analgesics for back pain, despite adjustments of the burden of pain. Hence, the possibility of weight-based undertreatment is not supported. These findings are reassuring because individuals with obesity generally experience a higher prevalence of back pain. The possibility of over-treatment associated with obesity, however, may warrant further investigation.
Sociodemographic and Behavioral Factors Associated With COVID-19 Stigmatizing Attitudes in the U.S.Grivel, M. M., Lieff, S. A., Meltzer, G. Y., Chang, V. W., Yang, L. H., & Jarlais, D. C.
Journal titleStigma and Health
Page(s)371-379AbstractTo control the spread of coronavirus disease (COVID-19) and prevent further verbal and physical discrimination against individuals affected by, or perceived to be responsible for, COVID-19, proactive efforts must be made to ameliorate stigmatizing attitudes. This study seeks to examine whether key sociobehavioral factors including news consumption and contact with Chinese individuals are associated with COVID-19 stigma as a first step to informing stigma interventions. Surveys were administered to N = 498non-representative national respondents in August 2020 via Amazon’s Mechanical Turk and includedassessments of COVID-19 stigma, worry, knowledge, contact with COVID-19 and Chinese individuals, and preferred news source. Prevalence of stigmatizing beliefs was 65.46%. Odds of endorsing stigma were higher among males (OR = 1.77, 95% CI [1.07–2.93]) vs. females, Non-Hispanic Black (OR = 3.12, 95% CI [1.42–6.86]) and Hispanic (OR = 4.77, 95% CI [2.32–9.78]) vs. Non-Hispanic White individuals, and individuals with college degrees (OR = 3.41, 95% CI [1.94–5.99]) and more than college degrees (OR = 3.04, 95% CI [1.34–6.89]) vs. those with less than college degrees. Consumers (vs. non-consumers) of Fox News (OR = 4.43, 95% CI [2.52–7.80]) and social media (OR = 2.48, 95% CI [1.46–4.20]) had higher odds of endorsing stigma. Contact with Chinese individuals (OR = 0.50, 95% CI [0.25–1.00]) wasassociated with lower odds of endorsing stigma. These findings suggest that individuals of Non-HispanicBlack or Hispanic race/ethnic background, consumers of Fox News and social media, men, and individuals with college degrees or higher are groups that should be prioritized for anti-stigma intervention. Our finding that social contact with Chinese individuals is associated with decreased odds of stigma that provides initial support for the implementation of interventions based on contact with individuals of Chinese descent
24-Year trends in educational inequalities in adult smoking prevalence in the context of a national tobacco control program: The case of BrazilBandi, P., Chang, V. W., Sherman, S. E., & Silver, D.
Journal titlePreventive Medicine
Volume131AbstractBrazil was a low and middle-income country (LMIC) in the late-1980s when it implemented a robust national tobacco-control program (NTCP) amidst rapid gains in national incomes and gender equality. We assessed changes in smoking prevalence between 1989 and 2013 by education level and related these changes to trends in educational inequalities in smoking. Data were from four nationally representative cross-sectional surveys (1989, n = 25,298; 2003 n = 3845; 2008 n = 28,938; 2013 n = 47,440, ages 25–69 years). We estimated absolute (slope index of inequality, SII) and relative (relative index of inequality, RII) educational inequalities in smoking prevalence, separately for males and females. Additional analyses stratified by birth-cohort to assess generational differences. Smoking declined significantly between 1989 and 2013 in all education groups but declines among females were steeper in higher-educated groups. Consequently, both absolute and relative educational inequalities in female smoking widened threefold between 1989 and 2013 (RII: 1.31 to 3.60, SII: 5.3 to 15.0), but absolute inequalities in female smoking widened mainly until 2003 (SII: 15.8). Conversely, among males, declines were steeper in higher-educated groups only in relative terms. Thus, relative educational inequalities in male smoking widened between 1989 and 2013 (RII: 1.58 to 3.19) but mainly until 2008 (3.22), whereas absolute equalities in male smoking were unchanged over the 24-year period (1989: 21.1 vs. 2013: 23.2). Younger-cohorts (born ≥1965) had wider relative inequalities in smoking vs. older-cohorts at comparable ages, particularly in the youngest female-cohorts (born 1979–1988). Our results suggest that younger lower-SES groups, especially females, may be particularly vulnerable to differentially higher smoking uptake in LMICs that implement population tobacco-control efforts amidst rapid societal gains.
The Economic Value of Education for Longer Lives and Reduced DisabilityKrueger, P. M., Dehry, I. A., & Chang, V. W.
Journal titleMilbank Quarterly
Page(s)48-73AbstractPolicy Points Although it is well established that educational attainment improves health and longevity, the economic value of this benefit is unknown. We estimate that the economic value of education for longer, healthier lives is comparable to or greater than the value of education for lifetime earnings. Policies that increase rates of completion of high school and college degrees could result in longer, healthier lives and substantial economic value for the population. We provide a template for assigning an economic value to the health benefits associated with education or other social determinants, allowing policymakers to prioritize those interventions that yield the greatest value for the population. Context: Policymakers often frame the value of educational attainment in terms of economic outcomes (eg, employment, productivity, wages). But that approach may understate the value of education if it ignores the economic value of both longer lives and the reduced disability associated with more education. Methods: In this article, we estimated the present value of the longer life and reduced disability associated with higher educational attainment at age 25 through age 84. We used prospective survival data and cross-sectional disability data from the National Health Interview Survey-Linked Mortality Files and drew on published estimates of the economic value of a statistical life. In addition, we used data from the Current Population Survey—Annual Social and Economic supplement to estimate the present value of education for lifetime earnings at age 25 through age 64 in order to provide a benchmark for comparing the value of education for health. Findings: Compared with those with less than a high school degree, the longer lives of those with a high school degree are worth an additional $450,000 for males and $479,000 for females, and the additional disability-adjusted life for those with a high school degree is worth $693,000 for males and $757,000 for females. By comparison, the additional lifetime earnings for those with a high school degree, rather than less than a high school degree, is $213,000 for males and $194,000 for females. Compared with those with a high school degree, the longer lives for those with a baccalaureate degree are worth an additional $446,000 for males and $247,000 for females. The value of the additional disability-adjusted life associated with having a baccalaureate degree rather than a high school degree is $611,000 for males and $407,000 among females. By comparison, the additional lifetime earnings for those with a baccalaureate degree, rather than a high school degree, is $628,000 for males and $459,000 for females. Conclusions: The value of education for longer, healthier lives may surpass the value for earnings. Estimates of the economic value of the social determinants of health, such as education, can help policymakers prioritize those policies that provide the greatest value for population health.
Health, Polysubstance Use, and Criminal Justice Involvement Among Adults With Varying Levels of Opioid UseWinkelman, T. N., Chang, V. W., & Binswanger, I. A.
Journal titleJAMA network open
Page(s)e180558AbstractImportance: Health profiles and patterns of involvement in the criminal justice system among people with various levels of opioid use are poorly defined. Data are needed to inform a public health approach to the opioid epidemic. Objective: To examine the association between various levels of opioid use in the past year and physical and mental health, co-occurring substance use, and involvement in the criminal justice system. Design, Setting, and Participants: This retrospective, cross-sectional analysis used the 2015-2016 National Survey on Drug Use and Health to assess the independent association of intensity of opioid use with health, co-occurring substance use, and involvement in the criminal justice system among US adults aged 18 to 64 years using multivariable logistic regression. Exposures: No opioid use vs prescription opioid use, misuse, or use disorder or heroin use. Main Outcomes and Measures: Self-reported physical and mental health, disability, co-occurring substance use, and past year and lifetime involvement in the criminal justice system. Results: The sample consisted of 78 976 respondents (42 495 women and 36 481 men), representative of 196 280 447 US adults. In the weighted sample, 124 026 842 adults reported no opioid use in the past year (63.2%; 95% CI, 62.6%-63.7%), 61 462 897 reported prescription opioid use in the past year (31.3%; 95% CI, 30.8%-31.8%), 8 439 889 reported prescription opioid misuse in the past year (4.3%; 95% CI, 4.1%-4.5%), 1 475 433 reported prescription opioid use disorder in the past year (0.8%; 95% CI, 0.7%-0.8%), and 875 386 reported heroin use in the past year (0.4%; 95% CI, 0.4%-0.5%). Individuals who reported any level of opioid use were significantly more likely than individuals who reported no opioid use to be white, have a low income, and report a chronic condition, disability, severe mental illness, or co-occurring drug use. History of involvement in the criminal justice system increased as intensity of opioid use increased (no use, 15.9% [19 562 158 of 123 319 911]; 95% CI, 15.4%-16.4%; prescription opioid use, 22.4% [13 712 162 of 61 204 541]; 95% CI, 21.7%-23.1%; prescription opioid misuse, 33.2% [2 793 391 of 8 410 638]; 95% CI, 30.9%-35.6%; prescription opioid use disorder, 51.7% [762 189 of 1 473 552]; 95% CI, 45.4%-58.0%; and heroin use, 76.8% [668 453 of 870 250]; 95% CI, 70.6%-82.1%). In adjusted models, any level of opioid use was associated with involvement in the criminal justice system in the past year compared with no opioid use. Conclusions and Relevance: Individuals who use opioids have complicated health profiles and high levels of involvement in the criminal justice system. Combating the opioid epidemic will require public health interventions that involve criminal justice systems, as well as policies that reduce involvement in the criminal justice system among individuals with substance use disorders.
Medicaid Expansion, Mental Health, and Access to Care among Childless Adults with and without Chronic ConditionsWinkelman, T. N., & Chang, V. W.
Journal titleJournal of general internal medicine
Page(s)376-383AbstractBackground: While the Affordable Care Act’s (ACA) Medicaid expansion has increased insurance coverage, its effects on health outcomes have been mixed. This may be because previous research did not disaggregate mental and physical health or target populations most likely to benefit. Objective: To examine the association between Medicaid expansion and changes in mental health, physical health, and access to care among low-income childless adults with and without chronic conditions. Design: We used a difference-in-differences analytical framework to assess differential changes in self-reported health outcomes and access to care. We stratified our analyses by chronic condition status. Participants: Childless adults, aged 18–64, with incomes below 138% of the federal poverty level in expansion (n = 69,620) and non-expansion states (n = 57,628). Intervention: Active Medicaid expansion in state of residence. Main Measures: Self-reported general health; total days in past month with poor health, poor mental health, poor physical health, or health-related activity restrictions; disability; depression; insurance coverage; cost-related barriers; annual check-up; and personal doctor. Key Results: Medicaid expansion was associated with reductions in poor health days (−1.2 days [95% CI, −1.6,-0.7]) and days limited by poor health (−0.94 days [95% CI, −1.4,-0.43]), but only among adults with chronic conditions. Trends in general health measures appear to be driven by fewer poor mental health days (−1.1 days [95% CI, −1.6,-0.6]). Expansion was also associated with a reduction in depression diagnoses (−3.4 percentage points [95% CI, −6.1,-0.01]) among adults with chronic conditions. Expansion was associated with improvements in access to care for all adults. Conclusions: Medicaid expansion was associated with substantial improvements in mental health and access to care among low-income adults with chronic conditions. These positive trends are likely to be reversed if Medicaid expansion is repealed.
Overweight or obese BMI is associated with earlier, but not later survival after common acute illnessesPrescott, H. C., & Chang, V. W.
Journal titleBMC Geriatrics
Issue1AbstractBackground: Obesity has been associated with improved short-term mortality following common acute illness, but its relationship with longer-term mortality is unknown. Methods: Observational study of U.S. Health and Retirement Study (HRS) participants with federal health insurance (fee-for-service Medicare) coverage, hospitalized with congestive heart failure (N = 4287), pneumonia (N = 4182), or acute myocardial infarction (N = 2001), 1996-2012. Using cox proportional hazards models, we examined the association between overweight or obese BMI (BMI ≥ 25.0 kg/m2) and mortality to 5 years after hospital admission, adjusted for potential confounders measured at the same time as BMI, including age, race, sex, education, partnership status, income, wealth, and smoking status. Body mass index (BMI) was calculated from self-reported height and weight collected at the HRS survey prior to hospitalization (a median 1.1 year prior to hospitalization). The referent group was patients with a normal BMI (18.5 to < 25.0 kg/m2). Results: Patients were a median of 79 years old (IQR 71-85 years). The majority of patients were overweight or obese: 60.3% hospitalized for heart failure, 51.5% for pneumonia, and 61.6% for acute myocardial infarction. Overweight or obese BMI was associated with lower mortality at 1 year after hospitalization for congestive heart failure, pneumonia, and acute myocardial infarction - with adjusted hazard ratios of 0.68 (95% CI 0.59-0.79), 0.74 (95% CI: 0.64-0.84), and 0.65 (95%CI: 0.53-0.80), respectively. Among participants who lived to one year, however, subsequent survival was similar between patients with normal versus overweight/obese BMI. Conclusions: In older Americans, overweight or obese BMI was associated with improved survival following hospitalization for congestive heart failure, pneumonia, and acute myocardial infarction. This association, however, is limited to the shorter-term. Conditional on surviving to one year, we did not observe a survival advantage associated with excess weight.
Ultra-processed food consumption and excess weight among US adultsJuul, F., Martinez-Steele, E., Parekh, N., Monteiro, C. A., & Chang, V. W.
Journal titleThe British journal of nutrition
Page(s)90-100AbstractUltra-processed foods provide 58 % of energy intake and 89 % of added sugars in the American diet. Nevertheless, the association between ultra-processed foods and excess weight has not been investigated in a US sample. The present investigation therefore aims to examine the association between ultra-processed foods and excess weight in a nationally representative sample of US adults. We performed a cross-sectional analysis of anthropometric and dietary data from 15 977 adults (20-64 years) participating in the National Health and Nutrition Examination Survey 2005-2014. Dietary data were collected by 24-h recall. Height, weight and waist circumference (WC) were measured. Foods were classified as ultra-processed/non-ultra-processed according to the NOVA classification. Multivariable linear and logistic regression was used to evaluate the association between ultra-processed food consumption (% energy) and BMI, WC and odds of BMI≥25 kg/m2, BMI≥30 kg/m2 and abdominal obesity (men: WC≥102 cm, women: WC≥88 cm). Prevalence of BMI≥25 kg/m2, BMI≥30 kg/m2 and abdominal obesity was 69·2, 36·1 and 53·0 %, respectively. Consuming ≥74·2 v. ≤36·5 % of total energy from ultra-processed foods was associated with 1·61 units higher BMI (95 % CI 1·11, 2·10), 4·07 cm greater WC (95 % CI 2·94, 5·19) and 48, 53 and 62 % higher odds of BMI≥25 kg/m2, BMI≥30 kg/m2 and abdominal obesity, respectively (OR 1·48; 95 % CI 1·25, 1·76; OR 1·53; 95 % CI 1·29, 1·81; OR 1·62; 95 % CI 1·39, 1·89, respectively; P for trend<0·001 for all). A significant interaction between being female and ultra-processed food consumption was found for BMI (F 4,79=4·89, P=0·002), WC (F 4,79=3·71, P=0·008) and BMI≥25 kg/m2 (F 4,79=5·35, P<0·001). As the first study in a US population, our findings support that higher consumption of ultra-processed food is associated with excess weight, and that the association is more pronounced among women.
Birth weight, early life weight gain and age at menarche: a systematic review of longitudinal studiesJuul, F., Chang, V. W., Brar, P., & Parekh, N.
Journal titleObesity Reviews
Page(s)1272-1288AbstractBackground and objective: Adiposity in pre- and postnatal life may influence menarcheal age. Existing evidence is primarily cross-sectional, failing to address temporality, for which the role of adiposity in early life remains unclear. The current study sought to systematically review longitudinal studies evaluating the associations between birth weight and infant/childhood weight status/weight gain in relation to menarcheal age. Methods: PubMed, EMBASE, Web of Science, Global Health (Ovid) and CINAHL were systematically searched. Selected studies were limited to English-language articles presenting multi-variable analyses. Seventeen studies reporting risk estimates for birth weight (n = 3), infant/childhood weight gain/weight status (n = 4) or both (n = 10), in relation to menarcheal age were included. Results: Lower vs. higher birth weight was associated with earlier menarche in nine studies and later menarche in one study, while three studies reported a null association. Greater BMI or weight gain over time and greater childhood weight were significantly associated with earlier menarche in nine of nine and six of seven studies, respectively. Conclusions: Studies suggested that lower birth weight and higher body weight and weight gain in infancy and childhood may increase the risk of early menarche. The pre- and postnatal period may thus be an opportune time for weight control interventions to prevent early menarche, and its subsequent consequences.
The obesity paradox and incident cardiovascular disease: A population-based studyChang, V. W., Langa, K. M., Weir, D., & Iwashyna, T. J.
Journal titlePloS one
Issue12AbstractBackground: Prior work suggests that obesity may confer a survival advantage among persons with cardiovascular disease (CVD). This obesity “paradox” is frequently studied in the context of prevalent disease, a stage in the disease process when confounding from illness-related weight loss and selective survival are especially problematic. Our objective was to examine the association of obesity with mortality among persons with incident CVD, where biases are potentially reduced, and to compare these findings with those based on prevalent disease. Methods: We used data from the Health and Retirement Study, an ongoing, nationally representative longitudinal survey of U.S. adults age 50 years and older initiated in 1992 and linked to Medicare claims. Cox proportional hazard models were used to estimate the association between weight status and mortality among persons with specific CVD diagnoses. CVD diagnoses were established by self-reported survey data as well as Medicare claims. Prevalent disease models used concurrent weight status, and incident disease models used pre-diagnosis weight status. Results: We examined myocardial infarction, congestive heart failure, stroke, and ischemic heart disease. A strong and significant obesity paradox was consistently observed in prevalent disease models (hazard of death 18–36% lower for obese class I relative to normal weight), replicating prior findings. However, in incident disease models of the same conditions in the same dataset, there was no evidence of this survival benefit. Findings from models using survey- vs. claims-based diagnoses were largely consistent. Conclusion: We observed an obesity paradox in prevalent CVD, replicating prior findings in a population-based sample with longer-term follow-up. In incident CVD, however, we did not find evidence of a survival advantage for obesity. Our findings do not offer support for reevaluating clinical and public health guidelines in pursuit of a potential obesity paradox.
Trends in the Relationship between Obesity and Disability, 1988-2012Chang, V. W., Alley, D. E., & Dowd, J. B.
Journal titleAmerican Journal of Epidemiology
Page(s)688-695AbstractRising obesity rates, coupled with population aging, have elicited serious concern over the impact of obesity on disability in later life. Prior work showed a significant increase in the association between obesity and disability from 1988 to 2004, calling attention to disability as a cost of longer lifetime exposure to obesity. It is not known whether this trend has continued. We examined functional impairment and impairment in activities of daily living (ADL) (defined as severe or moderate to severe) for adults aged 60 years or older (n = 16,770) over 3 time periods in the National Health and Nutrition Examination Survey. The relative odds of impairment for obese individuals versus normal-weight individuals significantly increased from period 1 (1988-1994) to period 2 (1999-2004) for all outcomes. In period 3 (2005-2012), this association remained stable for functional and severe ADL impairment and decreased for moderate-to-severe ADL impairment. The fraction of population disability attributable to obesity followed a similar trend. The trend of an increasing association between obesity and disability has leveled off in more recent years, and is even improving for some measures. These findings suggest that public health and policy concerns that obesity would continue to become more disabling over time have not been borne out.
Mortality attributable to low levels of education in the United StatesKrueger, P. M., Tran, M. K., Hummer, R. A., & Chang, V. W.
Journal titlePloS one
Issue7AbstractBackground: Educational disparities in U.S. adult mortality are large and have widened across birth cohorts. We consider three policy relevant scenarios and estimate the mortality attributable to: (1) individuals having less than a high school degree rather than a high school degree, (2) individuals having some college rather than a baccalaureate degree, and (3) individuals having anything less than a baccalaureate degree rather than a baccalaureate degree, using educational disparities specific to the 1925, 1935, and 1945 cohorts. Methods: We use the National Health Interview Survey data (1986-2004) linked to prospective mortality through 2006 (N=1,008,949), and discrete-time survival models, to estimate educationand cohort-specific mortality rates. We use those mortality rates and data on the 2010 U.S. population from the American Community Survey, to calculate annual attributable mortality estimates. Results: If adults aged 25-85 in the 2010 U.S. population experienced the educational disparities in mortality observed in the 1945 cohort, 145,243 deaths could be attributed to individuals having less than a high school degree rather than a high school degree, 110,068 deaths could be attributed to individuals having some college rather than a baccalaureate degree, and 554,525 deaths could be attributed to individuals having anything less than a baccalaureate degree rather than a baccalaureate degree. Widening educational disparities between the 1925 and 1945 cohorts result in a doubling of attributable mortality. Mortality attributable to having less than a high school degree is proportionally similar among women and men and among non-Hispanic blacks and whites, and is greater for cardiovascular disease than for cancer. Conclusions: Mortality attributable to low education is comparable in magnitude to mortality attributable to individuals being current rather than former smokers. Existing research suggests that a substantial part of the association between education and mortality is causal. Thus, policies that increase education could significantly reduce adult mortality.
Obesity and 1-year outcomes in older Americans with severe sepsisPrescott, H. C., Chang, V. W., O’Brien, J. M., Langa, K. M., & Iwashyna, T. J.
Journal titleCritical care medicine
Page(s)1766-1774AbstractObjectives: Although critical care physicians view obesity as an independent poor prognostic marker, growing evidence suggests that obesity is, instead, associated with improved mortality following ICU admission. However, this prior empirical work may be biased by preferential admission of obese patients to ICUs, and little is known about other patient-centered outcomes following critical illness. We sought to determine whether 1-year mortality, healthcare utilization, and functional outcomes following a severe sepsis hospitalization differ by body mass index. Design: Observational cohort study. Setting: U.S. hospitals. Patients: We analyzed 1,404 severe sepsis hospitalizations (1999-2005) among Medicare beneficiaries enrolled in the nationally representative Health and Retirement Study, of which 597 (42.5%) were normal weight, 473 (33.7%) were overweight, and 334 (23.8%) were obese or severely obese, as assessed at their survey prior to acute illness. Underweight patients were excluded a priori. Interventions: None. Measurements and main results: Using Medicare claims, we identified severe sepsis hospitalizations and measured inpatient healthcare facility use and calculated total and itemized Medicare spending in the year following hospital discharge. Using the National Death Index, we determined mortality. We ascertained pre-and postmorbid functional status from survey data. Patients with greater body mass indexes experienced lower 1-year mortality compared with nonobese patients, and there was a dose-response relationship such that obese (odds ratio = 0.59; 95% CI, 0.39-0.88) and severely obese patients (odds ratio = 0.46; 95% CI, 0.26-0.80) had the lowest mortality. Total days in a healthcare facility and Medicare expenditures were greater for obese patients (p < 0.01 for both comparisons), but average daily utilization (p = 0.44) and Medicare spending were similar (p = 0.65) among normal, overweight, and obese survivors. Total function limitations following severe sepsis did not differ by body mass index category (p = 0.64). Conclusions: Obesity is associated with improved mortality among severe sepsis patients. Due to longer survival, obese sepsis survivors use more healthcare and result in higher Medicare spending in the year following hospitalization. Median daily healthcare utilization was similar across body mass index categories.
Early life exposure to the 1918 influenza pandemic and old-age mortality by cause of deathMyrskylä, M., Mehta, N. K., & Chang, V. W.
Journal titleAmerican journal of public health
Page(s)e83-e90AbstractObjectives. We sought to analyze how early exposure to the 1918 influenza pandemic is associated with old-age mortality by cause of death. Methods. We analyzed the National Health Interview Survey (n = 81 571; follow-up 1989-2006; 43 808 deaths) and used year and quarter of birth to assess timing of pandemic exposure. We used Cox proportional and Fine-Gray competing hazard models for all-cause and cause-specific mortality, respectively. Results. Cohorts born during pandemic peaks had excess all-cause mortality attributed to increased noncancer mortality. We found evidence for a trade-off between noncancer and cancer causes: cohorts with high noncancer mortality had low cancer mortality, and vice versa. Conclusions. Early disease exposure increases old-age mortality through noncancer causes, which include respiratory and cardiovascular diseases, and may trigger a trade-off in the risk of cancer and noncancer causes. Potential mechanisms include inflammation or apoptosis. The findings contribute to our understanding of the causes of death behind the early disease exposure-latermortality association. The cancer-noncancer trade-off is potentially important for understanding the mechanisms behind these associations.
Obesity and MortalityMehta, N. K., & Chang, V. W. In The Oxford Handbook of the Social Science of Obesity.
Publication year2012AbstractThis chapter reports that the mortality penalty linked with obesity has been falling in recent decades. It describes how, in current data, the relationship between obesity and mortality is complex; although class II and III obesity are associated with elevated mortality risk, overweight and class I obesity are generally not associated with higher mortality. Studies that measure body mass index (BMI) when respondents are middle aged and model mortality into later life can give a better sense of the BMI and mortality relationship at the older ages. A high BMI is a small source of excess deaths in the United States, although this topic continues to be controversial. Studies that measure BMI in middle age and model subsequent mortality may give a better sense of the effect of BMI on mortality for those over the age of 50.
Gender equality, development, and cross-national sex gaps in life expectancyMedalia, C., & Chang, V. W.
Journal titleInternational Journal of Comparative Sociology
Page(s)371-389AbstractFemale life expectancy exceeds male life expectancy in almost every country throughout the world. Nevertheless, cross-national variation in the sex gap suggests that social factors, such as gender equality, may directly affect or mediate an underlying biological component. In this article, we examine the association between gender equality and the sex gap in mortality. Previous research has not addressed this question from an international perspective with countries at different levels of development. We examine 131 countries using a broad measure of national gender equality that is applicable in both Less Developed Countries (LDCs) and Highly Developed Countries (HDCs). We find that the influence of gender equality is conditional on level of development. While gender equality is associated with divergence between female and male life expectancies in LDCs, it is associated with convergence in HDCs. The relationship between gender equality and the sex gap in mortality in HDCs strongly relates to, but is not explained by, sex differences in lung cancer mortality. Finally, we find that divergence in LDCs is primarily driven by a strong positive association between gender equality and female life expectancy. In HDCs, convergence is potentially related to a weak negative association between gender equality and female life expectancy, though findings are not statistically significant.
Race/ethnic differences in adult mortality: The role of perceived stress and health behaviorsKrueger, P. M., Saint Onge, J. M., & Chang, V. W.
Journal titleSocial Science and Medicine
Page(s)1312-1322AbstractWe examine the role of perceived stress and health behaviors (i.e., cigarette smoking, alcohol consumption, physical inactivity, sleep duration) in shaping differential mortality among whites, blacks, and Hispanics. We use data from the 1990 National Health Interview Survey (N = 38,891), a nationally representative sample of United States adults, to model prospective mortality through 2006. Our first aim examines whether unhealthy behaviors and perceived stress mediate race/ethnic disparities in mortality. The black disadvantage in mortality, relative to whites, closes after adjusting for socioeconomic status (SES), but re-emerges after adjusting for the lower smoking levels among blacks. After adjusting for SES, Hispanics have slightly lower mortality than whites; that advantage increases after adjusting for the greater physical inactivity among Hispanics, but closes after adjusting for their lower smoking levels. Perceived stress, sleep duration, and alcohol consumption do not mediate race/ethnic disparities in mortality. Our second aim tests competing hypotheses about race/ethnic differences in the relationships among unhealthy behaviors, perceived stress, and mortality. The social vulnerability hypothesis predicts that unhealthy behaviors and high stress levels will be more harmful for race/ethnic minorities. In contrast, the Blaxter (1990) hypothesis predicts that unhealthy lifestyles will be less harmful for disadvantaged groups. Consistent with the social vulnerability perspective, smoking is more harmful for blacks than for whites. But consistent with the Blaxter hypothesis, compared to whites, current smoking has a weaker relationship with mortality for Hispanics, and low or high levels of alcohol consumption, high levels of physical inactivity, and short or long sleep hours have weaker relationships with mortality for blacks.
Secular declines in the association between obesity and mortality in the United StatesMehta, N. K., & Chang, V. W.
Journal titlePopulation and Development Review
Page(s)435-451AbstractRecent research suggests that rising obesity will restrain future gains in US life expectancy and that obesity is an important contributor to the current shortfall in us longevity compared to other high-income countries. Estimates of the contribution of obesity to current and future national-level mortality patterns are sensitive to estimates of the magnitude of the association between obesity and mortality at the individual level. We assessed secular trends in the obesity/mortality association among cohorts of middle-aged adults between 1948 and 2006 using three long-running US data sources: the Framingham Heart Study, the National Health and Nutrition Examination Survey, and the National Health Interview Survey. We find substantial declines over time in the magnitude of the association between obesity and overall mortality and, in certain instances, cardiovascular-specific mortality. We conclude that estimates of the contribution of obesity to current national-level mortality patterns should take into account recent reductions in the magnitude of the obesity and mortality association.
Metabolic syndrome and weight gain in adulthoodAlley, D. E., & Chang, V. W.
Journal titleJournals of Gerontology - Series A Biological Sciences and Medical Sciences
Page(s)111-117AbstractBackgroundThe influence of long-term adult weight history on metabolic risk independent of attained body mass index (BMI) is unknown.MethodsUsing nationally representative data on adults aged 50-64 years from the 1999-2006 National Health and Nutrition Examination Surveys, we examined weight change for two periods of adulthood: prime age (age 25-10 years ago) and midlife (the last 10 years). Weight changes in each period were categorized as stable (gain <10 kg) or gain (gain ≥10 kg) to create weight history comparison groups: stable-stable, gain-stable (prime age gain), stable-gain (midlife gain), and gain-gain (continuous gain). Persons who lost weight were excluded. Logistic regression predicted odds of metabolic syndrome and its subcomponents based on weight history, adjusting for current BMI and covariates.ResultsParticipants in the gain-stable group had 89% elevated odds of metabolic syndrome (odds ratio = 1.89, 95% CI: 1.19-3.01) relative to the stable-stable group, even after adjustment for current BMI. All weight gain groups had increased odds of low HDL and high triglycerides relative to participants with continuously stable weights. No significant associations were found between weight history and hypertension or high glucose.ConclusionsWeight history confers information about metabolic risk factors above and beyond attained weight status. In particular, adult weight gain is related to risk of low HDL and high triglycerides. Weight history may contribute to our understanding of why some obese older persons are metabolically healthy but others are not.
Quality of care among obese patientsChang, V. W., Asch, D. A., & Werner, R. M.
Journal titleJAMA - Journal of the American Medical Association
Page(s)1274-1281AbstractContext Clinicians often have negative attitudes toward obesity and express dissatisfaction in caring for obese patients. Moreover, obese patients often feel that clinicians are biased or disrespectful because of their weight. These observations raise the concern that obese patients may receive lower quality of care. Objective To determine whether performance on common outpatient quality measures differs by patient weight status. Design, Setting, and Participants Eight different performance measures were examined in 2 national-level patient populations: (1) Medicare beneficiaries (n=36122) using data from the Medicare Beneficiary Survey (1994-2006); and (2) recipients of care from the Veterans Health Administration (VHA) (n=33550) using data from an ongoing performance-evaluation program (2003-2004). Main Outcome Measures Performance measures among eligible patients for diabetes care (eye examination, glycated hemoglobin [HbA 1c] testing, and lipid screening), pneumococcal vaccination, influenza vaccination, screening mammography, colorectal cancer screening, and cervical cancer screening. Measures were based on a combination of administrative claims, survey, and chart review data. Results We found no evidence that obese or overweight patients were less likely to receive recommended care relative to normal-weight patients. Moreover, success rates were marginally higher for obese and/or overweight patients on several measures. The most notable differentials were observed for recommended diabetes care among Medicare beneficiaries: comparing obese vs normal-weight patients with diabetes, obese patients were more likely to receive recommended care on lipid screening (72% vs 65%; odds ratio, 1.37 [95% confidence interval, 1.09-1.73]) and HbA 1c testing (74% vs 62%; odds ratio, 1.73 [95% confidence interval, 1.41-2.11]). All analyses were adjusted for sociodemographic factors, health status, clinical complexity, and visit frequency. Conclusions Amongsamplesofpatients from theMedicareandVHApopulations, there was no evidence across 8 performance measures that obese or overweight patients received inferior care when compared with normal-weight patients. Being obese or overweight was associated with a marginally higher rate of recommended care on several measures.
Social capital and glucose controlLong, J. A., Field, S., Armstrong, K., Chang, V. W., & Metlay, J. P.
Journal titleJournal of Community Health
Page(s)519-526AbstractThere is a growing diabetes epidemic in the United States and if we are to halt its progress we need to better understand the social determinants of this disease and its control. Social capital, which has been associated with general health and mortality, may be one important mediator of glucose control. In this study we determine if neighborhood social capital is associated with glucose control, independent of individual factors. We performed a cross-sectional study of Black veterans with diabetes living in Philadelphia. We merged individual-level data from surveys and charts with six area-level social capital descriptors. Holding all other variables constant, patients who lived in neighborhoods that scored near the 5th percentile of working together to improve the neighborhood were estimated to have glycosylated hemoglobin (HbA1c) values that were at least one point above a conservative clinical definition of "diabetes control" (HbA1c B 8%). If these same patients were to live in neighborhoods in the 95th percentile, their expected HbA1c would be over a point below the cut-off value 8%. No other measure of social capital was associated with HbA1c. In this study of black veterans with diabetes we observed that living in neighborhoods where people work together is associated with better glucose control.