Virginia W Chang

Associate Professor of Social and Behavioral Sciences

Professional overview

Virginia W. Chang, MD, PhD is Associate Professor of Social and Behavioral Sciences 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.

Education

BS, Biomedical Sciences and Philosophy, University of Michigan, Ann Arbor, MI

MD, Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI

MA, Sociology, University of Chicago, Chicago, IL

PhD, Sociology, University of Chicago, Chicago, IL

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Fellow, Robert Wood Johnson Clinical Scholars Program, University of Chicago, Chicago, IL

Resident, Department of Medicine, University of Chicago, Chicago, IL

Intern, Department of Medicine, University of Chicago, Chicago, IL

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Diplomate, American Board of Internal Medicine

Licensed Medical Physician, Commonwealth of Pennsylvania

Honors and awards

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)

Areas of research and study

Global Health

Health Disparities

Internal Medicine

Obesity

Population Health

Social Behaviors

Publications

Publications

Anti-vaccine attitudes and COVID-19 vaccine status at the end of the U.S. public health emergency

Choi, J., Feelemyer, J., Choe, K., Lynch, K., McKnight, C., Yang, L. H., Jarlais, D. D., & Chang, V. W. (n.d.).

Publication year

2025

Journal title

Vaccine

Volume

55

10.1016/j.vaccine.2025.127003

Abstract

Abstract

Introduction: Despite the end of the federal COVID-19 public health emergency in May 2023, COVID-19 prevention remains a priority. This study investigates how public vaccination attitudes and perceived COVID-19 risks relate to vaccination status, aiming to identify factors associated with COVID-19 vaccination post-emergency. Methods: An online survey was conducted from April to May 2023 among a non-representative, nationally-based sample of MTurk workers. The primary outcome was COVID-19 vaccination status. Variables examined included anti-vaccine attitudes, health status, COVID-19 experiences, and sociodemographic factors. We created a composite measure of anti-vaccine attitudes from 15 items with three levels. Bivariate tests of association and multivariable logistic regression were performed. Results: A final sample of 989 adults were included in this analysis. In our multivariable model, individuals with higher anti-vaccine attitudes were less likely to be vaccinated against COVID-19 compared to those with low anti-vaccine attitudes (OR = 0.10, 95 % CI 0.04, 0.25). Those who identified as LGBQ+ (OR = 2.55, 95 % CI 1.32, 4.94), had chronic conditions (OR = 2.94, 95 % CI 1.43, 6.01) and had felt stigmatized from COVID-19 infections (OR = 3.33, 95 % CI 1.47, 7.58) were more likely to be vaccinated, even after adjusting for anti-vaccine attitudes. News source, perceived risk of contagion by contact, and long COVID-related factors were not significantly associated with vaccination status in the multivariable model. Discussion: Our findings highlight the persistent relationship between anti-vaccine attitudes and vaccination status in the “post-pandemic” era. Beyond vaccine attitudes, sexual orientation, chronic conditions, and stigmatization experiences may influence perceived need for protection. Stigma can sometimes reinforce social norms driving vaccination, but this effect is nuanced, particularly with anti-vaccine attitudes. To promote vaccine uptake, interventions should prioritize community support, counter misinformation, and enhance vaccine literacy. Building trust among vulnerable populations is essential, rather than relying on public health messaging that may reinforce social stigma.

Native Hawaiian and Other Pacific Islanders: Disparities in the Prevalence of Multiple Chronic Conditions

Cabrera, J. D., Cuevas, A. G., Xu, S., & Chang, V. W. (n.d.).

Publication year

2025

Journal title

American Journal of Health Promotion

Volume

39

Issue

7

Page(s)

1037-1041

10.1177/08901171251330397

Abstract

Abstract

Purpose: To examine multimorbidity prevalence by race/ethnicity and unique health disparities for Native Hawaiian and Other Pacific Islanders (NHPI). Design: Cross-sectional study. Setting: This study uses combined data from the 2014 National Health Interview Survey (NHIS) and the 2014 NHPI-NHIS. Sample: 38,965 adults, including a representative sample of 2,026 NHPIs. Measures: Self-reported diagnoses of ten chronic conditions and race/ethnicity, including Non-Hispanic (NH) Whites, NH Blacks, NH Asians, NH NHPIs, Hispanics and NH Mixed Race. Covariates include age, sex, marital status, education, family income, and employment status. Analysis: We used multinomial logistic regression models to evaluate the adjusted association between race/ethnicity and number of chronic conditions: none, 1, and ≥ 2 (multimorbidity). Results: Compared to Whites, Asians and Hispanics (aRRR = 0.39, P < .001 and aRRR = 0.59, P < .001) had significantly lower odds of having multimorbidity relative to no chronic condition. In contrast, Black Americans and NHPIs (aRRR = 1.27, P < .001 and aRRR = 1.22, P < .05) had significantly higher odds of multimorbidity compared to Whites. Of note, NHPIs showed significantly higher odds of multimorbidity compared to Asians (aRRR = 3.07, P < .001). Conclusion: Our findings highlight significantly higher risk of multimorbidity for NHPIs relative to Whites as well as Asians. This underscores the importance of disaggregating NHPI data from Asians as a whole. Future studies should incorporate additional social factors relevant to the NHPI community.

Who Works Non-Day Shifts? An Investigation of Population and Within-Cohort Trends

Cho, G., Chodosh, J., Hill, J., & Chang, V. W. (n.d.).

Publication year

2025

Journal title

Journal of Occupational and Environmental Medicine

Volume

67

Issue

7

Page(s)

e486-e492

10.1097/JOM.0000000000003394

Abstract

Abstract

Objectives We examined trends in the socioeconomic distribution of work schedules from 1990s to 2010s and how early adulthood disadvantages are associated work schedules over working age. Methods In a representative sample of US workers (Midlife in the U.S. Study (MIDUS), N = 3328), we calculated recycled predictions of day, evening, night, and long shift prevalence associated with time period. Logistic regression was used to analyze the association of non-day shifts with age and its variations by early adulthood disadvantage in US baby boomers (National Longitudinal Survey of Youth 79 (NLSY79), N = 10,293). Results In U.S. workers, between 1990s-2010s, evening shifts increased in adults without college education and night shifts increased in the lowest income quartile. Day shifts decreased in both groups. In US baby boomers, the odds of working non-day shifts decreased with age. However, being Black, not attending college, and poverty were associated with higher odds of non-day shiftwork throughout working age. Conclusions Evening and night shifts may have replaced day shifts in socioeconomically disadvantaged populations between 1990s-2010s. Early adulthood disadvantages may have sustained effects on work schedules.

Multi-discrimination exposure and biological aging: Results from the midlife in the United States study

Cuevas, A. G., Cole, S. W., Belsky, D. W., McSorley, A. M., Shon, J. M., & Chang, V. W. (n.d.).

Publication year

2024

Journal title

Brain, Behavior, and Immunity - Health

Volume

39

10.1016/j.bbih.2024.100774

Abstract

Abstract

Discrimination is a social determinant of health and health disparities for which the biological mechanisms remain poorly understood. This study investigated the hypothesis that discrimination contributes to poor health outcomes by accelerating biological processes of aging. We analyzed survey and blood DNA methylation data from the Midlife in the United States (MIDUS) study (N = 1967). We used linear regression analysis to test associations of everyday, major, and workplace discrimination with biological aging measured by the DunedinPACE, PhenoAge, and GrimAge2 epigenetic clocks. MIDUS participants who reported more discrimination tended to exhibit a faster pace of aging and older biological age as compared to peers who reported less discrimination. Effect-sizes for associations tended to be larger for the DunedinPACE pace-of-aging clock (effect-size range r = 0.1–0.2) as compared with the PhenoAge and GrimAge2 biological-age clocks (effect-sizes r < 0.1) and for experiences of everyday and major discrimination as compared with workplace discrimination. Smoking status and body-mass index accounted for roughly half of observed association between discrimination and biological aging. Reports of discrimination were more strongly associated with accelerated biological aging among White as compared with Black participants, although Black participants reported more discrimination overall and tended to exhibit older biological age and faster biological aging. Findings support the hypothesis that experiences of interpersonal discrimination contribute to accelerated biological aging and suggest that structural and individual-level interventions to reduce discrimination and promote adaptive coping have potential to support healthy aging and build health equity.

Neighborhood Social Environment and Dementia:The Mediating Role of Social Isolation

Choi, E. Y., Cho, G., & Chang, V. W. (n.d.).

Publication year

2024

Journal title

Journals of Gerontology - Series B Psychological Sciences and Social Sciences

Volume

79

Issue

4

10.1093/geronb/gbad199

Abstract

Abstract

Objectives: Despite the potential importance of the neighborhood social environment for cognitive health, the connection between neighborhood characteristics and dementia remains unclear. This study investigated the association between the prospective risk of dementia and three distinct aspects of neighborhood social environment: socioeconomic deprivation, disorder, and social cohesion. We also examined whether objective and subjective aspects of individual-level social isolation may function as mediators. Methods: Leveraging data from the Health and Retirement Study (2006–2018; N = 9,251), we used Cox proportional hazards models to examine the association between time-to-dementia incidence and each neighborhood characteristic, adjusting for covariates and the propensity to self-select into disadvantaged neighborhoods. We used inverse odds weighting to decompose significant total effects of neighborhood characteristics into mediational effects of objective and subjective social isolation. Results: The risk of dementia was associated with deprivation and disorder but not low cohesion. In deprived neighborhoods, individuals had an 18% increased risk of developing dementia (cause-specific hazard ratio [CHR] = 1.18, 95% CI: 1.02 to 1.38), and those in disordered areas had a 27% higher risk (CHR = 1.27, 95% CI: 1.03 to 1.59). 20% of the disorder’s effects were mediated by subjective social isolation, while the mediational effects of objective isolation were nonsignificant. Deprivation’s total effects were not partitioned into mediational effects given its nonsignificant associations with the mediators. Discussion: Neighborhood deprivation and disorder may increase middle to older adults’ risks of dementia. The disorder may adversely affect cognitive health through increasing loneliness. Our results suggest a clear need for dementia prevention targeting upstream neighborhood contexts, including the improvement of neighborhood conditions to foster social integration among residents.

Number of children and risk of dementia: a cohort study

Wolfova, K., Hubbard, R. A., Brennan Kearns, P., Chang, V. W., Crane, P., Lacroix, A. Z., Larson, E. B., & Tom, S. (n.d.).

Publication year

2024

Journal title

Journal of Epidemiology and Community Health

10.1136/jech-2024-222717

Abstract

Abstract

Background: Findings on the link between the number of children and dementia risk are inconsistent, mostly studied in females, suggesting pregnancy-related changes may be a key factor in this association. Methods: The Adult Changes in Thought Study is a cohort of adults aged ≥65 years from Kaiser Permanente Washington. The primary exposure was the number of children (0, 1, 2, 3 or ≥4), and the outcome was an incident dementia diagnosis. Cox proportional-hazards models were adjusted for demographic and early-life socioeconomic confounders. Models were then stratified by sex and by birth year <1928 versus ≥1928. Results: Among 4668 participants (average age at enrolment 74.1±SD 6.3 years; 59% female), 967 (21%) had 0 children, 484 (10%) had one child, 1240 (27%) had two children, 968 (21%) had three children and 1009 (22%) had four or more children. We found no association between the number of children and dementia overall or after stratification by birth cohort. When stratified by sex and adjusting for confounders, having ≥4 children compared with two children was associated with a higher rate of dementia in males (HR=1.31, 95% CI 1.01 to 1.71). Conclusions: The number of children was not consistently associated with the risk of dementia. We observed a greater risk of dementia only among males who had ≥4 children, with the lower bound of the 95% CI marginally exceeding 1. These findings suggest that the number of children may influence the risk of dementia through other than pregnancy-related pathways.

Time Path of Weight Status Before and After Incident Dementia

Zhang, Y. S., & Chang, V. W. (n.d.).

Publication year

2024

Journal title

Journal of Aging and Health

Volume

36

Issue

1

Page(s)

98-109

10.1177/08982643231170711

Abstract

Abstract

Objectives: Identifying whether obesity is a risk factor for dementia is complicated by the possibility of weight change as dementia evolves. This article investigates an extended time path of body mass index (BMI) before and after incident dementia in a nationally representative sample. Methods: Using the Health and Retirement Study (2000–2016), we examine (1) the longitudinal relationship between BMI and incident dementia and (2) heterogeneity in the BMI trajectory by initial BMI level. Results: Weight loss begins at least one decade before incident dementia, then accelerates in the years immediately preceding dementia onset and continues after incident dementia. Those with higher levels of BMI at baseline experienced a much greater decline relative to those with a normal weight. Discussion: Our results help explain the contradicting findings in the literature regarding the relationship between obesity and dementia and highlight the need for using extended longitudinal data to understand dementia risk.

Association between racial residential segregation and walkability in 745 U.S. cities

Spoer, B. R., Conderino, S. E., Lampe, T. M., Ofrane, R. H., De Leon, E., Thorpe, L. E., Chang, V. W., & Elbel, B. (n.d.).

Publication year

2023

Journal title

Health and Place

Volume

84

10.1016/j.healthplace.2023.103114

Abstract

Abstract

Despite higher chronic disease prevalence, minoritized populations live in highly walkable neighborhoods in US cities more frequently than non-minoritized populations. We investigated whether city-level racial residential segregation (RRS) was associated with city-level walkability, stratified by population density, possibly explaining this counterintuitive association. RRS for Black-White and Latino-White segregation in large US cities was calculated using the Index of Dissimilarity (ID), and walkability was measured using WalkScore. Median walkability increased across increasing quartiles of population density, as expected. Higher ID was associated with higher walkability; associations varied in strength across strata of population density. RRS undergirds the observed association between walkability and minoritized populations, especially in higher population density cities.

COVID-19 stigmatization after the development of effective vaccines: Vaccination behavior, attitudes, and news sources

Des Jarlais, D. C., Lieff, S., Grivel, M., Meltzer, G., Choi, J., Weng, C. A., Feelemyer, J. P., Chang, V. W., & Yang, L. (n.d.).

Publication year

2023

Journal title

PloS one

Volume

18

Issue

4

10.1371/journal.pone.0283467

Abstract

Abstract

Objective To compare COVID-19 stigmatization at two pandemic time points (1) August 2020—during lockdowns and prior to vaccine rollout, and (2) May 2021—during vaccine rollout, when approximately half of U.S. adults were vaccinated. Methods Comparison of COVID19-related stigmatization and associated factors in two national internet surveys conducted in August 2020 (N = 517) and May 2021 (N = 812). Factors associated with endorsing stigmatization were identified using regression analysis. The main outcomes included endorsement of stigmatization and behavioral restrictions towards persons with COVID-19 and towards persons of Chinese descent. A previously developed “stigmatizing attitudes and behavioral restrictions” scale was adapted to measure the intersection of negative attitudes toward COVID-19 disease and negative attitudes toward persons of Chinese descent. Results COVID-19 related stigmatization declined significantly from August 2020 to May 2021. Many factors were associated with stigmatizing in both surveys: full time employment, Black race, Hispanic ethnicity, worry about contracting COVID-19, probable depression, and Fox News and social media as sources of information (all positively associated), and self-assessed knowledge about COVID-19, contact with Chinese individuals, and publicly funded news as sources (all negatively associated). Positive attitudes toward vaccination were associated with stigmatization. Conclusions COVID-19 related stigmatization reduced substantially over these two points in the pandemic, with many continuities in the factors associated with stigmatizing. Despite the reduction in stigmatizing, however, some stigmatizing attitudes for both COVID-19 and Chinese individuals remained.

Cumulative exposure to extreme heat and trajectories of cognitive decline among older adults in the USA

Choi, E. Y., Lee, H., & Chang, V. W. (n.d.).

Publication year

2023

Journal title

Journal of Epidemiology and Community Health

Volume

77

Issue

11

Page(s)

728-735

10.1136/jech-2023-220675

Abstract

Abstract

Background The projected increase in extreme heat days is a growing public health concern. While exposure to extreme heat has been shown to negatively affect mortality and physical health, very little is known about its long-term consequences for late-life cognitive function. We examined whether extreme heat exposure is associated with cognitive decline among older adults and whether this association differs by race/ethnicity and neighbourhood socioeconomic status. Methods Data were drawn from seven waves of the Health and Retirement Study (2006-2018) merged with historical temperature data. We used growth curve models to assess the role of extreme heat exposure on trajectories of cognitive function among US adults aged 52 years and older. Results We found that high exposure to extreme heat was associated with faster cognitive decline for blacks and residents of poor neighbourhoods, but not for whites, Hispanics or residents of wealthier neighbourhoods. Conclusion Extreme heat exposure can disproportionately undermine cognitive health in later life for socially vulnerable populations. Our findings underscore the need for policy actions to identify and support high-risk communities for increasingly warming temperatures.

Health Insurance and Mental Health Treatment Use Among Adults With Criminal Legal Involvement After Medicaid Expansion

Howell, B. A., Hawks, L. C., Balasuriya, L., Chang, V. W., Wang, E. A., & Winkelman, T. N. (n.d.).

Publication year

2023

Journal title

Hospital and Community Psychiatry

Volume

74

Issue

10

Page(s)

1019-1026

10.1176/appi.ps.20220171

Abstract

Abstract

OBJECTIVE: Individuals with criminal legal involvement have high rates of substance use and other mental disorders. Before implementation of the Affordable Care Act's Medicaid expansion, they also had low health insurance coverage. The objective of this study was to assess the impact of Medicaid expansion on health insurance coverage and use of treatment for substance use or other mental disorders in this population. METHODS: The authors used restricted data (2010-2017) from the National Survey on Drug Use and Health (NSDUH). Using a difference-in-differences approach, the authors estimated the impact of Medicaid expansion on health insurance coverage and treatment for substance use or other mental disorders among individuals with recent criminal legal involvement. RESULTS: The sample consisted of 9,910 NSDUH respondents who were ages 18-64 years, had a household income ≤138% of the federal poverty level, and reported past-year criminal legal involvement. Medicaid expansion was associated with an 18 percentage-point increase in insurance coverage but no change in receipt of substance use treatment among individuals with substance use disorder. Individuals with any other mental illness had a 16 percentage-point increase in insurance coverage but no change in receipt of mental health treatment. CONCLUSIONS: Despite a large increase in health insurance coverage among individuals with criminal legal involvement and substance use or other mental disorders, Medicaid expansion was not associated with a significant change in treatment use for these conditions. Insurance access alone appears to be insufficient to increase treatment for substance use or other mental disorders in this population.

Internet usage and the prospective risk of dementia: A population-based cohort study

Cho, G., Betensky, R. A., & Chang, V. W. (n.d.).

Publication year

2023

Journal title

Journal of the American Geriatrics Society

Volume

71

Issue

8

Page(s)

2419-2429

10.1111/jgs.18394

Abstract

Abstract

Background: Little is known about the long-term cognitive impact of internet usage among older adults. This research characterized the association between various measures of internet usage and dementia. Methods: We followed dementia-free adults aged 50–64.9 for a maximum of 17.1 (median = 7.9) years using the Health and Retirement Study. The association between time-to-dementia and baseline internet usage was examined using cause-specific Cox models, adjusting for delayed entry and covariates. We also examined the interaction between internet usage and education, race-ethnicity, sex, and generation. Furthermore, we examined whether the risk of dementia varies by the cumulative period of regular internet usage to see if starting or continuing usage in old age modulates subsequent risk. Finally, we examined the association between the risk of dementia and daily hours of usage. Analyses were conducted from September 2021 to November 2022. Results: In 18,154 adults, regular internet usage was associated with approximately half the risk of dementia compared to non-regular usage, CHR (cause-specific hazard ratio) = 0.57, 95% CI = 0.46–0.71. The association was maintained after adjustments for self-selection into baseline usage (CHR = 0.54, 95% CI = 0.41–0.72) and signs of cognitive decline at the baseline (CHR = 0.62, 95% CI = 0.46–0.85). The difference in risk between regular and non-regular users did not vary by educational attainment, race-ethnicity, sex, and generation. In addition, additional periods of regular usage were associated with significantly reduced dementia risk, CHR = 0.80, 95% CI = 0.68–0.95. However, estimates for daily hours of usage suggested a U-shaped relationship with dementia incidence. The lowest risk was observed among adults with 0.1–2 h of usage, though estimates were non-significant due to small sample sizes. Conclusions: Regular internet users experienced approximately half the risk of dementia than non-regular users. Being a regular internet user for longer periods in late adulthood was associated with delayed cognitive impairment, although further evidence is needed on potential adverse effects of excessive usage.

Anti-Vaccine Attitudes among Adults in the U.S. during the COVID-19 Pandemic after Vaccine Rollout

Choi, J., Lieff, S., Meltzer, G., Grivel, M., Chang, V., Yang, L., & Desjarlais, D. (n.d.).

Publication year

2022

Journal title

Vaccines

Volume

10

Issue

6

10.3390/vaccines10060933

Abstract

Abstract

Even though vaccination is the most effective measure against COVID-19 infections, vaccine rollout efforts have been hampered by growing anti-vaccine attitudes. Based on current knowledge, we identified three domains (beliefs, discrimination, and news) as our correlates of primary interest to examine the association with anti-vaccine attitudes. This is one of the first studies to examine key correlates of anti-vaccine attitudes during the critical early stages of vaccine implementation in the United States. An online survey was administered in May 2021 to a non-representative, nationally based sample of adults (N = 789). Using multivariable logistic regression analysis, we found that individuals who expressed worry about COVID-19 (OR = 0.34, 95% CI 0.21, 0.55) and had greater knowledge of COVID-19 (OR = 0.50, 95% CI 0.25, 0.99) were less likely to hold antivaccine attitudes. Conversely, individuals who held stigmatizing views of COVID-19 (OR = 2.47, 95% CI 1.53, 3.99), had experienced racial discrimination (OR = 2.14, 95% CI 1.25, 3.67) and discrimination related to COVID-19 (OR = 2.84, 95% CI 1.54, 5.24), and who had been watching Fox News (OR = 3.95, 95% CI 2.61, 5.97) were more likely to hold anti-vaccine attitudes. These findings suggest COVID-19 beliefs, experiences of discrimination, and news sources should be considered when designing targeted approaches to address the anti-vaccine movement.

Obesity and Patient Activation: Confidence, Communication, and Information Seeking Behavior

Chang, J. E., Lindenfeld, Z., & Chang, V. W. (n.d.).

Publication year

2022

Journal title

Journal of Primary Care and Community Health

Volume

13

10.1177/21501319221129731

Abstract

Abstract

Introduction/Objectives: Patient activation describes the knowledge, skills, and confidence that allow patients to actively engage in managing their health. Prior studies have found a strong relationship between patient activation and clinical outcomes, costs of care, and patient experience. Patients who are obese or overweight may be less engaged than normal weight patients due to lower confidence or stigma associated with their weight. The objective of this study is to examine whether weight status is associated with patient activation and its sub-domains (confidence, communication, information-seeking behavior). Methods: This repeated cross-sectional study of the 2011 to 2013 Medicare Current Beneficiary Survey (MCBS) included a nationally representative sample of 13,721 Medicare beneficiaries. Weight categories (normal, overweight, obese) were based on body mass index. Patient activation (high, medium, low) was based on responses to the MCBS Patient Activation Supplement. Results: We found no differences in overall patient activation by weight categories. However, compared to those with normal weight, people with obesity had a higher relative risk (RRR 1.24; CI 1.09-1.42) of “low” rather than “high” confidence. Respondents with obesity had a lower relative risk (RRR 0.82; CI 0.73-0.92) of “low” rather than “high” ratings of communication with their doctor. Discussion and Conclusions: Though patients with obesity may be less confident in their ability to manage their health, they are more likely to view their communication with physicians as conducive to self-care management. Given the high receptivity among patients with obesity toward physician communication, physicians may be uniquely situated to guide and support patients in gaining the confidence they need to reach weight loss goals.

Patient-Provider Communication Quality, 2002-2016: A Population-based Study of Trends and Racial Differences

Cho, G., & Chang, V. W. (n.d.).

Publication year

2022

Journal title

Medical care

Volume

60

Issue

5

Page(s)

324-331

10.1097/MLR.0000000000001694

Abstract

Abstract

Background: 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, 1996–2017

Cho, G., & Chang, V. W. (n.d.).

Publication year

2022

Journal title

American journal of preventive medicine

Volume

62

Issue

3

Page(s)

422-426

10.1016/j.amepre.2021.08.016

Abstract

Abstract

Introduction: 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 2018

Juul, F., Parekh, N., Martinez-Steele, E., Monteiro, C. A., & Chang, V. W. (n.d.).

Publication year

2022

Journal title

American Journal of Clinical Nutrition

Volume

115

Issue

1

Page(s)

211-221

10.1093/ajcn/nqab305

Abstract

Abstract

Background: 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 source

Meltzer, G. Y., Chang, V. W., Lieff, S. A., Grivel, M. M., Yang, L. H., & Des Jarlais, D. C. (n.d.).

Publication year

2021

Journal title

International journal of environmental research and public health

Volume

18

Issue

21

10.3390/ijerph182111436

Abstract

Abstract

Non-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 US

Cho, G., & Chang, V. W. (n.d.).

Publication year

2021

Journal title

Journal of general internal medicine

Volume

36

Issue

9

Page(s)

2631-2638

10.1007/s11606-020-06581-9

Abstract

Abstract

Background: 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. (n.d.).

Publication year

2021

Journal title

Stigma and Health

Volume

6

Issue

4

Page(s)

371-379

10.1037/sah0000345

Abstract

Abstract

To 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.

24-Year trends in educational inequalities in adult smoking prevalence in the context of a national tobacco control program: The case of Brazil

Bandi, P., Chang, V. W., Sherman, S. E., & Silver, D. (n.d.).

Publication year

2020

Journal title

Preventive Medicine

Volume

131

10.1016/j.ypmed.2019.105957

Abstract

Abstract

Brazil 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 Disability

Krueger, P. M., Dehry, I. A., & Chang, V. W. (n.d.).

Publication year

2019

Journal title

Milbank Quarterly

Volume

97

Issue

1

Page(s)

48-73

10.1111/1468-0009.12372

Abstract

Abstract

Policy 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 Use

Winkelman, T. N., Chang, V. W., & Binswanger, I. A. (n.d.).

Publication year

2018

Journal title

JAMA network open

Volume

1

Issue

3

Page(s)

e180558

10.1001/jamanetworkopen.2018.0558

Abstract

Abstract

Importance: 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 Conditions

Winkelman, T. N., & Chang, V. W. (n.d.).

Publication year

2018

Journal title

Journal of general internal medicine

Volume

33

Issue

3

Page(s)

376-383

10.1007/s11606-017-4217-5

Abstract

Abstract

Background: 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 illnesses

Prescott, H. C., & Chang, V. W. (n.d.).

Publication year

2018

Journal title

BMC Geriatrics

Volume

18

Issue

1

10.1186/s12877-018-0726-2

Abstract

Abstract

Background: 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.