Interactive effects of obesity and physical fitness on risk of ischemic heart disease.

BACKGROUND/OBJECTIVES: Obesity and low physical fitness are known risk factors for ischemic heart disease (IHD), but their interactive effects are unclear. Elucidation of interactions between these common, modifiable risk factors may help inform more effective preventive strategies. We examined interactive effects of obesity, aerobic fitness and muscular strength in late adolescence on risk of IHD in adulthood in a large national cohort. SUBJECTS/METHODS: We conducted a national cohort study of all 1 547 407 military conscripts in Sweden during 1969-1997 (97-98% of all 18-year-old males each year). Aerobic fitness, muscular strength and body mass index (BMI) measurements were examined in relation to IHD identified from outpatient and inpatient diagnoses through 2012 (maximum age 62 years). RESULTS: There were 38 142 men diagnosed with IHD in 39.7 million person years of follow-up. High BMI or low aerobic fitness (but not muscular strength) was associated with higher risk of IHD, adjusting for family history and socioeconomic factors. The combination of high BMI (overweight/obese vs normal) and low aerobic fitness (lowest vs highest tertile) was associated with highest IHD risk (incidence rate ratio, 3.11; 95% confidence interval (CI), 2.91-3.31; P<0.001). These exposures had no additive and a negative multiplicative interaction (that is, their combined effect was less than the product of their separate effects). Low aerobic fitness was a strong risk factor even among those with normal BMI. CONCLUSIONS: In this large cohort study, low aerobic fitness or high BMI at age 18 was associated with higher risk of IHD in adulthood, with a negative multiplicative interaction. Low aerobic fitness appeared to account for a similar number of IHD cases among those with normal vs high BMI (that is, no additive interaction). These findings suggest that interventions to prevent IHD should begin early in life and include not only weight control but aerobic fitness, even among persons of normal weight.

Sociodemographic, psychiatric and somatic risk factors for suicide: a Swedish national cohort study.

BACKGROUND: More effective prevention of suicide requires a comprehensive understanding of sociodemographic, psychiatric and somatic risk factors. Previous studies have been limited by incomplete ascertainment of these factors. We conducted the first study of this issue using sociodemographic and out-patient and in-patient health data for a national population. METHOD: We used data from a national cohort study of 7,140,589 Swedish adults followed for 8 years for suicide mortality (2001-2008). Sociodemographic factors were identified from national census data, and psychiatric and somatic disorders were identified from all out-patient and in-patient diagnoses nationwide. RESULTS: There were 8721 (0.12%) deaths from suicide during 2001-2008. All psychiatric disorders were strong risk factors for suicide among both women and men. Depression was the strongest risk factor, with a greater than 15-fold risk among women or men and even higher risks (up to 32-fold) within the first 3 months of diagnosis. Chronic obstructive pulmonary disease (COPD), cancer, spine disorders, asthma and stroke were significant risk factors among both women and men (1.4-2.1-fold risks) whereas diabetes and ischemic heart disease were modest risk factors only among men (1.2-1.4-fold risks). Sociodemographic risk factors included male sex, unmarried status or non-employment; and low education or income among men. CONCLUSIONS: All psychiatric disorders, COPD, cancer, spine disorders, asthma, stroke, diabetes, ischemic heart disease and specific sociodemographic factors were independent risk factors for suicide during 8 years of follow-up. Effective prevention of suicide requires a multifaceted approach in both psychiatric and primary care settings, targeting mental disorders (especially depression), specific somatic disorders and indicators of social support.

Influence of individual and neighbourhood socioeconomic status on mortality among black, Mexican-American, and white women and men in the United States.

STUDY OBJECTIVE: s: This study examines the influence of individual and neighbourhood socioeconomic status (SES) on mortality among black, Mexican-American, and white women and men in the US. The authors had three study objectives. Firstly, they examined mortality rates by both individual level SES (measured by income, education, and occupational/employment status) and neighbourhood level SES (index of neighbourhood income/wealth, educational attainment, occupational status, and employment status). Secondly, they examined whether neighbourhood SES was associated with mortality after controlling for individual SES. Thirdly, they calculated the population attributable risk to estimate the reduction in mortality rates if all women and men lived in the highest SES neighbourhoods. DESIGN: National Health Interview Survey (1987-1994), linked with 1990 census tract (neighbourhood proxy) and mortality data through 1997. SETTING/PARTICIPANTS: Nationally representative sample of 59 935 black, 19 201 Mexican-American, and 344 432 white men and women (six gender and racial/ethnic groups), aged 25-64 at interview. MAIN RESULTS: Mortality rates for all six gender and racial/ethnic groups were two to four times higher for those with the lowest incomes (lowest quartile) who lived in the lowest SES neighbourhoods (lowest tertile) compared with those with the highest incomes who lived in the highest SES neighbourhoods. For the six groups, the age adjusted mortality risk associated with living in the lowest SES neighbourhoods ranged from 1.43 to 1.61. The mortality risk decreased but remained significant (p values <.05) after adjusting for each of the three individual measures of SES, with the exception of Mexican-American women. Furthermore, the mortality risk associated with living in the lowest SES neighbourhoods remained significant after simultaneously adjusting for all three individual measures of SES for white men (p<0.001) and white women (p<0.05). Deaths would hypothetically be reduced by about 20% for each subgroup if everyone had the same death rates as those living in the highest SES neighbourhoods (highest tertile). CONCLUSIONS: Living in a low SES neighbourhood confers additional mortality risk beyond individual SES.

Engaging ethnically diverse teens in a substance use prevention advocacy program.

Teen Activists for Community Change and Leadership Education is designed to engage high school students living in low-income neighborhoods in community advocacy efforts to transform their schools and communities so they do not reinforce use of alcohol, tobacco, and other drugs. This nine month intervention for 116 freshmen and sophomores in and near San Jose, California consisted of 30-90 minute meetings. Social cognitive constructs of sense of community, perceived self-efficacy, outcome expectancies, incentive value, policy control, and leadership competence guided the program. No changes in individual use of alcohol, tobacco, and other drugs were observed by the end of the program, but improvements in community involvement and self-perception of many of the constructs were observed.

Do logistic regression and signal detection identify different subgroups at risk? Implications for the design of tailored interventions.

Identifying subgroups of high-risk individuals can lead to the development of tailored interventions for those subgroups. This study compared two multivariate statistical methods (logistic regression and signal detection) and evaluated their ability to identify subgroups at risk. The methods identified similar risk predictors and had similar predictive accuracy in exploratory and validation samples. However, the 2 methods did not classify individuals into the same subgroups. Within subgroups, logistic regression identified individuals that were homogeneous in outcome but heterogeneous in risk predictors. In contrast, signal detection identified individuals that were homogeneous in both outcome and risk predictors. Because of the ability to identify homogeneous subgroups, signal detection may be more useful than logistic regression for designing distinct tailored interventions for subgroups of high-risk individuals.

Dietary intakes and serum nutrients differ between adults from food-insufficient and food-sufficient families: Third National Health and Nutrition Examination Survey, 1988-1994.

Approximately 10.2 million persons in the United States sometimes or often do not have enough food to eat, a condition known as food insufficiency. Using cross-sectional data from the Third National Health and Nutrition Examination Survey (NHANES III), we examined whether dietary intakes and serum nutrients differed between adults from food-insufficient families (FIF) and adults from food-sufficient families (FSF). Results from analyses, stratified by age group and adjusted for family income and other important covariates, revealed several significant findings (P < 0.05). Compared with their food-sufficient counterparts, younger adults (aged 20-59 y) from FIF had lower intakes of calcium and were more likely to have calcium and vitamin E intakes below 50% of the recommended amounts on a given day. Younger adults from FIF also reported lower 1-mo frequency of consumption of milk/milk products, fruits/fruit juices and vegetables. In addition, younger adults from FIF had lower serum concentrations of total cholesterol, vitamin A and three carotenoids (alpha-carotene, beta-cryptoxanthin and lutein/zeaxanthin). Older adults (aged > or =60 y) from FIF had lower intakes of energy, vitamin B-6, magnesium, iron and zinc and were more likely to have iron and zinc intakes below 50% of the recommended amount on a given day. Older adults from FIF also had lower serum concentrations of high-density lipoprotein cholesterol, albumin, vitamin A, beta-cryptoxanthin and vitamin E. Both younger and older adults from FIF were more likely to have very low serum albumin (<35 g/L) than were adults from FSF. Our findings show that adults from FIF have diets that may compromise their health.

Cardiovascular disease risk factors among older black, Mexican-American, and white women and men: an analysis of NHANES III, 1988-1994. Third National Health and Nutrition Examination Survey.

CONTEXT: There are few studies of ethnic differences in cardiovascular disease (CVD) risk factors in older populations. OBJECTIVES: To examine the association of ethnicity on CVD risk factors, after accounting for socioeconomic status (SES), and to examine health behaviors among those with CVD risk factors. DESIGN: Third National Health and Nutrition Examination Survey, 1988-1994. SETTING: Eighty-nine mobile examination centers. PARTICIPANTS: 700 black, 628 Mexican-American, and 2192 white women and men age 65 to 84 years. MEASUREMENTS: Ethnicity in relation to type II diabetes mellitus, physical inactivity, abdominal obesity, hypertension, cigarette smoking and non-high-density lipoprotein cholesterol (non-HDL-C). RESULTS: After accounting for age and SES, both black and Mexican-American women had significantly higher prevalences of type II diabetes than white women. In addition, black women were significantly more likely to have abdominal obesity and hypertension and to be physically inactive than white women. Black men had significantly higher prevalences of hypertension and physical inactivity than white men. However, black men had lower prevalences of abdominal obesity than white men, and black women had lower prevalences of high non-HDL-C than white women. Among those with CVD risk factors, health behaviors were in need of improvement, especially among Mexican-American women whose primary language was Spanish. CONCLUSIONS: In this national sample of older women and men, black and Mexican American women and black men were at the greatest risk for CVD. These findings parallel the heightened risk of CVD among younger ethnic minority populations and argue for appropriate primary and secondary prevention programs, modified for the language, cultural, and medical needs of older ethnic minorities.

Neighborhood context and cardiovascular disease risk factors: the contribution of material deprivation.

This paper investigates whether neighborhood material deprivation is associated with cardiovascular disease (CVD) risk factors (physical inactivity, diabetes, smoking, body mass index, blood pressure, cholesterol) independent of individual socioeconomic status (SES) in Black, Mexican-American, and White women and men aged 25-64 using data from the Third National Health and Nutrition Examination Survey (1988-1994, N = 9,961). The data were linked to 1990 Census tract characteristics (unemployment, car ownership, rented housing, crowded housing), which were used to construct a neighborhood-level material deprivation index. Results are stratified by gender and race/ethnicity. Multiple logistic and linear regression models were specified using SUDAAN to account for the clustered design. In general, residence in a deprived neighborhood increased the probability of having an adverse CVD risk profile, independent of an individual's SES. For example, after adjusting for SES, Black women living in deprived neighborhoods were at increased risk of being diabetic, being a smoker, and having a higher body mass index and blood pressure compared to Black women living in less deprived neighborhoods (P values <.05). Stronger associations were found between neighborhood deprivation and CVD risk factors in Blacks than in Mexican Americans despite living in similarly deprived neighborhoods. Neighborhood deprivation may influence CVD risk factors through a variety of mechanisms including the availability of healthy environments, municipal services, and political/cultural characteristics. Policies and interventions that address the socioeconomic context in which people live might reduce inequalities in CVD risk factors.

Using focus groups to develop a heart disease prevention program for ethnically diverse, low-income women.

Although low-income women have higher rates of cardiovascular disease (CVD) than higher-income women, health promotion and disease prevention are often low priorities due to financial, family, and health care constraints. In addition, most low-income women live in environments that tend to support and even promote high risk CVD behaviors. Low-income African-American, Hispanic, and White women constitute one of the largest groups at high risk for CVD but few heart disease prevention programs have effectively reached them. The purpose of this project was to use feedback from focus groups to generate ideas about how to best structure and implement future CVD intervention programs tailored to low-income populations. Seven focus groups were conducted with 51 low-income African-American, Hispanic, and White women from two urban and two agricultural communities in California. The women in the study shared many common experiences and barriers to healthy lifestyles, despite their ethnic diversity. Results of the focus groups showed that women preferred heart disease prevention programs that would address multiple CVD risk factors, emphasize staying healthy for themselves, teach specific skills about how to adopt heart-healthy behaviors, and offer them choices in effecting behavioral change. For health information, they preferred visual formats to written formats. They also expressed a desire to develop knowledge to help them separate health "myths" from health "facts" in order to reduce their misconceptions about CVD. Finally, they stressed that health care policies and programs need to address social and financial barriers that impede the adoption of heart-healthy behaviors.

Low awareness of cardiovascular disease risk among low-income African-American women.

Focus groups were conducted with low-income African-American women in six different community settings in Northern California to assess their awareness of and concern for cardiovascular disease (CVD). These women had low awareness of the prevalence of CVD, attributed CVD to stress and low socioeconomic status, saw the media as an important source of health-related knowledge, and saw a need for more community awareness on CVD among African-American people.

Population frequency distribution of non-high-density lipoprotein cholesterol (Third National Health and Nutrition Examination Survey [NHANES III], 1988-1994).

The objective of this study was to provide population frequency distribution data for non-high-density lipoprotein (HDL) cholesterol (total cholesterol minus HDL cholesterol) concentrations and to evaluate whether differences exist by gender, ethnicity, or level of education. Serum levels of non-HDL cholesterol and sociodemographic characteristics were determined for 3,618 black, 3,528 Mexican-American, and 6,043 white women and men, aged >/=25 years, from a national cross-sectional survey of the US population (National Health And Nutrition Examination Survey III, 1988-1994). Age-adjusted non-HDL cholesterol concentrations were lower in women than men (154.1 vs 160.4 mg/dL, p <0.001). In women and men, age was positively associated with non-HDL cholesterol in the 25 to 64-year age range, and the slope of the association was steeper for women. For women and men >/=65 years, age was negatively associated with non-HDL cholesterol, and the slope of the association was steeper for men. Black women and men had lower non-HDL cholesterol levels than either Mexican-American or white women and men (women, p <0.02; men, p <0.001, for both ethnic contrasts). Women with less education had higher levels of non-HDL cholesterol than women with more education (p <0.01). These nationally representative population frequency distribution data provide non-HDL cholesterol reference levels for clinicians and investigators and indicate that there are significant variations in non-HDL cholesterol by gender, age, ethnicity, and level of education.

Identifying patients for weight-loss treatment: an empirical evaluation of the NHLBI obesity education initiative expert panel treatment recommendations.

BACKGROUND: The NHLBI (National Heart, Lung, and Blood Institute) Obesity Education Initiative Expert Panel recently proposed that clinicians and other health care professionals use a new treatment algorithm to identify patients for weight-loss treatment. In addition to the usual assessment of body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), the new algorithm includes the assessment of abdominal obesity (as measured by waist circumference) and other cardiovascular disease (CVD) risk factors. METHODS: We examined the percentage of adults meeting the criteria of the panel's treatment algorithm: BMI > or =30 or ¿[BMI, 25.0-29.9 or waist circumference >88 cm (women) >102 cm (men)] and > or = 2 CVD risk factors¿ in a sample of 2844 black, 2754 Mexican American, and 3504 white adults, aged 25 to 64 years, from the Third National Health and Nutrition Examination Survey, 1988-1994. RESULTS: Across ethnic groups, more than 98% of adults (normal weight, overweight, and obese) received the same treatment recommendations using the panel's algorithm and an algorithm based only on BMI and CVD risk factors, without waist circumference. For normal-weight adults, almost none (0.0%-1.8%) had a large waist circumference as defined above and 2 or more CVD risk factors. Using the usual criterion of a BMI of 30 or higher, a substantial percentage of at-risk overweight women and men (BMI, 25.0-29.9) with 2 or more CVD risk factors were missed (8.4% and 19.3%, respectively). CONCLUSIONS: Despite the potential importance of abdominal obesity as a CVD risk factor, these results challenge the clinical utility of including waist circumference in this new algorithm and suggest that using BMI and CVD risk factors may be sufficient.

Cardiovascular risk factors in Mexican American adults: a transcultural analysis of NHANES III, 1988-1994.

OBJECTIVES: This study examined the extent to which cardiovascular disease risk factors differ among subgroups of Mexican Americans living in the United States. METHODS: Using data from a national sample (1988-1994) of 1387 Mexican American women and 1404 Mexican American men, aged 25 to 64 years, we examined an estimate of coronary heart disease mortality risk and 5 primary cardiovascular disease risk factors: systolic blood pressure, body mass index, cigarette smoking, non-high-density lipoprotein cholesterol, and type 2 diabetes mellitus. Differences in risk were evaluated by country of birth and primary language spoken. RESULTS: Estimated 10-year coronary heart disease mortality risk per 1000 persons, adjusted for age and education, was highest for US-born Spanish-speaking men and women (27.5 and 11.4, respectively), intermediate for US-born English-speaking men and women (22.5 and 7.0), and lowest for Mexican-born men and women (20.0 and 6.6). A similar pattern of higher risk among US-born Spanish-speaking men and women was demonstrated for each of the 5 cardiovascular disease risk factors. CONCLUSIONS: These findings illustrate the heterogeneity of the Mexican American population and identify a new group at substantial risk for cardiovascular disease and in need of effective heart disease prevention programs.

Ethnic variation in cardiovascular disease risk factors among children and young adults: findings from the Third National Health and Nutrition Examination Survey, 1988-1994.

CONTEXT: Knowledge about ethnic differences in cardiovascular disease (CVD) risk factors among children and young adults from national samples is limited. OBJECTIVE: To evaluate ethnic differences in CVD risk factors, the age at which differences were first apparent, and whether differences remained after accounting for socioeconomic status (SES). DESIGN: Third National Health and Nutrition Examination Survey, 1988-1994. SETTING: Eighty-nine mobile examination centers. PARTICIPANTS: A total of 2769 black, 2854 Mexican American, and 2063 white (non-Hispanic) children and young adults aged 6 to 24 years. MAIN OUTCOME MEASURES: Ethnicity and household level of education (SES) in relation to body mass index (BMI), percentage of energy from dietary fat, cigarette smoking, systolic blood pressure, glycosylated hemoglobin (HbA1c), and non-high-density lipoprotein cholesterol (non-HDL-C [the difference between total cholesterol and HDL-C]). RESULTS: The BMI levels were significantly higher for black and Mexican American girls than for white girls, with ethnic differences evident by the age of 6 to 9 years (a difference of approximately 0.5 BMI units) and widening thereafter (a difference of >2 BMI units among 18- to 24-year-olds). Percentages of energy from dietary fat paralleled these findings and were also significantly higher for black than for white boys. Blood pressure levels were higher for black girls than for white girls in every age group, and glycosylated hemoglobin levels were highest for black and Mexican American girls and boys in every age group. In contrast, smoking prevalence was highest for white girls and boys, especially for those from low-SES homes (77% of young men and 61% of young women, aged 18-24 years, from low-SES homes were current smokers). All ethnic differences remained significant after accounting for SES and age. CONCLUSION: These findings show strong ethnic differences in CVD risk factors among youths of comparable age and SES from a large national sample. The differences highlight the need for heart disease prevention programs to begin early in childhood and continue throughout young adulthood to reduce the risk of atherosclerosis.

Pathways by which SES and ethnicity influence cardiovascular disease risk factors.

Little is known about pathways by which socioeconomic status (SES) translates into individual differences in cardiovascular disease (CVD) risk factors. Because the socioeconomic structure is not the same for all ethnic subgroups, the pathways that lead to the development of CVD risk factors may vary by both SES and ethnicity. We used data from a large national survey to examine the independent associations of two indicators of SES (education and income) and ethnicity with six primary CVD risk factors. We then used data on smoking that reflected a temporal sequence to examine the extent to which SES and ethnicity influenced smoking at three different time points, from smoking onset, to a serious quit attempt, to successful quitting. These analyses provide an understanding of the relationships between SES, ethnicity, and CVD risk factors and suggest that if the timing, focus, and content of intervention programs take pathways into account they will result in more successful outcomes.

The interplay of socioeconomic status and ethnicity on Hispanic and white men's cardiovascular disease risk and health communication patterns.

In this article, we seek to confirm past studies that document increased levels of cardiovascular disease (CVD) risk factors among White men with lower educational attainment. Second, we include a population of Hispanic men (89% Mexican American) to examine the separate and interactive effects of ethnicity and education (our measure of socioeconomic status) on CVD risk factors. Third, we examine how education and ethnicity are related to receiving health messages from print media and interpersonal channels, with the hypothesis that less educated, higher CVD risk Hispanic and White men receive fewer messages than more educated men. Finally, we examine other psychosocial variables (e.g. knowledge, self-efficacy and motivation) that may help explain observed differences in CVD risk and health communication. The study sample included 2029 men, 25-64 years of age, from three population-based, cross-sectional surveys conducted from 1979 to 1990 as part of the Stanford Five-City Project. Hispanic and White men with lower educational attainment had higher levels of CVD risk factors, and received less health information from print media and interpersonal channels than Hispanic and White men with higher educational attainment. Furthermore, less educated men from both ethnic groups reported less CVD knowledge, lower self-efficacy and lower motivation to reduce CVD risk factors than higher educated men. These results highlight the need for effective intervention programs that target low educated Hispanic and White men to decrease their disproportionate risk of CVD.

Ethnic and socioeconomic differences in cardiovascular disease risk factors: findings for women from the Third National Health and Nutrition Examination Survey, 1988-1994.

CONTEXT: Cardiovascular disease (CVD) risk factors are higher among ethnic minority women than among white women in the United States. However, because ethnic minority women are disproportionately poor, socioeconomic status (SES) may substantially explain these risk factor differences. OBJECTIVE: To determine whether differences in CVD risk factors by ethnicity could be attributed to differences in SES. DESIGN: Third National Health and Nutrition Examination Survey conducted between 1988 and 1994. SETTING: Eighty-nine mobile examination centers. PARTICIPANTS: A total of 1762 black, 1481 Mexican American, and 2023 white women, aged 25 to 64 years, who completed both the home questionnaire and medical examination. MAIN OUTCOME MEASURES: Ethnicity and years of education (SES) in relation to systolic blood pressure, cigarette smoking, body mass index (BMI, a measure of weight in kilograms divided by the square of height in meters), physical inactivity, non-high-density lipoprotein cholesterol (non-HDL-C [the difference between total cholesterol and HDL-C]), and non-insulin-dependent diabetes mellitus. RESULTS: As expected, most CVD risk factors were higher among ethnic minority women than among white women. After adjusting for years of education, highly significant differences in blood pressure, BMI, physical inactivity, and diabetes remained for both black and Mexican American women compared with white women (P<.001). In addition, women of lower SES from each of the 3 ethnic groups had significantly higher prevalences of smoking and physical inactivity and higher levels of BMI and non-HDL-C than women of higher SES (P<.001). CONCLUSIONS: These findings provide the greatest evidence to date of higher CVD risk factors among black and Mexican American women than among white women of comparable SES. The striking differences by both ethnicity and SES underscore the critical need to improve screening, early detection, and treatment of CVD-related conditions for black and Mexican American women, as well as for women of lower SES in all ethnic groups.

Predicting achievement of a low-fat diet: a nutrition intervention for adults with low literacy skills.

BACKGROUND: This paper identifies factors that predict achievement of a low-fat diet among 242 California adults with low literacy skills, following their participation in the Stanford Nutrition Action Program (SNAP), a randomized classroom-based nutrition intervention trial (1993-1994). METHODS: The intervention classes received a newly developed curriculum that focuses on reducing dietary fat intake (SNAP); the control classes received an existing general nutrition (GN) curriculum. Data were collected at baseline and 3 months postintervention. This hypothesis-generating analysis uses a signal detection method to identify mutually exclusive groups that met the goal of a low fat diet, defined as < 30% of calories from total fat, at 3 months postintervention. RESULTS: Three mutually exclusive groups were identified. Twenty-three percent of Group 1, participants with high baseline dietary fat (> 60 g) who received either the GN or the SNAP curriculum, met the postintervention goal of < 30% of calories from total fat. Thirty-four percent of Group 2, participants with moderate baseline dietary fat (< or = 60 g) who received the GN curriculum, were successful. Sixty percent of Group 3, participants with moderate baseline dietary fat who received the SNAP curriculum, were successful. Members of Group 3 also significantly increased their intake of vegetables, grains, and fiber. CONCLUSIONS: Within this population of adults with low literacy skills, a large proportion of those with moderate baseline dietary fat who participated in the SNAP classes met the postintervention criteria for a low-fat diet. A much smaller proportion of those with high baseline dietary fat were successful, suggesting that this group may benefit from different, more intensive, or longer-term interventions.

Joint analysis of three U.S. community intervention trials for reduction of cardiovascular disease risk.

During the 1980s three comprehensive community-based heart disease prevention trials were conducted in the United States. The Stanford Five-City Project, Minnesota Heart Health Program, and Pawtucket Heart Health Program involved 12 cities; six received a 5-8 year multifactorial risk reduction program. This analysis pools data from the three studies to delineate the common intervention effects with greater sample size and power than could be attained by the single studies. Time trends were estimated for cigarette smoking, blood pressure, total cholesterol, body mass index, and coronary heart disease mortality risk in women and men aged 25-64 years. The joint estimates of intervention effect were in the expected direction in nine of 12 gender-specific comparisons; however, these were not statistically significant. The results illustrate the analytic challenges of evaluating community-based prevention trials and point to the smaller than expected net differences, rather than small sample size, as the reason for few statistically significant effects in the three U.S. prevention trials.