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REVIEWS Further Prematurity: An Overview and
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Marie C. McCormick,1,2 Jonathan S. Litt,2,3
Annu. Rev. Public Health 2011.32:367-379. Downloaded from www.annualreviews.org

Our comprehensive search Vincent C. Smith,2 and John A.F. Zupancic2

1
Department of Society, Human Development and Health, School of Public Health,
Harvard University, Boston, Massachusetts 02115; email: mmccormi@hsph.harvard.edu
2
Department of Neonatology, Beth Israel Deaconess Medical Center, Boston,
Massachusetts 02215; email: vsmith1@bidmc.harvard.edu, jzupanci@bidmc.harvard.edu
3
Division of Newborn Medicine, Childrens Hospital of Boston, Boston, Massachusetts
02115; email: Jonathan.Litt@childrens.harvard.edu

Annu. Rev. Public Health 2011. 32:36779 Keywords

First published online as a Review in Advance on infant mortality, childhood morbidity, prevention
December 21, 2010

The Annual Review of Public Health is online at Abstract

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The high rate of premature births in the United States remains a pub-
lic health concern. These infants experience substantial morbidity and
mortality in the newborn period, which translate into signicant med-
ical costs. In early childhood, survivors are characterized by a variety
of health problems, including motor delay and/or cerebral palsy, lower
IQs, behavior problems, and respiratory illness, especially asthma. Many
experience difculty with school work, lower health-related quality of
life, and family stress. Emerging information in adolescence and young
adulthood paints a more optimistic picture, with persistence of many
problems but with better adaptation and more positive expectations by
the young adults. Few opportunities for prevention have been identied;
therefore, public health approaches to prematurity include assurance of
delivery in a facility capable of managing neonatal complications, quality
improvement to minimize interinstitutional variations, early develop-
mental support for such infants, and attention to related family health
issues.

367
 PU32CH20-McCormick ARI 9 March 2011 20:25
INTRODUCTION
Historically, infants born too soon and/or too
Low birth weight small experienced high mortality rates (13).
(LBW): <2500 g or
However, only in the twentieth century were
5.5 lbs.
concepts underscoring the separate processes of
Prematurity: birth at
fetal weight gain and duration of gestation de-
less than 37 completed
ned with the World Health Organization def-
weeks of gestation
initions of low birth weight (LBW) as 2500 g
GA: gestational age
and prematurity as a gestation less than 37 com-
Very low birth
pleted weeks (13).
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weight (VLBW):
<1500 g or 3.3 pounds
Extremely low birth Definitions
Annu. Rev. Public Health 2011.32:367-379. Downloaded from www.annualreviews.org
weight (ELBW):
<1000 g or 2.2 pounds Before ultrasound could determine gestational
Infant mortality: age (GA), most studies of preterm infants relied
number of infant on birth weight designations to characterize risk
deaths less than 11 e.g., <1500 g [very low birth weight (VLBW)
completed months of 3.3 pounds] and <1000 g [extremely low birth
age divided by the
weight (ELBW), 2.2 pounds]. A recent Insti-
number of live births
tute of Medicine (IOM) report (3) argues that
the determinant of mortality and much of the
morbidity reects the degree of immaturity of
fetal development. Weight relative to duration
of gestation may add a component of risk for
adverse neonatal outcomes at the extremes, but
birth weight is not a proxy for fetal immaturity.
Among preterm births, designations of at
least three levels of risk are becoming accepted:
infants at the limits of viability (25 weeks);
very preterm infants (2633 weeks), who will
need access to neonatal intensive care for sur-
vival; and infants 3436 weeks, now desig-
nated as late preterm infants (65). Because late
preterm infants generally required less medi-
cal support to survive, their increased risk for
complications was underappreciated until re-
cent work (65). Because late and moderately
preterm infants are the majority of preterm
births, they constitute a public health concern
less in terms of mortality and more in terms of
morbidity and medical care costs.
Trends
For nearly three decades, the rates of prematu-
rity in the United States increased until 2006
(45), with a decline from 12.8% to 12.3% in
368 McCormick et al.
2008, a change seen in all maternal age and
racial/ethnic groups (44). The rates of other
preterm groups have remained relatively sta-
ble; thus, the increase has been in late preterm
birth (Figure 1).
Although the substantial racial disparity in
preterm birth rates between African American
and white mothers persists, much of the in-
crease has been among white women. Likewise,
although adolescent women have higher rates
of preterm births [although the proportion of
births to young women has been decreasing un-
til recently (9, 75)], the increases in prematu-
rity have been seen for both young women and
women 30 years of age and older (9). A portion
of the risk among older women is attributed to
the use of assisted fertility techniques among
women who have postponed child-bearing.
Such techniques are associated with both in-
creased incidences of multiple births, which are
more likely to be born preterm (3), and higher
rates of preterm delivery in singleton births as
well (3, 9).
INFANT MORTALITY
AND MORBIDITY
Infant Mortality
Infant mortality increases sharply with decreas-
ing GA, from 175.94 per 1,000 live births at
<32 weeks to 2.39 per 1,000 live births at 37
41 weeks (45). Mortality rates for all premature
infants have declined over the past four decades,
a result of increased survival owing to improve-
ments in obstetric and neonatal intensive care
(3, 14, 51). Of all infant deaths in the United
States in 2006, 54% occurred among the 2% of
infants born <32 weeks (45).
Neonatal Morbidity
Complications seen in the preterm infant fol-
lowing birth reect both the immaturity of
organ systems and the intensive interventions
needed for survival. As with mortality, the risk
of these complications decreases with increas-
ing GA and maturation.
 PU32CH20-McCormick ARI 9 March 2011 20:25
Nervous system. Major central nervous sys-
tem complications include intracranial bleed-
ing, white matter damage, and sensory impair-
ment (12, 39), affecting 20%25% of VLBW
infants. Twenty-ve percent of those with more
severe hemorrhages will also develop persistent
hydrocephalus (12). Abnormal development of
the immature eye may result in impaired reti-
nal function and retinal detachment (retinopa-
thy of prematurity); blindness results in 50%
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of those infants with the most severe and un-
treated forms (12). The rate of hearing loss
among VLBW or very preterm infants is 2%
Annu. Rev. Public Health 2011.32:367-379. Downloaded from www.annualreviews.org
4% (12).
Lung. Lung immaturity and respiratory dis-
tress, coupled with the ventilatory techniques
aimed at treating them, may lead to lung in-
jury (39). The most severe form is called bron-
chopulmonary dysplasia or chronic lung disease
and occurs in up to 35% of infants born <1500 g
(21). Such severe lung disease is associated
with a higher risk of hospital readmission (76,
78, 80).
Postnatal growth. Preterm infants experience
growth difculties, such that 97% of VLBW
and 99% of ELBW infants remain below the
tenth percentile at 36 weeks postmenstrual age
(37) as a result of both the increased caloric de-
mands of illness and decreased absorption in
the immature gut. Also, very preterm infants
may develop necrotizing enterocolitis (NEC),
a condition marked by infection and/or inam-
mation, damage to the intestinal lining, and per-
foration of the intestine (12, 39).
Sepsis. Infection contributes to morbidity via a
combination of immaturity of the immune sys-
tem and exposure to invasive interventions such
as ventilators and intravenous lines. The inci-
dence of early-onset sepsis is ten times as high in
VLBW than normal birth weight infants (12).
The provision of breast milk to preterm in-
fants appears to confer an advantage in provid-
ing some protection from a number of types
of infection and NEC (22), as well as being
associated with improved neurodevelopmental
outcomes (20, 88).
Normal birth weight:
2500 g or 5.5 pounds
OUTCOMES
IQ: intelligence
Beyond the newborn period, surviving preterm quotient
infants are only at modestly increased (gener-
ally 24 times) risk for an array of health, de-
velopmental, and behavioral problems. Many
of these problems also occur in term infants.
Because very preterm infants constitute only a
relatively small percentage of the overall child
population, their increased risk for common
problems has a limited effect on the popula-
tion prevalence of the problems, unlike their
contribution to mortality. Although we have
argued above for the use of GA in identify-
ing risk, much of the literature, until recently,
has employed birth weight cut-offs. Although
VLBW and ELBW children are almost all pre-
mature, using birth weight selects for samples
who are more likely to be small for GA (i.e.,
more mature for a given birth weight and, thus,
more likely to survive). To the extent that less
growth for a given duration of gestation confers
an additional risk for morbidity, birth-weight-
based samples may overestimate morbidity
risks.
Preschool and School-Age
Much of the outcome literature focuses on the
preschool and school-aged child. In part, the
density of literature on outcomes at this age re-
ects the difculties and costs of longer-term
follow-up. Moreover, for historical reasons, the
most frequently assessed outcomes were in-
telligence (IQ) and neurodevelopmental dis-
orders, especially cerebral palsy. By the late
preschool/early-school period most signicant
adverse outcomes would be evident, and rela-
tively good predictive validity of the testing for
later outcomes can be achieved. However, more
comprehensive assessment approaches have re-
vealed a number of ongoing and potentially in-
teractive outcomes in these children that speak
to the need for a more wholistic approach to
their care.
www.annualreviews.org Premature Births 369
 PU32CH20-McCormick ARI 9 March 2011 20:25
Growth. Whether poor growth persists into
childhood is uncertain. Many investigators
have shown a relationship of prematurity with
BPD:
bronchopulmonary low weight, short stature, and smaller head
dysplasia circumference. Others, however, have docu-
mented catch-up growth such that most chil-
dren achieve population norms by 611 years
of age (6, 19, 29). Being born small for GA de-
creases the chances for catch-up in early child-
hood (35, 55).
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Respiratory outcomes. Prematurity in-
creases the risk of many types of respiratory
Annu. Rev. Public Health 2011.32:367-379. Downloaded from www.annualreviews.org
conditions, including asthma. A recent meta-
analysis revealed that children born <37 weeks
are 7% more likely to be diagnosed with
asthma compared with term-born controls;
infants born at lower GA were at highest risk.
Likelihood of diagnosis lessens over time as
children age (33). However, preterm children
also perform poorly on tests of pulmonary
function when followed into school age (20).
Respiratory morbidity results in elevated use
of medical care: The majority of extremely
premature infants experience hospital readmis-
sions by age two irrespective of the presence of
bronchopulmonary dysplasia (BPD) (30). Even
late preterm infants have increased risk: 15%
are rehospitalized in the rst years of life (42,
52). In addition, respiratory morbidity, espe-
cially with prior BPD, is associated with higher
medication use, including brochodilators and
inhaled steroids (24, 52), as well as with missed
school days (52), perhaps contributing to school
difculties.
Neurodevelopment (cognitive/motor).
Motor delays in children born preterm are
common. Rates of cerebral palsy (CP) are
6%9% for infants born at 32 weeks and
16%28% at 26 weeks gestation (56). In
addition, more subtle neurologic ndings
persist into childhood, leading to problems
with coordination and completion of daily
living activities (3). Fine motor abilities may be
compromised even without evidence of abnor-
mality on head imaging (77). Although much
of the literature on motor delay is focused on
370 McCormick et al.
very preterm infants, late preterm infants also
have a higher risk of CP, mental retardation,
developmental disability, blindness, hearing
loss, and epilepsy compared with term controls
(64, 66).
Additionally, severe visual impairment af-
fects nearly 10% of children born 26 weeks
gestation and up to 2% of those born 32 weeks
(56). Up to 6% of children born before 27 weeks
may also suffer from profound hearing loss (3).
Children born preterm are at signicantly
higher risk for poor intellectual development
and low IQ than are infants born at term.
Up to 13% of children born <1000 g and
20% born <750 g have subnormal intelligence
(IQ between 7084). These differences persist
even when neurosensory impairment, neuro-
logic injury, and sociodemographic risk factors
are taken into account (27).
School achievement/learning disability.
Even children without severe neurosensory
impairment or intellectual disability may expe-
rience learning disabilities. Children born with
low birth weight have higher rates of disability
in both reading and math (74, 85), with math
reasoning being more severely affected (85).
Very preterm children are more likely to have
individual (65%) and multiple (30%) learning
disabilities compared with term controls (13%
and 3%, respectively) (25). Late preterm
infants are not immune to neurodevelopmental
difculties, having been shown to have lower
reading scores in kindergarten and rst grade
(66). Although birth weight and other factors
surrounding birth play a signicant role in
special educational placement, it should be
noted that sociodemographic characteristics
of the family also play a role, with greater
economic or educational advantage playing a
protective role (69).
Despite higher rates of learning disabilities,
LBW children with known learning disabilities
are less likely to have an Individualized Edu-
cation Plan or receive special education ser-
vices than are term-born peers (41). The gap
in achievement between the group of ELBW
children and normal birth weight controls leads
 PU32CH20-McCormick ARI 9 March 2011 20:25
to differences in grade retention and special ed-
ucation participation (71).
Behavior. Compared with term children,
preterm children have higher scores on tests of
inattentive and hyperactive behavior, and com-
bined forms of attention decit hyperactivity
disorder, perhaps related to the known prob-
lems with executive function and task comple-
tion (5, 28). Additionally, ELBW children have
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higher scores for measures of autism spectrum
disorders, but only a minority meets full criteria
for a diagnosis (38).
Annu. Rev. Public Health 2011.32:367-379. Downloaded from www.annualreviews.org
Quality of life. The higher prevalence of
these multiple health problems suggests that
preterm children will experience disparities in
the health-related quality of life. When exam-
ined, preterm infants were rated as having sig-
nicantly lower health-related quality of life
and quality-adjusted life years compared with
term controls (62, 68, 86). These differences
in health ratings are seen across all domains of
functional status (10).
Family impact. Likewise, the increased level
of many different types of morbidity may affect
family function and strain resources. Families
with ELBW children do describe high nan-
cial impact and caretaker/family burden com-
pared with families of term-born controls asso-
ciated with increased child neurodevelopmental
risk and the presence of chronic conditions (17).
The negative impact of preterm birth appears
to persist over time in the school years, but only
for families with higher resources (57).
Adolescence and Young Adulthood
A growing literature documents outcomes
(generally to their teens or twenties) of sur-
vivors of effective neonatal care. This lit-
erature highlights some intriguing evidence
of resilience and shows substantial continu-
ity with the much larger body of information
on younger children. These longer-term out-
comes will not, however, reect the neonatal
care as it is delivered today.
Neurodevelopmental outcomes. The rate of
CP and other motoric difculties in adolescence
are similar to that seen in younger age groups
(26, 59), with the added feature that the dispar-
ity in performance compared with term chil-
dren appears to be greater for more cognitively
demanding tasks (15). Likewise, IQ differences
noted above persist (1, 15), and even those who
have IQs in the average range may have spe-
cic decits, namely in higher-order executive
function cognitive abilities such as verbal u-
ency, working memory, and cognitive exibil-
ity. Decits in these skills, needed for academic
achievement and behavioral functioning, may
contribute to the problems experienced by very
preterm or VLBW youth in these areas (1).
Late complications such as retinal detach-
ments may occur in adulthood for those with
retinopathy of prematurity. Such complications
may prove difcult to treat, but repair is associ-
ated with good visual functioning (34, 87).
Behavioral issues and mental health. Behav-
ioral and mental health issues in former preterm
infants remain a controversial subject. Preterm
children have increased risk of behavior prob-
lems that some researchers suggest may per-
sist into adolescence and adulthood (26). Some
studies found affective disorders such as anxi-
ety increased among preterm women but gen-
erally no increased risk for depression (26). In
Scandinavian population studies, lower GA
increases the risk of disability payments for
psychological, developmental, behavioral, and
emotional disorders (including a small number
with autism) (59), as well as hospitalization for
psychiatric or addiction disorders (40).
Adolescents and young adults born preterm,
however, have equal or lower rates of risky
behavior compared with term-born peers (26,
31, 43, 59). This observation may be due to
parental protectiveness (26), less social compe-
tence, and/or less engagement in peer group
activities (26, 60).
Other health issues. Although young adults
who had BPD as neonates demonstrate
worse lung function, their exercise capacity is
www.annualreviews.org Premature Births 371
 PU32CH20-McCormick ARI 9 March 2011 20:25
similar to those born at term (4, 16). Despite
some studies suggesting an increased incidence
of asthma (83), respiratory disease is otherwise
NICU: neonatal
intensive care unit not a prominent feature of the health of adoles-
cents and young adults born preterm.
In preterm adolescents and young adults,
higher blood pressures (16, 26) with associated
impaired glucose tolerance (26) and less favor-
able fat distribution (18) have been noted, a
combination that might signal greater risk of
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adult onset cardiovascular disease. This risk is
of particular concern among preterm infants
born small for GA who experience rapid catch-
Annu. Rev. Public Health 2011.32:367-379. Downloaded from www.annualreviews.org
up growth in the postnatal period (2, 7).
Lower birth weights appear to be associated
with lower risks of some cancers (8, 54, 61,
92). As with cardiovascular disease, however,
the effects appear to reect growth for a given
duration of gestation rather than prematurity
per se.
Despite some reports of catch-up growth
during the preschool period, most very preterm
adolescents and adults remain smaller and
lighter than their term peers (7, 43, 91). Con-
troversy exists about whether very preterm ado-
lescents and young adults have lower bone mass
or whether it is appropriate for their smaller size
(26, 91).
Hospitalization rates in adolescence and
young adulthood have been reported to be 16%
higher in those born preterm compared with
those born at term. Reasons for hospitalization
were most strongly related to diabetes, eye dis-
orders, epilepsy, and congenital anomalies of
the genital organs. Among those born small
for GA, the risk of rehospitalization was even
higher, particularly for mental health disorders
and substance abuse (79).
Those born preterm report more disability-
limiting work capacity and receipt of disabil-
ity payments (59). Although they are less likely
to have children of their own, women born
preterm are at increased risk of preterm labor
(59, 84).
Despite preterm adolescents and young
adults reporting a greater number and sever-
ity of health problems (43, 71), they rate their
health-related quality of life (71), self-esteem
372 McCormick et al.
(43, 72), and expectations for economic and so-
cial goals (43) the same as term comparisons.
In fact, many of those without disability have
successfully transitioned to adult employment,
education, and family formation (73).
Factors Influencing Outcomes
GA is not the sole determinant of outcome.
Aspects of neonatal intensive care unit (NICU)
admission, including number of complications
and duration, confer an increased risk of
adverse outcome, especially with respect to
neurodevelopment (26, 36, 38, 39, 62, 78).
Likewise, an impoverished postdischarge envi-
ronment might lead to increased cognitive and
behavioral difculties in preterm infants (46).
Economic Impact
In a comprehensive review, the IOM estimated
the annual cost of prematurity in the United
States at more than $26 billion (2005 U.S. dol-
lars) (3). This estimate includes medical care
costs of $16.9 billion; the remainder is com-
posed of special education, early intervention,
maternal health care costs, and changes in adult
work productivity for both graduates and their
families. It is likely an underestimate owing to
poor data availability for certain categories of
expenses (93).
PUBLIC HEALTH IMPLICATIONS
Prevention
Few opportunities for prevention are available,
largely because of a limited understanding of
the basic biology underlying preterm delivery
(3). One strategy involves decreasing higher-
order multiple births resulting from assisted
reproductive technology. Another might be
improving the accuracy of early pregnancy
GA estimation, thereby reducing the number
of infants inadvertently delivered preterm
because of inaccurate dates. Both approaches
will have limited impact on the overall rate of
prematurity. To date, few interventions offered
 PU32CH20-McCormick ARI 9 March 2011 20:25
after the onset of preterm labor have proven
effective in preventing preterm birth (3).
Optimizing the Management of the
Preterm Infant
For those destined to be born preterm, optimal
survival relies on delivery in a setting in which
appropriate medical care is available. Improved
outcomes, especially for the smallest and most
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vulnerable infants, are seen in facilities with the
capacity, technologic support, and experience
for management of preterm infant care (3, 51,
Annu. Rev. Public Health 2011.32:367-379. Downloaded from www.annualreviews.org
82). Assuring the appropriate level of care is
best achieved by characterizing the functional
capacity of each hospital within a regionalized
system of perinatal care, thus assuring access to
appropriate services (82).
Quality Improvement
An equally important goal is to reduce dif-
ferences in complication rates and outcomes
among hospitals ostensibly providing the same
level of care (32, 48, 58, 70). Such differences
can lead to fourfold differential rates of CP
and mental retardation among very preterm in-
fants (89). Dramatic differences in duration of
hospitalization and technology use have eco-
nomic implications in the care of moderately
preterm infants (48). Quality-improvement ini-
tiatives, including statewide collaboratives with
state health department support, have had vary-
ing degrees of success in reducing the variation
in complication rates (11, 23, 32, 63, 70, 90).
Early Intervention
NICU strategies to provide environments more
appropriate to the developmental status of the
infants evolved to include modications of the
NICU to reduce unnecessary aversive stimuli
such as excessive light and noise, and to pro-
mote activities to provide general newborn ex-
periences such as rocking or soothing sounds.
Despite recent documentation of the weakness
of the evidence for any single intervention with
the exception of massage and possibly skin-
to-skin care (holding the baby on the parents
chest) (50), most NICUs employ many strate-
gies to attempt to normalize the environment
of the infants.
A variety of postdischarge interventions,
most of which focus on motor activities and
physical therapy as well as parental skills, have
emerged from studies of more general educa-
tional programs for disabled or disadvantaged
children. A recent systematic analysis of this lit-
erature (81) concluded that, on average, these
interventions improved cognitive outcome with
little effect on motor development. These re-
sults are driven largely by two major studies:
the Avon Premature Infant Project (1a) and
the Infant Health and Development Program
(IHDP) (49). Both these studies relied on well-
established curricula and used rigorous designs.
Both demonstrated improved cognitive devel-
opment at the end of the intervention period
and, for IHDP, improved behavior, as well.
Although IHDP has demonstrated sustained
differences favoring the intervention group
among moderately premature infants into ado-
lescence (47), neither intervention led to sus-
tained differences in more immature infants.
Early intervention has been incorporated
into the Individuals with Disability Education
Act (Part C); all states are obliged to offer
some services for children at risk of develop-
mental delay. However, these programs vary
across states in terms of service models, coor-
dination, and eligibility criteria; participation
ranges from 23% to 83% of children identi-
ed with a standard denition of eligibility, and
participation is lower for Hispanic and poor
children (53).
Establishing Maternal Outcomes
The literature on the outcomes of pregnan-
cies ending prematurely has focused on the
infant and ignores the fact that complicated
pregnancies may have consequences for ma-
ternal health. The mothers of VLBW infants
have been found to have higher rates of de-
pressive symptoms and posttraumatic stress
disorder, although acute distress may resolve
by six months. The risk of other health
www.annualreviews.org Premature Births 373
 PU32CH20-McCormick ARI 9 March 2011 20:25

problems is not well established. However,
the antecedents of prematurity include chronic
conditions, obesity, and adverse behaviors (3),
all of which should suggest some postpartum at-
tention for the mother and some of which, like
some chronic conditions, may be exacerbated
by pregnancy. At least one study has linked
complications related to prematurity to pre-
mature maternal mortality (41a). Thus, an im-
portant research agenda should be to establish
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attention than do conditions occurring much
more infrequently. The relative failure to pre-
vent preterm birth over almost two decades ar-
gues for a more robust program of basic sci-
ence inquiry to establish the biologic processes
underlying prematurity to identify potential in-
tervention strategies. For those infants who are
born prematurely, a growing body of evidence
suggests that at least some of the morbidity
is preventable or modiable. Many of the ap-

the needs of women who have experienced a proaches to doing so fall squarely in the do-
preterm delivery. main of public health: building and organizing
systems of care, fostering quality improvement,
Annu. Rev. Public Health 2011.32:367-379. Downloaded from www.annualreviews.org

and enhancing early childhood interventions

SUMMARY to improve developmental and behavioral out-
Preterm delivery now affects up to one out comes. Public health agencies need to play an
of every eight infants born in the United active role in fostering effective interventions
States, yet this issue receives far less systematic to address the issues of preterm birth.

SUMMARY POINTS
1. Premature birth affects more than 12% of all American infants and is a public health
problem.
2. From birth through adolescence, survivors of preterm delivery experience a variety of
health, behavioral, and cognitive difculties, with implications for schooling and their
families.
3. In adolescence, some positive adaptations occur such that those without signicant in-
tellectual disability appear to make a successful transition to adulthood.
4. Potential approaches to prevention seem limited.
5. Reduction of morbidity can be achieved by appropriate management during the newborn
period, reduction of interinstitutional variations in newborn care, and early developmen-
tal intervention.

FUTURE ISSUES
1. There should be a signicant investment in the basic science research on prematurity to
identify effective prevention strategies.
2. More attention should be given to the health of the parents of preterm infants and the
means of providing needed support.

DISCLOSURE STATEMENT
The authors are not aware of any afliations, memberships, funding, or nancial holdings that
might be perceived as affecting the objectivity of this review.

374 McCormick et al.

 PU32CH20-McCormick ARI 9 March 2011 20:25

ACKNOWLEDGMENTS
This work was supported in part by grants from the Maternal and Child Health Bureau
(T76MC00001) and Child Health Services Research Training Program (T32 HP10018).

LITERATURE CITED
1. Aarnoudse-Moens CS, Weisglas-Kuperus N, van Goudoever JB, Oosterlaan J. 2009. Meta-analysis of
neurobehavioral outcomes in very preterm and/or very low birth weight children. Pediatrics 124:71728
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91. Weiler HA, Yuen CK, Seshia MM. 2002. Growth and bone mineralization of young adults weighing
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Figure 1
PU32CH20-McCormick

% All live births

ARI

0%
1%
2%
3%
4%
5%
6%
7%

19
90

19
92
9 March 2011

19
94
20:25

19
96

19
98
Year

Trends in prematurity by weeks of gestation, United States.

20
00

20
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06

www.annualreviews.org Premature Births

C-1
36 weeks
<27 weeks

3235 weeks
2831 weeks
 PU32-FrontMatter ARI 18 February 2011 18:28

Annual Review of
Public Health

Contents Volume 32, 2011

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Symposium: Determinants of Changes in Cardiovascular Disease

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Cardiovascular Disease: Rise, Fall, and Future Prospects

Russell V. Luepker p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Proportion of the Decline in Cardiovascular Mortality Disease due to
Prevention Versus Treatment: Public Health Versus Clinical Care
Earl S. Ford and Simon Capewell p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 5
Prospects for a Cardiovascular Disease Prevention Polypill
Kaustubh C. Dabhadkar, Ambar Kulshreshtha, Mohammed K. Ali,
and K.M. Venkat Narayan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p23
Social Determinants and the Decline of Cardiovascular Diseases:
Understanding the Links
Sam Harper, John Lynch, and George Davey Smith p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p39
Sodium Intake and Cardiovascular Disease
Alanna C. Morrison and Roberta B. Ness p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p71

Epidemiology and Biostatistics

Administrative Record Linkage as a Tool for Public Health Research

Douglas P. Jutte, Leslie L. Roos, and Marni D. Brownell p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p91
Cardiovascular Disease: Rise, Fall, and Future Prospects
Russell V. Luepker p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Proportion of the Decline in Cardiovascular Mortality Disease due to
Prevention Versus Treatment: Public Health Versus Clinical Care
Earl S. Ford and Simon Capewell p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 5
Social Determinants and the Decline of Cardiovascular Diseases:
Understanding the Links
Sam Harper, John Lynch, and George Davey Smith p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p39
Sodium Intake and Cardiovascular Disease
Alanna C. Morrison and Roberta B. Ness p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p71

vii
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Prenatal Famine and Adult Health

L.H. Lumey, Aryeh D. Stein, and Ezra Susser p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 237

Environmental and Occupational Health

Advances and Current Themes in Occupational Health and

Environmental Public Health Surveillance
Jeffrey D. Shire, Gary M. Marsh, Evelyn O. Talbott, and Ravi K. Sharma p p p p p p p p p p p 109
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Climate Change, Noncommunicable Diseases, and Development:

The Relationships and Common Policy Opportunities
S. Friel, K. Bowen, D. Campbell-Lendrum, H. Frumkin, A.J. McMichael,
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and K. Rasanathan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 133

Genetic Susceptibility and the Setting of Occupational
Health Standards
Paul Schulte and John Howard p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 149
New Directions in Toxicity Testing
Daniel Krewski, Margit Westphal, Mustafa Al-Zoughool, Maxine C. Croteau,
and Melvin E. Andersen p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 161
Promoting Global Population Health While Constraining the
Environmental Footprint
A.J. McMichael and C.D. Butler p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 179
Prenatal Famine and Adult Health
L.H. Lumey, Aryeh D. Stein, and Ezra Susser p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 237

Public Health Practice

Accelerating Evidence Reviews and Broadening Evidence Standards to

Identify Effective, Promising, and Emerging Policy and
Environmental Strategies for Prevention of Childhood Obesity
Laura Brennan, Sarah Castro, Ross C. Brownson, Julie Claus,
and C. Tracy Orleans p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 199
Action on the Social Determinants of Health and Health Inequities
Goes Global
Sharon Friel and Michael G. Marmot p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 225
Prenatal Famine and Adult Health
L.H. Lumey, Aryeh D. Stein, and Ezra Susser p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 237
The Growing Impact of Globalization for Health and Public
Health Practice
Ronald Labonte, Katia Mohindra, and Ted Schrecker p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 263

viii Contents
 PU32-FrontMatter ARI 18 February 2011 18:28

Using Marketing Muscle to Sell Fat: The Rise of Obesity in the

Modern Economy
Frederick J. Zimmerman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 285
Cardiovascular Disease: Rise, Fall, and Future Prospects
Russell V. Luepker p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
New Directions in Toxicity Testing
Daniel Krewski, Margit Westphal, Mustafa Al-Zoughool, Maxine C. Croteau,
and Melvin E. Andersen p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 161
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Prematurity: An Overview and Public Health Implications

Marie C. McCormick, Jonathan S. Litt, Vincent C. Smith,
and John A.F. Zupancic p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 367
Annu. Rev. Public Health 2011.32:367-379. Downloaded from www.annualreviews.org

Proportion of the Decline in Cardiovascular Mortality Disease due to

Prevention Versus Treatment: Public Health Versus Clinical Care
Earl S. Ford and Simon Capewell p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 5
The U.S. Healthy People Initiative: Its Genesis and Its Sustainability
Lawrence W. Green and Jonathan Fielding p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 451

Social Environment and Behavior

Ecological Models Revisited: Their Uses and Evolution in Health

Promotion Over Two Decades
Lucie Richard, Lise Gauvin, and Kim Raine p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 307
Environmental Risk Conditions and Pathways to Cardiometabolic
Diseases in Indigenous Populations
Mark Daniel, Peter Lekkas, Margaret Cargo, Ivana Stankov,
and Alex Brown p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 327
Physical Activity for Health: What Kind? How Much? How Intense?
On Top of What?
Kenneth E. Powell, Amanda E. Paluch, and Steven N. Blair p p p p p p p p p p p p p p p p p p p p p p p p p p p p 349
Prematurity: An Overview and Public Health Implications
Marie C. McCormick, Jonathan S. Litt, Vincent C. Smith,
and John A.F. Zupancic p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 367
The Social Determinants of Health: Coming of Age
Paula Braveman, Susan Egerter, and David R. Williams p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 381
Toward a Fourth Generation of Disparities Research
to Achieve Health Equity
Stephen B. Thomas, Sandra Crouse Quinn, James Butler, Craig S. Fryer,
and Mary A. Garza p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 399

Contents ix
 PU32-FrontMatter ARI 18 February 2011 18:28

Action on the Social Determinants of Health and Health Inequities

Goes Global
Sharon Friel and Michael G. Marmot p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 225
Social Determinants and the Decline of Cardiovascular Diseases:
Understanding the Links
Sam Harper, John Lynch, and George Davey Smith p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p39
Using Marketing Muscle to Sell Fat: The Rise of Obesity in the
Modern Economy
Access provided by Universitatea de Medicina si Farmacie - Targu-Mures on 12/05/16. For personal use only.

Frederick J. Zimmerman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 285

Health Services
Annu. Rev. Public Health 2011.32:367-379. Downloaded from www.annualreviews.org

Prospects for a Cardiovascular Disease Prevention Polypill

Kaustubh C. Dabhadkar, Ambar Kulshreshtha, Mohammed K. Ali,
and K.M. Venkat Narayan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p23
The Health Care Workforce: Will It Be Ready as the Boomers Age?
A Review of How We Can Know (or Not Know) the Answer
Thomas C. Ricketts p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 417
The Health Effects of Economic Decline
Ralph Catalano, Sidra Goldman-Mellor, Katherine Saxton,
Claire Margerison-Zilko, Meenakshi Subbaraman, Kaja LeWinn,
and Elizabeth Anderson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 431
The U.S. Healthy People Initiative: Its Genesis and Its Sustainability
Lawrence W. Green and Jonathan Fielding p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 451
Underinsurance in the United States: An Interaction of Costs to
Consumers, Benet Design, and Access to Care
Shana Alex Lavarreda, E. Richard Brown, and Claudie Dandurand Bolduc p p p p p p p p p p p 471
Administrative Record Linkage as a Tool for Public Health Research
Douglas P. Jutte, Leslie L. Roos, and Marni D. Brownell p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p91

Indexes

Cumulative Index of Contributing Authors, Volumes 2332 p p p p p p p p p p p p p p p p p p p p p p p p p p p 483

Cumulative Index of Chapter Titles, Volumes 2332 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 488

Errata

An online log of corrections to Annual Review of Public Health articles may be found at
http://publhealth.annualreviews.org/

x Contents