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Categorizing the Attainment of a Ged in Studies of Chronic Disease

The informative article by Saydah and Lochner follows the common practice of combining people with educational attainment of a graduate equivalency diploma (GED) with people who have a high school diploma in their $12 years category.1 Although few studies have specifically examined the association of receipt of a GED and risk factors for chronic disease or health outcomes, we suggest that this may not be an optimal approach to categorizing education.2,3 Based on a review of these studies and of data from the National Health Interview Survey (NHIS) of 2002–2004, we found evidence that GED recipients tend to have a greater prevalence of risk factors than high school graduates and, in some cases, high school dropouts.4 The health behaviors examined in NHIS included smoking, obesity, physical inactivity, binge drinking, and sleep deprivation. In men, the percentage of GED recipients who were daily smokers was greater than the percentage of high school dropouts or high school graduates who were daily smokers. In women, the percentage of GED recipients who were daily smokers was the same as high school dropouts, and both percentages were lower than that of high school graduates. Also in the survey, male GED recipients had a greater chance of being obese (body mass index .30 kilograms/meter squared) than high school dropouts or high school graduates. Female GED recipients and high school dropouts had similarly high levels of obesity, and both levels were higher than women who completed high school. Both GED recipients and high school graduates were much less physically inactive than high school dropouts. Both men and women with GEDs had higher levels of binge drinking than high school dropouts or high school graduates. Both male and female GED recipients were more likely to get six or fewer hours of sleep in a 24-hour period than either high school dropouts or high school graduates. It seems clear that there may be important healthrelated differences among GED recipients, high school dropouts, and high school graduates. Although a GED is considered an equivalent of a high school diploma for some purposes, it does not have the same benefits in terms of earnings as a high school diploma. Furthermore, a typical year of high school involves at least 400 hours in classes compared with only about 30 hours for the average GED preparation. Whether or not the association is causal, for these behavioral risks, a GED seems to be a powerful risk marker. As such, we suggest that future research analyses should separate GED recipients from high school graduates and those with $12 years of education, grouping them with those who have ,12 years of education. Although this is not possible with all public-use data, the NHIS data offer the opportunity to easily do so in cross-sectional and follow-up analyses.