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1.  Race/ethnic disparities in reproductive age: An examination of ovarian reserve estimates across four race/ethnic groups of healthy, regularly-cycling women 
Fertility and sterility  2013;101(1):199-207.
To determine whether reproductive age, indexed by a validated marker of ovarian reserve (antimüllerian hormone [AMH]), varies between women of different race/ethnic backgrounds.
Cross-sectional study.
Community-based sample.
Multi-ethnic sample of 947 (277 white, 237 African-American, 220 Latina, and 213 Chinese) healthy and regularly-cycling pre-menopausal women, ages 25-45.
Main Outcome Measures(s)
AMH level.
A multivariate model was fit examining race/ethnicity, covariates, non-linear terms for age (age2, age3) and BMI (BMI2, BMI3), and 2-way interactions between race/ethnicity and each other predictor variable in relation to AMH. Following backward elimination, significant effects included race/ethnicity (F=8.45), age (F=349.94), race/ethnicity-by-linear age interaction (F=4.67), age2 (F=31.61), and BMI (F=10.69). Inspection of the significant race/ethnicity-by-linear age interaction showed AMH levels were consistently lower in the Latina vs. white women across all ages, whereas AMH levels were lower in the African-American and Chinese women vs. white women at younger and middle ages, respectively, and AMH levels were higher in the African-American vs. Latina and Chinese women at older ages.
Although results must be considered preliminary, findings are two-fold, suggesting 1) African-American women may have lower AMH levels at younger ages but experience less of a reduction in AMH with advancing age; and 2) Latina and Chinese women, compared to white women, may have lower AMH levels, marking a lower ovarian reserve and possible increased risk for earlier menopause.
PMCID: PMC3976042  PMID: 24182412
race/ethnicity; antimüllerian hormone (AMH); ovarian reserve; menopause; reproductive aging
2.  Soda and Cell Aging: Associations between Sugar-Sweetened Beverage Consumption and Leukocyte Telomere Length in Healthy Adults from the National Health and Nutrition Examination Surveys 
American journal of public health  2014;104(12):2425-2431.
We tested whether leukocyte telomere length maintenance, which underlies healthy cellular aging, provides a link between sugar-sweetened beverage (SSB) consumption and risk of cardiometabolic disease. We examined cross-sectional associations between consumption of SSBs, diet soda and fruit juice and telomere length in a nationally representative sample of healthy adults.
The study population included 5,309 adults, aged 20 to 65 years, with no prior history of diabetes or cardiovascular disease, from the 1999–2002 National Health and Nutrition Examination Surveys. Leukocyte telomere length was assayed from DNA specimens. Diet was assessed using 24-hour dietary recalls. Associations were examined using multivariate linear regression for the outcome of log-transformed telomere length.
After adjustment for sociodemographic and health-related characteristics, sugar-sweetened soda consumption was associated with shorter telomeres (β=−0.010, 95% CI −0.020, −0.001, P=0.04). Consumption of 100% fruit juice was marginally associated with longer telomeres (β= 0.016, 95% CI −0.000, 0.033). No significant associations were observed between consumption of diet sodas or non-carbonated sugar-sweetened beverages and telomere length.
Regular consumption of sugar-sweetened sodas may influence metabolic disease development through accelerated cell aging.
PMCID: PMC4229419  PMID: 25322305
3.  Pediatric Pulmonologists' Perceptions of Family Socioeconomic Status in Asthma Care 
Background: Physicians' assumptions about patients' socioeconomic status (SES) have been shown to influence clinical decision making in adult patients. The goal of this study is to assess the factors associated with pediatric pulmonologists' (PPs') subjective ratings of their patients' SES, and whether these factors differ by patient race/ethnicity.
Methods: Parents of children with asthma (n=171) presenting for pulmonary care reported their SES using the MacArthur Subjective SES 10-rung ladder. The PPs (n=7) also estimated each family's SES. Two-level linear regression models with random intercepts (level 1: PP's SES ratings; level 2: PPs) were used to assess the predictors of PP-estimated family SES. The analyses were then stratified by race/ethnicity.
Results: Parental educational, insurance type, age, and race/ethnic background were associated with PPs' SES ratings. Black/African American families were rated lower than white families, accounting for other demographic factors (b=−0.60, p<0.01), but families of other races/ethnicities were not (b=−0.10, p=0.29). Even when comparing families with the same level of parental education, black/African American families, but not families of other backgrounds, were judged to have lower SES than white families (from 0.77 rungs lower among parents with some college, to 1.2 rungs lower among parents with high school or less; both p<0.05).
Conclusions: Racial differences in PPs' ability to estimate families' subjective SES in asthma care may be a function of unconscious societal biases about race and class. Collecting subjective SES from families and PPs during the office visit could facilitate discussions about material and psychosocial needs and resources that influence treatment effectiveness.
PMCID: PMC4171381  PMID: 25276485
4.  Cultural and community determinants of subjective social status among Cherokee and White youth 
Ethnicity & health  2008;13(4):289-303.
Subjective social status (SSS) is associated with physical and mental health in diverse samples. However, community, cultural, and ethnic influences on SSS are poorly understood, especially among rural and American Indian populations.
We aimed to examine similarities and differences in how community poverty, family context, and life course attainment predict SSS among Cherokee and White youth in Appalachia.
We assessed culturally and developmentally appropriate aspects of life course attainment among 344 Cherokee and White youth (age 19–24) using the Life Trajectory Interview for Youth (Brown et al. 2006. International Journal of Methods in Psychiatric Research, 15, 192–206). Combined with information regarding community context and family history, these data were used to examine common patterns and ethnic differences in community, family, and cultural influences on SSS.
Overall, both Cherokee and White youth rank their families lower in SSS than previously studied US youth. Family poverty during childhood and low parental education negatively influence family SSS, Cherokee youth rank higher on subjective socioeconomic status (SES) than Whites, as do participants in high poverty areas. However, White youth rank higher on peer SSS. Ethnographically generated items perform better than standard demographic markers in predicting SSS. Educational attainment is associated with peer SSS among Cherokee (but not White) youths.
Cultural identity, community context, and local reference groups are crucial determinants of SSS. Both White and Cherokee youth in Appalachia exhibit SSS rankings consistent with socioeconomic and cultural marginalization. On a local scale, however, living in high poverty areas or minority communities may buffer individuals from some negative social comparisons regarding subjectively perceived SES. Meanwhile, social monitoring in small minority communities may constrain optimistic bias in assessments of peer popularity and status. Social ecology, family context, and individual attainment appear to exert distinctive influences on SSS across different cultural and ethnic groups.
PMCID: PMC4075651  PMID: 18701990
Native American; Appalachia; culture; socioeconomic status; social hierarchy; poverty
5.  Disruptions in ovarian function are related to depression and cardio-metabolic risk during pre-menopause 
Menopause (New York, N.Y.)  2013;20(6):631-639.
To evaluate the extent to which mild disruptions in ovarian function indexed by changes in menstrual cycle length may relate to cardio-metabolic and psychological health in pre-menopausal women.
Among 804 healthy, regularly-cycling women (ages 25–45, M=35.5 [5.5]), patterns of any change (shortening, lengthening, or increased variability) versus no change in menstrual cycle length were examined in relation to a composite of cardio-metabolic risk and individual risk factors (high-density lipoprotein [HDL], triglycerides, waist circumference, glucose, hypertensive status) as well as in relation to depression indicators (Center for Epidemiologic Studies Depression [CESD] score ≥16 [yes/no], lifetime depression diagnosis [yes/no], lifetime anti-depressant medication use [yes/no]). Models were also explored to test whether changes in menstrual cycle length mediated relations between depression history and cardio-metabolic risk.
In covariate-adjusted models, compared to no change, any change in menstrual cycle length was associated with higher cardio-metabolic risk composite scores and lower HDL (p’s<.05). In addition, compared to no change, any change in menstrual cycle length was associated with a CESD score ≥16, having received a depression diagnosis, and having used an anti-depressant medication (p’s<.05). In exploratory analyses, any change in menstrual cycle length partially mediated the relation between depression history and cardio-metabolic risk (b=0.152, p=.040) which attenuated (b=0.129, p=.083) when any change in menstrual cycle length was covaried.
Findings suggest disruptions in ovarian function marked by subtle changes in menstrual cycle length may relate to aspects of cardio-metabolic, and psychological health among healthy, pre-menopausal women.
PMCID: PMC3657585  PMID: 23715377
ovarian function; menstrual cycle length; depression; cardiovascular risk; cardio-metabolic risk; metabolic syndrome
6.  Low Socioeconomic Status is Associated with Increased Risk for Hypoglycemia in Diabetes Patients: the Diabetes Study of Northern California (DISTANCE) 
Social risk factors for hypoglycemia are not well understood.
Cross-sectional analysis from the DISTANCE study, a multi-language, ethnically-stratified random sample of adults in the Kaiser Permanente Northern California diabetes registry, conducted in 2005-2006 (response rate 62%). Exposures were income and educational attainment; outcome was patient report of severe hypoglycemia. To test the association, we used multivariable logistic regression to adjust for demographic and clinical factors.
14,357 patients were included. Reports of severe hypoglycemia were common (11%), and higher in low-income vs. high-income (16% vs. 8.8) and low-education vs. high-education (11.9% vs. 8.9%) groups. In multivariable analysis, incomes of less than $15,000 (OR 1.51 95%CI 1.19-1.91), $15,000-$24,999 (OR 1.57 95%CI 1.27-1.94), and high school or less education (OR 1.42, 95% CI 1.24-1.63) were associated with increased hypoglycemia, similar to insulin use (OR 1.44 95%CI 1.19-1.74).
Low income and educational attainment are important risk factors for hypoglycemia.
PMCID: PMC4034138  PMID: 24858863
Socioeconomic factors; hypoglycemia; diabetes mellitus; vulnerable populations
7.  Neighborhood Deprivation and Change in BMI Among Adults With Type 2 Diabetes 
Diabetes Care  2013;36(5):1200-1208.
To compare associations between neighborhood deprivation and measures of BMI change among adults with type 2 diabetes.
Using data from the Kaiser Permanente Diabetes Study of Northern California (DISTANCE) survey, we estimated the association between neighborhood deprivation and two measures of BMI change over 3 years: 1) a continuous measure and 2) a categorical measure of clinically substantive BMI loss or gain (≥7% of baseline BMI) versus stable BMI. The sample included 13,609 adults.
On average, there was little change in BMI (−0.12, SD 3.07); 17.0 and 16.1% had clinically substantive BMI loss or gain, respectively, at follow-up. There was a positive association between neighborhood deprivation and BMI change for adults in the most versus least-deprived quartile of neighborhood deprivation (β = 0.22, P = 0.02) in adjusted models. In addition, relative to the least-deprived quartile (Q1), adults in more-deprived quartiles of neighborhood deprivation were more likely to experience either substantive BMI loss (Q2 relative risk ratio 1.19, 95% CI 1.00–1.41; Q3 1.20, 1.02–1.42; Q4 1.30, 1.08–1.55) or gain (Q2 1.25, 1.04–1.49; Q3 1.24, 1.04–1.49; Q4 1.45, 1.20–1.75).
Greater neighborhood deprivation was positively associated with BMI change among adults with diabetes as well as with clinically substantive BMI loss or gain. Findings stress the importance of allowing for simultaneous associations with both gain and loss in future longitudinal studies of neighborhood deprivation and weight change, which may be particularly true for studies of patients with diabetes for whom both weight loss and gain have health implications.
PMCID: PMC3631838  PMID: 23275367
Biological psychology  2013;93(1):213-219.
To determine whether greater childhood adversity relates to younger menarcheal age; whether younger menarcheal age relates to increased CVD risk; and whether greater childhood adversity relates to increased CVD risk, directly or indirectly (mediated by menarcheal age).
Among 650 pre-menopausal women (ages 25-45; M=34.9[5.6]), SEM was performed to estimate relations between childhood adversity, menarcheal age, and CVD risk.
Results supported a covariate-adjusted model (RMSEA=0.035; CFI=0.983) in which greater childhood adversity was related to younger menarcheal age (β=−.13, p<.01) and younger menarcheal age was related to greater CVD risk (β=−.18, p<.05). Direct and indirect effects of childhood adversity on CVD risk were non-significant. Re-evaluation of the same model with additional covariate-adjustment for adulthood body composition showed the relation between menarcheal age and CVD risk attenuated (β=−.03, p=.376).
Cross-sectional evidence suggests family-related adversity experiences in childhood confer risk for earlier menarche which, in turn, relates to increased CVD risk in adulthood, possibly via post-pubertal body size.
PMCID: PMC3709571  PMID: 23428374
childhood adversity; puberty; pubertal timing; menarche; menarcheal age; cardiovascular risk
9.  Elevated Rates of Diabetes in Pacific Islanders and Asian Subgroups 
Diabetes Care  2013;36(3):574-579.
We estimated the prevalence and incidence of diabetes among specific subgroups of Asians and Pacific Islanders (APIs) in a multiethnic U.S. population with uniform access to care.
This prospective cohort analysis included 2,123,548 adult members of Kaiser Permanente Northern California, including 1,704,363 with known race/ethnicity (white, 56.9%; Latino, 14.9%; African American, 8.0%; Filipino, 4.9%; Chinese, 4.0%; multiracial, 2.8%; Japanese, 0.9%; Native American, 0.6%; Pacific Islander, 0.5%; South Asian, 0.4%; and Southeast Asian, Korean, and Vietnamese, 0.1% each). We calculated age-standardized (to the 2010 U.S. population) and sex-adjusted diabetes prevalence at baseline and incidence (during the 2010 calendar year). Poisson models were used to estimate relative risks.
There were 210,632 subjects with prevalent diabetes as of 1 January 2010 and 15,357 incident cases of diabetes identified during 2010. The crude diabetes prevalence was 9.9% and the incidence was 8.0 cases per 1,000 person-years and, after standardizing by age and sex to the 2010 U.S. Census, 8.9% and 7.7 cases per 1,000 person-years. There was considerable variation among the seven largest API subgroups. Pacific Islanders, South Asians, and Filipinos had the highest prevalence (18.3, 15.9, and 16.1%, respectively) and the highest incidence (19.9, 17.2, and 14.7 cases per 1,000 person-years, respectively) of diabetes among all racial/ethnic groups, including minorities traditionally considered high risk (e.g., African Americans, Latinos, and Native Americans).
High rates of diabetes among Pacific Islanders, South Asians, and Filipinos are obscured by much lower rates among the large population of Chinese and several smaller Asian subgroups.
PMCID: PMC3579366  PMID: 23069837
10.  Socioeconomic Factors and Leukocyte Telomere Length In A Multi-Ethnic Sample: Findings From The Multi-Ethnic Study of Atherosclerosis (MESA) 
Brain, behavior, and immunity  2012;28:108-114.
Previous findings have linked lower socioeconomic status (SES) with elevated morbidity and mortality. Leukocyte telomere length (LTL), which also has been associated with age-related disease morbidity and mortality, is a marker of aging at the cellular level, making it a valuable early biomarker of risk and an indicator of biological age. It is hypothesized that SES will be associated with LTL, indicating that SES influences disease risk by accelerating biological aging. In the present sample we test for associations of childhood SES and adult SES (i.e. education, income, home ownership) with LTL, and examine whether these associations vary by racial/ethnic group. Analyses on 963 subjects (18.7% White, 53% Hispanics, and 28.5% African American) from the Stress ancillary study of the Multi-Ethnic Study of Atherosclerosis revealed a significant difference in LTL between home owners and renters in Hispanic and White participants (p < .05), but not amongst African Americans (p = .98). There were no linear associations of adult education or family income with LTL, however, there was an inverse association between father’s education and LTL (p = .03). These findings suggest that for Whites and Hispanics renting vs. owning a home is associated with an older biological age; however we did not replicate previous findings linking education with LTL.
PMCID: PMC3544984  PMID: 23142704
Telomere length; childhood SES; socioeconomic status; home ownership; wealth; parental education; cellular aging; biological aging; ethnicity
11.  Depressive Symptomatology, Psychological Stress, and Ovarian Reserve: A Role for Psychological Factors in Ovarian Aging? 
Menopause (New York, N.Y.)  2012;19(11):1176-1185.
To examine psychological factors in relation to antral follicle count (AFC), a marker of ovarian reserve, in a multiethnic sample of 683 pre-menopausal women in the Ovarian Aging (OVA) Study.
In cross-sectional analyses, linear regression was performed to determine whether AFC decline across women varied over levels of depression as well as depression in combination with psychological stress. The total and subscale scores of the Center for Epidemiological Studies Depression Scale (CESD) were used to measure depression and the Perceived Stress Scale was used to measure psychological stress.
Following covariate-adjustment, the 2-way interaction of age-x-positive affect and the 3-way interaction of age-x-positive affect-x-stress were related to AFC (b = 0.047, p = .036; b = 0.012, p = .099, respectively). In stratified analyses, stress was related to AFC in women with low positive affect (b = −.070, p = .021) but not in women with high positive affect (b = .018, p = .54). AFC decline across women was progressively higher in women with low positive affect who reported low (−0.747 follicles/year), mid (−0.920 follicles/year), and high (−1.112 follicles/year) levels of stress. Results examining the CESD total and remaining subscale scores were all non-significant (p’s > .05).
Cross-sectional evidence suggests that 1) women with low positive affect may experience accelerated AFC decline and 2) low positive affect may be a vulnerability factor, or, alternatively, high positive affect may be a protective factor, in moderating the negative effects of psychological stress on AFC decline.
PMCID: PMC3465629  PMID: 22760086
depression; psychological stress; reproductive aging; ovarian aging; ovarian reserve; antral follicle count (AFC)
12.  Implicit Racial Bias as a Moderator of the Association Between Racial Discrimination and Hypertension: A Study of Midlife African American Men 
Psychosomatic medicine  2012;74(9):961-964.
Empirical findings on racial discrimination and hypertension risk have been inconsistent. Some studies have found no association between self-reported experiences of discrimination and cardiovascular health outcomes while others have found moderated or curvilinear relationships. The current cross-sectional study examined whether the association between racial discrimination and hypertension is moderated by implicit racial bias among African American midlife men.
This study examined data on 91 African American men between 30-50 years of age. Primary variables were self-reported experiences of racial discrimination; and unconscious racial bias as measured by the Black-White Implicit Association Test. Modified Poisson regression models were specified examining hypertension, defined as mean resting systolic ≥ 140 mm Hg or diastolic ≥ 90 mm Hg; or self-reported history of cardiovascular medication use with a physician diagnosis of hypertension.
No main effects for discrimination or implicit racial bias were found, but the interaction of the two variables was significantly related to hypertension (χ2 = 4.89, 1 df, p < 0.05). Among participants with an implicit anti-Black bias, more frequent reports of discrimination were associated with a higher probability of hypertension, while among those with an implicit pro-Black bias, it was associated with lower risk.
The combination of experiencing racial discrimination and holding an anti-Black bias may have particularly detrimental consequences for hypertension among African American midlife men, while holding an implicit pro-Black bias may buffer the effects of racial discrimination. Efforts to address both internalized racial bias and racial discrimination may lower cardiovascular risk in this population.
PMCID: PMC3501216  PMID: 23107842
African American men; hypertension; racial discrimination; implicit racial bias
13.  Differences in the Clinical Recognition of Depression in Diabetes Patients: The Diabetes Study of Northern California (DISTANCE) 
It is unknown to what extent the gap between need and care for depression among patients with diabetes differs across racial/ethnic groups.
We compared, by race/ethnicity, the likelihood of clinical recognition of depression (diagnosis or treatment) of patients who reported depressive symptoms in a well-characterized community-based population with diabetes.
We used a survey follow-up study of 20,188 patients with diabetes from Kaiser Permanente Northern California. Analyses were limited to 910 patients who scored 10 or higher on the Patient Health Questionnaire (PHQ-8) which was included in the survey and who had no clinical recognition of depression in the12 months prior to survey. Clinical recognition of depression was defined by a depression diagnosis, referral to mental health services, or antidepressant medication prescription.
Key Results
Among the 910 patients reporting moderate to severe depressive symptoms on the survey and who had no clinical recognition in the prior year, 12%, 8%, 8%, 14%, and 15% of African American, Asian, Filipino, Latino and white patients were clinically recognized for depression in the subsequent 12 months. After adjusting for sociodemographics, limited English proficiency, and depressive symptom severity, racial/ethnic minorities were less likely to be clinically recognized for depression compared to whites (relative risk: Filipino: 0.30, African American: 0.62).
More work is needed to understand the modifiable patient and provider factors that influence clinical recognition of depression among diabetes patients from different racial/ethnic groups, and the potential impact of low rates of clinical recognition on quality of care.
PMCID: PMC3703822  PMID: 23781889
14.  Stress appraisals and cellular aging: A key role for anticipatory threat in the relationship between psychological stress and telomere length 
Brain, Behavior, and Immunity  2012;26(4):573-579.
Chronic psychological stressis a risk factor formultiple diseases of aging. Accelerated cellular aging as indexed by short telomere length has emerged as a potential common biological mechanism linking various forms of psychological stress and diseases of aging. Stress appraisals determine the degree and type of biological stress responses and altered stress appraisals may be a common psychological mechanism linking psychological stress and diseases of aging. However, no previous studies have examined the relationship between stress appraisals and telomere length. We exposed chronically stressed female caregivers and non-caregiving controls (N= 50; M age = 62.14±6.10) to a standardized acute laboratory stressor and measured their anticipatory and retrospective threat and challenge appraisals of the stressor. We hypothesized that threat and challenge appraisals would be associated with shorter and longer telomere length respectively, and that chronic care giving stress would influence telomere length through altered stress appraisals. Higher anticipatory threat appraisals were associated with shorter age-adjusted telomere length (β = −.32, p = .03), but challenge appraisals and retrospective threat appraisals showed no independent association with telomere length. Caregivers reported significantly higher anticipatory (β = −.36, p = .006)and retrospective (β = −.29, p = .03) threat appraisals than controls, but similar challenge appraisals. Although there was no significant main effect of caregiver status on telomere length, care giving had a significant indirect effect on telomere length through anticipatory threat appraisals. Exaggerated anticipatory threat appraisals may be a common and modifiable psychological mechanism of psychological stress effects on cellular aging.
PMCID: PMC3322317  PMID: 22293459
cellular aging; challenge; chronic stress; stress appraisals; threat; telomere length
Psychosomatic Medicine  2012;74(2):193-199.
To evaluate the prospective relation between dispositional traits of optimism and pessimism and IVF treatment failure among women seeking medical intervention for infertility.
Among 198 women (ages 24-45, M=35.1[4.1]; 77% white), the outcome of each participant’s first IVF treatment cycle was examined. Treatment outcome was classified as being successful (vs. failed) if the woman either delivered a baby or was pregnant as a result of the cycle by the end of the 18-month study period. At baseline, optimism and pessimism were measured as a single bipolar dimension and as separate unipolar dimensions according to the Life Orientation Test (LOT) total score and the optimism and pessimism subscale scores, respectively.
Optimism/pessimism, measured as a single bipolar dimension, predicted IVF treatment failure initially (B = -.09; p = .02; OR = 0.917; 95% CI = 0.851 – 0.988), but this association attenuated following statistical control for trait negative affect (B = -.06; p = .13; OR = 0.938; 95% CI = 0.863 – 1.020). When examined as separate unipolar dimensions, pessimism (B = .14; p = .04; OR = 1.146; 95% CI = 1.008 – 1.303), but not optimism (B = -.09; p = .12; OR = 0.912; 95% CI = 0.813 – 1.023), predicted IVF treatment failure independently of risk factors for poor IVF treatment response as well as trait negative affect.
Being pessimistic may be a risk factor for IVF treatment failure. Future research should attempt to delineate the biological and behavioral mechanisms by which pessimism may negatively affect treatment outcomes.
PMCID: PMC3273547  PMID: 22286845
optimism; pessimism; trait negative affect; infertility; in vitro fertilization
16.  Occupational Mobility and Carotid Artery Intima-Media Thickness: Findings from the Coronary Artery Risk Development in Young Adults (CARDIA) Study 
Psychosomatic medicine  2011;73(9):795-802.
To examine whether 10-year change in occupational mobility is related to carotid artery intima-media thickness (IMT) 5 years later.
Data were obtained from 2350 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Occupational standing was measured at the Year 5 and 15 CARDIA follow-up exams when participants were 30.2+3.6 and 40.2+3.6 years of age, respectively. IMT (common (CCA), internal (ICA), and bulb) was measured at Year 20. Occupational mobility was defined as the change in occupational standing between Years 5 and 15 using two semi-continuous variables. Analyses controlled for demographics, CARDIA center, employment status, parents’ medical history, own medical history, Year 5 Framingham risk score, physiological risk factors and health behaviors averaged across the follow-up, and sonography reader.
Occupational mobility was unrelated to IMT save for an unexpected association of downward mobility with less CCA-IMT (β= −.04, p=.04). However, associations differed depending on initial standing (Year 5) and sex. For those with lower initial standings upward mobility was associated with less CCA-IMT (β= −.07, p=.003) and downward mobility with greater CCA-IMT and bulb-ICA-IMT (β= .14, p=.01 and β= .14, p=.03, respectively); for those with higher standings, upward mobility was associated with greater CCA-IMT (β= .15, p=.008) but downward mobility was unrelated to either IMT measure (ps>.20). Sex-specific analyses revealed associations of upward mobility with less CCA-IMT and bulb-ICA-IMT among men only (ps<.02).
Occupational mobility may have implications for future cardiovascular health. Effects may differ depending on initial occupational standing and sex.
PMCID: PMC3216404  PMID: 22021461
CARDIA; IMT; occupational mobility; occupational social class; socioeconomic status
17.  Physical activity moderates stressor-induced rumination on cortisol reactivity 
Psychosomatic medicine  2011;73(7):604-611.
Physically active individuals have lower rates of morbidity and mortality, and recent evidence indicates that physical activity may be particularly beneficial to those experiencing chronic stress. The tendency to ruminate increases and prolongs physiological stress responses, including hypothalamic-pituitary adrenal (HPA) axis responses as indexed by cortisol reactivity to stressful experiences. We examined the association between ruminating in response to a laboratory stressor task and HPA axis reactivity and recovery, and whether a physically active lifestyle moderates the associations between rumination and cortisol output trajectories.
Forty-six post-menopausal women underwent the Trier Social Stress Test while salivary cortisol was repeatedly measured. Twenty-five minutes after the end of the stressor, participants reported level of rumination in response to the stress.
Findings indicate that physical activity moderated the initial rate (B = −.10, SE = .04, p < .05) and curvature (B = −.03, SE = .01, p = .06) of the relationship between rumination and log-transformed cortisol trajectory. Among sedentary participants, those who responded to the stressor with higher levels of rumination had a more rapid initial increase in cortisol (0.26 vs 0.21, p < .001), a later peak (56 vs. 39 minutes), and a delayed recovery (curvature −0.07 vs. −0.08, p < .001) compared to those with lower levels of rumination. In active participants, cortisol trajectories were equivalent, regardless of level of rumination.
In sum, individuals who maintain a physically active lifestyle may be protected against the effects of rumination on HPA axis reactivity to and recovery from acute stress.
PMCID: PMC3167008  PMID: 21873586
acute stress; rumination; physical activity; mixed modeling; cortisol reactivity
18.  The Influence of Neighborhood Food Stores on Change in Young Girls’ Body Mass Index 
As the prevalence of childhood obesity has risen in past decades, more attention has been given to how the neighborhood food environment affects children’s health outcomes.
This exploratory study examined the relationship between the presence of neighborhood food stores within a girl’s neighborhood and 3-year risk of overweight/obesity and change in BMI, in girls aged 6 or 7 years at baseline.
A longitudinal analysis of participants in the Cohort Study of Young Girls’ Nutrition, Environment and Transitions (CYGNET) was conducted from 2005–2008. Neighborhood food stores were identified from a commercial database and classified according to industry codes in 2006. Generalized linear and logistic models were used to examine how availability of food stores within 0.25-mile and 1.0-mile network buffers of a girl’s residence were associated with BMI z-score change and risk of overweight or obesity, adjusting for baseline BMI/weight and family sociodemographic characteristics. Data were analyzed in 2010.
Availability of convenience stores within a 0.25-mile network buffer of a girl’s residence was associated with greater risk of overweight/obesity (OR 3.38, 95% CI 1.07, 10.68) and an increase in BMI z-score (β=0.13, 95% CI 0.00, 0.25). Availability of produce vendors/farmer’s markets within a 1.0-mile network buffer of a girl’s residence was inversely associated with overweight/ obesity (OR 0.22, 95% CI 0.05, 1.06). A significant trend was observed between availability of produce vendors/farmer’s markets and lower risk of overweight/obesity after 3 years.
Although food store inventories were not assessed and food store indices were not created, the availability of neighborhood food stores may affect a young girl’s weight trajectory over time.
PMCID: PMC3115539  PMID: 21665062
19.  Social disparities in internet patient portal use in diabetes: evidence that the digital divide extends beyond access 
The authors investigated use of the internet-based patient portal,, among a well-characterized population of adults with diabetes in Northern California. Among 14 102 diverse patients, 5671 (40%) requested a password for the patient portal. Of these, 4311 (76%) activated their accounts, and 3922 (69%), logged on to the patient portal one or more times; 2990 (53%) participants viewed laboratory results, 2132 (38%) requested medication refills, 2093 (37%) sent email messages, and 835 (15%) made medical appointments. After adjustment for age, gender, race/ethnicity, immigration status, educational attainment, and employment status, compared to non-Hispanic Caucasians, African–Americans and Latinos had higher odds of never logging on (OR 2.6 (2.3 to 2.9); OR 2.3 (1.9 to 2.6)), as did those without an educational degree (OR compared to college graduates, 2.3 (1.9 to 2.7)). Those most at risk for poor diabetes outcomes may fall further behind as health systems increasingly rely on the internet and limit current modes of access and communication.
PMCID: PMC3078675  PMID: 21262921
20.  Developmental Changes in Condom Use among Urban Adolescent Females: Influence of Partner Context 
National surveys have found the percentage of female adolescents who report condom use at last sex differs by age group. Using longitudinal data, the authors examined whether there are longitudinal changes in condom use and whether these longitudinal changes are due in part to developmental changes in the types of sexual relationships in which young women are involved.
A clinic sample of 298 African American females aged 14 to 19 years at enrollment were interviewed every 6 months for 36 months. At each interview, participants were asked to name all their recent sex partners, to classify each partner as main or casual and to report whether or not a condom was used at last sex with each of these partners. Hierarchical generalized linear modeling was used to analyze repeated measures within individuals.
On average, there was no statistically significant change in condom use over time. The odds of having a single main partner increased by 4% for each six months spent in the study (OR: 1.04, 95%CI: 1.02, 1.05). Stratifying females by longitudinal relationship patterns resulted in three distinct condom use trajectories.
Data suggest that longitudinal changes in condom use are a function of developmental changes in relationships, whereby young women trend toward monogamous relationships. As condoms are abandoned within these monogamous relationships, lowering infection rates in sex partners through broader STI screening or through community-level interventions aimed at sex networks may prove to be a more effective approach to reduce STI risk in young women.
PMCID: PMC3058143  PMID: 21402268
To characterize the backgrounds of women who have repeat abortions.
Study Design
In a cross-sectional study of 259 women (M=35.2±5.6 years), the relation between adverse experiences in childhood and risk of having 2+ abortions versus 0 or 1 abortion was examined. Self-reported adverse events occurring between ages 0-12 were summed.
Independent of confounding factors, women who experienced more abuse, personal safety, and total adverse events in childhood were more likely to have 2+ versus 0 abortions (OR=2.56, 95% CI=1.15-5.71; OR=2.74, 95% CI=1.29-5.82; OR=1.59, 95% CI=1.21-2.09) and versus 1 abortion (OR=5.83, 95% CI=1.71-19.89; OR=2.23, 95% CI=1.03-4.81; OR=1.37, 95% CI=1.04-1.81). Women who experienced more family disruption events in childhood were more likely to have 2+ versus 0 abortions (OR=1.75, 95% CI=1.14-2.69) but not versus 1 abortion (OR=1.16, 95% CI=0.79-1.70).
Women who have repeat abortions are more likely to have experienced childhood adversity than those having 0 or 1 abortion.
PMCID: PMC3032830  PMID: 21074137
contraception; early adversity; life events; repeat abortions
22.  The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: the DISTANCE Study 
Patient education and counseling  2010;81(2):222-228.
To assess the the association of limited English proficiency (LEP) and physician language concordance with patient reports of clinical interactions.
Cross-sectional survey of 8,638 Kaiser Permanente Northern California patients with diabetes. Patient responses were used to define English proficiency and physician language concordance. Quality of clinical interactions was based on 5 questions drawn from validated scales on communication, 2 on trust, and 3 on discrimination.
Respondents included 8,116 English-proficient and 522 LEP patients. Among LEP patients, 210 were language concordant and 153 were language discordant. In fully-adjusted models, LEP patients were more likely than English-proficient patients to report suboptimal interactions on 3 out of 10 outcomes, including 1 communication and 2 discrimination items. In separate analyses, LEP-discordant patients were more likely than English-proficient patients to report suboptimal clinician-patient interactions on 7 out of 10 outcomes, including 2 communication, 2 trust, and 3 discrimination items. In contrast, LEP-concordant patients reported similar interactions to English-proficient patients.
Reports of suboptimal interactions among patients with LEP were more common among those with language discordant physicians.
Expanding access to language concordant physicians may improve clinical interactions among patients with LEP. Quality and performance assessments should consider physician-patient language concordance.
PMCID: PMC2907435  PMID: 20223615
23.  Predictors of not pursuing infertility treatment after an infertility diagnosis: examination of a prospective U.S. cohort 
Fertility and sterility  2010;94(6):2369-2371.
We studied a prospective cohort of 434 couples in Northern California and found that 13% did not pursue any form of infertility treatment after their initial consultation. While age, education, and financial concerns remain important for patients in choosing whether to pursue infertility treatment, depressive symptoms may also be a barrier to achieving reproductive goals.
PMCID: PMC2946977  PMID: 20471010
24.  Social Inequalities in Childhood Dental Caries: The Convergent Roles of Stress, Bacteria and Disadvantage 
Social science & medicine (1982)  2010;71(9):1644-1652.
The studies reported here examines stress-related psychobiological processes that might account for the high, disproportionate rates of dental caries, the most common chronic disease of childhood, among children growing up in low socioeconomic status (SES) families. In two 2004 – 2006 studies of kindergarten children from varying socioeconomic backgrounds in the San Francisco Bay Area of California (Ns = 94 and 38), we performed detailed dental examinations to count decayed, missing or filled dental surfaces and microtomography to assess the thickness and density of microanatomic dental compartments in exfoliated, deciduous teeth (i.e., the shed, primary dentition). Cross-sectional, multivariate associations were examined between these measures and SES-related risk factors, including household education, financial stressors, basal and reactive salivary cortisol secretion, and the number of oral cariogenic bacteria. We hypothesized that family stressors and stress-related changes in oral biology might explain, fully or in part, the known socioeconomic disparities in dental health. We found that nearly half of the five-year-old children studied had dental caries. Low SES, higher basal salivary cortisol secretion, and larger numbers of cariogenic bacteria were each significantly and independently associated with caries, and higher salivary cortisol reactivity was associated with thinner, softer enamel surfaces in exfoliated teeth. The highest rates of dental pathology were found among children with the combination of elevated salivary cortisol expression and high counts of cariogenic bacteria. The socioeconomic partitioning of childhood dental caries may thus involve social and psychobiological pathways through which lower SES is associated with higher numbers of cariogenic bacteria and higher levels of stress-associated salivary cortisol. This convergence of psychosocial, infectious and stress-related biological processes appears to be implicated in the production of greater cariogenic bacterial growth and in the conferral of an increased physical vulnerability of the developing dentition.
PMCID: PMC2954891  PMID: 20870333
Dental caries; socioeconomic status; stress; vulnerability; USA; children; psychobiological

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