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1.  Do reports of sleep disturbance relate to coronary and aortic calcification in healthy middle-aged women?: Study of Women’s Health across the Nation 
Sleep medicine  2013;14(3):282-287.
Background
Poor sleep may be associated with the cardiovascular disease (CVD) morbidity and mortality. It is less clear if poor sleep is associated with subclinical CVD. We evaluated cross-sectional associations between self-reported sleep disturbance and duration and calcification in the coronary arteries (CAC) and aorta (AC) in healthy mid-life women.
Methods
512 black and white women enrolled in the SWAN Heart Study underwent a computed tomography protocol for measurement of CAC and AC and completed questionnaires about their sleep. Linear and partial proportional logit regression analyses adjusted for site, race, age, body mass index, and the Framingham risk score (model 1). Additional covariates of education, perceived health, hypnotic medication and alcohol use were evaluated (model 2), plus depressive symptoms (model 3).
Results
AC was related to higher levels of trouble falling asleep, waking earlier than planned, overall poor sleep quality, and cough/snoring and shorter sleep duration in linear regression analyses (model 1). Adjustment for additional covariates showed that poor sleep quality and waking earlier than planned remained associated with higher AC (models 2, 3). CAC was unrelated to sleep characteristics.
Conclusions
Poor sleep quality is related to AC in middle-aged women. Sleep quality should routinely be assessed in mid-life women.
doi:10.1016/j.sleep.2012.11.016
PMCID: PMC3582843  PMID: 23352420
sleep; insomnia; women; mid-life; calcification; aorta; cardiovascular risk factors
2.  Racial Differences in Perception of Healthy Body Weight in Mid-Life Women: Results from Do Stage Transitions Result in Detectable Effects (STRIDE) Study 
Menopause (New York, N.Y.)  2013;20(3):269-273.
Objectives
Perception of a healthy body weight may influence health behaviors including physical activity level, nutritional habits, and health outcomes, and these perceptions may vary importantly by race. Midlife is a critical period for women, which typically includes weight gain. We assessed the associations between perception of healthy body weight and body mass index (BMI) and whether they vary by race.
Methods
In the Do Stage Transitions Result in Detectable Effects (STRIDE) study, body mass index (BMI) and perception of body weight (healthy, underweight, or overweight) were measured at the baseline examination. Multinomial logistic regression models examined the associations, with race (White vs. Black) as a moderator variable.
Results
Of 729 women enrolled, 689 women (95%, N=145 Black, N=544 White) were included in these analyses. Even though the average BMI was higher for Black women compared to White women (33.1 vs. 29.2, respectively, p<.0001), Black women were less likely to report that they weighed too much (RRR (Relative Risk Ratio) [95% CI]: 0.4 [0.2, 0.9], p 0.022) and more likely to think that they did not weigh enough (RRR [95% CI]: 14.2 [1.8, 110], p 0.011).
Conclusion
Although Black women in general face a greater threat of morbidity from weight-related chronic diseases, they are more likely to be accepting of their weight at higher BMI’s, relative to Whites. Weight-loss interventions and counseling about healthy body size may influence healthy behavior and reduce chronic disease risk.
doi:10.1097/GME.0b013e31826e7574
PMCID: PMC3593962  PMID: 23435023
Midlife; Body Image; Weight-Perception; Race; Health; Behavior
3.  Socioeconomic Status, Antioxidant Micronutrients, and Correlates of Oxidative Damage: The Coronary Artery Risk Development in Young Adults (CARDIA) Study 
Psychosomatic medicine  2009;71(5):541-548.
Objective
Risk for chronic disease increases with decreasing socioeconomic status (SES). One pathway by which low SES might influence disease risk is by promoting oxidative stress. The aim of the present study is to examine whether SES (education, occupation, income), is associated both cross-sectionally and prospectively with circulating concentrations of (a) two correlates of oxidative damage, F2-isoprostanes (F2-IsoPs) and gamma-glutamyltransferase (GGT); and (b) antioxidant nutrients (ascorbic acid and carotenoids). We also examine whether the proposed associations are mediated by smoking, alcohol consumption and depression.
Methods
Data from 1278 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study were used to examine the association of SES with oxidation correlates and antioxidant nutrients. Education, occupation, health behaviors, and body mass index (BMI) were assessed during Years 0, 10, and 15 of the study; income and depression at Years 10 and 15. F2-IsoPs were measured at Year 15, GGT at Years 0 and 10, carotenoids at Years 0 and 15, and ascorbic acid at Years 10 and 15.
Results
Cross-sectionally, oxidation correlates decreased and antioxidant nutrients increased with increasing SES, estimated in several ways, independent of age, sex, race, and BMI. Prospectively, lower Year 0 education and occupation predicted greater increases in GGT and greater decreases in carotenoids over 10–15 years. Prospective associations of Year 0 SES with Year 15 carotenoids were independent of Year 15 SES. Smoking, drinking, and depression symptoms partially mediated these effects.
Conclusions
Circulating oxidation correlates increase and antioxidant nutrients decrease with decreasing SES, both cross-sectionally and prospectively.
doi:10.1097/PSY.0b013e31819e7526
PMCID: PMC3925505  PMID: 19414620
socioeconomic status; oxidative stress; antioxidants; prospective; CARDIA
4.  Childhood Physical Abuse Is Associated with Incident Metabolic Syndrome in Mid-Life Women 
Objective
Previous research has suggested that childhood emotional abuse, physical abuse, and sexual abuse are associated with an increased risk for ischemic heart disease. Our objective was to examine whether childhood abuse predicted incident metabolic syndrome, a precursor to heart disease, in mid-life women.
Methods
Participants were 342 (114 Black, 228 White) women from the Pittsburgh site of the Study of Women’s Health Across the Nation (SWAN). SWAN included a baseline assessment of premenopausal or early perimenopausal women in midlife (mean age = 45.7), and women were evaluated for presence of the metabolic syndrome over 7 annual follow-up visits. Women were classified as having metabolic syndrome if they met 3 of the following criteria: waist circumference > 88 cm, triglycerides ≥ 150 mg/dl, HDL < 50 mg/dl, SBP ≥ 130 or DBP ≥ 85 mmHg or on blood pressure medication, and fasting glucose ≥ 110 mg/dl or diabetic. The Childhood Trauma Questionnaire is a standardized measure that retrospectively assesses three domains of abuse in childhood and adolescence: emotional, physical, and sexual abuse.
Results
Approximately 34% of the participants reported a history of abuse. Cox model survival analysis showed that physical abuse was associated with incident metabolic syndrome over the course of seven years (HR = 2.12, p = .02), adjusted for ethnicity, age at baseline, and time-dependent menopausal status. Sexual abuse and emotional abuse were unrelated to the metabolic syndrome.
Conclusion
This is the first study to show that a history of childhood abuse, specifically physical abuse, is related to the development of metabolic syndrome in mid-life women.
doi:10.1037/a0027891
PMCID: PMC3641896  PMID: 22775234
childhood abuse; metabolic syndrome; menopause
5.  Self-reported and accelerometer physical activity levels and coronary artery calcification progression in older women: Results from the Healthy Women Study 
Menopause (New York, N.Y.)  2013;20(2):152-161.
Objective
Regardless of the well-supported biological link between PA and atherosclerosis, most previous studies report a null association between PA and CAC. To examine the relation between physical activity (PA) and coronary artery calcification (CAC) progression in 148 Healthy Women Study (HWS) participants over 28 years of observation.
Methods
The HWS was designed to examine cardiovascular risk factor changes from pre- to post-menopause. Based on CAC scores collected at two follow-up visits (EBT1 and EBT4) scheduled 12 years apart, participants were classified into one of three groups: 1) no detectable CAC (n=37; 0 CAC at both visits), 2) incident CAC (n=46; 0 CAC at the first- and >0 CAC at the last- visit), or 3) prevalent CAC (n=65; >0 CAC at both visits). PA data were collected regularly throughout the study using self-report questionnaires and accelerometers at EBT4.
Results
The percentage of HWS participants with no detectible CAC decreased from 56.1% at EBT1 to 25.0% at EBT4. Time spent per day in accumulated and bouts of moderate- to vigorous-intensity (MV)PA were each significantly higher in the no detectable CAC group when compared to the prevalent CAC group (both p≤.01). After covariate adjustment, these differences remained statistically significant (both p<.05). Although self-reported summary estimates collected throughout the study were significantly associated with accelerometer data at EBT4, there were no significant differences in self-reported physical activity levels by CAC groups after covariate adjustment.
Conclusions
Study findings suggest that low levels of accelerometer-derived MVPA may be indicative of subclinical disease in older women.
doi:10.1097/gme.0b013e31826115af
PMCID: PMC3897237  PMID: 22914209
coronary heart disease; motor activity; ambulatory monitoring; coronary calcification; women
6.  Progression Rates of Carotid Intima-media Thickness and Adventitial Diameter during the Menopausal Transition 
Menopause (New York, N.Y.)  2013;20(1):8-14.
Objectives
The authors assessed whether the levels and progression rates of carotid intima-media thickness (IMT) and adventitial diameter (AD) vary by menopausal stage.
Methods
249 Women (42–57 years old, premenopausal (49%) or early peri-menopausal (46%)) from the Study of Women’s Health Across the Nation were included in the current analysis. Participants were followed for up to 9 years (median=3.7 years) and had up to 5 carotid scans. Linear mixed models were used for analysis.
Results
The overall rate of change in IMT was 0.007 mm/year. Independent of age and race, progression rate of IMT increased substantially in late peri-menopausal stage (0.017 mm/year) compared to both premenopausal (0.007 mm/year) and early peri-menopausal (0.005 mm/year) stages; (P≤0.05). For AD, while the overall rate of change was negative (−0.009 mm/year), significant positive increases in the rate of change were observed in late peri-menopausal (0.024 mm/year) and postmenopausal (0.018 mm/year) stages compared to premenopausal stage (−0.032 mm/year); (P<0.05). In final models, postmenopausal stage was independently associated with higher levels of IMT and AD (P<0.05) compared to premenopausal stage.
Conclusions
During the menopausal transition, the carotid artery undergoes an adaptation that is reflected in adverse changes in IMT and AD. These changes may impact the vulnerability of the vessel to disease in older women.
doi:10.1097/gme.0b013e3182611787
PMCID: PMC3528819  PMID: 22990755
atherosclerosis; carotid intima-media thickness; epidemiology; menopause; risk factors
7.  Body Mass Index Following Natural Menopause and Hysterectomy with and without Bilateral Oophorectomy 
Objective
The directional and temporal nature of relationships between overweight and obesity and hysterectomy with or without oophorectomy is not well understood. Overweight and obesity may be both a risk factor for the indications for these surgeries and a possible consequence of the procedure. We used prospective data to examine whether body mass index (BMI) increased more following hysterectomy with and without bilateral oophorectomy compared to natural menopause among middle-aged women.
Methods
BMI was assessed annually for up to 10 years in the Study of Women’s Health Across the Nation (SWAN (n=1962). Piecewise linear mixed growth models were used to examine changes in BMI before and after natural menopause, hysterectomy with ovarian conservation, and hysterectomy with bilateral oophorectomy. Covariates included education, race/ethnicity, menopausal status, physical activity, self-rated health, hormone therapy use, antidepressant use, and age the visit prior to the final menstrual period (FMP; for natural menopause) or surgery (for hysterectomy/oophorectomy).
Results
By visit 10, 1780 (90.6%) women reached natural menopause, 106 (5.5%) reported hysterectomy with bilateral oophorectomy, and 76 (3.9%) reported hysterectomy with ovarian conservation. In fully adjusted models, BMI increased for all women from baseline to FMP or surgery (annual rate of change=.19 kg/m2 per year), with no significant differences in BMI change between groups. BMI also increased for all women following FMP, but increased more rapidly in women following hysterectomy with bilateral oophorectomy (annual rate of change=.21 kg/m2 per year) as compared to following natural menopause (annual rate of change=.08 kg/m2 per year, p=.03).
Conclusion
In this prospective examination, hysterectomy with bilateral oophorectomy was associated with greater increases in BMI in the years following surgery than following hysterectomy with ovarian conservation or natural menopause. This suggests that accelerated weight gain follows bilateral oophorectomy among women in midlife, which may increase risk for obesity-related chronic diseases.
doi:10.1038/ijo.2012.164
PMCID: PMC3530639  PMID: 23007036
menopause; oophorectomy; BMI; women’s health
8.  Psychosocial Features Associated with Lifetime Comorbidity of Major Depression and Anxiety Disorders Among a Community Sample of Mid-Life Women: The SWAN Mental Health Study 
Depression and anxiety  2012;29(12):1050-1057.
Background
In clinical samples, comorbidity between depressive and anxiety disorders is associated with greater symptom severity and elevated suicide risk. Less is known, however, regarding the long-term psychosocial impact that a lifetime history of both MDD and one or more anxiety disorders has in community samples. This report evaluates clinical, psychological, social, and stress-related characteristics associated with a lifetime history of MDD and anxiety.
Methods
Data from 915 women aged 42–52 who were recruited as part of the the Study of Women's Health Across the Nation Mental Health Study were used to examine clinical and psychosocial features across groups of women with a SCID-diagnosed lifetime history of MDD alone, anxiety alone, both MDD and anxiety, or neither MDD nor anxiety.
Results
As compared with women with a history of either MDD or anxiety alone, women with a comorbid history were more likely to report recurrent MDD, multiple and more severe lifetime anxiety disorders, greater depressive and anxiety symptoms, diminished social support, and more past-year distressing life events. Exploratory analyses indicated that women with a comorbid history also report more childhood abuse/neglect and diminished self-esteem, as compared with women with a history of either disorder alone.
Conclusions
Midlife women with a comorbid history that includes both MDD and anxiety disorders report diminished social support, more symptomatic distress, and a more severe and recurrent psychiatric history. Future research is needed to clarify the biological and psychosocial risk factors associated with this comorobid profile, and to develop targeted interventions for this at-risk group.
doi:10.1002/da.21990
PMCID: PMC3592574  PMID: 22930404
major depressive disorder; anxiety disorders; comorbidity; child abuse; social support; stress, psychological
9.  Socioeconomic Status, Nocturnal Blood Pressure Dipping, and Psychosocial Factors: A Cross-Sectional Investigation in Mexican-American Women 
Background
Despite established links between reduced nocturnal blood pressure (BP) dipping and cardiovascular disease, BP dipping research in Hispanics is limited.
Purpose
This study investigated socioeconomic status (SES) as a predictor of BP dipping and the contributions of psychosocial factors to this relationship. Analyses were conducted for the overall sample and separately for higher and lower acculturated women.
Methods
Mexican-American women (N=291; 40–65 years) reported demographics and completed psychosocial assessments and 36-h ambulatory BP monitoring.
Results
Lower SES related to reduced BP dipping in the overall sample and in more US-acculturated women (r’s=.17–.30, p’s<.05), but not in less-acculturated women (r’s=.07, p’s>.10). An indirect effect model from SES to BP dipping via psychosocial resources/risk fits well across samples.
Conclusions
In Mexican-American women, the nature of SES gradients in BP dipping and the roles of psychosocial resources/risk differ by acculturation level.
doi:10.1007/s12160-012-9387-0
PMCID: PMC3767761  PMID: 22777880
Ambulatory blood pressure; Nocturnal blood pressure dipping; Hispanic; Psychosocial; Socioeconomic status
10.  Endogenous Sex Hormones Impact the Progression of Subclinical Atherosclerosis in Women during the Menopausal Transition 
Atherosclerosis  2012;225(1):180-186.
Objective
To determine whether endogenous sex hormones (estradiol (E2), testosterone (T), sex hormone binding globulin (SHBG), and follicle-stimulating hormone (FSH)) are longitudinally associated with progression of atherosclerosis among women at midlife.
Methods
249 Pre- or early peri-menopausal women (42–57 years) from the Study of Women’s Health Across the Nation (SWAN) were followed for up to 9 years (median=3.7 years) and had up to 5 repeated measures of common carotid intima-media thickness (IMT) and adventitial diameter (AD). Linear mixed models were used for statistical analysis. Final models included age at baseline, time since baseline, cycle day of blood draw, race, income, SBP, BMI, insulin resistance index, lipids, C-reactive protein and co-morbidity.
Results
In final models for IMT, each one log unit decrease in SHBG was associated with a 0.005 mm/year increase in IMT progression (P=0.003). E2, T, and FSH were not associated with level or progression of IMT. For AD, each one log unit decrease in E2 was associated with a 0.012 mm/year increase in AD progression (P=0.04) and each one log unit increase in FSH was associated with a 0.016 mm/year increase in AD progression (P=0.003). T and SHBG were not associated with progression or level of AD.
Conclusions
Independent of SBP, BMI, lipids and other covariates, lower E2 and SHBG, and higher FSH were associated with increased subclinical atherosclerosis progression in women at midlife.
doi:10.1016/j.atherosclerosis.2012.07.025
PMCID: PMC3478422  PMID: 22981430
subclinical atherosclerosis; sex hormones; women
11.  Short Sleep Duration is Associated with Carotid Intima-Media Thickness Among Men in the CARDIA Study 
Background and purpose
Carotid intima-media thickness (CIMT) is a subclinical marker of cardiovascular disease (CVD). Recent studies suggest that shorter sleep duration is a risk factor for CVD, but there is limited evidence regarding this association using high-quality, objective assessments of sleep. The aim of this study is to determine whether sleep duration is associated with CIMT.
Methods
The study used an observational cohort consisting of 617 black and white middle-aged healthy participants (37–52 y; 58% female) in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Multivariable-adjusted linear regression analyses were performed. Sleep duration was measured using wrist actigraphy monitors. CIMT was calculated using the average of 20 measurements of the mean common carotid, bulb and internal CIMT, which was assessed using ultrasound images.
Results
After adjusting for covariates, one hour of longer sleep duration was associated with 0.026 mm less CIMT among men (p=0.02, 95% CI -0.047, -0.005), and 0.001 mm less CIMT among women (p=0.91, 95% CI -0.020, 0.022). Segment-specific analyses indicated that the carotid bulb was a key driver of the observed association.
Conclusions
Shorter objectively assessed sleep duration was associated with greater CIMT among men but not women.
doi:10.1161/STROKEAHA.112.660332
PMCID: PMC3479367  PMID: 22935396
Sleep; carotid intima-media thickness; atherosclerosis; cardiovascular disease
12.  Cortisol Response to Social Stress in Parentally Bereaved Youth 
Biological psychiatry  2012;73(4):379-387.
Background
Parental bereavement is associated with increased risk for psychiatric illness and functional impairment in youth. Dysregulated hypothalamic-pituitary-adrenal (HPA) axis functioning may be one pathway through which bereaved children experience increased risk for poor outcomes. However, few studies have prospectively examined the association between parental bereavement and cortisol response while accounting for psychiatric disorders in both youth and their caregivers.
Methods
One-hundred and eighty-one bereaved and nonbereaved offspring and their caregivers were assessed at multiple time points over a 5-year period after parental death. Offspring participated in an adaptation of the Trier Social Stress Task (TSST), and salivary cortisol samples were collected before and after exposure to social stressors. Mixed models for repeated measures were used to analyze the effects of bereavement status, psychiatric disorder in both offspring and caregiver, and demographic indices on trajectories of cortisol response.
Results
After controlling for demographic variables and offspring depression, bereaved offspring demonstrated significantly different trajectories of cortisol response compared with nonbereaved offspring, characterized by higher total cortisol output and an absence of cortisol reactivity to acute social stress. Within the bereaved group, offspring of parents who died by sudden natural death demonstrated significant cortisol reactivity to social stress compared with offspring whose parents died by suicide, who demonstrated more blunted trajectory of cortisol response.
Conclusions
Parentally bereaved youth demonstrate higher cortisol output than nonbereaved youth but are less able to mount an acute response in the face of social stressors.
doi:10.1016/j.biopsych.2012.08.016
PMCID: PMC3789373  PMID: 23021533
Adolescent; bereavement; cortisol; depression; HPA axis; TSST
13.  The Prospective Association of Socioeconomic Status with C-Reactive Protein Levels in the CARDIA Study 
Brain, behavior, and immunity  2012;26(7):1128-1135.
Better health is a well-documented benefit of having a higher socioeconomic status (SES). Inflammation may be one pathway through which SES influences health. Using 2658 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) Study, we examine whether two measures of SES assessed at baseline (mean age, 32±4 years)—years of education and household income—predict change in C-reactive protein (CRP) concentrations over the course of 13 years. We also examine whether four health-related behaviors—smoking, fruit and vegetable consumption, physical activity, and alcohol consumption—mediate the prospective association of SES with CRP. Both higher education and household income predicted smaller increases in CRP over the 13 years of follow-up independent of age, sex, race, CARDIA center, body mass, medical diagnoses, medications, and hormone use (among women). Associations did not differ by race or sex. When examined in separate analyses, smoking and fruit and vegetable intake each accounted for a significant proportion of the respective effects of education and household income on CRP change, and physical activity a significant proportion of the effect of household income. These findings suggest that poor health behaviors among persons of lower socioeconomic status can have long-term effects on inflammation.
doi:10.1016/j.bbi.2012.07.017
PMCID: PMC3454475  PMID: 22884413
C-reactive protein; CARDIA Study; health behaviors; inflammatory markers; mediation; socioeconomic status
14.  Sleep duration and weight change in midlife women: The SWAN Sleep Study 
Obesity (Silver Spring, Md.)  2013;21(1):77-84.
Short sleep duration has been associated with higher current body mass index (BMI) and subsequent weight gain. However, most prior longitudinal studies are limited by reliance on self-reported sleep duration, and none accounted for the potential confounding effect of sleep-disordered breathing. The associations of sleep duration with current BMI and BMI change were examined among 310 midlife women in the Study of Women’s Health Across the Nation (SWAN) Sleep Study (2003–2005). Sleep duration was assessed for approximately one month with concurrent wrist actigraphy and sleep diaries. The presence and severity of sleep-disordered breathing was quantified using the apnea-hypopnea index (AHI) based on in-home polysomnography. BMI was assessed annually through core SWAN visit 10 (2006 and 2008). Mean BMI increased from 29.6 (SD=7.8) kg/m2 to 30.0 (SD=8.0) kg/m2 over an average of 4.6 years (SD=1.0) of follow up. In cross-sectional analyses controlling for AHI, demographic variables, and several potential confounding variables, actigraphy (estimate=−1.22, 95%C.I.: −2.03, −.42) and diary (estimate=−.86, 95%C.I. −1.62, −.09) measures of sleep duration were inversely associated with BMI. Each hour of less sleep was associated with 1.22 kg/m2 greater BMI for actigraphy sleep duration, and a 0.86 kg/m2 greater BMI for diary sleep duration. Longitudinal associations between sleep duration and annual BMI change were non-significant in unadjusted and fully-adjusted models. In this cohort of midlife women, cross-sectional associations between sleep duration and current BMI were independent of sleep-disordered breathing, but sleep duration was not prospectively associated with weight change.
doi:10.1002/oby.20251
PMCID: PMC3484178  PMID: 23505171
15.  Association of past and recent major depression and menstrual characteristics in midlife: Study of Women’s Health Across the Nation 
Menopause (New York, N.Y.)  2012;19(9):959-966.
OBJECTIVE
To examine the association of a history of major depression (MD) with menstrual problems in a multi-ethnic sample of midlife women.
METHODS
Participants were 934 participants in the Study of Women’s Health Across the Nation (SWAN), a multi-site study of menopause and aging. The outcomes were menstrual bleeding problems and premenstrual symptoms (PMS) in the year prior to study entry. The Structured Clinical Interview for the Diagnosis of DSM-IV Axis I Disorders (SCID) was conducted to determine recent and past psychiatric diagnoses. Covariates included socio-demographics, behavioral, and gynecological factors.
RESULTS
One-third reported heavy bleeding, 20% other abnormal bleeding and 18% premenstrual symptoms. One-third had past; and 11% recent MD. Past MD was associated with an increased likelihood of heavy bleeding (Odds Ratio 1.89; 95% confidence interval: 1.25, 2.85) adjusting for recent MD, menopausal status and other covariates. Past MD was not associated with other abnormal bleeding or PMS in the final analysis that adjusted for recent MD.
CONCLUSIONS
Midlife women with a past history of MD are more likely to report heavy bleeding.
doi:10.1097/gme.0b013e318248f2d5
PMCID: PMC3404212  PMID: 22510936
major depression; bleeding; menstrual cycle; midlife
16.  Sex Differences in the Association of Childhood Socioeconomic Status with Adult Blood Pressure Change: The CARDIA Study 
Psychosomatic medicine  2012;74(7):728-735.
Objective
To examine sex differences in the relation of childhood socioeconomic status (CSES) to systolic (SBP) and diastolic (DBP) blood pressure trajectories during 15-years spanning young (30 ± 3 years) and middle (45±3 years) adulthood, independent of adult SES.
Method
4077 adult participants reported father’s and mother’s educational attainments at study enrollment (Year 0), and own educational attainment at enrollment and at all follow-up exams. Resting BP also was measured at all exams. Data from exam Years 5 (when participant mean age=30± 3 years), 7, 10, 15, and 20 are examined here. Associations of own adult [Year 5], mother’s, and father’s educations with 15-year BP trajectories were examined in separate multilevel models. Fully controlled models included time-invariant covariates (age, sex, race, recruitment center), and time-varying covariates that were measured at each exam (marital status, body mass, cholesterol, oral contraceptives/hormones, antihypertensives). Parental education analyses controlled for own education.
Results
When examined without covariates, higher education -- own (SBP γ=−0.03, DBP γ= −0.03), mother’s (SBP γ= −0.02, DBP γ= −0.02), and father’s (SBP γ= −0.02, DBP γ= −0.01) -- were associated with attenuated 15-year increases in BP (p<0.001). Associations of own (but not either parent’s) education with BP trajectories remained independent of standard controls. Sex moderated the apparent null effects of parental education, such that higher parental education–especially mother’s, predicted attenuated BP trajectories independent of standard covariates among women (SBP γ= −.02, p=.02; DBP γ= −.01, p=0.04) but not men (SBP γ=0.02, p=0.06; DBP γ=0.005, p=0.47; p-interaction SBP<0.001, p-interaction DBP=0.01).
Conclusion
CSES may influence women’s health independent of their own adult status.
doi:10.1097/PSY.0b013e31825e32e8
PMCID: PMC3434230  PMID: 22822232
blood pressure; childhood socioeconomic status; multilevel modeling; sex differences
17.  Associations Between Socioeconomic Status and Catecholamine Levels Vary by Acculturation Status in Mexican-American Women 
Background
Lower socioeconomic status (SES) is associated with poorer health, possibly through activation of the sympathetic nervous system.
Purpose
This study aimed to examine the association between SES and catecholamine levels, and variations by acculturation.
Methods
Three hundred one Mexican-American women underwent examination with a 12-h urine collection. Analyses tested associations of SES, acculturation (language and nativity), and their interaction with norepinephrine (NOREPI) and epinephrine (EPI).
Results
No main effects for SES or the acculturation indicators emerged. Fully adjusted models revealed a significant SES by language interaction for NOREPI (p<.01) and EPI (p<.05), and a SES by nativity interaction approached significance for NOREPI (p=.05). Simple slope analyses revealed that higher SES related to lower catecholamine levels in Spanish-speaking women, and higher NOREPI in English-speaking women. Although nonsignificant, similar patterns were observed for nativity.
Conclusions
Associations between SES and catecholamines may vary by acculturation, and cultural factors should be considered when examining SES health effects in Hispanics.
doi:10.1007/s12160-012-9365-6
PMCID: PMC3744889  PMID: 22555944
Socioeconomic stress; Hispanic; Stress; Acculturation
18.  Depressive Symptom Clusters and 5-Year Incidence of Coronary Artery Calcification: The CARDIA Study 
Circulation  2012;126(4):410-417.
Background
Because depression is a multidimensional construct and few studies have compared the relative importance of its facets in predicting cardiovascular risk, we evaluated the utility of depressive symptom clusters in predicting the 5-year incidence of coronary artery calcification (CAC).
Methods and Results
Participants were 2,171 middle-aged adults (58% female, 43% black) from the Coronary Artery Risk Development in Young Adults (CARDIA) Study who were free of cardiovascular disease. Depressive symptom clusters (z scores) were measured by questionnaires in 2000–2001, and CAC was measured by electron beam computed tomography in 2000–2001 and 2005–2006. There were 243 (11%) cases of incident CAC, defined as the absence of CAC at baseline and the presence of CAC at follow-up. Total depressive symptoms (OR = 1.16, 95% CI: 1.02–1.33, p = .03) and the depressed affect cluster (OR = 1.17, 95% CI: 1.03–1.33, p = .02) predicted incident CAC; however, the somatic, interpersonal distress, low positive affect, and pessimism clusters did not. The depressed affect-incident CAC relationship was independent of age, sex, race, education, and antidepressant use; was similar across gender and racial groups; and was partially accounted for by tobacco use and mean arterial pressure.
Conclusions
In contrast to recent results indicating that the somatic cluster is the most predictive of cardiovascular outcomes, we found that the prospective association between depressive symptoms and incident CAC was driven by the depressed affect cluster. Our findings raise the possibility that there may not be one facet of depression that is the most cardiotoxic across all contexts.
doi:10.1161/CIRCULATIONAHA.112.094946
PMCID: PMC3422690  PMID: 22711275
atherosclerosis; cardiovascular disease risk factors; coronary artery calcification; depression; epidemiology
19.  Are vasomotor symptoms associated with sleep characteristics among symptomatic midlife women? Comparisons of self-report and objective measures 
Menopause (New York, N.Y.)  2012;19(7):742-748.
Objective
Many women report vasomotor symptoms (VMS) and sleep problems during the menopausal transition. Although reported VMS are consistently related to reported sleep disturbance, findings using physiologic measures of VMS or sleep have been more mixed. Our objective was to examine whether more VMS during sleep are associated with poorer sleep among midlife women with VMS using physiologic measures of both VMS and sleep.
Methods
A subcohort of participants (N = 52) with VMS, a uterus and both ovaries, and free of medications affecting VMS from the Pittsburgh site of the Study of Women’s Health Across the Nation underwent four 24-hour periods of in-home ambulatory VMS and sleep measurement. Measures included sternal skin conductance for the measurement of VMS, actigraphy for assessing sleep, a VMS diary, and a sleep diary completed before bed and upon waking. Associations between VMS and sleep were evaluated using generalized estimating equations with covariates age, body mass index, medications affecting sleep, race, financial strain, and depressive symptoms.
Results
More VMS recalled upon waking were associated with significantly lower actigraphy-assessed sleep efficiency, significantly higher wakefulness after sleep onset, and somewhat longer sleep latency. Conversely, physiologically measured VMS and VMS reported during the night were largely unrelated to sleep characteristics.
Conclusions
Associations between VMS and sleep may depend more on the awareness of and recall of VMS rather than solely on their physiologic occurrence.
doi:10.1097/gme.0b013e3182422973
PMCID: PMC3551537  PMID: 22415568
Hot flashes; Night sweats; Vasomotor symptoms; Sleep; Actigraphy; Menopause
20.  Individual and Neighborhood Socioeconomic Status and Inflammation in Mexican-American Women: What is the Role of Obesity? 
Psychosomatic Medicine  2012;74(5):535-542.
Objective
Inflammation may represent a biological mechanism underlying associations of socioeconomic status (SES) with cardiovascular disease (CVD). The current study examined relationships of individual and neighborhood SES with inflammatory markers in Mexican-American women and evaluated contributions of obesity and related heath behaviors to these associations.
Methods
A random sample of 284 Mexican-American women (mean age 49.74 years) was recruited from socioeconomically diverse South San Diego communities. Women completed measures of sociodemographic characteristics and health behaviors, and a physical examination with fasting blood draw for assay of plasma C-reactive-protein (CRP), interleukin-6 (IL-6), and soluble intercellular adhesion molecule-1 (sICAM-1). Neighborhood SES was extracted from the US Census Bureau 2000 database.
Results
In multilevel models, a one-standard deviation (SD) higher individual and neighborhood SES related to a 27.35% and 23.56% lower CRP (ps < .01), a 7.04% and 5.32% lower sICAM-1 (ps < .05), and a 10.46% (p < .05) and 2.40% lower IL-6 level (NS), respectively. Controlling for individual SES, a one-SD higher neighborhood SES related to a 18.05% lower CRP (p = .07); there was no unique effect of neighborhood SES for IL-6 or sICAM-1. Differences in body mass index, waist circumference, and dietary fat consumption contributed significantly to SES-inflammation associations.
Conclusions
The findings support a link between SES and inflammatory markers in Mexican-American women, and implicate obesity and dietary fat in these associations. Additional effects of neighborhood SES were not statistically significant. These findings should be viewed tentatively because the relatively small sample size limits the evaluation of multiple contextual factors.
doi:10.1097/PSY.0b013e31824f5f6d
PMCID: PMC3372661  PMID: 22582313
Cardiovascular Disease; Hispanic; Inflamamtion; Obesity; Socioecomomic Status
21.  Socioeconomic Status, Psychosocial Resources and Risk, and Cardiometabolic Risk in Mexican-American Women 
Health Psychology  2011;31(3):334-342.
Objectives
The current study examined the contributions of psychosocial resource and risk factors to the association between socioeconomic status (SES) and metabolic syndrome (MetSyn) risk, in a randomly selected community cohort of 304 middle-aged (40–65 years old) Mexican-American women, a population at elevated cardiometabolic risk.
Methods
Participants underwent a clinical exam and completed measures of demographic factors and psychosocial resource (i.e., personal and social resources) and risk (i.e., negative emotions and cognitions) variables. Confirmatory factor analysis (CFA) and structural equation models (SEMs) were performed in the total sample and in more and less US-acculturated women (defined by language preference) separately.
Results
CFAs revealed single latent constructs for SES (i.e., income, education) and psychosocial resources/risk. For the MetSyn, a 3-factor solution was identified, with blood pressure (systolic and diastolic), lipids (high-density lipoprotein cholesterol and triglycerides), and metabolic variables (glucose and waist circumference) forming separate factors. SEMs showed that an indirect effects model with SES relating to MetSyn factors through psychosocial resources/risk provided a reasonable descriptive and statistical fit in the full and more acculturated sample (RMSEA and SRMR < .08); fit in the less acculturated sample was marginal according to RMSEA =.09. A significant mediated path from low SES to higher waist circumference/fasting glucose via lower psychosocial resources/higher psychosocial risk was identified in the overall and more acculturated samples (p < .05).
Conclusions
In this cohort of healthy, middle-aged Mexican-American women, contributions of psychosocial factors to SES-MetSyn associations were limited to the core underlying metabolic mechanisms, and to more US-acculturated women.
doi:10.1037/a0025689
PMCID: PMC3299900  PMID: 22059620
Hispanic; Metabolic Syndrome; Psychosocial; Risk Factors; Socioeconomic Status
22.  Mood Symptoms After Natural Menopause and Hysterectomy With and Without Bilateral Oophorectomy Among Women in Midlife 
Obstetrics and Gynecology  2012;119(5):935-941.
Objective
To examine whether mood symptoms increased more for women in the years after hysterectomy with or without bilateral oophorectomy relative to natural menopause.
Methods
Using data from the Study of Women’s Health Across the Nation (n=1,970), depression and anxiety symptoms were assessed annually for up to 10 years with the Center for Epidemiological Studies Depression Index and four anxiety questions, respectively. Piecewise hierarchical growth models were used to relate natural menopause, hysterectomy with ovarian conservation, and hysterectomy with bilateral oophorectomy to trajectories of mood symptoms before and after the final menstrual period or surgery. Covariates included educational attainment, race, menopausal status, age the year prior to final menstrual period or surgery, and time-varying body mass index, self-rated health, hormone therapy, and antidepressant use.
Results
By the 10th annual visit, 1,793 (90.9%) women reached natural menopause, 76 (3.9%) reported hysterectomy with ovarian conservation, and 101 (5.2%) reported hysterectomy with bilateral oophorectomy. For all women, depressive and anxiety symptoms decreased in the years after final menstrual period or surgery. These trajectories did not significantly differ by hysterectomy or oophorectomy status. The Center for Epidemiological Studies Depression Index means were .72 standard deviations lower, and anxiety symptoms .67 standard deviations lower, five years after final menstrual period or surgery.
Conclusion
In this study, mood symptoms continued to improve after the final menstrual period or hysterectomy for all women. Women who undergo a hysterectomy with or without bilateral oophorectomy in midlife do not experience more negative mood symptoms in the years after surgery.
doi:10.1097/AOG.0b013e31824f9c14
PMCID: PMC3339661  PMID: 22525904
23.  Role Stress, Role Reward, and Mental Health in a Multiethnic Sample of Midlife Women: Results from the Study of Women's Health Across the Nation (SWAN) 
Journal of Women's Health  2012;21(5):481-489.
Abstract
Background
Little is known about the independent associations of reward and stress within specific roles with multiple measures of mental health in an ethnically diverse community sample of midlife women. The objective of this study is to examine if (1) role reward (within each role and across roles) contributes directly to mental health and buffers the negative impact of role stress and (2) associations among role occupancy, role stress, and role reward and mental health vary by race/ethnicity.
Methods
With separate logistic regression analysis, we investigated cross-sectional relationships between role stress and role reward with presence/absence of high depressive symptoms (Center for Epidemiologic Studies Depression Scale [CES-D≥16]), anxiety symptoms (feeling tense or nervous, irritable or grouchy, fearful for no reason, and heart pounding or racing total score≥4), or low social functioning (bottom 25th percentile of the Short-Form-36 [SF-36] social functioning subscale) in 2549 women participating in the third visit of the Study of Women's Health Across the Nation (SWAN), a longitudinal population-based study of menopause.
Results
High reward across roles attenuated the negative impact of role stress on social functioning but not on anxiety or depression. High reward marriage buffered the impact of marital stress on depression, and high reward mothering buffered the effect of maternal stress on depression and social functioning. Compared to Caucasians, Hispanics and Chinese with high stress across roles had better social functioning, and African American mothers had lower odds of high depressive symptoms.
Conclusions
Role reward buffers the negative impact of stress on social functioning and depression, but not on anxiety. Minorities may respond to role stress by seeking social support.
doi:10.1089/jwh.2011.3180
PMCID: PMC3353828  PMID: 22360697
24.  The impact of menopause on health-related quality of life: results from the STRIDE longitudinal study 
Quality of Life Research  2011;21(3):535-544.
Purpose
We examine the impact of menopausal status, beyond menopausal symptoms, on health-related quality of life (HRQoL).
Methods
Seven hundred thirty-two women aged 40–65, regardless of health condition or menopausal status, were enrolled from single general internal medicine practice. Women completed annual questionnaires including HRQoL, and menopausal status and symptoms.
Results
The physical health composite of the RAND-36 is lower in late peri (45.6, P<.05), early post (45.4, P<.05), and late postmenopausal women (44.6, P<.01), and those who report a hysterectomy (44.2, P<.01) compared to premenopausal women (47.1), with effect sizes of Cohen’s d = .12-.23. The mental health composite of the RAND-36 is lower in late peri (44.7, P<.01), early post (44.9, P<.01), and late postmenopausal women (45.0, P<.05) and those who report a hysterectomy (44.2, P<.01) compared to premenopausal women (46.8), with effect sizes of Cohen’s d = .15–.20. Findings are comparable adjusted for menopausal symptom frequency and bother.
Conclusions
Over a 5-year follow-up period, we found a negative impact of menopause on some domains of HRQoL, regardless of menopausal symptoms. Clinicians should be aware of this relationship and work to improve HRQoL, rather than expect it to improve spontaneously when menopausal symptoms resolve.
doi:10.1007/s11136-011-9959-7
PMCID: PMC3252474  PMID: 21755412
Menopause; Health-related quality of life; Hot flashes; Vaginal dryness; Women’s health
25.  Hot flashes and cardiac vagal control during women’s daily lives 
Menopause (New York, N.y.)  2012;19(4):406-412.
Objective
The physiology of menopausal hot flashes is not well understood. The autonomic nervous system may play a role in hot flashes, but the current understanding is limited. We previously demonstrated in the laboratory that decreases in high frequency heart rate variability, an index of cardiac vagal control, occur during hot flashes relative to preceding and following periods. In the present study, we tested whether we would observe a similar phenomenon in the ambulatory setting. We additionally considered respiratory rate in these associations.
Methods
21 peri- and postmenopausal women ages 40–60 reporting daily hot flashes were monitored both for physiologic and reported hot flashes and heart rate variability over a 24-hour period as they went about their daily lives. Heart rate variability estimates were derived using the band-limited variance method. The interval during the hot flash was compared to two non-flash periods prior to and following the hot flash via mixed effects models.
Results
Heart rate variability significantly decreased during hot flashes relative to periods preceding (b=0.31, SE=0.03 p<0.0001) and following (b=0.30, SE=0.03, p<0.0001) physiologic hot flashes (covariates: age, race, education, menopausal status, physical activity, body mass index, anxiety). Findings were comparable considering self-reported hot flashes. Findings persisted controlling for respiratory rate.
Conclusions
Significant decreases in cardiac vagal control occurred during hot flashes assessed during women’s daily lives. These findings extend our work in the laboratory to the ambulatory setting, further shedding light on the physiology of hot flashes and underscoring a potential role of parasympathetic function in hot flashes.
doi:10.1097/gme.0b013e3182337166
PMCID: PMC3292670  PMID: 22095062
hot flashes; hot flushes; vasomotor symptoms; heart rate variability; autonomic nervous system; menopause

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