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1.  Sleep Duration and Cardiovascular Responses to Stress in Undergraduate Men 
Psychophysiology  2013;51(1):10.1111/psyp.12144.
Short sleep has been related to incident cardiovascular disease, but physiological mechanisms accounting for this relationship are largely unknown. This study examines sleep duration and cardiovascular stress responses in 79 healthy, young men. Sleep duration was assessed by wrist actigraphy for seven nights. Participants then completed a series of laboratory stress tasks while heart rate and blood pressure were monitored. Shorter total sleep time was related to a greater reduction in high-frequency heart rate variability during stress tasks, and to prolonged elevations in heart rate and diastolic pressure following tasks. Associations were independent of age, race, body mass index, caffeine intake, and smoking status. In sum, healthy young men with shorter actigraphy-assessed sleep exhibit less cardiac vagal activity, and poorer heart rate and diastolic blood pressure recovery, upon encountering stressful stimuli, than those with longer sleep.
PMCID: PMC3883723  PMID: 24016263
sleep; actigraphy; reactivity; recovery; heart rate; blood pressure; vagal; stress; heart rate variability
3.  Temporal relationships between physical activity and sleep in older women 
Medicine and science in sports and exercise  2013;45(12):10.1249/MSS.0b013e31829e4cea.
To examine the temporal and bidirectional relationship between accelerometer-derived physical activity estimates and actigraphy-assessed sleep characteristics among older women.
A sub-group of participants [N=143, mean age= 73y] enrolled in the Healthy Women Study wore an ActiGraph accelerometer on their waist and an Actiwatch sleep monitor on their wrist concurrently for 7-consecutive days. Multi-level models examined whether ActiGraph-assessed daily activity counts (ct·min·d-1) and moderate- to vigorous- intensity physical activity (MVPA; min·d-1) predicted Actiwatch-assessed sleep onset latency, total sleep time, sleep efficiency, and sleep fragmentation. Similar models were used to determine if nighttime sleep characteristics predicted physical activity the following day.
In unadjusted models, greater daily activity counts (B=-.05, p=.005) and more minutes of MVPA (B=-.03, p=.01) were temporally associated with less total sleep time across the week. Greater sleep efficiency was associated with greater daily activity counts (B=.37, p=.01) and more minutes of MVPA (B=.64, p=.009) the following day. Less sleep fragmentation was also associated with greater daily activity counts and more MVPA the following day. Findings were similar after adjustment for age, education, BMI, depressive symptoms, arthritis, and accelerometer wear time.
Few studies have used objective measures to examine the temporal relationship between physical activity and sleep. Notably, these findings suggest that nightly variations in sleep efficiency influence physical activity the following day. Thus, improving overall sleep quality in addition to reducing nightly fluctuations in sleep may be important for encouraging a physically active lifestyle in older women.
PMCID: PMC3833970  PMID: 23739529
accelerometer; Actiwatch; objective measurement; sleep efficiency; moderate to vigorous physical activity
4.  Menopause, Complement, and Hemostatic Markers in Women at Midlife: The Study of Women’s Health Across the Nation 
Atherosclerosis  2013;231(1):10.1016/j.atherosclerosis.2013.08.039.
To evaluate whether higher circulating levels of complement proteins C3 and C4 are associated with menopausal status and with hemostatic/thrombus formation markers (circulating factor VII (factor VIIc), fibrinogen, plasminogen activator inhibitor-1 (PAI-1) and tissue plasminogen activator antigen (tPA-ag)) in a sample of midlife women.
Methods and Results
A total of 100 women (50 late peri-/postmenopausal and 50 pre-/early peri menopausal women) from the Study of Women’s Health Across the Nation (SWAN) Pittsburgh site were included in the present analysis. Factor VIIc and PAI-1 were log transformed. Linear regression was used for analysis. The mean age of the study participants was 50.5±2.6 years with 73% were Caucasian and 27% were African American. C3 but not C4 was significantly higher in postmenopausal women compared to premenopausal women (P value=0.03), adjusting for age, race and BMI. In final model (adjusting for age, race, BMI and menopausal status), C3 was associated with higher levels of log PAI-1 (P value=0.0009) and tPA-ag (P value=0.0003), while C4 was associated with higher levels of log factor VIIc (P value=0.04) and fibrinogen (P value=0.005).
These data suggest that C3 and C4 may be related to blood clots via their associations with hemostatic markers and that C3 is related to menopausal status. Complement proteins C3 and C4 could be possible pathways by which postmenopausal women are at higher risk of atherosclerosis and cardiovascular related events. It is important to replicate these findings in a larger sample size.
PMCID: PMC3844281  PMID: 24125410
Epidemiology, Risk Factors; Coagulation, Fibrinolysis; Menopause
5.  Night/day ratios of ambulatory blood pressure among healthy adolescents: Roles of race, socioeconomic status, and psychosocial factors 
Elevated nighttime blood pressure (BP) predicts hypertension and its complications in adulthood.
To assess the independent effects of race and family income on night/day BP among adolescents and to examine whether negative emotions, low positive resources, and unpleasant interactions during the day are also related.
Healthy African American and Caucasian high school students (N=239) wore an ambulatory BP monitor for 48 hours, recorded quality of ongoing interpersonal interactions, and completed questionnaires.
African Americans and those with lower family income had higher night/day BP ratios. African Americans reporting greater negative emotions, lower positive resources, and more unpleasant interactions had higher night/day BP ratios.
Racial differences in night BP emerge by adolescence, independent of family income. African Americans, especially those high in negative emotions and low in positive resources, may be at higher relative risk for hypertension later in life in part due to elevated night BP.
PMCID: PMC3742588  PMID: 23549997
race; socioeconomic status; ambulatory blood pressure; BP dipping; adolescents; negative emotions; positive resources
6.  Racial differences in heart rate variability during sleep in women: The SWAN Sleep Study 
Psychosomatic medicine  2013;75(8):783-790.
Heart rate variability (HRV) differs markedly by race, yet few studies have evaluated these relationships in women. Moreover, none have evaluated HRV during sleep, despite sleep's importance to cardiovascular health.
We addressed these gaps by examining HRV during sleep in African American, Chinese and white women (mean age 51.2 ± 2.2). Sleep and HRV during sleep (sHRV) were measured concurrently.
Heart rate variability during stage 2 non-rapid eye movement (NREM) and rapid eye movement (REM) sleep differed significantly by race after adjusting for possible confounders. Normalized high frequency HRV was significantly lower in white compared to African American and Chinese participants (white NREM=0.35 ±.01, REM=0.23 ± .01; African American NREM=0.43 ± 0.02, REM=0.29 ± 0.02; Chinese NREM=0.47 ± 0.03, REM=0.33 ± 0.02; p’s<.001). The inverse was seen for low frequency power, with higher values in white compared to African American and Chinese participants (white NREM=0.66 ± .01, REM=0.77 ± .01; African American=NREM 0.58 ± 0.02, REM=0.71 ± 0.02; Chinese=0.53 ± 0.03, REM=0.68 ± 0.02; p’s<.010). Whites also exhibited higher low-to-high frequency HRV ratios during sleep compared to African American and Chinese women (white NREM=2.42 ± 1.07, REM=5.05 ± 1.07; African American NREM=1.69 ± 1.09, REM=3.51 ± 1.09; Chinese NREM=.35 ± 1.07, REM=2.88 ± 1.13; p’s<.001).
Race was robustly related to HRV during sleep. Compared to African American and Chinese women, whites exhibited decreased vagally-mediated control of the heart during sleep. Rresearch is needed to evaluate whether sHRV, including race differences, is prospectively associated with cardiovascular disease.
PMCID: PMC3902648  PMID: 24077772
heart rate variability; sleep; race; cardiovasular disease; autonomic tone; women
8.  Sleep quantity, quality and optimism in children 
Journal of sleep research  2011;20(1 0 1):12-20.
We tested the relationship of objectively-measured sleep quantity and quality with positive characteristics of the child. Sleep duration, sleep latency, and sleep efficiency were measured by an actigraph for an average seven (range = 3 to 14) consecutive nights in 291 eight-year-old children (SD = 0.3 years). Children's optimism, self-esteem, and social competence were rated by parents and/or teachers. Sleep duration showed a non-linear, reverse J-shaped relationship with optimism (P = 0.02) such that children with sleep duration in the middle of the distribution scored higher in optimism compared to children who slept relatively little. Shorter sleep latency was related to higher optimism (P = 0.01). The associations remained when adjusting for child's age, sex, body mass index and parental level of education; the effects of sleep on optimism were neither changed when the parents' own optimism was controlled. In conclusion, sufficient sleep quantity and good sleep quality are associated with positive characteristics of the child, further underlining their importance in promoting well-being in children.
PMCID: PMC4160149  PMID: 20561178
Sleep quantity; sleep quality; optimism; self-esteem; childhood
9.  Adipokines, adiposity, and vasomotor symptoms during the menopause transition: findings from the Study of Women’s Health Across the Nation 
Fertility and sterility  2013;100(3):793-800.e1.
To test relationships between adipokines, adiposity, and vasomotor symptoms (VMS), including how these associations vary by menopause stage.
A sub-cohort of the longitudinal cohort study the Study of Women’s Health Across the Nation completed questionnaires, physical measures, and a fasting blood draw annually for 8 years. Associations between a poorer adipokine profile [lower adiponectin, lower high molecular weight (HMW) adiponectin, higher leptin, lower soluble leptin receptor, higher monocyte chemoattractant protein-1 (MCP-1)] and VMS were tested using generalized estimating equations adjusting for potential confounders. Interactions by menopause stage (pre-/early perimenopause, late peri-/postmenopause) were tested.
536 women ages 42–52 at baseline
Main Outcome Measures
Associations between adipokines and hot flashes varied by menopause stage, with a poorer adipokine profile associated with higher odds of hot flashes early in the transition [adiponectinlog, OR(95% CI): 0.68 (0.51–0.90); HMW adiponectinlog, OR(95% CI): 0.70 (0.58–0.85); leptinlog, OR(95% CI): 1.23 (0.99–1.54), multivariable models including BMI], but not later in the transition. The direction of associations between BMI and VMS also varied by menopausal stage. Higher MCP-1 was associated with more night sweats [OR(95% CI): 1.37 (1.06–1.76)] across menopausal stages.
An adverse adipokine profile was associated with more VMS, particularly early in the menopause transition.
PMCID: PMC3759568  PMID: 23755948
Adipokines; adiposity; vasomotor symptoms; hot flashes
10.  Socioeconomic status and stress in Mexican–American women: a multi-method perspective 
Journal of behavioral medicine  2012;36(4):379-388.
Stress is a hypothesized pathway in socioeconomic status (SES)-physical health associations, but the available empirical data are inconsistent. In part, this may reflect discrepancies in the approach to measuring stress across studies, and differences in the nature of SES-stress associations across demographic groups. We examined associations of SES (education, income) with general and domain-specific chronic stressors, stressful life events, perceived stress, and stressful daily experiences in 318 Mexican–American women (40–65 years old). Women with higher SES reported lower perceived stress and fewer low-control experiences in everyday life (ps < .05), but greater chronic stress (education only, p < .05). Domain-specific analyses showed negative associations of income with chronic housing and financial stress (ps < .05), but positive associations of SES with chronic work and care-giving stress (all ps < .05 except for income and caregiving stress, p < .10). Sensitivity analyses showed that most SES-stress associations were consistent across acculturation levels. Future research should adopt a multi-dimensional assessment approach to better understand links among SES, stress, and physical health, and should consider the sociodemographic context in conceptualizing the role of stress in SES-related health inequalities.
PMCID: PMC3929319  PMID: 22644814
Hispanic; Latino; Socioeconomic status; Stress
11.  Changes in Cardiovascular Risk Factors by Hysterectomy Status with and without Oophorectomy: Study of Women’s Health across the Nation 
To compare the changes in risk factors for cardiovascular disease (CVD) leading up to and following hysterectomy with or without bilateral oophorectomy with the changes observed up to and following natural menopause.
Evidence suggests that hysterectomy status with or without bilateral oophorectomy may increase risk for CVD but most studies retrospectively assess menopausal status.
Study of Women’s Health across the Nation enrolled 3,302 premenopausal women not using hormone therapy between the ages of 42–52 years of age and followed them annually for over 11 years for sociodemographic characteristics, menopausal status, surgeries, body mass index (BMI), medication use, lifestyle factors, lipids, blood pressure, insulin resistance, and hemostatic and inflammatory factors. By 2008, 1,769 women had reached natural menopause, 77 women had a hysterectomy with ovarian conservation, and 106 women had a hysterectomy with bilateral oophorectomy. Piecewise hierarchical growth models compared these groups on annual changes in CVD risk factors prior to and following final menstrual period (FMP) or surgery.
Multivariable analyses showed that annual changes in CVD risk factors did not vary by group with few exceptions, and the significant group differences that did emerge were not in the anticipated direction.
Hysterectomy with or without ovarian conservation is not a key determinant of CVD risk factor status either before or after elective surgery in mid-life. These results should provide reassurance to women and their clinicians that hysterectomy in mid-life is unlikely to accelerate women’s CVD risk.
PMCID: PMC3777736  PMID: 23684687
hysterectomy; metabolic factors; inflammation; blood pressure; epidemiology
12.  Factors Related to Age at Natural Menopause: Longitudinal Analyses From SWAN 
American Journal of Epidemiology  2013;178(1):70-83.
Early age at the natural final menstrual period (FMP) or menopause has been associated with numerous health outcomes and might be a marker of future ill health. However, potentially modifiable factors affecting age at menopause have not been examined longitudinally in large, diverse populations. The Study of Women's Health Across the Nation (SWAN) followed 3,302 initially premenopausal and early perimenopausal women from 7 US sites and 5 racial/ethnic groups, using annual data (1996–2007) and Cox proportional hazards models to assess the relation of time-invariant and time-varying sociodemographic, lifestyle, and health factors to age at natural FMP. Median age at the FMP was 52.54 years (n = 1,483 observed natural FMPs). Controlling for sociodemographic, lifestyle, and health factors, we found that racial/ethnic groups did not differ in age at the FMP. Higher educational level, prior oral contraceptive use, and higher weight at baseline, as well as being employed, not smoking, consuming alcohol, having less physical activity, and having better self-rated health over follow-up, were significantly associated with later age at the FMP. These results suggest that age at the natural FMP reflects a complex interrelation of health and socioeconomic factors, which could partially explain the relation of late age at FMP to reduced morbidity and mortality.
PMCID: PMC3698989  PMID: 23788671
age; education; ethnicity; menopause; oral contraceptives; race; smoking; weight
13.  Chronic Exposure to Everyday Discrimination and Sleep in a Multi-Ethnic Sample of Middle-Aged Women 
Researchers have suggested that poor sleep may play a role in the association between discrimination and health, but studies linking experiences of discrimination to sleep are limited. The authors examined associations between reports of everyday discrimination over four years (chronic everyday discrimination) and subjective and objective indicators of poor sleep.
Participants were 368 African-American, Caucasian, and Chinese women from the Study of Women’s Health Across the Nation (SWAN) Sleep Study. Everyday discrimination was assessed each year from baseline through the third follow-up exam via questionnaire with the Everyday Discrimination Scale (Intraclass Correlation Coefficient over four years=.90). Subjective sleep complaints were measured beginning in year 5 with the Pittsburgh Sleep Quality Index. Objective indices of sleep continuity, duration, and architecture were assessed via in-home polysomnography (PSG), beginning in year 5.
In linear regression analyses adjusted for age, race/ethnicity and financial strain, chronic everyday discrimination was associated with more subjective sleep complaints (Estimate =1.52, p<.001) and PSG-assessed wakefulness after sleep onset (Estimate=.19, p<.02), a marker of sleep continuity. Findings did not differ by race/ethnicity and remained significant after adjusting for menopausal status, body mass index, medication use and depressive symptoms.
Experiences of chronic everyday discrimination are independently associated with both subjective and objective indices of poor sleep. Findings add to the growing literature linking discrimination to key markers of biobehavioral health.
PMCID: PMC3654016  PMID: 23088174
Discrimination; depression; polysomnography; sleep; stress; psychological; African-Americans; Chinese
14.  Hostility Modifies the Association between TV Viewing and Cardiometabolic Risk 
Journal of Obesity  2014;2014:784594.
Background. It was hypothesized that television viewing is predictive of cardiometabolic risk. Moreover, people with hostile personality type may be more susceptible to TV-induced negative emotions and harmful health habits which increase occurrence of cardiometabolic risk. Purpose. The prospective association of TV viewing on cardiometabolic risk was examined along with whether hostile personality trait was a modifier. Methods. A total of 3,269 Black and White participants in the coronary artery risk development in young adults (CARDIA) study were assessed from age 23 to age 35. A cross-lagged panel model at exam years 5, 10, 15, and 20, covering 15 years, was used to test whether hours of daily TV viewing predicted cardiometabolic risk, controlling confounding variables. Multiple group analysis of additional cross-lagged panel models stratified by high and low levels of hostility was used to evaluate whether the association was modified by the hostile personality trait. Results. The cross-lagged association of TV viewing at years 5 and 15 on clustered cardiometabolic risk score at years 10 and 20 was significant (B = 0.058 and 0.051), but not at 10 to 15 years. This association was significant for those with high hostility (B = 0.068 for exam years 5 to 10 and 0.057 for exam years 15 to 20) but not low hostility. Conclusion. These findings indicate that TV viewing is positively associated with cardiometabolic risk. Further, they indicate that hostility might be a modifier for the association between TV viewing and cardiometabolic risk.
PMCID: PMC4094870  PMID: 25050178
15.  Optimism, Response to Treatment of Depression, and Rehospitalization After Coronary Artery Bypass Graft Surgery 
Psychosomatic medicine  2012;74(2):200-207.
Optimism has been associated with a lower risk of rehospitalization after coronary artery bypass graft (CABG) surgery, but little is known about how optimism affects treatment of depression in post-CABG patients.
Using data from a collaborative care intervention trial for post-CABG depression, we conducted exploratory post hoc analyses of 284 depressed post-CABG patients (2-week posthospitalization score in the 9-item Patient Health Questionnaire ≥10) and 146 controls without depression who completed the Life Orientation Test – Revised (full scale and subscale) to assess dispositional optimism. We classified patients as optimists and pessimists based on the sample-specific Life Orientation Test – Revised distributions in each cohort (full sample, depressed, nondepressed). For 8 months, we assessed health-related quality of life (using the 36-item Short-Form Health Survey) and mood symptoms (using the Hamilton Rating Scale for Depression [HRS-D]) and adjudicated all-cause rehospitalization. We defined treatment response as a 50% or higher decline in HRS-D score from baseline.
Compared with pessimists, optimists had lower baseline mean HRS-D scores (8 versus 15, p = .001). Among depressed patients, optimists were more likely to respond to treatment at 8 months (58% versus 27%, odds ratio = 3.02, 95% confidence interval = 1.28–7.13, p = .01), a finding that was not sustained in the intervention group. The optimism subscale, but not the pessimism subscale, predicted treatment response. By 8 months, optimists were less likely to be rehospitalized (odds ratio = 0.54, 95% confidence interval = 0.32–0.93, p = .03).
Among depressed post-CABG patients, optimists responded to depression treatment at higher rates. Independent of depression, optimists were less likely to be rehospitalized by 8 months after CABG. Further research should explore the impact of optimism on these and other important long-term post-CABG outcomes.
PMCID: PMC4056336  PMID: 22286847
optimism; pessimism; depression; coronary artery bypass graft; collaborative care; randomized controlled trial
16.  Sociodemographic, Clinical and Psychological Factors Associated with Attrition in a Prospective Study of Cardiovascular Prevention: The Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) Study 
Annals of epidemiology  2013;23(6):328-333.
To identify factors associated with attrition in a longitudinal study of cardiovascular prevention.
Demographic, clinical and psychosocial variables potentially associated with attrition were investigated in 1,841 subjects enrolled in the southwestern Pennsylvania Heart Strategies Concentrating on Risk Evaluation study. Attrition was defined as study withdrawal, loss to follow-up, or missing ≥50% of study visits.
Over four years of follow up, 291 subjects (15.8%) met criteria for attrition. In multivariable regression models, factors that were independently associated with attrition were: Black race (Odds Ratio(OR):2.21, 95%Confidence Interval(CI):1.55, 3.16; P<0.001), younger age (OR per 5-year increment:0.88, 95%CI:0.79, 0.99; P<0.05), male sex (OR: 1.79, 95%CI: 1.27, 2.54; P<0.05), no health insurance (OR:2.04, 95%CI:1.20, 3.47; P<0.05), obesity (OR:1.80, 95%CI:1.07, 3.02; P<0.05), CES-D depression score≥16 (OR:2.02, 95%CI:1.29, 3.19; P<0.05), higher ongoing life events questionnaire score (OR=1.09, 95%CI= 1.04–1.13; P<0.001). Having a spouse/partner participating in the study was associated with lower odds of attrition (OR=0.60 95%CI=0.37–0.97; P<0.05). A synergistic interaction was identified between black race and depression.
Attrition over four years was influenced by sociodemographic, clinical and psychological factors that can be readily identified at study entry. Recruitment and retention strategies targeting these factors may improve participant follow-up in longitudinal cardiovascular prevention studies.
PMCID: PMC3660424  PMID: 23535026
Cardiovascular Diseases; Cohort Studies; Lost to Follow-Up
17.  Elevated CRP in adolescents: Roles of stress and coping 
Psychosomatic medicine  2013;75(5):449-452.
Psychological stress can upregulate inflammatory processes and increase disease risk. In the context of stress, differences in how individuals cope might have implications for health. The goal of this study was to evaluate associations among stress, coping, and inflammation in a sample of African-American and white adolescents.
Adolescents (n = 245) completed self-report measures of stressful life events and coping, provided daily diary reports of interpersonal conflict over seven days, and provided fasting blood samples for assessment of C-reactive protein (CRP).
In regression analyses adjusted for age, sex, race, body mass index, smoking, and socioeconomic status, there were no significant associations between stress and CRP, but significant interactions between stress and coping emerged. For adolescents reporting more unpleasant stressful life events in the past 12 months, positive engagement coping was inversely associated with CRP (β = −.19, p < .05), whereas coping was not significantly associated with CRP for adolescents reporting fewer stressful life events. Positive engagement coping was significantly and inversely associated with CRP in the context of interpersonal stress, whether measured as stressful life events reflecting interpersonal conflict (e.g., arguments with parents or siblings, conflict between adults in the home, friendship ended) or frequency of arguments with others reported in daily diaries. Disengagement coping was unrelated to CRP.
Findings suggest that positive engagement coping is associated with lower levels of inflammation, but only when adolescents are challenged by significant stress.
PMCID: PMC3679199  PMID: 23576771
adolescents; coping; inflammation; psychological stress; psychoneuroimmunology
18.  Does Risk for Anxiety Increase During the Menopausal Transition? Study of Women's Health Across the Nation (SWAN) 
Menopause (New York, N.Y.)  2013;20(5):488-495.
Little is known about the risk of anxiety in women during midlife and the menopausal transition. We examined anxiety as a cluster of 4 symptoms and determined the association between menopausal stage and high anxiety during ten years of follow-up of 2,956 women of multiple race/ethnicities.
This study was a longitudinal analysis of data from the multi-site Study of Women's Health Across the Nation (SWAN), a study of menopause and aging. Women were 42-52 at study entry. The outcome was high anxiety, a score of 4 or greater on the sum of four anxiety symptoms rated according to frequency in the previous 2 weeks from 0 (none) to 4 (daily) (upper 20%). Covariates included sociodemographics, health factors, stressors, and vasomotor symptoms (VMS).
Women with low anxiety at baseline were more likely to report high anxiety symptoms when early or late perimenopausal or postmenopausal compared to when they were premenopausal (odds ratios ranged from 1.56 to 1.61), independent of multiple risk factors, including upsetting life events, financial strain, fair/poor perceived health, and VMS. Women with high anxiety at baseline continued to have high rates of high anxiety throughout the follow-up but odds ratios did not differ by menopausal stage.
Women with high anxiety premenopausally may be chronically anxious and not at increased risk of high anxiety at specific stages of the menopausal transition. In contrast, women with low anxiety premenopausally may be more susceptible to high anxiety during and after the menopausal transition than before.
PMCID: PMC3641149  PMID: 23615639
anxiety; menopausal transition; vasomotor symptoms; longitudinal
19.  A pandemic of the poor: social disadvantage and the U.S. HIV epidemic 
The American psychologist  2013;68(4):197-209.
The U.S. HIV epidemic has evolved over the past 30 years and is now concentrated in socially marginalized and disenfranchised communities. The health disparities in this epidemic are striking, with most HIV infections occurring in sexual minorities and communities of color. While widely recognized, the health disparities in HIV and AIDS are not often discussed. In this paper, we examine the factors underlying health disparities in the U.S. HIV epidemic. We first discuss the interlocking relationships between biological, social, and behavioral factors that drive HIV epidemics. Guided by a well-established conceptual model of health disparities, we then describe the social positions of those most affected by HIV and AIDS, particularly racial and gender groups. Structural and economic conditions including environmental resources, constraints, access to care, and psychosocial influences are examined in relation to HIV disease trajectories. Greater attention to contextual factors and co-morbidities is needed to reduce the health disparities in HIV infection.
PMCID: PMC3700367  PMID: 23688088
20.  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.
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.
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).
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.
Poor sleep quality is related to AC in middle-aged women. Sleep quality should routinely be assessed in mid-life women.
PMCID: PMC3582843  PMID: 23352420
sleep; insomnia; women; mid-life; calcification; aorta; cardiovascular risk factors
21.  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.
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.
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.
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).
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.
PMCID: PMC3593962  PMID: 23435023
Midlife; Body Image; Weight-Perception; Race; Health; Behavior
22.  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.
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.
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.
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.
Circulating oxidation correlates increase and antioxidant nutrients decrease with decreasing SES, both cross-sectionally and prospectively.
PMCID: PMC3925505  PMID: 19414620
socioeconomic status; oxidative stress; antioxidants; prospective; CARDIA
23.  Childhood Physical Abuse Is Associated with Incident Metabolic Syndrome in Mid-Life Women 
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.
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.
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.
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.
PMCID: PMC3641896  PMID: 22775234
childhood abuse; metabolic syndrome; menopause
24.  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.
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.
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.
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.
Study findings suggest that low levels of accelerometer-derived MVPA may be indicative of subclinical disease in older women.
PMCID: PMC3897237  PMID: 22914209
coronary heart disease; motor activity; ambulatory monitoring; coronary calcification; women
25.  Progression Rates of Carotid Intima-media Thickness and Adventitial Diameter during the Menopausal Transition 
Menopause (New York, N.Y.)  2013;20(1):8-14.
The authors assessed whether the levels and progression rates of carotid intima-media thickness (IMT) and adventitial diameter (AD) vary by menopausal stage.
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.
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.
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.
PMCID: PMC3528819  PMID: 22990755
atherosclerosis; carotid intima-media thickness; epidemiology; menopause; risk factors

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