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1.  Abuse and Subclinical Cardiovascular Disease among Midlife Women: The Study of Women’s Health Across the Nation 
Background and Purpose
Some evidence suggests that abuse may be related to CVD risk among women. However, this relation has largely been addressed using self-reported measures of CVD. We tested whether a history of abuse was related to subclinical cardiovascular disease (CVD) among midlife women without clinical CVD.
The Study of Women’s Health Across the Nation (SWAN) is a longitudinal cohort study of women transitioning through the menopause. 1402 Caucasian, African American, Hispanic, and Chinese SWAN participants completed measures of childhood and adult physical and sexual abuse, underwent a blood draw, completed physical measures, and underwent a carotid artery ultrasound at SWAN study visit 12. Associations between abuse and IMT and plaque were tested in linear and multinomial logistic regression models controlling for age, site, race/ethnicity, financial strain, education, body mass index, lipids, blood pressure, measures of insulin resistance, smoking, alcohol use, physical activity, and medication use.
Findings indicated that a history of childhood sexual abuse was associated with higher IMT controlling for standard CVD risk factors and other confounders (beta (standard error)=0.022 (0.010), p<0.05; adjusted means, childhood sexual abuse: 0.800 mm vs. no childhood sexual abuse: 0.782 mm).
Childhood sexual abuse was associated with higher IMT controlling for CVD risk factors and other confounders. These findings indicate the importance of considering the potential impact of early life stressors on women’s later cardiovascular health.
PMCID: PMC4116433  PMID: 25034715
Abuse; trauma; atherosclerosis; subclinical cardiovascular disease; cardiovascular risk
2.  Chronic Pain, Body Mass Index and Cardiovascular Disease Risk Factors: Tests of Moderation, Unique and Shared Relationships in the Study of Women's Health Across the Nation (SWAN) 
Journal of behavioral medicine  2014;38(2):372-383.
Chronic pain may be related to cardiovascular disease (CVD) risk. The current study examined whether persistent bodily pain was related to cardiovascular disease risk factors, whether these effects were moderated by body mass index (BMI), and, if not, whether chronic pain accounted for unique variance in CVD risk factors. Participants were women (N=2135) in the Study of Women's Health Across the Nation. A High Pain Frequency variable (high pain in 0 through 4 assessments) was coded to reflect the frequency of high levels of bodily pain across the first 3 years of the study. Six CVD risk factors and BMI were measured at follow-up year 3. High Pain Frequency and BMI were correlated significantly with risk factors, although effects for the former were small. Hierarchical multiple regressions revealed High Pain Frequency × BMI interactions for 5 of 6 CVD risk factors. Dissecting the interactions revealed a similar pattern across 4 risk factors: for women with normal BMI, there was a “dose-response” in which increasing frequency of high pain revealed increasingly worse CVD risk factor levels, whereas for women with obese BMI, high pain frequency was unrelated to risk factors. For obese women, increasing frequency of high pain was associated with higher blood glucose. Although BMI is a well-established CVD risk factor, evaluation of CVD risk level may be improved by considering the incidence of persistent pain, particularly in normal weight women (BMI<25kg/m2) lower BMI.
PMCID: PMC4496954  PMID: 25427423
Persistent pain; BMI; CVD risk factors; moderation
3.  Chronic PM2.5 Exposure and Inflammation: Determining Sensitive Subgroups in Mid-life Women 
Environmental research  2014;132:168-175.
Several cohort studies report associations between chronic exposure to ambient fine particles (PM2.5) and cardiovascular mortality. Uncertainty exists about biological mechanisms responsible for this observation, but systemic inflammation has been postulated. In addition, the subgroups susceptible to inflammation have not been fully elucidated.
We investigated whether certain subgroups are susceptible to the effects of long-term exposure to PM2.5 on C-reactive protein (CRP), a marker of inflammation directly linked to subsequent cardiovascular disease. We used data from the SWAN cohort of 1,923 mid-life women with up to five annual repeated measures of CRP. Linear mixed and GEE models accounting for repeated measurements within an individual were used to estimate the effects of prior-year PM2.5 exposure on CRP. We examined CRP as a continuous and as binary outcome for CRP greater than 3 mg/l, a level of clinical significance.
We found strong associations between PM2.5 and CRP among several subgroups. For example a 10 µg/m3 increase in annual PM2.5 more than doubled the risk of CRP greater than 3 mg/l in older diabetics, smokers and the unmarried. Larger effects were also observed among those with low income, high blood pressure, or who were using hormone therapy, with indications of a protective effects for those using statins or consuming moderate amounts of alcohol.
In this study, we observed significant associations between long-term exposure to PM2.5 and CRP in several susceptible subgroups. This suggests a plausible pathway by which exposure to particulate matter may be associated with increased risk of cardiovascular disease.
PMCID: PMC4314307  PMID: 24792413
air pollution; PM2.5; C-reactive protein; cardiovascular diseases; susceptibility
4.  Everyday Discrimination Prospectively Predicts Inflammation Across 7-Years in Racially Diverse Midlife Women: Study of Women's Health Across the Nation 
The Journal of social issues  2014;70(2):298-314.
Self-reported discrimination has emerged as a predictor of negative psychological and physical health outcomes across racial/ethnic groups. The goals of this study were to determine whether C-reactive protein (CRP), a marker of inflammation and risk factor for future cardiovascular disease (CVD) was independently predicted by everyday discrimination or whether race or body mass index (BMI) modified this association over a 7-year period among 2,490 women from racially diverse backgrounds. At baseline, the 10-item Williams' measure of everyday discrimination was administered. Generalized estimating equations were used to assess these associations. Descriptive results showed that Black and Chinese women reported greater discrimination than White, Japanese, and Hispanic women, while Black and Hispanic women had the highest levels of CRP over the 7-year period. There was no main effect of everyday discrimination (B = .003, SE = .005, p = .58) and this association did not differ as a function of race (p's > .05). The everyday discrimination × BMI interaction term significantly predicted higher CRP levels over time in the full sample of women (p = .03). Specifically, in non-obese women (BMI less than 30), higher perceived everyday discrimination was associated with higher CRP levels over the 7-year period. These findings were independent of demographic, negative affect, biomedical, and behavioral factors. The results demonstrate that greater everyday discrimination is associated with increased inflammation over time in non-obese women. These findings highlight the implications of interpersonal sources of social stress for long-term physical health via their impact on intermediary biological pathways, specifically inflammation. Greater emphasis on such linkages is warranted as we work towards ameliorating health disparities exacerbated by individual-level factors.
PMCID: PMC4203661  PMID: 25342861
everyday discrimination; C-reactive protein; cardiovascular diseases; inflammation
5.  Sleep in Healthy Black and White Adolescents 
Pediatrics  2014;133(5):e1189-e1196.
Inadequate sleep among adolescents has negative consequences for self-regulation, emotional well-being, and risk behaviors. Using multiple assessment methods, we evaluated the adequacy of sleep among healthy adolescents from a lower socioeconomic community and expected differences by race.
A total of 250 healthy high school students enrolled in public school (mean age: 15.7 years; 57% black, 54% female) from families of low to middle class according to the Hollingshead scale participated in weeklong assessments of sleep duration and fragmentation, assessed by using actigraphy; sleep duration and perceived quality, assessed by using daily diaries; and daytime sleepiness and sleep delay, assessed by using a questionnaire.
Students slept during the school week a mean ± SD of 6.0 ± 0.9 hours per night according to actigraphy and 6.8 ± 1.1 hours according to daily diary, and during the weekend, a mean of 7.4 ± 1.2 and 8.7 ± 1.4 hours, respectively. Black participants and male participants slept less and had more fragmented sleep; female participants reported poorer quality of sleep in their daily diaries and more daytime sleepiness. The results remained significant after adjustments for age, physical activity, smoking status, and percentile BMI.
Most students slept less than the 8 to 9 hours suggested by the guidelines of the Centers for Disease Control and Prevention. Black male participants had the least amount of sleep, which may play a role in the substantial risks experienced by this demographic group. Our findings are consistent with recommendations that pediatricians should routinely screen their adolescent patients about their sleep, especially those from at-risk subgroups.
PMCID: PMC4006433  PMID: 24753532
adolescence; gender; health behaviors; race; sleep
6.  Daily Physical Activity and Hot Flashes in the Study of Women's Health Across the Nation FLASHES Study 
Fertility and sterility  2014;101(4):1110-1116.
To examine the role of physical activity in menopausal hot flashes. Competing models conceptualize physical activity as a risk or protective factor for hot flashes. Few studies have examined this relationship prospectively using physiologic measures of hot flashes and physical activity.
Over two 48 hour-periods, 51 participants wore a physiologic hot flash monitor and activity monitor, and reported their hot flashes in an electronic diary. Physiologic hot flashes, reported hot flashes and reported hot flashes without physiological corroboration were related to activity changes using hierarchical generalized linear modeling, adjusting for potential confounders.
Midlife women.
Main Outcome Measures
Physiologically-detected hot flashes and reported hot flashes with and without physiologic corroboration.
Hot flash reports without physiologic corroboration were more likely after activity increases (OR 1.04, 95% CI: 1.00-1.10, p=.01), particularly among women with higher levels of depressive symptoms (interaction p=.02). No other types of hot flashes were related to physical activity.
Acute increases in physical activity were associated with increased reporting of hot flashes lacking physiologic corroboration, particularly among women with depressive symptoms. Clinicians should consider the role of symptom perception and reporting in relations between physical activity and hot flashes.
PMCID: PMC3972358  PMID: 24491454
Menopause; hot flashes; physical activity
7.  Socioeconomic status over 12 years and subclinical cardiovascular disease: The Study of Women’s Health Across the Nation 
Background and purpose
The inverse relation between socioeconomic status (SES) and cardiovascular disease (CVD) is well-established. However, few studies have investigated SES assessed repeatedly over adulthood in relation to subclinical atherosclerosis. We aimed to test whether consistently low SES, as indexed by education, income, and financial strain over 12 years of midlife was related to later carotid intima media thickness (IMT) and plaque among women.
The Study of Women’s Health Across the Nation is a multi-site longitudinal study of midlife women. Education was assessed at the study baseline, income and financial strain were obtained yearly over 12 years, and a carotid ultrasound was obtained at study year 12 among 1402 women. Associations were tested in linear and multinomial logistic regression models adjusted for demographic, biological, and behavioral risk factors.
A high school education or less (OR (95%CI): 1.72(1.15,2.59), p<0.01), some college education (OR (95%CI): 1.65(1.17,2.32), p<0.01), consistently low income (OR (95%CI): 1.83(1.15,2.89), p<0.05) and consistent financial strain (OR (95%CI): 1.78(1.21,2.61), p<0.01) over 12 years were associated with higher carotid plaque, and consistent financial strain was associated with elevated maximal IMT (b(SE)=0.02(0.01), p<0.05) controlling for standard CVD risk factors. When SES indices were considered together, financial strain (b(SE); 0.02(0.01), p<0.05) and low education (high school education or less: OR (95%CI): 1.55(1.01,2.37), p<0.05; some college: OR (95%CI): 1.56(1.09,2.21), p<0.05) were most consistently associated with IMT and plaque, respectively, controlling for risk factors.
Findings indicate the importance of targeting economically disadvantaged women in efforts to prevent CVD among women.
PMCID: PMC3981101  PMID: 24578209
socioeconomic status; socioeconomic position; cardiovascular disease; subclinical cardiovascular disease; intima media thickness; atherosclerosis; education
Little is known about whether the childhood family psychosocial environment (characterized by cold, unaffectionate interactions, conflict, aggression, neglect and/or low nurturance) affects coronary heart disease (CHD) risk. Objectives were to evaluate associations of childhood family psychosocial environment with carotid intima media thickness (IMT), a subclinical measure of atherosclerosis. The study population included 2,659 CARDIA study participants, aged 37-52 years. Childhood family psychosocial environment was measured using a risky family questionnaire via self-report. Carotid IMT was calculated using the average of 20 measurements of mean common carotid, bulb and internal carotid IMT, assessed using high-resolution B-mode ultrasound images. Utilizing linear regression analyses adjusted for age, a 1-unit (range 0-21) increase in risky family score was associated with 0.0036 (95% CI:0.0006,0.0066 mm) and 0.0020 (95% CI:0.0002,0.0038) mm increase in mean IMT in white males and females, respectively. Formal mediation analyses and covariate adjustments suggested childhood socioeconomic position and smoking may be important mechanisms in white males and females, as well as education and depressive symptomatology in white males. No associations were found in black participants. Formal statistical tests for interaction between risky family score and sex, and between risky family score and race/ethnicity, demonstrated borderline evidence of interactions for both sex (p=0.12) and race/ethnicity (p=0.14) with risky family score for associations with mean IMT. In conclusion, childhood family psychosocial environment was positively associated with IMT in white participants, with little evidence of association in black participants. Mechanisms in white participants may include potential negative impacts of socioeconomic constraints on parenting quality, potentially influencing offspring's cardiovascular risk factors (e.g. smoking), socioeconomic position (e.g. education), and/or psychosocial functioning (e.g. depression), which may in turn lead to atherosclerotic processes. Borderline racial/ethnic differences in findings should be replicated, but add to literature exploring race/ethnicity-specific associations of parenting approaches with health outcomes.
PMCID: PMC4017861  PMID: 24581057
9.  Conceptualizing Health Consequences of Hurricane Katrina From the Perspective of Socioeconomic Status Decline 
The long-term health impact of acute unemployment and socioeconomic resource deficit has not been shown to be unique from the effects of stable socioeconomic status (SES) and serious life circumstances, such as trauma. This study examined associations between these acute socioeconomic declines and health of hurricane survivors, independent of prehurricane SES and hurricane trauma.
Participants were 215 African American adults (60% female, mean age = 39 years) living in the Greater New Orleans area at the time of Hurricane Katrina and survey 4 years later. The survey included prehurricane SES measures (i.e., education and neighborhood poverty level); acute unemployment and deficits in access to SES resources following Hurricane Katrina; and posthurricane health events (i.e., cardiometabolic events, chronic pain, posttraumatic stress disorder [PTSD], and major depressive disorder [MDD]).
Acute unemployment was associated with odds of experiencing a cardiometabolic event (odds ratio [OR] = 5.65, p < .05), MDD (OR = 2.76, p < .05) and chronic pain (OR = 2.76, p < .05), whereas acute socioeconomic resource deficit was associated with odds of chronic pain (OR = 1.93, p < .001) and MDD (OR = 1.19, p < .05). Associations were independent of prehurricane SES, hurricane trauma, potentially chronic SES resource deficits, and current unemployment.
This study shows that acute socioeconomic decline following a natural disaster can create long-term health disparities beyond those created by prehurricane SES level and traumatic hurricane experiences. Findings suggest that early intervention postdisaster to reduce pervasive socioeconomic disruption may reduce the long-term health impact of disasters.
PMCID: PMC4036525  PMID: 23527519
disaster; SES; unemployment; mental health; cardiometabolic
10.  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
12.  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
13.  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
14.  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
15.  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
17.  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
18.  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
19.  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
20.  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
21.  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
22.  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
23.  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
24.  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
25.  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

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