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1.  Bisphenol-A and disparities in birth outcomes: a review and directions for future research 
Racial disparities in pregnancy outcome in the United States are significant, persistent and costly, but the causes are poorly understood. We propose that disproportionate exposure of African-American women to environmental endocrine disrupting compounds (EDCs) may contribute to birth outcome disparities. Marked racial segregation, as well as health behaviors associated with poverty could result in differences in exposure to particular EDCs. One EDC that has aroused concern in recent years is bisphenol-A (BPA), a widely used industrial plasticizer with known estrogenic properties. Published studies indicate that excessive BPA exposure is associated with reduced fetal survival, as well as reductions in maternal weight and fetal body weight. Related findings include adverse effects of BPA exposure on ovarian function, mammary gland development, earlier age of puberty onset, and some metabolic parameters. However, these findings are largely limited to experimental animal studies, and need to be validated in human populations. Our review supports the need to move beyond the currently dominant toxicological approach to examining the effects of BPA exposure, and rely more on observational human studies and epidemiological methods. Many of the risk factors for racial disparities in pregnancy outcome are global or difficult to modify, but exposure to BPA is a potentially malleable risk factor. If BPA contributes to racial disparities in pregnancy outcome, there are important implications for prevention. It is our hope that this review will stimulate further research in this important and neglected area.
PMCID: PMC4028155  PMID: 19587689
Bisphenol-A; endocrine disrupting compounds; birth outcomes; racial disparities; environmental exposures
2.  Physical activity during recess in low-income 3rd grade students in Texas 
We estimated the prevalence of recess-based moderate and vigorous physical activity (MVPA) and vigorous physical activity (VPA) among third grade students attending low-income, urban schools in Texas.
Structured observations (n=77 class and 616 student observations) using SOFIT were conducted over three-months in 8 elementary schools with majority Hispanic students.
Students engaged in 66.4% and 19.2% of their ~20 minute recess time in MVPA and VPA, respectively. Boys engaged in more MVPA and VPA (P<.007). Contextual differences in activity (setting and activity type) were identified.
Findings underscore the importance of scheduled recess time for children’s physical activity.
PMCID: PMC3761405  PMID: 23985178
children; recess; physical activity; Hispanic; ecological model; gender
3.  Unbundling outcomes of a multilevel intervention to increase fruit, vegetables, and whole grains parents pack for their preschool children in sack lunches 
Packing fruit, vegetables, and whole grains in preschool children’s sack lunches is a powerful way for parents to teach their children eating habits and food preferences to support a lifetime of good health. A multilevel intervention pilot-tested in childcare settings increased servings of vegetables and whole grains, but the lunches still fell short of the intervention goals.
Secondary analyses were conducted to identify specific behavior changes underlying achieved increases in servings of vegetables and whole grains.
Food records from direct observation of 769 parent-packed lunches were investigated to unbundle and measure multiple aspects of lunch packing behavior. Changes from baseline to six week follow-up for the intervention (N=81) and comparison (N=51) parent-child dyads were evaluated in multilevel modeling.
The increase for whole grains was explained by more parents packing whole grain items whereas increase for vegetables was explained by parents packing vegetables on more days.
Tailored options were identified for further strategies to increase vegetables and whole grains in parent-packed sack lunches.
Translation to Health Education Practice
Linking achieved outcomes to specific behaviors can be an aid in assessing needs and designing interventions to maximize the chances for success.
PMCID: PMC3522465  PMID: 23243631
sack lunch; parent education; behavioral objectives; childcare
4.  Education and levels of salivary cortisol over the day in U.S. adults 
Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis is hypothesized to be an important pathway linking socioeconomic position and chronic disease.
This paper tests the association between education and the diurnal rhythm of salivary cortisol.
Up to 8 measures of cortisol (mean of 5.38 per respondent) over two days were obtained from 311 respondents, aged 18–70, drawn from the 2001–2002 Chicago Community Adult Health Study. Multi-level models with linear splines were used to estimate waking level, rates of cortisol decline, and area-under-the-curve over the day, by categories of education.
Lower education (0–11 years) was associated with lower waking levels of cortisol, but not the rate of decline of cortisol, resulting in a higher area-under-the-curve for more educated respondents throughout the day.
This study found evidence of lower cortisol exposure among individuals with less education and thus does not support the hypothesis that less education is associated with chronic over-exposure to cortisol.
PMCID: PMC3486742  PMID: 20812036
5.  Circadian rhythm of cortisol and neighborhood characteristics in a population-based sample: The Multi-Ethnic Study of Atherosclerosis 
Health & place  2011;17(2):625-632.
Although stress is often hypothesized to contribute to the effects of neighborhoods on health, very few studies have investigated associations of neighborhood characteristics with stress biomarkers. This study helps address the gap in the literature by examining whether neighborhood characteristics are associated with cortisol profiles. Analyses were based on data from the Multi-Ethnic Study of Atherosclerosis Stress study which collected multiple measures of salivary cortisol over three days on a population based sample of approximately 800 adults. Multilevel models with splines were used to examine associations of cortisol levels with neighborhood poverty, violence, disorder, and social cohesion. Neighborhood violence was significantly associated with lower cortisol values at wakeup and with a slower decline in cortisol over the earlier part of the day, after sociodemographic controls. Associations were weaker and less consistent for neighborhood poverty, social cohesion, and disorder. Results revealed suggestive, though limited, evidence linking neighborhood contexts to cortisol circadian rhythms.
PMCID: PMC3189702  PMID: 21292535
Neighborhood context; cortisol; biomarker; hierarchical linear modeling
6.  Psychosocial Risk Factors and Retinal Microvascular Signs 
American Journal of Epidemiology  2009;171(5):522-531.
The association between psychosocial risk factors and retinal microvascular signs was examined in the Multi-Ethnic Study of Atherosclerosis. Subjects were recruited from Baltimore, Maryland; Chicago, Illinois; Forsyth County, North Carolina; Los Angeles County, California; New York, New York; and St. Paul, Minnesota. Levels of depressive symptoms, trait anger, trait anxiety, chronic burdens, emotional support, and cynical distrust were assessed by questionnaire (from July 2000 to July 2002). Digital retinal images (from August 2002 to January 2004) from 6,147 participants were used to evaluate retinopathy and retinal vascular caliber. After controlling for potential confounding factors, the authors found that subjects without access to emotional support (Enriched Social Support Instrument score of <19 vs. ≥19) had 60% greater odds of retinopathy (odds ratio = 1.6, 95% confidence interval (CI): 1.3, 2.0). Subjects with high Spielberger trait-anxiety scale scores (≥22 vs. ≤14) and subjects with high depressive symptoms (Center for Epidemiology Studies Depression Scale score, ≥16 vs. <16) were also more likely to have retinopathy (odds ratio = 1.4, 95% CI: 1.1, 1.9 and odds ratio = 1.5, 95% CI: 1.2, 1.9), respectively. In this cross-sectional study, lack of emotional support, increased trait anxiety, and more depressive symptoms were associated with retinopathy signs, independently of other known risk factors.
PMCID: PMC2842225  PMID: 20035010
anger; anxiety; depression; microvessels; psychology, social; retina; social support
7.  Association of Salivary Cortisol Circadian Pattern with Cynical Hostility: The Multi-Ethnic Study of Atherosclerosis 
Psychosomatic medicine  2009;71(7):748-755.
To determine if cynical hostility is associated with alterations in diurnal profiles of cortisol. Hostility has been linked to cardiovascular disease but the biological mechanisms mediating this association remain unknown.
Up to 18 measures of salivary cortisol taken over three days were obtained from each of 936 participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Cynical hostility was measured using an 8-item subscale of the Cook-Medley Hostility scale. Cortisol profiles were modeled using regression spline models incorporating random parameters for subject-specific effects. Models were adjusted for race, sex, age, socioeconomic position, and lifestyle factors. The association of cynical hostility with key features of the cortisol diurnal profile, both in the full sample and important subsamples, was examined.
Waking cortisol levels as well as the extent of the morning surge in cortisol levels did not differ significantly across tertiles of cynical hostility. However respondents in the lowest tertile of cynical hostility experienced a 22% sharper decline in salivary cortisol (age-and sex-adjusted slope of −.49 μg/dl per hour) than respondents in the highest tertile (−.40 μg/dl per hour, p for difference=.0004). Intertertile differences in these parameters remained unaltered after further adjustment for potential confounders. This pattern of differences in cortisol diurnal profile tended to be related in a dose-response way to level of cynical hostility, and persisted in stratified analyses.
Cynical hostility is associated with the declining phase of the awakening cortisol response. The implications of this for cardiovascular and other health outcomes remain to be determined.
PMCID: PMC3040517  PMID: 19592518
Cortisol rhythms; cynical hostility; regression splines; random effects; cortisol awakening response
8.  The association of optimism and pessimism with inflammation and hemostasis in the Multi-Ethnic Study of Atherosclerosis (MESA) 
Psychosomatic medicine  2010;72(2):134-140.
Optimism and pessimism are associated with cardiovascular disease mortality and progression, however the biological mechanism remains unclear. This study investigates the association between optimism/pessimism and concentrations of seven inflammation and hemostasis markers.
This cross-sectional study used data from the Multi-Ethnic Study of Atherosclerosis (MESA), a study of 6814 persons aged 45–84 with no history of clinical cardiovascular disease. The Life-Orientation Test—Revised (LOT-R) was used to measure dispositional optimism and pessimism. Regression analyses were used to estimate associations of optimism and pessimism with interleukin-6 (IL-6), C-reactive protein (CRP), fibrinogen, homocysteine, factor VIII, D-dimer, and plasmin-antiplasmin, before and after adjustment for sociodemographics, depression, cynicism, health behaviors, BMI, hypertension, and diabetes.
Higher scores on the LOT-R (positive disposition) were related to lower concentrations of IL-6 (p=0.001), fibrinogen (p<0.001) and homocysteine (p=0.031). Associations were stronger for the pessimism subscale. After adjustment for demographics, the percentage differences in inflammatory markers corresponding to a 2-standard deviation increase in pessimism were 6.01% (p=0.001) for IL-6; 10.31% (p=0.001) for CRP; 2.47% (p<0.0001) for fibrinogen, and 1.36% (p=0.07) for homocysteine. Associations were attenuated but significant after adjustment for sociodemographics, depression, cynical distrust, and behaviors. Further adjustment for hypertension, BMI and diabetes reduced associations for CRP and IL-6. Pessimism remained associated with a 1.36% (p=0.02) increase in fibrinogen in the fully adjusted model. Factor VIII, D-dimer and plasmin-antiplasmin were not associated with the LOT-R or subscales.
Pessimism is related to higher levels of inflammation. Health behaviors, BMI, hypertension and diabetes appear to play a mediating role.
PMCID: PMC2842951  PMID: 20100888
Psychosocial factors; inflammation; coagulation; epidemiology; risk factors
9.  Implementation of Texas Senate Bill 19 to Increase Physical Activity in Elementary Schools 
Journal of public health policy  2009;30(Suppl 1):S221-S247.
In 2001, the 77th Texas legislature passed Senate Bill 19 (SB19) requiring elementary school children in publicly funded schools to participate in physical activity (PA) and schools to implement a coordinated school health program (CSHP) by September 1, 2007. We report on awareness of and adherence to SB19 in a statewide sample of elementary schools and a subsample in two public health regions located along the Texas/Mexico border. Statewide, structured interviews with principals indicated high awareness of SB19's requirements, but lower awareness of the need for parental involvement. Only 43% of Texas schools had adopted their coordinated program at one year or less prior to implementation deadline. Principals reported an average of 179 minutes of PE per week, higher than the 135 minute mandate. Among subsample border schools, principal PA reports triangulated with teacher logs and student reports. Further, direct observation of PE indicated 50% of class time was spent in MVPA, meeting the recommended level of PA intensity defined by Healthy People 2010. Differences observed by public health regions included: greater PA minutes in Region 10 (231 minutes compared to 217 minutes in Region 11), higher adoption CSHP (92% compared to 75%), more school health advisory committees (SHAC) (58% vs. 38%) and school-level SHACs (83% compared to 25%), and a lower prevalence of obesity in fourth grade students (21% compared to 32%). Differences by region suggest SB19 is not being adhered to equally across the state, and some regions may require further support to increase implementation. Results underscore the importance of continued monitoring of enacted legislation, that school-based legislation for child health requires funding and refinement to produce the original intent of the law.
PMCID: PMC2917835  PMID: 19190576
Texas; child; adolescent; physical education and training; physical activity; schools; health education; public policy; health policy; obesity
10.  Senate Bill 42: Implementation and Impact on Physical Activity in Middle Schools 
In 2005, the Texas state legislature passed Senate Bill 42 (SB42) that required public middle school students (grades 6–8) to participate in 30 minutes of daily structured physical activity. The purpose of this study was to assess awareness of and adherence to SB42 in Texas middle schools, and to assess the impact of SB42 on the frequency and quality of structured physical activity.
Key informant (school principals, physical education [PE] instructors, nurses, or designated personnel) telephone interviews on the implementation of SB42 were conducted from a statewide representative sample of public middle schools (n=112). Direct observation, key informant, and student report of physical activity in PE classes at 17 Texas-Mexico border middle schools assessed the frequency and quality of structured physical activity.
State level (94% ± 4.5%) and border district (94% ± 13.5%) key informants reported a high level of overall awareness of SB42. Post-implementation of SB42 border districts reported a minimum of four days per week of PE instruction and >58 minutes per PE class, exceeding the 30 minute minimum of structured physical activity per day or 135 minutes per week as required by SB42 (range 58.2– 61.4 minutes). A significant increase in the number of days of PE class was observed in the border sample between 2004–2005 and 2006–2008, with 8th grade students reporting an average of 2.0 days and 3.7 days of PE per week, respectively (p<0.001). Additionally, border districts met the Healthy People 2010 objective of 50% time in moderate-to-vigorous physical activity (MVPA; mean 54.9% ± 5.1%) during PE class.
Implementation of SB42 appears to have impacted the frequency of school PE in Texas and the prevalence of child self-reported physical activity behaviors along the Texas-Mexico border. General awareness of and adherence to SB42 was high in both statewide and among the border districts. Our mixed findings on adherence to specific components of the legislation suggest the need for further investigation of the factors that both facilitate and inhibit local leadership around school policy and the mechanisms to ensure the school policy is being implemented.
PMCID: PMC2903960  PMID: 19699442
Texas; adolescents; Latinos; physical activity; schools; health education; public policy; health policy; obesity; MVPA
11.  Socioeconomic and Psychosocial Gradients in Cardiovascular Pathogen Burden and Immune Response: The Multi-Ethnic Study of Atherosclerosis 
Brain, behavior, and immunity  2008;23(5):663-671.
The biologic mechanisms linking socioeconomic position and psychosocial factors to cardiovascular disease (CVD) are not well understood. Immune response to persistent pathogens may be one of these mechanisms.
We analyzed cross-sectional data from the Multi-Ethnic Study of Atherosclerosis (N=999) composed of adults age 45–84. Log-binomial regression and ordinal logistic regression models were used to examine associations of socioeconomic factors and psychosocial factors with pathogen burden and immune response among those infected. Pathogen burden was assessed based on seroprevalence of Helicobacter pylori, cytomegalovirus, herpes simplex virus-1, and Chlamydia pneumoniae and antibody levels were used to characterize high immune response to all four pathogens.
Low education was a strong and significant independent predictor of higher pathogen burden after adjustment for covariates (adjusted odds ratio (OR) 95% confidence interval (CI) 1.37, 1.19–1.57). Among subjects seropositive for all four pathogens, low education and a higher level of chronic psychosocial stress showed a positive association with higher antibody response, although associations were no longer significant in models with all covariates included (OR = 1.64, 95%CI 0.82–3.31 for lowest vs. highest educational category and OR= 1.29, 95%CI 0.96–1.73 for a one level increase in chronic stress).
Pathogen burden and heightened immune response may represent a biological pathway by which low socioeconomic position and chronic stress are related to increased rates of cardiovascular disease.
PMCID: PMC2694852  PMID: 19150399
Infection; inflammation; epidemiology; cardiovascular diseases
12.  Vulnerability to heat-related mortality in Latin America: a case-crossover study in São Paulo, Brazil, Santiago, Chile and Mexico City, Mexico 
Background Factors affecting vulnerability to heat-related mortality are not well understood. Identifying susceptible populations is of particular importance given anticipated rising temperatures from climatic change.
Methods We investigated heat-related mortality for three Latin American cities (Mexico City, Mexico; São Paulo, Brazil; Santiago, Chile) using a case-crossover approach for 754 291 deaths from 1998 to 2002. We considered lagged exposures, confounding by air pollution, cause of death and susceptibilities by educational attainment, age and sex.
Results Same and previous day apparent temperature were most strongly associated with mortality risk. Effect estimates remained positive though lowered after adjustment for ozone or PM10. Susceptibility increased with age in all cities. The increase in mortality risk for those ≥65 comparing the 95th and 75th percentiles of same-day apparent temperature was 2.69% (95% CI: −2.06 to 7.88%) for Santiago, 6.51% (95% CI: 3.57–9.52%) for São Paulo and 3.22% (95% CI: 0.93–5.57%) for Mexico City. Patterns of vulnerability by education and sex differed across communities. Effect estimates were higher for women than men in Mexico City, and higher for men elsewhere, although results by sex were not appreciably different for any city. In São Paulo, those with less education were more susceptible, whereas no distinct patterns by education were observed in the other cities.
Conclusions Elevated temperatures are associated with mortality risk in these Latin American cities, with the strongest associations in São Paulo, the hottest city. The elderly are an important population for targeted prevention measures, but vulnerability by sex and education differed by city.
PMCID: PMC2734062  PMID: 18511489
Brazil; cause of death; Chile; education; heat; Latin America; Mexico; mortality; sex; socioeconomic status; temperature
13.  Race/ethnicity and telomere length in the Multi-Ethnic Study of Atherosclerosis 
Aging cell  2009;8(3):251-257.
Telomere length has emerged as a marker of exposure to oxidative stress and aging. Race/ethnic differences in telomere length have been infrequently investigated. Leucocyte telomere length (LTL) was assessed 981 white, black and Hispanic men and women aged 45-84 years participating in the Multi-Ethnic Study of Atherosclerosis. Direct measurement and questionnaire were used to assess covariates. Linear regression was used to estimate associations of LTL with race/ethnicity and age after adjustment for sex, income, education, smoking, physical activity, diet, and body mass index. On average blacks and Hispanics had shorter telomeres than whites (adjusted mean differences (standard error) in T/S ratio compared to whites: -0.041 (0.018) for blacks and -0.044 (0.018) for Hispanics). Blacks and Hispanics showed greater differences in telomere length associated with age than whites (adjusted mean differences in T/S ratio per one year increase in age -0.0018, -0.0047, and -0.0055 in whites, blacks, and Hispanics respectively). Differences in age associations were more pronounced and only statistically significant in women. Race/ethnic differences in LTL may reflect the cumulative burden of differential exposure to oxidative stress (and its predictors) over the lifecourse.
PMCID: PMC2713110  PMID: 19302371
Telomeres; race/ethnicity; aging

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