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1.  Urban-Rural and Regional Variability in the Prevalence of Food Insecurity: the Survey of the Health of Wisconsin 
Background
Food insecurity is a public health concern and it is estimated to affect 18 million American households nationally, which can result in chronic nutritional deficiencies and other health risks. The relationships between food insecurity and specific demographic and geographic factors in Wisconsin is not well documented. The goals of this paper are to investigate socio-demographic and geographic features associated with food insecurity in a representative sample of Wisconsin adults.
Methods
This study used data from the Survey of the Health of Wisconsin (SHOW). SHOW annually collects health-related data on a representative sample of Wisconsin residents. Between 2008-2012, 2,947 participants were enrolled in the SHOW study. The presence of food insecurity was defined based on the participant's affirmative answer to the question “In the last 12 months, have you been concerned about having enough food for you or your family?”
Results
After adjustment for age, race, and gender, 13.2% (95% Confidence Limit (CI): 10.8%-15.1%) of participants reported food insecurity, 56.7% (95% CI: 50.6%-62.7%) of whom were female. Food insecurity did not statistically differ by state public health region (p=0.30). The adjusted prevalence of food insecurity in the urban core, other urban, and rural areas of Wisconsin was 14.1%, 6.5% and 10.5%, respectively. These differences were not statistically significant (p=0.13).
Conclusions
The prevalence of food insecurity is substantial, affecting an estimated number of 740,000 Wisconsin residents. The prevalence was similarly high in all urbanicity levels and across all state public health regions in Wisconsin. Food insecurity is a common problem with potentially serious health consequences affecting populations across the entire state.
PMCID: PMC4245074  PMID: 25211799
2.  Evaluation of a pilot healthy eating intervention in restaurants and food stores of a rural community: a randomized community trial 
BMC Public Health  2015;15:136.
Background
Research suggests that the food environment influences individual eating practices. To date, little is known about effective interventions to improve the food environment of restaurants and food stores and promote healthy eating in rural communities. We tested “Waupaca Eating Smart ” (WES), a pilot intervention to improve the food environment and promote healthy eating in restaurants and supermarkets of a rural community. WES focused on labeling, promoting, and increasing the availability of healthy foods.
Methods
We conducted a randomized community trial, with two Midwestern U.S. communities randomly assigned to serve as intervention or control site. We collected process and outcome data using baseline and posttest owner and customer surveys and direct observation methods. The RE-AIM framework was used to guide the evaluation and organize the results.
Results
Seven of nine restaurants and two of three food stores invited to participate in WES adopted the intervention. On a 0-4 scale, the average level of satisfaction with WES was 3.14 (SD=0.69) for restaurant managers and 3 (SD=0.0) for store managers. On average, 6.3 (SD=1.1) out of 10 possible intervention activities were implemented in restaurants and 9.0 (SD=0.0) out of 12 possible activities were implemented in food stores. One month after the end of the pilot implementation period, 5.4 (SD=1.6) and 7.5 (SD=0.7) activities were still in place at restaurants and food stores, respectively. The intervention reached 60% of customers in participating food outlets. Restaurant food environment scores improved from 13.4 to 24.1 (p < 0.01) in the intervention community and did not change significantly in the control community. Food environment scores decreased slightly in both communities. No or minimal changes in customer behaviors were observed after a 10-month implementation period.
Conclusion
The intervention achieved high levels of reach, adoption, implementation, and maintenance, suggesting the feasibility and acceptability of restaurant-and food store-based interventions in rural communities. Pilot outcome data indicated very modest levels of effectiveness, but additional research adequately powered to test the impact of this intervention on food environment scores and customer behaviors needs to be conducted in order to identify its potential to promote healthy eating in rural community settings.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-015-1469-z) contains supplementary material, which is available to authorized users.
doi:10.1186/s12889-015-1469-z
PMCID: PMC4331304
Healthy eating; Food environment; Restaurant interventions; Food store interventions; Rural communities
3.  Sleep-disordered Breathing and Cancer Mortality 
Rationale: Sleep-disordered breathing (SDB) has been associated with total and cardiovascular mortality, but an association with cancer mortality has not been studied. Results from in vitro and animal studies suggest that intermittent hypoxia promotes cancer tumor growth.
Objectives: The goal of the present study was to examine whether SDB is associated with cancer mortality in a community-based sample.
Methods: We used 22-year mortality follow-up data from the Wisconsin Sleep Cohort sample (n = 1,522). SDB was assessed at baseline with full polysomnography. SDB was categorized using the apnea-hypopnea index (AHI) and the hypoxemia index (percent sleep time below 90% oxyhemoglobin saturation). The hazards of cancer mortality across levels of SDB severity were compared using crude and multivariate analyses.
Measurements and Main Results: Adjusting for age, sex, body mass index, and smoking, SDB was associated with total and cancer mortality in a dose–response fashion. Compared with normal subjects, the adjusted relative hazards of cancer mortality were 1.1 (95% confidence interval [CI], 0.5–2.7) for mild SDB (AHI, 5–14.9), 2.0 (95% CI, 0.7–5.5) for moderate SDB (AHI, 15–29.9), and 4.8 (95% CI, 1.7–13.2) for severe SDB (AHI ≥ 30) (P-trend = 0.0052). For categories of increasing severity of the hypoxemia index, the corresponding relative hazards were 1.6 (95% CI, 0.6–4.4), 2.9 (95% CI, 0.9–9.8), and 8.6 (95% CI, 2.6–28.7).
Conclusions: Our study suggests that baseline SDB is associated with increased cancer mortality in a community-based sample. Future studies that replicate our findings and look at the association between sleep apnea and survival after cancer diagnosis are needed.
doi:10.1164/rccm.201201-0130OC
PMCID: PMC3406081  PMID: 22610391
cancer; cohort study; mortality; obstructive sleep apnea; sleep-disordered breathing
4.  Evaluating Effects of Statewide Smoking Regulations on Smoking Behaviors Among Participants in the Survey of the Health of Wisconsin 
Background
Studies have shown that laws banning smoking in public places reduce exposure to secondhand smoke, but the impact of such laws on exposure to smoke outside the home and on household smoking policies has not been well documented. The goal of this study was to evaluate the effects of 2009 Wisconsin Act 12, a statewide smoke-free law enacted in July 2010, among participants in the Survey of the Health of Wisconsin (SHOW).
Methods
Smoking history and demographic information was gathered from 1341 survey participants from 2008 to 2010. Smoking behaviors of independent samples of participants surveyed before and after the legislation was enacted were compared.
Results
The smoking ban was associated with a reduction of participants reporting exposure to smoke outside the home (from 55% to 32%; P < 0.0001) and at home (13% to 7%; P = 0.002). The new legislation was associated with an increased percentage of participants with no-smoking policies in their households (from 74% to 80%; P = .04). The results were stronger among participants who were older, wealthier, and more educated.
Conclusion
Smoke-free legislation appears to reduce secondhand smoke exposure and to increase no-smoking policies in households. Further research should be conducted to see if these effects are maintained.
PMCID: PMC3529004  PMID: 22970531
5.  Long-Term Variability of Inflammatory Markers and Associated Factors in a Population-Based Cohort 
OBJECTIVES
To investigate long-term variability in serum high sensitivity C-reactive protein (CRP) and interleukin-6 (IL-6) and to determine associated risk factors for high risk inflammatory profiles.
DESIGN
Prospective population-based cohort study.
PARTICIPANTS
Participants (N=1,443) of the Epidemiology of Hearing Loss Study and the Beaver Dam Eye Study, two population-based prospective studies of aging in the same cohort.
MEASUREMENTS
Among participants aged 43–79 years at the initial exam (1988–1990), serum high sensitivity CRP was measured from three time-points (1988–1990, 1998–2000, 2009–2010) and serum IL-6 was measured from two (1998–2000 and 2009–2010).
RESULTS
When IL-6 levels were categorized into tertiles, 50.8% of participants remained in the same group 10 years later (weighted Kappa(κ)=.34). When CRP was categorized into three risk groups, 53.4% of participants remained in the same group during 10 years (κ=.36), and 32.4% remained in the same group at all three examinations (κ=.27). Interleukin 6 increased from a geometric mean of 1.54 pg/L to 1.78 pg/L over 10 years, while CRP increased from a geometric mean of 1.67 mg/L to 2.25 mg/L over 10 years, and then decreased to 1.93 mg/L over the next 10 years. These 10-year decreases in CRP were not observed in those not reporting statin use. Factors associated with long-term higher levels of either IL-6 and CRP included older age (IL-6), obesity, smoking, lower physical activity (IL-6), lower HDL cholesterol (IL-6), and a history of statin (non)use (CRP).
CONCLUSION
Inflammatory marker levels tracked over the long-term into older age with within-person increases observed. Several potentially modifiable risk factors were associated with long-term higher levels of inflammatory markers.
doi:10.1111/jgs.12382
PMCID: PMC3743937  PMID: 23889670
Inflammation; Aging; Long-term Variability
6.  Oral Hygiene and Cardiometabolic Disease Risk in the Survey of the Health of Wisconsin 
Objectives
Poor oral health is an increasingly recognized risk factor for cardiovascular disease (CVD) and type 2 diabetes (T2D), but little is known about the association between toothbrushing or flossing and cardiometabolic disease risk. The purpose of this study was to examine the degree to which an oral hygiene index was associated with CVD and T2D risk scores among disease-free adults in the Survey of the Health of Wisconsin.
Methods
All variables were measured in 2008–2010 in this cross-sectional design. Based on toothbrushing and flossing frequency, and oral hygiene index (poor, fair, good, excellent) was created as the primary predictor variable. The outcomes, CVD and T2D risk score, were based on previous estimates from large cohort studies. There were 712 and 296 individuals with complete data available for linear regression analyses in the CVD and T2D samples, respectively.
Results
After covariate adjustment, the final model indicated that participants in the excellent (β±SE=−0.019±0.008, p=0.020) oral hygiene category had a significantly lower CVD risk score as compared to participants in the poor oral hygiene category. Sensitivity analyses indicated that both toothbrushing and flossing were independently associated with CVD risk score, and various modifiable risk factors. Oral hygiene was not significantly associated with T2D risk score.
Conclusions
Regular toothbrushing and flossing are associated with a more favorable CVD risk profile, but more experimental research is needed in this area to precisely determine the effects of various oral self-care maintenance behaviors on the control of individual cardiometabolic risk factors. These findings may inform future joint medical-dental initiatives designed to close gaps in the primary prevention of oral and systemic diseases.
doi:10.1111/cdoe.12015
PMCID: PMC3566323  PMID: 23106415
7.  Sleep Disordered Breathing and Metabolic Syndrome 
Background
Sleep disordered breathing (SDB) has been associated with cardiovascular disease, hypertension, and insulin resistance. This article examines the association between SDB and the prevalence of metabolic syndrome (MS) in a community-based sample.
Methods
A subset of participants in the Wisconsin Sleep Cohort Study (N=546) participated in an ancillary study to measure vascular and metabolic function. SDB was characterized using the apnea-hypopnea index (AHI) obtained in the polysomnography study closest to the collection of the metabolic measures. MS was defined using the National Cholesterol Education Program definition, and the homeostasis model assessment method (HOMA) was used to characterize insulin resistance.
Results
SDB was significantly correlated with insulin resistance (Spearman r correlation between AHI and HOMA=0.30, P<0.0001). Compared with those without SDB (AHI <5), the age-sex-adjusted odds ratios of MS associated with mild (AHA 5-14.9) and moderate/severe SDB (AHI >15 or CPAP) were 4.0 (95% CI 2.6, 6.3) and 5.3 (95% CI 3.2, 8.8), respectively. Additional adjustment for markers of sympathetic or neuroendocrine activation (urinary norepinephrine, cortisol, heart rate variability) did not materially alter these estimates. These associations were weaker but remained statistically significant after adjusting for body mass index.
Conclusion
SDB might be considered an integral component of MS.
PMCID: PMC2873189  PMID: 19743760
8.  Taste Intensity in the Beaver Dam Offspring Study 
The Laryngoscope  2013;123(6):1399-1404.
Objective
To determine the distribution of the perceived intensity of salt, sweet, sour, and bitter in a large population and to investigate factors associated with perceived taste intensity.
Study Design
Cross-sectional population.
Methods
Subjects (n = 2374, mean age=48.8 years) were participants in the Beaver Dam Offspring Study examined during 2005-2008. Perceived taste intensity was measured using paper disks and a general labeled magnitude scale. Multiple linear regression was performed.
Results
Mean intensity ratings were: salt=27.2 (standard deviation [s.d.]=18.5), sweet=20.4 (s.d.=15.0), sour=35.7 (s.d.=21.4), and bitter=49.6 (s.d.=23.3). Females and those with less than a college degree education rated tastes stronger. With adjustment for age, sex, and education, stronger perceived sour and bitter intensities were related to current smoking (Sour:B=2.8, 95% Confidence Interval [CI]=0.4,5.2; Bitter:B=2.8, 95% CI=0.3,5.4) and lipid-lowering medications (Sour:B=5.1, 95% CI=2.5,7.6; Bitter:B=3.2, 95% CI=0.6,5.8). Alcohol consumption in the past year was related to weaker salt (B= −2.8, 95% CI= −5.3,−0.3) and sweet intensity ratings (B= −2.3, 95% CI= −4.3,−0.3) while olfactory impairment was associated with higher sweet ratings (B=4.7, 95% CI=1.4,7.9).
Conclusion
Perceived intensities were strongest for bitter and weakest for sweet. Sex and education were associated with each taste while age did not demonstrate a consistent relationship. Associations with other factors differed by tastant with current smoking and alcohol consumption being related to some tastes.
doi:10.1002/lary.23894
PMCID: PMC3664123  PMID: 23625687
salt taste; sweet taste; sour taste; bitter taste
9.  Unmet Hearing Health Care Needs: The Beaver Dam Offspring Study 
American journal of public health  2013;103(6):1134-1139.
Objectives
We evaluated the use of hearing health care services (hearing testing and hearing aids) by adults aged 21 to 84 years.
Methods
Hearing was tested and medical and hearing health histories were obtained as part of the Beaver Dam Offspring Study between 2005 and 2008 (n = 3285, mean age = 49 years).
Results
Of the cohort, 34% (55% of participants aged ≥ 70 years) had a hearing test in the past 5 years. In multivariate modeling, older age, male gender, occupation, occupational noise, and having talked with a doctor about a hearing problem were independently associated with having had a hearing test in the past 5 years. Hearing aid use was low among participants with a moderate to severe hearing impairment (22.5%) and among participants with a hearing handicap (8.6%), as determined by the Hearing Handicap Inventory.
Conclusions
Data support the need for improvement in hearing health care. Hearing aids’ effectiveness is limited if patients do not acquire them or do not use them once acquired. Future research should focus on developing effective strategies for moving patients from diagnosis to treatment.
doi:10.2105/AJPH.2012.301031
PMCID: PMC3670658  PMID: 23597370
10.  Exposure to Neighborhood Green Space and Mental Health: Evidence from the Survey of the Health of Wisconsin  
Green space is now widely viewed as a health-promoting characteristic of residential environments, and has been linked to mental health benefits such as recovery from mental fatigue and reduced stress, particularly through experimental work in environmental psychology. Few population level studies have examined the relationships between green space and mental health. Further, few studies have considered the role of green space in non-urban settings. This study contributes a population-level perspective from the United States to examine the relationship between environmental green space and mental health outcomes in a study area that includes a spectrum of urban to rural environments. Multivariate survey regression analyses examine the association between green space and mental health using the unique, population-based Survey of the Health of Wisconsin database. Analyses were adjusted for length of residence in the neighborhood to reduce the impact of neighborhood selection bias. Higher levels of neighborhood green space were associated with significantly lower levels of symptomology for depression, anxiety and stress, after controlling for a wide range of confounding factors. Results suggest that “greening” could be a potential population mental health improvement strategy in the United States.
doi:10.3390/ijerph110303453
PMCID: PMC3987044  PMID: 24662966
green space; nature; neighborhood environment; mental health; population-based surveys; United States
11.  Perceived neighborhood quality, sleep quality, and health status: Evidence from the Survey of the Health of Wisconsin 
Why does living in a disadvantaged neighborhood predict poorer mental and physical health? Recent research focusing on the Southwestern United States suggests that disadvantaged neighborhoods favor poor health, in part, because they undermine sleep quality. Building on previous research, we test whether this process extends to the Midwestern United States. Specifically, we use cross-sectional data from the Survey of the Health of Wisconsin (SHOW), a statewide probability sample of Wisconsin adults, to examine whether associations among perceived neighborhood quality (e.g., perceptions of crime, litter, and pleasantness in the neighborhood) and health status (overall self-rated health and depression) are mediated by overall sleep quality (measured as self-rated sleep quality and physician diagnosis of sleep apnea). We find that perceptions of low neighborhood quality are associated with poorer self-rated sleep quality, poorer self-rated health, and more depressive symptoms. We also observe that poorer self-rated sleep quality is associated with poorer self-rated health and more depressive symptoms. Our mediation analyses indicate that self-rated sleep quality partially mediates the link between perceived neighborhood quality and health status. Specifically, self-rated sleep quality explains approximately 20% of the association between neighborhood quality and self-rated health and nearly 19% of the association between neighborhood quality and depression. Taken together, these results confirm previous research and extend the generalizability of the indirect effect of perceived neighborhood context on health status through sleep quality.
doi:10.1016/j.socscimed.2012.07.021
PMCID: PMC3733364  PMID: 22901794
Sleep; Sleep quality; Neighborhood context; Neighborhood quality; Self-rated health; Depression; Wisconsin; USA
12.  Sleep-disordered breathing and retinal microvascular diameter 
Atherosclerosis  2012;226(1):124-128.
Background
Sleep-disordered breathing (SDB) is an emerging risk factor for cardiovascular disease (CVD). Microvascular dysfunction has been proposed as a potential mechanism in the pathogenesis of CVD in SDB. The retinal vasculature offers a unique opportunity to investigate the systemic effects of microvascular dysfunction as it can be viewed non-invasively and is also structurally and functionally similar to microvasculature elsewhere in the body. We therefore examined the association between SDB and retinal microvascular diameter after adjusting for major confounders.
Methods
We examined n=476 participants from the Wisconsin Sleep Cohort Study. SDB was characterized using the apnea-hypopnea index (AHI) as <5 events/hr, 5-14.9 events/hr, and ≥15 events/hr. Outcomes of interest included the presence of retinal arteriolar narrowing (mean retinal arteriolar diameter <141.0 um) and retinal venular widening (mean venular diameter >223.0 um).
Results
Higher AHI was found to be positively associated with retinal venular dilatation, independent of body mass index, hypertension, diabetes, and lipid levels. Compared to an AHI of <5 events/hr (referent), the multivariable-adjusted odds ratio of retinal venular widening for an AHI of 5-14.9 events/hr was 1.31(0.75-2.28) and for an AHI of >15 events/hr was 2.08 (1.03-2.16); p-trend=0.045. In contrast, there was no association between AHI and retinal arteriolar narrowing (p-trend=0.72).
Conclusion
Higher AHI, a marker of SDB, was positively associated with wider retinal venules, independent of age, gender, BMI, hypertension, diabetes, and lipid levels. These data suggest that the association of SDB with cardiovascular disease may be mediated, in part, by microvasculature.
doi:10.1016/j.atherosclerosis.2012.10.046
PMCID: PMC3529805  PMID: 23137824
SDB; retinal arteriolar diameter; AHI
13.  Association of Biomarkers for Inflammation, Endothelial Dysfunction and Oxidative Stress with Cognitive Impairment. The Epidemiology of Hearing Loss Study (EHLS) 
Background
Individual biomarkers of inflammation, endothelial dysfunction and oxidative stress have been associated with cognitive impairment. This study explored whether a combination of biomarkers could prospectively identify those who developed cognitive decline.
Methods
Biomarkers were obtained during the baseline examination of the Beaver Dam Eye Study (1988–90), and cognitive status was assessed during the 5-year follow-up examination of the Epidemiology of Hearing Loss Study (1998–2000). Cognitive impairment was defined as a score of < 24 points on the Mini-Mental State Examination or self- or proxy report of Alzheimer Disease or dementia. Among those with cognitive data, interleukin-6, isoprostanes, protein carbonyl, soluble inter-cellular adhesion molecule-1 and vascular cell adhesion molecule-1 were available for 950 participants and 2,336 had high sensitivity C-reactive protein.
Results
Biomarkers of inflammation and endothelial dysfunction were not associated with cognitive impairment. There was a weak inverse association between higher levels of protein carbonyl content and cognitive impairment (OR, 0.8 per quartile of protein carbonyl content, p=0.045 unadjusted for multiple comparisons). This was not significant on multiple testing and may have been a chance finding.
Conclusion
We found that many markers of inflammation and endothelial dysfunction were not associated with cognitive impairment. An inverse association with carbonyl protein, a marker of oxidative stress needs further confirmation.
doi:10.5455/oams.031212.br.004
PMCID: PMC3693393  PMID: 23814681
oxidative stress; inflammation; biomarkers; cognitive impairment
14.  Intensity of Salt Taste and Prevalence of Hypertension Are Not Related in the Beaver Dam Offspring Study 
Chemosensory perception  2012;5(2):139-145.
BACKGROUND
Standard clinical advice for the prevention and treatment of hypertension includes limitation of salt intake. Previous studies of the association between perception of salt taste and hypertension prevalence have not reported consistent results and have usually been conducted in small study populations.
PURPOSE
To determine the cross-sectional relationship between intensity of salt taste, discretionary salt use, and hypertension. METHODS: Subjects (n=2371, mean age=48.8 years) were participants in the Beaver Dam Offspring Study (BOSS), an investigation of sensory loss and aging conducted in 2005–2008. Salt taste intensity was measured using a filter paper disk impregnated with 1.0 M sodium chloride and a general Labeled Magnitude Scale (gLMS). Hypertension was defined as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg, or use of high blood pressure medication.
RESULTS
Nearly 32% of the participants rated the salt disk as weak or having no taste while approximately 10% considered it to be very strong or stronger. The intensity was reported to be less strong by males (P < 0.001) and college graduates (P = 0.02) and was inversely associated with frequency of adding salt to foods (P = 0.02). There was no significant association between hypertension and the intensity of salt taste, before and after adjustment for covariates. Exclusion of subjects with a history of physician diagnosed hypertension did not appreciably alter these findings.
CONCLUSIONS
The perception of salt taste was related to the frequency of discretionary salt use but not to hypertension status or mean blood pressure.
doi:10.1007/s12078-012-9118-8
PMCID: PMC3381604  PMID: 22745848
high blood pressure; hypertension; population; salt taste; salt use; taste intensity
15.  Selection Bias in Population-Based Cancer Case–Control Studies Due to Incomplete Sampling Frame Coverage 
Background
Increasing numbers of individuals are choosing to opt out of population-based sampling frames due to privacy concerns. This is especially a problem in the selection of controls for case–control studies, as the cases often arise from relatively complete population-based registries, whereas control selection requires a sampling frame. If opt out is also related to risk factors, bias can arise.
Methods
We linked breast cancer cases who reported having a valid driver’s license from the 2004–2008 Wisconsin women’s health study (N = 2,988) with a master list of licensed drivers from the Wisconsin Department of Transportation (WDOT). This master list excludes Wisconsin drivers that requested their information not be sold by the state. Multivariate-adjusted selection probability ratios (SPR) were calculated to estimate potential bias when using this driver’s license sampling frame to select controls.
Results
A total of 962 cases (32%) had opted out of the WDOT sampling frame. Cases age <40 (SPR = 0.90), income either unreported (SPR = 0.89) or greater than $50,000 (SPR = 0.94), lower parity (SPR = 0.96 per one-child decrease), and hormone use (SPR = 0.93) were significantly less likely to be covered by the WDOT sampling frame (α = 0.05 level).
Conclusions
Our results indicate the potential for selection bias due to differential opt out between various demographic and behavioral subgroups of controls. As selection bias may differ by exposure and study base, the assessment of potential bias needs to be ongoing.
Impact
SPRs can be used to predict the direction of bias when cases and controls stem from different sampling frames in population-based case–control studies.
doi:10.1158/1055-9965.EPI-11-1066
PMCID: PMC3645306  PMID: 22490319
16.  Carotid Atherosclerosis and Cognitive Function in midlife: the Beaver Dam Offspring Study 
Atherosclerosis  2011;219(1):330-333.
Background
Atherosclerosis may be associated with cognitive function; however the studies are few, especially among midlife adults.
Methods
Participants in the Beaver Dam Offspring Study who had cognitive test data and gradable carotid artery ultrasound scans were included (n=2794, mean age: 49 years). Atherosclerosis was measured by carotid intima-media thickness (IMT) and presence of plaque. Cognitive function was measured by the Trail Making Test (TMT), Grooved Pegboard Test (GPT) and Mini-Mental State Examination (MMSE). Generalized cognitive function was defined by a summary score calculated from the TMT and GPT. Linear regression was used to evaluate the associations between carotid atherosclerosis and cognitive function tests.
Results
Larger IMT was associated with lower GPT, MMSE and the summary score adjusting for multiple factors, the coefficients were: 13.8 seconds (p<0.0001), −0.6 (p=0.007), and 0.47 (p=0.01), respectively for 1 mm increase in IMT. Plaque scores were significantly associated with TMT-B, GPT, MMSE, and the summary score adjusting for age, sex and education. The associations remained statistically significant after further adjustments except for the association with TMT-B, which was attenuated and no longer significant.
Conclusions
Our results show significant associations between markers of carotid atherosclerosis and cognitive function in a cohort of persons aged 21 to 84 years. Longitudinal studies are needed to further examine these associations.
doi:10.1016/j.atherosclerosis.2011.07.013
PMCID: PMC3206159  PMID: 21831374
atherosclerosis; cognitive function; epidemiology
17.  Tinnitus and its Risk Factors in the Beaver Dam Offspring Study 
OBJECTIVE
To assess the prevalence of tinnitus along with factors potentially associated with having tinnitus.
DESIGN
Data were from the Beaver Dam Offspring Study, an epidemiological cohort study of aging.
STUDY SAMPLE
After a personal interview and audiometric examination, participants (n=3267, ages 21-84 years) were classified as having tinnitus if in the past year they reported having tinnitus of at least moderate severity or that caused difficulty in falling asleep.
RESULTS
The prevalence of tinnitus was 10.6%. In a multivariable logistic regression model adjusting for age and sex, the following factors were associated with having tinnitus: hearing impairment (Odds Ratio (OR) = 3.20), currently having a loud job (OR = 1.90), history of head injury (OR = 1.84), depressive symptoms (OR = 1.82), history of ear infection (men, OR = 1.75), history of target shooting (OR = 1.56), arthritis (OR = 1.46), and use of NSAID medications (OR = 1.33). For women, ever drinking alcohol in the past year was associated with a decreased risk of having tinnitus (OR = 0.56).
CONCLUSIONS
These results suggest that tinnitus is a common symptom in this cohort and may be associated with some modifiable risk factors.
doi:10.3109/14992027.2010.551220
PMCID: PMC3073029  PMID: 21309642
Tinnitus; Demographics/Epidemiology; Hearing Conservation; Aging
18.  Bidirectional Association of Retinal Vessel Diameters and Estimated Glomerular Filtration Rate Decline: The Beaver Dam CKD Study 
Background
Recent cross-sectional studies have reported an association between retinal vessel caliber and chronic kidney disease (CKD), but the direction of the association between these two processes is not clear. In a prospective study with multiple measurements of retinal vessel diameters and serum creatinine, we examined if baseline retinal vessel diameters are associated with future risk of CKD, or vice versa.
Study design
Population-based cohort study
Setting and participants
3,199 Wisconsin adults aged 43-84 years who were followed prospectively for 15 years.
Predictor
Baseline retinal arteriolar and venular diameters for analysis 1, and baseline estimated glomerular filtration rate (eGFR) categories for analysis 2.
Outcomes and measurements
For analysis 1, incident CKD defined as eGFR <60 mL/min/1.73m2 accompanied by a 25% decrease in eGFR during follow up. For analysis 2, incident retinal arteriolar narrowing defined as a central retinal arteriolar equivalent measurement of <144.0μm and incident retinal venular dilation defined as a central retinal venular equivalent measurement of >243.8μm.
Results
Baseline retinal arteriolar and venular diameters were not found to be associated with the 15-year risk of incident CKD. After adjustment for age, sex, diabetes, hypertension and other confounders, the multivariable hazard ratio (HR) (95% confidence interval (CI) of incident CKD comparing the narrowest with the widest quartile was 1.15 (0.74-1.80) for retinal arteriolar and 1.05 (0.67-1.67) for retinal venular diameter. Similarly, there was no significant association between eGFR and 15-year risk of incident retinal arteriolar narrowing or retinal venular widening. Compared to eGFR >90 mL/min/1.73m2 (referent), the multivariable HR (95% CI) among those with eGFR <45 mL/min/1.73m2 was 1.66 (0.93-2.96) for incident retinal arteriolar narrowing and 0.60 (0.17-1.85) for retinal venular widening.
Limitations
Lack of data on albuminuria and loss to follow-up.
Conclusions
Retinal vessel diameters and CKD may run together through shared mechanisms but are not causally related.
doi:10.1053/j.ajkd.2010.11.025
PMCID: PMC3080044  PMID: 21439697
Retinal arteriolar diameter; retinal venular diameter; retinal vessel diameter; chronic kidney disease; eGFR; CKD; glomerular filtration rate
19.  The Prevalence of Hearing Impairment and Associated Risk Factors The Beaver Dam Offspring Study 
Objective
To estimate the prevalence of hearing impairment (HI) and evaluate the cross-sectional associations of environmental and cardiovascular disease risk factors and HI in middle-aged adults.
Design
Data were collected as part of the Beaver Dam Offspring Study (BOSS), an epidemiological cohort study of aging. HI was defined as a pure-tone average (PTA) 0.5,1,2,4kHz >25 db HL in either ear. Word recognition in competing message (WRCM) was measured using the Northwestern University #6 word list. Questionnaire information about behaviors, environmental factors and medical history was collected.
Subjects
Participants (n=3,285) were offspring of participants of the population-based Epidemiology of Hearing Loss Study, and ranged in age from 21–84 years (mean age=49 years).
Results
The prevalence of HI was 14.1%, and the median WRCM score was 64% (standard deviation=15%). In a multivariate model, controlling for age, sex, education, and occupational noise, a history of ear surgery (Odds Ratio (OR) = 4.11, 95%Confidence Interval (CI) = 2.37, 7.15), larger central retinal venular equivalent (CRVE) (OR = 1.77, 95%CI = 1.20, 2.60; 4th q vs. 1st q), and higher hematocrit percentage (OR = 0.77, 95% CI = 0.63, 0.95; per 5%) were independently associated with HI. Factors associated with lower WRCM scores were similar but also included mean intima-media thickness (mean difference= −0.63% (−1.06, −0.19) P= 0.005; per 0.1mm) and statin use (mean difference= −2.09% (−3.58, −0.60) P=0.005).
Conclusions
HI is a common condition in middle-aged adults. CVD risk factors may be important correlates of age-related auditory dysfunction.
doi:10.1001/archoto.2011.15
PMCID: PMC3096733  PMID: 21339392
20.  Socioeconomic Status and Subclinical Atherosclerosis in Older Adults 
Preventive medicine  2010;52(3-4):208-212.
Objective
This study investigated the long-term effects of socioeconomic status (SES) on atherosclerosis.
Methods
Data from the Epidemiology of Hearing Loss Study and the Beaver Dam Eye Study (Beaver Dam, WI, 1998-2000), were used to examine adult SES (education, household income, longest-held job) and childhood SES (household density and parental home ownership at age 13) associations with carotid intima-media thickness (IMT) and carotid plaque in a cohort of 2,042 men and women aged 53 to 94 years.
Results
For education, income, and occupation (women), those in the lowest SES group had statistically larger age-sex-adjusted IMT than those in the highest SES group (<12 vs. >12 years education: 0.92 vs. 0.86 mm respectively, P<0.0001), (<$10,000 vs. >$45,000: 0.97 vs. 0.87 mm, P<0.0001), (operator/fabricator/labor vs. manager/professional: 0.89 vs. 0.82 mm, P<0.001). Associations were similar using carotid plaque as the outcome. Participants with low levels of both adult and childhood SES measures had age-sex-adjusted IMT greater than those with persistently high levels of SES (0.93 vs. 0.84 mm, P<0.0001).
Conclusions
Measures of SES at two points in the life-span were associated with subclinical atherosclerosis.
doi:10.1016/j.ypmed.2010.12.009
PMCID: PMC3062713  PMID: 21195728
Socioeconomic Status; Intima-media Thickness; Atherosclerosis; Carotid Artery plaque; Cardiovascular disease; Life-course epidemiology
21.  Markers of inflammation predict the long-term risk of developing chronic kidney disease: a population-based cohort study 
Kidney International  2011;80(11):1231-1238.
In animal models, inflammatory processes have been shown to have an important role in the development of kidney disease. In humans, however, the independent relation between markers of inflammation and the risk of chronic kidney disease (CKD) is not known. To clarify this, we examined the relationship of several inflammatory biomarker levels (high-sensitivity C-reactive protein, tumor necrosis factor-α receptor 2, white blood cell count, and interleukin-6) with the risk of developing CKD in a population-based cohort of up to 4926 patients with 15 years of follow-up. In cross-sectional analyses, we found that all these inflammation markers were positively associated with the outcome of interest, prevalent CKD. However, in longitudinal analyses examining the risk of developing incident CKD among those who were CKD-free at baseline, only tumor necrosis factor-α receptor 2, white blood cell count, and interleukin-6 levels (hazard ratios comparing highest with the lowest tertile of 2.10, 1.90, and 1.45, respectively), and not C-reactive protein (hazard ratio 1.09), were positively associated with incident CKD. Thus, elevations of most markers of inflammation predict the risk of developing CKD. Each marker should be independently verified.
doi:10.1038/ki.2011.283
PMCID: PMC3260339  PMID: 21866089
chronic kidney disease; CRP; inflammation; tumor necrosis factor-alpha
22.  Impact of jail sanctions during drug court participation upon substance abuse treatment completion 
Addiction (Abingdon, England)  2011;106(1):135-142.
Aims
This study of participants in a U.S. drug treatment court describes the relationship between the imposition of short-term jail sanctions and substance abuse treatment drop-out, and examines offender characteristics moderating or modifying the impact of jail sanctions on treatment drop-out.
Methods
Data were derived from administrative information collected by the Dane County Wisconsin Drug Treatment Court from 1996–2004 on all 573 participants achieving a final disposition of treatment completion or failure during those program years. Iterative Cox proportional hazards models of time to treatment failure were created; jail sanctions during drug court participation were framed as time-dependent co-variates. A theoretical framework and specific statistical criteria guided construction of a final parsimonious model of time to treatment drop-out.
Findings
Treatment failure was associated with unemployment [hazard ratio (HR) in unemployed vs. employed = 1.41, p-value 0.0079], lower educational attainment (HR in high school non-graduate vs. graduate = 1.41, p = 0.02), and application of the first jail sanction (HR 2.71, p < 0.0001). The association between treatment failure and a first sanction was considerably stronger for sanctions administered earlier in participation (HR for sanction 1 at < 30 days 11.34, p-value 0.0002).
Conclusions
An initial jail sanction for non-adherence may be more likely to foster treatment compliance in less refractory individuals (i.e. those not already acclimated or socialized to incarceration or other corrections interventions). More stringent supervisory conditions and individualized services may be required to reintegrate such offenders and promote longer term public safety.
doi:10.1111/j.1360-0443.2010.03102.x
PMCID: PMC3057754  PMID: 21143687
23.  Effects of Sleep-disordered Breathing on Cerebrovascular Regulation 
Rationale: Cerebrovascular regulation is impaired in patients with moderate to severe obstructive sleep apnea; however, it is unknown whether this impairment exists in individuals with less severe sleep-disordered breathing.
Objectives: To test the hypothesis that cerebrovascular responses to hypercapnia are attenuated in a nonclinical population-based cohort.
Methods: A rebreathing test that raised end-tidal CO2 tension by 10 mm Hg was performed during wakefulness in 373 participants of the Wisconsin Sleep Cohort.
Measurements and Main Results: We measured cerebral flow velocity (transcranial Doppler ultrasound); heart rate (electrocardiogram); blood pressure (photoplethysmograph); ventilation (pneumotachograph); and end-tidal CO2 (expired gas analysis). Cerebrovascular CO2 responsiveness was quantified as the slope of the linear relationship between flow velocity and end-tidal CO2 during rebreathing. Linear regression analysis was performed using cerebrovascular CO2 responsiveness as the outcome variable. Main independent variables were the apnea–hypopnea index and the mean level of arterial oxygen saturation during sleep. We observed a positive correlation between cerebrovascular CO2 responsiveness and the mean level of oxygen saturation during sleep that was statistically significant in unadjusted analysis and after adjustment for known confounders and the increase in arterial pressure during rebreathing. Each 5% decrease in SaO2 during sleep predicted a decrease in cerebrovascular reactivity of 0.4 ± 0.2 cm/second/mm Hg PETCO2. In contrast, the negative correlation between cerebrovascular CO2 responsiveness and apnea–hypopnea index was statistically significant only in the unadjusted analysis.
Conclusions: Hypercapnic vasodilation in the cerebral circulation is blunted in individuals with sleep-disordered breathing. This impairment is correlated with hypoxemia during sleep.
doi:10.1164/rccm.201002-0313OC
PMCID: PMC3029932  PMID: 20639438
sleep apnea syndromes; cerebrovascular circulation; blood flow velocity; hypercapnia; endothelial function
24.  Obesity and Depression Symptoms in the Beaver Dam Offspring Study Population 
Depression and anxiety  2010;27(9):846-851.
Background
Depression and obesity are both important public health problems. However, it is not clear whether obesity contributes to depression. Our study aims to evaluate the association between obesity and possible depression.
Methods
During the Beaver Dam Offspring Study (BOSS) examination, participants’ body weight and height were measured with a Detecto 758C digital scale with height bar, and depression symptoms were measured with the Center for Epidemiological Studies-Depression Scale (CES-D). Other relevant information (such as demographic factors, lifestyle factors, comorbidities and use of anti-depressants) was also collected during the examination. There were 2641 participants included in the analyses.
Results
Obesity was associated with possible depression measured by CES-D scale (OR =1.6, 95% CI: 1.3–2.0) after controlling for age and gender. The association remained similar after further adjustments. Obesity was significantly associated with all four domains measured by CES-D scale after controlling for age and sex, with the largest effect on “Somatic complaints” domain (beta 0.15, 95% CI: 0.0836–0.223). The association with “Interpersonal difficulties” was not significant after further adjustments.
Conclusions
Obesity was associated with a higher risk of possible depression, and had different influences on specific domains of depression symptoms measured by CES-D scale. These findings suggest the need for longitudinal studies on the effects of obesity on specific depression symptoms.
doi:10.1002/da.20666
PMCID: PMC2891299  PMID: 20112247
obesity; depression; epidemiology
25.  The Prevalence of Age-Related Macular Degeneration and Associated Risk Factors: The Beaver Dam Offspring Study 
Archives of ophthalmology  2010;128(6):750-758.
Objective
To determine the prevalence of age-related macular degeneration (AMD) and examine relationships of retinal drusen, retinal pigmentary abnormalities and early AMD to age, sex and other risk factors in 2810 people 21-84 years of age, participating in the Beaver Dam Offspring Study (BOSS).
Methods
The presence and severity of various characteristics of drusen and other lesions typical of AMD were determined by grading digital color fundus images using the Wisconsin Age-Related Maculopathy Grading System.
Results
Early AMD was present in 3.4% of the cohort and varied from 2.4% in those 21-34 years of age to 9.8% in those 65 years of age or older. In a multivariable model (expressed as Odds Ratio [OR]; 95% Confidence Interval [CI]), age (1.22 per 5 years of age; 1.09, 1.36), being male (1.65; 1.01, 2.69), more pack years smoked (1 to 10 vs 0, 1.31; 0.75, 2.29; 11+ vs 0, 1.67; 1.03, 2.73), higher serum HDL cholesterol (per 5 mg/dL 0.91; 0.83, 0.998), and hearing impairment (2.28; 1.41, 3.71) were associated with early AMD. There were no associations of blood pressure level, body mass index, physical activity, history of heavy drinking, white blood cell count, hematocrit, platelet count, serum total cholesterol, or carotid intimal-medial thickness with early AMD.
Conclusion
These data indicate that early AMD is infrequent before age 55 years but increases with age thereafter. Early AMD is related to modifiable risk factors, e.g., smoking and serum HDL cholesterol.
doi:10.1001/archophthalmol.2010.92
PMCID: PMC2896217  PMID: 20547953
age-related macular degeneration; prevalence; risk factors

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