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1.  Emotion Suppression and Mortality Risk Over a 12-Year Follow-up 
Journal of psychosomatic research  2013;75(4):381-385.
Objective
Suppression of emotion has long been suspected to have a role in health, but empirical work has yielded mixed findings. We examined the association between emotion suppression and all-cause, cardiovascular, and cancer mortality over 12 years of follow-up in a nationally representative US sample.
Methods
We used the 2008 General Social Survey-National Death Index (NDI) cohort, which included an emotion suppression scale administered to 729 people in 1996. Prospective mortality follow up between 1996 and 2008 of 111 deaths (37 by cardiovascular disease, 34 by cancer) was evaluated using Cox proportional hazards models adjusted for age, gender, education, and minority race/ethnicity.
Results
The 75th vs. 25th percentile on the emotional suppression score was associated with hazard ratio (HR) of 1.35 (95% Confidence Interval [95% CI] = 1.00, 1.82; p = .049) for all-cause mortality. For cancer and cardiovascular disease mortality, the HRs were 1.70 (95% CI = 1.01, 2.88, p = 0.049) and 1.47 (95% CI = .87, 2.47, p = 0.148) respectively.
Conclusions
Emotion suppression may convey risk for earlier death, including death from cancer. Further work is needed to better understand the biopsychosocial mechanisms for this risk, as well as the nature of associations between suppression and different forms of mortality.
doi:10.1016/j.jpsychores.2013.07.014
PMCID: PMC3939772  PMID: 24119947
Emotion; Suppression; All-cause mortality; Cancer mortality; Cardiovascular disease mortality; General Social Survey
2.  Do the psychosocial risks associated with television viewing increase mortality? Evidence from the 2008 General Social Survey-National Death Index Dataset 
Annals of epidemiology  2013;23(6):355-360.
Background
Television viewing is associated with an increased risk of mortality, which could be caused by a sedentary lifestyle, the content of television programming (e.g., cigarette product placement or stress-inducing content), or both.
Methods
We examined the relationship between self-reported hours of television viewing and mortality risk over 30 years in a representative sample of the American adult population using the 2008 General Social Survey-National Death Index dataset. We also explored the intervening variable effect of various emotional states (e.g., happiness) and beliefs (e.g., trust in government) of the relationship between television viewing and mortality.
Results
We find that for each additional hour of viewing, mortality risks increased 4%. Given the mean duration of television viewing in our sample, this amounted to about 1.2 years of life expectancy in the US. This association was tempered by a number of potential psychosocial mediators, including self-reported measures of happiness, social capital, or confidence in institutions. While none of these were clinically significant, the combined mediation power was statistically significant (p < 0.001).
Conclusions
Television viewing among healthy adults is correlated with premature mortality in a nationally-representative sample of US adults, and this association may be partially mediated by programming content related to beliefs or affective states. However, this mediation effect is the result of many small changes in psychosocial states rather than large effects from a few factors.
doi:10.1016/j.annepidem.2013.03.014
PMCID: PMC3662979  PMID: 23683712
3.  When Overweight Is the Normal Weight: An Examination of Obesity Using a Social Media Internet Database 
PLoS ONE  2013;8(9):e73479.
Using a large social media database, Yahoo Answers, we explored postings to an online forum in which posters asked whether their height and weight qualify themselves as “skinny,” “thin,” “fat,” or “obese” over time and across forum topics. We used these data to better understand whether a higher-than-average body mass index (BMI) in one’s county might, in some ways, be protective for one’s mental and physical health. For instance, we explored whether higher proportions of obese people in one’s county predicts lower levels of bullying or “am I fat?” questions from those with a normal BMI relative to his/her actual BMI. Most women asking whether they were themselves fat/obese were not actually fat/obese. Both men and women who were actually overweight/obese were significantly more likely in the future to ask for advice about bullying than thinner individuals. Moreover, as mean county-level BMI increased, bullying decreased and then increased again (in a U-shape curve). Regardless of where they lived, posters who asked “am I fat?” who had a BMI in the healthy range were more likely than other posters to subsequently post on health problems, but the proportions of such posters also declined greatly as county-level BMI increased. Our findings suggest that obese people residing in counties with higher levels of BMI may have better physical and mental health than obese people living in counties with lower levels of BMI by some measures, but these improvements are modest.
doi:10.1371/journal.pone.0073479
PMCID: PMC3776815  PMID: 24058478
4.  Racial Disparities in Quality-Adjusted Life-Years Associated With Diabetes and Visual Impairment 
Diabetes Care  2012;35(8):1692-1694.
OBJECTIVE
Compare differences in health-related quality of life among blacks and whites to examine if race, diabetes, and visual impairment (VI) present a triple disadvantage in terms of quality-adjusted life expectancy.
RESEARCH DESIGN AND METHODS
Data were analyzed from the 2000–2003 Medical Expenditure Panel Survey, a nationally representative survey that contains the EuroQol 5D (EQ-5D). The EQ-5D generates health utility values that provide a measure of the morbidity associated with various health states, such as having moderate or severe problems with mobility. The EQ-5D score can be linked with life expectancy data to calculate quality-adjusted life-years (QALYs), the number of years of optimal health an individual is expected to live. Multivariate analyses were conducted to estimate and compare differences in QALYs by diabetes status, VI status, and race.
RESULTS
Whites had a higher quality-adjusted life expectancy across all diabetes/VI comparisons. Overall, blacks with diabetes and VI had the fewest number of QALYs remaining (19.6 years), and whites with no impairment had the greatest number of QALYs remaining (31.6 years). Blacks with diabetes only had 1.7 fewer years of optimal health (fewer QALYs) than whites with diabetes. Within individuals with both diabetes and VI, however, this gap more than doubled, with blacks experiencing 3.5 fewer QALYs than whites.
CONCLUSIONS
Although efforts to target and reduce racial health disparities associated with diabetes appear to be effective, black communities may be contributing to a greater overall burden of illness given poorer infrastructure and less accommodation for disabilities such as VI.
doi:10.2337/dc11-2433
PMCID: PMC3402250  PMID: 22751960
5.  Gender Differences in Material, Psychological, and Social Domains of the Income Gradient in Mortality: Implications for Policy 
PLoS ONE  2013;8(3):e59191.
We set out to examine the material, psychological, and sociological pathways mediating the income gradient in health and mortality. We used the 2008 General Social Survey-National Death Index dataset (N = 26,870), which contains three decades of social survey data in the US linked to thirty years of mortality follow-up. We grouped a large number of variables into 3 domains: material, psychological, and sociological using factor analysis. We then employed discrete-time hazard models to examine the extent to which these three domains mediated the income-mortality association among men and women. Overall, the gradient was weaker for females than for males. While psychological and material factors explained mortality hazards among females, hazards among males were explained only by social capital. Poor health significantly predicted both income and mortality, particularly among females, suggesting a strong role for reverse causation. We also find that many traditional associations between income and mortality are absent in this dataset, such as perceived social status.
doi:10.1371/journal.pone.0059191
PMCID: PMC3604107  PMID: 23527129
6.  The general social survey-national death index: an innovative new dataset for the social sciences 
BMC Research Notes  2011;4:385.
Background
Social epidemiology seeks in part to understand how social factors--ideas, beliefs, attitudes, actions, and social connections--influence health. However, national health datasets have not kept up with the evolving needs of this cutting-edge area in public health. Sociological datasets that do contain such information, in turn, provide limited health information.
Findings
Our team has prospectively linked three decades of General Social Survey data to mortality information through 2008 via the National Death Index. In this paper, we describe the sample, the core elements of the dataset, and analytical considerations.
Conclusions
The General Social Survey-National Death Index (GSS-NDI), to be released publicly in October 2011, will help shape the future of social epidemiology and other frontier areas of public health research.
doi:10.1186/1756-0500-4-385
PMCID: PMC3199263  PMID: 21978529
7.  The Impact of Socioeconomic Status on the Neural Substrates Associated with Pleasure 
Low socio-economic status (SES) is associated with increased morbidity and premature mortality. Because tonic adversity relates to a diminished ability to experience pleasure, we hypothesized that subjects living in poverty would show diminished neural responsivity to positive stimuli in regions associated with positive experience and reward. Visual images were presented to twenty-two subjects in the context of a EPI-BOLD fMRI paradigm. Significant differences in neural responses between SES groups to poverty vs. neutral images were assessed, examining group, condition, and interaction effects. The data suggest that persons living in low-SES have neural experiences consistent with diminished interest in things generally enjoyed and point toward a possible explanation for the relationship between socioeconomic inequalities and mood disorders, such as depression, by SES.
doi:10.2174/1874440000903010058
PMCID: PMC2731107  PMID: 19718457
fMRI; depression; mood; stress; socio-economic status.
8.  The body politic: the relationship between stigma and obesity-associated disease 
BMC Public Health  2008;8:128.
Background
It is commonly believed that the pathophysiology of obesity arises from adiposity. In this paper, I forward a complementary explanation; this pathophysiology arises not from adiposity alone, but also from the psychological stress induced by the social stigma associated with being obese.
Methods
In this study, I pursue novel lines of evidence to explore the possibility that obesity-associated stigma produces obesity-associated medical conditions. I also entertain alternative hypotheses that might explain the observed relationships.
Results
I forward four lines of evidence supporting the hypothesis that psychological stress plays a role in the adiposity-health association. First, body mass index (BMI) is a strong predictor of serological biomarkers of stress. Second, obesity and stress are linked to the same diseases. Third, body norms appear to be strong determinants of morbidity and mortality among obese persons; obese whites and women – the two groups most affected by weight-related stigma in surveys – disproportionately suffer from excess mortality. Finally, statistical models suggest that the desire to lose weight is an important driver of weight-related morbidity when BMI is held constant.
Conclusion
Obese persons experience a high degree of stress, and this stress plausibly explains a portion of the BMI-health association. Thus, the obesity epidemic may, in part, be driven by social constructs surrounding body image norms.
doi:10.1186/1471-2458-8-128
PMCID: PMC2386473  PMID: 18426601
9.  Is expanding Medicare coverage cost-effective? 
Background
Proposals to expand Medicare coverage tend to be expensive, but the value of services purchased is not known. This study evaluates the efficiency of the average private supplemental insurance plan for Medicare recipients.
Methods
Data from the National Health Interview Survey, the National Death Index, and the Medical Expenditure Panel Survey were analyzed to estimate the costs, changes in life expectancy, and health-related quality of life gains associated with providing private supplemental insurance coverage for Medicare beneficiaries. Model inputs included socio-demographic, health, and health behavior characteristics.
Parameter estimates from regression models were used to predict quality-adjusted life years (QALYs) and costs associated with private supplemental insurance relative to Medicare only. Markov decision analysis modeling was then employed to calculate incremental cost-effectiveness ratios.
Results
Medicare supplemental insurance is associated with increased health care utilization, but the additional costs associated with this utilization are offset by gains in quality-adjusted life expectancy. The incremental cost-effectiveness of private supplemental insurance is approximately $24,000 per QALY gained relative to Medicare alone.
Conclusion
Supplemental insurance for Medicare beneficiaries is a good value, with an incremental cost-effectiveness ratio comparable to medical interventions commonly deemed worthwhile.
doi:10.1186/1472-6963-5-23
PMCID: PMC1079833  PMID: 15766380
10.  Managing Febrile Respiratory Illnesses during a Hypothetical SARS Outbreak 
Emerging Infectious Diseases  2005;11(2):191-200.
Optimal management of febrile respiratory illnesses during a hypothetical SARS outbreak varies depending on a number of conditions, but increasing influenza vaccination rates would save money and lives.
Since the World Health Organization declared the global outbreak of severe acute respiratory syndrome (SARS) contained in July 2003, new cases have periodically reemerged in Asia. This situation has placed hospitals and health officials worldwide on heightened alert. In a future outbreak, rapidly and accurately distinguishing SARS from other common febrile respiratory illnesses (FRIs) could be difficult. We constructed a decision-analysis model to identify the most efficient strategies for managing undifferentiated FRIs within a hypothetical SARS outbreak in New York City during the season of respiratory infections. If establishing reliable epidemiologic links were not possible, societal costs would exceed $2.0 billion per month. SARS testing with existing polymerase chain reaction assays would have harmful public health and economic consequences if SARS made up <0.1% of circulating FRIs. Increasing influenza vaccination rates among the general population before the onset of respiratory season would save both money and lives.
doi:10.3201/eid1102.040524
PMCID: PMC3320437  PMID: 15752435
Severe Acute Respiratory Syndrome; Influenza-Like-Illness; Influenza Vaccination; Mass Screening; Cost-Benefit Analysis; Human; perspective
11.  Hospitalization for heart disease, stroke, and diabetes mellitus among Indian-born persons: a small area analysis 
Background
We set out to describe the risk of hospitalization from heart disease, stroke, and diabetes among persons born in India, all foreign-born persons, and U.S.-born persons residing in New York City.
Methods
We examined billing records of 1,083,817 persons hospitalized in New York City during the year 2000. The zip code of each patient's residence was linked to corresponding data from the 2000 U.S. Census to obtain covariates not present in the billing records. Using logistic models, we evaluated the risk of hospitalization for heart disease, stroke and diabetes by country of origin.
Results
After controlling for covariates, Indian-born persons are at similar risk of hospitalization for heart disease (RR = 1.02, 95% confidence interval 1.02, 1.03), stroke (RR = 1.00, 95% confidence interval, 0.99, 1.01), and diabetes mellitus (RR = 0.96 95% confidence interval 0.94, 0.97) as native-born persons. However, Indian-born persons are more likely to be hospitalized for these diseases than other foreign-born persons. For instance, the risk of hospitalization for heart disease among foreign-born persons is 0.70 (95% confidence interval 0.67, 0.72) and the risk of hospitalization for diabetes is 0.39 (95% confidence interval 0.37, 0.42) relative to native-born persons.
Conclusions
South Asians have considerably lower rates of hospitalization in New York than reported in countries with national health systems. Access may play a role. Clinicians working in immigrant settings should nonetheless maintain a higher vigilance for these conditions among Indian-born persons than among other foreign-born populations.
doi:10.1186/1471-2261-4-19
PMCID: PMC529471  PMID: 15509299

Results 1-11 (11)