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To examine the associations between insulin resistance and changes in body composition in older men without diabetes mellitus.Longitudinal cohort study of older men participating in the Osteoporotic Fractures in Men (MrOS) study.Six U.S. clinical centers.Three thousand one hundred thirty-two ambulatory men aged 65 and older at baseline.Baseline insulin resistance was calculated for men without diabetes mellitus using the homeostasis model assessment of insulin resistance (HOMA-IR). Total lean, appendicular lean, total fat, and truncal fat mass were measured using dual energy X-ray absorptiometry scans at baseline and 4.6 ± 0.3 years later in 3,132 men with HOMA-IR measurements.There was greater loss of weight, total lean mass, and appendicular lean mass and less gain in total fat mass and truncal fat mass with increasing quartiles of HOMA-IR (P.001 for trend). Insulin-resistant men in the highest quartile had higher odds of 5% or more loss of weight (odds ratio (OR)=1.88, 95% confidence interval (CI)=1.46-2.43), total lean mass (OR=2.09, 95% CI=1.60-2.73) and appendicular lean mass (OR=1.57, 95% CI=1.27-1.95) and lower odds of 5% or more gain in total fat mass (OR=0.56, 95% CI=0.45-0.68) and truncal fat mass (OR=0.52, 95% CI=0.42-0.64) than those in the lowest quartile. These findings remained significant after accounting for age, site, baseline weight, physical activity, and change in physical activity. These associations were also independent of other metabolic syndrome features and medications.Greater lean mass loss and lower fat mass gain occurred in insulin-resistant men without diabetes mellitus than in insulin-sensitive men. Insulin resistance may accelerate age-related sarcopenia.

We examined neighborhood socioeconomic status (NSES) in relation to depressive symptoms, perceived stress, and hostility in 5770 community-dwelling older black and white adults (mean age=73 years; 62% female) from 3 contiguous neighborhoods covering 82 census block groups in Chicago, IL. NSES was an average of z-scores of four Census 2000 block-group variables: % public assistance, % households earning$25,000 annually, % withcollege degree, and % owner-occupied dwellings valued$200,000. NSES was inversely related to hostility (beta=-0.305), stress (beta=-0.333), and depressive symptoms (beta=-0.223) (p0.001) in multi-level mixed-effects regression models adjusted for age, sex, race, and the number of years in the neighborhood. With further adjustment for education, income, marital status, and health conditions, NSES remained associated with depressive symptoms (beta=-0.078) and hostility (beta=-0.133) (p0.05); the association with hostility was strongest in non-black neighborhoods. Neighborhood social conditions contribute to the psychosocial well-being of older residents; research is needed to investigate pathways through which neighborhoods influence health outcomes in an aging population.

Evidence has accrued over the past half century clearly documenting the importance of psychosocial factors on health, well-being, and disease risk. This evidence has accumulated through the scientific contributions of multiple disciplines using a variety of study designs. The goal of this chapter is to present pertinent information regarding the assessment of psychosocial factors in population-based studies and therefore our focus is on epidemiologic studies and methods. We present a brief historical overview of the primary lines of evidence that have contributed to our understanding of the impact of psychosocial factors on health outcomes, followed by the rationale for choosing psychosocial factors for inclusion in population-based research. We then discuss frequently used methods of assessment, including associated strengths and challenges, and report on widely used interview and self-report questionnaire measures of psychosocial factors to guide readers in selecting appropriate measures for their studies. We conclude by noting important issues for future work.

The purpose of our study was to determine whether self-reported physical activity (PA), including recreational, household, and exercise activities, is associated with intra-abdominal fat (IAF) in community-dwelling white and black midlife women. We performed a cross-sectional study of 369 women from the Chicago site of the Study of Women's Health Across the Nation (SWAN) ancillary study, the SWAN Fat Patterning Study. PA level was the independent variable, and IAF, assessed by computerized tomography (CT) scan, was the dependent variable. Measures were obtained at SWAN Fat Patterning Baseline visit between August 2002 and December 2005. Linear regression models explored the association between PA and IAF. The first model included IAF as the outcome and total score PA as the main predictor, adjusting for total percent fat mass, age, and ethnicity. The second model included education, parity, sex hormone-binding globulin (SHBG) level, and depressive symptoms, measured by Center for Epidemiological Studies-Depression (CES-D) scale. Each 1-point higher total PA score was associated with a 4.0 cm(2) lower amount of IAF (P = 0.004), independent of total percent fat mass, age, ethnicity, SHBG level, educational level, CES-D, and parity. Associations did not differ between white and black women. This study demonstrates a significant negative association between PA and IAF independent of multiple covariates in midlife women. Our findings suggest that motivating white and black women to increase PA during midlife may lessen IAF, which may have a positive impact on subsequent development of diabetes and cardiovascular disease.

Background and Purpose— Depression and hopelessness are associated with increased cardiovascular disease (CVD) morbidity and mortality; however, few studies have compared these constructs early in the atherogenic process, particularly in women or minorities. Methods— This cross-sectional study examined associations of hopelessness and depressive symptoms with carotid artery intimal-medial thickening (IMT) in 559 women (62% white, 38% black; mean±SD age, 50.2±2.8 years) without evidence of clinical CVD from the Study of Women’s Health Across the Nation (SWAN) Heart Study. Hopelessness was measured by 2 questionnaire items; depressive symptoms were measured with the 20-item Center for Epidemiological Studies Depression Scale. Mean and maximum IMT were assessed by B-mode ultrasonography of the carotid arteries. Results— Increasing hopelessness was significantly related to higher mean ( P =0.0139) and maximum ( P =0.0297) IMT in regression models adjusted for age, race, site, income, and CVD risk factors. A weaker pattern of associations was noted for depressive symptoms and mean ( P =0.1056) and maximum ( P =0.0691) IMT. Modeled simultaneously in a risk factor-adjusted model, hopelessness was related to greater mean IMT ( P =0.0217) and maximum IMT ( P =0.0409), but depressive symptoms were unrelated to either outcome ( P >0.4). No interactions with race or synergistic effects of depressive symptoms and hopelessness were observed. Conclusions— Among middle-aged women, higher levels of hopelessness are associated with greater subclinical atherosclerosis independent of age, race, income, CVD risk factors, and depressive symptoms.

OBJECTIVE To examine the cross-sectional association between hostility and measures of abdominal fat (visceral, subcutaneous) in middle-aged African American and white women. Because fat-patterning characteristics are known to differ by race, we were particularly interested in examining whether these associations were similar for women of both racial/ethnic groups. METHODS Participants were 418 (45% African American, 55% white) middle-aged women from the Chicago site of the Study of Women's Health Across the Nation. Visceral and subcutaneous fat were measured by computed tomographic scans and hostility was assessed via questionnaire. Multivariate linear regression models were conducted to test associations among race/ethnicity, hostility, and measures of abdominal fat. RESULTS In models adjusted for race/ethnicity and total percent fat, higher levels of hostility were associated with a greater amount of visceral fat (B = 1.8, standard error = 0.69, p = .01). This association remained significant after further adjustments for education, and multiple coronary heart disease (CHD) risk factors. Hostility was not associated with subcutaneous fat (p = .8). Although there were significant racial/ethnic differences in hostility (p < .001) and the amount of total body (p < .001), subcutaneous (p < .001) and visceral fat (p < .001), the associations between hostility and measures of abdominal fat did not differ for African American compared with white women (race/ethnicity x hostility interaction, p = .67 for visceral, p = .85 for subcutaneous). CONCLUSIONS Hostility may affect CHD risk in women via the accumulation of visceral fat. Despite significant black-white differences in fat patterning and overall CHD risk, the association between hostility and visceral fat seems to be similar for both African American and white women.

Depression is associated with an increased risk of mortality and recurrent morbidity in patients with coronary heart disease (CHD) and depression may increase the risk of the initial onset of CHD in healthy populations (Rozanski et al., 1999; Suls and Bunde, 2005; Wulsin and Singal, 2003). In reporting the findings from these studies, the standard risk factors for CHD are statistically controlled for, and therefore do not preclude alternative risk factors or other intermediate pathways as explanatory factors or mediators in the associations between depression and CHD. Among the potential pathways that may be relevant to understanding depression's risk for CHD morbidity and mortality is chronic inflammation (Carney et al., 1995), which is thought to be important throughout the natural history of coronary atherosclerosis from the initial defect in endothelial function through plaque rupture (Ross, 1999). A marker of chronic inflammation that is a strong predictor of clinical coronary events is C-reactive protein (CRP) (Pearson et al., 2003). A recent meta-analysis of 51 cross-sectional studies, published between 1967 and 2008, found that depression was associated concurrently with CRP levels (Howren et al., 2009). Subanalyses showed that (a) the relationship was significant in men but not in women in those studies that stratified by gender; (b) the effect was larger in clinic-based as opposed to community-based samples; and (c) the studies that did not adjust for body mass index (BMI) reported associations three times larger than those studies that did adjust for BMI. That obesity might also moderate the association between depression and some inflammatory markers was not examined in the meta-analysis. However, in men enrolled in MONICA (Ladwig et al., 2003), depression and anxiety were related to CRP but only among those who were obese, suggesting stratification by obesity status may be informative. In summary, depression is a reliable correlate of CRP levels, with weaker associations apparent in women, in community samples, and in analyses that consider BMI. Recently it has been suggested that inflammation can produce symptoms resembling those of depression, including anhedonia, vegetative symptoms, and sleeping difficulties (Dantzer et al., 2009; Raison et al., 2006). Patients treated with interferon, which induces inflammation, develop depressive symptoms that can be ameliorated by antidepressants (Capuron et al., 2002). In experimental studies of healthy participants, endotoxin administration leads to short-term increases in anxiety, depressed mood, and poor memory performance (Reichenberg et al., 2001). These findings suggest that inflammation may not only be a consequence of depressive symptoms but also contribute to its presentation. In the present report, we addressed the bi-directional and temporal relation of depressive symptoms and CRP levels across 7 years among women enrolled in the Study of Women's Health Across the Nation (SWAN). Specifically, we addressed two questions: Are women with higher depressive symptoms likely to have higher CRP levels at the next annual visit, adjusted for the CRP levels at the prior visit? And, are women with higher CRP levels likely to have higher depressive symptoms at the next annual visit, adjusted for depressive symptom levels at the prior visit? Secondarily, we explore the role of obesity in understanding any observed relationships because obesity is a strong correlate of CRP.

Background:This study was done to determine whether physical activity at baseline is independently associated with musculoskeletal pain and fulfilling one’s physical role over 3 subsequent years.Methods:Our research involved a 3-year longitudinal study of over 2400 community-dwelling, midlife women from the Study of Women’s Health Across the Nation (SWAN). Measurements included baseline physical activity using the Kaiser Permanente Health Plan Activity Survey and SF-36 role-physical and bodily pain indices at each of 3 annual follow-up visits.Results:Each 1-point increase on the physical activity score was associated with a 7% greater likelihood of a high role-physical score (95% CI = 1.02– 1.13) and a 10% greater likelihood of a low bodily pain score (95% CI = 1.04–1.17) after adjusting for age, race, menopausal status, educational level, body mass index, depressive symptoms, smoking, and chronic medical conditions. The association between physical activity level and role-physical score was eliminated in the fully adjusted model after adjustment for pain level in post hoc analysis [OR = 1.04 (95% CI = 0.98–1.09)].Conclusion:This study demonstrates that women who are more physically active at midlife experience less bodily pain over time regardless of menopausal status, sociodemographics, and medical conditions. Higher physical activity level positively impacts fulfilling one’s physical role; however, this is mediated by pain level.

Objective To determine the respective roles of socio-economic status (SES) and ethnicity in the risk of incident metabolic syndrome in middle-aged women. Design and participants A total of 3302 pre- and peri-menopausal women, not receiving hormone therapy at baseline, took part in the Study of Women's Health Across the Nation, a multi-site, community-based, longitudinal study of the menopausal transition. The main outcome measures were to ascertain the prevalence of the metabolic syndrome and the incidence of the metabolic syndrome over 5 years of follow-up. Results At baseline, the prevalence of the metabolic syndrome was 21% (n = 673). Among 2512 women without metabolic syndrome at baseline, 12.8% (n = 321) developed the metabolic syndrome during 5 years of follow-up. Both ethnicity and SES were significant univariate predictors of incident metabolic syndrome. In multivariate logistic regression models that included age at baseline, menopausal status and site, baseline smoking and alcohol consumption at follow-up visit 1, as well as baseline values of each of the components of the metabolic syndrome, only education was an independent predictor of incident metabolic syndrome. Conclusion Approximately 13% of peri-menopausal women developed the metabolic syndrome during the 5-year follow-up period. Education, but not ethnicity, was an independent predictor of incident metabolic syndrome risk.

Background: Studies have reported declines with age in cognitive or physical functioning, but rarely identify whether these are parallel or linked events in the same study. Furthermore, most research in this area has focused on persons in late life rather than midlife. Objective: The objective of the study was to determine (1) if cognitive functioning was related to physical functioning and whether this relationship persisted after adjustment for age, menopause status, metabolic status, depression and socioeconomic resources, and (2) if changes in physical functioning were associated with changes in cognitive functioning over a 4-year follow-up period. Methods: Data were from the Study of Women’s Health Across the Nation (SWAN), a multi-site, longitudinal study of women aged 46–56 years at follow-up examination 4. Three follow-up examinations (study years 04, 06 and 08) included measures of physical functioning perception (MOS SF-36) and cognitive functioning [Symbol Digit Modality Test (SDMT), Digit Span Backward Test (DSBT), and East Boston Memory Test (EBMT)] (n = 2,405). Results: Women with lower cognitive functioning scores also had lower perceived physical functioning scores. While adjustment for covariates attenuated the association between perceived physical functioning and both the SDMT and EBMT cognitive measures, these associations remained statistically significant. Additionally, the 4-year change in perceived physical functioning was significantly associated with the 4-year change in the EBMT. Conclusions: At midlife, there were associated declines in cognitive and perceived physical functioning scores, commencing at midlife in women.

Background— Although evidence suggests adverse vascular changes among women with hot flashes, it is unknown whether hot flashes are associated with subclinical cardiovascular disease. The aim of this study was to examine relations between menopausal hot flashes and indices of subclinical cardiovascular disease. We hypothesized that women with hot flashes would show reduced flow-mediated dilation and greater coronary artery and aortic calcification compared with women without hot flashes. Methods and Results— The Study of Women’s Health Across the Nation Heart Study (2001 to 2003) is an ancillary study to the Study of Women’s Health Across the Nation, a community-based cohort study. Participants were 492 women (35% black, 65% white) 45 to 58 years of age who were free of clinical cardiovascular disease and had a uterus and at least 1 ovary. Measures included a brachial artery ultrasound to assess flow-mediated dilation, electron beam tomography to assess coronary artery and aortic calcification, reported hot flashes (any/none, previous 2 weeks), and a blood sample for measurement of estradiol concentrations. Cross-sectional associations were evaluated with linear regression and partial proportional odds models. Hot flashes were associated with significantly lower flow-mediated dilation (β=−1.01; SE, 0.41; P =0.01) and greater coronary artery (odds ratio, 1.48; 95% confidence interval, 1.04 to 2.12) and aortic (odds ratio, 1.55; 95% confidence interval, 1.10 to 2.19) calcification in age- and race-adjusted models. Significant associations between hot flashes and flow-mediated dilation (β=−0.97; SE, 0.44; P =0.03) and aortic calcification (odds ratio, 1.63; 95% confidence interval, 1.07 to 2.49) remained in models adjusted for cardiovascular disease risk factors and estradiol. Conclusions— Women with hot flashes had reduced flow-mediated dilation and greater aortic calcification. Hot flashes may mark adverse underlying vascular changes among midlife women.

Objective: As associations between endogenous sex hormones and the vasculature are not well characterized, the objective was to examine the cross-sectional associations of menopausal status and endogenous sex hormones with vascular characteristics. Design: Common carotid artery adventitial diameter and intima-media thickness were determined using B-mode ultrasonography among 483 middle-aged women enrolled in the Pittsburgh and Chicago sites of the Study of Women's Health Across the Nation. Results: Sixty-two percent of women were pre- or early perimenopausal (

Objective: Two competing hypotheses suggest how adiposity may affect menopausal hot flashes. The "thin hypothesis" asserts that aromatization of androgens to estrogens in body fat should be associated with decreased hot flashes. Conversely, thermoregulatory models argue that body fat should be associated with increased hot flashes. The study objective was to examine associations between abdominal adiposity and hot flashes, including the role of reproductive hormones in these associations. Design: The Study of Women's Health Across the Nation Heart Study (2001-2003) is an ancillary study to the Study of Women's Health Across the Nation, a community-based cohort study. Participants were 461 women (35% African American, 65% white) ages 45 to 58 years with an intact uterus and at least one ovary. Measures included a computed tomography scan to assess abdominal adiposity; reported hot flashes over the previous 2 weeks; and a blood sample for measurement of follicle-stimulating hormone, estradiol, and sex hormone-binding globulin-adjusted estradiol (free estradiol index). Associations were evaluated within multivariable logistic and linear regression models. Results: Every 1-SD increase in total (odds ratio [OR] = 1.28; 95% CI: 1.06-1.55) and subcutaneous (OR = 1.30; 95% CI: 1.07-1.58) abdominal adiposity was associated with increased odds of hot flashes in age- and site-adjusted models. Visceral adiposity was not associated with hot flashes. Associations were not reduced when models included reproductive hormone concentrations. Conclusion: Increased abdominal adiposity, particularly subcutaneous adiposity, is associated with increased odds of hot flashes, favoring thermoregulatory models of hot flashes. Body fat may not protect women from hot flashes as once thought.

The influence of menopausal status on depressive symptoms is unclear in diverse ethnic groups. This study examined the longitudinal relationship between changes in menopausal status and the risk of clinically relevant depressive symptoms and whether the relationship differed according to initial depressive symptom level.3302 African American, Chinese, Hispanic, Japanese, and White women, aged 42-52 years at entry into the Study of Women's Health Across the Nation (SWAN), a community-based, multisite longitudinal observational study, were evaluated annually from 1995 through 2002. Random effects multiple logistic regression analyses were used to determine the relationship between menopausal status and prevalence of low and high depressive symptom scores (CES-D16 oror =16) over 5 years.At baseline, 23% of the sample had elevated CES-D scores. A woman was more likely to report CES-Dor =16 when she was early peri-, late peri-, postmenopausal or currently/formerly using hormone therapy (HT), relative to when she was premenopausal (OR range 1.30 to 1.71). Effects were somewhat stronger for women with low CES-D scores at baseline. Health and psychosocial factors increased the odds of having a high CES-D and in some cases, were more important than menopausal status.We used a measure of current depressive symptoms rather than a diagnosis of clinical depression. Thus, we can only make conclusions about symptoms current at annual assessments.Most midlife women do not experience high depressive symptoms. Those that do are more likely to experience high depressive symptom levels when perimenopausal or postmenopausal than when premenopausal, independent of factors such as difficulty paying for basics, negative attitudes, poor perceived health, and stressful events.

Socioeconomic position (SEP) has been shown to be related to obesity and weight gain, especially among women. It is unclear how different measures of socioeconomic position may impact weight gain over long periods of time, and whether the effect of different measures vary by gender and age group. We examined the effect of childhood socioeconomic position, education, occupation, and log household income on a measure of weight gain using individual growth mixed regression models and Alameda County Study data collected over thirty four years(1965-1999).Analyses were performed in four groups stratified by gender and age at baseline: women, 17-30 years (n = 945) and 31-40 years (n = 712); men, 17-30 years (n = 766) and 31-40 years (n = 608).Low childhood SEP was associated with increased weight gain among women 17-30 (0.13 kg/year, p0.001). Low educational status was associated with increased weight gain among women 17-30 (0.14 kg/year, p = 0.030), 31-40 (0.14 kg/year, p = 0.014), and men 17-30 (0.20 kg/year, p = 0.001).Log household income was inversely associated with weight gain among men 31-40 (-0.10 kg/yr, p = 0.16). Long-term weight gain in adulthood is associated with childhood SEP and education in women and education and income in men.

Background: Emerging evidence suggests that exposure to discrimination may be associated with atherosclerosis in African-American women, although research in this area focused on short-term rather than chronic exposure to discriminatory events. Methods: We examined the relationship between chronic exposure to multiple types of discrimination (self-reported and averaged over 5 years) and coronary artery calcification (CAC) in a sample of 181 middle-aged African-American women. Discrimination was assessed at each time point, and the presence/absence of CAC was assessed at the fifth annual follow-up examination by electron beam tomography. We hypothesized that chronic discrimination would be more strongly associated with CAC than recent discrimination and that racial/ethnic discrimination would be more strongly associated with CAC than other types of discrimination. Results: Chronic exposure to discrimination was significantly associated with the presence of CAC in unadjusted logistic regression analyses (p = .007) and after adjustment for demographics (p = .01), standard cardiovascular risk factors (p = .02), and Body Mass Index (BMI) (p = .05). In contrast, recent discrimination was only marginally associated with the presence of CAC in both unadjusted (p = .06) and fully adjusted logistic regression models (p = .08). Persistent exposure to racial/ethnic discrimination was not more strongly associated with CAC compared with other types of discrimination in either unadjusted or adjusted models. Conclusion: Chronic exposure to discrimination may be an important risk factor for early coronary calcification in African-American women. This association appears to be driven by exposure to discrimination from multiple sources, rather than exposure to racial/ethnic discrimination alone.

Objectives. We investigated whether race differences in weight gain over 34 years were because of socioeconomic position (SEP) and psychosocial and behavioral factors (physical activity, cigarette smoking, alcohol consumption, depression, marital status, number of children). We used a life-course approach to SEP with 4 measures of SEP (childhood SEP, education, occupation, income) and a cumulative measure of SEP. Methods. We used mixed models and data collected from the Alameda County Study to examine the association between race and weight change slopes and baseline weight in men (n=1186) and women (n=1375) aged 17 to 40 years at baseline (in 1965). Results. All subjects gained weight over time. African American women weighed 4.96 kg (P < .001) more at baseline and gained 0.10 kg/year (P = .043) more weight than White women. Black men weighed 2.41 kg (P= .006) more at baseline but did not gain more weight than White men. The association of race with weight gain in women was largely because of cumulative SEP score. Conclusions. Interventions to prevent overweight and obesity should begin early in life and target the socioeconomically disadvantaged.

Type 2 diabetes mellitus imposes a major public health burden across populations. Over 150 million people suffer from the disease worldwide,1 including more than 18 million in the US.2 In the US, Type 2 diabetes is a major source of morbidity and mortality causing significant medical complications and resulting in over 200 000 deaths annually.2 The prevalence of Type 2 diabetes is strongly patterned by socioeconomic position (SEP). Persons with a lower SEP consistently have a higher prevalence of diabetes and an excess burden of morbidity and mortality compared with persons of greater SEP.3–6 Although diabetes prevalence is rising in the overall population, it is increasing more steeply for people with lower SEP.5 An inverse, graded association between SEP and diabetes prevalence has been found using different measures of SEP, such as education,3,5,7–10 occupation,3,7,10 income,3 poverty income ratio,7 the Green index (composite of education and occupation),11 and ecological measures of material deprivation or poverty.12–15 The social determinants of diabetes incidence are similar to those for prevalent disease. Persons of lower SEP have limited income, poorer occupational opportunity, and reduced access to health care services and information: factors that contribute to both diabetes risk and complications of disease management. However, few studies have examined the impact of socioeconomic factors on diabetes incidence. Limitations of previous research include small sample sizes, short follow-up, and lack of statistical control of covariates.16–24 Little is known about the different pathways through which socioeconomic factors may influence the occurrence of Type 2 diabetes. Many known risk factors, such as excess body weight, large waist circumference, and physical inactivity are patterned by SEP.25–34 Whether or not these factors are components of the causal pathway between SEP and diabetes incidence has not been extensively examined. This study used five waves of data collected over 34 years to examine the relationship between three measures of SEP (education, income, and occupation) and the incidence of Type 2 diabetes in a community sample. Three hypotheses were proposed. First, lower education, lower income, and blue-collar occupation would be significantly associated with an increased risk of developing diabetes; second, time-dependent measures of SEP would impart greater risk than baseline measures; and third, the association between SEP and incident diabetes would be explained by known diabetes risk factors or other factors that are potential components of the causal pathway.

This study examines racial differences in depressive symptoms among older adults over time. The subjects were 4,275 community-dwelling persons aged 65 and older (62% Black) who participated in the Chicago Health and Aging Project (CHAP) during a period of 9 years. Depression was measured using a summary score of the 10-item Center for Epidemiologic Studies-Depression scale (CES-D). We modeled depressive symptoms using the method of General Estimating Equations and a Poisson error structure. We found a significant race effect at baseline with Blacks reporting approximately 60% more symptoms than Whites (beta = 0.467 on the log scale, p < .001). The differences were larger for men than for women. After controlling for age, sex, time, education, income, and related interaction terms, the baseline race effect was reduced by almost half (beta = 0.225, p < .001) but remained robust. The racial differences increased slightly over time. Our findings support heightened awareness of depression in older Black populations.

Overall rates of obesity have increased dramatically in the United States, yet African American women remain disproportionately represented among the overweight and obese. The excess weight observed in African American women is primarily considered a result of low socioeconomic status, but recent cross-sectional findings suggest otherwise.We examined the interactive effects of race and 3 levels of education (low [high school or less]; moderate [some college]; and high [college degree or more]) on body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) and changes in BMI over 4 years in 2019 middle-aged African American and white women from the Study of Women's Health Across the Nation (SWAN). Data were analyzed with mixed effects regression models.At baseline, we observed a significant race x education interaction (estimate, -3.7; 95% confidence interval, -5.3 to -2.1; P.001) on BMI. Compared with whites, African Americans had higher BMIs, but only at the moderate (means, 32.1 and 29.2) and highest (means, 31.5 and 27.8) level of education. At the lowest level of education, African American and white women were similar in BMI (means, 31.1 [African American] and 31.2 [white]). Body mass index increased significantly for all women over follow-up (estimate, 0.22; 95% confidence interval, 0.17 to 0.26; P.001), but increases did not differ by race, education, or race x education. Results were unchanged after adjustment for potential confounding variables.For middle-aged women, racial disparities in BMI are largely patterned by education, with the greatest disparities observed at higher levels of education. The absence of significant longitudinal effects suggests that these race-education patterns are set in place and well established before midlife.

Objective We examined the association between depressive symptoms and all-cause mortality in a population sample. Published findings on the relation between depressive symptoms and mortality risk point to an inconsistent association and one that is likely influenced by health status. Few studies have assessed this relation in randomly selected population samples. Methods Participants were 3617 noninstitutionalized adults, age 25 years or older, from the Americans' Changing Lives Study, an ongoing longitudinal study of a nationally representative sample. Depressive symptoms were measured by the 11-item version of the Center for Epidemiological Studies Depression Scale (CES-D). Cox proportional hazards models estimated the relative risk of mortality as a function of the CES-D scores at baseline. Results In 7.5 years of follow-up, 542 deaths occurred. Each 1-standard unit increase on the CES-D predicted a 21% increased risk of all-cause mortality, adjusting for age, gender, and race (hazard ratio = 1.21, 95% confidence interval = 1.08 to 1.36, p = .001). This association was weakened somewhat following adjustment for education, income, body mass index, smoking and alcohol consumption (hazard ratio = 1.13, 95% confidence interval = 0.99 to 1.28, p = .06). However, control for self-reported functional limitations or chronic health conditions at baseline effectively eliminated the relationship. Analyses limited to participants with good to excellent health or no functional impairments at baseline showed no association between depressive symptoms and subsequent mortality risk. Secondary analyses showed no association between depressive symptoms and cardiovascular mortality. Conclusions These findings from a randomly selected, nationally representative sample do not support the hypothesis that depressive symptoms are independently related to mortality in the general population, after adequate adjustment for the confounding effects of physical health status.

Background— Hemodynamic reactions to mental stress may contribute to atherosclerosis. We previously observed cross-sectional relationships between blood pressure reactions to a standardized stress battery and carotid intima-media thickness (IMT) in the Kuopio Ischemic Heart Disease (KIHD) study. These are the first prospective results on this relationship. Methods and Results— Men from 4 age cohorts (42 to 60 years old at study onset) were challenged with a standardized mental stress battery, and heart rate and blood pressure reactions were assessed. Ultrasound measures of common carotid IMT were collected at this time and 7 years later as noninvasive markers of atherosclerosis. Data were collected from a sample of 756 men at both times. Systolic blood pressure reactions to mental stress at study onset were positively related to mean carotid IMT 7 years later (β=0.035, P =0.001, by blood pressure quartile, IMT=0.91, 0.93, 0.96, 1.00 mm) and to the progression of IMT (β=0.020, P =0.006, by blood pressure quartile, ΔIMT=0.08, 0.09, 0.11, 0.11 mm). Similar significant relations were shown for maximal IMT and plaque height. Diastolic blood pressure responses were less strongly related to carotid IMT than were systolic responses. Heart-rate responses were unrelated. Adjustment for standard risk factors did not substantially reduce the relation between systolic blood pressure reactivity and the progression of mean carotid IMT (standardized β=0.059, P =0.026), maximal carotid IMT (standardized β=0.084, P =0.006), or plaque height (standardized β=0.093, P =0.008). Conclusions— The degree of systolic blood pressure reactivity to mental challenge is prospectively related to carotid IMT in middle-aged and older men, independent of known risk factors.

Early life conditions are related to cognitive development and abilities in childhood and cognitive function in adulthood. However, the association between early life conditions and cognitive change in old age is unknown. The authors examined the relation between socioeconomic position (SEP) and cognitive milieu in childhood and change in cognitive function in a population-based sample of 4,398 community-dwelling adults (62.1% female; 61.7% Black) aged 65 years or older from Chicago, Illinois. Baseline data were collected in 1993-1997. Change in cognitive function was assessed by means of a global cognitive index derived from measures of memory, perceptual speed, and overall cognitive function administered at three in-home assessments between 1993 and 2003, with an average of 5.3 years of follow-up. After results were controlled for age, sex, race, and education, interactions of time with childhood SEP (beta = -0.003, t = -1.0, p = 0.32) and childhood cognitive milieu (beta = -0.0008, t = -0.5, p = 0.62) were nonsignificant, indicating that early life conditions were not related to cognitive change. SEP (beta = 0.034, t = 2.4, p = 0.01) and cognitive milieu (beta = 0.017, t = 2.2, p = 0.03) were associated with absolute level of cognitive function, with better performance being related to higher SEP and a better cognitive milieu. A better SEP and a more stimulating cognitive milieu in childhood have small but significant effects on absolute level of cognitive function; however, they do not seem to protect against cognitive decline in old age.

Background: No longitudinal studies have tracked cognitive performance through the menopausal transition and thus the impact of the transition on cognition, independent of aging, is not known. The authors hypothesized that a decline in cognitive functioning occurs as women progress through the menopausal transition, independent of age, educational level, family income, ethnicity, and baseline self-perceived health. Method: The authors began a population-based, longitudinal study in January 1996 with yearly follow-up interviews. This report includes follow-up through November 2001. The authors randomly selected African American and white women from a census of two contiguous Chicago communities. After screening for eligibility (age 42 to 52 years, premenopausal or early perimenopausal, no exogenous hormone use in the past 3 months, and no hysterectomy), 868 agreed to participate. Women who became pregnant, had a hysterectomy, or began using hormones were censored from that time onward. This study reports on 803 women for whom cognitive assessments were available. The authors assessed working memory (Digit Span Backward) and perceptual speed (Symbol Digit Modalities Test). Results: Contrary to the hypothesis, the authors found small but significant increases over time during the premenopausal and perimenopausal phases. This trend was not accounted for by chronological age, education, family income, ethnicity, or baseline self-perceived health. Conclusions: Transition through menopause is not accompanied by a decline in working memory and perceptual speed.

To the Editor: Weappreciate the interest in our article and the comment of Pizzi et al highlighting that some types of antidepressants may have harmful effects in patients with coronary heart disease. The participants in the SWAN as well as in the substudy SWAN Heart were middle-aged women undergoing the menopausal transition. Because rates of cardiovascular disease (CVD) increase for women in this age group, it is important to find ways to reduce their CVD burden. In this healthy population, we found that depressive symptoms were significantly positively related to progression of coronary artery calcification (CAC), an early marker of CVD, especially heart disease. In a recent review article, statins have been shown to be not effective in lowering CAC scores; therefore, it seems prudent to look for other measures that might benefit women. We had too few women treated with antidepressants to draw any conclusions as to the effects of antidepressant medication on CAC progression so that the issue remains an open research question. Because of the small number, we could not look at subgroups of different types of antidepressantmedications.We agreewith Pizzi et al that a clinical trial remains to be conducted to evaluate the effects of antidepressants, especially selective seratonin reuptake inhibitors in women with any CAC. The Study of Women's Health Across the Nation (SWAN) has grant support from the National Institutes of Health (NIH, DHHS), through the National Institute on Aging (NIA), the National Institute of Nursing Research (NINR) and the NIH Office of Research on Women’s Health (ORWH) (Grants NR004061; AG012505, AG012535, AG012531, AG012539, AG012546, AG012553, AG012554, AG012495). The content of this letter is solely the responsibility of the authors and does not necessarily represent the official views of the NIA, NINR, ORWH or the NIH.

Background Major depression and depressive symptoms are associated with cardiovascular disease (CVD), but the impact of depression on early atherogenesis is less well known, particularly in women and minorities. This study examined whether depressive symptoms are associated with progression of coronary artery calcification (CAC) among women at midlife. Methods The SWAN is a longitudinal, multisite study assessing health and psychologic factors in midlife women. An ancillary study (SWAN Heart) evaluated subclinical atherosclerosis in women who reported no history of CVD or diabetes. In 346 women, CAC was measured twice by electron beam computed tomography, an average of 2.3 years apart. Progression, defined as an increase by ≥10 Agatston units, was analyzed using relative risk (RR) regression. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression (CES-D) Scale. Results Progression of CAC was observed in 67 women (19.1%). Each 1-SD-higher CES-D score at baseline related to a 25% increased risk of CAC progression (RR 1.25, 95% CI 1.06-1.47, P = .007), adjusting for age, time between scans, ethnicity, education, menopausal status, and known CVD risk factors. This risk was similar to the risk induced by body mass index (RR 1.31, 95% CI 1.11-1.54, P = .001) and systolic blood pressure (RR 1.28, 95% CI 1.06-1.55, P = .01). Conclusions Depressive symptoms were independently associated with progression of CAC in this cohort of midlife women. Depressive symptoms may represent a risk factor that is potentially modifiable for early prevention of CVD in women.

Background We analyzed data from a single menstrual cycle from 630 women, aged 43 to 53 years, in the Daily Hormone Study component of the Study of Women’s Health Across the Nation to determine whether hormone levels are associated with trouble sleeping as women enter the menopausal transition. Methods Women recorded whether they had trouble sleeping the previous night. Morning urine specimens were obtained for daily determinations of levels of luteinizing hormone, follicle-stimulating hormone, estradiol metabolites (ie, estrone conjugates), and the progesterone metabolite (pregnanediol glucuronide). Women were categorized as premenopausal or early perimenopausal by bleeding patterns. Results Average adjusted odds of reporting trouble sleeping were 29% higher in perimenopausal than in premenopausal women. The highest percentages of women in both menopausal groups reported trouble sleeping in the beginning or at the end of their cycle. After controlling for covariates, pregnanediol glucuronide level was associated with increased trouble sleeping in perimenopausal women and follicle-stimulating hormone level was associated with increased trouble sleeping in premenopausal women. Mood and vasomotor symptoms were the strongest and most consistent cocontributors to trouble sleeping. Conclusion In this community-based sample of middle-aged women, the most trouble sleeping was observed at the beginning and end of the menstrual cycle.

Pouwer and de Jonge (1) raise two interesting points regarding our findings on depressive symptoms, insulin resistance, and diabetes risk (2). First, they suggest that insulin resistance may increase the risk for depression. This may be a plausible hypothesis, but it is an unlikely explanation for our findings. Participants were excluded from our analyses if they had overt diabetes (fasting blood glucose of ≥126 mg/dl or a self-reported history of diabetes) at the baseline examination. …

Poor sleep may be associated with the cardiovascular disease (CVD) morbidity and mortality. It is less clear if poor sleep is associated with subclinical CVD. We evaluated cross-sectional associations between self-reported sleep disturbance and duration and calcification in the coronary arteries (CAC) and aorta (AC) in healthy mid-life women.512 black and white women enrolled in the SWAN Heart Study, underwent a computed tomography protocol for measurement of CAC and AC and completed questionnaires about their sleep. Linear and partial proportional logit regression analyses adjusted for site, race, age, body mass index, and the Framingham risk score (model 1). Additional covariates of education, perceived health, hypnotic medication and alcohol use were evaluated (model 2), plus depressive symptoms (model 3).AC was related to higher levels of trouble falling asleep, waking earlier than planned, overall poor sleep quality, and cough/snoring and shorter sleep duration in linear regression analyses (model 1). Adjustments for additional covariates showed that poor sleep quality and waking earlier than planned remained associated with higher AC (models 2 and 3). CAC was unrelated to sleep characteristics.Poor sleep quality is related to AC in middle-aged women. Sleep quality should routinely be assessed in mid-life women.

Despite progress in reducing cigarette smoking in the general U.S. population, smoking rates, cancer morbidity and related heart disease remain strikingly high among the poor and underserved. Homeless individuals’ cigarette smoking rate remains an alarming 70 % or greater, and this population is generally untreated with smoking cessation interventions. Furthermore, the majority of homeless smokers also abuse alcohol and other drugs, which makes quitting more difficult and magnifies the health consequences of tobacco use. Participants will be randomized to one of three groups, including (1) an integrated intensive smoking plus alcohol intervention using cognitive behavioral therapy (CBT), (2) intensive smoking intervention using CBT or (3) usual care (i.e., brief smoking cessation and brief alcohol counseling). All participants will receive 12-week treatment with a nicotine patch plus nicotine gum or lozenge. Counseling will include weekly individual sessions for 3 months, followed by monthly booster group sessions for 3 months. The primary smoking outcome is cotinine-verified 7-day smoking abstinence at follow-up week 52, and the primary alcohol outcome will be breathalyzer-verified 90-day alcohol abstinence at week 52. This study protocol describes the design of the first community-based controlled trial (n = 645) designed to examine the efficacy of integrating alcohol abuse treatment with smoking cessation among homeless smokers. To further address the gap in effectiveness of evidence-based smoking cessation interventions in the homeless population, we are conducting a renewed smoking cessation clinical trial called Power to Quit among smokers experiencing homelessness. ClinicalTrials.gov Identifier: NCT01932996 . Date of registration: 20 November 2014.

Summary Background Intimate-partner violence might increase during and after exposure to collective violence. We assessed whether political violence was associated with male-to-female intimate-partner violence in the occupied Palestinian territory. Methods A nationally representative, cross-sectional survey was done between Dec 18, 2005, and Jan 18, 2006, by the Palestinian Central Bureau of Statistics. 4156 households were randomly selected with a multistage random cluster design, from which 3815 ever-married women aged 15–64 years were identified. We restricted our analysis to presently married women (n=3510, 92% participation rate), who completed a short version of the revised conflict tactics scales and exposure to political violence inventory. Exposure to political violence was characterised as the husband's direct exposure, his indirect exposure via his family's experiences, and economic effects of exposure on the household. We used adjusted multinomial logistic regression models to estimate odds ratios (ORs) for association between political violence and intimate-partner violence. Findings Political violence was significantly related to higher odds of intimate-partner violence. ORs were 1·89 (95% CI 1·29–2·76) for physical and 2·23 (1·49–3·35) for sexual intimate-partner violence in respondents whose husbands were directly exposed to political violence compared with those whose husbands were not directly exposed. For women whose husbands were indirectly exposed, ORs were 1·61 (1·25–2·07) for physical and 1·97 (1·49–2–60) for sexual violence, compared with those whose husbands were not indirectly exposed. Economic effects of exposure were associated with increased odds of intimate-partner violence in the Gaza Strip only. Interpretation Because exposure to political violence is associated with increased odds of intimate-partner violence, and exposure to many traumas is associated with poor health, a range of violent exposures should be assessed when establishing the need for psychosocial interventions in conflict settings. Funding Palestinian National Authority, Core Funding Group, Program in Health Disparities Research at the University of Minnesota.