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Educational disparities in health persist after adjustment for income and occupation, suggesting that other purely cognitive and psychosocial mechanisms may be involved. Unlike occupation- or income-mediated effects, effects of cognitive and psychosocial gains-as reflected in academic achievement-may be apparent even before schooling is completed.We used data spanning 10 years on a national U.S. cohort of 2546 children aged 3-14 years at baseline to estimate the effects of academic achievement, measured by standardized tests of cognitive achievement, on future health. We used marginal structural models to address potential mutual influence of achievement and health on each other over time.One SD higher academic achievement 1997-2002 was associated with a lower prevalence of poorer health status in 2007 in girls (prevalence ratio = 0.87 [(95% confidence interval) 0.78-0.97]) but not in boys (prevalence ratio = 0.96 [0.86-1.08]). Higher achievement was also weakly associated with lower body mass index and less psychological distress among girls only.Academic achievement may benefit future health but a number of questions remain unanswered, including reasons for the gender differences and how academic achievement-related health disparities may progress over the life course and interact with other social determinants of health.

Differential access to healthy foods has been hypothesized to contribute to health disparities, but evidence from low and middle-income countries is still scarce. This study examines whether the access of healthy foods varies across store types and neighborhoods of different socioeconomic statuses (SES) in a large Brazilian city. A cross-sectional study was conducted in 2010–2011 across 52 census tracts. Healthy food access was measured by a comprehensive in-store data collection, summarized into two indexes developed for retail food stores (HFSI) and restaurants (HMRI). Descriptive analyses and multilevel models were used to examine associations of store type and neighborhood SES with healthy food access. Fast food restaurants were more likely to be located in low SES neighborhoods whereas supermarkets and full service restaurants were more likely to be found in higher SES neighborhoods. Multilevel analyses showed that both store type and neighborhood SES were independently associated with in-store food measures. We found differences in the availability of healthy food stores and restaurants in Sao Paulo city favoring middle and high SES neighborhoods.

Cumulative cortisol burden is known to influence neuropsychiatric and metabolic disorders. To better understand the relationship between daily cortisol exposure and measures of the diurnal circadian cortisol rhythm, we examined the cross-sectional association of the cortisol awakening response (CAR) with wake-up cortisol, bedtime cortisol, diurnal slope, and total cortisol area under the curve (AUC). Up to 18 salivary cortisol samples were collected over 3 days from 935 White, Hispanic, and Black individuals (mean age 65 ± 9.8 years) in the Multi-Ethnic Study of Atherosclerosis. Outcome measures included awakening cortisol, CAR (awakening to 30 min post-awakening), early decline (30 min to 2 h post-awakening), late decline (2 h post-awakening to bedtime), and the corresponding AUCs. Total cortisol AUC was a summary measure of cumulative cortisol exposure. Higher CAR was associated with significantly lower wake-up cortisol (β = −0.56; 95% CI: −0.59 to −0.53) and a higher early decline AUC (β = 0.38; 95% CI: 0.34–0.42) but was not associated with total cortisol AUC (β = 0.04; 95% CI: −0.01 to 0.09), or other diurnal cortisol curve components following multivariable adjustment. Total cortisol AUC was significantly and positively associated with wake-up cortisol (β = 0.36; 95% CI: 0.32–0.40), bedtime cortisol (β = 0.61; 95% CI: 0.58–0.64), and other AUC measures, following multivariable adjustment. Associations were similar by sex, race/ethnicity, and age categories. We conclude that bedtime cortisol showed the strongest correlation with total cortisol AUC, suggesting it may be a marker of daily cortisol exposure.

OBJECTIVE The primary goal was to test the hypothesis that limited social support (SS) is related to shorter leukocyte telomere length (LTL), particularly in an older adult population. METHODS Cross-sectional analyses were performed on 948 participants aged 45 to 84 years at Examination 1 of the Multi-Ethnic Study of Atherosclerosis (18.4% white, 53.1% Hispanics, and 28.5% African American). LTL was determined by using quantitative polymerase chain reaction, and SS was measured with the Enhancing Recovery in Coronary Heart Disease SS inventory. RESULTS Across the entire sample, SS was not associated with LTL (p=.87) after adjusting for demographic (age, sex, race/ethnicity, socioeconomic status), age×sex, age×race, health (body mass index, diabetes, pulse pressure), and life-style factors (smoking, physical activity, diet); however, the interaction term age (dichotomized)×SS was significant (p=.001). Stratification by age group revealed a positive association between SS (score range, 5-25) and LTL in the older (65-84 years; B[SE]=.005[.002]; p=.007) but not younger participants (45-64 years; p=.12) after adjusting for covariates. CONCLUSIONS These results from a racially/ethnically diverse community sample of men and women provide initial evidence that low SS is associated with shorter LTL in adults aged 65 years and older and is consistent with the hypothesis that social environment may contribute to rates of cellular aging, particularly in late life.

We investigated whether associations between nativity/length of US residence and body mass index (BMI) and waist circumference (WC) varied over the past two decades.Mexican-Americans aged 20-64 years from the National Health and Nutrition Survey (NHANES) III (1988-1994), and NHANES (1999-2008). Sex-stratified multivariable linear regression models further adjusted for age, education, and NHANES period.We found no evidence of secular variation in the nativity/length of US residence gradient for men or women. Foreign-born Mexican-Americans, irrespective of residence length, had lower mean BMI and WC than their US-born counterparts. However among women, education modified secular trends in nativity differentials: notably, in less-educated women, nativity gradients widened over time due to alarming increases in BMI among the US-born and little increase in the foreign-born.Associations between nativity/length of US residence and BMI/WC did not vary over this 20-year period, but we noted important modifications by education in women. Understanding these trends is important for identifying vulnerable subpopulations among Mexican-Americans and for the development of effective health promotion strategies in this fast-growing segment of the population.

Background Recent obesity prevention initiatives focus on healthy neighborhood design, but most research examines neighborhood food retail and physical activity (PA) environments in isolation. We estimated joint, interactive, and cumulative impacts of neighborhood food retail and PA environment characteristics on body mass index (BMI) throughout early adulthood. Methods and findings We used cohort data from the Coronary Artery Risk Development in Young Adults (CARDIA) Study [n=4,092; Year 7 (24-42 years, 1992-1993) followed over 5 exams through Year 25 (2010-2011); 12,921 person-exam observations], with linked time-varying geographic information system-derived neighborhood environment measures. Using regression with fixed effects for individuals, we modeled time-lagged BMI as a function of food and PA resource density (counts per population) and neighborhood development intensity (a composite density score). We controlled for neighborhood poverty, individual-level sociodemographics, and BMI in the prior exam; and included significant interactions between neighborhood measures and by sex. Using model coefficients, we simulated BMI reductions in response to single and combined neighborhood improvements. Simulated increase in supermarket density (from 25(th) to 75(th) percentile) predicted inter-exam reduction in BMI of 0.09 kg/m(2) [estimate (95% CI): -0.09 (-0.16, -0.02)]. Increasing commercial PA facility density predicted BMI reductions up to 0.22 kg/m(2) in men, with variation across other neighborhood features [estimate (95% CI) range: -0.14 (-0.29, 0.01) to -0.22 (-0.37, -0.08)]. Simultaneous increases in supermarket and commercial PA facility density predicted inter-exam BMI reductions up to 0.31 kg/m(2) in men [estimate (95% CI) range: -0.23 (-0.39, -0.06) to -0.31 (-0.47, -0.15)] but not women. Reduced fast food restaurant and convenience store density and increased public PA facility density and neighborhood development intensity did not predict reductions in BMI. Conclusions Findings suggest that improvements in neighborhood food retail or PA environments may accumulate to reduce BMI, but some neighborhood changes may be less beneficial to women.

Background: Depression is a heritable trait that exists on a continuum of varying severity and duration. Yet, the search for genetic variants associated with depression has had few successes. We exploit the entire continuum of depression to find common variants for depressive symptoms.Methods: In this genome-wide association study, we combined the results of 17 population-based studies assessing depressive symptoms with the Center for Epidemiological Studies Depression Scale. Replication of the independent top hits (p Results: The discovery sample comprised 34,549 individuals (mean age of 66.5) and no loci reached genome-wide significance (lowest p = 1.05 x 10(-7)). Seven independent single nucleotide polymorphisms were considered for replication. In the replication set (n = 16,709), we found suggestive association of one single nucleotide polymorphism with depressive symptoms (rs161645, 5q21, p = 9.19 x 10(-3)). This 5q21 region reached genome-wide significance (p = 4.78 x 10(-8)) in the overall meta-analysis combining discovery and replication studies (n = 51,258).Conclusions: The results suggest that only a large sample comprising more than 50,000 subjects may be sufficiently powered to detect genes for depressive symptoms.

Epigenetic changes are a potential mechanism contributing to race/ethnic and socioeconomic disparities in health. However, there is scant evidence of the race/ethnic and socioeconomic patterning of epigenetic marks. We used data from the Multi-Ethnic Study of Atherosclerosis Stress Study (N = 988) to describe age- and gender- independent associations of race/ethnicity and socioeconomic status (SES) with methylation of Alu and LINE-1 repetitive elements in leukocyte DNA. Mean Alu and Line 1 methylation in the full sample were 24% and 81% respectively. In multivariable linear regression models, African-Americans had 0.27% (p

Background: Fine particulate matter (PM2.5) has been linked to cardiovascular disease, possibly via accelerated atherosclerosis. We examined associations between the progression of the intima-medial thickness (IMT) of the common carotid artery, as an indicator of atherosclerosis, and long-term PM2.5 concentrations in participants from the Multi-Ethnic Study of Atherosclerosis (MESA). Methods and Results: MESA, a prospective cohort study, enrolled 6,814 participants at the baseline exam (2000–2002), with 5,660 (83%) of those participants completing two ultrasound examinations between 2000 and 2005 (mean follow-up: 2.5 years). PM2.5 was estimated over the year preceding baseline and between ultrasounds using a spatio-temporal model. Cross-sectional and longitudinal associations were examined using mixed models adjusted for confounders including age, sex, race/ethnicity, smoking, and socio-economic indicators. Among 5,362 participants (5% of participants had missing data) with a mean annual progression of 14 mm/y, 2.5 mg/m 3 higher levels of residential PM2.5 during the follow-up period were associated with 5.0 mm/y (95% CI 2.6 to 7.4 mm/y) greater IMT progressions among persons in the same metropolitan area. Although significant associations were not found with IMT progression without adjustment for metropolitan area (0.4 mm/y [95% CI 20.4 to 1.2 mm/y] per 2.5 mg/m 3 ), all of the six areas showed positive associations. Greater reductions in PM2.5 over follow-up for a fixed baseline PM2.5 were also associated with slowed IMT progression (22.8 mm/y [95% CI 21.6 to 23.9 mm/y] per 1 mg/m 3 reduction). Study limitations include the use of a surrogate measure of atherosclerosis, some loss to follow-up, and the lack of estimates for air pollution concentrations prior to 1999. Conclusions: This early analysis from MESA suggests that higher long-term PM2.5 concentrations are associated with increased IMT progression and that greater reductions in PM2.5 are related to slower IMT progression. These findings, even over a relatively short follow-up period, add to the limited literature on air pollution and the progression of atherosclerotic processes in humans. If confirmed by future analyses of the full 10 years of follow-up in this cohort, these findings will help to explain associations between long-term PM2.5 concentrations and clinical cardiovascular events. Please see later in the article for the Editors’ Summary.

Background/Objectives Predictors of healthy aging have not been well-studied using longitudinal data with demographic, clinical, subclinical, and genetic information. The objective was to identify predictors of poor health outcome at 10 years of follow-up in the Multi-Ethnic Study of Atherosclerosis (MESA). Design Prospective cohort study. Setting Population-based sample from 6 U.S. communities. Participants 4,355 participants In the MESA Study. Measurements Poor health outcome at 10 years of follow-up was defined as having died or having clinical cardiovascular disease, depression, cognitive impairment, chronic obstructive pulmonary disease, or cancer other than non-melanoma skin cancer. Absolute risk regression was used to estimate risk differences in the outcome adjusting for demographic variables, clinical and behavioral risk factors, subclinical cardiovascular disease, and ApoE genotype. Models were weighted to account for selective attrition. Results Mean age at 10 years of follow-up was 69.5 years; 1,480 participants had a poor health outcome, 2,157 participants were in good health, and 718 were unknown. Older age, smoking, not taking a statin, hypertension, diabetes, and higher coronary calcium score were associated with higher probability of poor health outcome. After multivariable adjustment, participants in the lowest income and educational categories had 7 to 14% greater absolute risk of poor health outcome at 10 years of follow-up compared to those in the next highest categories of income or education (P = 0.002 for both). Those in the lowest categories of both income and education had 21% greater absolute risk of poor health outcome compared to those in the highest categories of both income and education. Conclusions Low income and educational level predict poor health outcome at 10 years of follow-up in an aging cohort, independent of clinical and behavioral risk factors and subclinical cardiovascular disease.

Neighborhood socioeconomic status (SES), an overall marker of neighborhood conditions, may determine residents' access to health care, independently of their own individual characteristics. It remains unclear, however, how the distinct settings where individuals seek care vary by neighborhood SES, particularly in US urban areas. With existing literature being relatively old, revealing how these associations might have changed in recent years is also timely in this US health care reform era. Using data on the Philadelphia region from 2002 to 2012, we performed multilevel analysis to examine the associations of neighborhood SES (measured as census tract median household income) with access to usual sources of primary care (physician offices, community health centers, and hospital outpatient clinics). We found no evidence that residence in a low-income (versus high-income) neighborhood was associated with poorer overall access. However, low-income neighborhood residence was associated with less reliance on physician offices [-4.40 percentage points; 95 % confidence intervals (CI) -5.80, -3.00] and greater reliance on the safety net provided by health centers [2.08; 95 % CI 1.42, 2.75] and outpatient clinics [1.61; 95 % CI 0.97, 2.26]. These patterns largely persisted over the 10 years investigated. These findings suggest that safety-net providers have continued to play an important role in ensuring access to primary care in urban, low-income communities, further underscoring the importance of supporting a strong safety net to ensure equitable access to care regardless of place of residence.

The cross-sectional associations of social class indicators with coronary heart disease prevalence and subclinical atherosclerosis were investigated among 15,800 persons from four US communities between 1987 and 1989. Among persons without clinical atherosclerotic disease, ultrasound-determined intimal-medial wall thickening of the carotid arteries was used as an indicator of subclinical atherosclerosis. Odds ratios for coronary heart disease prevalence and mean differences in carotid wall thickness were investigated before and after adjustment for cardiovascular risk factors. After adjustment for age and gender, the lowest income category was associated with a threefold increase in coronary heart disease odds compared with the highest category (for whites, odds ratio (OR) = 3.4, 95% confidence interval (CI) 1.8-6.6; for blacks, OR = 3.2, 95% CI 2.2-4.8). Odds ratios increased linearly with decreasing income (p < 0.0001). Low education was also associated with increased odds of coronary heart disease after adjustment for age and gender, but the association was stronger in whites than in blacks (lowest category vs. highest: for whites, OR = 3.8, 95% CI 2.5-5.9; for blacks, OR = 1.7, 95% CI 0.9-3.1). Similar patterns were found for subclinical atherosclerosis: Carotid wall thickness increased with decreasing income and education, but trends by education were clearer in whites than in blacks. Lower occupational categories were also associated with increased coronary heart disease prevalence odds and increased carotid wall thickness. After adjustment for risk factors, associations with clinical coronary heart disease persisted but associations with carotid wall thickness disappeared, suggesting that factors related to the clinical expression of lesions may vary by social class. The process of atherogenesis and its clinical expression are patterned by social class, emphasizing the need to address social inequalities in the prevention of cardiovascular disease.

Se analizó la influencia de variables de distintos niveles de agregación y el efecto del tiempo sobre la ocurrencia de homicidios por arma de fuego (HAF) en Argentina durante el periodo 1991-2006, con la técnica de niveles múltiples. Se utilizó un modelo de regresión de Poisson de tres niveles. El primer nivel correspondió a la distribución del número de HAF según sexo y grupo de edad para cada departamento y período; el segundo nivel a la variabilidad a lo largo del tiempo (cuatrienios) de los HAF al interior de cada departamento; y el tercero a la variabilidad entre departamentos según Nivel de Urbanización, Porcentaje de hogares con Necesidades Básicas Insatisfechas y Porcentaje de Población Ocupada. Se trabajó con 15.067 HAF en mayores de 14 años, ocurridos en los 493 departamentos en 1991-2006. El riesgo de morir por HAF fue superior en varones y en personas de 15 a 29 años de edad; el aumento de la edad se asoció con un menor riesgo. El efecto de la edad fue mayor en las zonas centro-urbanas. Se registró un mayor riesgo en 1999-2002. El Nivel de Urbanización fue la variable socioeconómica de mayor importancia. El riesgo de morir por HAF en las zonas centro-urbanas fue 1,6 veces mayor que en las zonas no centrales. En ambas zonas el riesgo fue superior en 1999-2002. The influence of variables at different levels of organization and the effect of time on the occurrence of firearm-related homicides (FRH) in Argentina between 1991 and 2006 was analyzed using multilevel analysis. A three-level Poisson regression model was used. The first level corresponded to the distribution of the number of FRH by sex and age group for each administrative region and (four-year) period; the second corresponded to the variation over time in the interior of each administrative region; the third modeled the variation between administrative regions in accordance with the Level of Urbanization, Percentage of Homes with Unsatisfied Basic Needs and the Percentage of Working Adults. There were 15,067 FRH in persons aged 14 and over between 1991 and 2006 in the 493 administrative regions. The risk of death was higher in males and persons of 15 to 29 years of age; ages above that were associated with a lower risk. The influence of age was greater in central-urban zones and between 1999 and 2002 than during other periods. The level of urbanization was the socioeconomic variable most strongly associated with FRH risk. The risk of death from FRH was 1.6 times higher in central-urban zones compared with non-central zones. In both zones, the risk was highest between 1999 and 2002.

A paradox exists in the outcomes of primary care: despite delivering apparently poorer quality disease care compared to that delivered by specialists, primary care is associated with better population health, lower inequality, and lower cost. Understanding the dynamics that give rise to this paradox could lead to better-informed interventions to promote more patient-centered, holistic, equitable, and cost-effective models of care. In this chapter, we articulate the paradox and how complexity science principles can make sense of its contradictions. We suggest a novel approach to advancing understanding through a participatory group modeling process to build and conduct experiments with an agent-based computational model.

Summary Objective To investigate the association between salivary cortisol and two markers of subclinical cardiovascular disease (CVD), coronary calcification (CAC), and ankle-brachial index (ABI). Methods Data from an ancillary study to the Multi-Ethnic Study of Atherosclerosis (MESA), the MESA Stress Study, were used to analyze associations of salivary cortisol data collected six times per day over three days with CAC and ABI. The authors used mixed models with repeat cortisol measures nested within persons to determine if specific features of the cortisol profile were associated with CAC and ABI. Results A total of 464 participants were included in the CAC analysis and 610 in the ABI analysis. The mean age of participants was 65.6 years. A 1-unit increase in log coronary calcium was associated with a 1.77% flatter early decline in cortisol (95% CI: 0.23, 3.34) among men and women combined. Among women low ABI was associated with a steeper early decline (−13.95% CI: −25.58, −3.39) and a marginally statistically significant flatter late decline (1.39% CI: −0.009, 2.81). The cortisol area under the curve and wake to bedtime slope were not associated with subclinical CVD. Conclusions This study provides weak support for the link between cortisol and measures of subclinical atherosclerosis. We found an association between some features of the diurnal cortisol profile and coronary calcification and ABI but associations were not consistent across subclinical measures. There are methodological challenges in detecting associations of cortisol measures at a point in time with health outcomes that develop over a lifetime. Studies of short-term mechanisms linking stress to physiological processes related to the development of early atherosclerosis may be more informative.

Previous findings have linked lower socioeconomic status (SES) with elevated morbidity and mortality. Leukocyte telomere length (LTL), which also has been associated with age-related disease morbidity and mortality, is a marker of aging at the cellular level, making it a valuable early biomarker of risk and an indicator of biological age. It is hypothesized that SES will be associated with LTL, indicating that SES influences disease risk by accelerating biological aging. In the present sample we test for associations of childhood SES and adult SES (i.e. education, income, home ownership) with LTL, and examine whether these associations vary by racial/ethnic group. Analyses on 963 subjects (18.7% White, 53% Hispanics, and 28.5% African American) from the Stress ancillary study of the Multi-Ethnic Study of Atherosclerosis revealed a significant difference in LTL between home owners and renters in Hispanic and White participants (p < .05), but not amongst African Americans (p = .98). There were no linear associations of adult education or family income with LTL, however, there was an inverse association between father’s education and LTL (p = .03). These findings suggest that for Whites and Hispanics renting vs. owning a home is associated with an older biological age; however we did not replicate previous findings linking education with LTL.

Racial discrimination has been associated with unhealthy behaviors, but the mechanisms responsible for these associations are not understood and may be related to residential racial segregation. We investigated associations between self-reported racial discrimination and health behaviors before and after controlling for individual- and neighborhood-level characteristics; and potential effect modification of these associations by segregation.We used data from the longitudinal Coronary Artery Risk Development in Young Adults (CARDIA) study for 1169 African-Americans and 1322 whites. To assess racial discrimination, we used a four category variable to capture the extent and persistence of self-reported discrimination between examination at years 7 (1992-1993) and 15 (2000-2001). We assessed smoking status, alcohol consumption, and physical activity at year 20 (2005-2006). Segregation was examined as the racial/ethnic composition at the Census tract level.Discrimination was more common in African-Americans (89.1%) than in whites (40.0%). Living in areas with high percentage of blacks was associated with less reports of discrimination in African-Americans but more reports in whites. After adjustment for selected characteristics including individual- and neighborhood-level socioeconomic conditions and segregation, we found significant positive associations of discrimination with smoking and alcohol consumption in African-Americans and with smoking in whites. African-Americans experiencing moderate or high discrimination were more physically active than those reporting no discrimination. Whites reporting some discrimination were also more physically active than those reporting no discrimination. We observed no interactions between discrimination and segregation measures in African-Americans or whites for any of the three health behaviors.Racial discrimination may impact individuals' adoption of healthy and unhealthy behaviors independent of racial/ethnic segregation. These behaviors may help individuals buffer or reduce the stress of discrimination.

It is often hypothesized that psychosocial stress may contribute to associations of socioeconomic position (SEP) with risk factors for cardiovascular disease (CVD). However, few studies have investigated this hypothesis among African Americans, who may be more frequently exposed to stressors due to social and economic circumstances. Cross-sectional data from the Jackson Heart Study (JHS), a large population-based cohort of African Americans, were used to examine the contributions of stressors to the association of SEP with selected cardiovascular (CVD) risk factors and subclinical atherosclerotic disease. Among women, higher income was associated with lower prevalence of hypertension, obesity, diabetes and carotid plaque and lower levels of stress. Higher stress levels were also weakly, albeit positively, associated with hypertension, diabetes, and obesity, but not with plaque. Adjustment for the stress measures reduced the associations of income with hypertension, diabetes and obesity by a small amount that was comparable to, or larger, than the reduction observed after adjustment for behavioral risk factors. In men, high income was associated with lower prevalence of diabetes and stressors were not consistently associated with any of the outcomes examined. Overall, modest mediation effects of stressors were observed for diabetes (15.9%), hypertension (9.7%), and obesity (5.1%) among women but only results for diabetes were statistically significant. No mediation effects of stressors were observed in men. Our results suggest that stressors may partially contribute to associations of SEP with diabetes and possibly hypertension and obesity in African American women. Further research with appropriate study designs and data is needed to understand the dynamic and interacting effects of stressors and behaviors on CVD outcomes as well as sex differences in these effects.

Although specific measurement instruments are necessary to better understand the relationship between features of neighborhoods and health, very few studies have developed instruments to measure neighborhood features in developing countries. The objective of the study was to develop valid and reliable measures of neighborhood context useful in a Latin American urban context, assess their psychometric and ecometric properties, and examine individual and neighborhood-level predictors of these measures. We analyzed data from a multistage household survey (2008–2009) conducted in Belo Horizonte City by the Observatory for Urban Health. One adult in each household was selected to answer a questionnaire that included scales to measure neighborhood domains. Census tracts were used to proxy neighborhoods. Internal consistency was evaluated by Cronbach’s alpha, and multilevel models were used to estimate ecometric properties and to estimate associations of neighborhood measures with socioeconomic indicators. The final sample comprised 4048 survey respondents representing 149 census tracts. We assessed ten neighborhood environment dimensions: public services, aesthetic quality, walking environment, safety, violence, social cohesion, neighborhood participation, neighborhood physical disorder, neighborhood social disorder, and neighborhood problems. Cronbach’s alpha coefficients ranged from 0.53 to 0.83; intraneighborhood correlations ranged from 0.02 to 0.53, and neighborhood reliability varied from 0.76 to 0.99. Most scales were associated with individual and neighborhood socioeconomic predictors. Questionnaires can be used to reliably measure neighborhood contexts in developing countries.

Understanding the impact of place on health is a key element of epidemiologic investigation, and numerous tools are being employed for analysis of spatial health-related data. This review documents the huge growth in spatial epidemiology, summarizes the tools that have been employed, and provides in-depth discussion of several methods. Relevant research articles for 2000–2010 from seven epidemiology journals were included if the study utilized a spatial analysis method in primary analysis (n = 207). Results summarized frequency of spatial methods and substantive focus; graphs explored trends over time. The most common spatial methods were distance calculations, spatial aggregation, clustering, spatial smoothing and interpolation, and spatial regression. Proximity measures were predominant and were applied primarily to air quality and climate science and resource access studies. The review concludes by noting emerging areas that are likely to be important to future spatial analysis in public health.

Objective: To determine whether long-term exposure to oxides of nitrogen (NO x ) is associated with left ventricular mass index (LVMI) in adults without known cardiovascular disease (CVD). Background: An association between very close (x , a specific, gaseous traffic related pollutant and more reliable surrogate for traffic-related pollution, has not been examined. Methods: This study included 4125 participants free of clinical cardiovascular disease in the Multi-Ethnic Study of Atherosclerosis (MESA) who underwent cardiac MRI, cardiac computed tomography (CT), and an extensive air pollution exposure assessment campaign to determine long-term individual residential exposure to NO x . This study used year 2000 average exposure to estimate long term exposure to NO x . LVMI was calculated by indexing cardiac MRI measures of left ventricular mass to body surface area measured at the exam. Agatston score was calculated based on cardiac CT. Multiple linear regression was used to examine the association between long-term exposure to NO x and LVMI, adjusted for multiple potential confounders including study site. To examine whether such relationships may be mediated by atherosclerosis or blood pressure, additional adjustment for Agatston score and blood pressure was performed. Results: An interquartile range (44 ppb) increase in estimated residential NO x was associated with significantly higher LVMI (1.6 g/m 2 , 95% CI: 0.1 to 3.1, p=0.03). Such estimates were comparable to prior associations observed for the relationship between close residential proximity to major roadways and LVMI (comparing individuals living 150m away). Additional adjustment for Agatston score and blood pressure had no effect on estimates of association. Stratified analyses suggested interactions with age, with younger individuals demonstrating larger associations than older individuals (p for interaction = 0.05). No significant evidence of effect modification by race, gender, other cardiovascular risk factors, or study site was observed. Conclusions: This study further supports the observation that long-term exposure to traffic-related air pollution is associated with higher left ventricular mass, and suggests that such associations may be independent of effects on blood pressure or atherosclerotic disease.

U.S. birth and longer length of U.S. residence among the foreign-born have been linked to higher anthropometric measures. However previous studies have been cross-sectional and few have examined heterogeneity by ethnic group. Cross-sectional findings that show immigrant weight converging to U.S.-born levels with longer time in the U.S. imply that immigrants’ weight is increasing at a faster rate relative to U.S.-born individuals. Prospective studies are necessary to confirm this pattern. Using longitudinal data from 1486 Hispanic and 802 Chinese adults aged 45–84 years in the Multi-ethnic Study of Atherosclerosis, we examined whether foreign-born participants experienced greater increases in body mass index (BMI) and waist circumference (WC) than the U.S.-born over a median follow-up of 5 years. We also investigated heterogeneity in these associations by Hispanic subgroup. Among Hispanics and Chinese, the foreign-born had a lower adjusted mean BMI and WC at baseline than the U.S.-born, but there were no significant differences in BMI or WC change over time. There was heterogeneity by Hispanic subgroup: despite small baseline nativity differences in WC, foreign-born Mexican Hispanics had a greater annual mean increase in WC over time compared to U.S.-born Mexican Hispanics (mean difference in annual change=0.28 cm, P=0.03). There were no nativity differences in the rate of WC increase over time among non-Mexican Hispanics. Foreign-born Mexican Hispanics also experienced a faster rate of WC increase compared to foreign-born non-Mexican Hispanics (mean difference in annual change=0.24 cm, P=0.01). Longer time in the U.S., examined prospectively, may only be linked to adverse anthropometric changes in some immigrant groups.

Subjective social status has been shown to be inversely associated with multiple cardiovascular risk factors, independent of objective social status. However, few studies have examined this association among African Americans and the results have been mixed. Additionally, the influence of discrimination on this relationship has not been explored. Using baseline data (2000–2004) from the Jackson Heart Study, an African American cohort from the U.S. South (N = 5301), we quantified the association of subjective social status with selected cardiovascular risk factors: depressive symptoms, perceived stress, waist circumference, insulin resistance and prevalence of diabetes. We contrasted the strength of the associations of these outcomes with subjective versus objective social status and examined whether perceived discrimination confounded or modified these associations. Subjective social status was measured using two 10-rung "ladders," using the U.S. and the community as referent groups. Objective social status was measured using annual family income and years of schooling completed. Gender-specific multivariable linear and logistic regression models were fit to examine associations. Subjective and objective measures were weakly positively correlated. Independent of objective measures, subjective social status was significantly inversely associated with depressive symptoms (men and women) and insulin resistance (women). The associations of subjective social status with the outcomes were modest and generally similar to the objective measures. We did not find evidence that perceived racial discrimination strongly confounded or modified the association of subjective social status with the outcomes. Subjective social status was related to depressive symptoms but not consistently to stress or metabolic risk factors in African Americans.

Access to healthy foods has received increasing attention due to growing prevalence of obesity and diet-related health conditions yet there are major obstacles in characterizing the local food environment. This study developed a method to retrospectively characterize supermarkets for a single historic year, 2005, in 19 counties in 6 states in the USA using a supermarket chain-name list and two business databases. Data preparation, merging, overlaps, added-value amongst various approaches and differences by census tract area-level socio-demographic characteristics are described. Agreement between two food store databases was modest: 63%. Only 55% of the final list of supermarkets were identified by a single business database and selection criteria that included industry classification codes and sales revenue >=$2 million. The added-value of using a supermarket chain-name list and second business database was identification of an additional 14% and 30% of supermarkets, respectively. These methods are particularly useful to retrospectively characterize access to supermarkets during a historic period and when field observations are not feasible and business databases are used.

A major challenge in studies of the impact of the local food environment is the accuracy of measures of healthy food access. The authors assessed agreement between self-reported and directly measured availability of healthful choices within neighborhood food stores and examined the validity of reported availability using directly measured availability as a “gold standard.” Reported availability was measured via a phone survey of 1,170 adults in Baltimore, Maryland, in 2004. Directly measured availability was assessed in 226 food stores in 2006 using a modified Nutrition Environment Measures Survey in Stores (NEMS-S). Whites, college-educated individuals, and higher income households (≥$50,000) had significantly higher reported and directly measured availability than did blacks, those with less education, and lower income households. Persons in areas with above average directly measured availability reported above average availability 70%–80% of the time (sensitivity = 79.6% for all stores within 1 mile (1.6 km) of participants’ homes and 69.6% for the store with the highest availability within 1 mile). Those with below average directly measured availability reported low availability only half the time. With revisions to improve specificity, self-reported measures can be reasonable indicators of healthy food availability and provide feasible proxy measures of directly assessed availability.

The adult smoking rate in the United States gradually declined from over 40% in the 1960s to about 20% in recent years.(1) However, differences in the prevalence of tobacco use by socioeconomic position (SEP) persist. Among currently working adults in the US, 28% of those who are below poverty level smoke while only 18% of those above poverty level do.(2) The discrepancy is reflected in a disproportional burden of tobacco-related health problems among the poor.(3) Understanding the mechanisms that create SEP gradients in tobacco use is a public health imperative. Income, education, and occupation are the three most commonly used measures of SEP, all indicating a person’s position relative to others in society. However, each SEP indicator’s independent associations with tobacco use may also provide clues regarding the causes of the social patterning of tobacco use. For example, education may in part reflect the ability to obtain health enhancing information and to act on the knowledge.(4) Therefore, educational gradients in tobacco use (4–7) may imply that interventions should focus on delivery of health information and assistance to individuals. Income could in part reflect access to material resources,(8, 9) including smoking cessation treatments. Thus, income gradients in tobacco use (6) could suggest that making treatment for smoking affordable would reduce the disparities. The role of occupation in tobacco disparities is complex. Occupational gradients in smoking (10–13) may simply reflect the education and income associated with the occupation. On the other hand, occupation may also reflect other unmeasured factors that facilitate smoking, such as work stress (with use of smoking as a coping mechanism), access to tobacco, and social norms that may facilitate or discourage tobacco use in the workplace. Studies that have investigated associations of occupation independent of income or education have reported inconsistent results. Using a Finnish sample, Laaksonen et al. showed that occupational differences in the current smoking rate disappeared after adjustments were made for economic factors.(14) In contrast, a national sample of young Americans showed that blue-collar and service workers had significantly higher rates of current smokers and heavy smokers even after household income and education were taken into account.(15) Because most studies of occupational gradients in smoking only present descriptive statistics,(e.g., 16) it is not well understood whether the differences across occupational groups are associated with some aspects of the job or simply reflect the education and income level correlated with the job. Another issue that needs to be taken into account in examining tobacco disparities across occupations is exposure to environmental tobacco smoke (ETS) in the workplace. Health impacts of ETS exposure have been widely recognized,(17, 18) and workplace smoking regulations have been implemented in many states.(19, 20) However, protection from workplace ETS varies by SEP. Workers with low income, low education, and in blue-collar and service jobs are less likely to be protected by the regulations.(21) Moreover, even if workplace smoking regulations are in place, violations have been reported, especially in blue-collar and service occupations.(22) While workplace smoking policies are associated with reduced tobacco consumption,(23, 24) those who work in occupations at the lower end of SEP may not benefit from the policies as much as those in other occupations, thereby increasing disparities in tobacco exposure. In sum, the impact of occupation on tobacco exposure, and specifically whether occupation has an impact independent of income and education, remains an understudied question. Specifically, it is not clear if the high prevalence of smoking among blue-collar workers is merely the function of income and education, or if there are other factors specific to blue-collar occupations that increase tobacco exposure. Identifying and eliminating occupational gradients in tobacco use is important because workers toward the bottom of the occupational hierarchy are more likely to be exposed to other hazards that may have synergistic effects with tobacco exposure, such as asbestos.(25) Using data from a sample of community residents, this study examines occupational gradients in various tobacco-related exposures while taking education and income into account.

Scientific and policy interest in health disparities, defined as systematic, plausibly avoidable health differences adversely affecting socially disadvantaged groups, has increased markedly over the past few decades. Like other research, research in health disparities is strongly influenced by the underlying conceptual model of the hypothetical causes of disparities. Conceptual models are important and a major source of debate because multiple types of factors and processes may be involved in generating disparities, because different disciplines emphasize different types of factors, and because the conceptual model often drives what is studied, how results are interpreted, and which interventions are identified as most promising. This article reviews common conceptual approaches to health disparities including the genetic model, the fundamental cause model, the pathways model, and the interaction model. Strengths and limitations of the approaches are highlighted. The article concludes by outlining key elements and implications of an integrative systems-based conceptual model.

Despite the growing burden of chronic disease globally, few studies have examined the socioeconomic patterning of risk across countries. The authors examined differences in the social patterning of body mass index (BMI) and current smoking by urbanicity among 70 countries from the 2002–2003 World Health Surveys. Age-adjusted, gender-stratified ordinary least squares and logistic regression analyses were conducted in each country to assess the relation between education and BMI or smoking. Meta-analytic techniques were used to assess heterogeneity between countries in the education-risk factor relations. Meta-regression was used to determine whether the heterogeneity could be explained by country-level urbanicity. In the least urban countries, persons with higher education had a higher BMI, while the opposite pattern was seen in the most urban countries, with this pattern being especially pronounced among women. In contrast, smoking was consistently concentrated among persons of lower education among all men and among women in the least urban countries. For women in the most urban countries, higher education was associated with higher odds of smoking, although there was substantial variability in this relation. These results highlight a global trend toward an increasing burden of chronic disease risk among persons of lower socioeconomic position as countries become more urban.

Using ∼60,000 SNPs selected for minimal linkage disequilibrium, we perform population structure analysis of 1,374 unrelated Hispanic individuals from the Multi-Ethnic Study of Atherosclerosis (MESA), with self-identification corresponding to Central America (n = 93), Cuba (n = 50), the Dominican Republic (n = 203), Mexico (n = 708), Puerto Rico (n = 192), and South America (n = 111). By projection of principal components (PCs) of ancestry to samples from the HapMap phase III and the Human Genome Diversity Panel (HGDP), we show the first two PCs quantify the Caucasian, African, and Native American origins, while the third and fourth PCs bring out an axis that aligns with known South-to-North geographic location of HGDP Native American samples and further separates MESA Mexican versus Central/South American samples along the same axis. Using k-means clustering computed from the first four PCs, we define four subgroups of the MESA Hispanic cohort that show close agreement with self-identification, labeling the clusters as primarily Dominican/Cuban, Mexican, Central/South American, and Puerto Rican. To demonstrate our recommendations for genetic analysis in the MESA Hispanic cohort, we present pooled and stratified association analysis of triglycerides for selected SNPs in the LPL and TRIB1 gene regions, previously reported in GWAS of triglycerides in Caucasians but as yet unconfirmed in Hispanic populations. We report statistically significant evidence for genetic association in both genes, and we further demonstrate the importance of considering population substructure and genetic heterogeneity in genetic association studies performed in the United States Hispanic population., Author Summary Using genotype data from about 60,000 distinct genetic markers, we examined population structure in 1,374 unrelated Hispanic individuals from the Multi-Ethnic Study of Atherosclerosis (MESA), with self-identification corresponding to Central America (n = 93), Cuba (n = 50), the Dominican Republic (n = 203), Mexico (n = 708), Puerto Rico (n = 192), and South America (n = 111). By comparing genetic ancestry of MESA Hispanic participants to reference samples representing worldwide diversity, we show major differences in ancestry of MESA Hispanics reflecting their Caucasian, African, and Native American origins, with finer differences corresponding to North-South geographic origins that separate MESA Mexican versus Central/South American samples. Based on our analysis, we define four subgroups of the MESA Hispanic cohort that show close agreement with the following self-identified regions of origin: Dominican/Cuban, Mexican, Central/South American, and Puerto Rican. We examine association of triglycerides with selected genetic markers, and we further demonstrate the importance of considering differences in genetic ancestry (or factors associated with genetic ancestry) when performing genetic studies of the United States Hispanic population.

We use an exploratory agent-based model of adults’ walking behavior within a city to examine the possible impact of interventions on socioeconomic differences in walking. Simulated results show that for persons of low socioeconomic status, increases in walking resulting from increases in their positive attitude towards walking may diminish over time if other features of the environment are not conducive to walking. Similarly, improving the safety level for the lower SES neighborhoods may be effective in increasing walking, however, the magnitude of its effectiveness varies by levels of land use mix, such that effects of safety are greatest when persons live in areas with a large mix of uses.

Background: Over 65 million Americans live in Primary Care Health Professional Shortage Areas (HPSAs) which are associated with less preventive care, poorer general health and an increased risk for hospitalizations. However, little is known about how living in a HPSA impacts primary prevention for CVD. Methods: We used data from CARDIA, a multi-center cohort study of black and white men and women. Participants who had risk factor data and geocoded addresses available at year 20 (2005) were included in this analysis (n=3479). Primary care HPSAs were defined using data from US HRSA. Diabetes, hypertension and hyperlipidemia prevalence and control were defined according to ADA Guidelines 2000, JNC VI, and ATP III, respectively. Individuals who reported being diagnosed or reported use of medications were considered aware of the risk factor. The prevalence of smoking and obesity was also examined. Neighborhood (census block) characteristics were derived from Census 2000 and ACCRA. Multivariable Poisson models were used to examine the independent association of HPSA residence with each outcome. Results: Over 11% of CARDIA participants live in a HPSA. Residents of HPSAs were more likely to be female (64% vs 56%), African American (81% vs 43%), have low education, and low income. HPSA residents had more difficulty paying for food/basics and medical care, had poorer access to medical care and lived in areas with a higher cost of healthcare and low neighborhood SES. HPSA residents had a higher prevalence of hypertension (PR 1.39, 95% CI 1.18-1.65), obesity (1.30, 1.16-1.45) and smoking (1.72, 1.46-2.03) and were less likely to have their hypertension (0.79, 0.66-0.95) or hyperlipidemia (0.66, 0.44-0.99) controlled as compared to non-residents. The association between HPSA and risk factors prevalence was explained by race and neighborhood SES. The cost of medical care and having a usual source of care were the largest mediators of the association between HPSA residence and risk factor control. Conclusion: The increased prevalence and poorer control of CVD risk factors in HPSAs, can be explained by the demographic and neighborhood characteristics of their residents. Future interventions should be targeted to these high-risk populations found within HPSAs.

Background Walking distance is an important concept in the fields of transportation and public health. A distance of 0.25 miles is often used as an acceptable walking distance in U.S. research studies. Overall, research on the distance and duration of walking trips for different purposes and across different population groups remains limited. Purpose This study examines the prevalence of walking and distances and durations of walking trips for different purposes among U.S. residents. Methods The distances and durations of walking trips for different purposes across population groups were compared using nationally representative data from the 2009 National Household Travel Survey (NHTS). Distance decay functions were used to summarize the distribution of walking distances and durations for different purposes and population subgroups. Data were analyzed in 2011. Results Sixteen percent of respondents had at least one daily walking trip. The mean and median values for walking distance were 0.7 and 0.5 miles, respectively. For walking duration, the mean and median values were 14.9 and 10 minutes. About 65% of walking trips were more than 0.25 miles in distance, and about 18% of walking trips were more than 1 mile. Large variations were found among various purposes for both distance and duration. The distances and durations of walking for recreation were substantially longer than those for other purposes. People with lower versus higher household income walked longer distances for work but shorter distances for recreation. Conclusions Only a small fraction of respondents walk, but trips longer than 0.25 miles are common. There is substantial variability in the distance and duration of walking trips by purpose and population subgroups. These differences have implications for developing strategies to increase physical activity through walking.

Prior research has identified associations between social-environmental factors and metabolic syndrome (MetS) components. The physiological mechanisms underlying these associations are not fully understood, but alterations in activity of the hypothalamic-pituitary-adrenal axis, a stress-responsive biological system, have been hypothesized to play a role.The aim of the study was to determine whether MetS diagnosis and specific clusters of MetS components (waist circumference, high-density lipoproteins, glucose, and blood pressure) are associated with cortisol levels.We conducted cross-sectional analyses of data from the Multi-Ethnic Study of Atherosclerosis (MESA) study in the general community.We studied a population-based sample of 726 adults (ages 48 to 89 yr) who do not have clinical diabetes.There were no interventions.Cortisol awakening response, cortisol decline across the waking day, and total cortisol output were analyzed (using 18 timed measures of salivary cortisol over 3 d).Overall, we found little evidence that the presence of MetS or its components is related to cortisol output or patterns. Contrary to expectation, the presence of MetS was associated with lower rather than higher area under the curve, and no consistent pattern was observed when MetS components or subsets of components were examined in relation to cortisol.Our findings do not support the hypothesis that differences in level or diurnal pattern of salivary cortisol output are associated with MetS among persons without clinical diabetes.

Background— Individuals living in primary care health professional shortage areas (PC-HPSA), often have difficulty obtaining medical care; however, no previous studies have examined association of PC-HPSA residence with prevalence of cardiovascular disease risk factors. Methods and Results— To examine this question, the authors used data from the Multi-Ethnic Study of Atherosclerosis baseline examination (2000–2002). Outcomes included the prevalence of diabetes, hypertension, hyperlipidemia, smoking, and obesity as well as the awareness and control of diabetes, hypertension, and hyperlipidemia. Multivariable Poisson models were used to examine the independent association of PC-HPSA residence with each outcome. Models were sequentially adjusted for demographics, acculturation, socioeconomic status, access to health care, and neighborhood socioeconomic status. Similar to the national average, 16.7% of Multi-Ethnic Study of Atherosclerosis participants lived in a PC-HPSA. In unadjusted analyses, prevalence rates of diabetes (14.8% versus 11.0%), hypertension (48.2% versus 43.1%), obesity (35.7% versus 31.1%), and smoking (15.5% versus 12.1%) were significantly higher among residents of PC-HPSAs. There were no significant differences in the awareness or control of diabetes, hypertension, or hyperlipidemia. After adjustment, residence in a PC-HPSA was not independently associated with cardiovascular disease risk factor prevalence, awareness, or control. Conclusions— This study suggests that increased prevalence of cardiovascular disease risk factors in PC-HPSAs are explained by the demographic and socioeconomic characteristics of their residents. Future interventions aimed at increasing the number of primary care physicians may not improve cardiovascular risk without first addressing other factors underlying health care disparities.

Coronary heart disease (CHD) mortality is one of the major contributors to racial disparities in health in the United States (US). We examined spatial heterogeneity in black–white differences in CHD mortality across the US and assessed the contributions of poverty and segregation. We used county-level, age-adjusted CHD mortality rates for blacks and whites in the continental US between 1996 and 2006. Geographically weighted regression was employed to assess spatial heterogeneity. There was significant spatial heterogeneity in black–white differences in CHD mortality (median black–white difference 17.7 per 100,000, 25th–75th percentile (IQR): 4.0, 34.0, P value for spatial non-stationarity < 0.0001) before controlling for poverty and segregation. This heterogeneity was no longer present after accounting for county differences in race-specific poverty and segregation and interactions of these variables with race (median black–white difference −13.5 per 100,000, IQR: −41.3, 15.7, P value for spatial non-stationarity = 0.4346). The results demonstrate the importance of spatial heterogeneity in understanding and eliminating racial disparities in CHD mortality. Additional research to identify the individual and contextual factors that explain the local variations in racial disparities is warranted.

Sex differences in cardiovascular disease mortality are more pronounced among non-Hispanic whites than other racial/ethnic groups, but it is unknown whether this variation is present in the earlier subclinical stages of disease. The authors examined racial/ethnic variation in sex differences in coronary artery calcification (CAC) and carotid intimal media thickness at baseline in 2000-2002 among participants (n = 6,726) in the Multi-Ethnic Study of Atherosclerosis using binomial and linear regression. Models adjusted for risk factors in several stages: age, traditional cardiovascular disease risk factors, behavioral risk factors, psychosocial factors, and adult socioeconomic position. Women had a lower prevalence of any CAC and smaller amounts of CAC when present than men in all racial/ethnic groups. Sex differences in the prevalence of CAC were more pronounced in non-Hispanic whites than in African Americans and Chinese Americans after adjustment for traditional cardiovascular disease risk factors, and further adjustment for behavioral factors, psychosocial factors, and socioeconomic position did not modify these results (for race/sex, P(interaction) = 0.047). Similar patterns were observed for amount of CAC among adults with CAC. Racial/ethnic variation in sex differences for carotid intimal media thickness was less pronounced. In conclusion, coronary artery calcification is differentially patterned by sex across racial/ethnic groups.

A blunted blood pressure (BP) decline during sleep is a significant predictor of mortality1–3 and cardiovascular disease (CVD) related outcomes,4 including cardiac hypertrophy, dysfunction, and structure,5,6 congestive heart failure,7 and renal insufficiency.8 African Americans (AA) are more likely than whites to experience blunted BP dipping or absence of BP dipping during sleep.9 This insufficient BP decline may contribute to existing disparities in CVD and renal outcomes. Important questions remain regarding the main risk factors for nondipping BP, especially in AA. The association of low socioeconomic position (SEP) with cardiovascular risk factors, including elevated BP is well recognized.10–14 Adverse neighborhood characteristics (e.g., socioeconomic disadvantage) have also been linked to poor cardiovascular outcomes and higher BP, even after adjustment for individual-level SEP (e.g., annual household income).12–19 Few studies have investigated the associations of individual and neighborhood SEP with BP dipping. Although three studies have reported associations of BP dipping with individual-level measures of SEP, sample sizes were small (the largest being 174 participants).20–22 We investigated associations of individual and neighborhood SEP measures with diurnal and nocturnal ambulatory BP measures in a large population-based sample of AA adults. We hypothesized that lower individual and neighborhood SEP would be associated with less BP dipping during sleep and that these associations would be independent of behavioral factors, body mass index (BMI), and other potential confounders.

Background Active transportation including walking and bicycling is an important source of physical activity. Promoting active transportation is a challenge for the fields of public health and transportation. Descriptive data on the predictors of active transportation, including seasonal patterns in active transportation in the US as a whole, is needed to inform interventions and policies. Methods This study analyzed monthly variation in active transportation for the US using National Household Travel Survey 2001 data. For each age group of children, adolescents, adults and elderly, logistic regression models were used to identify predictors of the odds of active transportation including gender, race/ethnicity, household income level, geographical region, urbanization level, and month. Results The probability of engaging in active transportation was generally higher for children and adolescents than for adults and the elderly. Active transportation was greater in the lower income groups (except in the elderly), was lower in the South than in other regions of the US, and was greater in areas with higher urbanization. The percentage of people using active transportation exhibited clear seasonal patterns: high during summer months and low during winter months. Children and adolescents were more sensitive to seasonality than other age groups. Women, non-Caucasians, persons with lower household income, who resided in the Midwest or Northeast, and who lived in more urbanized areas had greater seasonal variation. Conclusions These descriptive results suggest that interventions and policies that target the promotion of active transportation need to consider socio-demographic factors and seasonality.

Research to date demonstrates a relationship between exposure to ambient air pollutants and cardiovascular disease. Many studies have shown associations between short-term exposures to elevated levels of air pollutants and cardiovascular disease events, and several cohort studies suggest effects of long-term exposure on cardiovascular mortality, coronary heart disease events, and stroke. The biological mechanisms underlying this chronic exposure relationship are not entirely clear, but are hypothesized to include systemic inflammation, autonomic nervous system imbalance, changes in vascular compliance, altered cardiac structure, and development of atherosclerosis. The Multi-Ethnic Study of Atherosclerosis provides an especially well-characterized population in which to investigate the relationship between air pollution and cardiovascular disease and to explore these biological pathways. This paper reviews findings reported to date within this cohort, and summarizes the aims and anticipated contributions of a major ancillary study, the Multi-Ethnic Study of Atherosclerosis and Air Pollution.

Environmental effects on walking behavior have received attention in recent years because of the potential for policy interventions to increase population levels of walking. Most epidemiologic studies describe associations of walking behavior with environmental features. These analyses ignore the dynamic processes that shape walking behaviors. A spatial agent-based model (ABM) was developed to simulate people's walking behaviors within a city. Each individual was assigned properties such as age, SES, walking ability, attitude toward walking and a home location. Individuals perform different activities on a regular basis such as traveling for work, for basic needs, and for leisure. Whether an individual walks and the amount she or he walks is a function of distance to different activities and her/his walking ability and attitude toward walking. An individual's attitude toward walking evolves over time as a function of past experiences, walking of others along the walking route, limits on distances walked per day, and attitudes toward walking of the other individuals within her/his social network. The model was calibrated and used to examine the contributions of land use and safety to socioeconomic differences in walking. With further refinement and validation, ABMs may help to better understand the determinants of walking and identify the most promising interventions to increase walking.

In 2002 the United States Preventive Services Task Force and the American Heart Association recommended aspirin for the primary prevention of Coronary Heart Disease (CHD) in individuals with a Framingham risk score ≥ 6% or ≥ 10%, respectively. The regular use of aspirin (≥ 3 days per week) was examined in a cohort of 6452 White, Black, Hispanic, and Chinese individuals without cardiovascular disease in 2000-2002 and 5181 individuals from the same cohort in 2005-2007. Framingham risk scores were stratified into low (< 6%), increased (6% to 9.9%), and high risk (≥ 10%). In 2000-2002 the prevalence of aspirin use was 18% and 27% for those at increased and high risk, respectively. Whites (25%) used aspirin more than Blacks (14%), Hispanics (12%), or Chinese (14%) (P < 0.001) in the increased risk group. Corresponding prevalences for the high risk group were 38%, 25%, 17%, and 21%, respectively (P < 0.001). In 2005-2007 the prevalence of aspirin use was 31% and 44% for those at increased and high risk, respectively. Whites (41%) used aspirin more than Blacks (27%), Hispanics (24%), or Chinese (15%) in the increased risk group (P < 0.001). Corresponding prevalences for the high risk group were 53%, 43%, 38%, and 28%, respectively (P < 0.001). Racial/ethnic differences persisted after adjustment for age, gender, diabetes, income, and education. In conclusion, regular aspirin use in adults at increased and high risk for CHD remains suboptimal. Important racial/ethnic disparities exist for unclear reasons.

Cardiovascular disease (CVD) epidemiology is often presented as the paradigm for an approach to prevention that focuses on identifying individual-level risk factors and intervening on them through behavioral change (eg, diet and physical activity interventions) or through the early detection and treatment of biomedical risk factors (such as high blood pressure or dyslipidemias). At times, this approach has been criticized for failing to consider the more distal causes of these individual-level risk factors (many times of a social or economic nature) that drive the distributions of the proximal risks factors, shape population-level differences in cardiovascular risk, and present large potential opportunities for CVD prevention. Article see p 2262 In parallel to the risk factor approach, a long tradition in CVD epidemiology has documented the social patterning of CVD and the impact of a number of distal factors, including social class, work environments, and neighborhood environments, on cardiovascular events and risk factors. The article by Arcaya et al1 in this issue of Circulation on the links between foreclosures and blood pressure falls squarely within the latter tradition that aims to place CVD within social and economic contexts. Spurred perhaps in part by recent economic circumstances in the United States and worldwide, a growing body of work has attempted to document the health consequences of economic recessions or exposures to specific conditions (such as job loss, financial stress, or experiences of losing a home) that may be more common during recessions. As in other areas of health research, clearly specifying the causal question of interest is key. Precisely specifying the causal question is particularly important in investigating the health effects of distal economic processes because the total population health impact of economic recessions (which may involve unfavorable effects for those experiencing unemployment counterbalanced or even exceeded by favorable effects associated with …

Objectives. We investigated associations of socioeconomic position (SEP) with chronic disease risk factors, and heterogeneity in this patterning by provincial-level urbanicity in Argentina. Methods. We used generalized estimating equations to determine the relationship between SEP and body mass index, high blood pressure, diabetes, low physical activity, and eating fruit and vegetables, and examined heterogeneity by urbanicity with nationally representative, cross-sectional survey data from 2005. All estimates were age adjusted and gender stratified. Results. Among men living in less urban areas, higher education was either not associated with the risk factors or associated adversely. In more urban areas, higher education was associated with better risk factor profiles (P < .05 for 4 of 5 risk factors). Among women, higher education was associated with better risk factor profiles in all areas and more strongly in more urban than in less urban areas (P < 0.05 for 3 risk factors). Diet (in men) and physical activity (in men and women) were exceptions to this trend. Conclusions. These results provide evidence for the increased burden of chronic disease risk among those of lower SEP, especially in urban areas.

Background. Accu lturation affects health, but it has never been studied with kidney disease. Methods. W e studied the association of language spoken at home, generation and birth place with kidney function among Hispanics and Chinese in the Multi-Ethnic Study of Atherosclerosis (n = 2999). Kidney function was determined by cystatin C (eGFRcys) and albumin/creatinine ratio (ACR). We evaluated mediators in models: Model 1 = age, sex,income, education; Model 2 = Model 1 + behaviors; and Model 3 = Model 1 + comorbidities. Results. A mong Hispanics, speaking mixed Spanish/ English was significantly associated with lower eGFRcys (−2 .83 mL/min/1.73 m 2 , −5.69–0.04) and higher ACR (RD 40%, 17–68%) compared with speaking Spanish only; this was mildly attenuated by behaviors (−2.2 9, −5.33–0.75; RD 42%, 18–72%) but not comorbidities (−3.04, −5.83 to −0.23); RD 35%, 14–59%). US-born Hispanics had lower eGFRcys compared with foreign-born Hispanics [1.83 mL/min/1.73 m 2 lower (0.97–1.31) for Generation 1; 1.37 mL/min/1.73 m 2 lower (0.75–1.57) for Generation ≥2]. In contrast, Chinese who spoke any English had higher eGFRcys (2.53, 95% CI: −1. 70–6.78), but similar ACR (RD −5%, 95% CI: −26–23%) compared with those speaking Chinese only, but associations were not statistically significant. Conclusion. Hi gher acculturation was associated with worse kidney function in Hispanics, mediated perhaps by behavioral factors but not comorbidities. Associations may be in the opposite direction among Chinese. Future studies are needed to elucidate these mechanisms.

BackgroundThe reasons for racial/ethnic disparities in hypertension (HTN) prevalence in the United States are poorly understood.MethodsUsing data from the Multi-Ethnic Study of Atherosclerosis (MESA), we investigated whether individual- and neighborhood-level chronic stressors contribute to these disparities in cross-sectional analyses. The sample consisted of 2,679 MESA participants (45-84 years) residing in Baltimore, New York, and North Carolina. HTN was defined as systolic or diastolic blood pressure ≥140 or 90 mm Hg, or taking antihypertensive medications. Individual-level chronic stress was measured by self-reported chronic burden and perceived major and everyday discrimination. A measure of neighborhood (census tract) chronic stressors (i.e., physical disorder, violence) was developed using data from a telephone survey conducted with other residents of MESA neighborhoods. Binomial regression was used to estimate associations between HTN and race/ethnicity before and after adjustment for individual and neighborhood stressors.ResultsThe prevalence of HTN was 59.5% in African Americans (AAs), 43.9% in Hispanics, and 42.0% in whites. Age- and sex-adjusted relative prevalences of HTN (compared to whites) were 1.30 (95% confidence interval (CI): 1.22-1.38) for AA and 1.16 (95% CI: 1.04-1.31) for Hispanics. Adjustment for neighborhood stressors reduced these to 1.17 (95% CI: 1.11-1.22) and 1.09 (95% CI: 1.00-1.18), respectively. Additional adjustment for individual-level stressors, acculturation, income, education, and other neighborhood features only slightly reduced these associations.ConclusionNeighborhood chronic stressors may contribute to race/ethnic differences in HTN prevalence in the United States.American Journal of Hypertension (2010). doi:10.1038/ajh.2010.200. Language: en

Higher socioeconomic status (SES) has been associated with lower respiratory mortality and better lung function, but whether a similar gradient exists for computed tomography (CT) measures of subclinical emphysema is unknown.The Multi-Ethnic Study of Atherosclerosis (MESA) recruited African-American, Chinese, Hispanic, and white participants, ages 45 to 84 years, without clinical cardiovascular disease, from six US sites between 2000 and 2002. The MESA Lung Study assessed percent emphysema, defined based on the proportion of pixels below an attenuation threshold of 910 HU from lung windows of cardiac CT scans. Generalized linear models were adjusted for demographic characteristics, height, body mass index, history of respiratory illness, occupational and residential exposures, tobacco use, and CT scanner type.Among 3706 participants with a mean age of 61 (±10), the median value for percent emphysema was 18 (interquartile range = 20). Compared with those who did not complete high school, participants with a graduate degree had a higher percent emphysema (difference of 4; P.001). Income and wealth were also positively associated with percent emphysema. In contrast, higher SES was associated with better lung function. Descriptive and subgroup analyses were used to explore potential explanations for divergent results, including the possibility that suboptimal inspiration during CT scanning would decrease percent emphysema, making the lungs appear healthier when effort is relatively poor.Although SES indicators were positively associated with subclinical emphysema detectable on CT scan, this unexpected association may highlight potential bias because of effort dependence of both CT measures and spirometry.

Immigrants have a different social context from those who stay in their home country or those who were born to the country that immigrants now live. Cultural theory of risk perception suggests that social context influences one’s interpretation of questionnaire items. We examined psychometric properties of job control and job demand scales with US- and foreign-born workers who preferred English, Spanish, or Chinese (n=3114, mean age=58.1). Across all groups, the job control scale had acceptable Cronbach’s alpha (0.78–0.83) and equivalent factor loadings (ΔCFI