Racial/Ethnic Differences in Women's Life Event Exposure Across Midlife

OBJECTIVE

Stressful life events are associated with poorer physical, cognitive, and mental health. Examining life events trends across midlife illustrates normative experiences of stress in a critical life period for intervention and disease prevention. Further, there is a critical need for research with racially/ethnically diverse samples to identify differences in life event exposure, as they may relate to later health disparities.

METHOD

Annual life event reports were analyzed from 3,066 White, Black, Hispanic, Chinese, and Japanese women in the Study of Women's Health Across the Nation. Across ages 43-65, longitudinal trajectories were fit to annual number of life events and 9 subcategories of life events (i.e., work problems, economic problems, partner unemployment, illness/accident of loved one, caregiving, bereavement, relationship problems, family legal/police problems, and violent events that happened to the self or family). Racial/ethnic differences were examined, controlling for education.

RESULTS

Number of annual life events declined with age and plateaued in later midlife. This pattern was largely consistent across types of life events, though family health and bereavement-related life events increased in later midlife. Compared to White women, Black women experienced more life events, while Chinese, Hispanic, and Japanese women experienced fewer life events. Racial/ethnic differences were amplified in specific subtypes of life events.

DISCUSSION

Racial/ethnic differences in exposure to life events across midlife may contribute to racial/ethnic health disparities in later life.

Intercensal and Postcensal Estimation of Population Size for Small Geographic Areas in the United States

Introduction

Population estimation techniques are often used to provide updated data for a current year. However, estimates for small geographic units, such as census tracts in the United States, are typically not available. Yet there are growing demands from local policy making, program planning and evaluation practitioners for such data because small area population estimates are more useful than those for larger geographic areas.

Objectives

To estimate the population sizes at the census block level by subgroups (age, sex, and race/ethnicity) so that the population data can be aggregated up to any target small geographic areas.

Methods

We estimated the population sizes by subgroups at the census block level using an intercensal approach for years between 2000 and 2010 and a postcensal approach for the years following the 2010 decennial census (2011-2017). Then we aggregated the data to the county level (intercensal approach) and incorporated place level (postcensal approach) and compared our estimates to corresponding US Census Bureau (the Census) estimates.

Results

Overall, our intercensal estimates were close to the Census’ population estimates at the county level for the years 2000-2010; yet there were substantive errors in counties where population sizes experienced sudden changes. Our postcensal estimates were also close to the Census’ population estimates at the incorporated place level for years closer to the 2010 decennial census.

Conclusion

The approaches presented here can be used to estimate population sizes for any small geographic areas based on census blocks. The advantages and disadvantages of their application in public health practice should be considered.

0177 Measuring Sleep Health Across Survey, Actigraphy, and Diary Methods in Young Adults

Introduction

Sleep health is a relatively new construct including multiple dimensions of nighttime and daytime sleep across the 24-hour day. To date, few studies have investigated sleep health across various types of sleep measures. We collected sleep health data using survey, actigraphy, and daily diary, affording the unique ability to compare the latent factor structure of the sleep health construct across methods in a single sample of healthy young adults.

Methods

Undergraduates (N=540; 50% female; 71% white; mean age=18) self-reported sleep health via the 6-item RUSATED survey (Buysse, 2014), which queries “typical” sleep patterns including: daytime alertness and nocturnal sleep regularity, satisfaction, timing, efficiency, and duration (0=rarely/never to 2=usually/always); total score=0–12 (higher=better sleep health). A subsample (N=114) provided 7-day actigraphy and daily diaries, which were used to derive weeklong averages of the aforementioned sleep dimensions. Confirmatory factor analysis was conducted to assess model fit of three factors (survey, actigraphy, diary), each including within-method indicators of the six sleep dimensions; note the actigraphy model included diary satisfaction. Acceptable model fit was assessed using established criteria (e.g., Bentler, 1990): RMSEA < .08, CFI > .90, and TLI > .90. Maximum likelihood estimation was used.

Results

Average RUSATED total score was 7.1 (SD=2.5). Average actigraphy [diary] sleep dimensions were: Alertness (i.e., proportion of days napped)=21% [25%]; Duration=6.2hr [7.1hr]; Timing (i.e., midpoint)=5:00am [3:30am]; Regularity (i.e., SD of midpoint)=56 min [40 min]; Efficiency= 82% [95%]; Satisfaction=“average” to “good”. The survey model demonstrated acceptable fit (RMSEA [90%CI] = .06 [.03, .09], CFI=.96, TLI=.92) after correlating regularity and timing, as suggested by modification indices; factor loadings [λ(SE)] ranged from .27(.05) for efficiency to .71(.04) for satisfaction. Fit was poor for the diary model, whereas the actigraphy model failed to converge.

Conclusion

Sleep health models demonstrated adequate fit using survey but not actigraphy or diary data. The lack of acceptable fit for the latter may reflect differences in the measurement timeframe (e.g., “typical” sleep vs. 7-day averages) or the smaller sample size for the actigraphy/diary measures. Determining how to best measure sleep health and ultimately apply it to health-relevant outcomes is a valuable research agenda.

Support

T32HL07560; T32MH018269

0342 Self-Silencing within Intimate Relationships, Sleep, and Subclinical Atherosclerosis in Midlife Women

Introduction

Social relationships are important for health. In some relationships, women learn to self-silence, or to inhibit self-expression to avoid conflict or loss. Self-silencing is associated with reported psychiatric and physical symptoms, but no studies have examined whether self-silencing is related to worse sleep or cardiovascular (CV) health. We tested relationships of self-silencing to sleep and carotid plaque in midlife women; secondary analyses examined whether sleep mediated or moderated relationships between self-silencing and plaque.

Methods

In an ongoing community-based study of nonsmoking women, 304 women aged 40-60 were assessed at baseline; 157 of these women have been assessed 5 years later. At baseline, women reported on self-expression in their current/last intimate relationship via the Silencing the Self Scale. At both visits, women provided self-reports (demographics, medical history, CESD depression, PSQI sleep quality), physical measures, actigraphy (total sleep time [TST], wake after sleep onset [WASO], and efficiency), and carotid artery ultrasound to quantify plaque. Relationships of self-silencing and subscales to sleep (subjective and actigraphic sleep at baseline and averaged across visits) and carotid plaque (0, 1, ≥2) were tested in linear regression and multinomial regression models, respectively, adjusted for demographic and health indices, including depressive symptoms and snoring.

Results

At baseline, women (72% White) were on average 54 years old; 44% reported poor sleep quality, 46% had plaque (24% score ≥2), and average TST, WASO, and efficiency were 6.2 hrs, 46 min, and 84%, respectively. At baseline, self-silencing (particularly the tendency to judge oneself by external standards) was related to worse sleep quality (p=.001), but better actigraphic WASO (p=.02) and efficiency (p=.02). Self-silencing was related to worse average sleep quality across visits (p=.001). Self-silencing related to higher odds of baseline plaque ≥2 [OR(95% CI)=1.14 (1.02,1.28), p=.02], yet sleep did not explain or moderate this relationship.

Conclusion

Self-silencing was associated with worse subjective, but better actigraphic sleep at baseline, and with poorer sleep quality over 5 years. Self-silencing related to carotid atherosclerosis, yet sleep did not appear to impact this relationship. Emotional expression is relevant to midlife women’s sleep and CV health.

Support

R01HL105647, K24123565 (RCT); RF1AG053504 (RCT & PM); T32MH018269 (KPJ)

Oxidative stress, anti-oxidants and the cross-sectional and longitudinal association with depressive symptoms: results from the CARDIA study

Depression may be accompanied by increased oxidative stress and decreased circulating anti-oxidants. This study examines the association between depressive symptoms, F2-isoprostanes and carotenoids in a US community sample. The study includes 3009 participants (mean age 40.3, 54.2% female) from CARDIA (Coronary Artery Risk Development in Young Adults). Cross-sectional analyses were performed on data from the year 15 examination (2000-2001) including subjects whose depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale (CES-D) and had measurements of plasma F2-isoprostanes (gas chromatography/mass spectrometry) or serum carotenoids (high-performance liquid chromatography). Carotenoids zeaxanthin/lutein, β-cryptoxanthin, lycopene, α-carotene, β-carotene were standardized and summed. Longitudinal analyses were conducted using the data from other examinations at 5-year intervals. Cross-lagged analyses investigated whether CES-D predicted F2-isoprostanes or carotenoids at the following exam, and vice versa. Regression analyses were controlled for sociodemographics, health and lifestyle factors. F2-isoprostanes were higher in subjects with depressive symptoms (CES-D ⩾ 16) after adjustment for sociodemographics (55.7 vs 52.0 pg ml(-1); Cohen's d = 0.14, P < 0.001). There was no difference in F2-isoprostanes after further adjustment for health and lifestyle factors. Carotenoids were lower in those with CES-D scores ⩾ 16, even after adjustment for health and lifestyle factors (standardized sum 238.7 vs 244.0, Cohen's d = -0.16, P < 0.001). Longitudinal analyses confirmed that depression predicts subsequent F2-isoprostane and carotenoid levels. Neither F2-isoprostanes nor carotenoids predicted subsequent depression. In conclusion, depressive symptoms were cross-sectionally and longitudinally associated with increased F2-isoprostanes and decreased carotenoids. The association with F2-isoprostanes can largely be explained by lifestyle factors, but lower carotenoids were independently associated with depressive symptoms.

Body mass index following natural menopause and hysterectomy with and without bilateral oophorectomy

OBJECTIVE

The directional and temporal nature of relationships between overweight and obesity and hysterectomy with or without oophorectomy is not well understood. Overweight and obesity may be both a risk factor for the indications for these surgeries and a possible consequence of the procedure. We used prospective data to examine whether body mass index (BMI) increased more following hysterectomy with and without bilateral oophorectomy compared with natural menopause among middle-aged women.

METHODS

BMI was assessed annually for up to 10 years in the Study of Women's Health Across the Nation (SWAN (n=1962)). Piecewise linear mixed growth models were used to examine changes in BMI before and after natural menopause, hysterectomy with ovarian conservation and hysterectomy with bilateral oophorectomy. Covariates included education, race/ethnicity, menopausal status, physical activity, self-rated health, hormone therapy use, antidepressant use, age and visit before the final menstrual period (FMP; for natural menopause) or surgery (for hysterectomy/oophorectomy).

RESULTS

By visit 10, 1780 (90.6%) women reached natural menopause, 106 (5.5%) reported hysterectomy with bilateral oophorectomy and 76 (3.9%) reported hysterectomy with ovarian conservation. In fully adjusted models, BMI increased for all women from baseline to FMP or surgery (annual rate of change=0.19 kg m(-2) per year), with no significant differences in BMI change between groups. BMI also increased for all women following FMP, but increased more rapidly in women following hysterectomy with bilateral oophorectomy (annual rate of change=0.21 kg m(-2) per year) as compared with following natural menopause (annual rate of change=0.08 kg m(-2) per year, P=0.03).

CONCLUSION

In this prospective examination, hysterectomy with bilateral oophorectomy was associated with greater increases in BMI in the years following surgery than following hysterectomy with ovarian conservation or natural menopause. This suggests that accelerated weight gain follows bilateral oophorectomy among women in midlife, which may increase risk for obesity-related chronic diseases.

Major depression during and after the menopausal transition: Study of Women's Health Across the Nation (SWAN)

BACKGROUND

It is unclear whether risk for major depression during the menopausal transition or immediately thereafter is increased relative to pre-menopause. We aimed to examine whether the odds of experiencing major depression were greater when women were peri- or post-menopausal compared to when they were pre-menopausal, independent of a history of major depression at study entry and annual measures of vasomotor symptoms (VMS), serum levels of, or changes in, estradiol (E2), follicular stimulating hormone (FSH) or testosterone (T) and relevant confounders.

METHOD

Participants included the 221 African American and Caucasian women, aged 42-52 years, who were pre-menopausal at entry into the Pittsburgh site of a community-based study of menopause, the Study of Women's Health Across the Nation (SWAN). We conducted the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) to assess diagnoses of lifetime, annual and current major depression at baseline and at annual follow-ups. Psychosocial and health factors, and blood samples for assay of reproductive hormones, were obtained annually.

RESULTS

Women were two to four times more likely to experience a major depressive episode (MDE) when they were peri-menopausal or early post-menopausal. Repeated-measures logistic regression analyses showed that the effect of menopausal status was independent of history of major depression and annually measured upsetting life events, psychotropic medication use, VMS and serum levels of or changes in reproductive hormones. History of major depression was a strong predictor of major depression throughout the study.

CONCLUSIONS

The risk of major depression is greater for women during and immediately after the menopausal transition than when they are pre-menopausal.

Interpersonal violence in childhood as a risk factor for obesity: a systematic review of the literature and proposed pathways

We examined the associations between exposure to interpersonal violence in childhood and risk for obesity and central adiposity. Interpersonal violence is defined as behaviour that threatens, attempts or causes physical harm. In addition, we evaluated the evidence for three mechanisms that may connect interpersonal violence to obesity: negative affect, disordered eating and physical inactivity. Based on a literature search of Medline and PsycInfo databases, 36 separate studies were evaluated and ranked based on quality. Approximately 81% of the studies reported a significant positive association between some type of childhood interpersonal violence and obesity, although 83% of the studies were cross-sectional. Associations were consistent for caregiver physical and sexual abuse and peer bullying, and there was mixed evidence for community violence. Although few studies explored mechanisms, early evidence suggests that negative affect and disordered eating may be involved. More prospective studies are needed, as well as studies that examine the mechanisms connecting early childhood victimization to obesity and central adiposity.

An Analysis of Male-Recombination Elements in a Natural Population of DROSOPHILA MELANOGASTER in South Texas

Genomes from a group of Drosophila melanogaster collected from a natural population at San Benito, South Texas, in March of 1975 were analyzed for the presence of male-recombination elements. All three autosomes and both sex chromosomes were examined, with emphasis placed on the two major autosomes, the second and third chromosomes. In samples of 16 second and 16 third chromosomes, at least half, but not all, of each were found to carry male-recombination elements. It is suggested, although the data are not conclusive, that some of the fourth, X, and Y chromosomes might also be associated with male-recombination elements.-When a male-recombination element, or elements, was located in the second chromosome, relatively more male recombination was induced in the second than in the third chromosome. This situation was reversed when the element(s) was located in the third chromosome.-Distortion of transmission frequency, one of the characteristics of previously studied second chromosome lines associated with male recombination, was confirmed for these second chromosomes that carried male-recombination elements. Similar, but less pronounced, distortion was observed for the third chromosome lines that carried male-recombination elements.

Blood pressure dipping and sleep disturbance in African-American and Caucasian men and women

BACKGROUND

Elevated night time/daytime blood pressure (BP) ratios are associated with cardiovascular morbidity and mortality. We evaluated the associations between sleep/awake BP ratios and sleep disturbances.

METHODS

Sleep disturbances were assessed by in-home actigraphy and diary measures for nine nights, and polysomnography (PSG) for two nights; ambulatory BP was measured for at least 48 h. Participants were 186 middle-aged African-American and Caucasian men and women who were free from prevalent myocardial infarction, stroke, history of interventional cardiology procedures, diabetes, and diagnosed apnea or other sleep disorders.

RESULTS

Results showed that the greater the sleep/wake ratios of BP, the more fragmented the sleep, the greater the proportion in stage 1 (light) sleep and the smaller the proportion in rapid eye movement (REM) sleep, and the greater the number of arousals from sleep. These results were independent of age, race, gender, Framingham Risk status, cardiovascular medications, body mass index, and apnea/hypopnea index. Indicators of psychosocial stress were not greater among those with higher sleep/wake BP ratios.

CONCLUSIONS

Findings are consistent with the hypothesis that elevated night time/daytime pressure may be a consequence of poor sleep.

Factors related to declining luteal function in women during the menopausal transition

CONTEXT

Reproductive hormones are incompletely characterized during the menopause transition (MT).

HYPOTHESIS

Increased anovulation and decreased progesterone accompany progress through the MT.

DESIGN

The Daily Hormone Study (DHS) of the Study of Women's Health Across the Nation (SWAN) included 848 women aged 43-53 yr at baseline who collected daily urine for one cycle or up to 50 d annually for 3 yr.

MAIN OUTCOME MEASURES

LH, FSH, estrone conjugates, and pregnanediol glucuronide levels were assessed. Cycles were classified by presumed luteal (ovulatory) status and bleeding. Hormones were related to time in study, age, menopausal status, and selected variables.

RESULTS

Ovulatory-appearing cycles declined from 80.9% at baseline to 64.7% by the third assessment (H3). Cycles presumed anovulatory and not ending with bleeding by 50 d (anovulatory/nonbleeding) increased from 8.4 to 24% by H3 and were associated with progress to early perimenopause [odds ratio (OR) = 2.66; confidence interval (CI) = 1.17-6.04] or late perimenopause (OR = 56.21; CI = 18.79-168.12; P < 0.0001), African-American ethnicity (OR = 1.91; CI = 1.06-3.43), and less than high school education (OR = 3.51; CI = 1.62-7.62). Anovulatory cycles ending with bleeding remained at about 10% from baseline to H3; compared with ovulatory cycles, they were associated with obesity (OR = 4.68; CI = 1.33-16.52) and more than high school education (OR = 2.12; CI = 1.22-3.69; P = 0.02). Serum estradiol in both the highest and lowest categories was associated with anovulatory/nonbleeding collections. Pregnanediol glucuronide decreased 6.6% for each year on study. Insulin sensitivity measures did not relate strongly to menstrual cycle hormones.

CONCLUSIONS

Anovulation without bleeding represents progression of the MT. A small but detectable decrease in luteal progesterone excretion occurs as women progress through the MT.

The association of bone mineral density measures with incident cardiovascular disease in older adults

The associations of volumetric and areal bone mineral density (BMD) measures with incident cardiovascular disease (CVD) were studied in a biracial cohort of 2,310 older adults. BMD measures were inversely related to CVD in women and white men, independent of age and shared risk factors for osteoporosis and CVD.

INTRODUCTION

We investigated the associations of volumetric (vBMD) and areal (aBMD) bone mineral density measures with incident cardiovascular disease (CVD) in older adults enrolled in the Health, Aging, and Body Composition study.

METHODS

The incidence of CVD was ascertained in 2,310 well-functioning white and black participants (42% black; 55% women), aged 68-80 years. aBMD measures of the hip were assessed using DXA. Spine trabecular, integral, and cortical vBMD measures were obtained using QCT.

RESULTS

During an average follow-up of 5.4 years, 23% of men and 14% of women had incident CVD. Spine vBMD measures were inversely associated with incident CVD in white men [HR(integral)=1.39, 95% CI 1.03-1.87; HR(cortical)=1.38, 95% CI 1.03-1.84], but not in black men. In women, aBMD measures of the total hip (HR = 1.36, 95% CI 1.03-1.78), femoral neck (HR = 1.44, 95% CI 1.10-1.90), and trochanter (HR = 1.34, 95% CI 1.04-1.72) exhibited significant associations with CVD in blacks, but not in whites. All associations were independent of age and shared risk factors between osteoporosis and CVD, and were not explained by inflammatory cytokines or oxidized LDL.

CONCLUSION

Our results provide support for an inverse association between BMD and incident CVD. Further research should elucidate possible pathophysiological mechanisms linking osteoporosis and CVD.

Discrimination and unfair treatment: relationship to cardiovascular reactivity among African American and European American women

This study examined the relationship of cardiovascular reactivity to both interpersonal mistreatment and discrimination in a community-based sample of African American and European American women (N=363) in midlife. Subtle mistreatment related positively to diastolic blood pressure (DBP) reactivity for African American participants but not their European American counterparts. Moreover, among the African American participants, those who attributed mistreatment to racial discrimination exhibited greater average DBP reactivity. In particular, these women demonstrated greater DBP reactivity to the speech task, which bore similarities to an encounter with racial prejudice but not to a nonsocial mirror tracing task. These findings are consistent with the hypothesis that racial discrimination is a chronic stressor that can negatively impact the cardiovascular health of African Americans through pathogenic processes associated with physiologic reactivity.

Educational attainment and coronary and aortic calcification in postmenopausal women

OBJECTIVE

Low socioeconomic status is a risk factor for clinical coronary heart disease, a relatively crude outcome associated with important biases. By avoiding these biases, subclinical assessments could facilitate efforts to understand the association between socioeconomic status and coronary disease. The current study 1) evaluated the nature of the associations between educational attainment and subclinical atherosclerosis and 2) examined if biologic, behavioral, and psychosocial factors mediated these associations.

METHODS

Participants were 308 women from the Healthy Women Study who underwent a clinic examination of risk factors either 5 (N = 32) or 8 (N = 276) years after the menopausal transition. Aortic and coronary calcification were measured using electron beam tomography.

RESULTS

Logistic regression analysis with orthogonal polynomials revealed a marginally significant linear trend for coronary calcification, with the more educated groups showing lower calcification than the less educated groups. A significant linear trend was also observed for aortic calcification. In addition, a marginally significant quadratic trend was observed for aortic calcification so that the effect began to reverse at the highest level of education. Measured risk factors were associated with education and with the calcification outcomes, but they explained little of the associations between educational attainment and coronary or aortic calcification. None of the factors tested met the minimum criterion for mediation.

CONCLUSIONS

The findings show that lower education is associated with greater early stage atherosclerosis. Subclinical assessments, such as electron beam tomography, represent useful alternatives for studies of socioeconomic status and coronary artery disease.

Chronic stress influences cardiovascular and neuroendocrine responses during acute stress and recovery, especially in men

This study tests the influence of chronic stress on cardiovascular and neuroendocrine responses to and recovery from acute stressors and whether the effects are gender specific. Sixty-two healthy, middle-aged persons (50% women) performed mental-arithmetic and public-speaking tasks and relaxed thereafter for 1 hr while their cardiovascular and neuroendocrine function was measured. Participants with higher levels of chronic stress showed lower systolic blood pressure (SBP) and epinephrine (E; men only) and marginally lower levels of norepinephrine (NE) responses to the tasks and showed lower levels of cortisol and marginally lower NE responses during recovery. Relative to women, men had high diastolic blood pressure (DBP) responses to the tasks and high SBP, DBP, and E responses during recovery. Gender differences in cardiovascular disease in midlife may be due to gender differences in the inability to recover quickly, in addition to enhanced acute-stress response.

Cognitive appraisal biases: an approach to understanding the relation between socioeconomic status and cardiovascular reactivity in children

We tested the hypothesis that lower socioeconomic status (SES) children display heightened cardiovascular reactivity during stressful situations because they are more likely to appraise a wide variety of social situations, including ambiguous ones, as threatening. A sample of 201 children and adolescents, half White and half African American, were assessed initially. Ninety of these children were retested an average of 3 years later. At both time points, children were interviewed about appraisals of hostile intent and feelings of anger in response to scenarios with negative or ambiguous outcomes. Cardiovascular reactivity to 3 laboratory stress tasks was measured. Initially, lower SES was associated with greater hostile intent appraisal and anger during ambiguous scenarios across all participants. In addition, responses to ambiguous scenalios partially mediated the relation between SES and vascular reactivity. Longitudinally, low SES African American participants showed higher mean intensity of hostile intent appraisals during ambiguous scenarios, and these appraisals mediated the SES-reactivity relationship. These findings suggest that the way in which children appraise ambiguous social situations plays an important role in the relation between SES and cardiovascular reactivity.

Trajectory of psychological risk and incident hypertension in middle-aged women

The aim of the study was to test the hypotheses that the trajectory of psychological risk (ie, persistent or increasing measures of depression and anxiety symptoms, anger, and low social support over time) increases the risk for the development of hypertension and that blood pressure levels fluctuate with psychological changes in women. Initially, healthy normotensive middle-aged women (n=541; 90.6% white, 8.9% African American) were followed across an average of 9.2 years of follow-up. Psychological characteristics were assessed repeatedly via standardized questionnaires, and Cox proportional hazards and random regression models were used to analyze their impact, adjusting for hypertension risk factors (age, race, years of education, parental history of hypertension, baseline blood pressure, body mass index, physical activity, alcohol use, and cigarette smoking). Seventy-five women became hypertensive during the follow-up period. Baseline levels of depression, anxiety, anger, and social support did not predict subsequent hypertension. A high level of anxiety throughout the follow-up, an increase in the level of feelings of anger, and a decrease in the level of social support over the follow-up were significant predictors of hypertension incidence (all P<0.05), although covariate adjustment reduced some of the significance levels to nonsignificance. In women, increases in depressive symptoms were significantly associated (P=0.003) with concurrent increases in the level of systolic blood pressure, especially among hypertensive patients (P=0.0001). Increasing levels of anger, decreasing levels of social support, and high anxiety increase the likelihood of women's development of hypertension in midlife. These results emphasize the importance of evaluating the trajectory of psychological risk during the period of evolving hypertension.

Discrimination and unfair treatment: relationship to cardiovascular reactivity among African American and European American women

This study examined the relationship of cardiovascular reactivity to both interpersonal mistreatment and discrimination in a community-based sample of African American and European American women (N=363) in midlife. Subtle mistreatment related positively to diastolic blood pressure (DBP) reactivity for African American participants but not their European American counterparts. Moreover, among the African American participants, those who attributed mistreatment to racial discrimination exhibited greater average DBP reactivity. In particular, these women demonstrated greater DBP reactivity to the speech task, which bore similarities to an encounter with racial prejudice but not to a nonsocial mirror tracing task. These findings are consistent with the hypothesis that racial discrimination is a chronic stressor that can negatively impact the cardiovascular health of African Americans through pathogenic processes associated with physiologic reactivity.

Mortality of men versus women in comparable high-level jobs: 15-year experience in the Federal Women's Study

The authors investigated exposure to high-level occupations in relation to the well-known survival advantage of women compared with men of the same age. Women in the federal workforce in positions of General Schedule 14 and above in 1979--1993 (n = 4,727) were each matched with three men (n = 14,181) by age, General Schedule level, and supervisory role. Fifteen-year mortality rates were compared between men and women and against expected 15-year mortality from the US general population. Despite similar job demands, women experienced markedly lower 15-year mortality than did men. However, men in these positions had nearly 50% lower mortality compared with age-matched men in the general population; the comparable reduction for women was 38%. The simultaneous substantial, but unequal by gender, improvement in mortality resulted in a reduced male/female mortality ratio, from 1.67 in the general population to 1.40. The reduced male/female mortality ratio was especially prominent for cancer and was not evident for heart disease mortality. Survival was nominally higher in non-White than in White participants. In summary, high-level employment is associated with substantially reduced mortality in both men and women. The relative improvement in survival is greater in men despite a comparable reduction in risk of heart disease mortality by gender.

Body mass index in mid-life women: relative influence of menopause, hormone use, and ethnicity

OBJECTIVE

To assess the relative influence of menopausal status and hormone use on body mass index (BMI) among a multiethnic sample of mid-life women.

DESIGN

Cross-sectional telephone survey conducted at seven sites where each site targeted an ethnic minority group and Caucasians as part of Study of Women's Health Across the Nation (SWAN).

SUBJECTS

A total of 7181 Caucasians, 3949 African-Americans, 1660 Hispanics, 562 Chinese Americans, and 803 Japanese Americans between ages of 40 and 55 y residing in or near Boston, Chicago, Detroit, Los Angeles, Newark, NJ, Oakland, CA, and Pittsburgh, PA.

MEASUREMENTS

Self-reported BMI based on weight in kg divided by height in m(2) menopausal status, physical inactivity, postmenopausal hormone use, ethnicity, and age in years.

RESULTS

Compared to premenopausal women (covariate adjusted M=27.3), women reporting a surgical menopause (M=28.2) or being in the perimenopausal transition (M=27.7 for early and 27.9 for late perimenopause) had higher BMI. Women reporting a natural menopause (M=27.4) did not have a higher BMI than premenopausal women, after adjusting for chronological age and other covariates. Hormone use was associated with lower BMI (M=26.5 vs 27.3). A comparison of effect sizes showed that menopausal status (F=13.1), followed by chronological age (F=24.0), were the least powerful predictors of BMI, whereas the more powerful predictors were physical activity level (F=1377.1) and ethnicity (F=400.5).

CONCLUSIONS

The menopausal transition affects body mass index in mid-life, but the effect is small relative to other influences. Interventions to increase physical activity are highly recommended to prevent increases in adiposity common in mid-life.

Influence of estrogen replacement therapy on cardiovascular responses to stress of healthy postmenopausal women

Two experiments were conducted to understand the influence of estrogen exposure on cardiovascular responses to acute stress measured by impedance cardiography. Study I compared stress responses of 29 postmenopausal women who used postmenopausal hormone replacement therapy (HRT) and 29 who did not use HRT. Women who did not use HRT had higher systolic blood pressure and pulse pressure responses to the tasks relative to HRT users. Study 2 compared stress responses of 38 healthy postmenopausal women not initially on HRT who were randomly assigned to transdermal estradiol or placebo treatment for 6-8 weeks. HRT assignment did not influence substantially women's cardiovascular responses to stress. Characteristics correlated with HRT use, not HRT itself, or differences in type, duration, and dosage may account for the discrepancy in results.

Changes in cardiovascular risk factors during the perimenopause and postmenopause and carotid artery atherosclerosis in healthy women

BACKGROUND AND PURPOSE

The objectives of this study were to describe the changes in cardiovascular risk factors during the perimenopausal and early postmenopausal years and correlate those changes in risk factors with carotid intimal-medial thickness (IMT) and plaque index measured 5 to 8 years after menopause.

METHODS

Participants were women (n=372) from Allegheny County, Pennsylvania, enrolled in the Healthy Women Study who had been postmenopausal for at least 5 years. Risk factor changes were measured during the perimenopause, ie, between the premenopausal and first year postmenopausal examinations, and during the early postmenopause, ie, between the first and fifth year postmenopausal examinations. Carotid ultrasound scans measured IMT and plaque at examinations 5 to 8 years after menopause among 314 of the women.

RESULTS

Increases in LDL cholesterol and triglycerides and declines in HDL cholesterol were greater during perimenopause than postmenopause, whereas increases in blood pressure and fasting glucose levels were greater during postmenopause. Premenopausal systolic and pulse pressure, LDL and HDL cholesterol, triglycerides, and body mass index predicted IMT and plaque. Only the change in pulse pressure between premenopausal and first year postmenopausal examinations was related to both IMT and plaque.

CONCLUSIONS

Absolute risk for cardiovascular disease increases substantially in midlife, with a particularly adverse effect on lipid metabolism at the menopause. Premenopausal levels of risk factors are adequate to identify which women should be targeted for intervention.

Psychosocial variables are associated with atherosclerosis risk factors among women with chest pain: the WISE study

OBJECTIVE

We investigated associations between atherosclerosis risk factors (smoking behavior, serum cholesterol, hypertension, body mass index, and functional capacity) and psychological characteristics with suspected linkages to coronary disease (depression, hostility, and anger expression) in an exclusively female cohort.

METHODS

Six hundred eighty-eight middle-aged women with chest pain warranting clinical investigation completed a comprehensive diagnostic protocol that included quantitative coronary angiography to assess coronary artery disease (CAD). Primary analyses controlled for menopausal status, age, and socioeconomic status variables (income and education).

RESULTS

High depression scores were associated with a nearly three-fold risk of smoking (odds ratio (OR) = 2.8, 95% confidence interval (CI) = 1.4-5.7) after covariate adjustment, and women reporting higher depression symptoms were approximately four times more likely to describe themselves in the lowest category of functional capacity (OR = 3.7, 95% CI = 1.7-7.8). High anger-out scores were associated with a four-fold or greater risk of low high-density lipoprotein cholesterol concentration (<50 mg/dl; OR = 4.0, 95% CI = 1.4-11.1) and high low-density lipoprotein cholesterol concentration (>160 mg/dl; OR = 4.8, 95% CI = 1.5-15.7) and a larger body mass index (OR = 3.5, 95% CI = 1.1-10.8) after covariate adjustment.

CONCLUSIONS

These results demonstrate consistent and clinically relevant relationships between psychosocial factors and atherosclerosis risk factors among women and may aid our understanding of the increased mortality risk among women reporting high levels of psychological distress.

History of anxiety disorders is associated with a decreased likelihood of angiographic coronary artery disease in women with chest pain: the WISE study

OBJECTIVES

We sought to evaluate the ability of psychiatric anxiety-disorder history to discriminate between women with and without angiographic coronary artery disease (CAD) in a population with chest pain.

BACKGROUND

A total of 435 women with chest pain underwent a diagnostic battery including coronary angiography in order to improve testing guidelines for women with suspected CAD.

METHODS

Women referred for coronary angiography completed questionnaires assessing prior treatment history for anxiety disorder and current anxiety-related symptoms. Analyses controlled for standard CAD risk factors.

RESULTS

Forty-four women (10%) reported receiving prior treatment for an anxiety disorder. This group acknowledged significantly higher levels of autonomic symptoms (e.g., headaches, muscle tension [F = 25.0, p < 0.0011 and higher behavioral avoidance scores (e.g., avoidance of open places or traveling alone by bus [F = 4.2, p < 0.05]) at baseline testing compared with women without prior anxiety problems. Women with an anxiety-disorder history did not differ from those without such a history with respect to the presence of inducible ischemia or use of nitroglycerin, although they were younger and more likely to describe both "tight" and "sharp" chest pain symptoms and to experience back pain and episodes of nocturnal chest pain. Logistic regression results indicated that the positive-anxiety-history group was more likely to be free of underlying significant angiographic CAD (odds ratio = 2.74, 95% confidence interval 1.15 to 6.5, p = 0.03).

CONCLUSIONS

Among women with chest pain symptoms, a history of anxiety disorders is associated with a lower probability of significant angiographic CAD. Knowledge of anxiety disorder history may assist in the clinical evaluation of women with chest pain.

Illness representations according to age and effects on health behaviors following coronary artery bypass graft surgery

OBJECTIVES

To determine if illness representations differ as a function of age and how these representations, in conjunction with age, predict postoperative health behaviors.

DESIGN

Prospective study of patients undergoing coronary artery bypass graft (CABG) surgery.

SETTING

A large metropolitan hospital providing regional cardiac care for patients in a tri-state area, located in Pittsburgh, Pennsylvania.

PARTICIPANTS

All consenting patients (N = 309) from a consecutive series of patients scheduled for CABG surgery between January 1992 and January 1994. To be eligible for participation, patients could not be scheduled for any other coincidental surgery (e.g., valve replacement), and could not be in cardiac intensive care or experiencing angina at the time of the referral. Participants were predominantly male (70%) and married (80%), and averaged 62.8 years of age.

MEASUREMENTS

Postoperative self-reported health behaviors.

RESULTS

Older participants awaiting CABG surgery were significantly more likely to believe old age to be the cause of their coronary heart disease (CHD) and significantly less likely to believe genetics, health-damaging behaviors, health-protective behaviors, and emotions to be the cause of their CHD than were younger participants awaiting surgery. Furthermore, the older participants were significantly more likely to believe they had no control over the disease and that the disease would be gone after surgery, and reported fewer postoperative health behavior changes than did younger participants.

CONCLUSION

These findings demonstrate significant differences in illness representations as a function of age. Furthermore, differences in postoperative health behaviors were consistent with differing illness representations.

Usefulness of electron beam tomography to detect progression of coronary and aortic calcium in middle-aged women

Electron beam tomography (EBT) permits the noninvasive quantification of coronary and aortic calcium as a marker of atherosclerosis. Coronary and aortic calcium are strongly related to premenopausal cardiovascular risk factors in middle-aged women. This report evaluates changes in coronary and aortic calcium over an average of 18 months in 80 women. Measurement variation over time and between readings is also evaluated in these women who were followed through the menopausal transition. Eight years after menopause, 80 women (average age 63 years) underwent serial EBT of the coronary arteries and aorta separated by 18 months. Calcium scores were based on the number and density of calcific deposits. Duplicate readings were obtained to evaluate the effect of reading variation on calcium scores. At baseline, the median calcium score was 0 in the coronary arteries and 58 in the aorta. Average change in coronary (+11) and aortic (+112) calcium were significantly different from zero (p < 0.001). Reading variability did not contribute significantly to the variation in calcium scores. Extent of calcium in the coronary arteries was associated with progression of calcium in the aorta (p = 0.013). Both coronary and aortic calcium were significantly associated with premenopausal cardiovascular risk factors. Thus, progression of coronary and aortic calcium using EBT can be observed over a short time in healthy middle- aged women.

Estrogens and women's health: interrelation of coronary heart disease, breast cancer and osteoporosis

The determinants of blood levels of estrogen, estrogen metabolites, and relation to receptors and post-transitional effects are the likely primary cause of breast cancer. Very high risk women for breast cancer can now be identified by measuring bone mineral density and hormone levels. These high risk women have rates of breast cancer similar to risk of myocardial infarction. They are candidates for SERM therapies to reduce risk of breast cancer. The completion of the Women's Health Initiative and other such trials will likely provide a definite association of risk and benefit of both estrogen alone and estrogen-progesterone therapy, coronary heart disease, osteoporotic fracture, and breast cancer. The potential intervention of hormone replacement therapy, obesity, or weight gain and increased atherogenic lipoproteinemia may be of concern and confound the results of clinical trials. Estrogens, clearly, are important in the risk of bone loss and osteoporotic fracture. Obesity is the primary determinant of postmenopausal estrogen levels and reduced risk of fracture. Weight reduction may increase rates of bone loss and fracture. Clinical trials that evaluate weight loss should monitor effects on bone. The beneficial addition of increased physical activity, higher dose of calcium or vitamin D, or use of bone reabsorption drugs in coordination with weight loss should be evaluated. Any therapy that raises blood estrogen or metabolite activity and decreases bone loss may increase risk of breast cancer. Future clinical trials must evaluate multiple endpoints such as CHD, osteoporosis, and breast cancer within the study. The use of surrogate markers such as bone mineral density, coronary calcium, carotid intimal medial thickness and plaque, endothelial function, breast density, hormone levels and metabolites could enhance the evaluation of risk factors, genetic-environmental intervention, and new therapies.

Patterns of sympathetic and parasympathetic reactivity in a sample of children and adolescents

We hypothesized that patterns of sympathetic and parasympathetic reactivity observed in adults would be apparent in a sample of children and adolescents and that these patterns would be consistent across tasks. We explored the relationship between these patterns and psychosocial risk factors for cardiovascular disease. We measured preejection period (PEP) and an index of respiratory sinus arrhythmia (mean successive difference [MSD] statistic) during three reactivity tasks. We classified participants into four groups based on increases or decreases in PEP and MSD. Ninety percent of the sample exhibited the same pattern during at least two of the tasks. PEP and MSD demonstrated consistency, suggesting individual response stereotypy. Exhibiting a consistent pattern of decreased PEP and increased MSD was associated with less child- and parent-reported family conflict. These results are discussed in the context of vagal regulation of environmental demands.

Are vacations good for your health? The 9-year mortality experience after the multiple risk factor intervention trial

OBJECTIVE

The objective of this study was to determine the risk for various causes of posttrial death associated with vacation frequency during the Multiple Risk Factor Intervention Trial (MRFIT).

METHODS

Middle-aged men at high risk for coronary heart disease (CHD) were recruited for the MRFIT. As part of the questionnaires administered during the first five annual visits, men were asked whether they had had a vacation during the past year. For trial survivors (N = 12,338), the frequency of these annual vacations during the trial were used in a prospective analysis of posttrial all-cause and cause-specific mortality during the 9-year follow-up period.

RESULTS

The relative risk (RR) associated with more annual vacations during the trial was 0.83 (95% confidence interval [CI], 0.71-0.97) for all-cause mortality during the 9-year follow-up period. For cause of death, the RRs were 0.71 (95% CI, 0.58-0.89) and 0.98 (95% CI, 0.78-1.23) for cardiovascular and noncardiovascular causes, respectively. The RR was 0.68 (95% CI, 0.53-0.88) for CHD (including acute myocardial infarction). These associations remained when statistical adjustments were made for possible confounding variables, including baseline characteristics (eg, income), MRFIT group assignment, and occurrence of a nonfatal cardiovascular event during the trial.

CONCLUSIONS

The frequency of annual vacations by middle-aged men at high risk for CHD is associated with a reduced risk of all-cause mortality and, more specifically, mortality attributed to CHD. Vacationing may be good for your health.

The relationships of resting baroreflex sensitivity, heart rate variability and measures of impulse control in children and adolescents

The objectives of the present study were to assess: (1) the feasibility of using a non-invasive method to measure baroreflex sensitivity in children and adolescents; (2) the relationships of resting baroreflex sensitivity with resting levels of other cardiovascular variables; and (3) whether baroreflex sensitivity and heart rate variability, two indices of cardiac vagal control at rest, were related to measures of impulse control. Ninety-one Black and White children (ages 8-10) and adolescents (ages 15-17), both female and male, participated in the study. Baroreflex sensitivity, auscultatory blood pressure, EKG-derived heart rate, and the mean successive difference of interbeat intervals were collected during a 10-min rest period. Measures of impulse control came from the Interview for Antisocial Behavior. Baroreflex sensitivity was strongly positively correlated with mean successive difference and negatively correlated with heart rate for all participant groups; baroreflex sensitivity was negatively correlated with diastolic blood pressure, but only for children, males, and Blacks. Increased problems with impulse control was associated with decreased cardiac vagal control, but only in males. The usefulness of this technique as a measure of vagal activation is discussed.

Effects of lovastatin on cognitive function and psychological well-being

PURPOSE

Animal research and cross-sectional studies suggest that serum lipid concentrations may influence cognitive function, mood, and behavior, but few clinical trials have studied these effects.

SUBJECTS AND METHODS

In this double-blind investigation, 209 generally healthy adults with a serum low-density-lipoprotein (LDL) cholesterol level of 160 mg/dL or higher were randomly assigned to 6-month treatment with lovastatin (20 mg) or placebo. Assessments of neuropsychological performance, depression, hostility, and quality of life were conducted at baseline and at the end of the treatment period. Summary effect sizes were estimated as z scores on a standard deviation (SD) scale.

RESULTS

Placebo-treated subjects improved between baseline and posttreatment periods on neuropsychological tests in all five performance domains, consistent with the effects of practice on test performance (all P <0.04), whereas those treated with lovastatin improved only on tests of memory recall (P = 0.03). Comparisons of the changes in performance between placebo- and lovastatin-treated subjects revealed small, but statistically significant, differences for tests of attention (z score = 0.18; 95% confidence interval (CI), 0.06 to 0.31; P = 0.005) and psychomotor speed (z score = 0.17; 95% CI, 0.05 to 0.28; P = 0. 004) that were consistent with greater improvement in the placebo group. Psychological well-being, as measured several ways, was not affected by lovastatin.

CONCLUSION

Treatment of hypercholesterolemia with lovastatin did not cause psychological distress or substantially alter cognitive function. Treatment did result in small performance decrements on neuropsychological tests of attention and psychomotor speed, the clinical importance of which is uncertain.

Do the daily experiences of healthy men and women vary according to occupational prestige and work strain?

OBJECTIVE

This study evaluated the influence of occupational prestige and work strain on mood, the occurrence of interpersonal conflict, and ambulatory blood pressure and heart rate.

METHODS

Participants were 50 men and 50 women matched for occupational prestige who were healthy and middle-aged and who completed measures of mood and conflict simultaneously with measures of ambulatory blood pressure and heart rate recorded every 30 minutes during waking hours of two workdays and one nonworkday; at the end of each day, overall ratings were made. Work strain was assessed by the Work Section of the Self-Evaluation and Social Support Interview Schedule. Multiple level random regression coefficients analyses were conducted.

RESULTS

Men and women with low-prestige occupations experienced more interpersonal conflict, b = -0.03, p = .04, and higher ambulatory heart rate, b = -4.83, p = .004, throughout the three days of the study. Relative to those with low work strain, those reporting high work strain experienced negative emotion, b = -0.41, p < .0001, and boredom, b = -0.17, p < .0004. End of the day ratings of negative mood were more influenced by work strain among men than among women. No effects of occupational prestige or work strain were obtained for ambulatory blood pressure readings after adjustment for physical activity, posture, and location.

CONCLUSIONS

Individuals in low-prestige occupations experience greater exposure to interpersonal conflict and arousal as indexed by heart rate, which might increase risk for stress-related illnesses often associated with social class. Individuals who report work strain experience negative mood and boredom, both at work and at home. The absence of work effects on ambulatory blood pressure may be due to the participants being healthy.

Cerebrospinal fluid levels of corticotropin-releasing hormone in women with functional hypothalamic amenorrhea

OBJECTIVE

Women with functional hypothalamic amenorrhea are anovulatory because of reduced gonadotropin-releasing hormone drive. Several studies have documented hypercortisolemia, which suggests that functional hypothalamic amenorrhea is stress-induced. Further, with recovery (resumption of ovulation), cortisol decreased and gonadotropin-releasing hormone drive increased. Corticotropin-releasing hormone can increase cortisol and decrease gonadotropin-releasing hormone. To determine its role in functional hypothalamic amenorrhea, we measured corticotropin-releasing hormone in cerebrospinal fluid along with arginine vasopressin, another potent adrenocorticotropic hormone secretagog, and beta-endorphin, which is released by corticotropin-releasing hormone and can inhibit gonadotropin-releasing hormone.

STUDY DESIGN

Corticotropin-releasing hormone, vasopressin, and beta-endorphin levels were measured in cerebrospinal fluid from 14 women with eumenorrhea and 15 women with functional hypothalamic amenorrhea.

RESULTS

Levels of corticotropin-releasing hormone in cerebrospinal fluid and of vasopressin were comparable and beta-endorphin levels were lower in women with functional hypothalamic amenorrhea.

CONCLUSIONS

In women with established functional hypothalamic amenorrhea, increased cortisol and reduced gonadotropin-releasing hormone are not sustained by elevated cerebrospinal-fluid corticotropin-releasing hormone, vasopressin, or beta-endorphin. These data do not exclude a role for these factors in the initiation of functional hypothalamic amenorrhea.

Do negative emotions mediate the association between socioeconomic status and health?

In this chapter, we examine the possibility that negative emotions contribute to the relationship between socioeconomic status (SES) and health. A model of the associations among SES, emotion, and health is presented first. We then review the evidence for this model, showing associations of SES with depression, hopelessness, anxiety, and hostile affect and cognition, and of these negative emotions with disease. Notably, most of the data supporting the model provide only indirect evidence that negative emotions serve as a key contributor to the proposed associations. We, therefore, conclude with recommendations for longitudinal research, especially in children, that will more directly and comprehensively examine negative emotions as possible mediators of the SES and health relationship.

Does socioeconomic status relate to central serotonergic responsivity in healthy adults?

OBJECTIVE

We tested whether low SES was associated with reduced central serotonergic responsivity in a community sample of adult men and women and the extent to which standardized measures of aggression and impulsivity mediate the association.

METHODS

A total of 270 adults who were enrolled in a clinical trial on the neurobehavioral effects of lipid lowering were given a neuropharmacologic challenge (plasma prolactin response to orally administered fenfluramine) to measure serotonergic responsivity. Measures of family income and educational attainment were standardized and summed to derive an overall index of SES. Scores from the Brown-Goodwin Life History of Aggression interview, the Barratt Impulsiveness Scale, and the Angry Hostility subscale from the NEO Personality Inventory were also standardized and summed to form an aggression/impulsivity score.

RESULTS

Low SES was correlated with low prolactin responses to the fenfluramine challenge in the full sample (r = .15) as well as in whites, men, and women evaluated separately. Although the standardized SES score was correlated inversely with aggression/impulsivity measure (r = -.19, p < .01), the association between SES and prolactin responses remained significant when statistical adjustments were made for age, gender, body mass index, and aggression/impulsivity scores.

CONCLUSIONS

Blunted serotonergic responsivity is associated with low social class as measured by annual family income and educational attainment.

Negative emotions and acute physiological responses to stress

One pathway through which stressors are thought to influence physiology is through their effects on emotion. We used meta-analytic statistical techniques with data from nine studies to test the effects of acute laboratory stressors (speech, star mirror-image tracing, handgrip) on emotional (undifferentiated negative emotion, anger, anxiety) and cardiovascular (CV) response. In all of the studies, participants responded to stressors with both increased CV response and increased negative emotion. Increases in negative emotion were associated with increases in CV response across tasks, however, these associations were small. The range of variance accounted for was between 2% and 12%. Thus, the contribution of negative emotion, as assessed in these studies, to physiological responses to acute laboratory stressors was limited. Although these results raise questions about the role of emotion in mediating stress-elicited physiological responses, the nature of the acute laboratory stress paradigm may contribute to the lack of a strong association.

Hostile attitudes predict elevated vascular resistance during interpersonal stress in men and women

OBJECTIVE

Existing research indicates that hostility is associated with enhanced blood pressure responses during social stress, but little is known about the hemodynamic patterns underlying these blood pressure increases, particularly in women. The present study examined hemodynamic responses to a low-anger interpersonal stressor, testing the hypotheses that hostile individuals show enhanced vascular responses and that low hostile individuals show enhanced myocardial responses.

METHODS

Eighty undergraduate men and women were categorized as high or low in hostility on the basis of median splits of Cook-Medley Hostility Scale scores. Participants discussed a controversial topic with a confederate who disagreed with them, and hemodynamic responses were assessed with impedance cardiography.

RESULTS

High hostile individuals exhibited greater increases in diastolic blood pressure and total peripheral resistance and smaller increases in cardiac output during an interpersonal stressor than did low hostile individuals. Systolic blood pressure and heart rate increases were greater among high hostile relative to low hostile females and comparable among low and high hostile males. Affective responses and task perceptions were generally similar for high and low hostile participants, but the relationship between task perception and hemodynamic responses varied on the basis of hostility level.

CONCLUSIONS

These findings suggest that hostility in both men and women is associated with heightened vascular and dampened cardiac responsivity to interpersonal stress that is not deliberately anger provoking. Moreover, they indicate that the associations between task perception and hemodynamic responses vary between high and low hostile individuals.

Blood pressure levels and measurement of subclinical vascular disease

Increased blood pressure, especially systolic blood pressure (SBP), is linearly associated with an increased risk of cardiovascular disease and stroke. The attributable risk of vascular disease due to elevated blood pressure is greater for normal and high normal blood pressures and stage 1 hypertension than for more advanced hypertension (stages 2 and 3). The development of noninvasive methods for measuring the effects of blood pressure on the vascular system help identify early vascular disease, high risk populations at similar levels of blood pressure, and successful methods of therapy. The future goals of the control of elevated blood pressure should be to prevent: (1) the rise in blood pressure associated with increasing age; (2) the development of subclinical vascular disease associated with even slightly elevated blood pressure; and (3) clinical disease. Measurement of subclinical vascular disease should be a component of both observational epidemiological studies and clinical trials. The subclinical measures should include those primarily associated with the progression of atherosclerosis and the pathophysiology of elevated blood pressure.

Coronary and aortic calcification among women 8 years after menopause and their premenopausal risk factors : the healthy women study

In the Healthy Women Study, the relationship between cardiovascular risk factors measured premenopausally at age 48, use of hormone therapy, and coronary and aortic calcification at age 58 were evaluated among 169 women. Approximately 63% of women had no coronary calcification, but only 29% had no aortic calcification. Coronary calcification and aortic calcification were positively correlated with each other. There was a very strong association between low density lipoprotein cholesterol (LDL-C) level and coronary calcification. Among women with premenopausal levels of LDL-C <100 mg/dL, only 9% had a coronary calcium score >/=101 compared with 30% of women with an LDL-C >160 mg/dL. Only 5% of women with a high density lipoprotein cholesterol (HDL-C) level >60 mg/dL had high coronary scores. The level of HDL(2)-C was especially strongly inversely related to coronary calcium scores. Cigarette smoking was a very important determinant of both high aortic and high coronary calcium scores. Other risk factors associated with greater coronary calcium were higher systolic blood pressure, triglycerides levels, and blood glucose. Use of hormone replacement therapy was associated with less coronary calcium (NS). For both hormone replacement therapy users and nonusers, the levels of LDL-C and HDL-C measured premenopausally were predictors of coronary and aortic calcium scores. Thus, risk factors evaluated premenopausally are powerful predictors of coronary and aortic calcification, a marker of atherosclerosis, measured 8 years after menopause, 11 years later in these women.

Anger, hostility, and visceral adipose tissue in healthy postmenopausal women

Central obesity is an important risk factor for chronic disease. Its etiology remains unclear. We examined whether anger and hostility, ie, psychological attributes that influence cardiovascular morbidity and mortality, prospectively predict central visceral obesity across 13 years. Visceral adipose tissue (VAT) was determined by x-ray computed tomography (CT) at the L4-L5 disc space in a population-based sample of 157 postmenopausal Healthy Women Study participants. Standardized tests were completed to measure separately trait anger (anger frequency and intensity), style of anger expression (holding anger in and expressing it outwardly), and hostile (mistrustful) attitudes. The higher the VAT score, the higher the trait anger and anger-out scores measured 13 years earlier (Ps < .04) and the higher the concurrent hostile attitudes score (P < .02). Moreover, the higher the VAT score, the greater the increase in trait anger over the study period (P < .03). Trait anger and hostility predicted VAT independent of fasting insulin levels, although both predicted an increase in fasting insulin over time. Women were categorized into three groups according to the distribution of the average percent increase in trait anger and in weight across the study period, respectively. The mean VAT scores increased with the likelihood of being in the highest tertile of increasing trait anger (means: 129.1, 131.1, and 155.8, P < .048) and in the highest tertile of increasing weight (means: 122.4, 131.1, and 162.2, P < .003). The association between a high trait anger score and VAT remained significant, controlling for weight gain. We conclude that hostile attributes, fasting insulin, and weight gain in midlife may contribute to the development of VAT in healthy Caucasian women.

Anthropometric and psychosocial determinants of visceral obesity in healthy postmenopausal women

OBJECTIVE

To identify the best predictor among waist circumference, waist to hip ratio (WHR), weight and body mass index (BMI) of visceral obesity across 8.5-10.8 y. We also examined whether changes in waist across the study period co-occur with changes in psychosocial distress or quality of life, and tested whether action levels of waist (level 1 < 80 cm, level 1-2: 80-87.9 cm, level 2 > or = 88 cm) differentiate between women with varying levels of psychosocial distress and quality of life.

SUBJECTS AND MEASUREMENTS

Visceral adipose tissue (VAT) was determined by computerized-tomography at the L4-L5 disc space, and waist circumference, WHR, weight and BMI by anthropometric techniques in a population-based sample of postmenopausal Healthy Women Study participants. Psychosocial distress and quality of life were assessed by standardized tests of personality and behavior. The n varied from 120-345, depending on the research question.

RESULTS

Waist circumference was superior over the other anthropometric measures in predicting VAT accounting for 40.1-63.5% of the variance in VAT over the study period (P < 0.001). Associations between symptoms of depression, anxiety or distress, low levels of social support or impaired quality of life with waist circumference were cross-sectional (P < 0.04), with lower levels of distress and less impaired daily functioning being characteristic to women at the action level 1 relative to levels 1-2 or 2. Increasing anger over time was associated longitudinally with increasing waist circumference (P < 0.03).

CONCLUSIONS

Identification of healthy women with large waist circumferences is important for prevention and intervention of poor quality of life and chronic disease.

Modeling relationships among socioeconomic status, hostility, cardiovascular reactivity, and left ventricular mass in African American and White children

In African American and White children and adolescents (N = 147), socioeconomic status (SES) was measured in 2 ways: (a) using neighborhood-level measures of population density, median income, educational attainment, and the number of children born to single mothers and (b) using family-level measures of parents' occupation and education. Structural equation modeling revealed that both lower family SES and lower neighborhood SES were independently associated with greater hostility and consequently greater cardiovascular reactivity to laboratory stressors in African Americans. Independent of neighborhood SES, only lower family SES was associated with greater cardiovascular reactivity in Whites. Heightened cardiovascular reactivity was associated with greater left ventricular mass (LVM) in Whites and marginally greater LVM in African Americans. Results suggest the importance of using multiple indicators of SES and confirm the relationship between SES and LVM in African Americans and Whites, albeit through different pathways.

Effects of hostility on ambulatory blood pressure and mood during daily living in healthy adults

This study (a) tested the effects of hostile attributes on ambulatory blood pressure (BP), heart rate, and mood monitored repeatedly over 3 days in 100 healthy men and women and (b) determined whether the cardiovascular effects of trait hostility were moderated by mood. Multilevel random-coefficients regression analyses showed that hostile individuals exhibited higher systolic and diastolic BP and rated their current moods as more negative and less positive throughout the monitoring. Individuals low in hostility exhibited high BP only during the few occasions when they experienced negative mood. However, these patterns were true only when participants were classified by Potential for Hostility ratings from the Structured Interview (R. H. Rosenman, 1978), not by the Cynical Hostile Attitudes score derived from the Cook-Medley scale. Results provide convergent and ecological validity of interview rating of hostility and illuminate one possible dynamic mechanism by which overt hostile behaviors might contribute to the rates of increased cardiovascular morbidity and mortality.

Optimism and rehospitalization after coronary artery bypass graft surgery

OBJECTIVE

To determine whether optimism predicts lower rates of rehospitalization after coronary artery bypass graft surgery for the 6 months after surgery.

METHODS

A prospective, inception cohort design was used. The sample consisted of all consenting patients (N=309) from a consecutive series of patients scheduled for elective coronary artery bypass graft surgery at a large, metropolitan hospital in Pittsburgh, Pa. To be eligible, patients could not be scheduled for any other coincidental surgery (eg, valve replacement) and could not be in the cardiac intensive care unit or experiencing angina at the time of the referral. Participants were predominantly men (69.9%) and married (80.3%), and averaged 62.8 years of age. Recruitment occurred between January 1992 and January 1994.

RESULTS

Compared with pessimistic persons, optimistic persons were significantly less likely to be rehospitalized for a broad range of aggregated problems (including postsurgical sternal wound infection, angina, myocardial infarction, and the need for another bypass surgery or percutaneous transluminal coronary angioplasty) generally indicative of a poor response to the initial surgery (odds ratio=0.50, 95% confidence interval=0.33- 0.76; P=.001). The effect of optimism was independent of traditional sociodemographic and medical control variables, as well as independent of the effects of self-esteem, depression, and neuroticism. All-cause rehospitalization also tended to be less frequent for optimistic than for pessimistic persons (odds ratio=0.77, 95% confidence interval=0.57-1.05; P=.07).

CONCLUSIONS

Optimism predicts a lower rate of rehospitalization after coronary artery bypass graft surgery. Fostering positive expectations may promote better recovery.

Effects of optimism, pessimism, and trait anxiety on ambulatory blood pressure and mood during everyday life

This study tested whether dispositional measures of optimism, pessimism, and anxiety affected ambulatory blood pressure (BP) and mood and whether any cardiovascular effects of dispositions were moderated by mood. Pessimistic and anxious adults had higher BP levels and felt more negative and less positive than did optimists or low anxious adults throughout the monitoring. The few times that optimists did feel negative were associated with levels of BP as high as those observed among pessimists or anxious individuals, regardless of their mood. To the extent that trait anxiety measures neuroticism, these findings suggest that neuroticism is directly related to health indicators rather than simply to illness behavior. Furthermore, the results suggest that pessimism has broad physiological and psychological consequences.