Genome-wide association analyses identify 95 risk loci and provide insights into the neurobiology of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) genetics are characterized by lower discoverability than most other psychiatric disorders. The contribution to biological understanding from previous genetic studies has thus been limited. We performed a multi-ancestry meta-analysis of genome-wide association studies across 1,222,882 individuals of European ancestry (137,136 cases) and 58,051 admixed individuals with African and Native American ancestry (13,624 cases). We identified 95 genome-wide significant loci (80 new). Convergent multi-omic approaches identified 43 potential causal genes, broadly classified as neurotransmitter and ion channel synaptic modulators (for example, GRIA1, GRM8 and CACNA1E), developmental, axon guidance and transcription factors (for example, FOXP2, EFNA5 and DCC), synaptic structure and function genes (for example, PCLO, NCAM1 and PDE4B) and endocrine or immune regulators (for example, ESR1, TRAF3 and TANK). Additional top genes influence stress, immune, fear and threat-related processes, previously hypothesized to underlie PTSD neurobiology. These findings strengthen our understanding of neurobiological systems relevant to PTSD pathophysiology, while also opening new areas for investigation.

Pre-Pandemic Resilience to Trauma & COVID-19 Infection in Older Women

OBJECTIVE

Prior work suggests psychological resilience to trauma may protect not only mental but also physical health. This study examined the relationship of pre-pandemic psychological resilience to lifetime trauma with self-reported COVID-19 infection and symptoms during the early years of the COVID-19 pandemic.

METHODS

Data are from 18,670 longitudinal cohort participants in the Nurses' Health Study II. Based on prior evidence that trauma and subsequent distress can increase infection risk and severity, and that psychological assets may offset this risk, we hypothesized higher versus lower psychological resilience to prior trauma would be associated with lower risk for COVID-19 infection. Pre-pandemic resilience was assessed via self-report between 2017-2019 based on self-reported lifetime trauma exposure and psychological health. COVID-19 infection and symptoms were self-reported on 7 questionnaires administered between May 2020 - October 2021, from which we derived a composite outcome measure of probable COVID-19 infection, defined as having 3+ COVID-19 symptoms (out of 9) and/or a positive COVID-19 test result at any single assessment.

RESULTS

Multivariable regression revealed significant associations between higher pre-pandemic resilience scores and lower risk for probable COVID-19 infection, adjusting for socio-demographic and COVID-19-related risk factors (RR = 0.90 [95% CI 0.87, 0.93]). Considering subcomponents of the composite COVID-19 infection measure separately, pre-pandemic resilience was significantly associated with lower risk of reported symptoms (RR = 0.83 [95% CI 0.79, 0.88]), but not with a positive test result alone (RR = 0.96 (95% CI 0.91, 1.01]).

CONCLUSION

Identifying protective factors for infection risk may help inform psychosocial interventions to improve health outcomes.

Neighborhood-level economic characteristics and depression and PTSD symptoms among Houstonians who have experienced Hurricane Harvey and COVID-19

Little is known about how neighborhood economic characteristics relate to risk of depression and Posttraumatic Stress Disorder (PTSD) in the context of multiple disasters. We sampled 88 super neighborhoods in Houston, Texas and surveyed 872 residents who were living in Houston during Hurricane Harvey and COVID-19 and lived in the same residence since Hurricane Harvey, about their demographics and symptoms of depression and PTSD. Using data from the American Community Survey, we estimated neighborhood-level unemployment, median income, and income inequality (i.e., Gini coefficient). We investigated whether these underlying neighborhood socioeconomic factors were associated with the mental health consequences of mass traumatic events. We examined associations between neighborhood-level constructs and individual-level depression and PTSD, using multilevel linear models. Partially adjusted multilevel models showed that lower neighborhood median income was associated with higher symptom scores of PTSD, while greater neighborhood income inequality was associated with higher symptom scores of depression and PTSD. However, fully adjusted models showed that these associations are better accounted for by event-specific stressors and traumas. These findings suggest that in the context of multiple large scale traumatic events, neighborhood socioeconomic context may structure individual-level exposure to stressful and traumatic events.

Phytosterol intake and risk of coronary artery disease: Results from 3 prospective cohort studies

BACKGROUND

Phytosterols are structurally similar to cholesterol and partially inhibit intestinal absorption of cholesterol, although their impact on coronary artery disease (CAD) risk remains to be elucidated.

OBJECTIVES

This study aimed to prospectively assess the associations between total and individual phytosterol intake and CAD risk in United States health professionals.

METHODS

The analysis included 213,992 participants from 3 prospective cohorts-the Nurses' Health Study (NHS), NHSII, and Health Professionals Follow-Up Study-without cardiovascular disease or cancer at baseline. Diet was assessed using a validated food frequency questionnaire every 2-4 y since baseline. Associations between phytosterol intake and the risk of CAD, such as nonfatal myocardial infarction and fatal CAD, were evaluated using Cox proportional hazards regression models.

RESULTS

More than 5,517,993 person-years, 8725 cases with CAD were documented. Comparing extreme quintiles, pooled hazard ratios (95% CIs) of CAD were 0.93 (0.86, 1.01; P-trend = 0.16) for total phytosterols, 0.89 (0.82, 0.96; P-trend = 0.05) for campesterol, 0.95 (0.88, 1.02; P-trend = 0.10) for stigmasterol, and 0.92 (0.85, 1.00; P-trend = 0.09) for β-sitosterol. Nonlinear associations were observed for total phytosterols, campesterol, and β-sitosterol: the risk reduction plateaued at intakes above ∼180, 30, and 130 mg/d, respectively (P-nonlinearity < 0.001). In a subset of participants (N range between 11,983 and 22,039), phytosterol intake was inversely associated with plasma concentrations of total cholesterol, triglycerides, high-density lipoprotein cholesterol, and IL-6 and positively associated with adiponectin, whereas no significant associations were observed for low-density lipoprotein cholesterol or C-reactive protein concentrations.

CONCLUSIONS

Higher long-term intake of total and major subtypes of phytosterols may be associated with a modest reduction in CAD risk, displaying a nonlinear relationship that plateau at moderate intake levels. The role of phytosterols in preventing CAD warrants further investigation.

Validity and Reproducibility of a Semiquantitative Food Frequency Questionnaire for Measuring Intakes of Foods and Food Groups

We evaluated the validity and reproducibility of a semiquantitative food frequency questionnaire (FFQ) for measuring intakes of 149 foods and 25 food groups among 736 participants of the Women's Lifestyle Validation Study (WLVS, 2010-2012) and 649 participants of the Men's Lifestyle Validation Study (MLVS, 2011-2013). Validity of the FFQ compared with two 7-day dietary records measured 6 months apart and the reproducibility between 2 FFQs administered 1 year apart (FFQ1 and FFQ2) were assessed using Spearman correlations and intraclass correlation coefficients. The average 1-year reproducibility of FFQ-measured foods was 0.64 in both the WLVS and MLVS. Reproducibility of the food groups (mean = 0.71 among women and 0.72 among men) was generally higher than that for individual foods. Among women, the average validity correlation for individual foods was 0.59 when comparing FFQ2 with the 7-day dietary records. Among men, the corresponding average validity correlation was 0.61. Compared with individual foods, food groups had slightly higher validity correlations in both women (range, 0.45-0.92; mean = 0.61) and men (range, 0.46-0.88; mean = 0.65). This study reaffirms that the FFQ performs well in measuring most foods and food groups and provides data to adjust for measurement errors in epidemiologic studies of foods and food groups.

Post-traumatic stress disorder symptom remission and cognition in a large cohort of civilian women

BACKGROUND

Post-traumatic stress disorder (PTSD) is associated with cognitive impairments. It is unclear whether problems persist after PTSD symptoms remit.

METHODS

Data came from 12 270 trauma-exposed women in the Nurses' Health Study II. Trauma and PTSD symptoms were assessed using validated scales to determine PTSD status as of 2008 (trauma/no PTSD, remitted PTSD, unresolved PTSD) and symptom severity (lifetime and past-month). Starting in 2014, cognitive function was assessed using the Cogstate Brief Battery every 6 or 12 months for up to 24 months. PTSD associations with baseline cognition and longitudinal cognitive changes were estimated by covariate-adjusted linear regression and linear mixed-effects models, respectively.

RESULTS

Compared to women with trauma/no PTSD, women with remitted PTSD symptoms had a similar cognitive function at baseline, while women with unresolved PTSD symptoms had worse psychomotor speed/attention and learning/working memory. In women with unresolved PTSD symptoms, past-month PTSD symptom severity was inversely associated with baseline cognition. Over follow-up, both women with remitted and unresolved PTSD symptoms in 2008, especially those with high levels of symptoms, had a faster decline in learning/working memory than women with trauma/no PTSD. In women with remitted PTSD symptoms, higher lifetime PTSD symptom severity was associated with a faster decline in learning/working memory. Results were robust to the adjustment for sociodemographic, biobehavioral, and health factors and were partially attenuated when adjusted for depression.

CONCLUSION

Unresolved but not remitted PTSD was associated with worse cognitive function assessed six years later. Accelerated cognitive decline was observed among women with either unresolved or remitted PTSD symptoms.

Longitudinal assessment of mental health after a flood: roles of social support, hope, recovery stressors, and prior lifetime trauma

OBJECTIVES

Severe weather events have mental health consequences for survivors that may change over time. We assessed post-flood mental health longitudinally in three groups of mostly middle-aged and older adults who varied in current and prior severe weather experiences.

METHOD

Predictors of central interest were age, perceived social support, state hope (including agency and pathways), recovery stressors, and prior lifetime trauma. Criterion variables included symptoms of depression, post-traumatic stress disorder (PTSD), and worry.

RESULTS

Analyses of variance yielded significant Disaster Exposure Group x Wave interactions for depression and PTSD symptoms. Those with flooded homes and properties had elevated symptoms at Wave 1 which were reduced at Wave 2. Older age was associated with fewer symptoms of depression, PTSD, and worry. Recovery stressors and lifetime trauma predicted more PTSD symptoms. Greater agency predicted less PTSD and depression symptoms, whereas pathways predicted less worry.

CONCLUSION

These data show that mental health symptoms may decrease over time for those directly impacted by severe flooding. State hope appears to contribute to better mental health after exposure to a devastating flood. Implications for understanding the dynamic relationships among risk variables and positive factors that promote post-disaster mental health in the years after a flood are considered.

Discovery of 95 PTSD loci provides insight into genetic architecture and neurobiology of trauma and stress-related disorders

Posttraumatic stress disorder (PTSD) genetics are characterized by lower discoverability than most other psychiatric disorders. The contribution to biological understanding from previous genetic studies has thus been limited. We performed a multi-ancestry meta-analysis of genome-wide association studies across 1,222,882 individuals of European ancestry (137,136 cases) and 58,051 admixed individuals with African and Native American ancestry (13,624 cases). We identified 95 genome-wide significant loci (80 novel). Convergent multi-omic approaches identified 43 potential causal genes, broadly classified as neurotransmitter and ion channel synaptic modulators (e.g., GRIA1, GRM8, CACNA1E ), developmental, axon guidance, and transcription factors (e.g., FOXP2, EFNA5, DCC ), synaptic structure and function genes (e.g., PCLO, NCAM1, PDE4B ), and endocrine or immune regulators (e.g., ESR1, TRAF3, TANK ). Additional top genes influence stress, immune, fear, and threat-related processes, previously hypothesized to underlie PTSD neurobiology. These findings strengthen our understanding of neurobiological systems relevant to PTSD pathophysiology, while also opening new areas for investigation.

Intakes of Unprocessed and Minimally Processed and Ultraprocessed Food Are Associated with Diet Quality in Female and Male Health Professionals in the United States: A Prospective Analysis

BACKGROUND

High unprocessed and minimally processed food (UMP) intake has been associated with high-quality diets, whereas the opposite has been shown for ultraprocessed food (UPF). Nevertheless, the association between UMP and UPF consumption and diet quality over the long-term warrants further examination.

OBJECTIVE

This study aimed to assess whether UMP and UPF intake are associated with three diet-quality metrics in female and male health professionals from two US cohorts over 3 decades of follow-up.

DESIGN

This was a cohort study, including data from the Nurses' Health Study (NHS), from 1986 to 2010 (N = 51,956) and the Health Professionals Follow-up Study (HPFS) from 1986 to 2006 (n = 31,307).

PARTICIPANTS AND SETTING

Participants were invited in 1976 (NHS) and 1986 (HPFS) to respond to mailed questionnaires every 2 to 4 years and diet was assessed with a semi-quantitative food frequency questionnaire every 4 years.

MAIN EXPOSURE MEASURES

UMP and UPF intake were calculated using the NOVA classification.

STATISTICAL ANALYSES

Generalized estimating equations for marginal means and repeated cross-sectional associations between diet-quality metrics and quintiles of UMP and UPF. Diets were assessed every 4 years from 1986 to 2010.

RESULTS

With increasing quintiles of UMP intakes, the Alternate Healthy Eating Index-2010 increased 7.1% (3.80 points, 95% CI 3.66 to 3.93) in the NHS and 10.1% (5.75 points, 95% CI 5.52 to 5.98) in the HPFS; the Mediterranean diet index increased 11.7% (0.50 points, 95% CI 0.47 to 0.52) in the NHS and 14.0% (0.64 points, 95% CI 0.60 to 0.68) in the HPFS; and the Dietary Approaches To Stop Hypertension diet score increased 7.5% (1.81 points, 95% CI 1.76 to 1.87) in the NHS and 10.6% (2.66 points, 95% CI 2.57 to 2.76) in the HPFS. In the fifth quintile of UPF intake compared with the first, the Alternate Healthy Eating Index-2010 was -9.3% (-4.60 points, 95% CI -4.73 to -4.47) lower in the NHS and -13.7% (-6.89 points, 95% CI -7.12 to -6.66) lower in the HPFS; the Mediterranean diet index was -14.7% (-0.55 points, 95% CI -0.57 to -0.53) lower in the NHS, and -19.0% (-0.74 points, 95% CI -0.78 to -0.70) lower in the HPFS; and the Dietary Approaches To Stop Hypertension diet score was -8.1% (-1.81 points, 95% CI -1.86 to -1.76) lower in the NHS and -12.8% (-2.84 points, 95% CI -2.93 to -2.74) lower in the HPFS.

CONCLUSIONS

Consumption of UMP was associated with better dietary quality, whereas consumption of UPF was associated with poorer dietary quality.

Depression and PTSD among Houston Residents who Experienced Hurricane Harvey and COVID-19: Implications for Urban Areas Affected by Multiple Disasters

Little is known about the combined impact of the COVID-19 pandemic and other major disasters on mental health. Hurricane Harvey hit the Gulf Coast in 2017, resulting in substantial costs, significant levels of displacement, and approximately 100 deaths, and was followed in 2020 by the COVID-19 pandemic. We randomly sampled 1167 Houstonians from 88 designated super-neighborhoods and surveyed them about their demographics, event-specific traumas and stressors, and symptoms of current depression and post-traumatic stress disorder (PTSD). We estimated the prevalence of depression (5.8%) and PTSD (12.6%) more than three years after Hurricane Harvey, and assessed the relative influence of event-specific stressors and traumas on current mental health. Overall, we observed evidence for two key findings that are salient for residents of urban environments in the context of multiple disasters. First, stressors were primary influences on depression, whereas both stressors and traumas influenced PTSD. Second, the influences of stressors and traumas on depression and PTSD symptoms faded with time.

Stressful life events and incident depression among U.S. military personnel

PURPOSE

Although stressful life events (i.e., stressors) and depression are often assumed to be linked, the relation between stressors and incident depression is rarely studied, particularly in the military. The National Guard is a part-time subset of the U.S. military for whom civilian life stressors may be particularly salient, due to the soldiers' dual roles and frequent transitions between military and civilian life.

METHODS

We used a dynamic cohort study of National Guard members from 2010 to 2016 to investigate the relationship between recent stressful experiences (e.g., divorce) and incident depression, with an exploratory analysis of effect modification by income.

RESULTS

Respondents endorsing at least one of nine past-year stressful events (a time-varying exposure, lagged by 1 year) had almost twice the adjusted rate of incident depression compared to those with no stressful events (HR = 1.8; 95% CI 1.4, 2.4). This association may be modified by income: among individuals making under $80,000 per year, those with past-year stressors had twice the rate of depression compared to those with no stressors, but among those making over $80,000, past-year stressors were associated with only 1.2 times the rate of depression.

CONCLUSION

Stressful life events outside of deployment are important determinants of incident depression among National Guard servicemembers, but the effect of these events may be buffered by higher income.

"You can't wash your hands in a house without running water": pandemic precautionary behaviors after Hurricane Laura

Hurricane Laura made landfall in southwestern Louisiana in August 2020 while the world was several months into the COVID-19 pandemic. In the present research, we examined pandemic precautionary behaviors in a sample of adults who varied in exposure and damage due to Hurricane Laura, a destructive Category 4 hurricane. A total of 127 participants responded to an online survey that assessed pandemic worry and precautionary behaviors, hurricane exposure and damage, and health-related quality of life. We found that Hurricane Laura victims neglected pandemic precautionary behaviors at significantly higher levels in the weeks immediately following Hurricane Laura than did indirectly impacted control participants, although the two comparison groups did not differ in COVID-19 worry or adherence to precautionary pandemic behavior 14-22 months after Hurricane Laura made landfall. Older age was negatively correlated with COVID-19 worry prior to Hurricane Laura, which was unexpected given that older people in general were more vulnerable to COVID-19 by their membership in a high-risk group. Future directions for research on post-disaster vulnerabilities during a global pandemic are discussed.

Abstract 5411: Efficient development of prognostic tests for detecting cancer risk using proteomic technology

Background: Prognostic models for assessing future health outcomes can be developed using time-to-event (also known as “survival”) data. This methodology is ubiquitous in statistical literature and in the analysis of cancer outcomes, but its use in high-dimensional analyses tends to be limited as the methods are difficult to implement in a machine learning environment. Additionally, development of certified prognostic clinical tests using proteomic biomarkers for detecting future cancer risk can be time-consuming, prone to overfitting issues, and difficult to navigate. We demonstrate the utility of combining SomaScan® proteomic data with pipeline machine learning tools and survival analysis methodology to identify powerful and robust LDT-certifiable prognostic tests for assessing future risk of cancer.

Methods: Data pipeline and analysis tools were developed using R. In addition to standard machine learning techniques, statistical methods include elastic net AFT models, subsampling survival techniques, and metrics for assessing predictive survival models. The pipeline takes the analyst from data processing and QC through identification of optimal models for prediction of clinical endpoints, and then through validation on a hold-out test set. The tools include an assessment of model robustness against sample handling issues, longitudinal stability, the impacts of assay noise on model performance, effects of putative interferents, and risk of failure during CLIA validation in the lab. We demonstrate the utility of the tools and methods for development of a lung cancer risk model.

Results: Analysis time for validation of an optimal clinical model was reduced by at least 80%, resulting in the development of 7 LDT-certified tests within 3 years, including a test for lung cancer risk. Inclusion of methods that allow for subsampling and penalized regression using AFT models show improved predictive performance and identification of top features related to clinical endpoints.

Conclusion: Not only are powerful, prognostic tests do-able, but they can be LDT certified in an efficient manner and made to be robust to real-life lab settings. Survival analysis in a machine-learning setting allow us to leverage proteomic technology in new ways, leading to tests that assess future cancer risk, which can be used for precision medicine applications.

Citation Format: Yolanda Hagar, Leigh Alexander, Jessica Chadwick, Gargi Datta, Joe Gogain, Rachel Ostroff, Clare Paterson, Laura Sampson, Caleb Scheidel, Sama Shrestha, Amy Zhang, Michael Hinterberg. Efficient development of prognostic tests for detecting cancer risk using proteomic technology. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5411.

Religiosity and Social Support Predict Resilience in Older Adults After a Flood

In this study, we examined religiosity and social support as predictors of resilience after a devastating flood. Three flood exposure groups of primarily middle-aged and older adults were compared: (1) non-flooded adults as controls, (2) once-flooded adults with structural damage to homes and property in the 2016 flood, and (3) twice-flooded adults who had relocated inland because of prior catastrophic losses in the 2005 Hurricanes Katrina and Rita and then flooded again in 2016. Resilience was assessed using the Connor-Davidson Resilience Scale (CD-RISC). Correlation analyses confirmed that older age was correlated with higher religiosity, charitable work done for others, and resilience. Regression analyses indicated that religious beliefs and coping, social support, and charitable work done for others were associated with higher levels of resilience, whereas flood damage was unrelated to resilience. Implications for current views on post-disaster adversity and resilience in later life are discussed.

Intimate Partner Violence, Mental Health Symptoms, and Modifiable Health Factors in Women During the COVID-19 Pandemic in the US

Importance

During the COVID-19 pandemic, the prevalence and severity of intimate partner violence (IPV) increased. Associations between IPV and mental health symptoms and modifiable health factors early in the pandemic have yet to be explored.

Objective

To prospectively investigate the association of IPV with greater risk of mental health symptoms and adverse health factors during the COVID-19 pandemic in 3 cohorts of female participants.

Design, Setting, and Participants

This cohort study used observational data from 3 prospective, population-based, longitudinal cohorts in the US: the Nurses' Health Study II, Growing Up Today Study, and Nurses' Health Study 3. Data analyzed included baseline and follow-up survey responses about IPV experiences early in the pandemic (March-September 2020); mental health domains of depression, anxiety, and posttraumatic stress symptoms (PTSS); and modifiable health factors (May 2020-October 2021). Female participants (both health care professionals and non-health care workers) aged 21 to 60 years from the 3 cohorts were included in the full analytic sample.

Exposures

Experience of IPV measured by the Relationship Assessment Tool and fear of partner.

Main Outcomes and Measures

Mental health symptoms, including depression, anxiety, and PTSS, and modifiable health factors, including sleep duration, sleep quality, physical activity, alcohol use, and use of alcohol or other substances to cope with stress.

Results

The full analytic sample included 13 597 female participants with a mean (SD) age of 44 (10.6) years. Accounting for sociodemographic factors and prepandemic mental health symptoms and correcting for multiple testing, experiencing IPV was associated with higher endorsement of depression (odds ratio [OR], 1.44; 95% CI, 1.38-1.50), anxiety (OR, 1.31; 95% CI, 1.26-1.36), and PTSS (OR, 1.22; 95% CI, 1.15-1.29) in random-effects meta-analyses across the 3 cohorts. The IPV experience was also associated with poorer sleep quality (OR, 1.21; 95% CI, 1.16-1.26), shorter sleep duration (OR, 1.13; 95% CI, 1.08-1.19), increased use of alcohol (OR, 1.10; 95% CI, 1.06-1.14), and use of alcohol or other substances to cope with stress (OR, 1.13; 95% CI, 1.08-1.18) across all cohorts as well as decreased physical activity (OR, 1.17; 95% CI, 1.09-1.26) in the Nurses' Health Study II only.

Conclusions and Relevance

Results of the study showed that IPV experiences at the start of the pandemic were associated with worse mental health symptoms and modifiable health factors for female participants younger than 60 years. Screening and interventions for IPV and related health factors are needed to prevent severe, long-term health consequences.

Abstract MP42: Associations Between Psychological Resilience and Lifestyle Behaviors Among Adults in Puerto Rico Affected by Repeated Adverse Events

Residents of Puerto Rico have repeatedly experienced adverse events over the past five years including Hurricanes Irma and Maria in 2017, earthquakes in 2019-2020, Hurricane Fiona in 2022, sociopolitical unrest, a deep economic crisis, and the COVID-19 pandemic (including strict lockdown protocols). Higher psychological resilience, or the ability to “bounce back” after adversity, has been associated with better cardiovascular health in other contexts. One potential mechanism for this relationship is that higher resilience may contribute to engaging in healthier behaviors, such as higher diet quality, more physical activity, and healthier sleep duration and quality, as well as less smoking and drinking. However, such relationships have not yet been explored in this population. We cross-sectionally surveyed 1,240 adults in Puerto Rico in 2019-2022, with recruitment both before and during the COVID-19 pandemic, as part of the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT). Participants responded to the Brief Resilience Scale (BRS) and Brief Resilient Coping Scale (BCS). Diet was assessed with a food frequency questionnaire and diet quality was defined by the Alternate Healthy Eating Index (AHEI). Physical activity was measured via the Harvard Alumni Activity Survey. We also collected data on average hours of sleep, quality of sleep, alcohol intake, and tobacco use. Logistic regression models estimated the odds ratios (OR, 95% CI) for following each healthy behavior by established categories of resilience (high and medium vs. low), adjusted for sociodemographic factors and co-morbidities. Of the sample, 39% (452 out of 1175) and 73% (851 out of 1170) were classified with high resilience and coping using the BRS and BCS, respectively. Adults with high resilience (vs. low) on the BRS had twice the odds [OR: 2.01, 95% CI: 1.22, 3.29] of reporting healthy sleep hours (7-8 hours/night compared to either 6 or fewer/night or 9 or more/night). High resilience was also associated with higher odds of being in the upper AHEI tertile (better diet quality) [OR: 1.61 (0.97, 2.68)], and having moderate or heavy physical activity [OR: 1.54 (1.04, 2.29) compared to sedentary or light activity]. These associations persisted when further adjusting for mental health disorders, perceived stress, and social support. Moreover, the relationships were stronger among participants interviewed during the COVID-19 pandemic, suggesting that psychological resilience may be particularly relevant during an ongoing stressor. No significant associations were noted between resilience and tobacco or alcohol use. Given Puerto Rico’s susceptibility to adverse events, seeking to improve population resilience in this and similarly vulnerable populations may lead to better health over the life course.

Pre-pandemic resilience to trauma and mental health outcomes during COVID-19

PURPOSE

The stress-sensitization hypothesis posits that individuals with prior trauma are at elevated risk for poor mental health when faced with subsequent stressors. Little work has examined whether those who have demonstrated psychological resilience to prior trauma would show either increased resilience or vulnerability to subsequent stressors. We examined pre-pandemic psychological resilience to lifetime trauma in relation to mental health outcomes amid the coronavirus disease 2019 (COVID-19) pandemic, a major societal stressor.

METHODS

The sample included 16,900 trauma-exposed women from the Nurses' Health Study II. Pre-pandemic resilience was defined by psychological health in 2017-2019 (characterized by levels of both distress and positive emotional well-being) relative to lifetime trauma. Resilience was defined categorically by cross-classifying unfavorable, adequate, and favorable psychological health by higher versus lower trauma burden, and continuously as the residual difference in predicted versus actual psychological health regressed on trauma burden. Mental health outcomes as of May-August 2020 included psychological distress symptoms and overall positive emotional well-being. Associations were assessed using covariate-adjusted regression models.

RESULTS

Pre-pandemic resilience was associated with lower distress and higher well-being early in the COVID-19 pandemic. Relative to the women showing highest resilience (favorable psychological health despite higher trauma), only those with lower trauma and favorable prior psychological health had significantly lower distress and higher positive emotional well-being during the pandemic. Higher continuous pre-pandemic resilience was also significantly associated with lower distress and higher positive emotional well-being during the pandemic.

CONCLUSION

Preventing mental health problems following trauma may contribute to protecting population well-being amid major stressors.

PSYCHOLOGICAL WELL-BEING IN OLDER ADULTS AFTER MULTIPLE SEVERE WEATHER EVENTS

Catastrophic hurricanes and flooding threaten health and well-being, although the long-term consequences of these events for survivors are poorly understood. In 2005, Hurricane Katrina devastated the US Gulf Coast. Many lost homes in these storms and relocated permanently inland. In August of 2016, historic flooding in Baton Rouge, Louisiana devastated a 22-parish (county) region, resulting in widespread destruction and a second round of disaster-related losses for those who relocated to Baton Rouge after Katrina. The present research is part of a larger longitudinal study on health and well-being after multiple disasters. Cherry et al. (2021) reported that greater flood damage was associated with more symptoms of depression and post-traumatic stress during the Wave 1 immediate impact phase. Here we examined symptoms of depression, anxiety and post-traumatic stress at Wave 2, a follow-up assessment that occurred 9 (+/- 3) months after Wave 1 testing. Three flood exposure groups were compared: non-flooded (controls), single disaster (flooded in 2016) and double disaster (flooded in 2005 and again in 2016). Results indicated that symptoms of depression and post-traumatic stress, which were elevated at Wave 1 for the single and double disaster groups relative to the non-flooded controls, were reduced at Wave 2 and did not differ from the controls. Correlation analyses revealed that age was negatively associated with symptoms of post-traumatic stress, depression, and anxiety, consistent with the inoculation view of post disaster psychological reactions. Implications of these data for understanding older adults’ psychological health after multiple disaster exposures are discussed.

Mitigating the mental health consequences of mass shootings: An in-silico experiment

BACKGROUND

There is emerging evidence that mass shootings are associated with adverse mental health outcomes at the community level. Data from other mass-traumatic events examined the effectiveness of usual care (UC), (i.e., psychological first aid approaches without triage), and stepped care (SC) approaches, with triage, in reducing the burden of post-traumatic stress disorder (PTSD) in a community.

METHODS

We built an agent-based model of 118,000 people that was demographically comparable to the population of Parkland and Coral Springs, Florida, US. We parametrized the model with data from other traumatic events. Using simulations, we then estimated the community prevalence of PTSD one month following the Stoneman Douglas High School (Florida, US) shooting and reported the potential reach, effectiveness, and cost effectiveness of different what-if treatment scenarios (SC or UC) over a two-year period.

FINDINGS

One month following the mass shooting, PTSD prevalence in the community was 11.3% (95% CI: 11.1-11.5%). The reach of SC was 3461 (95% CI: 3573-3736) per 10,000 and the reach of UC was 2457 (95% CI: 2401-2510) per 10,000. SC was superior to UC in reducing PTSD prevalence, yielding, after two years, a risk difference of -0.044 (95% CI, -0.046 to -0.042) and a risk ratio of 0.452 (95% CI, 0.437-0.468). SC was also superior to UC in reducing the persistence of PTSD, yielding, after two years, a risk difference of -0.39 (95% CI, -0.401 to -0.379) and a risk ratio of 0.452 (95% CI, 0.439-0.465). The incremental cost-effectiveness of SC compared to UC was $2718.49 per DALYs saved, and $0.47 per PTSD-free day.

INTERPRETATION

This simulation demonstrated the potential benefits of different community-level approaches in mitigating the burden of PTSD following a mass shooting. These results warrant further research on community-based interventions to mitigate the mental health consequences of mass shootings.

FUNDING

None.

Stressful life events and trajectories of depression symptoms in a U.S. military cohort

Depression is a common mental disorder that may comprise distinct, underlying symptom patterns over time. Associations between stressful life events throughout the civilian lifecourse-including during childhood-and adult depression have been documented in many populations, but are less commonly assessed in military samples. We identified different trajectories of depression symptoms across four years in a military cohort using latent class growth analysis, and investigated the relationship between these trajectories and two domains of civilian life experiences: childhood adversity (e.g., being mistreated during childhood) and more proximal stressful experiences (e.g., divorce). A four-group depression model was identified, including a symptom-free group (62%), an increasing symptom group (13%), a decreasing symptom group (16%), and a "chronic" symptom group (9%). Compared to the symptom-free group, soldiers with childhood adversity were more likely to be in the chronic depression, decreasing, and increasing symptom groups. Time-varying adult stressors had the largest effect on depression symptoms for the increasing symptom group compared to other groups, particularly in the last two years of follow-up. This study indicates the importance of considering events from throughout the lifecourse-not only those from deployment-when studying the mental health of servicemembers.

Validity and Reproducibility of FFQ in Measuring Food and Food Group Intakes

Objectives

We evaluated the validity and reproducibility of a 149-item semi-quantitative Food Frequency Questionnaire (FFQ) in measuring food and food group intakes among 736 participants of the Women's Lifestyle Validation Study (WLVS) and 649 participants of the Men's Lifestyle Validation Study (MLVS).

Methods

The WLVS was conducted among a subset of the Nurses' Health Study (NHS) and NHSII participants aged 45–80 years in 2010. Participants of the MLVS aged 46–82 years between 2011 and 2013 were recruited from the Health Professionals Follow-up Study and members of Harvard Pilgrim Health Care. We matched 10,128 foods with unique food codes collected from the 7-day dietary records (7DDRs) to the 149 foods listed on the FFQ based on the similarity of food descriptions. After the matching, we converted gram intakes of the 7DDR-measured foods into servings using the amounts specified on the FFQ. Food group intakes were calculated as the sum of the individual component foods in servings. Validity of the FFQ compared to repeated 7DDRs measured six months apart and the reproducibility between two FFQs administered one year apart were assessed using Spearman correlations.

Results

Foods generally considered to be healthy were often overreported through FFQs, while those perceived unhealthy were underreported. The average 1-year reproducibility of all foods listed on the FFQ was 0.64 in both the WLVS and MLVS. Reproducibility of the food groups (mean: 0.70 among women and 0.71 among men) was generally higher than that for individual foods. Among women, the average validity correlation for individual foods was 0.59 when comparing the FFQ completed at the end of the 1-year study period with the 7DDRs and correcting for within-person variations in 7DDRs. Among men, the corresponding average validity correlation was 0.61. Food groups assessed by the FFQ had slightly higher validity correlations than did individual foods in both women (range: 0.44–0.92, mean: 0.61) and men (0.46–0.88, mean: 0.64).

Conclusions

This study reaffirms that the FFQ performs well in measuring foods and food groups and provides the data enabling investigators to adjust for measurement error in epidemiologic studies of foods and food groups in relation to health outcomes.

Funding Sources

The Women's Lifestyle Validation Study and Men's Lifestyle Validation Study were funded by National Cancer Institute.

Trauma, Post-Traumatic Stress Disorder, and Treatment Among Middle-Aged and Older Women in the Nurses' Health Study II

OBJECTIVE

Trauma and post-traumatic stress disorder (PTSD) are common among women and associated with negative health outcomes across the life course. Relatively few studies, however, have examined the epidemiology of trauma, PTSD, and treatment among middle-aged and older civilian women, who are at elevated risk for adverse health outcomes. We aimed to characterize trauma, PTSD, and trauma-related treatment prevalence and correlates in a large cohort of middle-aged and older women.

DESIGN

Cross-sectional, nested substudy within the Nurses' Health Study II cohort.

SETTING

United States, 2018-2020.

PARTICIPANTS

33,327 current or former nurses, aged 53-74 years.

MEASUREMENTS

16-item modified version of the Brief Trauma Questionnaire; modified PTSD Checklist for the Diagnostic and Statistical Manual, Version 5.

RESULTS

The majority (82.2%) of women reported one or more lifetime traumas. The most common trauma types were unexpected death of a loved one (44.9%) and interpersonal violence (43.5%). Almost 30% reported occupational (nursing-related) trauma. Among the trauma-exposed, 10.5% met criteria for lifetime PTSD and 1.5% had past-month PTSD. One-third of lifetime PTSD cases were due to interpersonal violence event types. One-third of women with lifetime PTSD-and nearly half of those with PTSD from a nursing-related trauma-reported never receiving trauma-related treatment. Women aged 65 years and older with PTSD were less likely to be in treatment than those aged less than 65 years.

CONCLUSION

History of trauma and PTSD is prevalent in this population, and a treatment gap persists. Addressing this treatment gap is warranted, particularly among older women and those with nursing-related trauma.

The association of posttraumatic stress disorder, depression, and head injury with mid-life cognitive function in civilian women

BACKGROUND

Despite evidence linking posttraumatic stress disorder (PTSD), depression, and head injury, separately, with worse cognitive performance, investigations of their combined effects on cognition are limited in civilian women.

METHODS

The Cogstate Brief Battery assessment was administered in 10,681 women from the Nurses' Health Study II cohort, mean age 64.9 years (SD = 4.6). Psychological trauma, PTSD, depression, and head injury were assessed using online questionnaires. In this cross-sectional analysis, we used linear regression models to estimate mean differences in cognition by PTSD/depression status and stratified by history of head injury.

RESULTS

History of head injury was prevalent (36%), and significantly more prevalent among women with PTSD and depression (57% of women with PTSD and depression, 21% of women with no psychological trauma or depression). Compared to having no psychological trauma or depression, having combined PTSD and depression was associated with worse performance on psychomotor speed/attention ( β  = -.15, p = .001) and learning/working memory ( β  = -.15, p < .001). The joint association of PTSD and depression on worse cognitive function was strongest among women with past head injury, particularly among those with multiple head injuries.

CONCLUSIONS

Head injury, like PTSD and depression, was highly prevalent in this sample of civilian women. In combination, these factors were associated with poorer performance on cognitive tasks, a possible marker of future cognitive health. Head injury should be further explored in future studies of PTSD, depression and cognition in women.

Suicide Ideation and Social Support Trajectories in National Guard and Reserve Servicemembers

Objective: Since 2004 increased rates of suicide have been noted in the US Armed Forces. We examined the association of social support (SS) trajectories and suicide ideation (SI) over a four-year period in Reserve Component (RC) servicemembers (National Guard and Reserve). We also examined baseline mental health measures, as predictors of the identified trajectories. Methods: Structured interviews were conducted with a nationally representative sample of 1,582 RC servicemembers at baseline and three follow-up waves. Latent growth mixture modeling identified SS trajectories and the association with follow-up SI. Multinomial logistic regression analyses were used to predict SS trajectories using baseline measures of demographics and mental health. Results: We identified four trajectories of SS and their associated prevalence of follow-up SI: low (n = 60, 3.8%; SI = 30.5%), medium (n = 229, 14.5%; SI = 14.1%), high-low (n = 66, 4.2%; SI = 13.6%), and high-high (n = 1,227, 77.5%; SI = 4.2%). There were significant differences in follow-up SI prevalence between each pair of SS trajectories except between the medium-SS and high-low-SS trajectories. Baseline SI, post-traumatic stress disorder (PTSD), depression, binge drinking, and mental health diagnosis were associated with increased likelihood of being on a low-SS or medium-SS trajectory. Baseline PTSD discriminated being on the high-high-SS and high-low-SS trajectories. Conclusion: Results support four trajectories of social support and that individuals with low or decreasing SS are likely to have greater follow-up SI. Baseline mental health assessments can identify these risk trajectories.

Consumption of Olive Oil and Risk of Total and Cause-Specific Mortality Among U.S. Adults

BACKGROUND

Olive oil consumption has been shown to lower cardiovascular disease risk, but its associations with total and cause-specific mortality are unclear.

OBJECTIVES

The purpose of this study was to evaluate whether olive oil intake is associated with total and cause-specific mortality in 2 prospective cohorts of U.S. men and women.

METHODS

The authors used multivariable-adjusted Cox proportional-hazards models to estimate HRs for total and cause-specific mortality among 60,582 women (Nurses' Health Study, 1990-2018) and 31,801 men (Health Professionals Follow-up Study, 1990-2018) who were free of cardiovascular disease or cancer at baseline. Diet was assessed by a semiquantitative food frequency questionnaire every 4 years.

RESULTS

During 28 years of follow-up, 36,856 deaths occurred. The multivariable-adjusted pooled HR for all-cause mortality among participants who had the highest consumption of olive oil (>0.5 tablespoon/day or >7 g/d) was 0.81 (95% CI: 0.78-0.84) compared with those who never or rarely consumed olive oil. Higher olive oil intake was associated with 19% lower risk of cardiovascular disease mortality (HR: 0.81; 95% CI: 0.75-0.87), 17% lower risk of cancer mortality (HR: 0.83; 95% CI: 0.78-0.89), 29% lower risk of neurodegenerative disease mortality (HR: 0.71; 95% CI: 0.64-0.78), and 18% lower risk of respiratory disease mortality (HR: 0.82; 95% CI: 0.72-0.93). In substitution analyses, replacing 10 g/d of margarine, butter, mayonnaise, and dairy fat with the equivalent amount of olive oil was associated with 8%-34% lower risk of total and cause-specific mortality. No significant associations were observed when olive oil was compared with other vegetable oils combined.

CONCLUSIONS

Higher olive oil intake was associated with lower risk of total and cause-specific mortality. Replacing margarine, butter, mayonnaise, and dairy fat with olive oil was associated with lower risk of mortality.

Trauma, Posttraumatic Stress Disorder, and Treatment Among Middle-Aged And Older Women

Posttraumatic stress disorder (PTSD) is twice as prevalent in women as in men, and is an established risk factor for chronic disease, but few studies have comprehensively assessed lifetime PTSD in middle-aged and older civilian women. We surveyed 33,328 women aged 54-74 from the Nurses’ Health Study II from August 2018 to January 2020 to understand trauma exposure, PTSD based on the Diagnostic and Statistical Manual of Mental Disorders Version 5, and trauma-related treatment use. The majority (82.2%) of women reported one or more lifetime traumas. 10.5% of those with trauma had lifetime PTSD and 1.5% had past-month PTSD. The most common trauma types were sudden or unexpected death of a loved one (44.9%) and interpersonal or sexual violence (43.5%). Almost 30% experienced occupational (nursing-related) trauma. Interpersonal or sexual violence event types explained the largest proportion of PTSD cases (33.6%) out of seven categories of events assessed. Only 25% of women with trauma ever accessed trauma-related treatment, but this proportion was higher (66.4%) among those with diagnosable PTSD, and among those with current depression (35.9%). Treatment was most common among women who experienced interpersonal/sexual violence and lowest among those with occupational trauma, but treatment satisfaction did not vary by worst trauma type. Psychotherapy was the most common type of treatment. These results demonstrate that trauma is nearly universal in middle-aged to older women, which has important implications for their long-term health and well-being—particularly in the era of COVID-19 which is likely to produce additional trauma in this population.

Demography, education, and research trends in the interdisciplinary field of disease ecology

Micro- and macroparasites are a leading cause of mortality for humans, animals, and plants, and there is great need to understand their origins, transmission dynamics, and impacts. Disease ecology formed as an interdisciplinary field in the 1970s to fill this need and has recently rapidly grown in size and influence. Because interdisciplinary fields integrate diverse scientific expertise and training experiences, understanding their composition and research priorities is often difficult. Here, for the first time, we quantify the composition and educational experiences of a subset of disease ecology practitioners and identify topical trends in published research. We combined a large survey of self-declared disease ecologists with a literature synthesis involving machine-learning topic detection of over 18,500 disease ecology research articles. The number of graduate degrees earned by disease ecology practitioners has grown dramatically since the early 2000s. Similar to other science fields, we show that practitioners in disease ecology have diversified in the last decade in terms of gender identity and institution, with weaker diversification in race and ethnicity. Topic detection analysis revealed how the frequency of publications on certain topics has declined (e.g., HIV, serology), increased (e.g., the dilution effect, infectious disease in bats), remained relatively common (e.g., malaria ecology, influenza, vaccine research and development), or have consistently remained relatively infrequent (e.g., theoretical models, field experiments). Other topics, such as climate change, superspreading, emerging infectious diseases, and network analyses, have recently come to prominence. This study helps identify the major themes of disease ecology and demonstrates how publication frequency corresponds to emergent health and environmental threats. More broadly, our approach provides a framework to examine the composition and publication trends of other major research fields that cross traditional disciplinary boundaries.

A comorbid mental disorder paradox: Using causal diagrams to understand associations between posttraumatic stress disorder and suicide

OBJECTIVE

Although some studies document that posttraumatic stress disorder (PTSD) increases suicide risk, other studies have produced the paradoxical finding that PTSD decreases suicide risk. We sought to understand methodologic biases that may explain these paradoxical findings through the use of directed acyclic graphs (DAGs).

METHOD

DAGs are causal diagrams that visually encode a researcher's assumptions about data generating mechanisms and assumed causal relations among variables. DAGs can connect theories to data and guide statistical choices made in study design and analysis. In this article, we describe DAGs and explain how they can be used to identify biases that may arise from inappropriate analytic decisions and data limitations.

RESULTS

We define a particular form of bias, collider bias, that is a likely explanation for why studies have found a supposedly protective association of PTSD with suicide. This protective association is interpreted by some researchers as evidence that PTSD reduces the risk of suicide. Collider bias may occur through inappropriate adjustment for a psychiatric comorbidity, such as adjustment for variables that are affected by PTSD and share common causes with suicide.

CONCLUSIONS

We recommend that researchers collect longitudinal measurements of psychiatric comorbidities, which would help establish the temporal ordering of variables and avoid the biases discussed in this article. Furthermore, researchers could use DAGs to explore how results may be impacted by design and analytic decisions prior to execution. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cohort profile: the Ohio Army National Guard Mental Health Initiative (OHARNG-MHI)

PURPOSE

Rates of mental disorders in the United States military have increased in recent years. National Guard members may be particularly at risk for mental disorders, given their dual role as citizen-soldiers and their increased involvement in combat deployments during recent conflicts. The Ohio Army National Guard Mental Health Initiative (OHARNG-MHI) was launched to assess the prevalence, incidence, and potential causes and consequences of mental disorders in this unique population.

METHODS

OHARNG-MHI is a decade-long dynamic cohort study that followed over 3,000 National Guard members yearly through structured telephone interviews.

RESULTS

Findings thus far have applied a pre-, peri-, post-deployment framework, identifying factors throughout the life course associated with mental disorders, including childhood events and more recent events, both during and outside of deployment. An estimated 61% of participants had at least one mental disorder in their lifetime, the majority of which initiated prior to military service. Psychiatric comorbidity was common, as were alcohol use and stressful events. Latent class growth analyses revealed four distinct trajectory paths of both posttraumatic stress and depression symptoms across four years. Only 37% of soldiers with probable past-year mental disorders accessed mental health services in the subsequent year, with substance use disorders least likely to be treated.

CONCLUSION

Strengths of this study include a large number of follow-up interviews, detailed data on both military and non-military experiences, and a clinical assessment subsample that assessed the validity of the telephone screening instruments. Findings, methods, and procedures of the study are discussed, and collaborations are welcome.

Persistent depressive symptoms during COVID-19: a national, population-representative, longitudinal study of U.S. adults

BACKGROUND

The COVID-19 pandemic and its consequences have been associated with an increase in poor population mental health. We assessed how depressive symptoms changed among U.S. adults over the course of the COVID-19 pandemic and identified the key risk factors for these symptoms.

METHODS

Longitudinal panel study of a nationally representative group of U.S. adults ages 18 years and older surveyed in March-April 2020 (Time 1; N=1441) and March-April 2021 (Time 2; N=1161) in the COVID-19 and Life Stressors Impact on Mental Health and Well-being study (CLIMB). The Patient Health Questionnaire-9 (PHQ-9) was used to define elevated depressive symptoms (cut-off ≥10) and depressive symptoms score (0-27).

FINDINGS

The prevalence of elevated depressive symptoms persisted from 27.8% in 2020 (95% CI: 24.9, 30.9) to 32.8% in 2021 (95% CI: 29.1, 36.8). Over time, the central drivers of depressive symptoms were low household income, not being married, and experiencing multiple stressors during the COVID-19 pandemic. The odds ratio of elevated depressive symptoms for low income relative to high income persons increased from 2.3 (95% CI: 1.2, 4.2) in 2020 to 7.0 (95% CI: 3.7, 13.3) in 2021. Fewer people reported experiencing 4 or more COVID-19 stressors in 2021 than in 2020 (47.5% in 2020 vs 37.1% in 2021), but the odds ratio of elevated depressive symptoms associated with 4 or more stressors relative to 1 stressor or less increased from 1.9 (95% CI: 1.2, 3.1) in 2020 to 5.4 (95% CI: 3.2, 9.2) in 2021.

INTERPRETATION

The burden of depressive symptoms in the U.S. adult population increased over the course of the COVID-19 pandemic. Mental health gaps grew between populations with different assets and stressor experiences during the COVID-19 pandemic.

FUNDING

CLIMB Time 1 was sponsored by the Rockefeller Foundation-Boston University 3-D Commission. CLIMB Time 2 was sponsored by the de Beaumont Foundation.

Categorising ultra-processed foods in large-scale cohort studies: evidence from the Nurses' Health Studies, the Health Professionals Follow-up Study, and the Growing Up Today Study

This manuscript details the strategy employed for categorising food items based on their processing levels into the four NOVA groups. Semi-quantitative food frequency questionnaires (FFQs) from the Nurses' Health Studies (NHS) I and II, the Health Professionals Follow-up Study (HPFS) and the Growing Up Today Studies (GUTS) I and II cohorts were used. The four-stage approach included: (i) the creation of a complete food list from the FFQs; (ii) assignment of food items to a NOVA group by three researchers; (iii) checking for consensus in categorisation and shortlisting discordant food items; (iv) discussions with experts and use of additional resources (research dieticians, cohort-specific documents, online grocery store scans) to guide the final categorisation of the short-listed items. At stage 1, 205 and 315 food items were compiled from the NHS and HPFS, and the GUTS FFQs, respectively. Over 70 % of food items from all cohorts were assigned to a NOVA group after stage 2. The remainder were shortlisted for further discussion (stage 3). After two rounds of reviews at stage 4, 95⋅6 % of food items (NHS + HPFS) and 90⋅7 % items (GUTS) were categorised. The remaining products were assigned to a non-ultra-processed food group (primary categorisation) and flagged for sensitivity analyses at which point they would be categorised as ultra-processed. Of all items in the food lists, 36⋅1 % in the NHS and HPFS cohorts and 43⋅5 % in the GUTS cohorts were identified as ultra-processed. Future work is needed to validate this approach. Documentation and discussions of alternative approaches for categorisation are encouraged.

Lignan Intake and Risk of Coronary Heart Disease

BACKGROUND

Evidence regarding lignan consumption in relation to coronary heart disease (CHD) risk remains limited and mixed.

OBJECTIVES

The aim of this study was to prospectively examine associations between lignan intake and CHD risk in U.S. men and women.

METHODS

We prospectively followed 214,108 men and women in 3 cohorts who did not have cardiovascular disease or cancer at baseline. Diet was repeatedly assessed using a validated food frequency questionnaire every 2-4 years since baseline.

RESULTS

During 5,517,225 person-years of follow-up, we documented 10,244 CHD cases, including 6,283 nonfatal myocardial infarction and 3,961 fatal CHD cases. In multivariable-adjusted analyses, comparing extreme quintiles, the pooled hazard ratios of CHD were 0.85 (95% CI: 0.79-0.92) for total lignans, 0.76 (95% CI: 0.71-0.82) for matairesinol, 0.87 (95% CI: 0.81-0.93) for secoisolariciresinol, 0.89 (95% CI: 0.83-0.95) for pinoresinol, and 0.89 (95% CI: 0.83-0.95) for lariciresinol (all P values for trend ≤0.003). Nonlinear relationships were found for total lignan, matairesinol, and secoisolariciresinol: the risk reduction plateaued at intakes above approximately 300 μg/d, 10 μg/d, and 100 μg/d, respectively (P < 0.01 for all nonlinearity). The inverse associations for total lignan intake appeared to be more apparent among participants with higher total fiber intake (P = 0.04 for interaction). In addition, lignan intake was more strongly associated with plasma concentrations of enterolactone when fiber intake was higher.

CONCLUSIONS

Increased long-term intake of lignans was associated with a significantly lower risk of total CHD in both men and women. Possible synergistic effects may exist between lignan and fiber intake in relation to CHD risk reduction, possibly through enhancing the production of enterolignans.

Self-Reported Dietary Supplement Use Is Reproducible and Relatively Valid in the Cancer Prevention Study-3 Diet Assessment Substudy

BACKGROUND

Dietary supplement use is common, particularly among cancer survivors and those at increased risk for cancer.

OBJECTIVE

The objectives of this study were to assess 1-year test-retest reproducibility of dietary supplement use reported via food frequency questionnaire (FFQ-1 vs FFQ-2) and relative validity in comparison to repeated 24-hour dietary recalls (FFQ-2 vs DRs).

DESIGN

This ancillary study was conducted within a large prospective cohort, the American Cancer Society's Cancer Prevention Study-3.

PARTICIPANTS/SETTING

Between 2015 and 2016, 684 participants in the United States (64% women; 62% non-Hispanic White, 23% non-Hispanic Black, and 15% Hispanic) completed two FFQs and up to six unannounced telephone interviewer-administered DRs over 1 year as part of the Cancer Prevention Study-3 Diet Assessment Substudy.

PRIMARY OUTCOME MEASURES

FFQs queried current multivitamin-mineral supplement (≥10 components) use, frequency and dose (range) for seven supplements taken individually or as part of a complex (individual/complex) including calcium, vitamins D, C, and E, folic acid, fish oil, and glucosamine. DRs allowed exact reporting of supplement frequency and dose.

STATISTICAL ANALYSES

Weighted κ statistics were used to evaluate reproducibility between FFQ-1 and FFQ-2 and Spearman correlation coefficients assessed agreement between supplemental nutrient amounts assessed by FFQ-2 and the average of DRs.

RESULTS

Just more than half of the participants reported taking multivitamin-mineral supplements on the baseline FFQ. Kappa statistics for the comparison of categorical responses between FFQ-1 and FFQ-2 were 0.67 for multivitamin-mineral supplements. Kappas for individual/complex supplements ranged from 0.47 for folic acid to 0.74 for vitamin D, with a mean of 0.64. Results were similar between men and women. Spearman correlation coefficients comparing FFQ-2 with the average of DRs (validity) for nutrient intakes from all sources ranged from 0.65 (fish oil for women) to 0.77 (vitamin D for men and calcium for women); results were similar among men and women.

CONCLUSIONS

These findings suggest the FFQ used in Cancer Prevention Study-3 has good reproducibility over 1 year and yields estimates comparable to a more detailed assessment for commonly consumed dietary supplements.

Consumption of Total Olive Oil and Risk of Total and Cause-Specific Mortality in US Adults

Objectives

The association between olive oil intake and the risk of mortality has not been evaluated before in the US population. Our objective was to examine whether olive oil intake is associated with total and cause-specific mortality in two prospective cohorts of US men and women. We hypothesize that higher olive oil consumption is associated with lower risk of total and cause-specific mortality.

Methods

We followed 61,096 women (Nurses’ Health Study, 1990–2016) and 31,936 men (Health Professionals Follow-up Study, 1990–2016) who were free of diabetes, cardiovascular disease and cancer at baseline. Diet was assessed by a semi quantitative food frequency questionnaire at baseline and then every 4 years. Cox proportional hazards regressions were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

During 26 years of follow-up, 32,868 deaths occurred. Compared with those participants who never consumed olive oil, those with higher olive oil intake (&gt;1/2 tablespoon/d or &gt;8g/d) had 15% lower risk of total mortality [pooled hazard ratio (95% confidence interval): 0.85 (0.81, 0.88)] after adjustment for potential confounders. Higher olive oil intake was associated with 15% lower risk of CVD death [0.85 (0.78, 0.92)], 38% lower risk of neurodegenerative disease death [0.62 (0.54, 0.71)], and 12% lower risk of respiratory death [0.88 (0.77, 1.00)]. Replacing 10 g of margarine, mayonnaise, and dairy fat with the equivalent amount of olive oil was associated with 7–20% lower risk of total mortality, and death from CVD, cancer, neurodegenerative, and respiratory diseases. No significant associations were observed when olive oil was replacing other vegetable oils combined (corn, safflower, soybean and canola oil).

Conclusions

We observed that higher olive oil intake was associated with a lower risk of total mortality and cause-specific mortality in a large prospective cohort of U.S. men and women. The substitution of margarine, mayonnaise, and dairy fat with olive oil was associated with a reduced risk of mortality.

Funding Sources

This work was supported by grants from the National Institutes of Health.

Long-term Intake of Gluten and Cognitive Function Among US Women

IMPORTANCE

Gluten avoidance has been suggested as having a benefit to cognitive health among the general population, given the link between gluten and cognitive impairment in patients with celiac disease. However, data are lacking in individuals without celiac disease.

OBJECTIVE

To examine whether gluten intake is associated with cognitive function in women without celiac disease.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included US women who participated in the longitudinal, population-based Nurses' Health Study II and had not previously or subsequently been diagnosed with celiac disease. Dietary data were collected from 1991 to 2015, and data on cognitive function were collected from 2014 to 2019. Data analysis was conducted from October 2020 to April 2021.

EXPOSURES

Energy-adjusted gluten intake, cumulatively averaged across questionnaire cycles prior to cognitive assessment.

MAIN OUTCOMES AND MEASURES

Three standardized cognitive scores assessed by the validated Cogstate Brief Battery: (1) psychomotor speed and attention score, (2) learning and working memory score, and (3) global cognition score. Higher scores indicated better performance.

RESULTS

The cohort included 13 494 women (mean [SD] age, 60.6 [4.6] years). The mean (SD) gluten intake was 6.3 (1.6) g/d. After controlling for demographic and lifestyle risk factors in linear regression, no significant differences in standardized cognitive scores (mean [SD], 0 [1]) by quintile of gluten intake were found across highest and lowest quintiles of gluten intake (psychomotor speed and attention: -0.02; 95% CI, -0.07 to 0.03; P for trend = .22; learning and working memory: 0.02; 95% CI, -0.03 to 0.07; P for trend = .30; global cognition: -0.002; 95% CI, -0.05 to 0.05; P for trend = .78). The null associations persisted after additional adjustment for major sources of dietary gluten (ie, refined grains or whole grains), comparing decile categories of gluten intake, using gluten intake updated at each previous questionnaire cycle, or modeling changes in gluten intake. Similarly, these associations were not materially altered in sensitivity analyses that excluded women who had reported cancer or dementia diagnosis or had not completed all dietary assessments.

CONCLUSIONS AND RELEVANCE

In this study, long-term gluten intake was not associated with cognitive scores in middle-aged women without celiac disease. Our results do not support recommendations to restrict dietary gluten to maintain cognitive function in the absence of celiac disease or established gluten sensitivity.

Disaster stressors and psychological well-being in older adults after a flood

We examined the inoculation and stress sensitization explanations concerning mental health outcomes in 223 predominately middle-aged and older adults after a flood (M age = 49.6 years, SD = 17.7 years, range: 18-88 years). In multiple linear regression models, having flood damage was associated with higher levels of posttraumatic stress disorder (PTSD) and depressive symptoms, while social support was associated with fewer symptoms. Greater lifetime trauma and flood-related stress were associated with more symptoms of depression and PTSD, respectively. Older age was associated with more religious coping and fewer depressive and worry symptoms. Future directions for research on postdisaster vulnerabilities and resilience are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Cancer Prevention Study-3 FFQ Is a Reliable and Valid Measure of Nutrient Intakes among Racial/Ethnic Subgroups, Compared with 24-Hour Recalls and Biomarkers

BACKGROUND

Valid assessment of dietary intake in diverse populations is important for studies of chronic disease risk in the United States.

OBJECTIVES

We evaluated the reproducibility and validity of a food frequency questionnaire (FFQ) modified for the American Cancer Society's Cancer Prevention Study-3 (CPS-3) prospective cohort, among a racially/ethnically diverse subgroup.

METHODS

The Diet Assessment Substudy included 677 CPS-3 participants (64% women; 61% non-Hispanic white, 24% non-Hispanic black, 15% Hispanic), aged 31-70 y, who completed 2 FFQs 1 y apart (FFQ1, FFQ2), 4-6 telephone-administered 24-h dietary recalls (24HRs), and 2 fasting blood samples and 24-h urine collections ∼6 mo apart in the interim. Spearman rank correlation coefficients (ρ) were used to evaluate FFQ reproducibility and validity compared with 24HRs for 67 nutrient exposures. For 18 of these nutrients, we used the method of triads to calculate validity coefficients (VCs, ρ) from pairwise correlations of FFQ2, 24HRs, and biomarkers. Analyses were stratified by sex, race/ethnicity, education, and BMI.

RESULTS

Mean (range) FFQ reproducibility correlations were ρ = 0.65 (0.50-0.91) for men and ρ = 0.63 (0.37-0.89) for women; mean (range) energy-adjusted, deattenuated correlations of FFQ2 with 24HRs were ρ = 0.60 (0.33-0.84) for men and ρ = 0.55 (0.21-0.79) for women. FFQ2 VCs (ρ) among men ranged from 0.42 for β-cryptoxanthin to 0.91 for omega-3 (n-3) fatty acids and, among women, from 0.41 for sodium to 0.79 for total vitamin D. Mean FFQ reproducibility and validity were highest among whites (ρ = 0.68, ρ = 0.58, respectively) and slightly lower among blacks (ρ = 0.57, ρ = 0.49, respectively) and Hispanics (ρ = 0.59, 0.55, respectively). FFQ reproducibility and validity were slightly lower among those with less than a 4-y college degree, and those with a BMI ≥30 kg/m2.

CONCLUSIONS

Reproducibility and validity of the CPS-3 FFQ were comparable with similar studies for most nutrients, among all subgroups. These findings support future dietary analyses in the contemporary CPS-3 cohort and other similar cohorts.

A Machine Learning Approach to Predicting New-onset Depression in a Military Population

OBJECTIVE

Depression is one of the most common mental disorders in the United States in both civilian and military populations, but few prospective studies assess a wide range of predictors across multiple domains for new-onset (incident) depression in adulthood. Supervised machine learning methods can identify predictors of incident depression out of many different candidate variables, without some of the assumptions and constraints that underlie traditional regression analyses. The objectives of this study were to identify predictors of incident depression across 5 years of follow-up using machine learning, and to assess prediction accuracy of the algorithms.

METHODS

Data were from a cohort of Army National Guard members free of history of depression at baseline (n = 1951 men and 298 women), interviewed once per year for probable depression. Classification trees and random forests were constructed and cross-validated, using 84 candidate predictors from the baseline interviews.

RESULTS

Stressors and traumas such as emotional mistreatment and adverse childhood experiences, demographics such as being a parent or student, and military characteristics including paygrade and deployment location were predictive of probable depression. Cross-validated random forest algorithms were moderately accurate (68% for women and 73% for men).

CONCLUSIONS

Events and characteristics throughout the life course, both in and outside of deployment, predict incident depression in adulthood among military personnel. Although replication studies are needed, these results may help inform potential intervention targets to reduce depression incidence among military personnel. Future research should further refine and explore interactions between identified variables.

Risk and Protective Factors for Difficulty Controlling Violent Behavior in National Guard and Reserve Service Members

Violent behavior is an important problem for military service members and veterans. A representative cohort of U.S. Reserve and National Guard personnel (N = 1,293) were interviewed to assess self-reported problems controlling violent behavior, deployment traumas, posttraumatic stress disorder (PTSD), alcohol abuse, and social support. Poisson regression models were used to estimate the associations of violent behavior with risk and protective factors. Problems controlling violent behavior were uncommon among male (3.3%) and female (1.7%) service members. Adjusted prevalence ratios (aPR) showed associations between violent behavior and deployment traumas (aPR = 1.67, 95% confidence interval [CI] = [1.34, 2.08]), PTSD (aPR = 9.95, 95% CI = [5.09, 19.48]), and PTSD symptom severity (aPR for each additional PTSD symptom = 1.07, 95% CI = [1.06, 1.09]). Social support was associated with lower prevalence of violent behavior (aPR = 0.62, 95% CI = [0.52, 0.76]). The association between violent behavior and alcohol abuse was not statistically significant (aPR = 1.94, 95% CI = [0.92, 4.09]). Results were consistent when the population was restricted to personnel who had deployed to a war zone. Problems controlling violent behavior were less common in this cohort than has been documented in other studies. Associations of violent behavior with risk and protective factors are consistent with prior research.

Financial hardship and health risk behavior during COVID-19 in a large US national sample of women

COVID-19 has caused over 300,000 US deaths thus far, but its long-term health consequences are not clear. Policies to contain the pandemic have led to widespread economic problems, which likely increase stress and resulting health risk behaviors, particularly among women, who have been hardest hit both by job loss and caregiving responsibilities. Further, women with pre-existing disadvantage (e.g., those without health insurance) may be most at risk for stress and consequent health risk behavior. Our objective was to estimate the associations between financial stressors from COVID-19 and health risk behavior changes since COVID-19, with potential effect modification by insurance status. We used multilevel logistic regression to assess the relationships between COVID-19-related financial stressors (job loss, decreases in pay, trouble paying bills) and changes in health risk behavior (less exercise, sleep, and healthy eating; more smoking/vaping and drinking alcohol), controlling for both individual-level and zip code-level confounders, among 90,971 US women who completed an online survey in March–April 2020. Almost 40% of women reported one or more COVID-19-related financial stressors. Each financial stressor was significantly associated with higher odds of each type of health risk behavior change. Overall, reporting one or more financial stressors was associated with 56% higher odds (OR = 1.56; 95% CI: 1.51, 1.60) of reporting two or more health risk behavior changes. This association was even stronger among women with no health insurance (OR = 2.46; 95% CI: 1.97, 3.07). COVID-19-related economic stress is thus linked to shifts in health risk behaviors among women, which may have physical health consequences for years to come. Further, the relationship between financial hardship and health risk behavior among women may be modified by health insurance status, as a marker for broader socioeconomic context and resources. The most socioeconomically vulnerable women are likely at highest risk for long-term health effects of COVID-19 financial consequences.

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Over 1/3 of women in this study reported COVID-19-related financial stress.

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Financial stress was associated with higher odds of health risk behavior changes.

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This relationship was modified by health insurance status among women.

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These behavior changes may eventually lead to cardiovascular disease.

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Women who are already more vulnerable are likely at even higher risk.

Low assets and financial stressors associated with higher depression during COVID-19 in a nationally representative sample of US adults

BACKGROUND

COVID-19 and related containment policies have caused or heightened financial stressors for many in the USA. We assessed the relation between assets, financial stressors and probable depression during the COVID-19 pandemic.

METHODS

Between 31 March 2020 and 13 April 2020, we surveyed a probability-based, nationally representative sample of US adults ages 18 and older using the COVID-19 and Life stressors Impact on Mental Health and Well-being survey (n=1441). We calculated the prevalence of probable depression using the Patient Health Questionnaire-9 (cut-off ≥10) and exposure to financial stressors by financial, physical and social assets categories (household income, household savings, home ownership, educational attainment and marital status). We estimated adjusted ORs and predicted probabilities of probable depression across assets categories and COVID-19 financial stressor exposure groups.

RESULTS

We found that (1) 40% of US adults experienced COVID-19-related financial stressors during this time period; (2) low assets (OR: 3.0, 95% CI 2.1 to 4.2) and COVID-19 financial stressor exposure (OR: 2.8, 95% CI 2.1 to 3.9) were each associated with higher odds of probable depression; and (3) among persons with low assets and high COVID-19 financial stressors, 42.7% had probable depression; and among persons with high assets and low COVID-19 financial stressors, 11.1% had probable depression. Persons with high assets and high COVID-19 financial stressors had a similar prevalence of probable depression (33.5%) as persons with low assets and low COVID-19 financial stressors (33.5%). The more assets a person had, the lower the level of probable depression.

CONCLUSION

Populations with low assets are bearing a greater burden of mental illness during the COVID-19 pandemic.

Exposure to Armed Conflict in Childhood vs Older Ages and Subsequent Onset of Major Depressive Disorder

Importance

This study offers a rare opportunity to evaluate life-course differences in the likelihood of developing major depressive disorder (MDD) after exposure to georeferenced neighborhood-level violence during an armed conflict.

Objective

To examine age cohort (age <11 vs ≥11 years) differences in associations of neighborhood-level violence with subsequent depression onset, independently of individual exposure and other key characteristics.

Design, Setting, and Participants

The Chitwan Valley Family Study is a population-representative panel study (1995 to present) conducted in Western Chitwan in Nepal, a low-income country that experienced a medium-intensity armed conflict from 2000 to 2006. Data for violent events were collected during the armed conflict and were linked to lifetime histories of MDD (collected in 2016-2018). The present cohort study analyzes 10 623 participants within 151 neighborhoods, systematically selected and representative of Western Chitwan. All residents aged 15 to 59 years at MDD assessment were eligible (response rate, 93%). Data analysis was performed from May 2019 to July 2020.

Exposures

Georeferenced number of armed conflict-related physical beatings within 1 km of residential neighborhood.

Main Outcomes and Measures

The main outcome was onset of MDD, as defined by Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), during or after the conflict, stratified by children (aged <11 years) and older individuals (aged ≥11 years), assessed by the Nepal-specific World Mental Health-Composite International Diagnostic Instrument 3.0 with a life history calendar.

Results

In total, 10 623 participants (5745 female [54.08%]; 4074 [38.35%] aged <11 years at the conflict start) contributed 171 899 person-years of exposure to the risk of MDD. Two or more beatings occurred within 1 km of 15 neighborhoods (9.9%). Discrete-time survival models showed that children (but not older individuals) living in neighborhoods with 2 or more beatings had a higher likelihood of developing MDD than those who lived in a community with no beatings (odds ratio, 1.82; 95% CI, 1.17-2.84; P = .008); there was also a significant interaction between age group and neighborhood beatings (odds ratio, 1.85; 95% CI, 1.27-2.70; P = .001). A confirmatory, multivariable, multilevel matching analysis showed a neighborhood association for children (z = -2.66; P = .008), but not older individuals (z = -0.454; P = .65). The mean (SE) incidence of MDD among children living in neighborhoods with 2 or more beatings nearby was 12.69% (2.37%) vs 5.08% (1.56%) in the matched unexposed sample.

Conclusions and Relevance

The youngest individuals may be the most at risk during times of violence, with mental health consequences lasting long after conflicts have subsided and should be a priority for population-level interventions. Future research should consider other disorders, other types of violence, and elderly individuals.

Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic

IMPORTANCE

The coronavirus disease 2019 (COVID-19) pandemic and the policies to contain it have been a near ubiquitous exposure in the US with unknown effects on depression symptoms.

OBJECTIVE

To estimate the prevalence of and risk factors associated with depression symptoms among US adults during vs before the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This nationally representative survey study used 2 population-based surveys of US adults aged 18 or older. During COVID-19, estimates were derived from the COVID-19 and Life Stressors Impact on Mental Health and Well-being study, conducted from March 31, 2020, to April 13, 2020. Before COVID-19 estimates were derived from the National Health and Nutrition Examination Survey, conducted from 2017 to 2018. Data were analyzed from April 15 to 20, 2020.

EXPOSURES

The COVID-19 pandemic and outcomes associated with the measures to mitigate it.

MAIN OUTCOMES AND MEASURES

Depression symptoms, defined using the Patient Health Questionnaire-9 cutoff of 10 or higher. Categories of depression symptoms were defined as none (score, 0-4), mild (score, 5-9), moderate (score, 10-14), moderately severe (score, 15-19), and severe (score, ≥20).

RESULTS

A total of 1470 participants completed the COVID-19 and Life Stressors Impact on Mental Health and Well-being survey (completion rate, 64.3%), and after removing those with missing data, the final during-COVID-19 sample included 1441 participants (619 participants [43.0%] aged 18-39 years; 723 [50.2%] men; 933 [64.7%] non-Hispanic White). The pre-COVID-19 sample included 5065 participants (1704 participants [37.8%] aged 18-39 years; 2588 [51.4%] women; 1790 [62.9%] non-Hispanic White). Depression symptom prevalence was higher in every category during COVID-19 compared with before (mild: 24.6% [95% CI, 21.8%-27.7%] vs 16.2% [95% CI, 15.1%-17.4%]; moderate: 14.8% [95% CI, 12.6%-17.4%] vs 5.7% [95% CI, 4.8%-6.9%]; moderately severe: 7.9% [95% CI, 6.3%-9.8%] vs 2.1% [95% CI, 1.6%-2.8%]; severe: 5.1% [95% CI, 3.8%-6.9%] vs 0.7% [95% CI, 0.5%-0.9%]). Higher risk of depression symptoms during COVID-19 was associated with having lower income (odds ratio, 2.37 [95% CI, 1.26-4.43]), having less than $5000 in savings (odds ratio, 1.52 [95% CI, 1.02-2.26]), and exposure to more stressors (odds ratio, 3.05 [95% CI, 1.95-4.77]).

CONCLUSIONS AND RELEVANCE

These findings suggest that prevalence of depression symptoms in the US was more than 3-fold higher during COVID-19 compared with before the COVID-19 pandemic. Individuals with lower social resources, lower economic resources, and greater exposure to stressors (eg, job loss) reported a greater burden of depression symptoms. Post-COVID-19 plans should account for the probable increase in mental illness to come, particularly among at-risk populations.

Intake of whole grain foods and risk of type 2 diabetes: results from three prospective cohort studies

OBJECTIVE

To examine the associations between the intake of total and individual whole grain foods and the risk of type 2 diabetes.

DESIGN

Prospective cohort studies.

SETTING

Nurses' Health Study (1984-2014), Nurses' Health Study II (1991-2017), and Health Professionals Follow-Up Study (1986-2016), United States.

PARTICIPANTS

158 259 women and 36 525 men who did not have type 2 diabetes, cardiovascular disease, or cancer at baseline.

MAIN OUTCOME MEASURES

Self-reports of incident type 2 diabetes by participants identified through follow-up questionnaires and confirmed by a validated supplementary questionnaire.

RESULTS

During 4 618 796 person years of follow-up, 18 629 participants with type 2 diabetes were identified. Total whole grain consumption was categorized into five equal groups of servings a day for the three cohorts. After adjusting for lifestyle and dietary risk factors for diabetes, participants in the highest category for total whole grain consumption had a 29% (95% confidence interval 26% to 33%) lower rate of type 2 diabetes compared with those in the lowest category. For individual whole grain foods, pooled hazard ratios (95% confidence intervals) for type 2 diabetes in participants consuming one or more servings a day compared with those consuming less than one serving a month were 0.81 (0.77 to 0.86) for whole grain cold breakfast cereal, 0.79 (0.75 to 0.83) for dark bread, and 1.08 (1.00 to 1.17) for popcorn. For other individual whole grains with lower average intake levels, comparing consumption of two or more servings a week with less than one serving a month, the pooled hazard ratios (95% confidence intervals) were 0.79 (0.75 to 0.83) for oatmeal, 0.88 (0.82 to 0.94) for brown rice, 0.85 (0.80 to 0.90) for added bran, and 0.88 (0.78 to 0.98) for wheat germ. Spline regression showed a non-linear dose-response association between total whole grain intake and the risk of type 2 diabetes where the rate reduction slightly plateaued at more than two servings a day (P<0.001 for curvature). For whole grain cold breakfast cereal and dark bread, the rate reduction plateaued at about 0.5 servings a day. For consumption of popcorn, a J shaped association was found where the rate of type 2 diabetes was not significantly raised until consumption exceeded about one serving a day. The association between higher total whole grain intake and lower risk of type 2 diabetes was stronger in individuals who were lean than in those who were overweight or obese (P=0.003 for interaction), and the associations did not vary significantly across levels of physical activity, family history of diabetes, or smoking status.

CONCLUSION

Higher consumption of total whole grains and several commonly eaten whole grain foods, including whole grain breakfast cereal, oatmeal, dark bread, brown rice, added bran, and wheat germ, was significantly associated with a lower risk of type 2 diabetes. These findings provide further support for the current recommendations of increasing whole grain consumption as part of a healthy diet for the prevention of type 2 diabetes.

The American Cancer Society Cancer Prevention Study-3 FFQ Has Reasonable Validity and Reproducibility for Food Groups and a Diet Quality Score

BACKGROUND

FFQs are commonly used to assess dietary intake and it is important to evaluate their performance in the target population.

OBJECTIVE

We evaluated the reproducibility and relative validity of the Cancer Prevention Study-3 (CPS-3) FFQ in estimating usual intake of 63 food groups and diet quality in accordance with the American Cancer Society dietary guidelines for cancer prevention.

METHODS

A subset of participants from the CPS-3 (433 women, 244 men), 31-70 y of age, were included in a cross-sectional diet assessment substudy (2015-2016). Reproducibility was assessed by comparing estimates from repeat FFQs, approximately 1 y apart, using Spearman correlation coefficient (rs) and Pearson correlation coefficient (rp) correlations for food groups and diet quality, respectively. Validity was assessed similarly by comparing FFQ estimates with estimates from ≤6 interviewer-administered 24-h dietary recall (24HR). Analyses were stratified by sex and race/ethnicity.

RESULTS

Reproducibility correlations for repeated FFQs were > 0.50 for 83-97% of food groups analyzed across strata of sex and race. Although participants tended to overreport plant foods (e.g., fruits and legumes) and underreport refined grains and sugar-sweetened beverages, the median energy-adjusted, deattenuated Spearman correlations comparing the second FFQ to the 24HR were 0.50 and 0.52 among men and women (range: 0.05-0.82), respectively, suggesting that ranking was preserved for most food groups. Validity was highest for coffee, alcohol, and total dairy, and lowest for pasta and regular-fat yogurt. Median validity across food groups varied by race/ethnicity and was highest among whites (rs = 0.54) followed by Hispanics (rs = 0.49) and African Americans (rs = 0.45). The diet quality score had good validity in all subgroups examined, but was higher among men (rp = 0.69) than women (rp = 0.61), and lower among whites (rp = 0.62) than Hispanics (rp = 0.64) or African Americans (rp = 0.73).

CONCLUSIONS

This study indicates good reproducibility and validity of the CPS-3 FFQ for most major food groups and the diet quality score in all sex and race/ethnicity groups examined.

Suicide fatalities in the US compared to Canada: Potential suicides averted with lower firearm ownership in the US

Introduction and objective

The United States (US) has the highest rate of firearm suicides in the world. The US and Canada are comparable countries with markedly different rates of firearm ownership, providing an opportunity to estimate suicide fatalities that could be averted in the US with a lower rate of firearm ownership.

Methods

We compared 2016 US suicide fatality rates–standardized within fourteen sex-specific age groups to reflect the ethnic composition of Canada–to 2016 Canadian suicide rates. We then calculated the number and proportion of suicides that could be averted in the US if the US had the same rates of suicide as in Canada.

Results

If the US had the same suicide rates as in Canada, we estimate there would be approximately 25.9% fewer US suicide fatalities, equivalent to 11,630 suicide fatalities averted each year. This decline would be driven by a 79.3% lower rate of firearm-specific suicide fatalities. The male suicide fatality rate would be 28.8% lower and equivalent to 9,992 fewer suicide fatalities each year. The female suicide fatality rate would be 16.0% lower and equivalent to 1,638 fewer suicide fatalities each year. While 36% of firearm suicide fatalities could be replaced by non-firearm suicide fatalities, 64% of firearm fatalities could be averted entirely.

Conclusions

US policymakers may wish to consider policies that would reduce rates of firearm ownership, given that that about 26% of US suicide fatalities might be averted if the US had the same suicide rates as in Canada, a country with drastically lower firearm ownership rates.

Olive Oil Consumption and Cardiovascular Risk in U.S. Adults

BACKGROUND

Olive oil intake has been associated with lower risk of cardiovascular disease (CVD) in Mediterranean populations, but little is known about these associations in the U.S population.

OBJECTIVES

This study sought to examine whether olive oil intake is associated with total CVD, coronary heart disease (CHD), and stroke risk.

METHODS

This study included 61,181 women from the Nurses' Health Study (1990 to 2014) and 31,797 men from the Health Professionals Follow-up Study (1990 to 2014) who were free of cancer, heart disease, and stroke at baseline. Diet was assessed using food frequency questionnaires at baseline and then every 4 years. Cox proportional hazards regressions were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

During 24 years of follow-up, this study documented 9,797 incident cases of CVD, including 6,034 CHD cases and 3,802 stroke cases. After adjusting for major diet and lifestyle factors, compared with nonconsumers, those with higher olive oil intake (>0.5 tablespoon/day or >7 g/day) had 14% lower risk of CVD (pooled HR: 0.86; 95% CI: 0.79 to 0.94) and 18% lower risk of CHD (pooled HR: 0.82; 95% CI: 0.73 to 0.91). No significant associations were observed for total or ischemic stroke. Replacing 5 g/day of margarine, butter, mayonnaise, or dairy fat with the equivalent amount of olive oil was associated with 5% to 7% lower risk of total CVD and CHD. No significant associations were observed when olive oil was compared with other plant oils combined. In a subset of participants, higher olive oil intake was associated with lower levels of circulating inflammatory biomarkers and a better lipid profile.

CONCLUSIONS

Higher olive oil intake was associated with lower risk of CHD and total CVD in 2 large prospective cohorts of U.S. men and women. The substitution of margarine, butter, mayonnaise, and dairy fat with olive oil could lead to lower risk of CHD and CVD.

Mental Health and Suicidality in Separating U.S. Reserve and National Guard Personnel

OBJECTIVE

We examined the association of U.S. Reserve Component (RC) personnel separating from military service with the risk of mental health problems at three time periods.

METHODS

Structured interviews were conducted with a nationally representative sample of 1,582 RC personnel at baseline and three follow-up waves from 2010 to 2013. Multivariate logistic regression analyses examined posttraumatic stress disorder (PTSD), major depressive disorder (MDD), binge drinking, suicide ideation, and mental health diagnosis by a health provider.

RESULTS

Approximately 10%, 20%, and 28% of RC personnel reported separating from military service at waves 2-4. At an estimated 6 months since leaving military service, there were no differences between those who left and those who remained in service. However, at 1 year after leaving service, those who had left had a higher risk of MDD, suicidal ideation, and reporting having mental health diagnosis by a health provider. At 1.6 years after leaving military service, those who had left had a higher risk of reporting having mental health diagnosis by a health provider. The results were essentially unchanged after adjusting for baseline mental disorder for each outcome.

CONCLUSION

Results suggest a higher risk of mental health problems in RC veterans separating, compared to those who remained in the military. This risk may not occur immediately following separation but may occur within the first year or two after separation. Transition from military to civilian life may be a critical period for interventions to address the unique needs of the RC's citizen-soldiers and reduce their risk of adverse mental health outcomes.