Kristin Litzelman

Does the perception that stress affects health matter? The association with health and mortality.

OBJECTIVE This study sought to examine the relationship among the amount of stress, the perception that stress affects health, and health and mortality outcomes in a nationally representative sample of U.S. adults. METHODS Data from the 1998 National Health Interview Survey were linked to prospective National Death Index mortality data through 2006. Separate logistic regression models were used to examine the factors associated with current health status and psychological distress. Cox proportional hazard models were used to determine the impact of perceiving that stress affects health on all-cause mortality. Each model specifically examined the interaction between the amount of stress and the perception that stress affects health, controlling for sociodemographic, health behavior, and access to health care factors. RESULTS 33.7% of nearly 186 million (unweighted n = 28,753) U.S. adults perceived that stress affected their health a lot or to some extent. Both higher levels of reported stress and the perception that stress affects health were independently associated with an increased likelihood of worse health and mental health outcomes. The amount of stress and the perception that stress affects health interacted such that those who reported a lot of stress and that stress impacted their health a lot had a 43% increased risk of premature death (HR = 1.43, 95% CI [1.2, 1.7]). CONCLUSIONS High amounts of stress and the perception that stress impacts health are each associated with poor health and mental health. Individuals who perceived that stress affects their health and reported a large amount of stress had an increased risk of premature death.

Telomere length varies by DNA extraction method: implications for epidemiologic research

Background: Both shorter and longer telomeres in peripheral blood leukocyte (PBL) DNA have been associated with cancer risk. However, associations remain inconsistent across studies of the same cancer type. This study compares DNA preparation methods to determine telomere length from patients with colorectal cancer. Methods: We examined PBL relative telomere length (RTL) measured by quantitative PCR (qPCR) in 1,033 patients with colorectal cancer and 2,952 healthy controls. DNA was extracted with phenol/chloroform, PureGene, or QIAamp. Results: We observed differences in RTL depending on DNA extraction method (P < 0.001). Phenol/chloroform-extracted DNA had a mean RTL (T/S ratio) of 0.78 (range 0.01–6.54) compared with PureGene-extracted DNA (mean RTL of 0.75; range 0.00–12.33). DNA extracted by QIAamp yielded a mean RTL of 0.38 (range 0.02–3.69). We subsequently compared RTL measured by qPCR from an independent set of 20 colorectal cancer cases and 24 normal controls in PBL DNA extracted by each of the three extraction methods. The range of RTL measured by qPCR from QIAamp-extracted DNA (0.17–0.58) was less than from either PureGene or phenol/chloroform (ranges, 0.04–2.67 and 0.32–2.81, respectively). Conclusions: RTL measured by qPCR from QIAamp-extracted DNA was less than from either PureGene or phenol/chloroform (P < 0.001). Impact: Differences in DNA extraction method may contribute to the discrepancies between studies seeking to find an association between the risk of cancer or other diseases and RTL. Cancer Epidemiol Biomarkers Prev; 22(11); 2047–54. ©2013 AACR.

Caring for caregivers and patients: Research and clinical priorities for informal cancer caregiving.

Informal/family caregivers are a fundamental source of care for cancer patients in the United States, yet the population of caregivers and their tasks, psychosocial needs, and health outcomes are not well understood. Changes in the nature of cancer care and its delivery, along with the growing population of survivors and their caregivers, warrant increased attention to the roles and demands of caregiving. This article reviews current evidence presented at a 2‐day meeting examining the state of the science of informal cancer caregiving that was convened by the National Cancer Institute and the National Institute of Nursing Research. The meeting sought to define who is an informal cancer caregiver, summarize the state of the science in informal cancer caregiving, and describe both the kinds of interventions developed to address caregiving challenges and the various outcomes used to evaluate their impact. This article offers recommendations for moving science forward in 4 areas: 1) improving the estimation of the prevalence and burden of informal cancer caregiving; 2) advancing the development of interventions designed to improve outcomes for cancer patients, caregivers, and patient‐caregiver dyads; 3) generating and testing strategies for integrating caregivers into formal health care settings; and 4) promoting the use of technology to support informal cancer caregivers. Cancer 2016;122:1987–95.

Stress-mediated quality of life outcomes in parents of childhood cancer and brain tumor survivors: a case–control study

PurposeTo determine if caring for a child with cancer or a brain tumor affects parental health and mental health and if and to what extent stress mediates the relationship between case status and parental quality of life.MethodsIn person interviewer-assisted surveys were administered to 74 case dyads (children diagnosed with cancer or a brain tumor and their parents) and 129 control dyads (children without health problems and their parents from a community sample) to assess health-related quality of life and perceived levels of stress.ResultsParents of children with cancer or a brain tumor had significantly worse health-related quality of life, including worse overall mental health. Overall physical health was no different between cases and controls. Staged multivariate analysis revealed that worse health-related quality of life is completely mediated by perceived stress in these parents.ConclusionsThe experience of caring for a child with cancer is not in itself related to poor quality of life, but is related to an increased level of stress that may adversely impact parental mental health and quality of life.

Maternal Stressful Life Events Prior to Conception and the Impact on Infant Birth Weight in the United States

OBJECTIVES We sought to determine if and to what extent a womans exposure to stressful life events prior to conception (PSLEs) were associated with subsequent infant birth weight by using a nationally representative sample of US women. METHODS We examined 9350 mothers and infants participating in the first wave of the Early Childhood Longitudinal Study, Birth Cohort in 2001. Weighted regressions estimated the effect of exposure on very low and low birth weight, adjusting for maternal sociodemographic and health factors and stress during pregnancy. RESULTS Twenty percent of women experienced any PSLE. In adjusted analyses, exposed women were 38% more likely to have a very low birth weight infant than nonexposed women. Furthermore, the accumulation of PSLEs was associated with reduced infant birth weight. CONCLUSIONS This was the first nationally representative study to our knowledge to investigate the impact of PSLEs on very low and low birth weight in the United States. Interventions aimed to improve birth outcomes will need to shift the clinical practice paradigm upstream to the preconception period to reduce womens exposure to stress over the life course and improve the long-term health of children.

Telomere Length and Pancreatic Cancer: A Case–Control Study

Background: Telomeres, the ends of chromosomes, are critical for maintaining genomic stability and grow shorter with age. Shortened telomeres in pancreatic tissue play a key role in the pathogenesis of pancreatic cancer, and shorter telomeres in peripheral blood leukocytes (PBL) have been associated with increased risk for several cancer types. We hypothesized that shorter blood telomeres are associated with higher risk for pancreatic cancer. Methods: Telomere length was measured in PBLs using quantitative real-time PCR in 499 cases with pancreatic cancer and 963 cancer-free controls from the Mayo Clinic. ORs and confidence intervals (CI) were computed using logistic generalized additive models (GAM) adjusting for multiple variables. Results: In multivariable adjusted models, we observed a significant nonlinear association between telomere length in peripheral blood samples and the risk for pancreatic cancer. Risk was lower among those with longer telomeres compared with shorter telomeres across a range from the 1st percentile to 90th percentile of telomere length. There was also some evidence for higher risk among those with telomeres in the longest extreme. Conclusions: Short telomeres in peripheral blood are associated with an increased risk for pancreatic cancer across most of the distribution of length, but extremely long telomeres may also be associated with higher risk. Impact: Although the temporality of this relationship is unknown, telomere length may be useful as either a marker of pancreatic cancer risk or of the presence of undetected pancreatic cancer. If telomere shortening precedes cancer incidence, interventions to preserve telomere length may be an effective strategy to prevent pancreatic cancer. Cancer Epidemiol Biomarkers Prev; 21(11); 2095–100. ©2012 AACR.

Preterm Birth in the United States: The Impact of Stressful Life Events Prior to Conception and Maternal Age

OBJECTIVES We determined whether and to what extent a womans exposure to stressful life events prior to conception (PSLEs) was associated with preterm birth and whether maternal age modified this relationship. METHODS We examined 9350 mothers and infants participating in the first wave of the Early Childhood Longitudinal Study, Birth Cohort, a nationally representative sample of US women and children born in 2001, to investigate the impact of PSLEs on preterm birth in the United States. We estimated the effect of exposure on preterm birth with weighted logistic regression, adjusting for maternal sociodemographic and health factors and stress during pregnancy. RESULTS Of the women examined, 10.9% had a preterm birth. In adjusted analyses, women aged 15 to 19 years who experienced any PSLE had over a 4-fold increased risk for having a preterm birth. This association differed on the basis of the timing of the PSLE. CONCLUSIONS Findings suggest that adolescence may be a sensitive period for the risk of preterm birth among adolescents exposed to PSLEs. Clinical, programmatic, and policy interventions should address upstream PSLEs, especially for adolescents, to reduce the prevalence of preterm birth and improve maternal and child health.

Access to Adequate Outpatient Depression Care for Mothers in the USA: A Nationally Representative Population-Based Study

Maternal depression is often untreated, resulting in serious consequences for mothers and their children. Factors associated with receipt of adequate treatment for depression were examined in a population-based sample of 2,130 mothers in the USA with depression using data from the 1996–2005 Medical Expenditure Panel Survey. Chi-squared analyses were used to evaluate differences in sociodemographic and health characteristics by maternal depression treatment status (none, some, and adequate). Multivariate regression was used to model the odds of receiving some or adequate treatment, compared to none. Results indicated that only 34.8% of mothers in the USA with depression received adequate treatment. Mothers not in the paid workforce and those with health insurance were more likely to receive treatment, while minority mothers and those with less education were less likely to receive treatment. Understanding disparities in receipt of adequate treatment is critical to designing effective interventions, reducing treatment inequities, and ultimately improving the mental health and health of mothers and their families.Maternal depression is often untreated, resulting in serious consequences for mothers and their children. Factors associated with receipt of adequate treatment for depression were examined in a population-based sample of 2,130 mothers in the USA with depression using data from the 1996–2005 Medical Expenditure Panel Survey. Chi-squared analyses were used to evaluate differences in sociodemographic and health characteristics by maternal depression treatment status (none, some, and adequate). Multivariate regression was used to model the odds of receiving some or adequate treatment, compared to none. Results indicated that only 34.8% of mothers in the USA with depression received adequate treatment. Mothers not in the paid workforce and those with health insurance were more likely to receive treatment, while minority mothers and those with less education were less likely to receive treatment. Understanding disparities in receipt of adequate treatment is critical to designing effective interventions, reducing treatment inequities, and ultimately improving the mental health and health of mothers and their families.

The Impact of Childhood Activity Limitations on Parental Health, Mental Health, and Workdays Lost in the United States

OBJECTIVE The aim of this study was to determine if and to what extent the onset and persistence of childhood activity limitations (ongoing, resolved, or newly reported) resulted in subsequent adverse health, mental health, and work attendance outcomes among parents in the United States. METHODS A study was conducted using 10 panels (1996-2005) of the Medical Expenditure Panel Survey (MEPS), a household survey of a nationally representative sample of the civilian noninstitutionalized population in the United States. Participants in this study were 18 827 parents and their children aged 0 to 17 years. RESULTS During the 2-year study period, 15.6% of parents reported caring for a child aged 0 to 17 years with a limitation. Parents of children with any activity limitation were significantly more likely to experience subsequent poor health and mental health. Parents of children with ongoing or newly reported limitations had an increased number of lost workdays as compared with parents of children without limitations. Moreover, caring for multiple children with activity limitations was predictive of adverse parental mental health outcomes. Parents of children with ongoing activity limitations had significantly increased odds of poor mental health compared with parents of children with resolved limitations. CONCLUSIONS Caring for a child with activity limitations affects the health, mental health, and work attendance of parents. These findings indicate that child health can importantly influence the health and work behavior of the family and that health care providers should consider a family-centered approach to care.

How Are Spousal Depressed Mood, Distress, and Quality of Life Associated with Risk of Depressed Mood in Cancer Survivors? Longitudinal Findings from a National Sample

Background: Spouses of cancer survivors experience both positive and negative effects from caregiving. However, it is less clear what role spousal well-being may have on cancer survivors. This study aimed to determine the impact of spousal psychosocial factors on survivor depressed mood and whether this association differed by gender. Methods: We examined longitudinal data on cancer survivors and their spouses (n = 910 dyads) from the 2004–2012 Medical Expenditures Panel Survey and a matched sample of cancer-free dyads. Subjects reported depressed mood, psychologic distress, and mental and physical health-related quality of life (HRQoL) at two time points (T1/T2). Dyadic multilevel models evaluated the impact of psychosocial factors at T1 on depressed mood at T2, controlling for sociodemographics, cancer type, survivor treatment status, and depressed mood at T1. Results: Cancer survivors whose spouses reported depressed mood at T1 were 4.27 times more likely to report depressed mood at T2 [95% confidence interval (CI), 2.01–9.07]; this was stronger for female survivors (OR, 9.49; 95% CI, 2.42–37.20). Better spousal mental and physical HRQoL at T1 were associated with a 30% decrease in survivor depressed mood risk at T2. Most spillover effects were not observed in comparison dyads. Conclusion: Depressed mood and poor HRQoL in spouses may increase the risk of depressed mood in cancer survivors. The risk may be especially strong for female survivors. Impact: Identifying and improving spousal mental health and HRQoL problems may reduce the risk of depressed mood in cancer survivors. Future research should examine whether incorporating spousal care into psychooncology and survivorship programs improves survivor outcomes. Cancer Epidemiol Biomarkers Prev; 24(6); 969–77. ©2015 AACR.