Tené T. Lewis

Chronic exposure to everyday discrimination and coronary artery calcification in African-American women: the SWAN Heart Study.

Background: Emerging evidence suggests that exposure to discrimination may be associated with atherosclerosis in African-American women, although research in this area focused on short-term rather than chronic exposure to discriminatory events. Methods: We examined the relationship between chronic exposure to multiple types of discrimination (self-reported and averaged over 5 years) and coronary artery calcification (CAC) in a sample of 181 middle-aged African-American women. Discrimination was assessed at each time point, and the presence/absence of CAC was assessed at the fifth annual follow-up examination by electron beam tomography. We hypothesized that chronic discrimination would be more strongly associated with CAC than recent discrimination and that racial/ethnic discrimination would be more strongly associated with CAC than other types of discrimination. Results: Chronic exposure to discrimination was significantly associated with the presence of CAC in unadjusted logistic regression analyses (p = .007) and after adjustment for demographics (p = .01), standard cardiovascular risk factors (p = .02), and Body Mass Index (BMI) (p = .05). In contrast, recent discrimination was only marginally associated with the presence of CAC in both unadjusted (p = .06) and fully adjusted logistic regression models (p = .08). Persistent exposure to racial/ethnic discrimination was not more strongly associated with CAC compared with other types of discrimination in either unadjusted or adjusted models. Conclusion: Chronic exposure to discrimination may be an important risk factor for early coronary calcification in African-American women. This association appears to be driven by exposure to discrimination from multiple sources, rather than exposure to racial/ethnic discrimination alone. CVD = cardiovascular disease; CAC = coronary artery calcification; SWAN = Study of Women’s Health Across the Nation; EBT = electron beam tomographic; CES-D = Center for Epidemiological Studies Depression; BMI = body mass index; FRS = Framingham Risk score; HDL-c = high density lipoprotein cholesterol; CRP = C-reactive protein; OR = odds ratio; CI = confidence interval; IMT = intima-media thickness.

Self-reported Experiences of Everyday Discrimination are associated with Elevated C-Reactive Protein levels in older African-American Adults

Self-reported experiences of everyday discrimination have been linked to indices of cardiovascular disease and overall mortality and findings have been particularly pronounced for African-American populations. However, the biological mechanisms underlying these associations remain unclear. C-reactive protein (CRP), a marker of inflammation, is a known correlate of cardiovascular and other health outcomes and has also been linked to several psychosocial processes. To our knowledge, no studies have examined the association between experiences of discrimination and CRP. We examined the cross-sectional association between self-reported experiences of discrimination and CRP in a sample of 296 older African-American adults (70% female, mean age=73.1). Experiences of discrimination were assessed with the 9-item everyday discrimination scale and CRP was assayed from blood samples. In linear regression models adjusted for age, sex and education, experiences of discrimination were associated with higher levels of CRP (B=.10, p=.03). This association remained significant after additional adjustments for depressive symptoms (B=.10, p=.04), smoking, and chronic health conditions (heart disease, diabetes, hypertension) that might influence inflammation (B=.11, p=.02). However, results were attenuated when body mass index (BMI) was added to the model (B=.09, p=.07). In conclusion, self-reported experiences of everyday discrimination are associated with higher levels of CRP in older African-American adults, although this association is not completely independent of BMI.

Early Life Adversity and Inflammation in African Americans and Whites in the Midlife in the United States Survey

Objectives: To determine whether early life adversity (ELA) was predictive of inflammatory markers and to determine the consistency of these associations across racial groups. Methods: We analyzed data from 177 African Americans and 822 whites aged 35 to 86 years from two preliminary subsamples of the Midlife in the United States biomarker study. ELA was measured via retrospective self-report. We used multivariate linear regression models to examine the associations between ELA and C-reactive protein, interleukin-6, fibrinogen, endothelial leukocyte adhesion molecule-1, and soluble intercellular adhesion molecule-1, independent of age, gender, and medications. We extended race-stratified models to test three potential mechanisms for the observed associations. Results: Significant interactions between ELA and race were observed for all five biomarkers. Models stratified by race revealed that ELA predicted higher levels of log interleukin-6, fibrinogen, endothelial leukocyte adhesion molecule-1, and soluble intercellular adhesion molecule-1 among African Americans (p < .05), but not among whites. Some, but not all, of these associations were attenuated after adjustment for health behaviors and body mass index, adult stressors, and depressive symptoms. Conclusions: ELA was predictive of high concentrations of inflammatory markers at midlife for African Americans, but not whites. This pattern may be explained by an accelerated course of age-related disease development for African Americans. BMI = body mass index; CRP = C-reactive protein; CVD = cardiovascular diseases; E-selectin = endothelial leukocyte adhesion molecule-1; ELA = early life adversity; GCRC = general clinical research center; IL = interleukin; MIDUS = Midlife in the U.S. survey; SEP = socioeconomic position; sICAM-1 = soluble intercellular adhesion molecule-1.

Abdominal adiposity and hot flashes among midlife women

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

Self-reported Experiences of Discrimination and Visceral Fat in Middle-aged African-American and Caucasian Women

The authors examined the association between self-reported experiences of discrimination and subtypes of abdominal fat (visceral, subcutaneous) in a population-based cohort of African-American and Caucasian women. Prior studies examining associations between discrimination and abdominal fat have yielded mixed results. A major limitation of this research has been the reliance on waist circumference, which may be a poor marker of visceral fat, particularly for African-American women. Participants were 402 (45% African-American, 55% Caucasian) middle-aged women from the Chicago, Illinois, site of the Study of Womens Health Across the Nation. Visceral and subcutaneous fat were assessed via computed tomography scans between 2002 and 2005. Linear regression models were conducted to test associations among discrimination and visceral and subcutaneous fat. After adjustment for age and race, every one-point increase on the discrimination scale was associated with a 13.03-cm(2) higher amount of visceral fat (P = 0.04). This association remained significant after further adjustments for total body fat and relevant risk factors, including depressive symptoms. Discrimination was not associated with subcutaneous fat in minimally (P = 0.95) or fully adjusted models. Associations did not differ by race. Findings suggest that visceral fat may be one potential pathway through which experiences of discrimination increase cardiovascular risk.

Psychosocial Factors and Coronary Calcium in Adults without Clinical Cardiovascular Disease

Context The role of psychosocial risk factors in the pathogenesis of coronary heart disease (CHD) is difficult to ascertain after patients develop CHD symptoms. Contribution The authors administered standardized questionnaires about psychosocial factors and did electron-beam chest computed tomography in a community-based sample of 6814 adults without CHD symptoms. The prevalence of coronary calcium varied from approximately 35% to approximately 70% by race and ethnicity and sex. Psychosocial factors were not associated with coronary artery calcium scores. Cautions The study used 1-time measurement of psychosocial factors, whose effects are probably cumulative. Implications The results make it less likely that psychosocial factors are a contributing cause of CHD. The Editors The extent to which psychosocial factors are important risk factors for coronary heart disease has been debated (1-3). Measures of depression, anxiety, hostility, and anger have been shown to be associated with coronary heart disease in prospective studies (4-8). When present, these associations seem to be independent of behavioral risk factors. The biological mechanisms through which psychosocial factors exert their effects have not been fully elucidated. The recent emergence of markers of subclinical atherosclerosis allows investigation of whether psychosocial factors are related to early asymptomatic disease. Psychosocial factors may be related to atherosclerosis through their association with behavioral risk factors, such as smoking, physical activity, and diet. Psychosocial factors may also directly affect biological processes, such as inflammation (9-11), hemostasis (12, 13), cardiovascular reactivity (14, 15), endothelial injury and endothelial function (16-18), platelet activation (19-21), autonomic function (22, 23), and abdominal obesity (24), that are involved in the development of atherosclerosis. These biological effects may be mediated in part through effects of psychosocial factors on the hypothalamicpituitaryadrenal axis and the sympathetic and parasympathetic nervous systems (25). The presence and amount of coronary calcium have recently emerged as markers of subclinical coronary atherosclerosis (26-28). Only 4 studies have investigated associations of psychosocial factors with coronary calcification, with conflicting results (29-32). Using data from the Multiethnic Study of Atherosclerosis (MESA), a large, population-based study of the determinants of subclinical atherosclerosis, we investigated cross-sectional associations of 4 psychosocial measures (anger, anxiety, depression, and chronic stress burden) with coronary calcification in a large sample of adults, 45 to 84 years of age, with no history of clinical cardiovascular disease. We hypothesized that depression, anxiety, anger, and chronic stress burden would be positively associated with the prevalence of calcification and with the amount of calcium, independent of established cardiovascular risk factors. Methods The MESA is a longitudinal study supported by the National Heart, Lung, and Blood Institute (NHLBI); its goal is identifying risk factors for subclinical atherosclerosis. Details of the study design have been published elsewhere (33). Between July 2000 and August 2002, 6814 men and women 45 to 84 years of age who identified themselves as white, black, Hispanic, or Chinese and were free of clinically apparent cardiovascular disease were recruited from 6 U.S. communities: Baltimore City and Baltimore County, Maryland; Chicago, Illinois; Forsyth County, North Carolina; Los Angeles County, California; Northern Manhattan and the Bronx, New York; and St. Paul, Minnesota. Each field site recruited participants from locally available sources, which included lists of residents, lists of dwellings, and telephone exchanges. In the last few months of the recruitment period, supplemental sources, such as lists of Medicare beneficiaries from the Centers for Medicare & Medicaid Services and referrals by participants, were used to ensure adequate numbers of minority and elderly participants. The age distribution of the final sample was as follows: 45 to 54 years (27%), 55 to 64 years (28%), 65 to 74 years (30%), and 75 years or older (16%). Percentages do not sum to 100 because of rounding. Coronary calcium was assessed by using chest computed tomography (CT) with a cardiac-gated electron-beam CT scanner (34) (Chicago, Los Angeles, and New York field centers) or a multidetector CT system (35) (Baltimore, Forsyth County, and St. Paul field centers) (36). All participants had scanning over phantoms of known physical calcium concentration. A cardiologist read all scans at the Harbor-UCLA Research and Education Institute in Torrance, California, to identify and quantify coronary calcification, calibrated according to the readings of the calcium phantom. Scans were read blindly with respect to scan pairs and to other participant data by using a computerized interactive scoring system similar to that described by Yaghoubi and colleagues (37). The score of Agatston and colleagues (38) was used in all analyses. The Agatston score and the volumetric calcium score were very highly correlated in this sample (r= 0.99). The presence of calcification was defined as an average Agatston score greater than 0. Psychosocial factors were assessed by using standardized questionnaires written in English, Spanish, or Chinese. Depression was assessed by using the Center for Epidemiology StudiesDepression (CES-D) scale (39), anger and anxiety were assessed by using the Spielberger trait anger and the Spielberger trait anxiety scales (40), and chronic psychological stress was assessed by using the chronic burden scale (41). The Spielberger trait anger scale, the Spielberger trait anxiety scale, and the CES-D have been used extensively in community samples and were scored according to standard criteria, with possible ranges of 10 to 40 for trait anger, 10 to 40 for trait anxiety, and 0 to 60 for CES-D; higher scores indicated higher levels of anger, anxiety, and depressive symptoms, respectively. Scores were analyzed as continuous variables and were categorized into 4 groups according to quartiles of the full distribution. The CES-D score was also dichotomized into scores of 16 or greater (often used as a screening cutoff for depression) and scores less than 16. The Spielberger trait anger and anxiety scales were designed to measure relatively stable individual differences (traits as opposed to states). In responding to the CES-D, participants are asked to refer to the way they have felt during the past week. The chronic burden scale (41) consists of 5 items that ask participants to report ongoing difficulties in 5 domains: health of self, health of others, job or ability to work, finances, and relationships. Participants were coded as having a difficulty in the domain in question if they reported a moderately stressful or severely stressful ongoing problem that had been present for 6 months or more. The chronic burden score was the number of items for which participants reported an ongoing difficulty (range, 1 to 5). Participants were classified into 3 groups (0, 1, and 2 ongoing difficulties) for analyses. We also investigated anger, anxiety, and depression jointly by constructing a cumulative score of negative affectivity (42). This cumulative score was constructed by assigning a separate score of 0 to 3 to quartiles of the anger, anxiety, and depression measures separately and summing across the 3 measures. Information on sociodemographic indicators and cardiovascular risk factors was obtained from the MESA baseline questionnaire. Race and ethnicity were characterized on the basis of participants responses to questions modeled on the 2000 U.S. Census. Family annual income and education were each classified into 3 groups (<

Depressive Symptoms and Increased Visceral Fat in Middle-Aged Women

20000,

Perceived Discrimination and Blood Pressure in Older African American and White Adults

20000 to

Job Strain, Job Insecurity, and Incident Cardiovascular Disease in the Women’s Health Study: Results from a 10-Year Prospective Study

49999, and

Neighborhood- and individual-level socioeconomic variation in perceptions of racial discrimination

50000 and less than high school; completed high school, technical school certificate or associate degree; and completed college or more). Cardiovascular risk factors (smoking history, body mass index [BMI], low-density lipoprotein [LDL] and high-density lipoprotein [HDL] cholesterol levels, hypertension [43], and diabetes [44]) were assessed as part of the baseline examination. Body mass index was calculated as weight in kilograms divided by the square of height in meters. Resting blood pressure was measured 3 times with a Dinamap model Pro 1000 automated oscillometric sphygmomanometer (Critikon, Tampa, Florida) with participants in the seated position. The average of the last 2 measurements was used in the analysis. High-density lipoprotein cholesterol and glucose levels were measured from blood samples obtained after a 12-hour fast. Low-density lipoprotein cholesterol level was calculated with the equation of Friedewald and colleagues (45). Diabetes was defined as a fasting glucose level greater than 6.99 mmol/L (>126 mg/dL) or use of hypoglycemic medication. Statistical Analysis The internal consistency of the psychosocial scales was investigated by estimating Cronbach coefficients. Because the predictors of having any coronary calcification may be different from the predictors of the amount of calcium in persons with calcification, we modeled the presence and amount of calcium in separate analyses. We used relative risk regression to directly estimate prevalence ratios of coronary calcification associated with the exposures of interest. Relative prevalences can be derived from binomial regression models fitted by using Proc Genmod in SAS (SAS Institute, Inc., Cary, North Carolina) (46, 47). Because the use of a binomial error resulted in convergence problems, a Gaussian error was used (48). To avoid underestimation of standard errors, robust standard errors (49) were estimated by using the Proc Genmod repeated statement in SAS (47). When a Gaussian error model with a log link is used, estimated prevalences falling below 0 or increasing above