David Rehkopf

All Publications

• Long-Term Effects of Local-Area New Deal Work Relief in Childhood on Educational, Economic, and Health Outcomes Over the Life Course: Evidence From the Wisconsin Longitudinal Study. Demography Modrek, S., Roberts, E., Warren, J. R., Rehkopf, D. 2022

  Abstract

  The economic characteristics of one's childhood neighborhood have been found to determine long-term well-being. Policies enacted during childhood may change neighborhood trajectories and thus impact long-term outcomes for children. We use individual-level data from the Wisconsin Longitudinal Study to examine the enduring consequences of childhood exposure to local-area New Deal emergency employment work-relief activity. Our outcomes include adolescent cognition, educational attainment, midlife income, health behaviors, late-life cognition, and mortality. We find that children (ages 0-3) living in neighborhoods with moderate work-relief activity in 1940 had higher adolescent IQ scores, had higher class rank, and were more likely to obtain at least a bachelor's degree. We find enduring benefits for midlife income and late-life cognition for males who grew up in areas with a moderate amount of work relief. We find mixed results for males who grew up in the most disadvantaged areas with the highest levels of work-relief activity. These children had similar educational outcomes as those in the most advantaged districts with the lowest work-relief activity but had higher adult smoking rates. Our findings provide some of the first evidence of the long-term consequences of New Deal policies on children's long-term life course outcomes.

  View details for DOI 10.1215/00703370-10111856

  View details for PubMedID 35852411

• The Earned Income Tax Credit as supplementary food benefits and savings for durable goods CONTEMPORARY ECONOMIC POLICY Fisher, J., Rehkopf, D. H. 2022

  View details for DOI 10.1111/coep.12565

  View details for Web of Science ID 000747877600001

• Public health impacts of an imminent Red Sea oil spill. Nature sustainability Huynh, B. Q., Kwong, L. H., Kiang, M. V., Chin, E. T., Mohareb, A. M., Jumaan, A. O., Basu, S., Geldsetzer, P., Karaki, F. M., Rehkopf, D. H. 2021; 4 (12): 1084-1091

  Abstract

  The possibility of a massive oil spill in the Red Sea is increasingly likely. The Safer, a deteriorating oil tanker containing 1.1 million barrels of oil, has been deserted near the coast of Yemen since 2015 and threatens environmental catastrophe to a country presently in a humanitarian crisis. Here, we model the immediate public health impacts of a simulated spill. We estimate that all of Yemen's imported fuel through its key Red Sea ports would be disrupted and that the anticipated spill could disrupt clean-water supply equivalent to the daily use of 9.0-9.9 million people, food supply for 5.7-8.4 million people and 93-100% of Yemen's Red Sea fisheries. We also estimate an increased risk of cardiovascular hospitalization from pollution ranging from 5.8 to 42.0% over the duration of the spill. The spill and its potentially disastrous impacts remain entirely preventable through offloading the oil. Our results stress the need for urgent action to avert this looming disaster.

  View details for DOI 10.1038/s41893-021-00774-8

  View details for PubMedID 34926834

  View details for PubMedCentralID PMC8682806

• A US State Index of Successful Aging: Differences Between States and Over Time. The Milbank quarterly Rehkopf, D. H., Furstenberg, F. F., Elser, H., Jackson, C., Levy, N., Rowe, J. W., AGING SOCIETY RESEARCH NETWORK 2021

  Abstract

  Policy Points The focus of successful aging is on the social contexts that enable individuals to be productively engaged and secure, with an emphasis on equity. There is currently no index to measure progress towards this goal at the US state level. We developed an empirical index for the evaluation of US state adaptation to societal aging across five critical domains that support successful population aging: (1) productivity and engagement, (2) security, (3) equity, (4) cohesion, and (5) well-being. Our index shows substantial variability over time and is not overly influenced by the performance of an individual domain. This suggests that it can be used to monitor state progress over time toward the goal of supporting successful aging. Rather than a major national trend, there are large between-state differences and changes in our index over time. This suggests individual US state policies and programs, as well as local economic conditions, may have a substantial impact on adaptations to societal aging.CONTEXT: Although it is recognized that aspects of US state environments impact the likelihood that older adults age successfully, there is currently no reliable and comprehensive measure of contexts that best support successful aging at a state level. The current project adapts a multidimensional index previously used to assess adaptation to successful aging in developed countries and applies it to the 50 US states and the District of Columbia.METHODS: We obtained data from multiple sources for all 50 US states and the District of Columbia from 2003 to 2017 in order to measure five distinct domains that define successful population aging: (1) productivity and engagement, (2) security, (3) equity, (4) cohesion, and (5) well-being. We created a ranking of states for the year 2017 based on these domains, and also examined how individual US state rankings changed over time from 2003 to 2017.FINDINGS: The level of adaptation to successful aging varied substantially between states and over time. The highest-ranked states in 2017 were Vermont, Hawaii, Iowa, Colorado, and New Hampshire, and the lowest-ranked states were Louisiana, Arkansas, Kentucky, West Virginia, and Mississippi. Mississippi, South Carolina, Iowa, Arizona, and Delaware had the greatest improvement in their ranking over the period of 2003 to 2017. Our findings were generally robust to the weighting scheme used and were not overly influenced by any particular domain.CONCLUSIONS: The US State Index of Successful Aging can be used to monitor US state progress in promoting the well-being and health of aging populations. Factors driving the changes in the index remain to be elucidated.

  View details for DOI 10.1111/1468-0009.12542

  View details for PubMedID 34812519

• Explaining the variance in cardiovascular disease risk factors: A comparison of demographic, socioeconomic, and genetic predictors. Epidemiology (Cambridge, Mass.) Hamad, R., Glymour, M. M., Calmasini, C., Nguyen, T. T., Walter, S., Rehkopf, D. H. 2021

  Abstract

  Efforts to explain the burden of cardiovascular disease (CVD) often focus on genetic factors or social determinants of health. There is little evidence on the comparative predictive value of each, which could guide clinical and public health investments in measuring genetic versus social information. We compared the variance in CVD-related outcomes explained by genetic versus socioeconomic predictors.Data were drawn from the Health and Retirement Study (N=8,720). We examined self-reported diabetes, heart disease, depression, smoking, and body mass index, and objectively measured total and high-density lipoprotein cholesterol. For each outcome, we compared the variance explained by demographic characteristics, socioeconomic position (SEP), and genetic characteristics including a polygenic score for each outcome and principal components (PCs) for genetic ancestry. We used R-squared values derived from race-stratified multivariable linear regressions to evaluate the variance explained.The variance explained by models including all predictors ranged from 3.7% to 14.3%. Demographic characteristics explained more than half this variance for most outcomes. SEP explained comparable or greater variance relative to the combination of the polygenic score and PCs for most conditions among both white and Black participants. The combination of SEP, polygenic score, and PCs performed substantially better, suggesting that each set of characteristics may independently contribute to prediction of CVD related outcomes.Focusing on genetic inputs into personalized medicine predictive models, without considering measures of social context that have clear predictive value, needlessly ignores relevant information that is more feasible and affordable to collect on patients in clinical settings.

  View details for DOI 10.1097/EDE.0000000000001425

  View details for PubMedID 34799480

• The impact of a private sector living wage intervention on consumption and cardiovascular disease risk factors in a middle income country BMC PUBLIC HEALTH Rehkopf, D. H., Burmaster, K., Landefeld, J. C., Adler-Milstein, S., Flynn, E. P., Acevedo, M., Jones-Smith, J. C., Adler, N., Fernald, L. H. 2018; 18: 179

  Abstract

  A positive association of socioeconomic position and health is well established in high-income countries. In poorer nations, however, higher income individuals often have more cardiovascular risk factors (including obesity) than do those with less income. Our study goal was to estimate the effects of receiving a living wage (340% higher income) on short-term changes in consumption and cardiovascular risk factors among low-wage workers in a middle-income country.This cross-sectional study matched workers at an apparel factory (n=105) in the Dominican Republic with those at a similar factory (n=99) nearby, 15 months after the intervention factory introduced a substantially higher living wage. Statistical matching on non-time varying individual characteristics (childhood health, childhood living conditions, work experience, demographic factors) strengthened causal inference. Primary outcomes were blood pressure (systolic and diastolic), pulse rate, body mass index and waist circumference. Secondary outcomes were dietary consumption and spending on services, consumables and durable goods.Receiving the living wage was associated with increased consumption of protein, dairy, soda and juice and sugars, but not with cardiovascular risk factors. Intervention factory workers spent more on grocery items and household durable goods.While having a higher income in a middle-income country might be expected to increase obesity and its associated health risks, the current study found no short-term negative associations. There may be possible longer-term negative health consequences of increases in consumption of soda, juice and sugars, however. It is important to consider complementary interventions to support healthy dietary intake in areas with increasing wages.

  View details for PubMedID 29370797

• Differential DNA methylation and lymphocyte proportions in a Costa Rican high longevity region EPIGENETICS & CHROMATIN McEwen, L. M., Morin, A. M., Edgar, R. D., MacIsaac, J. L., Jones, M. J., Dow, W. H., Rosero-Bixby, L., Kobor, M. S., Rehkopf, D. H. 2017; 10

  Abstract

  The Nicoya Peninsula in Costa Rica has one of the highest old-age life expectancies in the world, but the underlying biological mechanisms of this longevity are not well understood. As DNA methylation is hypothesized to be a component of biological aging, we focused on this malleable epigenetic mark to determine its association with current residence in Nicoya versus elsewhere in Costa Rica. Examining a population's unique DNA methylation pattern allows us to differentiate hallmarks of longevity from individual stochastic variation. These differences may be characteristic of a combination of social, biological, and environmental contexts.In a cross-sectional subsample of the Costa Rican Longevity and Healthy Aging Study, we compared whole blood DNA methylation profiles of residents from Nicoya (n = 48) and non-Nicoya (other Costa Rican regions, n = 47) using the Infinium HumanMethylation450 microarray.We observed a number of differences that may be markers of delayed aging, such as bioinformatically derived differential CD8+ T cell proportions. Additionally, both site- and region-specific analyses revealed DNA methylation patterns unique to Nicoyans. We also observed lower overall variability in DNA methylation in the Nicoyan population, another hallmark of younger biological age.Nicoyans represent an interesting group of individuals who may possess unique immune cell proportions as well as distinct differences in their epigenome, at the level of DNA methylation.

  View details for DOI 10.1186/s13072-017-0128-2

  View details for Web of Science ID 000400745800001

  View details for PubMedID 28465725

• Systematic assessment of the correlations of household income with infectious, biochemical, physiological, and environmental factors in the United States, 1999-2006. American journal of epidemiology Patel, C. J., Ioannidis, J. P., Cullen, M. R., Rehkopf, D. H. 2015; 181 (3): 171-179

  Abstract

  A fuller understanding of the social epidemiology of disease requires an extended description of the relationships between social factors and health indicators in a systematic manner. In the present study, we investigated the correlations between income and 330 indicators of physiological, biochemical, and environmental health in participants in the US National Health and Nutrition Examination Survey (NHANES) (1999-2006). We combined data from 3 survey waves (n = 249-23,649 for various indicators) to search for linear and nonlinear (quadratic) correlates of income, and we validated significant (P < 0.00015) correlations in an independent testing data set (n = 255-7,855). We validated 66 out of 330 factors, including infectious (e.g., hepatitis A), biochemical (e.g., carotenoids, high-density lipoprotein cholesterol), physiological (e.g., upper leg length), and environmental (e.g., lead, cotinine) measures. We found only a modest amount of association modification by age, race/ethnicity, and gender, and there was no association modification for blacks. The present study is descriptive, not causal. We have shown in our systematic investigation the crucial place income has in relation to health risk factors. Future research can use these correlations to better inform theory and studies of pathways to disease, as well as utilize these findings to understand when confounding by income is most likely to introduce bias.

  View details for DOI 10.1093/aje/kwu277

  View details for PubMedID 25589242

  View details for PubMedCentralID PMC4312426

• The short-term impacts of Earned Income Tax Credit disbursement on health INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Rehkopf, D. H., Strully, K. W., Dow, W. H. 2014; 43 (6): 1884-1894

  Abstract

  There are conflicting findings regarding long- and short-term effects of income on health. Whereas higher average income is associated with better health, there is evidence that health behaviours worsen in the short-term following income receipt.Prior studies revealing such negative short-term effects of income receipt focus on specific subpopulations and examine a limited set of health outcomes.The United States Earned Income Tax Credit (EITC) is an income supplement tied to work, and is the largest poverty reduction programme in the USA. We utilize the fact that EITC recipients typically receive large cash transfers in the months of February,March and April, in order to examine associated changes in health outcomes that can fluctuate on a monthly basis. We examine associations with 30 outcomes in the categories of diet, food security, health behaviours, cardiovascular biomarkers, metabolic biomarkers and infection and immunity among 6925 individuals from the U.S. National Health and Nutrition Survey. Our research design approximates a natural experiment,since whether individuals were sampled during treatment or non-treatment months is independent of social, demographic and health characteristics that do not vary with time.There are both beneficial and detrimental short-term impacts of income receipt.Although there are detrimental impacts on metabolic factors among women, most other impacts are beneficial, including those for food security, smoking and trying to lose weight.The short-term impacts of EITC income receipt are not universally health promoting, but on balance there are more health benefits than detriments.

  View details for DOI 10.1093/ije/dyu172

  View details for Web of Science ID 000348575500032

  View details for PubMedID 25172139

• Effects of Prenatal Poverty on Infant Health: State Earned Income Tax Credits and Birth Weight AMERICAN SOCIOLOGICAL REVIEW Strully, K. W., Rehkopf, D. H., Xuan, Z. 2010; 75 (4): 534-562

  View details for DOI 10.1177/0003122410374086

  View details for Web of Science ID 000282155000003

• Report on the Joint Workshop on the Relations between Health Inequalities, Ageing and Multimorbidity, Iceland, May 3-4, 2023. Clinical epidemiology Vandenbroucke, J. P., Sorensen, H. T., Rehkopf, D. H., Gradus, J. L., Mackenbach, J. P., Glymour, M. M., Galea, S., Henderson, V. W. 2024; 16: 9-22

  Abstract

  This paper is a summary of key presentations from a workshop in Iceland on May 3-4, 2023 arranged by Aarhus University and with participation of the below-mentioned scientists. Below you will find the key messages from the presentations made by: Professor Jan Vandenbroucke, Department of Clinical Epidemiology, Aarhus University, Emeritus Professor, Leiden University; Honorary Professor, London School of Hygiene & Tropical Medicine, UKProfessor, Chair Henrik Toft Sorensen, Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, DenmarkProfessor David H. Rehkopf, Director, the Stanford Center for Population Health Sciences, Stanford University, CA., USProfessor Jaimie Gradus, Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USProfessor Johan Mackenbach, Emeritus Professor, Department of Public Health, Erasmus University Rotterdam, HollandProfessor, Chair M Maria Glymour, Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, Massachusetts, USProfessor, Dean Sandro Galea, School of Public Health, Boston University, Boston, Massachusetts, USProfessor Victor W. Henderson, Departments of Epidemiology & Population Health and of Neurology & Neurological Sciences, Stanford University, Stanford, CA, US; Department of Clinical Epidemiology, Aarhus University, Aarhus, DK.

  View details for DOI 10.2147/CLEP.S443152

  View details for PubMedID 38259327

• Associations between county-level public health expenditures and community health planning activities with COVID-19 incidence and mortality. Preventive medicine reports Liang, R., Kiang, M. V., Grant, P., Jackson, C., Rehkopf, D. H. 2023; 36: 102410

  Abstract

  The COVID-19 pandemic has revealed consequences of past defunding of the U.S. public health system, but the extent to which public health infrastructure is associated with COVID-19 burden is unknown. We aimed to determine whether previous county-level public health expenditures and community health planning activities are associated with COVID-19 cases and deaths. We examined 3050 of 3143 U.S. counties and county equivalents from March 1, 2020 to February 28, 2022. Multivariable-adjusted linear regression and generalized additive models were used to estimate associations between county-level public health expenditures and completion of community health planning activities by a county health department with outcomes of county-level COVID-19 cases and deaths per 100,000 population. After adjusting for county-level covariates, counties in the highest tertile of public health expenditures per capita had on average 542 fewer COVID-19 cases per 100,000 population (95% CI, -1004 to -81) and 21 fewer deaths per 100,000 population (95% CI, -32 to -10) than counties in the lowest tertile. For analyses of community health planning activities, adjusted estimates of association remained negative for COVID-19 deaths, but confidence intervals included negative and positive values. In conclusion, higher levels of local public health expenditures and community health planning activities were associated with fewer county-level COVID-19 deaths, and to a lesser extent, cases. Future public health funding should be aligned with evidence for the value of county health departments programs and explore further which types of spending are most cost effective.

  View details for DOI 10.1016/j.pmedr.2023.102410

  View details for PubMedID 37732021

  View details for PubMedCentralID PMC10507150

• Changes in leukocyte telomere length among children with obesity participating in a behavioural weight control program. Pediatric obesity Rehkopf, D. H., Wojcicki, J. M., Haydel, K. F., Lin, J., Smith, D. L., Kapphahn, K. I., Robinson, T. N. 2023: e13082

  Abstract

  To examine changes in leukocyte telomere length (LTL) during and after a behavioural weight control program for children with obesity.We measured LTL among a cohort of 158 children 8-12 years of age with a body mass index greater than or equal to the 95th percentile for age and sex. Children were 55% female, 29% white, 52% Latinx, 8% Asian and 11% Pacific Islander, other or multiethnic. All children participated in a 6-month, family-based, group behavioural weight control program and were assessed before treatment, after treatment and 1 year after the end of treatment. To test the sample population slope of LTL over the intervention and maintenance time periods, we fit spline mixed-effect regression models.LTL increased an average of 0.09 T/S units per year (95% confidence interval [CI] 0.04 to 0.13; p = 0.0001) during the weight control program intervention period, followed by an average decline of -0.05 T/S units per year (95% CI -0.08 to -0.03; p < 0.0001) during the 1 year of follow-up after the completion of the intervention. Among 26 social, psychological, behavioural and physiological factors we examined, we did not find any predictors of these changes.LTL increased in response to a behavioural weight control program among children with obesity, suggesting an impact on biological health and cellular aging from participation in a behavioural weight control intervention. LTL may be a useful biomarker for assessing changes in response to behavioural interventions.

  View details for DOI 10.1111/ijpo.13082

  View details for PubMedID 37873898

• Effects of Housing Vouchers on the Long-Term Exposure to Neighborhood Opportunity among Low-Income Families: The Moving to Opportunity Experiment. Housing studies Kim, H., Schmidt, N. M., Osypuk, T. L., Thyden, N., Rehkopf, D. 2023; 38 (1): 128-151

  Abstract

  Tenant-based rental assistance has received much attention as a tool to ameliorate American poverty and income segregation. We examined whether a tenant-based voucher program improves long-term exposure to neighborhood opportunity overall and across multiple domains-social/economic, educational, and health/environmental-among low-income families with children. We used data from the Moving to Opportunity (MTO) experiment (1994-2010) with a 10- to 15-year follow-up period and used an innovative and multidimensional measure of neighborhood opportunities for children. Compared with controls in public housing, MTO voucher recipients experienced improvement in neighborhood opportunity overall and across domains during the entire study period, with a larger treatment effect for families in the MTO voucher group who received supplementary housing counseling, than the Section 8 voucher group. Our results also suggests that effects of housing vouchers on neighborhood opportunity may not be uniform across subgroups. Results from model-based recursive partitioning for neighborhood opportunity identified several potential effect modifiers for housing vouchers, including study sites, health and developmental problems of household members, and having vehicle access.

  View details for DOI 10.1080/02673037.2022.2112154

  View details for PubMedID 36861113

  View details for PubMedCentralID PMC9970262

• COVID-19 Vaccine Strategy Left Small Primary Care Practices On The Sidelines. Health affairs (Project Hope) Hao, S., Rehkopf, D. H., Velasquez, E., Vala, A., Bazemore, A. W., Phillips, R. L. 2023; 42 (8): 1147-1151

  Abstract

  We report on the experience of small primary care practices participating in a national clinical registry with COVID-19 vaccines and vaccination data. At the end of 2021, 11.2percent of these practices' 3.9million patients had records of COVID-19 vaccination; 43.1percent of clinics had no record of patients' COVID-19 vaccinations, but 93.4percent of clinics had provided or recorded other routine vaccinations.

  View details for DOI 10.1377/hlthaff.2023.00114

  View details for PubMedID 37549323

• Groundwater constituents and the incidence of kidney cancer. Cancer Soerensen, S. J., Montez-Rath, M. E., Cheng, I., Gomez, S. L., Oh, D. L., Jackson, C., Li, J., Rehkopf, D., Chertow, G. M., Langston, M. E., Ganesan, C., Pao, A. C., Chung, B. I., Leppert, J. T. 2023

  Abstract

  Kidney cancer incidence demonstrates significant geographic variation suggesting a role for environmental risk factors. This study sought to evaluate associations between groundwater exposures and kidney cancer incidence.The authors identified constituents from 18,506 public groundwater wells in all 58 California counties measured in 1996-2010, and obtained county-level kidney cancer incidence data from the California Cancer Registry for 2003-2017. The authors developed a water-wide association study (WWAS) platform using XWAS methodology. Three cohorts were created with 5 years of groundwater measurements and 5-year kidney cancer incidence data. The authors fit Poisson regression models in each cohort to estimate the association between county-level average constituent concentrations and kidney cancer, adjusting for known risk factors: sex, obesity, smoking prevalence, and socioeconomic status at the county level.Thirteen groundwater constituents met stringent WWAS criteria (a false discovery rate <0.10 in the first cohort, followed by p values <.05 in subsequent cohorts) and were associated with kidney cancer incidence. The seven constituents directly related to kidney cancer incidence (and corresponding standardized incidence ratios) were chlordane (1.06; 95% confidence interval [CI], 1.02-1.10), dieldrin (1.04; 95% CI, 1.01-1.07), 1,2-dichloropropane (1.04; 95% CI, 1.02-1.05), 2,4,5-TP (1.03; 95% CI, 1.01-1.05), glyphosate (1.02; 95% CI, 1.01-1.04), endothall (1.02; 95% CI, 1.01-1.03), and carbaryl (1.02; 95% CI, 1.01-1.03). Among the six constituents inversely related to kidney cancer incidence, the standardized incidence ratio furthest from the null was for bromide (0.97; 95% CI, 0.94-0.99).This study identified several groundwater constituents associated with kidney cancer. Public health efforts to reduce the burden of kidney cancer should consider groundwater constituents as environmental exposures that may be associated with the incidence of kidney cancer.

  View details for DOI 10.1002/cncr.34898

  View details for PubMedID 37287332

• Association of Adverse Childhood Experiences With Accelerated Epigenetic Aging in Midlife. JAMA network open Kim, K., Yaffe, K., Rehkopf, D. H., Zheng, Y., Nannini, D. R., Perak, A. M., Nagata, J. M., Miller, G. E., Zhang, K., Lloyd-Jones, D. M., Joyce, B. T., Hou, L. 2023; 6 (6): e2317987

  Abstract

  Adverse childhood experiences (ACEs) are associated with the risk of poorer health, and identifying molecular mechanisms may lay the foundation for health promotion in people with ACEs.To investigate the associations of ACEs with changes in epigenetic age acceleration (EAA), a biomarker associated with various health outcomes in middle-aged adults, in a population with balanced race and sex demographics.Data for this cohort study were from the Coronary Artery Risk Development in Young Adults (CARDIA) study. Participants in CARDIA underwent 8 follow-up exams from baseline (year 0 [Y0]; 1985-1986) to Y30 (2015-2016), and participant blood DNA methylation information was obtained at Y15 (2000-2001) and Y20 (2005-2006). Individuals from Y15 and Y20 with available DNA methylation data and complete variables for ACEs and covariates were included. Data were analyzed from September 2021 to August 2022.Participant ACEs (general negligence, emotional negligence, physical violence, physical negligence, household substance abuse, verbal and emotional abuse, and household dysfunction) were obtained at Y15.The primary outcome consisted of results from 5 DNA methylation-based EAA measurements known to be associated with biological aging and long-term health: intrinsic EAA (IEAA), extrinsic EAA (EEAA), PhenoAge acceleration (PhenoAA), GrimAge acceleration (GrimAA), and Dunedin Pace of Aging Calculated From the Epigenome (DunedinPACE), measured at Y15 and Y20. Linear regression and generalized estimating equations were used to assess associations of the burden of ACEs (≥4 vs <4 ACEs) with EAA adjusting for demographics, health-related behaviors, and early life and adult socioeconomic status.A total of 895 participants for Y15 (mean [SD] age, 40.4 [3.5] years; 450 males [50.3%] and 445 females [49.7%]; 319 Black [35.6%] and 576 White [64.4%]) and 867 participants for Y20 (mean [SD] age, 45.4 [3.5] years; 432 males [49.8%] and 435 females [50.2%]; 306 Black [35.3%] and 561 White [64.7%]) were included after excluding participants with missing data. There were 185 participants with (20.7%) vs 710 participants without (79.3%) 4 or more ACEs at Y15 and 179 participants with (20.6%) vs 688 participants without (79.4%) 4 or more ACEs at Y20. Having 4 or more ACEs was positively associated with EAA in years at Y15 (EEAA: β = 0.60 years; 95% CI, 0.18-1.02 years; PhenoAA: β = 0.62 years; 95% CI = 0.13-1.11 years; GrimAA: β = 0.71 years; 95% CI, 0.42-1.00 years; DunedinPACE: β = 0.01; 95% CI, 0.01-0.02) and Y20 (IEAA: β = 0.41 years; 95% CI, 0.05-0.77 years; EEAA: β = 1.05 years; 95% CI, 0.66-1.44 years; PhenoAA: β = 0.57 years; 95% CI, 0.08-1.05 years; GrimAA: β = 0.57 years; 95% CI, 0.28-0.87 years; DunedinPACE: β = 0.01; 95% CI, 0.01-0.02) after adjusting for demographics, health-related behaviors, and socioeconomic status.In this cohort study, ACEs were associated with EAA among middle-aged adults after controlling for demographics, behavior, and socioeconomic status. These findings of the associations between early life experience and the biological aging process in midlife may contribute to health promotion in a life course perspective.

  View details for DOI 10.1001/jamanetworkopen.2023.17987

  View details for PubMedID 37306997

• A complex systems model of breast cancer etiology: The Paradigm II Model. PloS one Hiatt, R. A., Worden, L., Rehkopf, D., Engmann, N., Troester, M., Witte, J. S., Balke, K., Jackson, C., Barlow, J., Fenton, S. E., Gehlert, S., Hammond, R. A., Kaplan, G., Kornak, J., Nishioka, K., McKone, T., Smith, M. T., Trasande, L., Porco, T. C. 2023; 18 (5): e0282878

  Abstract

  Complex systems models of breast cancer have previously focused on prediction of prognosis and clinical events for individual women. There is a need for understanding breast cancer at the population level for public health decision-making, for identifying gaps in epidemiologic knowledge and for the education of the public as to the complexity of this most common of cancers.We developed an agent-based model of breast cancer for the women of the state of California using data from the U.S. Census, the California Health Interview Survey, the California Cancer Registry, the National Health and Nutrition Examination Survey and the literature. The model was implemented in the Julia programming language and R computing environment. The Paradigm II model development followed a transdisciplinary process with expertise from multiple relevant disciplinary experts from genetics to epidemiology and sociology with the goal of exploring both upstream determinants at the population level and pathophysiologic etiologic factors at the biologic level. The resulting model reproduces in a reasonable manner the overall age-specific incidence curve for the years 2008-2012 and incidence and relative risks due to specific risk factors such as BRCA1, polygenic risk, alcohol consumption, hormone therapy, breastfeeding, oral contraceptive use and scenarios for environmental toxin exposures.The Paradigm II model illustrates the role of multiple etiologic factors in breast cancer from domains of biology, behavior and the environment. The value of the model is in providing a virtual laboratory to evaluate a wide range of potential interventions into the social, environmental and behavioral determinants of breast cancer at the population level.

  View details for DOI 10.1371/journal.pone.0282878

  View details for PubMedID 37205649

  View details for PubMedCentralID PMC10198497

• The Neighborhood Atlas Area Deprivation Index And Recommendations For Area-Based Deprivation Measures. Health affairs (Project Hope) Rehkopf, D. H., Phillips, R. L. 2023; 42 (5): 710-711

  Abstract

  Edward Hannan and colleagues found that a lack of standardization of input variables to the Area Deprivation Index (ADI) available from the Neighborhood Atlas overweights the index for median home value and thus potentially further disadvantages already disadvantaged communities. We recommend that a revised ADI be created that addresses the error, and we offer five steps to avoid future errors in the creation of area deprivation measures.

  View details for DOI 10.1377/hlthaff.2023.00282

  View details for PubMedID 37126740

• Centenarian clocks: epigenetic clocks for validating claims of exceptional longevity. GeroScience Dec, E., Clement, J., Cheng, K., Church, G. M., Fossel, M. B., Rehkopf, D. H., Rosero-Bixby, L., Kobor, M. S., Lin, D. T., Lu, A. T., Fei, Z., Guo, W., Chew, Y. C., Yang, X., Putra, S. E., Reiner, A. P., Correa, A., Vilalta, A., Pirazzini, C., Passarino, G., Monti, D., Arosio, B., Garagnani, P., Franceschi, C., Horvath, S. 2023

  Abstract

  Claims surrounding exceptional longevity are sometimes disputed or dismissed for lack of credible evidence. Here, we present three DNA methylation-based age estimators (epigenetic clocks) for verifying age claims of centenarians. The three centenarian clocks were developed based on n = 7039 blood and saliva samples from individuals older than 40, including n = 184 samples from centenarians, 122 samples from semi-supercentenarians (aged 105 +), and 25 samples from supercentenarians (aged 110 +). The oldest individual was 115 years old. Our most accurate centenarian clock resulted from applying a neural network model to a training set composed of individuals older than 40. An epigenome-wide association study of age in different age groups revealed that age effects in young individuals (age < 40) are correlated (r = 0.55) with age effects in old individuals (age > 90). We present a chromatin state analysis of age effects in centenarians. The centenarian clocks are expected to be useful for validating claims surrounding exceptional old age.

  View details for DOI 10.1007/s11357-023-00731-7

  View details for PubMedID 36964402

  View details for PubMedCentralID 6424156

• Associations between pregnancy glucose measurements and risk of preterm birth: a retrospective cohort study of commercially insured women in the United States from 2003-2021. Annals of epidemiology Liang, R., Panelli, D. M., Stevenson, D. K., Rehkopf, D. H., Shaw, G. M. 2023

  Abstract

  To investigate associations between glucose measurements during pregnancy and risk of preterm birth (PTB).Retrospective cohort study of commercially insured women with singleton live births in the United States from 2003-2021 using longitudinal medical claims, socioeconomic data, and eight glucose results from different types of fasting and post-load tests performed between 24-28 weeks of gestation for gestational diabetes screening. Risk ratios of PTB (<37 weeks) were estimated via Poisson regression for z-standardized glucose measures. Non-linear relationships for continuous glucose measures were examined via generalized additive models.Elevations in all eight glucose measures were associated with increased risk (adjusted risk ratio point estimates: 1.05-1.19) of PTB for 196,377 women with non-fasting 50-gram glucose challenge test (one glucose result), 31,522 women with complete 100-gram, 3-hour fasting oral glucose tolerance test (OGTT) results (four glucose results), and 10,978 women with complete 75-gram, 2-hour fasting OGTT results (three glucose results). Associations were consistent after adjusting for and stratifying by sociodemographic and clinical factors. Substantial non-linear relationships (U-, J-, and S-shaped) were observed between several glucose measurements and PTB.Elevations in various glucose measures were linearly and non-linearly associated with increased risk of PTB, even before diagnostic thresholds for gestational diabetes.

  View details for DOI 10.1016/j.annepidem.2023.03.002

  View details for PubMedID 36905977

• Does educational attainment modify the causal relationship between adiposity and cardiovascular disease? A Mendelian randomization study. SSM - population health Schell, R. C., Dow, W. H., Fernald, L. C., Bradshaw, P. T., Rehkopf, D. H. 2023; 21: 101351

  Abstract

  A greater risk of cardiovascular disease is associated with low educational attainment and high adiposity. Despite the correlation between low educational attainment and high adiposity, whether educational attainment modifies the risk of CVD caused by high adiposity remains poorly understood. We investigated the effect of adiposity (body mass index [BMI] and waist-to-hip ratio adjusted for BMI [WHRadjBMI]) on incident CVD among individuals with varying education levels, using associational and one-sample Mendelian randomization (MR) survival analyses. Data were collected from 2006 to 2021, and sample sizes were 254,281 (27,511 CVD cases) for BMI and 253,968 (27,458 CVD cases) for WHRadjBMI. In the associational model, a standard deviation (SD) higher BMI was associated with 19.81 (95% CI: 18.55-21.06) additional cases of incident CVD per 10,000 person-years for individuals with a secondary education, versus 32.96 (95% CI: 28.75-37.17) for those without. When university degree served as the education variable, education group differences attenuated, with 18.26 (95% CI: 16.37-20.15) cases from a one SD higher BMI for those with a university degree versus 23.18 [95% CI: 21.56-24.72] for those without. For the MR model, an SD higher BMI resulted in 11.75 (95% CI: -0.84-24.38) and 29.79 (95% CI: 17.20-42.44) additional cases of incident CVD per 10,000 person-years for individuals with versus without a university degree. WHRadjBMI exhibited no effect differences by education. While the associational model showed evidence of educational attainment modifying the relationship between adiposity and incident CVD, it does not modify the association between adiposity and incident CVD in the MR models. This suggests either less education does not cause greater risk of incident CVD from high adiposity, or MR models cannot detect the effect difference. The associational point estimates exist within the MR models' confidence intervals in all BMI analyses, so we cannot rule out the effect sizes in the associational models.

  View details for DOI 10.1016/j.ssmph.2023.101351

  View details for PubMedID 36819121

• Socioeconomic inequalities in the risk of suicide attempts among sexual minority adolescents: Findings from the UK's Millennium Cohort Study. The Lancet regional health. Europe White, J., Borgia, S., Rehkopf, D. H. 2023; 26: 100570

  Abstract

  Both sexual minority and socioeconomically deprived young people are at an increased risk of making a suicide attempt. Intersectionality theory predicts these risk factors will interact synergistically to create unique vulnerabilities. We investigated the risk of suicide attempts in sexual minority socioeconomically deprived young people in a contemporary national cohort.The Millennium Cohort Study (MCS) is a birth cohort study in the UK following children born 2000-2002. Children in the MCS have been followed up over seven sweeps to date at ages 9 months, 3, 5, 7, 11, 14 and 17 years. The relative risk (RR) of self-reported suicide attempts at 17 years by sexual minority status and parental unemployment was estimated using multivariable log-binomial regression. Additive interaction, representing the synergistic effect, was estimated using the relative excess risk due to interaction (RERI).Between January, 2018 and March, 2019, 10,247 adolescents provided their sexuality and parents their employment status. 758 (7.4%) of 10,247 adolescents had made a suicide attempt. Relative to heterosexual young people living with no unemployed parents, the RR for sexual minorities living with no unemployed parents/carers was 2.93 (95% CI 2.26-3.79), one unemployed was 4.46 (95% CI 2.94-6.77), and two was 6.35 (95% CI 3.62-11.14). There was evidence of a positive additive interaction. The RERI for having one unemployed parent was 1.08 (95% CI -0.54 to 2.69) and two was 3.10 (95% CI -1.58 to 7.78). Sensitivity analyses using housing tenure and in a sample with no missing data generated comparable results.To our knowledge, this is the first evidence that socioeconomically deprived sexual minority adolescents are uniquely vulnerable to making a suicide attempt. Health and educational practitioners need to be aware of the increased risk of suicide attempts in socioeconomically deprived sexual minority adolescents.Economic and Social Research Council (ESRC).

  View details for DOI 10.1016/j.lanepe.2022.100570

  View details for PubMedID 36619211

  View details for PubMedCentralID PMC9813783

• Manmade earthquakes and healthcare visits for anxiety disorders in Oklahoma, 2010-2019 ENVIRONMENTAL EPIDEMIOLOGY Elser, H., Kempinsky, A., Goldman-Mellor, S., Li, M., Catalano, R., Rehkopf, D. H., Casey, J. A. 2023; 7 (1)

  View details for DOI 10.1097/EE9.0000000000000232

  View details for Web of Science ID 000898983300006

• Distribution of working hour characteristics by race, age, gender, and shift schedule among U.S. manufacturing workers. Chronobiology international Ferguson, J. M., Bradshaw, P. T., Eisen, E. A., Rehkopf, D., Cullen, M. R., Costello, S. 2023: 1-14

  Abstract

  Shift work is a common occupational exposure, however, few studies have examined aspects of shift work beyond night work and long hours, such as rotational patterns or weekend work, which may contribute to poor health through disruption of the body's circadian rhythms. In this manuscript, we calculated the prevalence of working hour characteristics using algorithms for type (e.g., day), duration, intensity, rotational direction, and social aspects (e.g., weekend work) in a nationwide cohort of American manufacturing workers (Nna=23,044) between 2003 and 2014. Distributions of working hour characteristics were examined by schedules (e.g., permanent day, day/night) and demographics, and were cross-classified in a matrix to examine co-occurrence. Approximately 55% of shifts may cause circadian rhythm disruption as they were non-day shifts or day shifts with a quick return or rotation, or were 13h or longer. Older workers, female workers, and White workers worked permanent day shifts most often, while workers of color worked more day/night schedules. Night and evening shifts had more frequent shift rotations, quick returns, and longer hours than day shifts. Yet, day shifts, which are presumed to have little negative circadian impact, may cause circadian rhythm disruption as long hours, quick returns and rotations also occurred within day shifts.

  View details for DOI 10.1080/07420528.2023.2168200

  View details for PubMedID 36691907

• Associations of local area level new deal employment in childhood with late life cognition: evidence from the census-linked health and retirement study. Journal of epidemiology and community health Lee, M., Harrati, A., Rehkopf, D. H., Modrek, S. 2022

  Abstract

  Emergency employment programmes during the 1930s and 1940s invested income, infrastructure and social services into communities affected by the Great Depression. We estimate the long-term associations of growing up in an area exposed to New Deal emergency employment in 1940 with cognitive functioning in later life.Members of the Health and Retirement Study cohort (N=5095; mean age 66.3 at baseline) who were age 0-17 in 1940 were linked to their census record from that year, providing prospective information about childhood contextual and family circumstances. We estimated the association between subcounty-level emergency employment participation in 1940 and baseline cognition and rate of cognitive decline between 1998 and 2016.Compared with those living in the lowest emergency employment quintile in 1940, those who were exposed to moderate levels of emergency employment (third quintile) had better cognitive functioning in 1998 (b=0.092 SD, 95% CI 0.011 to 0.173), conditional on sociodemographic factors. This effect was modestly attenuated after adjusting for respondents' adult education, finances and health factors. There were no significant effects of area-level emergency employment on rate of cognitive decline.Exposure to New Deal employment policies during childhood is associated with long-term cognitive health benefits. This is partially explained by increases in educational attainment among those with greater levels of emergency employment activity in the place where they were raised. Future research should investigate which types of New Deal investments may most be related to long-term cognitive health, or if the associations we observe are due to co-occurring programmes.

  View details for DOI 10.1136/jech-2022-219259

  View details for PubMedID 36600558

• Sex differences in epigenetic age in Mediterranean high longevity regions. Frontiers in aging Engelbrecht, H. R., Merrill, S. M., Gladish, N., MacIsaac, J. L., Lin, D. T., Ecker, S., Chrysohoou, C. A., Pes, G. M., Kobor, M. S., Rehkopf, D. H. 2022; 3: 1007098

  Abstract

  Sex differences in aging manifest in disparities in disease prevalence, physical health, and lifespan, where women tend to have greater longevity relative to men. However, in the Mediterranean Blue Zones of Sardinia (Italy) and Ikaria (Greece) are regions of centenarian abundance, male-female centenarian ratios are approximately one, diverging from the typical trend and making these useful regions in which to study sex differences of the oldest old. Additionally, these regions can be investigated as examples of healthy aging relative to other populations. DNA methylation (DNAm)-based predictors have been developed to assess various health biomarkers, including biological age, Pace of Aging, serum interleukin-6 (IL-6), and telomere length. Epigenetic clocks are biological age predictors whose deviation from chronological age has been indicative of relative health differences between individuals, making these useful tools for interrogating these differences in aging. We assessed sex differences between the Horvath, Hannum, GrimAge, PhenoAge, Skin and Blood, and Pace of Aging predictors from individuals in two Mediterranean Blue Zones and found that men displayed positive epigenetic age acceleration (EAA) compared to women according to all clocks, with significantly greater rates according to GrimAge (β = 3.55; p = 1.22 × 10-12), Horvath (β = 1.07; p = 0.00378) and the Pace of Aging (β = 0.0344; p = 1.77 × 10-08). Other DNAm-based biomarkers findings indicated that men had lower DNAm-predicted serum IL-6 scores (β = -0.00301, p = 2.84 × 10-12), while women displayed higher DNAm-predicted proportions of regulatory T cells than men from the Blue Zone (p = 0.0150, 95% Confidence Interval [0.00131, 0.0117], Cohen's d = 0.517). All clocks showed better correlations with chronological age in women from the Blue Zones than men, but all clocks showed large mean absolute errors (MAE >30 years) in both sexes, except for PhenoAge (MAE <5 years). Thus, despite their equal survival to older ages in these Mediterranean Blue Zones, men in these regions remain biologically older by most measured DNAm-derived metrics than women, with the exception of the IL-6 score and proportion of regulatory T cells.

  View details for DOI 10.3389/fragi.2022.1007098

  View details for PubMedID 36506464

  View details for PubMedCentralID PMC9726738

• Trends and inequities in the diagnosis and treatment of poststroke depression: a retrospective cohort study of privately insured patients in the USA, 2003-2020. Journal of neurology, neurosurgery, and psychiatry Elser, H., Caunca, M., Rehkopf, D. H., Andres, W., Gottesman, R. F., Kasner, S. E., Yaffe, K., Schneider, A. L. 2022

  Abstract

  BACKGROUND: Depression is a common neuropsychiatric consequence of stroke, but there is little empiric evidence regarding clinical diagnosis and management of poststroke depression.METHODS: Retrospective cohort study among 831 471 privately insured patients with first stroke in the USA from 2003 to 2020. We identified diagnoses of poststroke depression using codes from the International Classification of Diseases. We identified treatment based on prescriptions for antidepressants. We used Cox proportional hazards regression analysis to examine rates of poststroke depression diagnosis by gender, age and race/ethnicity. Among individuals who received a diagnosis of poststroke depression, we estimated treatment rates by gender, race/ethnicity and age using negative binomial regression analysis.RESULTS: Annual diagnosis and treatment rates for poststroke depression increased from 2003 to 2020 (both p for trend<0.001). Diagnosis rates were higher in women than men (HR 1.53, 95% CI 1.51 to 1.55), lower among members of racial/ethnic minorities (vs white patients: Asian HR 0.63, 95% CI 0.60 to 0.66; Black HR 0.76, 95% CI 0.74 to 0.78; Hispanic HR 0.88, 95% CI 0.86 to 0.90) and varied by age. Among individuals diagnosed with poststroke depression, 69.8% were prescribed an antidepressant. Rates of treatment were higher in women vs men (rate ratio, RR=1.19, 95% CI: 1.17 to 1.21), lower among members of racial/ethnic minorities (vs white patients: Asian RR 0.85, 95% CI 0.80 to 0.90; Black RR 0.92, 95% CI 0.89 to 0.94; Hispanic RR 0.96, 95% CI 0.93 to 0.99) and higher among older patients.CONCLUSIONS: In this insured population, we identify potential inequities in clinical management of poststroke depression by gender, race/ethnicity and age that may reflect barriers other than access to healthcare.

  View details for DOI 10.1136/jnnp-2022-330179

  View details for PubMedID 36400454

• Association Between Social Disadvantage and Otitis Media Treatment in US Children With Commercial Insurance. JAMA otolaryngology-- head & neck surgery Qian, Z. J., Rehkopf, D. H. 2022

  Abstract

  Importance: It is well established that social disadvantage is associated with earlier, more frequent, and more severe otitis media in children. Appropriate medical and surgical treatment of otitis media can prevent hearing loss and other complications, which may affect future academic and employment opportunities in socially disadvantaged populations. Clinical treatment patterns for otitis media in the US are unclear.Objective: To describe and quantify social disparities in the treatment patterns of otitis media in children in the US.Design, Setting, and Participants: This cross-sectional study included claims data from the Optum Clinformatics Data Mart Database between January 1, 2003, and March 31, 2021, with linked inpatient, outpatient, and pharmaceutical claims for 4 831 408 children with otitis media.Exposures: Age at first otitis media diagnosis, sex, environmental allergies, gastroesophageal reflux, adenotonsillar hyperplasia, zip code, social deprivation index score, social vulnerability index score.Main Outcomes and Measures: Treatment of recurrent and suppurative otitis media in children, insertion of tympanostomy tubes, and treatment for severe complications of undertreated otitis media. The principal measure of social disadvantage was the social deprivation index. The social vulnerability index was used for sensitivity analyses to ensure external validity. Multiple logistic regression analyses were used to quantify the association of all projected variables with the study outcomes.Results: Among 4 831 408 US children with otitis media (median [IQR] age, 4 [1-8] years; 2 491 557 boys [51.57%]), 994 921 (20.59%) were treated for recurrent otitis media, 717 978 (14.86%) were treated for suppurative otitis media, 335 949 (6.95%) received tympanostomy tubes, and 10 975 (0.23%) had severe complications of otitis media. In multivariable regression models including patient factors and social indices, earlier age at diagnosis, male sex, environmental allergies, gastroesophageal reflux, and adenotonsillar hyperplasia were associated with increased treatment for otitis media, whereas social deprivation index was associated with lower odds of medical treatment for recurrent otitis media (odds ratio [OR], 0.86; 95% CI, 0.85-0.87), suppurative otitis media (OR, 0.61; 95% CI, 0.60-0.62), and insertion of tympanostomy tubes (OR, 0.76; 95% CI, 0.75-0.78) but higher odds of having severe complications (OR, 1.28; 95% CI, 1.19-1.37).Conclusions and Relevance: The findings of this cross-sectional study suggest that children with otitis media who were socially disadvantaged were less likely to receive treatment and more likely to experience complications for undertreated otitis media. As otitis media is a modifiable risk factor for hearing loss, efforts need to be made to ensure equitable access to treatment for all children.

  View details for DOI 10.1001/jamaoto.2022.3560

  View details for PubMedID 36355356

• Mapping of machine learning approaches for description, prediction, and causal inference in the social and health sciences. Science advances Leist, A. K., Klee, M., Kim, J. H., Rehkopf, D. H., Bordas, S. P., Muniz-Terrera, G., Wade, S. 2022; 8 (42): eabk1942

  Abstract

  Machine learning (ML) methodology used in the social and health sciences needs to fit the intended research purposes of description, prediction, or causal inference. This paper provides a comprehensive, systematic meta-mapping of research questions in the social and health sciences to appropriate ML approaches by incorporating the necessary requirements to statistical analysis in these disciplines. We map the established classification into description, prediction, counterfactual prediction, and causal structural learning to common research goals, such as estimating prevalence of adverse social or health outcomes, predicting the risk of an event, and identifying risk factors or causes of adverse outcomes, and explain common ML performance metrics. Such mapping may help to fully exploit the benefits of ML while considering domain-specific aspects relevant to the social and health sciences and hopefully contribute to the acceleration of the uptake of ML applications to advance both basic and applied social and health sciences research.

  View details for DOI 10.1126/sciadv.abk1942

  View details for PubMedID 36260666

• Effects of housing vouchers on the long-term exposure to neighbourhood opportunity among low-income families: the moving to opportunity experiment HOUSING STUDIES Kim, H., Schmidt, N. M., Osypuk, T. L., Thyden, N., Rehkopf, D. 2022

  View details for DOI 10.1080/02673037.2022.2112154

  View details for Web of Science ID 000843053200001

• Work Schedule Control and Allostatic Load Biomarkers: Disparities Between and Within Gender SOCIAL INDICATORS RESEARCH Wang, S., Li, L., Lu, Z., Li, S., Rehkopf, D. 2022

  View details for DOI 10.1007/s11205-022-02940-7

  View details for Web of Science ID 000797262900001

• Epigenome-wide association study and epigenetic age acceleration associated with cigarette smoking among Costa Rican adults. Scientific reports Cardenas, A., Ecker, S., Fadadu, R. P., Huen, K., Orozco, A., McEwen, L. M., Engelbrecht, H., Gladish, N., Kobor, M. S., Rosero-Bixby, L., Dow, W. H., Rehkopf, D. H. 2022; 12 (1): 4277

  Abstract

  Smoking-associated DNA methylation (DNAm) signatures are reproducible among studies of mostly European descent, with mixed evidence if smoking accelerates epigenetic aging and its relationship to longevity. We evaluated smoking-associated DNAm signatures in the Costa Rican Study on Longevity and Healthy Aging (CRELES), including participants from the high longevity region of Nicoya.We measured genome-wide DNAm in leukocytes, tested Epigenetic Age Acceleration (EAA) from five clocks and estimates of telomere length (DNAmTL), and examined effect modification by the high longevity region.489 participants had a mean (SD) age of 79.4 (10.8) years, and 18% were from Nicoya. Overall, 7.6% reported currently smoking, 35% were former smokers, and 57.4% never smoked. 46 CpGs and five regions (e.g. AHRR, SCARNA6/SNORD39, SNORA20, and F2RL3) were differentially methylated for current smokers. Former smokers had increased Horvath's EAA (1.69-years; 95% CI 0.72, 2.67), Hannum's EAA (0.77-years; 95% CI 0.01, 1.52), GrimAge (2.34-years; 95% CI1.66, 3.02), extrinsic EAA (1.27-years; 95% CI 0.34, 2.21), intrinsic EAA (1.03-years; 95% CI 0.12, 1.94) and shorter DNAmTL (-0.04-kb; 95% CI -0.08, -0.01) relative to non-smokers. There was no evidence of effect modification among residents of Nicoya. Our findings recapitulate previously reported and novel smoking-associated DNAm changes in a Latino cohort.

  View details for DOI 10.1038/s41598-022-08160-w

  View details for PubMedID 35277542

• Advancing primary care with Artificial Intelligence and Machine Learning. Healthcare (Amsterdam, Netherlands) Yang, Z., Silcox, C., Sendak, M., Rose, S., Rehkopf, D., Phillips, R., Peterson, L., Marino, M., Maier, J., Lin, S., Liaw, W., Kakadiaris, I. A., Heintzman, J., Chu, I., Bazemore, A. 1800; 10 (1): 100594

  Abstract

  Primary care is the largest healthcare delivery platform in the US. Facing the Artificial Intelligence and Machine Learning technology (AI/ML) revolution, the primary care community would benefit from a roadmap revealing priority areas and opportunities for developing and integrating AI/ML-driven clinical tools. This article presents a framework that identifies five domains for AI/ML integration in primary care to support care delivery transformation and achieve the Quintuple Aims of the healthcare system. We concluded that primary care plays a critical role in developing, introducing, implementing, and monitoring AI/ML tools in healthcare and must not be overlooked as AI/ML transforms healthcare.

  View details for DOI 10.1016/j.hjdsi.2021.100594

  View details for PubMedID 34954571

• Racial/Ethnic Disparities in Opioid-Related Mortality in the USA, 1999-2019: the Extreme Case of Washington DC. Journal of urban health : bulletin of the New York Academy of Medicine Kiang, M. V., Tsai, A. C., Alexander, M. J., Rehkopf, D. H., Basu, S. 2021

  View details for DOI 10.1007/s11524-021-00573-8

  View details for PubMedID 34664185

• Subjective social status and physical health: The role of negative affect and reappraisal. Social science & medicine (1982) O'Leary, D., Uysal, A., Rehkopf, D. H., Gross, J. J. 2021; 291: 114272

  Abstract

  RATIONALE: Having low subjective social status is associated with an array of negative health outcomes. However, the mechanisms linking subjective social status to health are not yet clear. One candidate mechanism is negative affect. Researchers have proposed that having low subjective social status may be associated with higher levels of negative affect, and these higher levels of negative affect may be associated with poor health. However, research demonstrating that status-related negative affect is prospectively associated with health in humans is limited.OBJECTIVE: We examined whether negative affect prospectively mediates the relationship between subjective social status and physical health. In addition, we tested whether reappraisal - an affect regulation strategy used to downregulate negative affect - moderates the links among subjective social status, negative affect, and physical health.METHOD: We used two-wave longitudinal data from the Midlife in the United States (MIDUS) project to conduct a series of regression, mediation, and moderated mediation analyses to examine the relationships among subjective social status, negative affect, reappraisal, and health (i.e., four outcomes, chronic conditions, somatic symptoms, self-reported health and mortality).RESULTS: Negative affect mediates the relationship between status and change in morbidity (n=3289; i.e., change in number of chronic conditions, somatic symptoms, self-reported health) and mortality (n=4953), such that subjective social status is inversely associated with negative affect, and negative affect is positively associated with poor health. Reappraisal moderates each of these relationships, such that individuals who are low on subjective social status and have high scores on a novel measure of reappraisal experience lower levels of negative affect and better health than individuals who are low on subjective social status but who have low scores on this measure.CONCLUSION: These results have important implications for our understanding of subjective social status and how it relates to physical health.

  View details for DOI 10.1016/j.socscimed.2021.114272

  View details for PubMedID 34717282

• What to Do When Everything Happens at Once: Analytic Approaches to Estimate the Health Effects of Co-Occurring Social Policies. Epidemiologic reviews Matthay, E. C., Gottlieb, L. M., Rehkopf, D., Tan, M. L., Vlahov, D., Glymour, M. M. 2021

  Abstract

  Social policies have great potential to improve population health and reduce health disparities. Thus, increasing empirical research seeks to quantify the health effects of social policies by exploiting variation in the timing of policy changes across places. Multiple social policies are often adopted simultaneously or in close succession in the same locations, creating co-occurrence which must be handled analytically for valid inferences. Although this is a substantial methodological challenge for studies aiming to isolate social policy effects, limited prior work has systematically considered analytic solutions within a causal framework or assessed whether these solutions are being adopted. We designated seven analytic solutions to policy co-occurrence, including efforts to disentangle individual policy effects and efforts to estimate the combined effects of co-occurring policies. We leveraged an existing systematic review of social policies and health to evaluate how often policy co-occurrence is identified as a threat to validity and how often each analytic solution is applied in practice. Of the 55 studies, only 17 (31%) reported checking for any co-occurring policies, although 36 (67%) used at least one approach that helps address policy co-occurrence. The most common approaches were: adjusting for measures of co-occurring policies; defining the outcome on subpopulations likely to be affected by the policy of interest (but not other co-occurring policies); and selecting a less-correlated measure of policy exposure. As health research increasingly focuses on policy changes, we must systematically assess policy co-occurrence and apply analytic solutions to strengthen future studies on the health effects of social policies.

  View details for DOI 10.1093/epirev/mxab005

  View details for PubMedID 34215873

• Reply to the Editorial Comment on: Using an Automated Electronic Health Record Score To Estimate Life Expectancy In Men Diagnosed With Prostate Cancer In The Veterans Health Administration. Urology. 2021. Urology Soerensen, S. J., Thomas, I., Schmidt, B., Daskivich, T., Skolarus, T. A., Jackson, C., Osborne, T. F., Chertow, G. M., Brooks, J. D., Rehkopf, D., Leppert, J. T. 2021

  Abstract

  OBJECTIVES: To determine if an automatically calculated electronic health record score can estimate intermediate-term life expectancy in men with prostate cancer to provide guideline concordant care.METHODS: We identified all men (n=36,591) diagnosed with prostate cancer in 2013-2015 in the VHA. Of the 36,591, 35,364 (96.6%) had an available Care Assessment Needs (CAN) score (range: 0-99) automatically calculated in the 30 days prior to the date of diagnosis. It was designed to estimate short-term risks of hospitalization and mortality. We fit unadjusted and multivariable Cox proportional hazards regression models to determine the association between the CAN score and overall survival among men with prostate cancer. We compared CAN score performance to two established comorbidity measures: The Charlson Comorbidity Index and Prostate Cancer Comorbidity Index (PCCI).RESULTS: Among 35,364 men, the CAN score correlated with overall stage, with mean scores of 46.5 (±22.4), 58.0 (±24.4), and 68.1 (±24.3) in localized, locally advanced, and metastatic disease, respectively. In both unadjusted and adjusted models for prostate cancer risk, the CAN score was independently associated with survival (HR=1.23 95%CI 1.22-1.24 & adjusted HR=1.17 95%CI 1.16-1.18 per 5-unit change, respectively). The CAN score (overall C-Index 0.74) yielded better discrimination (AUC=0.76) than PCCI (AUC=0.65) or Charlson Comorbidity Index (AUC=0.66) for 5-year survival.CONCLUSIONS: The CAN score is strongly associated with intermediate-term survival following a prostate cancer diagnosis. The CAN score is an example of how learning health care systems can implement multi-dimensional tools to provide fully automated life expectancy estimates to facilitate patient-centered cancer care.

  View details for DOI 10.1016/j.urology.2021.05.056

  View details for PubMedID 34139251

• Anomalously warm weather and acute care visits in patients with multiple sclerosis: A retrospective study of privately insured individuals in the US. PLoS medicine Elser, H., Parks, R. M., Moghavem, N., Kiang, M. V., Bozinov, N., Henderson, V. W., Rehkopf, D. H., Casey, J. A. 2021; 18 (4): e1003580

  Abstract

  BACKGROUND: As the global climate changes in response to anthropogenic greenhouse gas emissions, weather and temperature are expected to become increasingly variable. Although heat sensitivity is a recognized clinical feature of multiple sclerosis (MS), a chronic demyelinating disorder of the central nervous system, few studies have examined the implications of climate change for patients with this disease.METHODS AND FINDINGS: We conducted a retrospective cohort study of individuals with MS ages 18-64 years in a nationwide United States patient-level commercial and Medicare Advantage claims database from 2003 to 2017. We defined anomalously warm weather as any month in which local average temperatures exceeded the long-term average by ≥1.5°C. We estimated the association between anomalously warm weather and MS-related inpatient, outpatient, and emergency department visits using generalized log-linear models. From 75,395,334 individuals, we identified 106,225 with MS. The majority were women (76.6%) aged 36-55 years (59.0%). Anomalously warm weather was associated with increased risk for emergency department visits (risk ratio [RR] = 1.043, 95% CI: 1.025-1.063) and inpatient visits (RR = 1.032, 95% CI: 1.010-1.054). There was limited evidence of an association between anomalously warm weather and MS-related outpatient visits (RR = 1.010, 95% CI: 1.005-1.015). Estimates were similar for men and women, strongest among older individuals, and exhibited substantial variation by season, region, and climate zone. Limitations of the present study include the absence of key individual-level measures of socioeconomic position (i.e., race/ethnicity, occupational status, and housing quality) that may determine where individuals live-and therefore the extent of their exposure to anomalously warm weather-as well as their propensity to seek treatment for neurologic symptoms.CONCLUSIONS: Our findings suggest that as global temperatures rise, individuals with MS may represent a particularly susceptible subpopulation, a finding with implications for both healthcare providers and systems.

  View details for DOI 10.1371/journal.pmed.1003580

  View details for PubMedID 33901187

• High School Composition and Health Outcomes in Adulthood: A Cohort Study. International journal of environmental research and public health Cohen, A. K., Ozer, E. J., Rehkopf, D. H., Abrams, B. 2021; 18 (7)

  Abstract

  BACKGROUND: A multitude of empirical evidence documents links between education and health, but this focuses primarily on educational attainment and not on characteristics of the school setting. Little is known about the extent to which aggregate characteristics of the school setting, such as student body demographics, are associated with adult health outcomes.METHODS: We use the U.S. nationally representative National Longitudinal Survey of Youth 1979 cohort to statistically assess the association between two different measures of high school student composition (socioeconomic composition, racial/ethnic composition) and two different health outcomes at age 40 (self-rated health and obesity).RESULTS: After adjusting for confounders, high school socioeconomic composition, but not racial/ethnic composition, was weakly associated with both obesity and worse self-rated health at age 40. However, after adding adult educational attainment to the model, only the association between high school socioeconomic composition and obesity remained statistically significant.CONCLUSIONS: Future research should explore possible mechanisms and also if findings are similar across other populations and in other school contexts. These results suggest that education policies that seek to break the link between socioeconomic composition and negative outcomes remain important but may have few spillover effects onto health.

  View details for DOI 10.3390/ijerph18073799

  View details for PubMedID 33917294

• Land use impacts on parasitic infection: a cross-sectional epidemiological study on the role of irrigated agriculture in schistosome infection in a dammed landscape. Infectious diseases of poverty Lund, A. J., Rehkopf, D. H., Sokolow, S. H., Sam, M. M., Jouanard, N., Schacht, A., Senghor, S., Fall, A., Riveau, G., De Leo, G. A., Lopez-Carr, D. 2021; 10 (1): 35

  Abstract

  BACKGROUND: Water resources development promotes agricultural expansion and food security. But are these benefits offset by increased infectious disease risk? Dam construction on the Senegal River in 1986 was followed by agricultural expansion and increased transmission of human schistosomes. Yet the mechanisms linking these two processes at the individual and household levels remain unclear. We investigated the association between household land use and schistosome infection in children.METHODS: We analyzed cross-sectional household survey data (n=655) collected in 16 rural villages in August 2016 across demographic, socio-economic and land usedimensions, which were matched to Schistosoma haematobium (n=1232) and S. mansoni (n=1222) infection data collected from school-aged children. Mixed effects regression determined the relationship between irrigated area and schistosome infection presence and intensity.RESULTS: Controlling for socio-economic and demographic risk factors, irrigated area cultivated by a household was associated with an increase in the presence of S. haematobium infection (odds ratio [OR]=1.14; 95% confidence interval [95% CI]: 1.03-1.28) but not S. mansoni infection (OR=1.02; 95% CI: 0.93-1.11). Associations between infection intensity and irrigated area were positive but imprecise (S. haematobium: rate ratio [RR]=1.05; 95% CI: 0.98-1.13, S. mansoni: RR=1.09; 95% CI: 0.89-1.32).CONCLUSIONS: Household engagement in irrigated agriculture increases individual risk of S. haematobium but not S. mansoni infection. Increased contact with irrigated landscapes likely drives exposure, with greater impacts on households relying on agricultural livelihoods.

  View details for DOI 10.1186/s40249-021-00816-5

  View details for PubMedID 33745442

• Leisure time activities and biomarkers of chronic stress: The mediating roles of alcohol consumption and smoking. Scandinavian journal of public health Wang, S., Li, L. Z., Zhang, J., Rehkopf, D. H. 2021: 1403494820987461

  Abstract

  AIMS: Previous research found an association between leisure time activities such as arts and cultural activities and self-reported health over the life course-a measure prone to response bias. This study tested the relationship between arts and cultural activities and allostatic load, a biomarker of chronic stress, and examined risky health behaviors, including alcohol consumption and smoking, as possible mediators.METHODS: The sample consists of 8948 adults from the second wave of the United Kingdom Household Longitudinal Study, which is representative of the British population. The cross-sectional association between arts and cultural activities and allostatic load was tested with negative binomial models, and the mediation roles of alcohol consumption and smoking in the association was tested with the Karlson-Holm-Breen (KHB) decomposition method.RESULTS: Frequent participation in arts, frequent attendance of cultural events, visits to museums or galleries, and visits to historical sites have negative associations with allostatic load. The associations are mediated by lower frequency of alcohol drinking and smoking.CONCLUSIONS: Cultural capital may promote health by reducing the frequency of health risk behaviors such as drinking alcohol and smoking. Future research and public health policies should consider whether cultural capital acts as a social determinant of health to promote healthy leisure activities over the life course.

  View details for DOI 10.1177/1403494820987461

  View details for PubMedID 33570003

• Correction to: Racial/Ethnic Disparities in Opioid-Related Mortality in the USA, 1999-2019: the Extreme Case of Washington DC. Journal of urban health : bulletin of the New York Academy of Medicine Kiang, M. V., Tsai, A. C., Alexander, M. J., Rehkopf, D. H., Basu, S. 2021

  View details for DOI 10.1007/s11524-021-00592-5

  View details for PubMedID 34799823

• Relative Deprivation, Income Inequality, and Cardiovascular Health: Observational and Mendelian Randomization Studies in Hong Kong Chinese. Frontiers in public health Kwok, M. K., Kawachi, I., Rehkopf, D., Ni, M. Y., Leung, G. M., Schooling, C. M. 2021; 9: 726617

  Abstract

  The associations between absolute vs. relative income at the household or neighborhood level and cardiovascular disease (CVD) risk remain understudied in the Chinese context. Further, it is unclear whether stress biomarkers, such as cortisol, are on the pathway from income to CVD risk. We examined the associations of absolute and relative income with CVD risk observationally, as well as the mediating role of cortisol, and validated the role of cortisol using Mendelian Randomization (MR) in Hong Kong Chinese. Within Hong Kong's FAMILY Cohort, associations of absolute and relative income at both the individual and neighborhood levels with CVD risk [body mass index (BMI), body fat percentage, systolic blood pressure, diastolic blood pressure, self-reported CVD and self-reported diabetes] were examined using multilevel logistic or linear models (n = 17,607), the mediating role of cortisol using the mediation analysis (n = 1,562), and associations of genetically predicted cortisol with CVD risk using the multiplicative generalized method of moments (MGMMs) or two-stage least squares regression (n = 1,562). In our cross-sectional observational analysis, relative household income deprivation (per 1 SD, equivalent to USD 128 difference in Yitzhaki index) was associated with higher systolic blood pressure (0.47 mmHg, 95% CI 0.30-0.64), but lower BMI (-0.07 kg/m2, 95% CI -0.11 to -0.04), independent of absolute income. Neighborhood income inequality was generally unrelated to CVD and its risk factors, nor was absolute income at the household or neighborhood level. Cortisol did not clearly mediate the association of relative household income deprivation with systolic blood pressure. Using MR, cortisol was unrelated to CVD risk. Based on our findings, relative household income deprivation was not consistently associated with cardiovascular health in Hong Kong Chinese, nor were neighborhood income inequality and absolute income, highlighting the context-specific ways in which relative and absolute income are linked to CVD risk.

  View details for DOI 10.3389/fpubh.2021.726617

  View details for PubMedID 35127607

• AUTHOR REPLY. Urology Soerensen, S. J., Thomas, I. C., Schmidt, B., Daskivich, T. J., Skolarus, T. A., Jackson, C., Osborne, T. F., Chertow, G. M., Brooks, J. D., Rehkopf, D. H., Leppert, J. T. 2021; 155: 76

  View details for DOI 10.1016/j.urology.2021.05.058

  View details for PubMedID 34489006

• Identification of Modifiable Social and Behavioral Factors Associated With Childhood Cognitive Performance. JAMA pediatrics LeWinn, K. Z., Bush, N. R., Batra, A., Tylavsky, F., Rehkopf, D. 2020

  Abstract

  Importance: Inequities in social environments are likely associated with a large portion of racial disparities in childhood cognitive performance. Identification of the specific exposures associated with cognitive development is needed to inform prevention efforts.Objective: To identify modifiable factors associated with childhood cognitive performance.Design, Setting, and Participants: This longitudinal pregnancy cohort study included 1503 mother-child dyads who were enrolled in the University of Tennessee Health Science Center-Conditions Affecting Neurodevelopment and Learning in Early Life study between December 1, 2006, and July 31, 2011, and assessed annually until the children were aged 4 to 6 years. The analytic sample comprised 1055 mother-child dyads. A total of 155 prenatal, perinatal, and postnatal exposures were included to evaluate environment-wide associations. Participants comprised a community-based sample of pregnant women who were recruited between 16 weeks and 28 weeks of gestation from 4 hospitals in Shelby County, Tennessee. Women with high-risk pregnancies were excluded. Data were analyzed from June 1, 2018, to April 15, 2019.Exposures: Individual and neighborhood socioeconomic position, family structure, maternal mental health, nutrition, delivery complications, birth outcomes, and parenting behaviors.Main Outcomes and Measures: Child's full-scale IQ measured by the Stanford-Binet Intelligence Scales, Fifth Edition, at age 4 to 6 years.Results: Of 1055 children included in the analytic sample, 532 (50.4%) were female. Among mothers, the mean (SD) age was 26.0 (5.6) years; 676 mothers (64.1%) were Black, and 623 mothers (59.0%) had an educational level of high school or less. Twenty-four factors were retained in the least absolute shrinkage and selection operator regression analysis and full models adjusted for potential confounding. Associations were noted between child cognitive performance and parental education and breastfeeding; for each increase of 1.0 SD in exposure, positive associations were found with cognitive growth fostering from observed parent-child interactions (beta=1.12; 95% CI, 0.24-2.00) and maternal reading ability (beta=1.42; 95% CI, 0.16-2.68), and negative associations were found with parenting stress (beta=-1.04; 95% CI, -1.86 to -0.21). A moderate increase in these beneficial exposures was associated with a notable improvement in estimated cognitive test scores using marginal means (0.5% of an SD). Black children experienced fewer beneficial cognitive performance exposures; in a model including all 24 exposures and covariates, no racial disparity was observed in cognitive performance (95% CIs for race included the null).Conclusions and Relevance: The prospective analysis identified multiple beneficial and modifiable cognitive performance exposures that were associated with mean differences in cognitive performance by race. The findings from this observational study may help guide experimental studies focused on reducing racial disparities in childhood cognitive performance.

  View details for DOI 10.1001/jamapediatrics.2020.2904

  View details for PubMedID 32955555

• A Complex Systems Model of Breast Cancer Etiology: The Paradigm II Conceptual Model CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Hiatt, R. A., Engmann, N. J., Balke, K., Rehkopf, D. H., Paradigm Multidisciplinary Pane 2020; 29 (9): 1720–30

  Abstract

  The etiology of breast cancer is a complex system of interacting factors from multiple domains. New knowledge about breast cancer etiology continues to be produced by the research community, and the communication of this knowledge to other researchers, practitioners, decision makers, and the public is a challenge.We updated the previously published Paradigm model (PMID: 25017248) to create a framework that describes breast cancer etiology in four overlapping domains of biologic, behavioral, environmental, and social determinants. This new Paradigm II conceptual model was part of a larger modeling effort that included input from multiple experts in fields from genetics to sociology, taking a team and transdisciplinary approach to the common problem of describing breast cancer etiology for the population of California women in 2010. Recent literature was reviewed with an emphasis on systematic reviews when available and larger epidemiologic studies when they were not. Environmental chemicals with strong animal data on etiology were also included.The resulting model illustrates factors with their strength of association and the quality of the available data. The published evidence supporting each relationship is made available herein, and also in an online dynamic model that allows for manipulation of individual factors leading to breast cancer (https://cbcrp.org/causes/).The Paradigm II model illustrates known etiologic factors in breast cancer, as well as gaps in knowledge and areas where better quality data are needed.The Paradigm II model can be a stimulus for further research and for better understanding of breast cancer etiology.

  View details for DOI 10.1158/1055-9965.EPI-20-0016

  View details for Web of Science ID 000566862600003

  View details for PubMedID 32641370

• Predicting mortality from 57 economic, behavioral, social, and psychological factors. Proceedings of the National Academy of Sciences of the United States of America Puterman, E., Weiss, J., Hives, B. A., Gemmill, A., Karasek, D., Mendes, W. B., Rehkopf, D. H. 2020

  Abstract

  Behavioral and social scientists have identified many nonbiological predictors of mortality. An important limitation of much of this research, however, is that risk factors are not studied in comparison with one another or from across different fields of research. It therefore remains unclear which factors should be prioritized for interventions and policy to reduce mortality risk. In the current investigation, we compare 57 factors within a multidisciplinary framework. These include (i) adverse socioeconomic and psychosocial experiences during childhood and (ii) socioeconomic conditions, (iii) health behaviors, (iv) social connections, (v) psychological characteristics, and (vi) adverse experiences during adulthood. The current prospective cohort investigation with 13,611 adults from 52 to 104 y of age (mean age 69.3 y) from the nationally representative Health and Retirement Study used weighted traditional (i.e., multivariate Cox regressions) and machine-learning (i.e., lasso, random forest analysis) statistical approaches to identify the leading predictors of mortality over 6 y of follow-up time. We demonstrate that, in addition to the well-established behavioral risk factors of smoking, alcohol abuse, and lack of physical activity, economic (e.g., recent financial difficulties, unemployment history), social (e.g., childhood adversity, divorce history), and psychological (e.g., negative affectivity) factors were also among the strongest predictors of mortality among older American adults. The strength of these predictors should be used to guide future transdisciplinary investigations and intervention studies across the fields of epidemiology, psychology, sociology, economics, and medicine to understand how changes in these factors alter individual mortality risk.

  View details for DOI 10.1073/pnas.1918455117

  View details for PubMedID 32571904

• Psychological Distress Mediates the Prospective Association of Household Income with Body Mass Index in Adolescent Girls. Affective science O'Leary, D., Gross, J. J., Rehkopf, D. H. 2020; 1 (2): 97-106

  Abstract

  The primary objective of this study was to examine whether psychological distress mediates the relationship between income and increases in body mass index in adolescent girls. To answer this question, we analyzed data from 2379 participants in the longitudinal NHLBI Growth and Health Study using regularized regression and path analysis. The exposure was household income at age 9-10 and the outcome was body mass index at age 18-19. Income negatively predicted psychological distress, which in turn predicted psychological and behavioral factors that were associated with increases in body mass index. Overall, psychological distress and related variables accounted for around 20% of the relationship between income and increases in body mass index in adolescent girls. The impacts of income on a complex constellation of psychological risks for obesity support the evaluation of income support policies for reducing economic inequalities in obesity. Obesity reduction programs focused on changing psychological distress should be developed with consideration of the household economic environment.

  View details for DOI 10.1007/s42761-020-00010-0

  View details for PubMedID 36042968

  View details for PubMedCentralID PMC9383009

• Short-term effects of the earned income tax credit on mental health and health behaviors. Preventive medicine Collin, D. F., Shields-Zeeman, L. S., Batra, A. n., Vable, A. M., Rehkopf, D. H., Machen, L. n., Hamad, R. n. 2020: 106223

  Abstract

  Poverty has consistently been linked to poor mental health and risky health behaviors, yet few studies evaluate the effectiveness of programs and policies to address these outcomes by targeting poverty itself. We test the hypothesis that the earned income tax credit (EITC)-the largest U.S. poverty alleviation program-improves short-term mental health and health behaviors in the months immediately after income receipt. We conducted parallel analyses in two large longitudinal national data sets: the National Health Interview Survey (NHIS, 1997-2016, N=379,603) and the Panel Study of Income Dynamics (PSID, 1985-2015, N=29,808). Outcomes included self-rated health, psychological distress, tobacco use, and alcohol consumption. We employed difference-in-differences analysis, a quasi-experimental technique. We exploited seasonal variation in disbursement of the EITC, which is distributed as a tax refund every spring: we compared outcomes among EITC-eligible individuals interviewed immediately after refund receipt (Feb-Apr) with those interviewed in other months more distant from refund receipt (May-Jan), "differencing out" seasonal trends among non-eligible individuals. For most outcomes, we were unable to rule out the null hypothesis that there was no short-term effect of the EITC. Findings were cross-validated in both data sets. The exception was an increase in smoking in PSID, although this finding was not robust to sensitivity analyses. While we found no short-term "check effect" of the EITC on mental health and health behaviors, others have found long-term effects on these outcomes. This may be because recipients anticipate EITC receipt and smooth their income accordingly.

  View details for DOI 10.1016/j.ypmed.2020.106223

  View details for PubMedID 32735990

• Income, inflammation and cancer mortality: a study of U.S. National Health and Nutrition Examination Survey mortality follow-up cohorts. BMC public health Chan, J. E., Mann, A. K., Kapp, D. S., Rehkopf, D. H. 2020; 20 (1): 1805

  Abstract

  To estimate the relationship between inflammatory biomarkers and cancer mortality in a nationally representative sample of the U.S. population while controlling for education, occupation, and income.Data were obtained from the U.S. National Health and Nutrition Examination Survey from 1988 to 1994 (N = 7817) and 1999-2002 (N = 2344). We fit Cox proportional hazard models to examine the relationship between C-reactive protein (CRP) and fibrinogen with cancer mortality.In the full Cox multivariate model, clinically raised CRP was associated with cancer mortality in NHANES 1988-1994 (> 0.99 mg/dL: 95%CI: 1.04-2.13). However, across two inflammatory biomarkers (CRP and Fibrinogen), two NHANES time periods (1998-1994 and 1999-2002) and three income levels (12 strata in total), Hazard ratio confidence intervals did not include the null only for one association: CRP and cancer mortality among low income participants from 1988 to 1994 (HR = 1.83, 95% CI: 1.10-3.04).We find evidence that only in one unique stratum is earlier life CRP, and not fibrinogen, associated with prospective cancer mortality. After more complete control for socioeconomic confounding, CRP and fibrinogen do not predict cancer mortality in most subpopulations.

  View details for DOI 10.1186/s12889-020-09923-8

  View details for PubMedID 33243216

• Are long telomeres better than short? Relative contributions of genetically predicted telomere length to neoplastic and non-neoplastic disease risk and population health burden. PloS one Protsenko, E., Rehkopf, D., Prather, A. A., Epel, E., Lin, J. 2020; 15 (10): e0240185

  Abstract

  BACKGROUND: Mendelian Randomization (MR) studies exploiting single nucleotide polymorphisms (SNPs) predictive of leukocyte telomere length (LTL) have suggested that shorter genetically determined telomere length (gTL) is associated with increased risks of degenerative diseases, including cardiovascular and Alzheimer's diseases, while longer gTL is associated with increased cancer risks. These varying directions of disease risk have long begged the question: when it comes to telomeres, is it better to be long or short? We propose to operationalize and answer this question by considering the relative impact of long gTL vs. short gTL on disease incidence and burden in a population.METHODS AND FINDINGS: We used odds ratios (OR) of disease associated with gTL from a recently published MR meta-analysis to approximate the relative contributions of gTL to the incidence and burden of neoplastic and non-neoplastic disease in a European population. We obtained incidence data of the 9 cancers associated with long gTL and 4 non-neoplastic diseases associated with short gTL from the Institute of Health Metrics (IHME). Incidence rates of individual cancers from SEER, a database of United States cancer records, were used to weight the ORs in order to align with the available IHME data. These data were used to estimate the excess incidences due to long vs. short gTL, expressed as per 100,000 persons per standard deviation (SD) change in gTL. To estimate the population disease burden, we used the Disability Adjusted Life Years (DALY) metric from the IHME, a measure of overall disease burden that accounts for both mortality and morbidity, and similarly calculated the excess DALY associated with long vs. short gTL.RESULTS: Our analysis shows that, despite the markedly larger ORs of neoplastic disease, the large incidence of degenerative diseases causes the excess incidence attributable to gTL to balance that of neoplastic diseases. Long gTL is associated with an excess incidence of 94.04 cases/100,000 persons/SD (45.49-168.84, 95%CI) from the 9 cancer, while short gTL is associated with an excess incidence of 121.49 cases/100,000 persons/SD (48.40-228.58, 95%CI) from the 4 non-neoplastic diseases. When considering disease burden using the DALY metric, long gTL is associated with an excess 1255.25 DALYs/100,000 persons/SD (662.71-2163.83, 95%CI) due to the 9 cancers, while short gTL is associated with an excess 1007.75 DALYs/100,000 persons/SD (411.63-1847.34, 95%CI) due to 4 non-neoplastic diseases.CONCLUSIONS: Our results show that genetically determined long and short telomere length are associated with disease risk and burden of approximately equal magnitude. These results provide quantitative estimates of the relative impact of genetically-predicted short vs. long TL in a human population, and provide evidence in support of the cancer-aging paradox, wherein human telomere length is balanced by opposing evolutionary forces acting to minimize both neoplastic and non-neoplastic diseases. Importantly, our results indicate that odds ratios alone can be misleading in different clinical scenarios, and disease risk should be assessed from both an individual and population level in order to draw appropriate conclusions about the risk factor's role in human health.

  View details for DOI 10.1371/journal.pone.0240185

  View details for PubMedID 33031470

• The role of cortisol in ischemic heart disease, ischemic stroke, type 2 diabetes, and cardiovascular disease risk factors: a bi-directional Mendelian randomization study. BMC medicine Kwok, M. K., Kawachi, I. n., Rehkopf, D. n., Schooling, C. M. 2020; 18 (1): 363

  Abstract

  Cortisol, a steroid hormone frequently used as a biomarker of stress, is associated with cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). To clarify whether cortisol causes these outcomes, we assessed the role of cortisol in ischemic heart disease (IHD), ischemic stroke, T2DM, and CVD risk factors using a bi-directional Mendelian randomization (MR) study.Single nucleotide polymorphisms (SNPs) strongly (P < 5 × 10-6) and independently (r2 < 0.001) predicting cortisol were obtained from the CORtisol NETwork (CORNET) consortium (n = 12,597) and two metabolomics genome-wide association studies (GWAS) (n = 7824 and n = 2049). They were applied to GWAS of the primary outcomes (IHD, ischemic stroke and T2DM) and secondary outcomes (adiposity, glycemic traits, blood pressure and lipids) to obtain estimates using inverse variance weighting, with weighted median, MR-Egger, and MR-PRESSO as sensitivity analyses. Conversely, SNPs predicting IHD, ischemic stroke, and T2DM were applied to the cortisol GWAS.Genetically predicted cortisol (based on 6 SNPs from CORNET; F-statistic = 28.3) was not associated with IHD (odds ratio (OR) 0.98 per 1 unit increase in log-transformed cortisol, 95% confidence interval (CI) 0.93-1.03), ischemic stroke (0.99, 95% CI 0.91-1.08), T2DM (1.00, 95% CI 0.96-1.04), or CVD risk factors. Genetically predicted IHD, ischemic stroke, and T2DM were not associated with cortisol.Contrary to observational studies, genetically predicted cortisol was unrelated to IHD, ischemic stroke, T2DM, or CVD risk factors, or vice versa. Our MR results find no evidence that cortisol plays a role in cardiovascular risk, casting doubts on the cortisol-related pathway, although replication is warranted.

  View details for DOI 10.1186/s12916-020-01831-3

  View details for PubMedID 33243239

• A data-driven prospective study of dementia among older adults in the United States. PloS one Weiss, J. n., Puterman, E. n., Prather, A. A., Ware, E. B., Rehkopf, D. H. 2020; 15 (10): e0239994

  Abstract

  Studies examining risk factors for dementia have typically focused on testing a priori hypotheses within specific risk factor domains, leaving unanswered the question of what risk factors across broad and diverse research fields may be most important to predicting dementia. We examined the relative importance of 65 sociodemographic, early-life, economic, health and behavioral, social, and genetic risk factors across the life course in predicting incident dementia and how these rankings may vary across racial/ethnic (non-Hispanic white and black) and gender (men and women) groups.We conducted a prospective analysis of dementia and its association with 65 risk factors in a sample of 7,908 adults aged 51 years and older from the nationally representative US-based Health and Retirement Study. We used traditional survival analysis methods (Fine and Gray models) and a data-driven approach (random survival forests for competing risks) which allowed us to account for the semi-competing risk of death with up to 14 years of follow-up. Overall, the top five predictors across all groups were lower education, loneliness, lower wealth and income, and lower self-reported health. However, we observed variation in the leading predictors of dementia across racial/ethnic and gender groups such that at most four risk factors were consistently observed in the top ten predictors across the four demographic strata (non-Hispanic white men, non-Hispanic white women, non-Hispanic black men, non-Hispanic black women).We identified leading risk factors across racial/ethnic and gender groups that predict incident dementia over a 14-year period among a nationally representative sample of US aged 51 years and older. Our ranked lists may be useful for guiding future observational and quasi-experimental research that investigates understudied domains of risk and emphasizes life course economic and health conditions as well as disparities therein.

  View details for DOI 10.1371/journal.pone.0239994

  View details for PubMedID 33027275

• Trends in Mental and Physical Health-Related Quality of Life in Low-Income Older Persons in the United States, 2003 to 2017. JAMA network open Rehkopf, D. H., Furstenberg, F. F., Rowe, J. W. 2019; 2 (12): e1917868

  View details for DOI 10.1001/jamanetworkopen.2019.17868

  View details for PubMedID 31851343

• Layoffs and the mental health and safety of remaining workers: a difference-in-differences analysis of the US aluminium industry. Journal of epidemiology and community health Elser, H., Ben-Michael, E., Rehkopf, D., Modrek, S., Eisen, E. A., Cullen, M. R. 2019

  Abstract

  BACKGROUND: Relatively few studies have examined the effects of layoffs on remaining workers, although the effects of layoffs and downsizing events may extend beyond those employees who lose their jobs.METHODS: We examined the effects of layoffs on mental healthcare utilisation and injury risk among workers at 30 US plants between 2003 and 2013. We defined layoffs as reductions in the hourly workforce of 20% or more at each plant. Using a difference-in-differences approach, we compared the change in outcomes during layoffs versus the same 3-month period 1year previously, accounting for secular trends with control plants.RESULTS: Our study population included 15502 workers and 7 layoff events between 2003 and 2013. Layoffs were associated with only minor decreases in injuries (-0.006, 95%CI -0.013 to 0.001). The probability of outpatient visits related to mental health increased by 1% during layoffs (0.010, 95%CI 0.003 to 0.017), and the probability of mental health-related prescriptions increased by 1.4% (0.014, 95%CI -0.0006 to 0.027). Among women, the increase in outpatient visits was more pronounced (0.017, 95%CI 0.003 to 0.031). Increased prescription utilisation appeared attributable primarily to opioid use (0.016, 95%CI 0.005 to 0.027).CONCLUSION: Our results indicate an association between layoffs and remaining workers' mental health and safety, although changes mental healthcare utilisation may reflect both changes in underlying mental health and changes in care-seeking. Future research on concordance of service utilisation and underlying health may yield valuable insight into the experiences employed workers in the wake of layoffs.

  View details for DOI 10.1136/jech-2018-211774

  View details for PubMedID 31533963

• Socioeconomic gradients in cancer incidence by race and ethnicity in California, 2008-2012: the influence of tobacco use or screening detectable cancers CANCER CAUSES & CONTROL Rehkopf, D. H., Rodriguez, D., Cress, R., Braithwaite, D., Oakley-Girvan, I., West, D., Hiatt, R. A. 2019; 30 (7): 697–706

  View details for DOI 10.1007/s10552-019-01172-4

  View details for Web of Science ID 000473820600004

• Educational attainment and cardiovascular disease in the United States: A quasi-experimental instrumental variables analysis. PLoS medicine Hamad, R., Nguyen, T. T., Bhattacharya, J., Glymour, M. M., Rehkopf, D. H. 2019; 16 (6): e1002834

  Abstract

  BACKGROUND: There is ongoing debate about whether education or socioeconomic status (SES) should be inputs into cardiovascular disease (CVD) prediction algorithms and clinical risk adjustment models. It is also unclear whether intervening on education will affect CVD, in part because there is controversy regarding whether education is a determinant of CVD or merely correlated due to confounding or reverse causation. We took advantage of a natural experiment to estimate the population-level effects of educational attainment on CVD and related risk factors.METHODS AND FINDINGS: We took advantage of variation in United States state-level compulsory schooling laws (CSLs), a natural experiment that was associated with geographic and temporal differences in the minimum number of years that children were required to attend school. We linked census data on educational attainment (N = approximately 5.4 million) during childhood with outcomes in adulthood, using cohort data from the 1992-2012 waves of the Health and Retirement Study (HRS; N = 30,853) and serial cross-sectional data from 1971-2012 waves of the National Health and Nutrition Examination Survey (NHANES; N = 44,732). We examined self-reported CVD outcomes and related risk factors, as well as relevant serum biomarkers. Using instrumental variables (IV) analysis, we found that increased educational attainment was associated with reduced smoking (HRS beta -0.036, 95%CI: -0.06, -0.02, p < 0.01; NHANES beta -0.032, 95%CI: -0.05, -0.02, p < 0.01), depression (HRS beta -0.049, 95%CI: -0.07, -0.03, p < 0.01), triglycerides (NHANES beta -0.039, 95%CI: -0.06, -0.01, p < 0.01), and heart disease (HRS beta -0.025, 95%CI: -0.04, -0.002, p = 0.01), and improvements in high-density lipoprotein (HDL) cholesterol (HRS beta 1.50, 95%CI: 0.34, 2.49, p < 0.01; NHANES beta 0.86, 95%CI: 0.32, 1.48, p < 0.01), but increased BMI (HRS beta 0.20, 95%CI: 0.002, 0.40, p = 0.05; NHANES beta 0.13, 95%CI: 0.01, 0.32, p = 0.05) and total cholesterol (HRS beta 2.73, 95%CI: 0.09, 4.97, p = 0.03). While most findings were cross-validated across both data sets, they were not robust to the inclusion of state fixed effects. Limitations included residual confounding, use of self-reported outcomes for some analyses, and possibly limited generalizability to more recent cohorts.CONCLUSIONS: This study provides rigorous population-level estimates of the association of educational attainment with CVD. These findings may guide future implementation of interventions to address the social determinants of CVD and strengthen the argument for including educational attainment in prediction algorithms and primary prevention guidelines for CVD.

  View details for DOI 10.1371/journal.pmed.1002834

  View details for PubMedID 31237869

• Gender, Depression, and Blue-collar Work A Retrospective Cohort Study of US Aluminum Manufacturers EPIDEMIOLOGY Elser, H., Rehkopf, D. H., Meausoone, V., Jewell, N. R., Eisen, E. A., Cullen, M. R. 2019; 30 (3): 435–44

  View details for DOI 10.1097/EDE.0000000000000993

  View details for Web of Science ID 000480682000024

• Novel ranking of protective and risk factors for adolescent adiposity in US females OBESITY SCIENCE & PRACTICE Narla, A., Rehkopf, D. H. 2019; 5 (2): 177–86

  View details for DOI 10.1002/osp4.323

  View details for Web of Science ID 000465036700010

• Life-course BMI and biomarkers in persons aged 60 years or older: a comparison of the USA and Costa Rica PUBLIC HEALTH NUTRITION Rehkopf, D. H., Duong, A., Dow, W. H., Rosero-Bixby, L. 2019; 22 (2): 314–23

  Abstract

  There is a large literature linking current BMI to levels of cardiovascular risk biomarkers, but it is unknown whether measures of BMI earlier in the life course and maximum BMI are predictive of current levels of biomarkers. The objective of the current study was to determine how current, maximum and age-25 BMI among individuals over the age of 60 years are associated with their current levels of cardiovascular risk biomarkers.Cross-sectional study with retrospective recall.Costa Rica (n 821) and the USA (n 4110).Nationally representative samples of adults aged 60 years or over.We used regression models to examine the relationship between multiple meaures of BMI with four established cardiovascular risk biomarkers. The most consistent predictor of current levels of systolic blood pressure, TAG and HDL-cholesterol was current BMI. However, maximum BMI was the strongest predictor of glycosylated Hb (HbA1c) and was also related to HDL-cholesterol and TAG. HbA1c was independent of current BMI. We found that these relationships are consistent between Costa Rica and the USA for HbA1c and for HDL-cholesterol.Current levels of cardiovascular risk biomarkers are not only the product of current levels of BMI, but also of maximum lifetime BMI, particularly for levels of HbA1c and for HDL-cholesterol. Managing maximum obtained BMI over the life course may be most critical for maintaining the healthiest levels of cardiovascular risk.

  View details for DOI 10.1017/S1368980018002276

  View details for Web of Science ID 000458515400013

  View details for PubMedID 30306887

  View details for PubMedCentralID PMC6351185

• Similarities in Maternal Weight and Birth Weight Across Pregnancies and Across Sisters MATERNAL AND CHILD HEALTH JOURNAL Luecke, E., Cohen, A. K., Brillante, M., Rehkopf, D. H., Coyle, J., Hendrick, C., Abrams, B. 2019; 23 (2): 138–47

  Abstract

  Objectives The current study examined how prepregnancy body mass index (BMI), gestational weight gain, and birth weight cluster between births within women and between women who are sisters. Methods Using data from the National Longitudinal Survey of Youth 1979 cohort, we utilized nested, multivariable hierarchical linear models to examine the correlation of these three outcomes between births (n = 6006) to women (n = 3605) and sisters (n = 3170) so that we can quantify the clustering by sibship and by woman for these three pregnancy-related outcomes. Results After controlling for confounding covariates, prepregnancy BMI (intraclass correlation (ICC) 0.24, 95% CI 0.16, 0.32), gestational weight gain (ICC 0.23, 95% CI 0.16, 0.31), and infant's birthweight (ICC 0.07, 95% CI 0.003, 0.13) were correlated between sisters. Additionally, all three outcomes were significantly correlated between births for each sister, suggesting that prepregnancy BMI (ICC 0.82, 95% CI 0.81, 0.83), gestational weight gain (ICC 0.45, 95% CI 0.42, 0.49), and birth weight (ICC 0.31, 95% CI 0.28, 0.35) track between pregnancies in the same woman. Conclusions for Practice The observed clustering both within women and between sisters suggests that shared genetic and environmental factors among sisters play a role in pregnancy outcomes above and beyond that of women's own genetic and environmental factors. Findings suggest that asking a woman about her sisters' pregnancy outcomes could provide insight into the possible outcomes for her current pregnancy. Future research should test if collecting such a family history and providing tailored clinical recommendations accordingly would be useful.

  View details for PubMedID 30032445

• Socioeconomic gradients in cancer incidence by race and ethnicity in California, 2008-2012: the influence of tobacco use or screening detectable cancers. Cancer causes & control : CCC Rehkopf, D. H., Rodriguez, D. n., Cress, R. n., Braithwaite, D. n., Oakley-Girvan, I. n., West, D. n., Hiatt, R. A. 2019

  Abstract

  There are clearly documented inequalities in cancer incidence by socioeconomic position, but it is unclear whether this is due primarily to differences in tobacco exposure and screening practices or to other factors.Our study included 741,373 incident cases of invasive cancer from 2008 to 2012 in California. We calculated age-standardized incidence rates across twelve categories of census tract poverty as a measure of socioeconomic position (SEP) for (1) all cancer sites combined, (2) sites not strongly related to tobacco use, (3) sites not related to screening, and (4) sites not related to tobacco use or screening.There was higher cancer incidence among those living in areas with higher levels of poverty for sites not strongly related to tobacco use or screening, among Whites, Blacks, and Asians, but not among Latinos. Among Whites there was no relationship with census tract poverty at lower levels of poverty-the relationship with cancer incidence was primarily among those in higher poverty. For Blacks and Asians, there is a more linear relationship with cancer incidence across levels of poverty.SEP gradients in cancer incidence remain after exclusion of cancer sites strongly related to tobacco use and screening. Our findings demonstrate a need for research on other environmental and social causes of cancer where exposures are differentially distributed by SEP.

  View details for PubMedID 31065915

• Transition From Heart Disease to Cancer as the Leading Cause of Death in the United States. Annals of internal medicine Hastings, K. G., Kapphahn, K. n., Boothroyd, D. B., Rehkopf, D. H., Cullen, M. R., Palaniappan, L. n. 2019; 171 (3): 225

  View details for DOI 10.7326/L19-0203

  View details for PubMedID 31382280

• Quality and quantity: The association of state-level educational policies with later life cardiovascular disease. Preventive medicine Hamad, R. n., Nguyen, T. T., Glymour, M. M., Vable, A. n., Manly, J. J., Rehkopf, D. H. 2019

  Abstract

  Education is a powerful predictor of cardiovascular morbidity and mortality. While the majority of the literature has focused on years of educational attainment or degree attainment, fewer studies examine the role of educational quality in the prevention of cardiovascular disease (CVD). We tested the hypothesis that average state-level educational quality was associated with CVD, linking state-level data on educational quality with individual demographic and health data from multiple waves of the National Health and Nutrition Examination Survey (N = 34,770). We examined thirteen CVD-related outcomes-including blood pressure, cholesterol, and heart attack-to understand the multiple pathways through which educational quality may influence CVD. The primary predictor was a composite index of educational quality, combining state-level measures of student-teacher ratios, per-pupil expenditures, and school term length. We fit multivariable models, regressing each outcome on the educational quality composite index and adjusting for individual- and state-level covariates. We also assessed whether the association between state educational quality and CVD differed for less educated individuals. Overall, higher educational quality was associated with less smoking (OR = 0.86, 95%CI: 0.77, 0.97), but there was no statistically significant association for the other 12 outcomes. Interaction tests indicated that less educated individuals benefited less from higher educational quality relative to those with more education for several outcomes. Our study suggests that state-level educational quality is not strongly associated with CVD, and that this null association overall may mask heterogeneous benefits that accrue disproportionately to those with higher levels of education.

  View details for DOI 10.1016/j.ypmed.2019.06.008

  View details for PubMedID 31195021

• Differential associations between state-level educational quality and cardiovascular health by race: Early-life exposures and late-life health. SSM - population health Vable, A. M., Nguyen, T. T., Rehkopf, D. n., Glymour, M. M., Hamad, R. n. 2019; 8: 100418

  Abstract

  Cardiovascular diseases (CVD) are patterned by educational attainment but educational quality is rarely examined. Educational quality differences may help explain racial disparities. Health and Retirement Study respondent data (1992-2014; born 1900-1951) were linked to state- and year-specific educational quality measures when the respondent was 6 years old. State-level educational quality was a composite of state-level school term length, student-to-teacher ratio, and per-pupil expenditure. CVD-related outcomes were self-reported (N = 24,339) obesity, heart disease, stroke, ever-smoking, high blood pressure, diabetes and objectively measured (N = 10,704) uncontrolled blood pressure, uncontrolled blood sugar, total cholesterol, high-density lipoprotein cholesterol (HDL), and C-reactive protein. Race/ethnicity was classified as White, Black, or Latino. Cox models fit for dichotomous time-to-event outcomes and generalized estimating equations for continuous outcomes were adjusted for individual and state-level confounders. Heterogeneities by race were evaluated using state-level educational quality by race interaction terms; race-pooled, race by educational quality interaction, and race-specific estimates were calculated. In race-pooled analyses, higher state-level educational quality was protective for obesity (HR = 0.92; 95%CI(0.87,0.98)). In race-specific estimates for White Americans, state-level educational quality was protective for high blood pressure (HR = 0.95; 95%CI(0.91,0.99). Differential relationships among Black compared to White Americans were observed for obesity, heart disease, stroke, smoking, high blood pressure, and HDL cholesterol. In race-specific estimates for Black Americans, higher state-level educational quality was protective for obesity (HR = 0.88; 95%CI(0.84,0.93)), but predictive of heart disease (HR = 1.07; 95%CI(1.01,1.12)), stroke (HR = 1.20; 95%CI(1.08,1.32)), and smoking (HR = 1.05; 95%CI(1.02,1.08)). Race-specific hazard ratios for Latino and Black Americans were similar for obesity, stroke, and smoking. Better state-level educational quality had differential associations with CVD by race. Among minorities, better state-level educational quality was predominately associated with poorer CVD outcomes. Results evaluate the 1900-1951 birth cohorts; secular changes in the racial integration of schools since the 1950s, means results may not generalize to younger cohorts.

  View details for DOI 10.1016/j.ssmph.2019.100418

  View details for PubMedID 31249857

  View details for PubMedCentralID PMC6586990

• Correlates of longitudinal leukocyte telomere length in the Costa Rican Longevity Study of Healthy Aging (CRELES): On the importance of DNA collection and storage procedures. PloS one Rosero-Bixby, L. n., Rehkopf, D. H., Dow, W. H., Lin, J. n., Epel, E. S., Azofeifa, J. n., Leal, A. n. 2019; 14 (10): e0223766

  Abstract

  The objective is to identify cofactors of leukocyte telomere length (LTL) in a Latin American population, specifically the association of LTL with 36 socio-demographic, early childhood, and health characteristics, as well as with DNA sample collection and storage procedures. The analysis is based on longitudinal information from a subsample of 1,261 individuals aged 60+ years at baseline from the Costa Rican Study of Longevity and Healthy Aging (CRELES): a nationally representative sample of elderly population. Random effects regression models for panel data were used to estimate the associations with LTL and its longitudinal changes. Sample collection procedures and DNA refrigerator storage time were strongly associated with LTL: telomeres are longer in blood collected in October-December, in DNA extracted from <1-year-old blood cells, and in DNA stored at 4°C for longer periods of time up to five years. The data confirmed that telomeres are shorter at older ages, as well as among males, and diabetic individuals, whereas telomeres are longer in the high-longevity Nicoya region. Most health, biomarkers, and early childhood indicators did not show significant associations with LTL. Longitudinal LTL variation over approximately two years was mainly associated with baseline LTL levels, as found in other studies. Our findings suggest that if there is unavoidable variability in season of sample collection and DNA storage time, these factors should be controlled for in all demographic and epidemiologic studies of LTL. However, due to unobserved components of measurement variation, statistical control may be inadequate as compared to standardization of data collection procedures.

  View details for DOI 10.1371/journal.pone.0223766

  View details for PubMedID 31603943

• Estimating the Short-Term Effects of the Earned Income Tax Credit on Child Health AMERICAN JOURNAL OF EPIDEMIOLOGY Hamad, R., Collin, D. F., Rehkopf, D. H. 2018; 187 (12): 2633–41

  Abstract

  The Earned Income Tax Credit (EITC) is the largest US poverty-alleviation program, yet few studies examine its effects on the health of recipients' children. We employed quasiexperimental techniques to test the hypothesis that EITC refund receipt is associated with short-term improvements in child health. The data set included children in families surveyed in the Third National Health and Nutrition Examination Survey (n = 7,444). We employed a difference-in-differences approach, exploiting the seasonal nature of EITC refund receipt. We compared children of EITC-eligible families interviewed immediately after refund receipt (February to April) with those interviewed during other months (May to January), differencing out seasonal variation among non-EITC-eligible families. We examined outcomes that were likely to be affected immediately after refund receipt, including general health, nutrition, metabolic and inflammatory biomarkers, and test scores. There were improvements in physician-reported overall health after refund receipt but no changes in infection, serum metabolic or inflammatory markers, or test scores, and there were contradictory findings for food insufficiency. In summary, EITC refunds are not strongly associated with most short-term health outcomes among recipients' children, although numerous previous studies have demonstrated impacts on longer-term outcomes. This highlights the importance of examining the effects of public policies on beneficiaries and their children using varying study designs.

  View details for PubMedID 30188968

• Socioeconomic Differences in the Epidemiologic Transition From Heart Disease to Cancer as the Leading Cause of Death in the United States, 2003 to 2015: An Observational Study. Annals of internal medicine Hastings, K. G., Boothroyd, D. B., Kapphahn, K., Hu, J., Rehkopf, D. H., Cullen, M. R., Palaniappan, L. 2018

  Abstract

  Background: Recent data suggest that the United States is in the midst of an epidemiologic transition in the leading cause of death.Objective: To examine county-level sociodemographic differences in the transition from heart disease to cancer as the leading cause of death in the United States.Design: Observational study.Setting: U.S. death records, 2003 to 2015.Participants: Decedents aged 25 years or older, classified by racial/ethnic group.Measurements: All-cause, heart disease, and cancer mortality stratified by quintiles of county median household income. Age- and sex-adjusted mortality rates and average annual percentage of change were calculated.Results: Heart disease was the leading cause of death in 79% of counties in 2003 and 59% in 2015. Cancer was the leading cause of death in 21% of counties in 2003 and 41% in 2015. The shift to cancer as the leading cause of death was greatest in the highest-income counties. Overall, heart disease mortality rates decreased by 28% (30% in high-income counties vs. 22% in low-income counties) from 2003 to 2015, and cancer mortality rates decreased by 16% (18% in high-income counties vs. 11% in low-income counties). In the lowest-income counties, heart disease remained the leading cause of death among all racial/ethnic groups, and improvements were smaller for both heart disease and cancer.Limitation: Use of county median household income as a proxy for socioeconomic status.Conclusion: Data show that heart disease is more likely to be the leading cause of death in low-income counties. Low-income counties have not experienced the same decrease in mortality rates as high-income counties, which suggests a later transition to cancer as the leading cause of death in low-income counties.Primary Funding Source: National Institute on Minority Health and Health Disparities.

  View details for PubMedID 30422275

• The association of early life socioeconomic position on breast cancer incidence and mortality: a systematic review INTERNATIONAL JOURNAL OF PUBLIC HEALTH Akinyemiju, T. F., Demb, J., Izano, M. A., Rehkopf, D. H., Fang, M., Hiatt, R. A., Braithwaite, D. 2018; 63 (7): 787–97

  Abstract

  We conducted a systematic review of the literature relating early life socioeconomic position (SEP) to breast cancer incidence and mortality from a critical period and life-course trajectory perspective.PubMed, EMBASE and Web of Science were searched to identify cohort studies that evaluated the impact of early life SEP indicators on the incidence and/or mortality from breast cancer in adulthood.Nine distinct studies evaluated the relationship between early life SEP and breast cancer between 1990 and 2016. Five reports assessed breast cancer incidence and five assessed breast cancer mortality as outcomes; one study assessed both incidence and mortality. While lower early life SEP was associated with reduced breast cancer incidence and increased breast cancer mortality in the US, studies conducted in Europe were unable to establish a consistent association.We found moderate support for the association between early life SEP and incidence and mortality from breast cancer. The impact of early life SEP on breast cancer incidence and mortality appeared to vary between countries. We urge further investigation of the role of lifelong SEP trajectories in breast cancer outcomes.

  View details for PubMedID 29197969

  View details for PubMedCentralID PMC5984656

• How and why studies disagree about the effects of education on health: A systematic review and meta-analysis of studies of compulsory schooling laws SOCIAL SCIENCE & MEDICINE Hamad, R., Elser, H., Tran, D. C., Rehkopf, D. H., Goodman, S. N. 2018; 212: 168–78

  Abstract

  Rich literatures across multiple disciplines document the association between increased educational attainment and improved health. While quasi-experimental studies have exploited variation in educational policies to more rigorously estimate the health effects of education, there remains disagreement about whether education and health are causally linked. The aim of this study was to conduct a systematic review and meta-analysis to characterize this literature, with a focus on quasi-experimental studies of compulsory schooling laws (CSLs). Articles from 1990 to 2015 were obtained through electronic searches and manual searches of reference lists. We searched for English-language studies and included manuscripts if: (1) they involved original data analysis; (2) outcomes were health-related; and (3) the primary predictor utilized variation in CSLs. We identified 89 articles in 25 countries examining over 25 health outcomes, with over 600 individual point estimates. We systematically characterized heterogeneity on key study design features and conducted a meta-analysis of studies with comparable health outcome and exposure variables. Within countries, studies differed in terms of birth cohorts included, the measurement of health outcomes within a given category, and the type of CSL variation examined. Over 90% of manuscripts included multiple analytic techniques, such as econometric and standard regression methods, with as many as 31 "primary" models in a single study. A qualitative synthesis of study findings indicated that educational attainment has an effect on the majority of health outcomes-most beneficial, some negative-while the meta-analysis demonstrated small beneficial effects for mortality, smoking, and obesity. Future work could focus on inconsistent findings identified by this study, or review the health effects of other types of educational policies.

  View details for PubMedID 30036767

• Associations between cumulative neighborhood deprivation, long-term mobility trajectories, and gestational weight gain HEALTH & PLACE Headen, I., Mujahid, M., Deardorff, J., Rehkopf, D. H., Abrams, B. 2018; 52: 101–9

  Abstract

  Existing research on neighborhood environment and gestational weight gain (GWG) focuses on point-in-time measures of neighborhood context. This precludes understanding how long-term exposure to adverse neighborhood environments influences GWG. We estimated associations between average exposure to and trajectories of long-term neighborhood socioeconomic deprivation and risk of inadequate or excessive GWG. Using data from 5690 full-term, singleton pregnancies in the 1979 National Longitudinal Survey of Youth, we estimated associations between cumulative deprivation and GWG, overall and by race/ethnicity, controlling for individual and residential covariates. A one standard deviation unit (8-point) increase in neighborhood deprivation increased risk of inadequate GWG (Relative Risk (RR): 1.08; 95% Confidence Interval (CI): 1.00-1.16) for all women and excessive GWG (RR: 1.11; 95% CI 1.02-1.21) for white women. Persistent low deprivation (RR: 0.78; 95% CI: 0.64-0.94) and upward mobility (RR: 0.76; 95% CI: 0.61-0.96), compared to persistent high deprivation, reduced risk of inadequate GWG. Persistent low deprivation also reduced risk of excessive GWG (RR: 0.84; 95% CI: 0.71-0.98). Long-term neighborhood deprivation contributes to patterns of GWG over women's life course.

  View details for PubMedID 29883957

• A New Tool for Case Studies in Epidemiology-the Synthetic Control Method. Epidemiology (Cambridge, Mass.) Rehkopf, D. H., Basu, S. 2018; 29 (4): 503–5

  View details for PubMedID 29613871

• Poverty dynamics, poverty thresholds and mortality: An age-stage Markovian model PLOS ONE Bernstein, S., Rehkopf, D., Tuljapurkar, S., Horvitz, C. C. 2018; 13 (5): e0195734

  Abstract

  Recent studies have examined the risk of poverty throughout the life course, but few have considered how transitioning in and out of poverty shape the dynamic heterogeneity and mortality disparities of a cohort at each age. Here we use state-by-age modeling to capture individual heterogeneity in crossing one of three different poverty thresholds (defined as 1×, 2× or 3× the "official" poverty threshold) at each age. We examine age-specific state structure, the remaining life expectancy, its variance, and cohort simulations for those above and below each threshold. Survival and transitioning probabilities are statistically estimated by regression analyses of data from the Health and Retirement Survey RAND data-set, and the National Longitudinal Survey of Youth. Using the results of these regression analyses, we parameterize discrete state, discrete age matrix models. We found that individuals above all three thresholds have higher annual survival than those in poverty, especially for mid-ages to about age 80. The advantage is greatest when we classify individuals based on 1× the "official" poverty threshold. The greatest discrepancy in average remaining life expectancy and its variance between those above and in poverty occurs at mid-ages for all three thresholds. And fewer individuals are in poverty between ages 40-60 for all three thresholds. Our findings are consistent with results based on other data sets, but also suggest that dynamic heterogeneity in poverty and the transience of the poverty state is associated with income-related mortality disparities (less transience, especially of those above poverty, more disparities). This paper applies the approach of age-by-stage matrix models to human demography and individual poverty dynamics. In so doing we extend the literature on individual poverty dynamics across the life course.

  View details for PubMedID 29768416

• Machine learning approaches to the social determinants of health in the health and retirement study SSM-POPULATION HEALTH Seligman, B., Tuljapurkar, S., Rehkopf, D. 2018; 4: 95–99

  Abstract

  Social and economic factors are important predictors of health and of recognized importance for health systems. However, machine learning, used elsewhere in the biomedical literature, has not been extensively applied to study relationships between society and health. We investigate how machine learning may add to our understanding of social determinants of health using data from the Health and Retirement Study.A linear regression of age and gender, and a parsimonious theory-based regression additionally incorporating income, wealth, and education, were used to predict systolic blood pressure, body mass index, waist circumference, and telomere length. Prediction, fit, and interpretability were compared across four machine learning methods: linear regression, penalized regressions, random forests, and neural networks.All models had poor out-of-sample prediction. Most machine learning models performed similarly to the simpler models. However, neural networks greatly outperformed the three other methods. Neural networks also had good fit to the data (R 2 between 0.4-0.6, versus <0.3 for all others). Across machine learning models, nine variables were frequently selected or highly weighted as predictors: dental visits, current smoking, self-rated health, serial-seven subtractions, probability of receiving an inheritance, probability of leaving an inheritance of at least $10,000, number of children ever born, African-American race, and gender.Some of the machine learning methods do not improve prediction or fit beyond simpler models, however, neural networks performed well. The predictors identified across models suggest underlying social factors that are important predictors of biological indicators of chronic disease, and that the non-linear and interactive relationships between variables fundamental to the neural network approach may be important to consider.

  View details for PubMedID 29349278

• Geographic Clustering of Polygenic Scores at Different Stages of the Life Course. The Russell Sage Foundation journal of the social sciences : RSF Domingue, B. W., Rehkopf, D. H., Conley, D., Boardman, J. D. 2018; 4 (4): 137–49

  Abstract

  We interrogate state-level clustering of polygenic scores at different points in the life course and variation in the association of mean polygenic scores in a respondent's state of birth with corresponding phenotypes. The polygenic scores for height and smoking show the most state-level clustering (2 to 4 percent) with relatively little clustering observed for the other scores. However, even the small amounts of observed clustering are potentially meaningful. The state-mean polygenic score for educational attainment is strongly associated with an individual's educational attainment net of that person's polygenic score. The ecological clustering of polygenic scores may denote a new environmental factor in gene-environment research. We conclude by discussing possible mechanisms that underlie this association and the implications of our findings for social and genetic research.

  View details for PubMedID 30740524

• AMultiple-Imputation "Forward Bridging" Approach to Address Changes in the Classification of Asian Race/Ethnicity on the US Death Certificate AMERICAN JOURNAL OF EPIDEMIOLOGY Thompson, C. A., Boothroyd, D. B., Hastings, K. G., Cullen, M. R., Palaniappan, L. P., Rehkopf, D. H. 2018; 187 (2): 347–57

  Abstract

  The incomparability of old and new classification systems for describing the same data can be seen as a missing-data problem, and, under certain assumptions, multiple imputation may be used to "bridge" 2 classification systems. One example of such a change is the introduction of detailed Asian-American race/ethnicity classifications on the 2003 version of the US national death certificate, which was adopted for use by 38 states between 2003 and 2011. Using county- and decedent-level data from 3 different national sources for pre- and postadoption years, we fitted within-state multiple-imputation models to impute ethnicities for decedents classified as "other Asian" during preadoption years. We present mortality rates derived using 3 different methods of calculation: 1) including all states but ignoring the gradual adoption of the new death certificate over time, 2) including only the 7 states with complete reporting of all ethnicities, and 3) including all states and applying multiple imputation. Estimates from our imputation model were consistently in the middle of the other 2 estimates, and trend results demonstrated that the year-by-year estimates of the imputation model were more similar to those of the 7-state model. This work demonstrates how multiple imputation can provide a "forward bridging" approach to make more accurate estimates over time in newly categorized populations.

  View details for PubMedID 29401361

  View details for PubMedCentralID PMC5860289

• Association Between Cardiorespiratory Fitness and Health Care Costs: The Veterans Exercise Testing Study MAYO CLINIC PROCEEDINGS Myers, J., Doom, R., King, R., Fonda, H., Chan, K., Kokkinos, P., Rehkopf, D. H. 2018; 93 (1): 48–55

  Abstract

  To determine the association between cardiorespiratory fitness (CRF) and annual health care costs in Veterans.The sample included 9942 subjects (mean age, 59±11 years) undergoing a maximal exercise test for clinical reasons between January 2005 and December 2012. Cardiorespiratory fitness, expressed as a percentage of age-predicted peak metabolic equivalents (METs) achieved, was categorized in quartiles. Total and annualized health care costs, derived from the Veterans Administration Allocated Resource Center, were compared using multiple regression, controlling for demographic and clinical characteristics.A gradient for reduced health care costs was observed as CRF increased, with subjects in the least-fit quartile having approximately $14,662 (P<.001) higher overall costs per patient per year compared with those in the fittest quartile, after controlling for potential confounding variables. Each 1-MET higher increment in fitness was associated with a $1592 annual reduction in health care costs (5.6% lower cost per MET), and each higher quartile of fitness was associated with a $4163 annual cost reduction per patient. The effect of CRF was more pronounced among subjects without cardiovascular disease (CVD), suggesting that the results were not driven by the possibility that less-fit individuals had greater CVD. Cost savings attributable to higher fitness were greatest in overweight and obese subjects, with lower savings observed among those individuals with a body mass index less than 25 kg/m2. In a model including historical, clinical, and exercise test responses, heart failure was the strongest predictor of health care costs, followed by CRF (P<.01).Low CRF is associated with higher health care costs. Efforts to improve CRF may not only improve health but also result in lower health care costs.

  View details for PubMedID 29195922

• Motherhood, fatherhood and midlife weight gain in a US cohort: Associations differ by race/ethnicity and socioeconomic position SSM-POPULATION HEALTH Brown, D. M., Abrams, B., Cohen, A. K., Rehkopf, D. H. 2017; 3: 558–65

  Abstract

  While there is an association of greater short-term weight gain with childbearing among women, less is known about longer-term weight gain, whether men have similar gains, and how this varies by race/ethnicity and socioeconomic position. Our cohort consisted of a nationally representative sample of 7,356 Americans with oversampling of Black and Hispanic populations. We estimated the associations between number of biological children and parental weight, measured as both change in self-reported body mass index (BMI) from age 18 and overweight/obese status (BMI ≥ 25) at age 40. We performed multivariate linear and logistic regression analysis and tested for effect modification by gender. For change in BMI, men gained on average 0.28 BMI (95% CI: (0.01, 0.55)) units per child, while women gained 0.13 units per child (95% CI: (-0.22, 0.48)). The adjusted odds ratios for overweight/obesity associated with each child were 1.32 (95% CI: (1.11, 1.58)) for men and 1.15 (95% CI: (1.01, 1.31)) for women. Stratified analyses by race/ethnicity and socioeconomic position suggested that the observed full-cohort differences were driven primarily by gendered differences in low-income Hispanics and Whites - with the greatest associations among Hispanic men. For example, among low-income Hispanic men we observed a positive relationship between the number of children and weight change by age 40, with average weight change of 0.47 units per child (95%CI: (-0.65, 1.59 For low-income Hispanic women, however, the average weight change was -0.59 units per child (95%CI: (-1.70, 0.47), and the P-value for the test of interaction between gender and number of children was P < 0.001. Our findings suggest that the shared social and economic aspects of raising children play an important role in determining parental weight at mid-life.

  View details for PubMedID 29204513

• The need to monitor actions on the social determinants of health BULLETIN OF THE WORLD HEALTH ORGANIZATION Pega, F., Valentine, N. B., Rasanathan, K., Hosseinpoor, A., Torgersen, T. P., Ramanathan, V., Posayanonda, T., Robbel, N., Kalboussi, Y., Rehkopf, D. H., Dora, C., Montesinos, E., Neira, M. P. 2017; 95 (11): 784–87

  View details for PubMedID 29147060

  View details for PubMedCentralID PMC5677605

• Excessive Gestational Weight Gain and Subsequent Maternal Obesity at Age 40: A Hypothetical Intervention AMERICAN JOURNAL OF PUBLIC HEALTH Abrams, B., Coyle, J., Cohen, A. K., Headen, I., Hubbard, A., Ritchie, L., Rehkopf, D. H. 2017; 107 (9): 1463–69

  Abstract

  To model the hypothetical impact of preventing excessive gestational weight gain on midlife obesity and compare the estimated reduction with the US Healthy People 2020 goal of a 10% reduction of obesity prevalence in adults.We analyzed 3917 women with 1 to 3 pregnancies in the prospective US National Longitudinal Survey of Youth, from 1979 to 2012. We compared the estimated obesity prevalence between 2 scenarios: gestational weight gain as reported and under the scenario of a hypothetical intervention that all women with excessive gestational weight gain instead gained as recommended by the Institute of Medicine (2009).A hypothetical intervention was associated with a significantly reduced estimated prevalence of obesity for first (3.3 percentage points; 95% confidence interval [CI] = 1.0, 5.6) and second (3.0 percentage points; 95% CI = 0.7, 5.2) births, and twice as high in Black as in White mothers, but not significant in Hispanics. The population attributable fraction was 10.7% (95% CI = 3.3%, 18.1%) in first and 9.3% (95% CI = 2.2%, 16.5%) in second births.Development of effective weight-management interventions for childbearing women could lead to meaningful reductions in long-term obesity.

  View details for PubMedID 28727522

  View details for PubMedCentralID PMC5551596

• Social disadvantage and the black-white disparity in spontaneous preterm delivery among California births PLOS ONE Carmichael, S. L., Kan, P., Padula, A. M., Rehkopf, D. H., Oehlert, J. W., Mayo, J. A., Weber, A. M., Wise, P. H., Shaw, G. M., Stevenson, D. K. 2017; 12 (8): e0182862

  Abstract

  We examined the contribution of social disadvantage to the black-white disparity in preterm birth. Analyses included linked vital and hospital discharge records from 127,358 black and 615,721 white singleton California births from 2007-11. Odds ratios (OR) were estimated by 4 logistic regression models for 2 outcomes: early (<32 wks) and moderate (32-36 wks) spontaneous preterm birth (ePTB, mPTB), stratified by 2 race-ethnicity groups (blacks and whites). We then conducted a potential impact analysis. The OR for less than high school education (vs. college degree) was 1.8 (95% confidence interval 1.6, 2.1) for ePTB among whites but smaller for the other 3 outcome groups (ORs 1.3-1.4). For all 4 groups, higher census tract poverty was associated with increased odds (ORs 1.03-1.05 per 9% change in poverty). Associations were less noteworthy for the other variables (payer, and tract percent black and Gini index of income inequality). Setting 3 factors (education, poverty, payer) to 'favorable' values was associated with lower predicted probability of ePTB (25% lower among blacks, 31% among whites) but a 9% higher disparity, compared to probabilities based on observed values; for mPTB, respective percentages were 28% and 13% lower probability, and 17% lower disparity. Results suggest that social determinants contribute to preterm delivery and its disparities, and that future studies should focus on ePTB and more specific factors related to social circumstances.

  View details for PubMedID 28800643

• Crowdsourced Health Data: Comparability to a US National Survey, 2013-2015 AMERICAN JOURNAL OF PUBLIC HEALTH Yank, V., Agarwal, S., Loftus, P., Asch, S., Rehkopf, D. 2017; 107 (8): 1283–89

  Abstract

  To determine the generalizability of crowdsourced, electronic health data from self-selected individuals using a national survey as a reference.Using the world's largest crowdsourcing platform in 2015, we collected data on characteristics known to influence cardiovascular disease risk and identified comparable data from the 2013 Behavioral Risk Factor Surveillance System. We used age-stratified logistic regression models to identify differences among groups.Crowdsourced respondents were younger, more likely to be non-Hispanic and White, and had higher educational attainment. Those aged 40 to 59 years were similar to US adults in the rates of smoking, diabetes, hypertension, and hyperlipidemia. Those aged 18 to 39 years were less similar, whereas those aged 60 to 75 years were underrepresented among crowdsourced respondents.Crowdsourced health data might be most generalizable to adults aged 40 to 59 years, but studies of younger or older populations, racial and ethnic minorities, or those with lower educational attainment should approach crowdsourced data with caution. Public Health Implications. Policymakers, the national Precision Medicine Initiative, and others planning to use crowdsourced data should take explicit steps to define and address anticipated underrepresentation by important population subgroups.

  View details for PubMedID 28640681

  View details for PubMedCentralID PMC5508142

• Geographic Variations in Cardiovascular Disease Mortality Among Asian American Subgroups, 2003-2011 JOURNAL OF THE AMERICAN HEART ASSOCIATION Pu, J., Hastings, K. G., Boothroyd, D., Jose, P. O., Chung, S., Shah, J. B., Cullen, M. R., Palaniappan, L. P., Rehkopf, D. H. 2017; 6 (7)

  Abstract

  There are well-documented geographical differences in cardiovascular disease (CVD) mortality for non-Hispanic whites. However, it remains unknown whether similar geographical variation in CVD mortality exists for Asian American subgroups. This study aims to examine geographical differences in CVD mortality among Asian American subgroups living in the United States and whether they are consistent with geographical differences observed among non-Hispanic whites.Using US death records from 2003 to 2011 (n=3 897 040 CVD deaths), age-adjusted CVD mortality rates per 100 000 population and age-adjusted mortality rate ratios were calculated for the 6 largest Asian American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) and compared with non-Hispanic whites. There were consistently lower mortality rates for all Asian American subgroups compared with non-Hispanic whites across divisions for CVD mortality and ischemic heart disease mortality. However, cerebrovascular disease mortality demonstrated substantial geographical differences by Asian American subgroup. There were a number of regional divisions where certain Asian American subgroups (Filipino and Japanese men, Korean and Vietnamese men and women) possessed no mortality advantage compared with non-Hispanic whites. The most striking geographical variation was with Filipino men (age-adjusted mortality rate ratio=1.18; 95% CI, 1.14-1.24) and Japanese men (age-adjusted mortality rate ratio=1.05; 95% CI: 1.00-1.11) in the Pacific division who had significantly higher cerebrovascular mortality than non-Hispanic whites.There was substantial geographical variation in Asian American subgroup mortality for cerebrovascular disease when compared with non-Hispanic whites. It deserves increased attention to prioritize prevention and treatment in the Pacific division where approximately 80% of Filipinos CVD deaths and 90% of Japanese CVD deaths occur in the United States.

  View details for PubMedID 28701306

• Shorter Leukocyte Telomere Length in Relation to Presumed Nonalcoholic Fatty Liver Disease in Mexican-American Men in NHANES 1999-2002. International journal of hepatology Wojcicki, J. M., Rehkopf, D., Epel, E., Rosenthal, P. 2017; 2017: 8435178

  Abstract

  Leukocyte telomere length is shorter in response to chronic disease processes associated with inflammation such as diabetes mellitus and coronary artery disease. Data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2002 was used to explore the relationship between leukocyte telomere length and presumed NAFLD, as indicated by elevated serum alanine aminotransferase (ALT) levels, obesity, or abdominal obesity. Logistic regression models were used to evaluate the relationship between telomere length and presumed markers of NAFLD adjusting for possible confounders. There was no relationship between elevated ALT levels, abdominal obesity, or obesity and telomere length in adjusted models in NHANES (OR 1.13, 95% CI 0.48-2.65; OR 1.17, 95% CI 0.52-2.62, resp.). Mexican-American men had shorter telomere length in relation to presumed NAFLD (OR 0.07, 95% CI 0.006-0.79) and using different indicators of NAFLD (OR 0.012, 95% CI 0.0006-0.24). Mexican origin with presumed NAFLD had shorter telomere length than men in other population groups. Longitudinal studies are necessary to evaluate the role of telomere length as a potential predictor to assess pathogenesis of NALFD in Mexicans.

  View details for DOI 10.1155/2017/8435178

  View details for PubMedID 28740738

  View details for PubMedCentralID PMC5504924

• Maternal History of Child Abuse and Obesity Risk in Offspring: Mediation by Weight in Pregnancy. Childhood obesity Leonard, S. A., Petito, L. C., Rehkopf, D. H., Ritchie, L. D., Abrams, B. 2017

  Abstract

  Women's experience of childhood adversity may contribute to their children's risk of obesity. Possible causal pathways include higher maternal weight and gestational weight gain, which have been associated with both maternal childhood adversity and obesity in offspring.This study included 6718 mother-child pairs from the National Longitudinal Survey of Youth 1979 in the United States (1979-2012). We applied multiple log-binomial regression models to estimate associations between three markers of childhood adversity (physical abuse, household alcoholism, and household mental illness) and offspring obesity in childhood. We estimated natural direct effects to evaluate mediation by prepregnancy BMI and gestational weight gain.Among every 100 mothers who reported physical abuse in childhood, there were 3.7 (95% confidence interval: -0.1 to 7.5) excess cases of obesity in 2- to 5-year olds compared with mothers who did not report physical abuse. Differences in prepregnancy BMI, but not gestational weight gain, accounted for 25.7% of these excess cases. There was no evidence of a similar relationship for household alcoholism or mental illness or for obesity in older children.In this national, prospective cohort study, prepregnancy BMI partially explained an association between maternal physical abuse in childhood and obesity in preschool-age children. These findings underscore the importance of life-course exposures in the etiology of child obesity and the potential multi-generational consequences of child abuse. Research is needed to determine whether screening for childhood abuse and treatment of its sequelae could strengthen efforts to prevent obesity in mothers and their children.

  View details for DOI 10.1089/chi.2017.0019

  View details for PubMedID 28440693

• Social, Psychological, And Physical Aspects Of The Work Environment Could Contribute To Hypertension Prevalence. Health affairs Rehkopf, D. H., Modrek, S., Cantley, L. F., Cullen, M. R. 2017; 36 (2): 258-265

  Abstract

  Studies on the physical and social characteristics of the workplace have begun to provide evidence for the role of specific workplace factors on health. However, the overall contribution of the workplace to health has not been considered. Estimates of the influences on health across domains of the work environment are a critical first step toward understanding what level of priority the workplace should take as the target for public policies to improve health. The influences or contribution of these domains on health in the work environment are particularly useful to study since they are potentially modifiable through changes in policies and environment. Our analysis used detailed data from blue-collar industrial workers at two dozen Alcoa plants. It includes work environmental measures of psychological hazards, physical hazards, and the workplace social environment, to estimate the overall importance of the workplace environment for hypertension. Our findings suggest that social, psychological, and physical aspects of the work environment could contribute to a substantial proportion of hypertension prevalence. These attributes of the workplace could thus be a useful target for improving workforce health.

  View details for DOI 10.1377/hlthaff.2016.1186

  View details for PubMedID 28167714

• Predicting later life health status and mortality using state-level socioeconomic characteristics in early life. SSM - population health Hamad, R., Rehkopf, D. H., Kuan, K. Y., Cullen, M. R. 2016; 2: 269-276

  Abstract

  Studies extending across multiple life stages promote an understanding of factors influencing health across the life span. Existing work has largely focused on individual-level rather than area-level early life determinants of health. In this study, we linked multiple data sets to examine whether early life state-level characteristics were predictive of health and mortality decades later. The sample included 143,755 U.S. employees, for whom work life claims and administrative data were linked with early life state-of-residence and mortality. We first created a "state health risk score" (SHRS) and "state mortality risk score" (SMRS) by modeling state-level contextual characteristics with health status and mortality in a randomly selected 30% of the sample (the "training set"). We then examined the association of these scores with objective health status and mortality in later life in the remaining 70% of the sample (the "test set") using multivariate linear and Cox regressions, respectively. The association between the SHRS and adult health status was β=0.14 (95%CI: 0.084, 0.20), while the hazard ratio for the SMRS was 0.96 (95%CI: 0.93, 1.00). The association between the SHRS and health was not statistically significant in older age groups at a p-level of 0.05, and there was a statistically significantly different association for health status among movers compared to stayers. This study uses a life course perspective and supports the idea of "sensitive periods" in early life that have enduring impacts on health. It adds to the literature examining populations in the U.S. where large linked data sets are infrequently available.

  View details for PubMedID 27713921

• Prevalence of Chronic Disease and Their Risk Factors Among Iranian, Ukrainian, Vietnamese Refugees in California, 2002-2011. Journal of immigrant and minority health Nguyen, M. T., Rehkopf, D. H. 2016; 18 (6): 1274-1283

  Abstract

  Little is known about how the health status of incoming refugees to the United States compares to that of the general population. We used logistic regression to assess whether country of origin is associated with prevalence of hypertension, obesity, type-II diabetes, and tobacco-use among Iranian, Ukrainian and Vietnamese refugees arriving in California from 2002 to 2011 (N = 21,968). We then compared the prevalence among refugees to that of the Californian general population (CGP). Ukrainian origin was positively associated with obesity and negatively with smoking, while the opposite was true for Vietnamese (p < 0.001). Iranian origin was positively associated with type-II diabetes and smoking (p < 0.001). After accounting for age and gender differences, refugees had lower prevalence of obesity and higher prevalence of smoking than CGP. Individually, all refugee groups had lower type-II diabetes prevalence than CGP. Grouping all refugees together can hide distinct health needs associated with country of origin.

  View details for PubMedID 26691740

• Leukocyte Telomere Length in Relation to 17 Biomarkers of Cardiovascular Disease Risk: A Cross-Sectional Study of US Adults PLOS MEDICINE Rehkopf, D. H., Needham, B. L., Lin, J., Blackburn, E. H., Zota, A. R., Wojcicki, J. M., Epel, E. S. 2016; 13 (11)

  Abstract

  Leukocyte telomere length (LTL) is a putative biological marker of immune system age, and there are demonstrated associations between LTL and cardiovascular disease. This may be due in part to the relationship of LTL with other biomarkers associated with cardiovascular disease risk. However, the strength of associations between LTL and adiposity, metabolic, proinflammatory, and cardiovascular biomarkers has not been systematically evaluated in a United States nationally representative population.We examined associations between LTL and 17 cardiovascular biomarkers, including lipoproteins, blood sugar, circulatory pressure, proinflammatory markers, kidney function, and adiposity measures, in adults ages 20 to 84 from the cross-sectional US nationally representative 1999-2002 National Health and Nutrition Examination Survey (NHANES) (n = 7,252), statistically adjusting for immune cell type distributions. We also examine whether these associations differed systematically by age, race/ethnicity, gender, education, and income. We found that a one unit difference in the following biomarkers were associated with kilobase pair differences in LTL: BMI -0.00478 (95% CI -0.00749--0.00206), waist circumference -0.00211 (95% CI -0.00325--0.000969), percentage of body fat -0.00516 (95% CI -0.00761--0.0027), high density lipoprotein (HDL) cholesterol 0.00179 (95% CI 0.000571-0.00301), triglycerides -0.000285 (95% CI -0.000555--0.0000158), pulse rate -0.00194 (95% CI -0.00317--0.000705), C-reactive protein -0.0363 (95% CI 0.0601--0.0124), cystatin C -0.0391 (95% CI -0.0772--0.00107). When using clinical cut-points we additionally found associations between LTL and insulin resistance -0.0412 (95% CI -0.0685--0.0139), systolic blood pressure 0.0455 (95% CI 0.00137-0.0897), and diastolic blood pressure -0.0674 (95% CI -0.126--0.00889). These associations were 10%-15% greater without controlling for leukocyte cell types. There were very few differences in the associations by age, race/ethnicity, gender, education, or income. Our findings are relevant to the relationships between these cardiovascular biomarkers in the general population but not to cardiovascular disease as a clinical outcome.LTL is most strongly associated with adiposity, but is also associated with biomarkers across several physiological systems. LTL may thus be a predictor of cardiovascular disease through its association with multiple risk factors that are physiologically correlated with risk for development of cardiovascular disease. Our results are consistent with LTL being a biomarker of cardiovascular aging through established physiological mechanisms.

  View details for DOI 10.1371/journal.pmed.1002188

  View details for Web of Science ID 000391233800024

  View details for PubMedID 27898678

  View details for PubMedCentralID PMC5127504

• Changing national guidelines is not enough: the impact of 1990 IOM recommendations on gestational weight gain among US women. International journal of obesity Hamad, R., Cohen, A. K., Rehkopf, D. H. 2016; 40 (10): 1529-1534

  Abstract

  Gestational weight gain (GWG) is associated with both long- and short-term maternal and child health outcomes, particularly obesity. Targeting maternal nutrition through policies is a potentially powerful pathway to influence these outcomes. Yet prior research has often failed to evaluate national policies and guidelines that address maternal and child health. In 1990, the U.S. Institute of Medicine (IOM) released guidelines recommending different GWG thresholds based on women's pre-pregnancy body mass index (BMI), with the goal of improving infant birth weight. In this study, we employ quasi-experimental methods to examine whether the release of the IOM guidelines led to changes in GWG among a diverse and nationally representative sample of women.Our sample included female participants of the National Longitudinal Survey of Youth who self-reported GWG for pregnancies during 1979-2000 (n=7442 pregnancies to 4173 women). We compared GWG before and after the guidelines were released using difference-in-differences (DID) and regression discontinuity (RD) analyses.In DID analyses we found no reduction in GWG among overweight/obese women relative to normal/underweight women. Meanwhile, RD analyses demonstrated no changes in GWG by pre-pregnancy BMI for either overweight/obese or normal/underweight women. Results were similar for women regardless of educational attainment, race or parity.These findings suggest that national guidelines had no effect on weight gain among pregnant women. These results have implications for the implementation of policies targeting maternal and child health via dietary behaviors.

  View details for DOI 10.1038/ijo.2016.97

  View details for PubMedID 27200502

  View details for PubMedCentralID PMC5050079

• Telomere length and health outcomes: A two-sample genetic instrumental variables analysis. Experimental gerontology Hamad, R., Walter, S., Rehkopf, D. H. 2016; 82: 88-94

  Abstract

  Previous studies linking telomere length (TL) and health have been largely associational. We apply genetic instrumental variables (IV) analysis, also known as Mendelian randomization, to test the hypothesis that shorter TL leads to poorer health. This method reduces bias from reverse causation or confounding.We used two approaches in this study that rely on two separate data sources: (1) individual-level data from the Health and Retirement Study (HRS) (N=3734), and (2) coefficients from genome-wide association studies (GWAS). We employed two-sample genetic IV analyses, constructing a polygenic risk score (PRS) of TL-associated single nucleotide polymorphisms. The first approach examined the association of the PRS with nine individual health outcomes in HRS. The second approach took advantage of estimates available in GWAS databases to estimate the impact of TL on five health outcomes using an inverse variance-weighted meta-analytic technique.Using individual-level data, shorter TL was marginally statistically significantly associated with decreased risk of stroke and increased risk of heart disease. Using the meta-analytic approach, shorter TL was associated with increased risk of coronary artery disease (OR 1.02 per 100 base pairs, 95%CI: 1.00, 1.03).With the exception of a small contribution to heart disease, our findings suggest that TL may be a marker of disease rather than a cause. They also demonstrate the utility of the inverse variance-weighted meta-analytic approach when examining small effect sizes.

  View details for DOI 10.1016/j.exger.2016.06.005

  View details for PubMedID 27321645

  View details for PubMedCentralID PMC4969151

• Racial and Socioeconomic Variation in Genetic Markers of Telomere Length: A Cross-Sectional Study of U.S. Older Adults. EBioMedicine Hamad, R., Tuljapurkar, S., Rehkopf, D. H. 2016; 11: 296-301

  Abstract

  Shorter telomere length (TL) has been associated with stress and adverse socioeconomic conditions, yet U.S. blacks have longer TL than whites. The role of genetic versus environmental factors in explaining TL by race and socioeconomic position (SEP) remains unclear.We used data from the U.S. Health and Retirement Study (N=11,934) to test the hypothesis that there are differences in TL-associated SNPs by race and SEP. We constructed a TL polygenic risk score (PRS) and examined its association with race/ethnicity, educational attainment, assets, gender, and age.U.S. blacks were more likely to have a lower PRS for TL, as were older individuals and men. Racial differences in TL were statistically accounted for when controlling for population structure using genetic principal components. The GWAS-derived SNPs for TL, however, may not have consistent associations with TL across different racial/ethnic groups.This study showed that associations of race/ethnicity with TL differed when accounting for population stratification. The role of race/ethnicity for TL remains uncertain, however, as the genetic determinants of TL may differ by race/ethnicity. Future GWAS samples should include racially diverse participants to allow for better characterization of the determinants of TL in human populations.

  View details for DOI 10.1016/j.ebiom.2016.08.015

  View details for PubMedID 27566956

  View details for PubMedCentralID PMC5049995

• Reply to Yang et al.: GCTA produces unreliable heritability estimates. Proceedings of the National Academy of Sciences of the United States of America Krishna Kumar, S., Feldman, M. W., Rehkopf, D. H., Tuljapurkar, S. 2016; 113 (32): E4581-?

  View details for DOI 10.1073/pnas.1608425113

  View details for PubMedID 27457962

  View details for PubMedCentralID PMC4987787

• Educational Attainment and Gestational Weight Gain among US Mothers WOMENS HEALTH ISSUES Cohen, A. K., Kazi, C., Headen, I., Rehkopf, D. H., Hendrick, C. E., Patil, D., Abrams, B. 2016; 26 (4): 460-467

  Abstract

  Education is an important social determinant of many health outcomes, but the relationship between educational attainment and the amount of weight gained over the course of a woman's pregnancy (gestational weight gain [GWG]) has not been established clearly.We used data from 1979 through 2010 for women in the National Longitudinal Survey of Youth (1979) cohort (n = 6,344 pregnancies from 2,769 women). We used generalized estimating equations to estimate the association between educational attainment and GWG adequacy (as defined by 2009 Institute of Medicine guidelines), controlling for diverse social factors from across the life course (e.g., income, wealth, educational aspirations and expectations) and considering effect measure modification by race/ethnicity and prepregnancy overweight status.In most cases, women with more education had increased odds of gaining a recommended amount of gestational weight, independent of educational aspirations and educational expectations and relatively robust to sensitivity analyses. This trend manifested itself in a few different ways. Those with less education had higher odds of inadequate GWG than those with more education. Among those who were not overweight before pregnancy, those with less education had higher odds of excessive GWG than college graduates. Among women who were White, those with less than a high school degree had higher odds of excessive GWG than those with more education.The relationship between educational attainment and GWG is nuanced and nonlinear.

  View details for DOI 10.1016/j.whi.2016.05.009

  View details for Web of Science ID 000380748900014

  View details for PubMedID 27372419

  View details for PubMedCentralID PMC4958525

• Adverse childhood experiences and later life adult obesity and smoking in the United States. Annals of epidemiology Rehkopf, D. H., Headen, I., Hubbard, A., Deardorff, J., Kesavan, Y., Cohen, A. K., Patil, D., Ritchie, L. D., Abrams, B. 2016; 26 (7): 488-492 e5

  Abstract

  Prior work demonstrates associations between physical abuse, household alcohol abuse, and household mental illness early in life with obesity and smoking. Studies, however, have not generally been in nationally representative samples and have not conducted analyses to account for bias in the exposure.We used data from the 1979 U.S. National Longitudinal Survey of Youth to test associations between measures of adverse childhood experiences with obesity and smoking and used an instrumental variables approach to address potential measurement error of the exposure.Models demonstrated associations between childhood physical abuse and obesity at age 40 years (odds ratio [OR] 1.23; 95% confidence interval [CI], 1.00-1.52) and ever smoking (OR 1.83; 95% CI, 1.56-2.16), as well as associations between household alcohol abuse (OR 1.53; 95% CI, 1.31-1.79) and household mental illness (OR 1.29; 95% CI, 1.04-1.60) with ever smoking. We find no evidence of association modification by gender, socioeconomic position, or race and/or ethnicity. Instrumental variables analysis using a sibling's report of adverse childhood experiences demonstrated a relationship between household alcohol abuse and smoking, with a population attributable fraction of 17% (95% CI, 2.0%-37%) for ever smoking and 6.7% (95% CI, 1.6%-12%) for currently smoking.Findings suggest long-term impacts of childhood exposure to physical abuse, household alcohol abuse, and parental mental illness on obesity and smoking and that the association between household alcohol abuse and smoking is not solely due to measurement error.

  View details for DOI 10.1016/j.annepidem.2016.06.003

  View details for PubMedID 27449570

• Adverse childhood experiences and later life adult obesity and smoking in the United States ANNALS OF EPIDEMIOLOGY Rehkopf, D. H., Headen, I., Hubbard, A., Deardorff, J., Kesavan, Y., Cohen, A. K., Divya, P. B., Ritchie, L. D., Abrams, B. 2016; 26 (7): 488-492

  Abstract

  Prior work demonstrates associations between physical abuse, household alcohol abuse, and household mental illness early in life with obesity and smoking. Studies, however, have not generally been in nationally representative samples and have not conducted analyses to account for bias in the exposure.We used data from the 1979 U.S. National Longitudinal Survey of Youth to test associations between measures of adverse childhood experiences with obesity and smoking and used an instrumental variables approach to address potential measurement error of the exposure.Models demonstrated associations between childhood physical abuse and obesity at age 40 years (odds ratio [OR] 1.23; 95% confidence interval [CI], 1.00-1.52) and ever smoking (OR 1.83; 95% CI, 1.56-2.16), as well as associations between household alcohol abuse (OR 1.53; 95% CI, 1.31-1.79) and household mental illness (OR 1.29; 95% CI, 1.04-1.60) with ever smoking. We find no evidence of association modification by gender, socioeconomic position, or race and/or ethnicity. Instrumental variables analysis using a sibling's report of adverse childhood experiences demonstrated a relationship between household alcohol abuse and smoking, with a population attributable fraction of 17% (95% CI, 2.0%-37%) for ever smoking and 6.7% (95% CI, 1.6%-12%) for currently smoking.Findings suggest long-term impacts of childhood exposure to physical abuse, household alcohol abuse, and parental mental illness on obesity and smoking and that the association between household alcohol abuse and smoking is not solely due to measurement error.

  View details for DOI 10.1016/j.annepidem.2016.06.003

  View details for Web of Science ID 000380866600007

  View details for PubMedCentralID PMC4966898

• Weight gain in pregnancy and child weight status from birth to adulthood in the United States. Pediatric obesity Leonard, S. A., Petito, L. C., Rehkopf, D. H., Ritchie, L. D., Abrams, B. 2016

  Abstract

  High weight gain in pregnancy has been associated with child adiposity, but few studies have assessed the relationship across childhood or in racially/ethnically diverse populations.The objectives of the study are to test if weight gain in pregnancy is associated with high birthweight and overweight/obesity in early, middle and late childhood and whether these associations differ by maternal race/ethnicity.Mother-child dyads (n = 7539) were included from the National Longitudinal Survey of Youth 1979, a nationally representative cohort study in the USA (1979-2012). Log-binomial regression models were used to analyse associations between weight gain and the outcomes: high birthweight (>4000 g) and overweight/obesity at ages 2-5, 6-11 and 12-19 years.Excessive weight gain was positively associated, and inadequate weight gain was negatively associated with high birthweight after confounder adjustment (P < 0.05). Only excessive weight gain was associated with overweight in early, middle and late childhood. These associations were not significant in Hispanics or Blacks although racial/ethnic interaction was only significant ages 12-19 years (P = 0.03).Helping pregnant women gain weight within national recommendations may aid in preventing overweight and obesity across childhood, particularly for non-Hispanic White mothers.

  View details for DOI 10.1111/ijpo.12163

  View details for PubMedID 27350375

  View details for PubMedCentralID PMC5404997

• Poverty and Child Development: A Longitudinal Study of the Impact of the Earned Income Tax Credit AMERICAN JOURNAL OF EPIDEMIOLOGY Hamad, R., Rehkopf, D. H. 2016; 183 (9): 775-784

  Abstract

  Although adverse socioeconomic conditions are correlated with worse child health and development, the effects of poverty-alleviation policies are less understood. We examined the associations of the Earned Income Tax Credit (EITC) on child development and used an instrumental variable approach to estimate the potential impacts of income. We used data from the US National Longitudinal Survey of Youth (n = 8,186) during 1986-2000 to examine effects on the Behavioral Problems Index (BPI) and Home Observation Measurement of the Environment inventory (HOME) scores. We conducted 2 analyses. In the first, we used multivariate linear regressions with child-level fixed effects to examine the association of EITC payment size with BPI and HOME scores; in the second, we used EITC payment size as an instrument to estimate the associations of income with BPI and HOME scores. In linear regression models, higher EITC payments were associated with improved short-term BPI scores (per $1,000, β = -0.57; P = 0.04). In instrumental variable analyses, higher income was associated with improved short-term BPI scores (per $1,000, β = -0.47; P = 0.01) and medium-term HOME scores (per $1,000, β = 0.64; P = 0.02). Our results suggest that both EITC benefits and higher income are associated with modest but meaningful improvements in child development. These findings provide valuable information for health researchers and policymakers for improving child health and development.

  View details for DOI 10.1093/aje/kwv317

  View details for Web of Science ID 000376097600001

  View details for PubMedID 27056961

  View details for PubMedCentralID PMC4851995

• Predicting Survival from Telomere Length versus Conventional Predictors: A Multinational Population-Based Cohort Study PLOS ONE Glei, D. A., Goldman, N., Risques, R. A., Rehkopf, D. H., Dow, W. H., Rosero-Bixby, L., Weinstein, M. 2016; 11 (4)

  Abstract

  Telomere length has generated substantial interest as a potential predictor of aging-related diseases and mortality. Some studies have reported significant associations, but few have tested its ability to discriminate between decedents and survivors compared with a broad range of well-established predictors that include both biomarkers and commonly collected self-reported data. Our aim here was to quantify the prognostic value of leukocyte telomere length relative to age, sex, and 19 other variables for predicting five-year mortality among older persons in three countries. We used data from nationally representative surveys in Costa Rica (N = 923, aged 61+), Taiwan (N = 976, aged 54+), and the U.S. (N = 2672, aged 60+). Our study used a prospective cohort design with all-cause mortality during five years post-exam as the outcome. We fit Cox hazards models separately by country, and assessed the discriminatory ability of each predictor. Age was, by far, the single best predictor of all-cause mortality, whereas leukocyte telomere length was only somewhat better than random chance in terms of discriminating between decedents and survivors. After adjustment for age and sex, telomere length ranked between 15th and 17th (out of 20), and its incremental contribution was small; nine self-reported variables (e.g., mobility, global self-assessed health status, limitations with activities of daily living, smoking status), a cognitive assessment, and three biological markers (C-reactive protein, serum creatinine, and glycosylated hemoglobin) were more powerful predictors of mortality in all three countries. Results were similar for cause-specific models (i.e., mortality from cardiovascular disease, cancer, and all other causes combined). Leukocyte telomere length had a statistically discernible, but weak, association with mortality, but it did not predict survival as well as age or many other self-reported variables. Although telomere length may eventually help scientists understand aging, more powerful and more easily obtained tools are available for predicting survival.

  View details for DOI 10.1371/journal.pone.0152486

  View details for Web of Science ID 000373603500043

  View details for PubMedID 27049651

  View details for PubMedCentralID PMC4822878

• Maternal Childhood Adversity, Prepregnancy Obesity, and Gestational Weight Gain. American journal of preventive medicine Ranchod, Y. K., Headen, I. E., Petito, L. C., Deardorff, J. K., Rehkopf, D. H., Abrams, B. F. 2016; 50 (4): 463-469

  Abstract

  Growing evidence suggests that exposure to childhood adversity may influence obesity across the life course. High maternal weight complicates pregnancy and increases the risk of child obesity. This study examined the association between maternal childhood adversity and pregnancy-related weight in a large U.S.Data on 6,199 pregnancies from 2,873 women followed from 1979 to 2012 by the National Longitudinal Survey of Youth 1979 were analyzed in 2014. Associations between three adversity exposures before age 18 years (history of physical abuse, alcohol problems, or mental illness in the household) and two maternal weight outcomes (prepregnancy obesity and excessive gestational weight gain) were modeled separately using survey-adjusted log-binomial models.After adjusting for race/ethnicity and early-life socioeconomic factors, childhood physical abuse was associated with a 60% increase in the risk of prepregnancy obesity (adjusted risk ratio=1.6, 95% CI=1.1, 2.2). Household alcohol abuse was associated with a 30% increase in prepregnancy obesity (adjusted risk ratio=1.3, 95% CI=1.0, 1.7), as was household mental illness (adjusted risk ratio=1.3, 95% CI=0.8, 1.9), but the mental illness exposure was not significant. Physical abuse and household alcohol abuse were associated with a significant 20% increase in the risk of excessive gestational weight gain; mental illness was not.Adversity in early life may affect maternal weight before and during pregnancy. Screening and treating women of reproductive age for childhood adversity and its negative effects could significantly reduce obesity-related health outcomes for women and their children.

  View details for DOI 10.1016/j.amepre.2015.08.032

  View details for PubMedID 26558699

  View details for PubMedCentralID PMC4801674

• Heterogeneous Effects of Housing Vouchers on the Mental Health of US Adolescents. American journal of public health Nguyen, Q. C., Rehkopf, D. H., Schmidt, N. M., Osypuk, T. L. 2016; 106 (4): 755-762

  Abstract

  To assess the mental health effects on adolescents of low-income families residing in high-poverty public housing who received housing vouchers to assist relocation.We defined treatment effects to compare 2829 adolescents aged 12 to 19 years in families offered housing vouchers versus those living in public housing in the Moving to Opportunity experiment (1994-1997; Boston, MA; Baltimore, MD; Chicago, IL; Los Angeles, CA; New York, NY). We employed model-based recursive partitioning to identify subgroups with heterogeneous treatment effects on psychological distress and behavior problems measured in 2002. We tested 35 potential baseline treatment modifiers.For psychological distress, Chicago participants experienced null treatment effects. Outside Chicago, boys experienced detrimental effects, whereas girls experienced beneficial effects. Behavior problems effects were null for adolescents who were aged 10 years or younger at baseline. For adolescents who were older than 10 years at baseline, violent crime victimization, unmarried parents, and unsafe neighborhoods increased adverse treatment effects. Adolescents who were older than 10 years at baseline without learning problems or violent crime victimization, and whose parents moved for better schools, experienced beneficial effects.Health effects of housing vouchers varied across subgroups. Supplemental services may be necessary for vulnerable subgroups for whom housing vouchers alone may not be beneficial.

  View details for DOI 10.2105/AJPH.2015.303006

  View details for PubMedID 26794179

  View details for PubMedCentralID PMC4986050

• Health Behaviors, Mental Health, and Health Care Utilization Among Single Mothers After Welfare Reforms in the 1990s AMERICAN JOURNAL OF EPIDEMIOLOGY Basu, S., Rehkopf, D. H., Siddiqi, A., Glymour, M. M., Kawachi, I. 2016; 183 (6): 531-538

  View details for DOI 10.1093/aje/kwv249

  View details for Web of Science ID 000372579500003

• Health Behaviors, Mental Health, and Health Care Utilization Among Single Mothers After Welfare Reforms in the 1990s. American journal of epidemiology Basu, S., Rehkopf, D. H., Siddiqi, A., Glymour, M. M., Kawachi, I. 2016; 183 (6): 531-538

  Abstract

  We studied the health of low-income US women affected by the largest social policy change in recent US history: the 1996 welfare reforms. Using the Behavioral Risk Factor Surveillance System (1993-2012), we performed 2 types of analysis. First, we used difference-in-difference-in-differences analyses to estimate associations between welfare reforms and health outcomes among the most affected women (single mothers aged 18-64 years in 1997; n = 219,469) compared with less affected women (married mothers, single nonmothers, and married nonmothers of the same age range in 1997; n = 2,422,265). We also used a synthetic control approach in which we constructed a more ideal control group for single mothers by weighting outcomes among the less affected groups to match pre-reform outcomes among single mothers. In both specifications, the group most affected by welfare reforms (single mothers) experienced worse health outcomes than comparison groups less affected by the reforms. For example, the reforms were associated with at least a 4.0-percentage-point increase in binge drinking (95% confidence interval: 0.9, 7.0) and a 2.4-percentage-point decrease in the probability of being able to afford medical care (95% confidence interval: 0.1, 4.8) after controlling for age, educational level, and health care insurance status. Although the reforms were applauded for reducing welfare dependency, they may have adversely affected health.

  View details for DOI 10.1093/aje/kwv249

  View details for PubMedID 26946395

• Basu et al. Respond to "Interdisciplinary Approach for Policy Evaluation". American journal of epidemiology Basu, S., Rehkopf, D. H., Siddiqi, A., Glymour, M. M., Kawachi, I. 2016; 183 (6): 542-543

  View details for DOI 10.1093/aje/kwv239

  View details for PubMedID 26946397

• The Consistency Assumption for Causal Inference in Social Epidemiology: When a Rose is Not a Rose. Current epidemiology reports Rehkopf, D. H., Glymour, M. M., Osypuk, T. L. 2016; 3 (1): 63-71

  Abstract

  The assumption that exposures as measured in observational settings have clear and specific definitions underpins epidemiologic research and allows us to use observational data to predict outcomes in interventions. This leap between exposures as measured and exposures as intervened upon is typically supported by the consistency assumption. The consistency assumption has received extensive attention in risk factor epidemiology but relatively little emphasis in social epidemiology. However, violations of the consistency assumption may be especially important to consider when understanding how social and economic exposures influence health. Efforts to clarify the definitions of our exposures, thus bolstering the consistency assumption, will help guide interventions to improve population health and reduce health disparities. This article focuses on the consistency assumption as considered within social epidemiology. We explain how this assumption is articulated in the causal inference literature and give examples of how it might be violated for three common exposure in social epidemiology research: income, education and neighborhood characteristics. We conclude that there is good reason to worry about consistency assumption violations in much of social epidemiology research. Theoretically motivated explorations of mechanisms along with empirical comparisons of research findings under alternative operationalizations of exposure can help identify consistency violations. We recommend that future social epidemiology studies be more explicit to name and discuss the consistency assumption when describing the exposure of interest, including reconciling disparate results in the literature.

  View details for PubMedID 27326386

• Trends in Socioeconomic Inequalities in Body Mass Index, Underweight and Obesity among English Children, 2007-2008 to 2011-2012 PLOS ONE White, J., Rehkopf, D., Mortensen, L. H. 2016; 11 (1)

  Abstract

  Socioeconomic inequalities in childhood obesity have been reported in most developed countries, with obesity more common in deprived groups. Whether inequalities are found in the prevalence of underweight, the rest of the body mass index (BMI) distribution, or have changed across time is not clear.The sample comprised 5,027,128 children on entry (4 to 5 years old) and leaving (10 to 11 years) state primary (elementary) school who participated in the National Child Measurement Programme (England, United Kingdom). We used area-level deprivation (Indices of Multiple Deprivation at the lower super output area) as a measure of socioeconomic deprivation. From 2007-2008 to 2011-2012 inequalities in obesity between the most compared to least deprived group increased (from 7.21% to 8.30%; p<0.001), whereas inequalities in the prevalence of underweight (1.50% to 1.21%; p = 0.15) were stable during this period. There were no differences by age group or by sex, but a three-way interaction suggested inequalities in obesity had increased at a faster rate for 10 to 11 year old girls, than 4 to 5 year old boys, (2.03% vs 0.07%; p<0.001 for interaction). Investigating inequalities across the distribution of zBMI showed increases in mean zBMI (0.18 to 0.23, p<0.001) could be attributed to increases in inequalities between the 50th and 75th centiles of BMI. Using the 2011 to 2012 population attributable risk estimates, if inequalities were halved, 14.04% (95% CI 14.00% to 14.07%) of childhood obesity could be avoided.Socioeconomic inequalities in childhood obesity and zBMI increased in England between 2007-2008 and 2011-2012. Inequalities in the prevalence of underweight did not change. Traditional methods of examining inequalities only at the clinical thresholds of overweight and obesity may have led the magnitude of inequalities in childhood BMI to be underestimated.

  View details for DOI 10.1371/journal.pone.0147614

  View details for Web of Science ID 000369528000044

  View details for PubMedID 26812152

  View details for PubMedCentralID PMC4727904

• Limitations of GCTA as a solution to the missing heritability problem PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Kumar, S. K., Feldman, M. W., Rehkopf, D. H., Tuljapurkar, S. 2016; 113 (1): E61-E70

  Abstract

  Genome-wide association studies (GWASs) seek to understand the relationship between complex phenotype(s) (e.g., height) and up to millions of single-nucleotide polymorphisms (SNPs). Early analyses of GWASs are commonly believed to have "missed" much of the additive genetic variance estimated from correlations between relatives. A more recent method, genome-wide complex trait analysis (GCTA), obtains much higher estimates of heritability using a model of random SNP effects correlated between genotypically similar individuals. GCTA has now been applied to many phenotypes from schizophrenia to scholastic achievement. However, recent studies question GCTA's estimates of heritability. Here, we show that GCTA applied to current SNP data cannot produce reliable or stable estimates of heritability. We show first that GCTA depends sensitively on all singular values of a high-dimensional genetic relatedness matrix (GRM). When the assumptions in GCTA are satisfied exactly, we show that the heritability estimates produced by GCTA will be biased and the standard errors will likely be inaccurate. When the population is stratified, we find that GRMs typically have highly skewed singular values, and we prove that the many small singular values cannot be estimated reliably. Hence, GWAS data are necessarily overfit by GCTA which, as a result, produces high estimates of heritability. We also show that GCTA's heritability estimates are sensitive to the chosen sample and to measurement errors in the phenotype. We illustrate our results using the Framingham dataset. Our analysis suggests that results obtained using GCTA, and the results' qualitative interpretations, should be interpreted with great caution.

  View details for DOI 10.1073/pnas.1520109113

  View details for Web of Science ID 000367520400011

  View details for PubMedCentralID PMC4711841

• Limitations of GCTA as a solution to the missing heritability problem. Proceedings of the National Academy of Sciences of the United States of America Krishna Kumar, S., Feldman, M. W., Rehkopf, D. H., Tuljapurkar, S. 2016; 113 (1): E61-70

  Abstract

  Genome-wide association studies (GWASs) seek to understand the relationship between complex phenotype(s) (e.g., height) and up to millions of single-nucleotide polymorphisms (SNPs). Early analyses of GWASs are commonly believed to have "missed" much of the additive genetic variance estimated from correlations between relatives. A more recent method, genome-wide complex trait analysis (GCTA), obtains much higher estimates of heritability using a model of random SNP effects correlated between genotypically similar individuals. GCTA has now been applied to many phenotypes from schizophrenia to scholastic achievement. However, recent studies question GCTA's estimates of heritability. Here, we show that GCTA applied to current SNP data cannot produce reliable or stable estimates of heritability. We show first that GCTA depends sensitively on all singular values of a high-dimensional genetic relatedness matrix (GRM). When the assumptions in GCTA are satisfied exactly, we show that the heritability estimates produced by GCTA will be biased and the standard errors will likely be inaccurate. When the population is stratified, we find that GRMs typically have highly skewed singular values, and we prove that the many small singular values cannot be estimated reliably. Hence, GWAS data are necessarily overfit by GCTA which, as a result, produces high estimates of heritability. We also show that GCTA's heritability estimates are sensitive to the chosen sample and to measurement errors in the phenotype. We illustrate our results using the Framingham dataset. Our analysis suggests that results obtained using GCTA, and the results' qualitative interpretations, should be interpreted with great caution.

  View details for DOI 10.1073/pnas.1520109113

  View details for PubMedID 26699465

  View details for PubMedCentralID PMC4711841

• The Geographic Distribution of Genetic Risk as Compared to Social Risk for Chronic Diseases in the United States BIODEMOGRAPHY AND SOCIAL BIOLOGY Rehkopf, D. H., Domingue, B. W., Cullen, M. R. 2016; 62 (1): 126-142

  Abstract

  There is an association between chronic disease and geography, and there is evidence that the environment plays a critical role in this relationship. Yet at the same time, there is known to be substantial geographic variation by ancestry across the United States. Resulting geographic genetic variation-that is, the extent to which single nucleotide polymorphisms (SNPs) related to chronic disease vary spatially-could thus drive some part of the association between geography and disease. We describe the variation in chronic disease genetic risk by state of birth by taking risk SNPs from genome-wide association study meta-analyses for coronary artery disease, diabetes, and ischemic stroke and creating polygenic risk scores. We compare the amount of variability across state of birth in these polygenic scores to the variability in parental education, own education, earnings, and wealth. Our primary finding is that the polygenic risk scores are only weakly differentially distributed across U.S. states. The magnitude of the differences in geographic distribution is very small in comparison to the distribution of social and economic factors and thus is not likely sufficient to have a meaningful effect on geographic disease differences by U.S. state.

  View details for DOI 10.1080/19485565.2016.1141353

  View details for Web of Science ID 000373629600008

  View details for PubMedID 27050037

• Diabetic Phenotypes and Late-Life Dementia Risk A Mechanism-specific Mendelian Randomization Study ALZHEIMER DISEASE & ASSOCIATED DISORDERS Walter, S., Marden, J. R., Kubzansky, L. D., Mayeda, E. R., Crane, P. K., Chang, S., Cornelis, M., Rehkopf, D. H., Mukherjee, S., Glymour, M. M. 2016; 30 (1): 15-20

  Abstract

  Mendelian Randomization (MR) studies have reported that type 2 diabetes (T2D) was not associated with Alzheimer disease (AD). We adopted a modified, mechanism-specific MR design to explore this surprising result.Using inverse-variance weighted MR analysis, we evaluated the association between T2D and AD using data from 39 single nucleotide polymorphisms (SNPs) significantly associated with T2D in DIAbetes Genetics Replication And Meta-analysis (DIAGRAM) and the corresponding associations of each SNP with AD risk obtained from the International Genomics of Alzheimer's Project (IGAP, n=17,008 AD cases and n=37,154 controls). We evaluated mechanism-specific genetic subscores, including β-cell function, insulin sensitivity, and adiposity, and repeated analyses in 8501 Health and Retirement Study participants for replication and model validation.In IGAP, the overall T2D polygenic score did not predict AD [odds ratio (OR) for the T2D polygenic score=1.01; 95% confidence interval (CI), 0.96, 1.06] but the insulin sensitivity polygenic score predicted higher AD risk (OR=1.17; 95% CI, 1.02, 1.34). In the Health and Retirement Study, polygenic scores were associated with T2D risk; the associations between insulin sensitivity genetic polygenic score and cognitive phenotypes were not statistically significant.Evidence from polygenic scores suggests that insulin sensitivity specifically may affect AD risk, more than T2D overall.

  View details for DOI 10.1097/WAD.0000000000000128

  View details for Web of Science ID 000373515000003

  View details for PubMedID 26650880

  View details for PubMedCentralID PMC4879683

• Predicting later life health status and mortality using state-level socioeconomic characteristics in early life SSM - Population Health Hamad, R., Rehkopf, D. H., Kuan, K. Y., Cullen, M. R. 2016; 2: 269–76

  Abstract

  Studies extending across multiple life stages promote an understanding of factors influencing health across the life span. Existing work has largely focused on individual-level rather than area-level early life determinants of health. In this study, we linked multiple data sets to examine whether early life state-level characteristics were predictive of health and mortality decades later. The sample included 143,755 U.S. employees, for whom work life claims and administrative data were linked with early life state-of-residence and mortality. We first created a "state health risk score" (SHRS) and "state mortality risk score" (SMRS) by modeling state-level contextual characteristics with health status and mortality in a randomly selected 30% of the sample (the "training set"). We then examined the association of these scores with objective health status and mortality in later life in the remaining 70% of the sample (the "test set") using multivariate linear and Cox regressions, respectively. The association between the SHRS and adult health status was β=0.14 (95%CI: 0.084, 0.20), while the hazard ratio for the SMRS was 0.96 (95%CI: 0.93, 1.00). The association between the SHRS and health was not statistically significant in older age groups at a p-level of 0.05, and there was a statistically significantly different association for health status among movers compared to stayers. This study uses a life course perspective and supports the idea of "sensitive periods" in early life that have enduring impacts on health. It adds to the literature examining populations in the U.S. where large linked data sets are infrequently available.

  View details for DOI 10.1016/j.ssmph.2016.04.005

  View details for PubMedCentralID PMC5047283

• Changing national guidelines is not enough: The impact of 1990 IOM recommendations on gestational weight gain among U.S. women International Journal of Obesity Hamad, R., Cohen, A. K., Rehkopf, D. H. 2016: 1529–34

  Abstract

  Gestational weight gain (GWG) is associated with both long- and short-term maternal and child health outcomes, particularly obesity. Targeting maternal nutrition through policies is a potentially powerful pathway to influence these outcomes. Yet prior research has often failed to evaluate national policies and guidelines that address maternal and child health. In 1990, the U.S. Institute of Medicine (IOM) released guidelines recommending different GWG thresholds based on women's pre-pregnancy body mass index (BMI), with the goal of improving infant birth weight. In this study, we employ quasi-experimental methods to examine whether the release of the IOM guidelines led to changes in GWG among a diverse and nationally representative sample of women.Our sample included female participants of the National Longitudinal Survey of Youth who self-reported GWG for pregnancies during 1979-2000 (n=7442 pregnancies to 4173 women). We compared GWG before and after the guidelines were released using difference-in-differences (DID) and regression discontinuity (RD) analyses.In DID analyses we found no reduction in GWG among overweight/obese women relative to normal/underweight women. Meanwhile, RD analyses demonstrated no changes in GWG by pre-pregnancy BMI for either overweight/obese or normal/underweight women. Results were similar for women regardless of educational attainment, race or parity.These findings suggest that national guidelines had no effect on weight gain among pregnant women. These results have implications for the implementation of policies targeting maternal and child health via dietary behaviors.

  View details for DOI 10.1038/ijo.2016.97

  View details for PubMedCentralID PMC5050079

• Shape of the association between income and mortality: a cohort study of Denmark, Finland, Norway and Sweden in 1995 and 2003 BMJ OPEN Mortensen, L. H., Rehnberg, J., Dahl, E., Diderichsen, F., Elstad, J. I., Martikainen, P., Rehkopf, D., Tarkiainen, L., Fritzell, J. 2016; 6 (12)

  Abstract

  Prior work has examined the shape of the income-mortality association, but work has not compared gradients between countries. In this study, we focus on changes over time in the shape of income-mortality gradients for 4 Nordic countries during a period of rising income inequality. Context and time differentials in shape imply that the relationship between income and mortality is not fixed.Population-based cohort study of Denmark, Finland, Norway and Sweden.We collected data on individuals aged 25 or more in 1995 (n=12.98 million individuals, 0.84 million deaths) and 2003 (n=13.08 million individuals, 0.90 million deaths). We then examined the household size equivalised disposable income at the baseline year in relation to the rate of mortality in the following 5 years.A steep income gradient in mortality in men and women across all age groups except the oldest old in Denmark, Finland, Norway and Sweden. From the 1990s to 2000s mortality dropped, but generally more so in the upper part of the income distribution than in the lower part. As a consequence, the shape of the income gradient in mortality changed. The shift in the shape of the association was similar in all 4 countries.A non-linear gradient exists between income and mortality in most cases and because of a more rapid mortality decline among those with high income the income gradient has become steeper over time.

  View details for DOI 10.1136/bmjopen-2015-010974

  View details for Web of Science ID 000391303600105

  View details for PubMedID 28011804

  View details for PubMedCentralID PMC5223725

• Correlates of poor glycemic control among patients with diabetes initiating hemodialysis for end-stage renal disease BMC NEPHROLOGY Rhee, J. J., Ding, V. Y., Rehkopf, D. H., Arce, C. M., Winkelmayer, W. C. 2015; 16

  Abstract

  Maintaining tight glycemic control is important for prevention of diabetes-related outcomes in end-stage renal disease patients with diabetes, especially in light of their poor prognosis. This study aimed to determine factors associated with poor glycemic control among U.S. patients with diabetes mellitus initiating hemodialysis for end-stage renal disease.Using data from the U.S. Renal Data System, electronic health records of a large national dialysis provider, and U.S. Census data, we performed a cross-sectional multivariable Poisson regression analysis to characterize risk factors associated with poor glycemic control, defined as glycated hemoglobin (HbA1c) > 7 vs. ≤ 7 %, in adult patients with diabetes who initiated hemodialysis at an outpatient facility between 2006 and 2011.Of 16,297 patients with diabetes, 21.2 % had HbA1c >7 %. In multivariable analysis, younger patients, patients of Native American race, and those of Hispanic ethnicity had higher prevalence of poor glycemic control. Independent correlates of poor glycemic control further included higher platelet count, white blood cell count, and ferritin; higher body mass index, systolic blood pressure, total cholesterol and triglyceride concentrations; lower HDL and albumin concentrations; lower normalized protein catabolic rate; and higher estimated glomerular filtration rate at initiation of dialysis (all P < 0.05). No independent associations were found with area-level socioeconomic indicators. Occurrence of diabetes in patients < 40 years of age, a proxy for type 1 diabetes, was associated with poor HbA1c control compared with that in patients ≥ 40 years of age, which was classified as type 2 diabetes. These findings were robust to the different outcome definitions of HbA1c > 7.5 % and > 8 %.In this cohort of incident end-stage renal disease patients with diabetes, poor glycemic control was independently associated with younger age, Native American race, Hispanic ethnicity, higher body mass index, and clinical risk factors including atherogenic lipoprotein profile, hypertension, inflammation, and markers indicative of malnutrition and a more serious systemic disease.

  View details for DOI 10.1186/s12882-015-0204-4

  View details for Web of Science ID 000366173000002

  View details for PubMedID 26645204

  View details for PubMedCentralID PMC4673753

• Poverty, Pregnancy, and Birth Outcomes: A Study of the Earned Income Tax Credit PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Hamad, R., Rehkopf, D. H. 2015; 29 (5): 444-452

  Abstract

  Economic interventions are increasingly recognised as a mechanism to address perinatal health outcomes among disadvantaged groups. In the US, the earned income tax credit (EITC) is the largest poverty alleviation programme. Little is known about its effects on perinatal health among recipients and their children. We exploit quasi-random variation in the size of EITC payments to examine the effects of income on perinatal health.The study sample includes women surveyed in the 1979 National Longitudinal Survey of Youth (n = 2985) and their children born during 1986-2000 (n = 4683). Outcome variables include utilisation of prenatal and postnatal care, use of alcohol and tobacco during pregnancy, term birth, birthweight, and breast-feeding status. We first examine the health effects of both household income and EITC payment size using multivariable linear regressions. We then employ instrumental variables analysis to estimate the causal effect of income on perinatal health, using EITC payment size as an instrument for household income.We find that EITC payment size is associated with better levels of several indicators of perinatal health. Instrumental variables analysis, however, does not reveal a causal association between household income and these health measures.Our findings suggest that associations between income and perinatal health may be confounded by unobserved characteristics, but that EITC income improves perinatal health. Future studies should continue to explore the impacts of economic interventions on perinatal health outcomes, and investigate how different forms of income transfers may have different impacts.

  View details for DOI 10.1111/ppe.12211

  View details for Web of Science ID 000359633400010

  View details for PubMedID 26212041

  View details for PubMedCentralID PMC4536129

• Racial/Ethnic Disparities in Inadequate Gestational Weight Gain Differ by Pre-pregnancy Weight MATERNAL AND CHILD HEALTH JOURNAL Headen, I., Mujahid, M. S., Cohen, A. K., Rehkopf, D. H., Abrams, B. 2015; 19 (8): 1672-1686

  Abstract

  Pre-pregnancy body mass index (BMI) varies by race/ethnicity and modifies the association between gestational weight gain (GWG) and adverse pregnancy outcomes, which disproportionately affect racial/ethnic minorities. Yet studies investigating whether racial/ethnic disparities in GWG vary by pre-pregnancy BMI are inconsistent, and none studied nationally representative populations. Using categorical measures of GWG adequacy based on Institute of Medicine recommendations, we investigated whether associations between race/ethnicity and GWG adequacy were modified by pre-pregnancy BMI [underweight (<18.5 kg/m(2)), normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), or obese (≥30.0 kg/m(2))] among all births to Black, Hispanic, and White mothers in the 1979 USA National Longitudinal Survey of Youth cohort (n = 6,849 pregnancies; range 1-10). We used generalized estimating equations, adjusted for marital status, parity, smoking during pregnancy, gestational age, and multiple measures of socioeconomic position. Effect measure modification between race/ethnicity and pre-pregnancy BMI was significant for inadequate GWG (Wald test p value = 0.08). Normal weight Black [risk ratio (RR) 1.34, 95 % confidence interval (CI) 1.18, 1.52] and Hispanic women (RR 1.33, 95 % CI 1.15, 1.54) and underweight Black women (RR 1.38, 95 % CI 1.07, 1.79) experienced an increased risk of inadequate GWG compared to Whites. Differences in risk of inadequate GWG between minority women, compared to White women, were not significant among overweight and obese women. Effect measure modification between race/ethnicity and pre-pregnancy BMI was not significant for excessive GWG. The magnitude of racial/ethnic disparities in inadequate GWG appears to vary by pre-pregnancy weight class, which should be considered when designing interventions to close racial/ethnic gaps in healthy GWG.

  View details for DOI 10.1007/s10995-015-1682-5

  View details for Web of Science ID 000358064600003

  View details for PubMedCentralID PMC4503500

• Early-Life State-of-Residence Characteristics and Later Life Hypertension, Diabetes, and Ischemic Heart Disease AMERICAN JOURNAL OF PUBLIC HEALTH Rehkopf, D. H., Eisen, E. A., Modrek, S., Horner, E. M., Goldstein, B., Costello, S., Cantley, L. F., Slade, M. D., Cullen, M. R. 2015; 105 (8): 1689-1695

  Abstract

  We examined how state characteristics in early life are associated with individual chronic disease later in life.We assessed early-life state of residence using the first 3 digits of social security numbers from blue- and white-collar workers from a US manufacturing company. Longitudinal data were available from 1997 to 2012, with 305 936 person-years of observation. Disease was assessed using medical claims. We modeled associations using pooled logistic regression with inverse probability of censoring weights.We found small but statistically significant associations between early-state-of-residence characteristics and later life hypertension, diabetes, and ischemic heart disease. The most consistent associations were with income inequality, percentage non-White, and education. These associations were similar after statistically controlling for individual socioeconomic and demographic characteristics and current state characteristics.Characteristics of the state in which an individual lives early in life are associated with prevalence of chronic disease later in life, with a strength of association equivalent to genetic associations found for these same health outcomes.

  View details for DOI 10.2105/AJPH.2014.302547

  View details for Web of Science ID 000362950400058

  View details for PubMedCentralID PMC4504286

• Early-Life State-of-Residence Characteristics and Later Life Hypertension, Diabetes, and Ischemic Heart Disease. American journal of public health Rehkopf, D. H., Eisen, E. A., Modrek, S., Mokyr Horner, E., Goldstein, B., Costello, S., Cantley, L. F., Slade, M. D., Cullen, M. R. 2015; 105 (8): 1689-1695

  Abstract

  We examined how state characteristics in early life are associated with individual chronic disease later in life.We assessed early-life state of residence using the first 3 digits of social security numbers from blue- and white-collar workers from a US manufacturing company. Longitudinal data were available from 1997 to 2012, with 305 936 person-years of observation. Disease was assessed using medical claims. We modeled associations using pooled logistic regression with inverse probability of censoring weights.We found small but statistically significant associations between early-state-of-residence characteristics and later life hypertension, diabetes, and ischemic heart disease. The most consistent associations were with income inequality, percentage non-White, and education. These associations were similar after statistically controlling for individual socioeconomic and demographic characteristics and current state characteristics.Characteristics of the state in which an individual lives early in life are associated with prevalence of chronic disease later in life, with a strength of association equivalent to genetic associations found for these same health outcomes.

  View details for DOI 10.2105/AJPH.2014.302547

  View details for PubMedID 26066927

  View details for PubMedCentralID PMC4504286

• Leukocyte telomere length and mortality in the national health and nutrition examination survey, 1999-2002. Epidemiology Needham, B. L., Rehkopf, D., Adler, N., Gregorich, S., Lin, J., Blackburn, E. H., Epel, E. S. 2015; 26 (4): 528-535

  Abstract

  This study examined the association between leukocyte telomere length--a marker of cell aging--and mortality in a nationally representative sample of US adults ages 50-84 years. We also examined moderating effects of age, sex, race/ethnicity, and education.Data were from the National Health and Nutrition Examination Survey, 1999-2002 (n = 3,091). Cox proportional hazards regression was used to estimate the risk of all-cause and cause- specific mortality adjusting for sociodemographic characteristics, smoking, body mass index, and chronic conditions.Eight hundred and seventy deaths occurred over an average of 9.5 years of follow-up. In the full sample, a decrease of 1 kilobase pair in telomere length at baseline was marginally associated with a 10% increased hazard of all-cause mortality (hazard ratio [HR]: 1.1, 95% confidence interval [CI]: 0.9, 1.4) and a 30% increased hazard of death due to diseases other than cardiovascular disease or cancer (HR: 1.3, 95% CI: 0.9, 1.9). Among African-American but not white or Mexican-American respondents, a decrease of 1 kilobase pair in telomere length at baseline was associated with a two-fold increased hazard of cardiovascular mortality (HR: 2.0, 95% CI: 1.3, 3.1). There was no association between telomere length and cancer mortality.The association between leukocyte telomere length and mortality differs by race/ethnicity and cause of death.

  View details for DOI 10.1097/EDE.0000000000000299

  View details for PubMedID 26039272

• The evidence suggests we should care about social inequalities in health. The American journal of bioethics : AJOB Rehkopf, D. H., Mortensen, L. H. 2015; 15 (3): 56-8

  View details for DOI 10.1080/15265161.2014.998380

  View details for PubMedID 25786020

• Genetic vulnerability to diabetes and obesity: Does education offset the risk? Social science & medicine Liu, S. Y., Walter, S., Marden, J., Rehkopf, D. H., Kubzansky, L. D., Nguyen, T., Glymour, M. M. 2015; 127: 150-158

  Abstract

  The prevalence of type 2 diabetes (T2D) and obesity has recently increased dramatically. These common diseases are likely to arise from the interaction of multiple genetic, socio-demographic and environmental risk factors. While previous research has found genetic risk and education to be strong predictors of these diseases, few studies to date have examined their joint effects. This study investigates whether education modifies the association between genetic background and risk for type 2 diabetes (T2D) and obesity. Using data from non-Hispanic Whites in the Health and Retirement Study (HRS, n = 8398), we tested whether education modifies genetic risk for obesity and T2D, offsetting genetic effects; whether this effect is larger for individuals who have high risk for other (unobserved) reasons, i.e., at higher quantiles of HbA1c and BMI; and whether effects differ by gender. We measured T2D risk using Hemoglobin A1c (HbA1c) level, and obesity risk using body-mass index (BMI). We constructed separate genetic risk scores (GRS) for obesity and diabetes respectively based on the most current available information on the single nucleotide polymorphism (SNPs) confirmed as genome-wide significant predictors for BMI (29 SNPs) and diabetes risk (39 SNPs). Linear regression models with years of schooling indicate that the effect of genetic risk on HbA1c is smaller among people with more years of schooling and larger among those with less than a high school (HS) degree compared to HS degree-holders. Quantile regression models show that the GRS × education effect systematically increased along the HbA1c outcome distribution; for example the GRS × years of education interaction coefficient was -0.01 (95% CI = -0.03, 0.00) at the 10th percentile compared to -0.03 (95% CI = -0.07, 0.00) at the 90th percentile. These results suggest that education may be an important socioeconomic source of heterogeneity in responses to genetic vulnerability to T2D.

  View details for DOI 10.1016/j.socscimed.2014.09.009

  View details for PubMedID 25245452

• Social disparities in heart disease risk and survivor bias among autoworkers: an examination based on survival models and g-estimation OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Costello, S., Picciotto, S., Rehkopf, D. H., Eisen, E. A. 2015; 72 (2): 138-144

  Abstract

  To examine gender and racial disparities in ischaemic heart disease (IHD) mortality related to metalworking fluid exposures and in the healthy worker survivor effect.A cohort of white and black men and women autoworkers in the USA was followed from 1941 to 1995 with quantitative exposure to respirable particulate matter from water-based metalworking fluids. Separate analyses used proportional hazards models and g-estimation.The HR for IHD among black men was 3.29 (95% CI 1.49 to 7.31) in the highest category of cumulative synthetic fluid exposure. The HR for IHD among white women exposed to soluble fluid reached 2.44 (95% CI 0.96 to 6.22). However, no increased risk was observed among white men until we corrected for the healthy worker survivor effect. Results from g-estimation indicate that if white male cases exposed to soluble or synthetic fluid had been unexposed to that fluid type, then 1.59 and 1.20 years of life would have been saved on average, respectively.We leveraged the strengths of two different analytic approaches to examine the IHD risks of metalworking fluids. All workers may have the same aetiological risk; however, black and female workers may experience more IHD from water-based metalworking fluid exposure because of a steeper exposure-response or weaker healthy worker survivor effect.

  View details for DOI 10.1136/oemed-2014-102168

  View details for Web of Science ID 000347772900010

  View details for PubMedID 25415971

  View details for PubMedCentralID PMC4316942

• Associations of cadmium and lead exposure with leukocyte telomere length: findings from national health and nutrition examination survey, 1999-2002. American journal of epidemiology Zota, A. R., Needham, B. L., Blackburn, E. H., Lin, J., Park, S. K., Rehkopf, D. H., Epel, E. S. 2015; 181 (2): 127-136

  Abstract

  Cadmium and lead are ubiquitous environmental contaminants that might increase risks of cardiovascular disease and other aging-related diseases, but their relationships with leukocyte telomere length (LTL), a marker of cellular aging, are poorly understood. In experimental studies, they have been shown to induce telomere shortening, but no epidemiologic study to date has examined their associations with LTL in the general population. We examined associations of blood lead and cadmium (n = 6,796) and urine cadmium (n = 2,093) levels with LTL among a nationally representative sample of US adults from the National Health and Nutrition Examination Survey (1999-2002). The study population geometric mean concentrations were 1.67 µg/dL (95% confidence interval (CI): 1.63, 1.70) for blood lead, 0.44 µg/L (95% CI: 0.42, 0.47) for blood cadmium, and 0.28 µg/L (95% CI: 0.27, 0.30) for urine cadmium. After adjustment for potential confounders, the highest (versus lowest) quartiles of blood and urine cadmium were associated with -5.54% (95% CI: -8.70, -2.37) and -4.50% (95% CI: -8.79, -0.20) shorter LTLs, respectively, with evidence of dose-response relationship (P for trend < 0.05). There was no association between blood lead concentration and LTL. These findings provide further evidence of physiological impacts of cadmium at environmental levels and might provide insight into biological pathways underlying cadmium toxicity and chronic disease risks.

  View details for DOI 10.1093/aje/kwu293

  View details for PubMedID 25504027

• Impact of a private sector living wage intervention on depressive symptoms among apparel workers in the Dominican Republic: a quasi-experimental study BMJ OPEN Burmaster, K. B., Landefeld, J. C., Rehkopf, D. H., Lahiff, M., Sokal-Gutierrez, K., Adler-Milstein, S., Fernald, L. C. 2015; 5 (8)

  View details for DOI 10.1136/bmjopen-2014-007336

  View details for Web of Science ID 000359164800006

  View details for PubMedID 26238394

• The EARN-Health Trial: protocol for a randomised controlled trial to identify health effects of a financial savings programme among low-income US adults. BMJ open Basu, S., Hamad, R., White, J. S., Modrek, S., Rehkopf, D. H., Cullen, M. R. 2015; 5 (10): e009366

  Abstract

  A theory within the social epidemiology field is that financial stress related to having inadequate financial savings may contribute to psychological stress, poor mental health and poor health-related behaviours among low-income US adults. Our objective is to test whether an intervention that encourages financial savings among low-income US adults improves health behaviours and mental health.A parallel group two-arm controlled superiority trial will be performed in which 700 participants will be randomised to the intervention or a wait list. The intervention arm will be provided an online Individual Development Account (IDA) for 6 months, during which participants receive a $5 incentive (£3.2, €4.5) for every month they save $20 in their account (£12.8, €18), and an additional $5 if they save $20 for two consecutive months. Both groups will be provided links to standard online financial counselling materials. Online surveys in months 0 (prior to randomisation), 6 and 12 (6 months postintervention) will assess self-reported health behaviours and mental health among participants in both arms. The surveys items were tested previously in the US Centers for Disease Control and Prevention national health interviews and related health studies, including self-reported overall health, health-related quality of life, alcohol and tobacco use, depression symptoms, financial stress, optimism and locus of control, and spending and savings behaviours. Trial data will be analysed on an intent-to-treat basis.This protocol was approved by the Institutional Review Board of Stanford University (Protocol ID: 30641). The findings of the trial will be disseminated through peer-reviewed publication.Identifier NCT02185612; Pre-results.

  View details for DOI 10.1136/bmjopen-2015-009366

  View details for PubMedID 26443663

  View details for PubMedCentralID PMC4606428

• Correlates of poor glycemic control among patients with diabetes initiating hemodialysis for end-stage renal disease. BMC nephrology Rhee, J. J., Ding, V. Y., Rehkopf, D. H., Arce, C. M., Winkelmayer, W. C. 2015; 16: 204-?

  Abstract

  Maintaining tight glycemic control is important for prevention of diabetes-related outcomes in end-stage renal disease patients with diabetes, especially in light of their poor prognosis. This study aimed to determine factors associated with poor glycemic control among U.S. patients with diabetes mellitus initiating hemodialysis for end-stage renal disease.Using data from the U.S. Renal Data System, electronic health records of a large national dialysis provider, and U.S. Census data, we performed a cross-sectional multivariable Poisson regression analysis to characterize risk factors associated with poor glycemic control, defined as glycated hemoglobin (HbA1c) > 7 vs. ≤ 7 %, in adult patients with diabetes who initiated hemodialysis at an outpatient facility between 2006 and 2011.Of 16,297 patients with diabetes, 21.2 % had HbA1c >7 %. In multivariable analysis, younger patients, patients of Native American race, and those of Hispanic ethnicity had higher prevalence of poor glycemic control. Independent correlates of poor glycemic control further included higher platelet count, white blood cell count, and ferritin; higher body mass index, systolic blood pressure, total cholesterol and triglyceride concentrations; lower HDL and albumin concentrations; lower normalized protein catabolic rate; and higher estimated glomerular filtration rate at initiation of dialysis (all P < 0.05). No independent associations were found with area-level socioeconomic indicators. Occurrence of diabetes in patients < 40 years of age, a proxy for type 1 diabetes, was associated with poor HbA1c control compared with that in patients ≥ 40 years of age, which was classified as type 2 diabetes. These findings were robust to the different outcome definitions of HbA1c > 7.5 % and > 8 %.In this cohort of incident end-stage renal disease patients with diabetes, poor glycemic control was independently associated with younger age, Native American race, Hispanic ethnicity, higher body mass index, and clinical risk factors including atherogenic lipoprotein profile, hypertension, inflammation, and markers indicative of malnutrition and a more serious systemic disease.

  View details for DOI 10.1186/s12882-015-0204-4

  View details for PubMedID 26645204

  View details for PubMedCentralID PMC4673753

• The EARN-Health Trial: protocol for a randomised controlled trial to identify health effects of a financial savings programme among low-income US adults. BMJ open Basu, S., Hamad, R., White, J. S., Modrek, S., Rehkopf, D. H., Cullen, M. R. 2015; 5 (10)

  Abstract

  A theory within the social epidemiology field is that financial stress related to having inadequate financial savings may contribute to psychological stress, poor mental health and poor health-related behaviours among low-income US adults. Our objective is to test whether an intervention that encourages financial savings among low-income US adults improves health behaviours and mental health.A parallel group two-arm controlled superiority trial will be performed in which 700 participants will be randomised to the intervention or a wait list. The intervention arm will be provided an online Individual Development Account (IDA) for 6 months, during which participants receive a $5 incentive (£3.2, €4.5) for every month they save $20 in their account (£12.8, €18), and an additional $5 if they save $20 for two consecutive months. Both groups will be provided links to standard online financial counselling materials. Online surveys in months 0 (prior to randomisation), 6 and 12 (6 months postintervention) will assess self-reported health behaviours and mental health among participants in both arms. The surveys items were tested previously in the US Centers for Disease Control and Prevention national health interviews and related health studies, including self-reported overall health, health-related quality of life, alcohol and tobacco use, depression symptoms, financial stress, optimism and locus of control, and spending and savings behaviours. Trial data will be analysed on an intent-to-treat basis.This protocol was approved by the Institutional Review Board of Stanford University (Protocol ID: 30641). The findings of the trial will be disseminated through peer-reviewed publication.Identifier NCT02185612; Pre-results.

  View details for DOI 10.1136/bmjopen-2015-009366

  View details for PubMedID 26443663

  View details for PubMedCentralID PMC4606428

• Socioeconomic disadvantage in childhood as a predictor of excessive gestational weight gain and obesity in midlife adulthood. Emerging themes in epidemiology Chaffee, B. W., Abrams, B., Cohen, A. K., Rehkopf, D. H. 2015; 12: 4-?

  Abstract

  Lower childhood socioeconomic position is associated with greater risk of adult obesity among women, but not men. Pregnancy-related weight changes may contribute to this gender difference. The objectives of this study were to determine the associations between: 1. childhood socioeconomic disadvantage and midlife obesity; 2. excessive gestational weight gain (GWG) and midlife obesity; and 3. childhood socioeconomic disadvantage and excessive GWG, among a representative sample of childbearing women.We constructed marginal structural models for seven measures of childhood socioeconomic position for 4780 parous women in the United States, using National Longitudinal Survey of Youth (1979-2010) data. Institute of Medicine definitions were used for excessive GWG; body mass index ≥30 at age 40 defined midlife obesity. Analyses were separated by race/ethnicity. Additionally, we estimated controlled direct effects of childhood socioeconomic disadvantage on midlife obesity under a condition of never gaining excessively in pregnancy.Low parental education, but not other measures of childhood disadvantage, was associated with greater midlife obesity among non-black non-Hispanic women. Among black and Hispanic mothers, childhood socioeconomic disadvantage was not consistently associated with midlife obesity. Excessive GWG was associated with greater midlife obesity in all racial/ethnic groups. Childhood socioeconomic disadvantage was not statistically significantly associated with excessive GWG in any group. Controlled direct effects were not consistently weaker than total effects.Childhood socioeconomic disadvantage was associated with adult obesity, but not with excessive gestational weight gain, and only for certain disadvantage measures among non-black non-Hispanic mothers. Prevention of excessive GWG may benefit all groups through reducing obesity, but excessive GWG does not appear to serve as a mediator between childhood socioeconomic position and adult obesity in women.

  View details for DOI 10.1186/s12982-015-0026-7

  View details for PubMedID 25755672

  View details for PubMedCentralID PMC4353468

• Soda and cell aging: associations between sugar-sweetened beverage consumption and leukocyte telomere length in healthy adults from the national health and nutrition examination surveys. American journal of public health Leung, C. W., Laraia, B. A., Needham, B. L., Rehkopf, D. H., Adler, N. E., Lin, J., Blackburn, E. H., Epel, E. S. 2014; 104 (12): 2425-2431

  Abstract

  We tested whether leukocyte telomere length maintenance, which underlies healthy cellular aging, provides a link between sugar-sweetened beverage (SSB) consumption and the risk of cardiometabolic disease.We examined cross-sectional associations between the consumption of SSBs, diet soda, and fruit juice and telomere length in a nationally representative sample of healthy adults. The study population included 5309 US adults, aged 20 to 65 years, with no history of diabetes or cardiovascular disease, from the 1999 to 2002 National Health and Nutrition Examination Surveys. Leukocyte telomere length was assayed from DNA specimens. Diet was assessed using 24-hour dietary recalls. Associations were examined using multivariate linear regression for the outcome of log-transformed telomere length.After adjustment for sociodemographic and health-related characteristics, sugar-sweetened soda consumption was associated with shorter telomeres (b = -0.010; 95% confidence interval [CI] = -0.020, -0.001; P = .04). Consumption of 100% fruit juice was marginally associated with longer telomeres (b = 0.016; 95% CI = -0.000, 0.033; P = .05). No significant associations were observed between consumption of diet sodas or noncarbonated SSBs and telomere length.Regular consumption of sugar-sweetened sodas might influence metabolic disease development through accelerated cell aging.

  View details for DOI 10.2105/AJPH.2014.302151

  View details for PubMedID 25322305

  View details for PubMedCentralID PMC4229419

• The association between a living wage and subjective social status and self-rated health: A quasi-experimental study in the Dominican Republic SOCIAL SCIENCE & MEDICINE Landefeld, J. C., Burmaster, K. B., Rehkopf, D. H., Syme, S. L., Lahiff, M., Adler-Milstein, S., Fernald, L. C. 2014; 121: 91-97

  View details for DOI 10.1016/j.socscimed.2014.09.051

  View details for Web of Science ID 000345183900012

• The association between a living wage and subjective social status and self-rated health: a quasi-experimental study in the Dominican Republic. Social science & medicine Landefeld, J. C., Burmaster, K. B., Rehkopf, D. H., Syme, S. L., Lahiff, M., Adler-Milstein, S., Fernald, L. C. 2014; 121: 91-97

  Abstract

  Poverty, both absolute and relative, is associated with poorer health. This is of particular concern in middle- and low-income countries facing a significant and growing burden of disease. There has been limited research specifically on whether interventions that increase income may foster better health outcomes. The establishment of a "living wage" apparel factory in the Dominican Republic provided a minimum income standard for factory workers, thus creating a natural experiment through which to study the effects of increased income on health indicators. The primary component of the intervention was a 350% wage increase, but apparel workers in the intervention factory also received education and professional development and were exposed to an enhanced occupational health and safety program. Workers at the intervention factory (n = 99) were compared with workers at a matched apparel factory (n = 105). Data were collected via in-person interviews in July and August of 2011, which was 15-16 months after workers were initially hired at the intervention site. Primary analyses used employment at the intervention factory as the independent variable and examined associations with two dependent variables: subjective social status and self-rated health. Results showed that receiving a 350% higher wage was associated with substantially higher subjective social status scores, as well as higher global and comparative self-rated health scores; effects were strongest in women. Subjective social status and self-rated health are associated with future health outcomes, so these results indicate that income increases for apparel workers may have positive long-term health outcomes, particularly for women.

  View details for DOI 10.1016/j.socscimed.2014.09.051

  View details for PubMedID 25442370

• Socioeconomic status and age at menarche: an examination of multiple indicators in an ethnically diverse cohort ANNALS OF EPIDEMIOLOGY Deardorff, J., Abrams, B., Ekwaru, J. P., Rehkopf, D. H. 2014; 24 (10): 727-733

  View details for DOI 10.1016/j.annepidem.2014.07.002

  View details for Web of Science ID 000342329100004

• Socioeconomic status and age at menarche: an examination of multiple indicators in an ethnically diverse cohort. Annals of epidemiology Deardorff, J., Abrams, B., Ekwaru, J. P., Rehkopf, D. H. 2014; 24 (10): 727-733

  Abstract

  Ethnic disparities exist in US girls' ages at menarche. Overweight and low socioeconomic status (SES) may contribute to these disparities but past research has been equivocal. We sought to determine which SES indicators were associated uniquely with menarche, for which ethnic groups, and whether associations operated through overweight.Using National Longitudinal Study of Youth data, we examined associations between SES indicators and age at menarche. Participants were 4851 girls and their mothers. We used survival analyses to examine whether SES, at various time points, was associated with menarche, whether body mass index mediated associations, and whether race/ethnicity modified associations.Black and Hispanic girls experienced menarche earlier than whites. After adjusting for SES, there was a 50% reduction in the effect estimate for "being Hispanic" and 40% reduction for "being black" versus "being white" on menarche. SES indicators were associated uniquely with earlier menarche, including mother's unmarried status and lower family income. Associations varied by race/ethnicity. Body mass index did not mediate associations.Racial differences in menarche may in large part be due to SES differences. Future experimental or quasiexperimental studies should examine whether intervening on SES factors could have benefits for delaying menarche among blacks and Hispanics.

  View details for DOI 10.1016/j.annepidem.2014.07.002

  View details for PubMedID 25108688

  View details for PubMedCentralID PMC4170010

• A multilevel model of postmenopausal breast cancer incidence. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology Hiatt, R. A., Porco, T. C., Liu, F., Balke, K., Balmain, A., Barlow, J., Braithwaite, D., Diez-Roux, A. V., Kushi, L. H., Moasser, M. M., Werb, Z., Windham, G. C., Rehkopf, D. H. 2014; 23 (10): 2078-2092

  Abstract

  Breast cancer has a complex etiology that includes genetic, biologic, behavioral, environmental, and social factors. Etiologic factors are frequently studied in isolation with adjustment for confounding, mediating, and moderating effects of other factors. A complex systems model approach may present a more comprehensive picture of the multifactorial etiology of breast cancer.We took a transdisciplinary approach with experts from relevant fields to develop a conceptual model of the etiology of postmenopausal breast cancer. The model incorporated evidence of both the strength of association and the quality of the evidence. We operationalized this conceptual model through a mathematical simulation model with a subset of variables, namely, age, race/ethnicity, age at menarche, age at first birth, age at menopause, obesity, alcohol consumption, income, tobacco use, use of hormone therapy (HT), and BRCA1/2 genotype.In simulating incidence for California in 2000, the separate impact of individual variables was modest, but reduction in HT, increase in the age at menarche, and to a lesser extent reduction in excess BMI >30 kg/m(2) were more substantial.Complex systems models can yield new insights on the etiologic factors involved in postmenopausal breast cancer. Modification of factors at a population level may only modestly affect risk estimates, while still having an important impact on the absolute number of women affected.This novel effort highlighted the complexity of breast cancer etiology, revealed areas of challenge in the methodology of developing complex systems models, and suggested additional areas for further study.

  View details for DOI 10.1158/1055-9965.EPI-14-0403

  View details for PubMedID 25017248

• A Multilevel Model of Postmenopausal Breast Cancer Incidence CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Hiatt, R. A., Porco, T. C., Liu, F., Balke, K., Balmain, A., Barlow, J., Braithwaite, D., Diez-Roux, A. V., Kushi, L. H., Moasser, M. M., Werb, Z., Windham, G. C., Rehkopf, D. H. 2014; 23 (10): 2078-2092

  View details for DOI 10.1158/1055-9965.EPI-14-0403

  View details for Web of Science ID 000345277400014

• Excessive gestational weight gain over multiple pregnancies and the prevalence of obesity at age 40 INTERNATIONAL JOURNAL OF OBESITY Cohen, A. K., Chaffee, B. W., Rehkopf, D. H., COYLE, J. R., Abrams, B. 2014; 38 (5): 714-718

  Abstract

  Although several studies have found an association between excessive gestational weight gain (GWG) and obesity later in life, to the best of our knowledge, no studies have explored the role of GWG events across the life course.We describe how the prevalence of midlife obesity (BMI⩾30 at age 40 or 41) among women varies by life course patterns of GWG (using 2009 IOM guidelines) in the USA's National Longitudinal Survey of Youth 1979 cohort.Among women who reported 1-3 births before age 40, the prevalence of midlife obesity increased with a rising number of excessive GWG events: from none (23.4%, n=875) to one (37.6%, n=707), from none (23.4%, n=875) to two (46.8%, n=427) and from none (23.4%, n=875) to three (54.6%, n=108), P<0.00005 for trend. Obesity prevalence was similar for the same number of excessive GWG events, regardless of parity. No clear pattern emerged for the sequencing of excessive GWG event(s) and later obesity.In our descriptive exploratory study, excessive GWG events appear to be associated with increased prevalence of obesity for parous women, suggesting the importance of preventive interventions regardless of timing of pregnancy-related weight changes over the life course.

  View details for DOI 10.1038/ijo.2013.156

  View details for Web of Science ID 000335445300014

  View details for PubMedID 23958794

  View details for PubMedCentralID PMC3930624

• Seasonal Variation of Peripheral Blood Leukocyte Telomere Length in Costa Rica: A Population-Based Observational Study AMERICAN JOURNAL OF HUMAN BIOLOGY Rehkopf, D. H., Dow, W. H., Rosero-Bixby, L., Lin, J., Epel, E. S., Blackburn, E. H. 2014; 26 (3): 367-375

  Abstract

  Peripheral blood leukocyte telomere length (LTL) is increasingly being used as a biomarker of aging, but its natural variation in human populations is not well understood. Several other biomarkers show seasonal variation, as do several determinants of LTL. We examined whether there was monthly variation in LTL in Costa Rica, a country with strong seasonal differences in precipitation and infection.We examined a longitudinal population-based cohort of 581 Costa Rican adults age 60 and above, from which blood samples were drawn between October 2006 and July 2008. LTL was assayed from these samples using the quantitative PCR method. Multivariate regression models were used to examine correlations between month of blood draw and LTL.Telomere length from peripheral blood leukocytes varied by as much as 200 base pairs depending on month of blood draw, and this difference is not likely to be due to random variation. A moderate proportion of this association is statistically accounted for by month and region specific average rainfall. We found shorter telomere length associated with greater rainfall.There are two possible explanations of our findings. First, there could be relatively rapid month-to-month changes in LTL. This conclusion would have implications for understanding the natural population dynamics of telomere length. Second, there could be seasonal differences in constituent cell populations. This conclusion would suggest that future studies of LTL use methods to account for the potential impact of constituent cell type. Am. J. Hum. Biol., 2014. © 2014 Wiley Periodicals, Inc.

  View details for DOI 10.1002/ajhb.22529

  View details for Web of Science ID 000334925200009

  View details for PubMedID 24615938

• Pregnancy and post-delivery maternal weight changes and overweight in preschool children. Preventive medicine Robinson, C. A., Cohen, A. K., Rehkopf, D. H., Deardorff, J., Ritchie, L., Jayaweera, R. T., Coyle, J. R., Abrams, B. 2014; 60: 77-82

  Abstract

  High maternal weight before and during pregnancy contributes to child obesity. To assess the additional role of weight change after delivery, we examined associations between pre- and post-pregnancy weight changes and preschooler overweight.Sample: 4359 children from the Children and Young Adults of the 1979 National Longitudinal Survey of Youth (NLSY) born to 2816 NLSY mothers between 1979 and 2006 and followed to age 4-5years old. Exposures: gestational weight gain (GWG) and post-delivery maternal weight change (PDWC). Outcome: child overweight (body mass index (BMI) ≥85th percentile).Adjusted models suggested that both increased GWG (OR: 1.08 per 5kg GWG, 95% CI: 1.01, 1.16) and excessive GWG (OR: 1.29 versus adequate GWG, 95% CI: 1.06, 1.56) were associated with preschooler overweight. Maternal weight change after delivery was also independently associated with child overweight (OR: 1.12 per 5kg PDWC, 95% CI: 1.04, 1.21). Associations were stronger among children with overweight or obese mothers.Increased maternal weight gain both during and after pregnancy predicted overweight in preschool children. Our results suggest that healthy post-pregnancy weight may join normal pre-pregnancy BMI and adequate GWG as a potentially modifiable risk factor for child overweight.

  View details for DOI 10.1016/j.ypmed.2013.12.018

  View details for PubMedID 24370455

• Systematic evaluation of environmental and behavioural factors associated with all-cause mortality in the United States National Health and Nutrition Examination Survey. International journal of epidemiology Patel, C. J., Rehkopf, D. H., Leppert, J. T., Bortz, W. M., Cullen, M. R., Chertow, G. M., Ioannidis, J. P. 2013; 42 (6): 1795-1810

  Abstract

  Environmental and behavioural factors are thought to contribute to all-cause mortality. Here, we develop a method to systematically screen and validate the potential independent contributions to all-cause mortality of 249 environmental and behavioural factors in the National Health and Nutrition Examination Survey (NHANES).We used Cox proportional hazards regression to associate 249 factors with all-cause mortality while adjusting for sociodemographic factors on data in the 1999-2000 and 2001-02 surveys (median 5.5 follow-up years). We controlled for multiple comparisons with the false discovery rate (FDR) and validated significant findings in the 2003-04 survey (median 2.8 follow-up years). We selected 249 factors from a set of all possible factors based on their presence in both the 1999-2002 and 2003-04 surveys and linkage with at least 20 deceased participants. We evaluated the correlation pattern of validated factors and built a multivariable model to identify their independent contribution to mortality.We identified seven environmental and behavioural factors associated with all-cause mortality, including serum and urinary cadmium, serum lycopene levels, smoking (3-level factor) and physical activity. In a multivariable model, only physical activity, past smoking, smoking in participant's home and lycopene were independently associated with mortality. These three factors explained 2.1% of the variance of all-cause mortality after adjusting for demographic and socio-economic factors.Our association study suggests that, of the set of 249 factors in NHANES, physical activity, smoking, serum lycopene and serum/urinary cadmium are associated with all-cause mortality as identified in previous studies and after controlling for multiple hypotheses and validation in an independent survey. Whereas other NHANES factors may be associated with mortality, they may require larger cohorts with longer time of follow-up to detect. It is possible to use a systematic association study to prioritize risk factors for further investigation.

  View details for DOI 10.1093/ije/dyt208

  View details for PubMedID 24345851

• Educational attainment and obesity: a systematic review OBESITY REVIEWS Cohen, A. K., Rai, M., Rehkopf, D. H., Abrams, B. 2013; 14 (12): 989-1005

  Abstract

  Although previous systematic reviews considered the relationship between socioeconomic status and obesity, almost 200 peer-reviewed articles have been published since the last review on that topic, and this paper focuses specifically on education, which has different implications. The authors systematically review the peer-reviewed literature from around the world considering the association between educational attainment and obesity. Databases from public health and medicine, education, psychology, economics, and other social sciences were searched, and articles published in English, French, Portuguese and Spanish were included. This paper includes 289 articles that report on 410 populations in 91 countries. The relationship between educational attainment and obesity was modified by both gender and the country's economic development level: an inverse association was more common in studies of higher-income countries and a positive association was more common in lower-income countries, with stronger social patterning among women. Relatively few studies reported on lower-income countries, controlled for a comprehensive set of potential confounding variables and/or attempted to assess causality through the use of quasi-experimental designs. Future research should address these gaps to understand if the relationship between educational attainment and obesity may be causal, thus supporting education policy as a tool for obesity prevention.

  View details for DOI 10.1111/obr.12062

  View details for Web of Science ID 000326764500005

  View details for PubMedCentralID PMC3902051

• The Nonlinear Relationship Between Education and Mortality: An Examination of Cohort, Race/Ethnic, and Gender Differences POPULATION RESEARCH AND POLICY REVIEW Everett, B. G., Rehkopf, D. H., Rogers, R. G. 2013; 32 (6): 893-917

  View details for DOI 10.1007/s11113-013-9299-0

  View details for Web of Science ID 000327141700004

• Longer leukocyte telomere length in Costa Rica's Nicoya Peninsula: A population-based study EXPERIMENTAL GERONTOLOGY Rehkopf, D. H., Dow, W. H., Rosero-Bixby, L., Lin, J., Epel, E. S., Blackburn, E. H. 2013; 48 (11): 1266-1273

  Abstract

  Studies in humans suggest that leukocyte telomere length may act as a marker of biological aging. We investigated whether individuals in the Nicoya region of Costa Rica, known for exceptional longevity, had longer telomere length than those in other parts of the country. After controlling for age, age squared, rurality, rainy season and gender, the mean leukocyte telomere length in Nicoya was substantially longer (81 base pairs, p<0.05) than in other areas of Costa Rica, providing evidence of a biological pathway to which this notable longevity may be related. This relationship remains unchanged (79 base pairs, p<0.05) after statistically controlling for nineteen potential biological, dietary and social and demographic mediators. Thus the difference in the mean leukocyte telomere length that characterizes this unique region does not appear to be explainable by traditional behavioral and biological risk factors. More detailed examination of mean leukocyte telomere length by age shows that the regional telomere length difference declines at older ages.

  View details for DOI 10.1016/j.exger.2013.08.005

  View details for Web of Science ID 000325750900017

  View details for PubMedID 23988653

  View details for PubMedCentralID PMC3819141

• Social isolation: a predictor of mortality comparable to traditional clinical risk factors. American journal of public health Pantell, M., Rehkopf, D., Jutte, D., Syme, S. L., Balmes, J., Adler, N. 2013; 103 (11): 2056-2062

  Abstract

  We explored the relationship between social isolation and mortality in a nationally representative US sample and compared the predictive power of social isolation with that of traditional clinical risk factors.We used data on 16,849 adults from the Third National Health and Nutrition Examination Survey and the National Death Index. Predictor variables were 4 social isolation factors and a composite index. Comparison predictors included smoking, obesity, elevated blood pressure, and high cholesterol. Unadjusted Kaplan-Meier tables and Cox proportional hazards regression models controlling for sociodemographic characteristics were used to predict mortality.Socially isolated men and women had worse unadjusted survival curves than less socially isolated individuals. Cox models revealed that social isolation predicted mortality for both genders, as did smoking and high blood pressure. Among men, individual social predictors included being unmarried, participating infrequently in religious activities, and lacking club or organization affiliations; among women, significant predictors were being unmarried, infrequent social contact, and participating infrequently in religious activities.The strength of social isolation as a predictor of mortality is similar to that of well-documented clinical risk factors. Our results suggest the importance of assessing patients' level of social isolation.

  View details for DOI 10.2105/AJPH.2013.301261

  View details for PubMedID 24028260

• Maternal Pre-pregnancy BMI, Gestational Weight Gain, and Age at Menarche in Daughters MATERNAL AND CHILD HEALTH JOURNAL Deardorff, J., Berry-Millett, R., Rehkopf, D., Luecke, E., Lahiff, M., Abrams, B. 2013; 17 (8): 1391-1398

  Abstract

  Life course theory suggests that early life experiences can shape health over a lifetime and across generations. Associations between maternal pregnancy experience and daughters' age at menarche are not well understood. We examined whether maternal pre-pregnancy BMI and gestational weight gain (GWG) were independently related to daughters' age at menarche. Consistent with a life course perspective, we also examined whether maternal GWG, birth weight, and prepubertal BMI mediated the relationship between pre-pregnancy BMI and daughter's menarcheal age. We examined 2,497 mother-daughter pairs from the 1979 National Longitudinal Survey of Youth. Survival analysis with Cox proportional hazards was used to estimate whether maternal pre-pregnancy overweight/obesity (BMI ≥ 25.0 kg/m(2)) and GWG adequacy (inadequate, recommended, and excessive) were associated with risk for earlier menarche among girls, controlling for important covariates. Analyses were conducted to examine the mediating roles of GWG adequacy, child birth weight and prepubertal BMI. Adjusting for covariates, pre-pregnancy overweight/obesity (HR = 1.20, 95 % CI 1.06, 1.36) and excess GWG (HR = 1.13, 95 % CI 1.01, 1.27) were associated with daughters' earlier menarche, while inadequate GWG was not. The association between maternal pre-pregnancy weight and daughters' menarcheal timing was not mediated by daughter's birth weight, prepubertal BMI or maternal GWG. Maternal factors, before and during pregnancy, are potentially important determinants of daughters' menarcheal timing and are amenable to intervention. Further research is needed to better understand pathways through which these factors operate.

  View details for DOI 10.1007/s10995-012-1139-z

  View details for Web of Science ID 000325024100008

  View details for PubMedID 23054446

• Invited Commentary: Off-Roading With Social Epidemiology-Exploration, Causation, Translation AMERICAN JOURNAL OF EPIDEMIOLOGY Glymour, M. M., Osypuk, T. L., Rehkopf, D. H. 2013; 178 (6): 858-863

  Abstract

  Population health improvements are the most relevant yardstick against which to evaluate the success of social epidemiology. In coming years, social epidemiology must increasingly emphasize research that facilitates translation into health improvements, with continued focus on macro-level social determinants of health. Given the evidence that the effects of social interventions often differ across population subgroups, systematic and transparent exploration of the heterogeneity of health determinants across populations will help inform effective interventions. This research should consider both biological and social risk factors and effect modifiers. We also recommend that social epidemiologists take advantage of recent revolutionary improvements in data availability and computing power to examine new hypotheses and expand our repertoire of study designs. Better data and computing power should facilitate underused analytic approaches, such as instrumental variables, simulation studies and models of complex systems, and sensitivity analyses of model biases. Many data-driven machine-learning approaches are also now computationally feasible and likely to improve both prediction models and causal inference in social epidemiology. Finally, we emphasize the importance of specifying exposures corresponding with realistic interventions and policy options. Effect estimates for directly modifiable, clearly defined health determinants are most relevant for building translational social epidemiology to reduce disparities and improve population health.

  View details for DOI 10.1093/aje/kwt145

  View details for Web of Science ID 000325150600005

  View details for PubMedID 24008902

• Were the mental health benefits of a housing mobility intervention larger for adolescents in higher socioeconomic status families? Health & place Nguyen, Q. C., Schmidt, N. M., Glymour, M. M., Rehkopf, D. H., Osypuk, T. L. 2013; 23: 79-88

  Abstract

  Moving to Opportunity (MTO) was a social experiment to test how relocation to lower poverty neighborhoods influences low-income families. Using adolescent data from 4 to 7 year evaluations (aged 12-19, n=2829), we applied gender-stratified intent-to-treat and adherence-adjusted linear regression models, to test effect modification of MTO intervention effects on adolescent mental health. Low parental education, welfare receipt, unemployment and never-married status were not significant effect modifiers. Tailoring mobility interventions by these characteristics may not be necessary to alter impact on adolescent mental health. Because parental enrollment in school and teen parent status adversely modified MTO intervention effects on youth mental health, post-move services that increase guidance and supervision of adolescents may help support post-move adjustment.

  View details for DOI 10.1016/j.healthplace.2013.05.002

  View details for PubMedID 23792412

• Parity and Body Mass Index in US Women: A Prospective 25-Year Study OBESITY Abrams, B., Heggeseth, B., Rehkopf, D., Davis, E. 2013; 21 (8): 1514-1518

  Abstract

  Objective: To investigate long-term body mass index (BMI) changes with childbearing. Design and Methods: Adjusted mean BMI changes were estimated by race-ethnicity, baseline BMI and parity using longitudinal regression models in 3943 young females over 10 and 25 year follow-up from the ongoing 1979 National Longitudinal Survey of Youth cohort. Results: Estimated BMI increases varied by group, ranging from a low of 2.1 BMI units for white, non-overweight nulliparas over the first 10 years to a high of 10.1 BMI units for black, overweight multiparas over the full 25-year follow-up. Impacts of parity were strongest among overweight multiparas and primaparas at ten years, ranges 1.4-1.7 and 0.8-1.3 BMI units, respectively. Among non-overweight women at 10 years, parity-related gain varied by number of births among black and whites but was unassociated in Hispanic women. After 25 years, childbearing significantly increased BMI only among overweight multiparous black women. Conclusion: Childbearing is associated with permanent weight gain in some women, but the relationship differs by maternal BMI in young adulthood, number of births, race-ethnicity and length of follow-up. Given that overweight black women may be at special risk for accumulation of permanent, long-term weight after childbearing, effective interventions for this group are particularly needed.

  View details for DOI 10.1002/oby.20503

  View details for Web of Science ID 000323521500003

  View details for PubMedID 23630108

• Income Gains and Very Low-Weight Birth among Low-Income Black Mothers in California BIODEMOGRAPHY AND SOCIAL BIOLOGY Bruckner, T. A., Rehkopf, D. H., Catalano, R. A. 2013; 59 (2): 141-156

  Abstract

  We test the hypothesis suggested in the literature that an acute income gain in the form of the earned income tax credit reduces the odds of a very low-weight birth among low-income non-Hispanic black mothers. We apply ecological time series and supplemental individual-level logistic regression methods to monthly birth data from California between 1989 and 1997. Contrary to our hypothesis, the odds of very low-weight birth increases above its expected value two months after mothers typically receive the credit. We discuss our findings in relation to the epidemiologic literature concerned with ambient events during pregnancy and recommend further investigation.

  View details for DOI 10.1080/19485565.2013.833802

  View details for Web of Science ID 000326868400003

  View details for PubMedID 24215256

• Patient-physician interaction and quality of life in recently diagnosed breast cancer patients BREAST CANCER RESEARCH AND TREATMENT Kwan, M. L., Tam, E. K., Ergas, I. J., Rehkopf, D. H., Roh, J. M., Lee, M. M., Somkin, C. P., Stewart, A. L., Kushi, L. H. 2013; 139 (2): 581-595

  Abstract

  Few studies have explored how patient-physician interactions influence patients' quality of life (QOL). In a prospective cohort study of 1,855 women diagnosed with invasive breast cancer in the Kaiser Permanente Northern California Medical Care Program from 2006 to 2011, we examined associations between patient-physician interactions during cancer treatment and QOL, overall and by racial/ethnic group. Participants completed the interpersonal processes of care (IPC) survey at approximately 8 months post-diagnosis to assess specific domains of the patient-physician interaction during the months after cancer diagnosis. Domains included: compassion, elicited concerns, explained results, decided together, lack of clarity, discrimination due to race/ethnicity, and disrespectful office staff. The functional assessment of cancer therapy-breast cancer was completed concurrently to measure QOL. Linear regression models examined the association of IPC with QOL, first adjusting for patient covariates including age, race, clinical factors, and psychosocial measures and then for physician characteristics such as age, sex, race/ethnicity, and specialty. For all participants (n = 1,855), IPC scores suggesting greater lack of clarity, discrimination due to race/ethnicity, and disrespectful office staff in patient-physician interactions were associated with lower QOL (P< 0.01). IPC scores suggesting physicians demonstrating compassion, eliciting concerns, or explaining results were associated with higher QOL (P< 0.01). Among Whites (n = 1,306), only the associations with higher QOL remained. African Americans (n = 110) who reported higher scores on physician compassion and elicited concerns had higher QOL, whereas higher scores for disrespectful office staff had lower QOL. No associations were observed among Asians (n = 201) and Hispanics (n = 186). After further adjustment for physician factors, the associations among Whites remained, whereas those among African Americans disappeared. In the breast cancer treatment setting, characteristics of the patient-physician interaction as perceived by the patient are associated with QOL, yet were not specific to patient race/ethnicity.

  View details for DOI 10.1007/s10549-013-2569-z

  View details for Web of Science ID 000321069600028

  View details for PubMedID 23715629

• Employment status and quality of life in recently diagnosed breast cancer survivors PSYCHO-ONCOLOGY Timperi, A. W., Ergas, I. J., Rehkopf, D. H., Roh, J. M., Kwan, M. L., Kushi, L. H. 2013; 22 (6): 1411-1420

  Abstract

  BACKGROUND: Breast cancer survivors are less likely to be employed than similar healthy women, yet effects of employment on the well being of survivors are largely unknown. In a prospective cohort study of 2013 women diagnosed from 2006 to 2011 with invasive breast cancer in Kaiser Permanente Northern California, we describe associations between hours worked per week and change in employment with quality of life (QOL) from diagnosis through active treatment. METHODS: Participants completed information on employment status and QOL approximately 2 and 8 months post-diagnosis. QOL was assessed by the Functional Assessment of Cancer Therapy-Breast Cancer. Multivariable linear regression models were adjusted for potential confounders including demographic, diagnostic, and medical care factors to examine associations between employment and QOL. RESULTS: At baseline, overall well being was higher for women who worked at least some hours per week compared with women who were not working. Women working 1-19 h/week at baseline also had higher functional well being compared with women who were not working. There was a significant, positive association between hours worked per week and physical and social well being. At the 6-month follow-up, women working at least 20 h/week had higher physical and functional well being than those who were not working. Lower scores for physical and functional well being were observed among women who stopped working during the 6-month follow-up period. CONCLUSIONS: Continuing to work after a breast cancer diagnosis may be beneficial to multiple areas of QOL. Strategies to help women continue working through treatment should be explored. Copyright © 2012 John Wiley & Sons, Ltd.

  View details for DOI 10.1002/pon.3157

  View details for Web of Science ID 000320105500029

  View details for PubMedID 22912069

  View details for PubMedCentralID PMC3519968

• Socioeconomic status, health behavior, and leukocyte telomere length in the National Health and Nutrition Examination Survey, 1999-2002 SOCIAL SCIENCE & MEDICINE Needham, B. L., Adler, N., Gregorich, S., Rehkopf, D., Lin, J., Blackburn, E. H., Epel, E. S. 2013; 85: 1-8

  Abstract

  The purpose of this study was to examine the association between socioeconomic status (SES) and leukocyte telomere length (LTL) - a marker of cell aging that has been linked to stressful life circumstances - in a nationally representative, socioeconomically and ethnically diverse sample of US adults aged 20-84. Using data from the National Health and Nutrition Examination Survey (NHANES), 1999-2002, we found that respondents who completed less than a high school education had significantly shorter telomeres than those who graduated from college. Income was not associated with LTL. African-Americans had significantly longer telomeres than whites, but there were no significant racial/ethnic differences in the association between education and telomere length. Finally, we found that the association between education and LTL was partially mediated by smoking and body mass index but not by drinking or sedentary behavior.

  View details for DOI 10.1016/j.socscimed.2013.02.023

  View details for Web of Science ID 000317880300001

  View details for PubMedID 23540359

  View details for PubMedCentralID PMC3666871

• Chronic Psychological Stress and Racial Disparities in Body Mass Index Change Between Black and White Girls Aged 10-19 ANNALS OF BEHAVIORAL MEDICINE Tomiyama, A. J., Puterman, E., Epel, E. S., Rehkopf, D. H., Laraia, B. A. 2013; 45 (1): 3-12

  Abstract

  One of the largest health disparities in the USA is in obesity rates between Black and White females.The objective of this study was to test the hypothesis that the stress-obesity link is stronger in Black females than in White females aged 10-19.Multilevel modeling captured the dynamic of acute (1 month) and chronic (10 years) stress and body mass index (BMI; weight in kilograms divided by height in meters squared) change in the National Heart, Lung, and Blood Institute Growth and Health Study, which consists of 2,379 Black and White girls across a span of socioeconomic status. The girls were assessed longitudinally from ages 10 to 19.Higher levels of stress during the 10 years predicted significantly greater increases in BMI over time compared to lower levels of stress. This relationship was significantly stronger for Black compared to White girls.Psychological stress is a modifiable risk factor that may moderate early racial disparities in BMI.

  View details for DOI 10.1007/s12160-012-9398-x

  View details for Web of Science ID 000314293300002

  View details for PubMedID 22993022

• Education and obesity at age 40 among American adults SOCIAL SCIENCE & MEDICINE Cohen, A. K., Rehkopf, D. H., Deardorff, J., Abrams, B. 2013; 78: 34-41

  Abstract

  Although many have studied the association between educational attainment and obesity, studies to date have not fully examined prior common causes and possible interactions by race/ethnicity or gender. It is also not clear if the relationship between actual educational attainment and obesity is independent of the role of aspired educational attainment or expected educational attainment. The authors use generalized linear log link models to examine the association between educational attainment at age 25 and obesity (BMI≥30) at age 40 in the USA's National Longitudinal Survey of Youth 1979 cohort, adjusting for demographics, confounders, and mediators. Race/ethnicity but not gender interacted with educational attainment. In a complete case analysis, after adjusting for socioeconomic covariates from childhood, adolescence, and adulthood, among whites only, college graduates were less likely than high school graduates to be obese (RR = 0.69, 95%CI: 0.57, 0.83). The risk ratio remained similar in two sensitivity analyses when the authors adjusted for educational aspirations and educational expectations and analyzed a multiply imputed dataset to address missingness. This more nuanced understanding of the role of education after controlling for a thorough set of confounders and mediators helps advance the study of social determinants of health and risk factors for obesity.

  View details for DOI 10.1016/j.socscimed.2012.11.025

  View details for Web of Science ID 000314739300005

  View details for PubMedID 23246398

  View details for PubMedCentralID PMC3545063

• The Nicoya region of Costa Rica: a high longevity island for elderly males. Vienna yearbook of population research Rosero-Bixby, L., Dow, W. H., Rehkopf, D. H. 2013; 11: 109-136

  Abstract

  Reliable data show that the Nicoyan region of Costa Rica is a hot spot of high longevity. A survival follow-up of 16,300 elderly Costa Ricans estimated a Nicoya death rate ratio (DRR) for males 1990-2011 of 0.80 (0.69-0.93 CI). For a 60-year-old Nicoyan male, the probability of becoming centenarian is seven times that of a Japanese male, and his life expectancy is 2.2 years greater. This Nicoya advantage does not occur in females, is independent of socio-economic conditions, disappears in out-migrants and comes from lower cardiovascular (CV) mortality (DRR = 0.65). Nicoyans have lower levels of biomarkers of CV risk; they are also leaner, taller and suffer fewer disabilities. Two markers of ageing and stress-telomere length and dehydroepiandrosterone sulphate-are also more favourable. The Nicoya diet is prosaic and abundant in traditional foods like rice, beans and animal protein, with low glycemic index and high fibre content.

  View details for PubMedID 25426140

• Quantile Regression for Hypothesis Testing and Hypothesis Screening at the Dawn of Big Data EPIDEMIOLOGY Rehkopf, D. H. 2012; 23 (5): 665-667

  View details for DOI 10.1097/EDE.0b013e318261f7be

  View details for Web of Science ID 000307560700003

  View details for PubMedID 22872112

• The relative importance of predictors of body mass index change, overweight and obesity in adolescent girls INTERNATIONAL JOURNAL OF PEDIATRIC OBESITY Rehkopf, D. H., Laraia, B. A., Segal, M., Braithwaite, D., Epel, E. 2011; 6 (2-2): E233-E242

  Abstract

  To determine the relative importance of familial, dietary, behavioral, psychological and social risk factors for predicting body mass index (BMI) change, and onset of overweight and obesity among adolescent girls.Data from the NHLBI Growth and Health Study (n = 2 150), a longitudinal cohort of girls, were used to identify the most important predictors of change in BMI percentile between the ages of 9 and 19 years, and second, risk for becoming overweight and obese. Forty-one baseline predictors were assessed using a tree-based regression method (Random forest) to rank the relative importance of risk factors.The five factors that best predicted change in BMI percentile (p < 0.05) were related to family socio-economic position (income and parent education) and drive to restrict eating and weight (body dissatisfaction, drive for thinness and unhappiness with physical appearance). The factors that were statistically significant (p < 0.05) predictors of both onset of overweight and obesity were income, ineffectiveness and race.Family socio-economic position and emotion regulation appeared as the top predictors of both BMI change and onset of overweight and obesity. Our results build upon prior findings that policies to prevent the onset of obesity during adolescence be targeted towards girls from lower socio-economic position households. Our findings also suggest several novel psychological factors including ineffectiveness as predictors of obesity during adolescence. These predictive findings offer a direction for future inquiry into adolescent obesity etiology using causal methods.

  View details for DOI 10.3109/17477166.2010.545410

  View details for Web of Science ID 000292704500028

  View details for PubMedID 21244233

• Discrepancy between objective and subjective measures of job stress and sickness absence SCANDINAVIAN JOURNAL OF WORK ENVIRONMENT & HEALTH Rehkopf, D. H., Kuper, H., Marmot, M. G. 2010; 36 (6): 449-457

  Abstract

  The aim of this study was to examine the association of the discrepancy between externally and self-assessed measures of work environment with long- and short-term sickness absence.The study population included 6997 middle-aged men and women from the Whitehall II cohort, whose work characteristics were examined at baseline (1985-1988) through both an external evaluation and self-report, with a follow-up of up to 13 years of sickness absence reporting from administrative records. The primary exposure of interest was the discrepancy between measures of work stress for fast job pace, conflicting demands, and decision latitude.In mutually adjusted models, external measures of job characteristics were more strongly associated with higher rates of sickness absence compared with self-assessed measures, for both lower frequency of fast work pace and lower conflicting demands (i.e., "passive" levels). Individuals who self-reported higher frequencies of fast work pace and conflicting demands than were reported through external assessment had higher rates of short-term sickness absence [incident rate ratios (IRR) of 1.13 (95% confidence interval [95% CI] 1.11-1.15) and IRR 1.14 (95% CI 1.11-1.16), respectively]. There was no difference in rates of sickness absence found for decision latitude [IRR 1.02 (95% CI 1.00-1.04)].Our findings demonstrate that the discrepancy between externally and self-assessed job demand measures have additional predictive power beyond each individual measure of job structure, which may be related to the extent of cognitive and emotional processing of assessment questions as compared to decision latitude measures.

  View details for Web of Science ID 000283701800004

  View details for PubMedID 20725704

• Differences in the association of cardiovascular risk factors with education: a comparison of Costa Rica (CRELES) and the USA (NHANES) JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH Rehkopf, D. H., Dow, W. H., Rosero-Bixby, L. 2010; 64 (9): 821-828

  Abstract

  Despite different levels of economic development, Costa Rica and the USA have similar mortalities among adults. However, in the USA there are substantial differences in mortality by educational attainment, and in Costa Rica there are only minor differences. This contrast motivates an examination of behavioural and biological correlates underlying this difference.The authors used data on adults aged 60 and above from the Costa Rican Longevity and Healthy Ageing Study (CRELES) (n=2827) and from the US National Health and Nutrition Examination Survey (NHANES) (n=5607) to analyse the cross-sectional association between educational level and the following risk factors for cardiovascular disease (CVD): ever smoked, current smoker, sedentary, high saturated fat, high carbohydrates, high calorie diet, obesity, severe obesity, large waist circumference, HDL cholesterol, LDL cholesterol, triglycerides, hemoglobin A1c, fasting glucose, C-reactive protein, systolic blood pressure and BMI.There were significantly fewer hazardous levels of risk biomarkers at higher levels of education for more than half (10 out of 17) of the risk factors in the USA, but for less than a third of the outcomes in Costa Rica (five out of 17).These results are consistent with the context-specific nature of educational differences in risk factors for CVD and with a non-uniform nature of association of CVD risk factors with education within countries. Our results also demonstrate that social equity in mortality is achieved without uniform equity in all risk factors.

  View details for DOI 10.1136/jech.2009.086926

  View details for Web of Science ID 000281308900016

  View details for PubMedID 19822554

• The association of earnings with health in middle age: Do self-reported earnings for the previous year tell the whole story? SOCIAL SCIENCE & MEDICINE Rehkopf, D. H., Jencks, C., Glymour, M. M. 2010; 71 (3): 431-439

  Abstract

  Research on earnings and health frequently relies on self-reported earnings (SRE) for a single year, despite repeated criticism of this measure. We use 31 years (1961-1991) of earnings recorded by the United States Social Security Administration (SSA) to predict the 1992 prevalence of disability, diabetes, stroke, heart disease, cancer, depression and death by 2002 in a subset of Health and Retirement Study participants (n = 5951). We compare odds ratios (ORs) for each health outcome associated with self-reported or administratively recorded earnings. Individuals with no 1991 SSA earnings had worse health in multiple domains than those with positive earnings. However, this association diminished as the time lag between earnings and health increased, so that the absence of earnings before approximately 1975 did not predict health in 1992. Among those with positive earnings, lengthening the lag between SSA earnings and health did not significantly diminish the magnitude of the association with diabetes, heart disease, stroke, or death. Longer lags did reduce but did not eliminate the association between earnings and both disability and depression. Despite theoretical limitations of single year SRE, there were no statistically significant differences between the ORs estimated with single-year SRE and those estimated with a 31-year average of SSA earnings. For example, a one unit increase in logged SRE for 1991 predicted a 19% reduction in the odds of dying by 2002 (OR = 0.81; 95% confidence interval: 0.72,0.90), while a similar increase in average SSA earnings for 1961-1991 had an OR of 0.72 (0.63, 0.82). The point estimates for the OR associated with 31 year average SSA earnings were further from the null than the ORs associated with single year SRE for heart disease, depression, and death, and closer to the null for disability, diabetes, and stroke, but none of these differences was statistically significant.

  View details for DOI 10.1016/j.socscimed.2010.03.045

  View details for Web of Science ID 000280120100002

  View details for PubMedID 20580858

• Association of maternal gestational weight gain with short- and long-term maternal and child health outcomes. American journal of obstetrics and gynecology Margerison Zilko, C. E., Rehkopf, D., Abrams, B. 2010; 202 (6): 574 e1-8

  Abstract

  The purpose of this study was to investigate the associations between gestational weight gain (GWG) and small- and large-for-gestational-age (SGA, LGA), cesarean delivery, child overweight, and maternal postpartum weight retention in a diverse sample of women in the Unites States.We estimated associations between GWG (continuous and within categories defined by the Institute of Medicine), maternal prepregnancy body mass index, and each outcome in 4496 births in the National Longitudinal Survey of Youth 1979, which was a prospective cohort.GWG (kilograms) was associated with decreased risk of SGA and increased risk of LGA, cesarean delivery, postpartum weight retention, and child overweight independent of maternal demographic and pregnancy characteristics. Gain above the Institute of Medicine guidelines was associated with decreased risk of SGA and increased risk of all other outcomes.Excessive gain may have long-term consequences for maternal and child body size, but the benefits of lower gain must be balanced against risk of SGA.

  View details for DOI 10.1016/j.ajog.2009.12.007

  View details for PubMedID 20132923

• Commentary: It's not all means and genes-socio-economic position, variation and genetic confounding INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Rehkopf, D. H., Adler, N. 2010; 39 (2): 415-416

  View details for DOI 10.1093/ije/dyp396

  View details for Web of Science ID 000276303800018

  View details for PubMedID 20123950

• Biologic Risk Markers for Coronary Heart Disease Nonlinear Associations With Income EPIDEMIOLOGY Rehkopf, D. H., Krieger, N., Coull, B., Berkman, L. F. 2010; 21 (1): 38-46

  Abstract

  It is unclear whether a linear relationship is an appropriate description of the association between income and biologic markers of coronary heart disease risk. Stronger associations at certain levels of income would have implications for underlying mechanisms.The study is based on a healthy sample of 25-64 year olds (n = 14,022) from a nationally representative cross-sectional study (the 1988-1994 United States Third National Health and Nutrition Examination Survey). We use regression splines to model the shape of the association between income and 8 biologic markers for coronary heart disease risk, controlling for age, race/ethnicity, marital status, and education.Substantial income-biomarker associations were found for 5 outcomes among women (HDL cholesterol, triglycerides, C-reactive protein, systolic blood pressure, and venous blood lead) and for 3 outcomes among men (HDL cholesterol, triglycerides, and venous blood lead). The most common shapes of association were a stronger association at lower income levels and a greater risk level of biomarker near median income.We find that the associations of income with biologic risk markers are often nonlinear. The differences in the shape of association suggest there are multiple pathways through which income is associated with coronary heart disease risk.

  View details for DOI 10.1097/EDE.0b013e3181c30b89

  View details for Web of Science ID 000272872900009

  View details for PubMedID 20010209

• Socioeconomic gradients in health in international and historical context BIOLOGY OF DISADVANTAGE: SOCIOECONOMIC STATUS AND HEALTH Dow, W. H., Rehkopf, D. H. 2010; 1186: 24-36

  Abstract

  This article places socioeconomic gradients in health into a broader international and historical context. The data we present supports the conclusion that current socioeconomic gradients in health within the United States are neither inevitable nor immutable. This literature reveals periods in the United States with substantially smaller gradients, and identifies many examples of other countries whose different social policy choices appear to have led to superior health levels and equity even with fewer aggregate resources. The article also sheds light on the potential importance of various hypothesized mechanisms in driving major shifts in U.S. population health patterns. While it is essential to carefully examine individual mechanisms contributing to health patterns, it is also illuminating to take a more holistic view of the set of factors changing in conjunction with major shifts in population health. In this article, we do so by focusing on the period of the 1980s, during which U.S. life expectancy gains slowed markedly relative to other developed countries, and U.S. health disparities substantially increased. A comparison with Canada suggests that exploring broad social policy differences, such as the weaker social safety net in the United States, may be a promising area for future investigation.

  View details for DOI 10.1111/j.1749-6632.2009.05384.x

  View details for Web of Science ID 000277908000003

  View details for PubMedID 20201866

• Socioeconomic status in relation to early menarche among black and white girls CANCER CAUSES & CONTROL Braithwaite, D., Moore, D. H., Lustig, R. H., Epel, E. S., Ong, K. K., Rehkopf, D. H., Wang, M. C., Miller, S. M., Hiatt, R. A. 2009; 20 (5): 713-720

  Abstract

  Early menarche is a risk factor for breast cancer. We investigated the variation in age at menarche by socioeconomic status (SES) and race.A cohort study was conducted on 1,091 black and 986 white girls from the three sites in the United States as part of the NHLBI Growth and Health Study (NGHS), who were aged 9-10 years at baseline and followed through adolescence over a 10-year period with annual exams. Using logistic regression models, we evaluated the nature and strength of associations between two socioeconomic indicators (household income and parental education) and early menarche (<12 years old) unadjusted and adjusted for anthropometry and maternal age at menarche.Proportionately, more black girls were menarcheal before 12 years of age compared to their white counterparts (46%, n = 468 vs. 26%, n = 240, respectively, p < 0.0001). Parental education was not a significant predictor of early menarche. The graded association between household income and age at menarche was strong and significant among black girls but less clear among white girls. Compared with those in the lowest quartile of household income, white girls in the highest quartile were at a significantly lower risk of early menarche [adjusted odds ratio (OR) = 0.37, 95% confidence intervals (CIs) 0.18-0.80]. The inverse was true for black girls: those in the highest quartile of household income were at an increased risk of early menarche (adjusted OR = 2.15, 95% CI 1.27-3.63)The SES factor selected (household income versus parental education) affected the findings regarding racial differences in the timing of menarche. It will be important for future studies to elucidate the link between household income and age at menarche in developed countries.

  View details for DOI 10.1007/s10552-008-9284-9

  View details for Web of Science ID 000266340200023

  View details for PubMedID 19107561

• Life course priorities among Appalacian emerging adults: revisiting Wallace's organization of diversity Ethos Brown R, Rehkopf DH, Worthman CM, Copland W, Costello EJ 2009; 37 (2): 225-242
• The non-linear risk of mortality by income level in a healthy population: US National Health and Nutrition Examination Survey mortality follow-up cohort, 1988-2001 BMC PUBLIC HEALTH Rehkopf, D. H., Berkman, L. F., Coull, B., Krieger, N. 2008; 8

  Abstract

  An examination of where in the income distribution income is most strongly associated with risk of mortality will provide guidance for identifying the most critical pathways underlying the connections between income and mortality, and may help to inform public health interventions to reduce socioeconomic disparities. Prior studies have suggested stronger associations at the lower end of the income distribution, but these studies did not have detailed categories of income, were unable to exclude individuals whose declining health may affect their income and did not use methods to determine exact threshold points of non-linearity. The purpose of this study is to describe the non-linear risks of all-cause and cause-specific mortality across the income distribution.We examined potential non-linear risk of mortality by family income level in a population that had not retired early, changed jobs, or changed to part-time work due to health reasons, in order to minimize the effects of illness on income. We used data from the US National Health and Nutrition Examination Survey (1988-1994), among individuals age 18-64 at baseline, with mortality follow-up to the year 2001 (ages 25-77 at the end of follow-up, 106 037 person-years of time at risk). Differential risk of mortality was examined using proportional hazard models with penalized regression splines in order to allow for non-linear associations between mortality risk and income, controlling for age, race/ethnicity, marital status, level of educational attainment and occupational category.We observed significant non-linear risks of all-cause mortality, as well as for certain specific causes of death at different levels of income. Typically, risk of mortality decreased with increasing income levels only among persons whose family income was below the median; above this level, there was little decreasing risk of mortality with higher levels of income. There was also some variation in mortality risk at different levels of income by cause and gender.The majority of the income associated mortality risk in individuals between the ages of 18-77 in the United States is among the population whose family income is below the median (equal to $20,190 in 1991, 3.2 times the poverty level). Efforts to decrease socioeconomic disparities may have the greatest impact if focused on this population.

  View details for DOI 10.1186/1471-2458-8-383

  View details for Web of Science ID 000261409300001

  View details for PubMedID 19000311

• Depression among Latinos in the United States: A meta-analytic review JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Mendelson, T., Rehkopf, D. H., Kubzansky, L. D. 2008; 76 (3): 355-366

  Abstract

  The authors conducted a meta-analytic review to assess the prevalence of major depressive disorder and depressive symptoms among Latinos compared with non-Latino Whites in the United States using community-based data. Random-effects estimates were calculated for 8 studies meeting inclusion criteria that reported lifetime prevalence of major depressive disorder (combined N = 76,270) and for 23 studies meeting inclusion criteria that reported current prevalence of depressive symptoms (combined N = 38,997). Findings did not indicate a group difference in lifetime prevalence of major depressive disorder (odds ratio = 0.89, 95% confidence interval = 0.72, 1.10). Latinos reported more depressive symptoms than non-Latino Whites (standardized mean difference = 0.19, 95% confidence interval = 0.12, 0.25); however, this effect was small and does not appear to suggest a clinically meaningful preponderance of depressive symptoms among Latinos. Findings are examined in the context of theories on vulnerability and resilience, and recommendations for future research are discussed.

  View details for DOI 10.1037/0022-006X.76.3.355

  View details for Web of Science ID 000256326700001

  View details for PubMedID 18540730

• The fall and rise of US inequities in premature mortality: 1960-2002 PLOS MEDICINE Krieger, N., Rehkopf, D. H., Chen, J. T., Waterman, P. D., Marcelli, E., Kennedy, M. 2008; 5 (2): 227-241

  Abstract

  Debates exist as to whether, as overall population health improves, the absolute and relative magnitude of income- and race/ethnicity-related health disparities necessarily increase-or decrease. We accordingly decided to test the hypothesis that health inequities widen-or shrink-in a context of declining mortality rates, by examining annual US mortality data over a 42 year period.Using US county mortality data from 1960-2002 and county median family income data from the 1960-2000 decennial censuses, we analyzed the rates of premature mortality (deaths among persons under age 65) and infant death (deaths among persons under age 1) by quintiles of county median family income weighted by county population size. Between 1960 and 2002, as US premature mortality and infant death rates declined in all county income quintiles, socioeconomic and racial/ethnic inequities in premature mortality and infant death (both relative and absolute) shrank between 1966 and 1980, especially for US populations of color; thereafter, the relative health inequities widened and the absolute differences barely changed in magnitude. Had all persons experienced the same yearly age-specific premature mortality rates as the white population living in the highest income quintile, between 1960 and 2002, 14% of the white premature deaths and 30% of the premature deaths among populations of color would not have occurred.The observed trends refute arguments that health inequities inevitably widen-or shrink-as population health improves. Instead, the magnitude of health inequalities can fall or rise; it is our job to understand why.

  View details for DOI 10.1371/journal.pmed.0050046

  View details for Web of Science ID 000254928800014

  View details for PubMedID 18303941

• US disparities in health: Descriptions, causes, and mechanisms ANNUAL REVIEW OF PUBLIC HEALTH Adler, N. E., Rehkopf, D. H. 2008; 29: 235-252

  Abstract

  Eliminating health disparities is a fundamental, though not always explicit, goal of public health research and practice. There is a burgeoning literature in this area, but a number of unresolved issues remain. These include the definition of what constitutes a disparity, the relationship of different bases of disadvantage, the ability to attribute cause from association, and the establishment of the mechanisms by which social disadvantage affects biological processes that get into the body, resulting in disease. We examine current definitions and empirical research on health disparities, particularly disparities associated with race/ethnicity and socioeconomic status, and discuss data structures and analytic strategies that allow causal inference about the health impacts of these and associated factors. We show that although health is consistently worse for individuals with few resources and for blacks as compared with whites, the extent of health disparities varies by outcome, time, and geographic location within the United States. Empirical work also demonstrates the importance of a joint consideration of race/ethnicity and social class. Finally, we discuss potential pathways, including exposure to chronic stress and resulting psychosocial and physiological responses to stress, that serve as mechanisms by which social disadvantage results in health disparities.

  View details for DOI 10.1146/annurev.publhealth.29.020907.090852

  View details for Web of Science ID 000255349400018

  View details for PubMedID 18031225

• Socioeconomic position and the metabolic syndrome in early, middle, and late life: Evidence from NHANES 1999-2002 ANNALS OF EPIDEMIOLOGY Loucks, E. B., Magnusson, K. T., Cook, S., Rehkopf, D. H., Ford, E. S., Berkman, L. F. 2007; 17 (10): 782-790

  Abstract

  To evaluate whether there is an association between socioeconomic position (SEP) and the metabolic syndrome at various ages, including adolescent, middle-aged and older participants in gender-specific analyses.Participants were from the 1999-2002 National Health and Nutrition Examination Survey. SEP was measured by income and years of education. Metabolic syndrome was measured in adults using the American Heart Association guidelines and in adolescents using methods based on national reference data. Cross-sectional multivariable-adjusted logistic regression analyses were performed.In women aged 25 to 45 and 46 to 65 years, income below the poverty line (poverty income ratio [PIR] less than one) was associated with higher odds of metabolic syndrome compared with PIR greater than 3 (odds ratio [OR] = 4.90; 95% confidence interval (CI) = 2.24, 10.71, and OR = 2.54; CI = 1.38, 4.67, for the respective age groups) after adjustment for age, race/ethnicity, and menopause. Similar findings were observed for educational attainment. In adolescents, older adults (aged >65 years), and males, income and education were not related to the metabolic syndrome.This report demonstrates that SEP is associated with the metabolic syndrome in females aged 25 to 65 years and is less strongly associated in males, adolescents, or older participants. These findings provide physiologic mechanistic evidence linking SEP to risk for coronary heart disease.

  View details for DOI 10.1016/j.annepidem.2007.05.003

  View details for Web of Science ID 000250067200005

  View details for PubMedID 17697786

• Socioeconomic disparities in metabolic syndrome differ by gender: Evidence from NHANES III ANNALS OF EPIDEMIOLOGY Loucks, E. B., Rehkopf, D. H., Thurston, R. C., Kawachi, I. 2007; 17 (1): 19-26

  Abstract

  The aim of the study is to examine whether socioeconomic position (SEP) is associated with metabolic syndrome and whether the association differs by gender and race/ethnicity.Study participants were from the Third National Health and Nutrition Examination Survey. SEP was measured by using education and poverty income ratio (PIR). Metabolic syndrome was measured according to the National Institutes of Health guidelines. Multivariable-adjusted logistic regression analyses were performed.Low education (<12 years) was associated with metabolic syndrome in women (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.39-2.24) and less so in men (OR, 1.27; 95% CI, 0.97-1.66) versus more than 12 years of education. For income, low PIR (

  View details for DOI 10.1016/j.annepidem.2006.07.002

  View details for Web of Science ID 000243281300003

  View details for PubMedID 17140811

• Monitoring socioeconomic disparities in death: Comparing individual-level education and area-based socioeconomic measures AMERICAN JOURNAL OF PUBLIC HEALTH Rehkopf, D. H., Haughton, L. T., Chen, J. T., Waterman, P. D., Subramanian, S. V., Krieger, N. 2006; 96 (12): 2135-2138

  Abstract

  We compared all-cause mortality rates stratified by individual-level education and by census tract area-based socioeconomic measures for Massachusetts (1999-2001). Among persons aged 25 and older, the age-adjusted relative index of inequality was slightly higher for the census tract than for the individual education measures (1.5 vs 1.2, respectively). Only the census tract socioeconomic measures could provide a relative index of inequality (2-3) for deaths before age 25 or detect expected socioeconomic disparities for deaths among persons 65 and older (relative index of inequality= approximately 1.2 vs 0.8 for census tract measures and individual education, respectively).

  View details for DOI 10.2105/AJPH.2005.075408

  View details for Web of Science ID 000242474500010

  View details for PubMedID 16809582

• Comparing individual- and area-based socioeconomic measures for the surveillance of health disparities: A multilevel analysis of Massachusetts births, 1989-1991 AMERICAN JOURNAL OF EPIDEMIOLOGY Subramanian, S. V., Chen, J. T., Rehkopf, D. H., Waterman, P. D., Krieger, N. 2006; 164 (9): 823-834

  Abstract

  The absence of individual-level socioeconomic information in most US health surveillance data necessitates using area-based socioeconomic measures (ABSMs) to monitor health inequalities. Using the 1989-1991 birth weight data from Massachusetts, the authors compared estimates of health disparities detected with census tract- and block group-level ABSMs pertaining to poverty and education, as well as parental education, both independently and together. In separate models, adjusted for infant's sex, mother's age, and parents' race/ethnicity, worst-off categories of census tract ABSMs and parental education had a comparable birth weight deficit of approximately 70 g. Similar results were observed for low birth weight (<2,500 g), with worst-off categories of census tract ABSMs and parental education having an odds ratio of approximately 1.37 (p < 0.001). In mutually adjusted models for birth weight and low birth weight, census tract ABSMs still detected an effect estimate nearly 50% of that detected by parental education. Additionally, census tract ABSMs detected socioeconomic gradients in birth weight among births to mothers aged less than 25 years, an age group in which educational attainment is unlikely to be completed. These results suggest that aptly chosen ABSMs can be used to monitor socioeconomic inequalities in health. The risk, if any, in the absence of individual-level socioeconomic information is a conservative estimate of socioeconomic inequalities in health.

  View details for DOI 10.1093/aje/kwj313

  View details for Web of Science ID 000241432000002

  View details for PubMedID 16968866

• Mapping and measuring social disparities in premature mortality: The impact of census tract poverty within and across Boston neighborhoods, 1999-2001 JOURNAL OF URBAN HEALTH-BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE Chen, J. T., Rehkopf, D. H., Waterman, P. D., Subramanian, S. V., Coull, B. A., Cohen, B., Ostrem, M., Krieger, N. 2006; 83 (6): 1063-1084

  Abstract

  The identification and documentation of health disparities are important functions of public health surveillance. These disparities, typically falling along lines defined by gender, race/ethnicity, and social class, are often made visible in urban settings as geographic disparities in health between neighborhoods. Recognizing that premature mortality is a powerful indicator of disparities in both health status and access to health care that can readily be monitored using routinely available public health surveillance data, we undertook a systematic analysis of spatial variation in premature mortality in Boston (1999-2001) across neighborhoods and sub-neighborhoods in relation to census tract (CT) poverty. Using a multilevel model based framework, we estimated that the incidence of premature mortality was 1.39 times higher (95% credible interval 1.09-1.78) among persons living in the most economically deprived CTs (>/=20% below poverty) compared to those in the least impoverished tracts (<5% below poverty). We present maps of model-based standardized mortality ratios that show substantial within-neighborhood variation in premature mortality and a sizeable decrease in spatial variation after adjustment for CT poverty. Additionally, we present maps of model-based direct standardized rates that can more readily be compared to externally published rates and targets, as well as maps of the population attributable fraction that show that in some of Boston's poorest neighborhoods, the proportion of excess deaths associated with CT poverty reaches 25-30%. We recommend that these methods be incorporated into routine analyses of public health surveillance data to highlight continuing social disparities in premature mortality.

  View details for DOI 10.1007/s11524-006-9089-7

  View details for Web of Science ID 000243181900007

  View details for PubMedID 17001522

• Race/ethnicity and changing US socioeconomic gradients in breast cancer incidence: California and Massachusetts, 1978-2002 (United States) CANCER CAUSES & CONTROL Krieger, N., Chen, J. T., Waterman, P. D., Rehkopf, D. H., Yin, R. H., Coull, B. A. 2006; 17 (2): 217-226

  Abstract

  We tested the hypothesis that the US socioeconomic gradient in breast cancer incidence is declining, with the decline most pronounced among racial/ethnic groups with the highest incidence rates.We geocoded the invasive incident breast cancer cases for three US population-based cancer registries covering: Los Angeles County, CA (1978-1982, 1988-1992, 1998-2002; n = 68,762 cases), the San Francisco Bay Area, CA (1978-1982, 1988-1992, 1998-2002; n = 37,210 cases) and Massachusetts (1988-1992, 1998-2002; n = 48,111 cases), linked the records to census tract area-based socioeconomic measures, and, for each socioeconomic stratum, computed average annual breast cancer incidence rates for the 5-year period straddling the 1980, 1990, and 2000 census, overall and by race/ethnicity and gender.Our findings indicate that the socioeconomic gradient in breast cancer incidence is: (a) relatively small (at most 1.2) and stable among US white non-Hispanic and black women; (b) sharper and generally increasing among Hispanic and Asian and Pacific Islander American women; and (c) cannot be meaningfully analyzed without considering effect modification by race/ethnicity and immigration.Our results indicate that secular changes in US socioeconomic gradients in breast cancer incidence exist and vary by race/ethnicity.

  View details for DOI 10.1007/s10552-005-0408-1

  View details for Web of Science ID 000234754500011

  View details for PubMedID 16425100

• The association between suicide and the socio-economic characteristics of geographical areas: a systematic review PSYCHOLOGICAL MEDICINE Rehkopf, D. H., Buka, S. L. 2006; 36 (2): 145-157

  Abstract

  Despite an extensive literature, there have been widely divergent findings regarding the direction of the association between area socio-economic characteristics and area suicide rates, with high-quality studies finding either a direct relation (higher rates of suicide in higher socio-economic areas), an inverse relation (lower rates of suicide in higher socio-economic areas) or no association.We performed a systematic review of the literature dating from 1897 to 2004 and identified 86 publications with 221 separate analyses that met our inclusion criteria. We examined the percent of direct, inverse and null findings stratified by key study characteristics including size of aggregated area, socio-economic measure used, region of study, control variables and study design.Analyses at the community level are significantly more likely to demonstrate lower rates of suicide among higher socio-economic areas than studies using larger areas of aggregation. Measures of area poverty and deprivation are most likely to be inversely associated with suicide rates and median income is least likely to be inversely associated with suicide rates. Analyses using measures of unemployment and education and occupation were equally likely to demonstrate inverse associations. Study results did not vary significantly by gender or by study design.The heterogeneity of associations is mostly accounted for by study design features that have largely been neglected in this literature. Enhanced attention to size of region and measurement strategies provide a clearer picture of how suicide rates vary by region. Resources for suicide prevention should be targeted to high poverty/deprivation and high unemployment areas.

  View details for DOI 10.1017/S003329170500588X

  View details for Web of Science ID 000235200800001

  View details for PubMedID 16420711

• Painting a truer picture of US socioeconomic and racial/ethnic health inequalities: The public health disparities geocoding project AMERICAN JOURNAL OF PUBLIC HEALTH Krieger, N., Chen, J. T., Waterman, P. D., Rehkopf, D. H., Subramanian, S. V. 2005; 95 (2): 312-323

  Abstract

  We describe a method to facilitate routine monitoring of socioeconomic health disparities in the United States.We analyzed geocoded public health surveillance data including events from birth to death (c. 1990) linked to 1990 census tract (CT) poverty data for Massachusetts and Rhode Island.For virtually all outcomes, risk increased with CT poverty, and when we adjusted for CT poverty racial/ethnic disparities were substantially reduced. For half the outcomes, more than 50% of cases would not have occurred if population rates equaled those of persons in the least impoverished CTs. In the early 1990s, persons in the least impoverished CT were the only group meeting Healthy People 2000 objectives a decade ahead.Geocoding and use of the CT poverty measure permit routine monitoring of US socioeconomic inequalities in health, using a common and accessible metric.

  View details for DOI 10.2105/AJPH.2003.032482

  View details for Web of Science ID 000226851000030

  View details for PubMedID 15671470

• Racial disparities-in context: A multilevel analysis of neighborhood variations in poverty and excess mortality among black populations in Massachusetts AMERICAN JOURNAL OF PUBLIC HEALTH Subramanian, S. V., Chen, J. T., Rehkopf, D. H., Waterman, P. D., Krieger, N. 2005; 95 (2): 260-265

  Abstract

  We analyzed neighborhood heterogeneity in associations among mortality, race/ethnicity, and area poverty.We performed a multilevel statistical analysis of Massachusetts all-cause mortality data for the period 1989 through 1991 (n=142836 deaths), modeled as 79813 cells (deaths and denominators cross-tabulated by age, gender, and race/ethnicity) at level 1 nested within 5532 block groups at level 2 within 1307 census tracts (CTs) at level 3. We also characterized CTs by percentage of the population living below poverty level.Neighborhood variation in mortality across CTs and block groups was not accounted for by these areas' age, gender, and racial/ethnic composition. Neighborhood variation in mortality was much greater for the Black population than for the White population, largely because of CT-level variation in poverty rates.Neighborhood heterogeneity in the relationship between mortality and race/ethnicity in Massachusetts is statistically significant and is closely related to CT-level variation in poverty.

  View details for DOI 10.2105/AJPH.2003.034132

  View details for Web of Science ID 000226851000022

  View details for PubMedID 15671462

• Evaluating vancomycin use at a pediatric hospital: New approaches and insights INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY Bolon, M. K., Arnold, A. D., Feldman, H. A., Rehkopf, D. H., Strong, E. F., GOLDMANN, D. A., Wright, S. B. 2005; 26 (1): 47-55

  Abstract

  To characterize vancomycin use at a pediatric tertiary-care hospital, to discriminate between initial (< or = 72 hours) and prolonged (> 72 hours) inappropriate use, and to define patient characteristics associated with inappropriate use.Vancomycin courses were retrospectively reviewed using an algorithm modeled on HICPAC guidelines. Data were collected regarding patient demographics, comorbidities, other medication use, and nosocomial infections. The association between each variable and the outcome of inappropriate use was determined by longitudinal regression analysis. A multivariable model was constructed to assess risk factors for inappropriate initial and prolonged vancomycin use.A pediatric tertiary-care medical center.Children older than 1 year who received intravenous vancomycin from November 2000 to June 2001.Three hundred twenty-seven vancomycin courses administered to 260 patients were evaluated for appropriateness. Of initial courses, 114 (35%) were considered inappropriate. Of 143 prolonged courses, 103 (72%) were considered inappropriate. Multivariable risk factor analysis identified the following variables as significantly associated with inappropriate initial use: admission to the surgery service, having a malignancy, receipt of a stem cell transplant, and having received a prior inappropriate course of vancomycin. No variables were identified as significant risk factors for inappropriate prolonged use.Substantial inappropriate use of vancomycin was identified. Prolonged inappropriate use was a particular problem. This risk factor analysis suggests that interventions targeting patients admitted to certain services or receiving multiple courses of vancomycin could reduce inappropriate use.

  View details for Web of Science ID 000226369700007

  View details for PubMedID 15693408

• Race/ethnicity, gender, and monitoring socioeconomic gradients in health: A comparison of area-based socioeconomic measures - The public health disparities geocoding project AMERICAN JOURNAL OF PUBLIC HEALTH Krieger, N., Chen, J. T., Waterman, P. D., Rehkopf, D. H., Subramanian, S. V. 2003; 93 (10): 1655-1671

  Abstract

  Use of multilevel frameworks and area-based socioeconomic measures (ABSMs) for public health monitoring can potentially overcome the absence of socioeconomic data in most US public health surveillance systems. To assess whether ABSMs can meaningfully be used for diverse race/ethnicity-gender groups, we geocoded and linked public health surveillance data from Massachusetts and Rhode Island to 1990 block group, tract, and zip code ABSMs. Outcomes comprised death, birth, cancer incidence, tuberculosis, sexually transmitted infections, childhood lead poisoning, and nonfatal weapons-related injuries. Among White, Black, and Hispanic women and men, measures of economic deprivation (e.g., percentage below poverty) were most sensitive to expected socioeconomic gradients in health, with the most consistent results and maximal geocoding linkage evident for tract-level analyses.

  View details for Web of Science ID 000185881100016

  View details for PubMedID 14534218

• Assessing health impact assessment: multidisciplinary and international perspectives JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH Krieger, N., Northridge, M., Gruskin, S., Quinn, M., Kriebel, D., Smith, G. D., Bassett, M., Rehkopf, D. H., Miller, C. 2003; 57 (9): 659-662

  Abstract

  Health impact assessment (HIA) seeks to expand evaluation of policy and programmes in all sectors, both private and public, to include their impact on population health. While the idea that the public's health is affected by a broad array of social and economic policies is not new and dates back well over two centuries, what is new is the notion-increasingly adopted by major health institutions, such as the World Health Organisation (WHO) and the United Kingdom National Health Services (NHS)-that health should be an explicit consideration when evaluating all public policies. In this article, it is argued that while HIA has the potential to enhance recognition of societal determinants of health and of intersectoral responsibility for health, its pitfalls warrant critical attention. Greater clarity is required regarding criteria for initiating, conducting, and completing HIA, including rules pertaining to decision making, enforcement, compliance, plus paying for their conduct. Critical debate over the promise, process, and pitfalls of HIA needs to be informed by multiple disciplines and perspectives from diverse people and regions of the world.

  View details for Web of Science ID 000184853800008

  View details for PubMedID 12933768

• Identification, characterization, and functional analysis of a gene encoding the ferric uptake regulation protein in Bartonella species JOURNAL OF BACTERIOLOGY Park, S. Y., Kelminson, K. L., Lee, A. K., Zhang, P., Warner, R. E., Rehkopf, D. H., Calderwood, S. B., Koehler, J. E. 2001; 183 (19): 5751-5755

  Abstract

  Environmental iron concentrations coordinately regulate transcription of genes involved in iron acquisition and virulence via the ferric uptake regulation (fur) system. We identified and sequenced the fur gene and flanking regions of three Bartonella species. The most notable difference between Bartonella Fur and other Fur proteins was a substantially higher predicted isoelectric point. No promoter activity or Fur autoregulation was detected using a gfp reporter gene fused to the 204 nucleotides immediately upstream of the Bartonella fur gene. Bartonella henselae fur gene expression complemented a Vibrio cholerae fur mutant.

  View details for Web of Science ID 000170958900035

  View details for PubMedID 11544240

  View details for PubMedCentralID PMC95469

• Transcriptional mapping and RNA processing of the Plasmodium falciparum mitochondrial mRNAs MOLECULAR AND BIOCHEMICAL PARASITOLOGY Rehkopf, D. H., Gillespie, D. E., Harrell, M. I., Feagin, J. E. 2000; 105 (1): 91-103

  Abstract

  The mitochondrial genome of Plasmodium falciparum encodes three protein coding genes and highly fragmented rRNAs. The genome is polycistronically transcribed and, since gene-size transcripts are much more abundant than the polycistronic transcripts, the latter are presumably cleaved to produce the smaller, mature mRNAs and rRNAs. Mapping the transcripts of the P. falciparum mitochondrial protein coding genes shows that the 3' end of each gene directly abuts the 5' end of the gene located immediately downstream. The 5' ends of the protein coding genes are also closely apposed to adjacent genes, with one directly abutting a gene on the same DNA strand and two others separated by just 13 nt from an rDNA fragment encoded on the opposite strand. These mapping data are consistent with production of the mRNAs by cleavage from a polycistronic precursor transcript. Further processing of the mRNAs comes from addition of oligo(A) tails. Unexpectedly, the presence and length of such tails varies in a gene-specific fashion. In this regard, polyadenylation of the P. falciparum mitochondrial mRNAs is more similar to that seen for the P. falciparum mitochondrial rRNAs than that of mitochondrial mRNAs in other organisms.

  View details for Web of Science ID 000084168400009

  View details for PubMedID 10613702

• The fragmented mitochondrial ribosomal RNAs of Plasmodium falciparum have short A tails NUCLEIC ACIDS RESEARCH Gillespie, D. E., Salazar, N. A., Rehkopf, D. H., Feagin, J. E. 1999; 27 (11): 2416-2422

  Abstract

  The mitochondrial genome of Plasmodium falciparum encodes highly fragmented rRNAs. Twenty small RNAs which are putative rRNA fragments have been found and 15 of them have been identified as corresponding to specific regions of rRNA sequence. To investigate the possible interactions between the fragmented rRNAs in the ribosome, we have mapped the ends of many of the small transcripts using primer extension and RNase protection analysis. Results obtained from these studies revealed that some of the rRNA transcripts were longer than the sequences which encode them. To investigate these size discrepancies, we performed 3' RACE PCR analysis and RNase H mapping. These analyses revealed non-encoded oligo(A) tails on some but not all of these small rRNAs. The approximate length of the oligo(A) tail appears to be transcript-specific, with some rRNAs consistently showing longer oligo(A) tails than others. The oligoadenylation of the rRNAs may provide a buffer zone against 3' exonucleolytic attack, thereby preserving the encoded sequences necessary for secondary structure interactions in the ribosome.

  View details for Web of Science ID 000080678100025

  View details for PubMedID 10325433

• The sta-1 mutation prevents assembly of starch granules in nitrogen-starved cells and serves as a useful morphological marker during sexual reproduction in Chlamydomonas monoica Journal of Phycology Rickoll W, Rehkopf DH, Dunn C, Malmberg A, VanWinkle-Swift K 1998; 34 (1): 147-151
• The Plasmodium falciparum 6 kb element is polycistronically transcribed MOLECULAR AND BIOCHEMICAL PARASITOLOGY JI, Y. E., Mericle, B. L., Rehkopf, D. H., Anderson, J. D., Feagin, J. E. 1996; 81 (2): 211-223

  Abstract

  The Plasmodium falciparum 6 kb element encodes three protein coding genes and highly fragmented large and small subunit rRNAs; its gene content makes it the probable mitochondrial genome. Many of the genes are encoded so close to each other that there is insufficient room for specific promoters upstream of each gene. RNase protection analysis of two rRNA fragments whose genes are adjacent provided evidence for a polycistronic transcript containing sequences from both, as well as separate small RNAs. To evaluate the possibility of further polycistronic transcription, several sets of oligonucleotide primers located in different regions of the 6 kb element were employed to amplify cDNAs. These analyses have revealed the existence of 6 kb element transcripts as long as 5.9 kb. Both mRNA and rRNA sequences are included on these putative precursor transcripts. Since these types of RNA are known to have different patterns of abundance changes during the erythrocytic portion of the parasite life cycle, RNA stability is presumably an important feature in regulating mitochondrial transcript abundance.

  View details for Web of Science ID A1996VM86500009

  View details for PubMedID 8898336