Shawna Follis

All Publications

• Quantifying structural racism in cohort studies to advance prospective evidence. SSM - population health Follis, S., Breathett, K., Garcia, L., Jimenez, M., Cené, C. W., Whitsel, E., Hedlin, H., Paskett, E. D., Zhang, S., Thomson, C. A., Stefanick, M. L. 2023; 22: 101417

  Abstract

  Calls-to-action in health research have described a need to improve research on race, ethnicity, and structural racism. Well-established cohort studies typically lack access to novel structural and social determinants of health (SSDOH) or precise race and ethnicity categorization, contributing to a loss of rigor to conduct informative analyses and a gap in prospective evidence on the role of structural racism in health outcomes. We propose and implement methods that prospective cohort studies can use to begin to rectify this, using the Women's Health Initiative (WHI) cohort as a case study. To do so, we evaluated the quality, precision, and representativeness of race, ethnicity, and SSDOH data compared with the target US population and operationalized methods to quantify structural determinants in cohort studies. Harmonizing racial and ethnic categorization to the current standards set by the Office of Management and Budget improved measurement precision, aligned with published recommendations, disaggregated groups, decreased missing data, and decreased participants reporting "some other race". Disaggregation revealed sub-group disparities in SSDOH, including a greater proportion of Black-Latina (35.2%) and AIAN-Latina (33.3%) WHI participants with income below the US median compared with White-Latina (42.5%) participants. We found similarities in the racial and ethnic patterning of SSDOH disparities between WHI and US women but less disparity overall in WHI. Despite higher individual-level advantage in WHI, racial disparities in neighborhood resources were similar to the US, reflecting structural racism. Median neighborhood income was comparable between Black WHI ($39,000) and US ($34,700) women. WHI SSDOH-associated outcomes may be generalizable on the basis of comparing across race and ethnicity but may quantitatively (but not qualitatively) underestimate US effect sizes. This paper takes steps towards data justice by implementing methods to make visible hidden health disparity groups and operationalizing structural-level determinants in prospective cohort studies, a first step to establishing causality in health disparities research.

  View details for DOI 10.1016/j.ssmph.2023.101417

  View details for PubMedID 37207111

  View details for PubMedCentralID PMC10189286

• Resiliency among Women's Health Initiative women aged 80 and older by race, ethnicity, and neighborhood socioeconomic status. The journals of gerontology. Series B, Psychological sciences and social sciences Krok-Schoen, J. L., Naughton, M. J., Felix, A. S., Cene, C. W., Springfield, S., Yu, M., McLaughlin, E. M., Shadyab, A. H., Nolan, T. S., Kroenke, C. H., Garcia, L., Follis, S., Jackson, R. D. 2023

  Abstract

  OBJECTIVES: A comprehensive examination of resilience by race, ethnicity, and neighborhood socioeconomic status (NSES) among women aged ≥80 is needed, given the aging of the US population, increasing longevity, and growing racial and ethnic diversity.METHODS: Participants were women aged ≥80 enrolled in the Women's Health Initiative (WHI). Resilience was assessed with a modified version of the Brief Resilience Scale. Descriptive statistics and multiple linear regression examined the association of demographic, health, and psychosocial variables with resilience by race, ethnicity, and NSES.RESULTS: Participants (n=29,367, median age=84.3) were White (91.4%), Black (3.7%), Hispanic (1.9%), and Asian (1.7%) women. There were no significant differences by race and ethnicity on mean resiliency scores (p=0.06). Significant differences by NSES were observed regarding mean resiliency scores between those with low NSES (3.94±0.83, out of 5) and high NSES (4.00±0.81). Older age, higher education, higher self-rated health, lower stress, and living alone were significant positive correlates of resilience in the sample. Social support was correlated with resilience among White, Black, and Asian women, but not for Hispanic women. Depression was a significant correlate of lower resilience, except among Asian women. Living alone, smoking, and spirituality were significantly associated with higher resilience among women with moderate NSES.DISCUSSION: Multiple factors were associated with resilience among women aged ≥80 in the WHI. Despite some differing correlates of resilience by race, ethnicity, and NSES, there were many similarities. These results may aid in the design of resilience interventions for the growing, increasingly diverse population of older women.

  View details for DOI 10.1093/geronb/gbad048

  View details for PubMedID 36933001

• Social Support, social ties, and cognitive function of women with breast cancer: findings from the Women's Health Initiative (WHI) Life and Longevity After Cancer (LILAC) Study. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer Yang, Y., McLaughlin, E. M., Naughton, M. J., Lustberg, M. B., Nolan, T. S., Kroenke, C. H., Weitlauf, J. C., Saquib, N., Shadyab, A. H., Follis, S., Pan, K., Paskett, E. D. 2022; 31 (1): 48

  Abstract

  PURPOSE: This study examined associations between self-reported cognitive functioning and social support as well as social ties among women with breast cancer.METHODS: The study included 3351 women from the Women's Health Initiative Life and Longevity After Cancer cohort who were diagnosed with breast cancer stages I-III. Social support was assessed using a modified Medical Outcomes Study (MOS) Social Support Survey, and marital status was obtained from the baseline questionnaire. We also assessed social ties (e.g., number of friends, relatives, living children) and cognitive function (Functional Assessment of Cancer Therapy-Cognitive Function [FACT-COG]) on the year-1-follow up questionnaire. Multivariable quantile regression was used to estimate the changes in median cognitive scores. Kruskal-Wallis tests were used to assess the association of cognitive function with social ties.RESULTS: The majority of participants were non-Hispanic White (93.3%), presently married (49%), with at least a 4-year college degree (53.2%), and had been diagnosed with localized breast cancer (79%). A 10-point higher social support score correlated to a 0.32 higher (better) median cognitive score (p<0.001). Women who were presently married tended to have better cognition than women who were divorced/separated or widowed (p=0.01). Significant associations were also present for having close relatives (p<0.001) or friends (p<0.001), with cognitive scores being higher in those with at least one close relative or friend compared to none.CONCLUSION: Women reporting higher social support and greater numbers of friends or relatives have higher cognitive functioning. Compared to divorced or separated women, married women were likely to have higher cognitive functioning. These findings suggest that social support assessments have the potential to help identify women at higher risk of cognitive decline.

  View details for DOI 10.1007/s00520-022-07505-5

  View details for PubMedID 36525119

• Correction: Taking action to advance the study of race and ethnicity: the Women's Health Initiative (WHI). Women's midlife health Garcia, L., Follis, S., Thomson, C. A., Breathett, K., Cene, C. W., Jimenez, M., Kooperberg, C., Masaki, K., Paskett, E. D., Pettinger, M., Aragaki, A., Dilworth-Anderson, P., Stefanick, M. L. 2022; 8 (1): 13

  View details for DOI 10.1186/s40695-022-00083-w

  View details for PubMedID 36434684

• REEXAMINING RACE AND ETHNICITY FROM A STRUCTURAL RACISM AND SOCIAL DETERMINANTS OF HEALTH LENS IN COHORT STUDIES Follis, S. OXFORD UNIV PRESS. 2022: 810

  View details for Web of Science ID 000913044004094

• Contributions of the Women's Health Initiative to Cardiovascular Research: JACC State-of-the-Art Review. Journal of the American College of Cardiology LaMonte, M. J., Manson, J. E., Anderson, G. L., Baker, L. D., Bea, J. W., Eaton, C. B., Follis, S., Hayden, K. M., Kooperberg, C., LaCroix, A. Z., Limacher, M. C., Neuhouser, M. L., Odegaard, A., Perez, M. V., Prentice, R. L., Reiner, A. P., Stefanick, M. L., Van Horn, L., Wells, G. L., Whitsel, E. A., Rossouw, J. E. 2022; 80 (3): 256-275

  Abstract

  The WHI (Women's Health Initiative) enrolled 161,808 racially and ethnically diverse postmenopausal women, ages 50-79 years, from 1993 to 1998 at 40 clinical centers across the United States. In its clinical trial component, WHI evaluated 3 randomized interventions (menopausal hormone therapy; diet modification; and calcium/vitamin D supplementation) for the primary prevention of major chronic diseases, including cardiovascular disease, in older women. In the WHI observational study, numerous clinical, behavioral, and social factors have been evaluated as predictors of incident chronic disease and mortality. Although the original interventions have been completed, the WHI data and biomarker resources continue to be leveraged and expanded through ancillary studies to yield novel insights regarding cardiovascular disease prevention and healthy aging in women.

  View details for DOI 10.1016/j.jacc.2022.05.016

  View details for PubMedID 35835498

• Taking action to advance the study of race and ethnicity: the Women's Health Initiative (WHI). Women's midlife health Garcia, L., Follis, S., Thomson, C. A., Breathett, K., Cene, C. W., Jimenez, M., Kooperberg, C., Masaki, K., Paskett, E. D., Pettinger, M., Aragaki, A., Dilworth-Anderson, P., Stefanick, M. L. 1800; 8 (1): 1

  Abstract

  "Race" and "ethnicity" are socially constructed terms, not based on biology - in contrast to biologic ancestry and genetic admixture - and are flexible, contested, and unstable concepts, often driven by power. Although individuals may self-identify with a given race and ethnic group, as multidimensional beings exposed to differential life influencing factors that contribute to disease risk, additional social determinants of health (SDOH) should be explored to understand the relationship of race or ethnicity to health. Potential health effects of structural racism, defined as "the structures, policies, practices, and norms resulting in differential access to goods, services, and opportunities of society by "race," have been largely ignored in medical research. The Women's Health Initiative (WHI) was expected to enroll a racially and ethnically diverse cohort of older women at 40U.S. clinical centers between 1993 and 1998; yet, key information on the racial and ethnic make-up of the WHI cohort of 161,808 women was limited until a 2020-2021 Task Force was charged by the WHI Steering Committee to better characterize the WHI cohort and develop recommendations for WHI investigators who want to include "race" and/or "ethnicity" in papers and presentations. As the lessons learned are of relevance to most cohorts, the essence of the WHI Race and Ethnicity Language and Data Interpretation Guide is presented in this paper. Recommendations from the WHI Race and Ethnicity Language and Data Interpretation Guide include: Studies should be designed to include all populations and researchers should actively, purposefully and with cultural-relevance, commit to recruiting a diverse sample; Researchers should collect robust data on race, ethnicity and SDOH variables that may intersect with participant identities, such as immigration status, country of origin, acculturation, current residence and neighborhood, religion; Authors should use appropriate terminology, based on a participant's self-identified "race" and "ethnicity", and provide clear rationale, including a conceptual framework, for including race and ethnicity in the analytic plan; Researchers should employ appropriate analytical methods, including mixed-methods, to study the relationship of these sociocultural variables to health; Authors should address how representative study participants are of the population to which results might apply, such as by age, race and ethnicity.

  View details for DOI 10.1186/s40695-021-00071-6

  View details for PubMedID 34983682

• MRI based validation of abdominal adipose tissue measurements from DXA in postmenopausal women. Journal of clinical densitometry : the official journal of the International Society for Clinical Densitometry Bea, J. W., Chen, Z., Blew, R. M., Nicholas, J. S., Follis, S., Bland, V. L., Cheng, T. D., Ochs-Balcom, H. M., Wactawski-Wende, J., Banack, H. R., Neuhouser, M. L., Laddu, D., Stefanick, M. L., Cauley, J. A., Caan, B., LeBoff, M. S., Chlebowski, R. T., Odegaard, A. O. 2021

  Abstract

  INTRODUCTION: Visceral adipose tissue (VAT) is a hypothesized driver of chronic disease. Dual-energy X-ray absorptiometry (DXA) potentially offers a lower cost and more available alternative compared to gold-standard magnetic resonance imaging (MRI) for quantification of abdominal fat sub-compartments, VAT and subcutaneous adipose tissue (SAT). We sought to validate VAT and SAT area (cm2) from historical DXA scans against MRI.METHODOLOGY: Participants (n = 69) from the Women's Health Initiative (WHI) completed a 3 T MRI scan and a whole body DXA scan (Hologic QDR2000 or QDR4500; 2004-2005). A subset of 43 participants were scanned on both DXA devices. DXA-derived VAT and SAT at the 4th lumbar vertebrae (5 cm wide) were analyzed using APEX software (v4.0, Hologic, Inc., Marlborough, MA). MRI VAT and SAT areas for the corresponding DXA region of interest were quantified using sliceOmatic software (v5.0, Tomovision, Magog, Canada). Pearson correlations between MRI and DXA-derived VAT and SAT were computed, and a Bland-Altman analysis was performed.RESULTS: Participants were primarily non-Hispanic white (86%) with a mean age of 70.51 ± 5.79 years and a mean BMI of 27.33 ± 5.40 kg/m2. Correlations between MRI and DXA measured VAT and SAT were 0.90 and 0.92, respectively (p ≤ 0.001). Bland-Altman plots showed that DXA-VAT slightly overestimated VAT on the QDR4500 (-3.31 cm2); this bias was greater in the smaller subset measured on the older DXA model (QDR2000; -30.71 cm2). The overestimation of DXA-SAT was large (-85.16 to -118.66 cm2), but differences were relatively uniform for the QDR4500.CONCLUSIONS: New software applied to historic Hologic DXA scans provide estimates of VAT and SAT that are well-correlated with criterion MRI among postmenopausal women.

  View details for DOI 10.1016/j.jocd.2021.07.010

  View details for PubMedID 34404568

• The intersectional role of social stress in fracture risk: results from the Women's Health Initiative. Journal of epidemiology and community health Follis, S., Klimentidis, Y. C., Bea, J., Hu, C., Garcia, D., Wactawski-Wende, J., Kohler, L., Shadyab, A. H., Flores, M., Tindle, H. A., Chen, Z. 2021

  Abstract

  BACKGROUND: The biological consequences of stress from the social environment pattern health outcomes. This study investigated whether social stress is prospectively associated with fracture incidence among racially and ethnically diverse, postmenopausal women.METHODS: Data from 160 709 postmenopausal women in the Women's Health Initiative was analysed using Cox proportional hazards regression models to examine prospective associations of social stress with time to total and hip fracture incidence. Self-reported questionnaires measuring social strain, social functioning and social support were used to assess social stress.RESULTS: Age and race/ethnicity modified associations between social stress and total and hip fractures. HRs for the associations between higher social support (indicating lower social stress) and total fractures among those age 50-59 years were 0.92 (95% CI: 0.90 to 0.94); HR=0.94 (95% CI: 0.93 to 0.95) for those age 60-69 years and HR=0.96 (95% CI: 0.95 to 0.98) for those age 70-79 years. Higher social strain was associated with greater hip fracture incidence among Native American women (HR=1.84, 95% CI: 1.10 to 3.10), Asian women (HR=1.37, 95% CI: 1.01 to 1.86) and white women (HR=1.04, 95% CI: 1.01 to 1.08).CONCLUSION: Identifying population patterns of fracture incidence as biological expressions of social environments reveals how race/ethnic specific social environmental factors influence disparities in fractures.

  View details for DOI 10.1136/jech-2020-216354

  View details for PubMedID 34039659

• Comparison of Wearable Sensor to Traditional Methods in Functional Outcome Measures: A Systematic Review. Journal of orthopaedic research : official publication of the Orthopaedic Research Society Follis, S., Chen, Z., Mishra, S., Howe, C. L., Toosizadeh, N., Dohm, M. 2020

  Abstract

  Traditional methods of collecting functional outcome measures are widely used for lower extremity arthroplasty outcome assessment. Wearable sensors are emerging as viable tools for functional outcome measures in monitoring of post-arthroplasty recovery. The objective of this review was to compare the efficacy of wearable sensors with traditional methods for monitoring post-arthroplasty functional recovery. Articles were searched for inclusion in this review that used both traditional and wearable sensor functional outcome measures to assess lower-extremity function before and after lower extremity arthroplasty. Two independent screeners reviewed all articles, and resolved differences through consensus and consultation with the senior author. Studies that met inclusion criteria were evaluated for methodologic quality using performed risk of bias assessments. Results from several traditional and wearable sensor functional outcome measures from baseline through follow-up were normalized across studies. Fourteen articles met inclusion criteria. Six studies used statistical methods to directly compare functional outcome measures, and eight studies used qualitative description of comparisons. This review found evidence that wearable sensors detected nuanced functional outcome information on the specific biomechanics and timing of recovery, which were unaccounted for using traditional methods.Wearable sensors have shown promising utility in providing additional recovery information from lower extremity arthroplasty compared with traditional functional outcome measures, but future research is needed to assess the clinical significance of this additional information. Wearable sensor technology is an emerging clinical tool providing advanced and determinative data with the potential for advancing assessment of lower extremity arthroplasty outcomes. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/jor.24950

  View details for PubMedID 33300119

• Psychosocial stress and bone loss among postmenopausal women: results from the Women's Health Initiative JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH Follis, S. L., Bea, J., Klimentidis, Y., Hu, C., Crandall, C. J., Garcia, D. O., Shadyab, A. H., Nassir, R., Chen, Z. 2019; 73 (9): 888–92

  Abstract

  Bone loss is a major public health concern with large proportions of older women experiencing osteoporotic fractures. Previous research has established a relationship between psychosocial stressors and fractures. However, few studies have investigated bone loss as an intermediary in this relationship. This study investigates whether social stress is associated with bone loss during a 6-year period in postmenopausal women.Data from 11 020 postmenopausal women from the USA was used to examine self-reported psychosocial stress in relation to change in bone mineral density (BMD) measured at the femoral neck, lumbar spine and total hip. Linear regression models were used to examine associations between social measures of psychosocial stress (social strain, social functioning and social support) and per cent change in BMD over 6 years.High social stress was associated with decreased BMD over 6 years. After adjustment for confounders, each point higher in social strain was associated with 0.082% greater loss of femoral neck BMD, 0.108% greater loss of total hip BMD and 0.069% greater loss of lumbar spine BMD (p<0.05). Low social functioning and low social support were associated with greater decreases in femoral neck BMD, and low social functioning was associated with greater decreases in total hip BMD.The findings provide evidence for an association between high social stress and greater bone loss over 6 years of follow-up. In agreement with the prior literature, the findings for social strain and social functioning suggest that poor quality of social relationships may be associated with bone loss in postmenopausal women.

  View details for DOI 10.1136/jech-2019-212516

  View details for Web of Science ID 000490193000016

  View details for PubMedID 31289118

• Reply to Effects of Hormone Replacement Therapy on Sarcopenia: Is It Real? JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Follis, S., Bea, J. W., Cauley, J. A., Shadyab, A. H., Cook, A., Chen, Z. 2019; 67 (6): 1298–99

  View details for DOI 10.1111/jgs.15805

  View details for Web of Science ID 000471133600034

  View details for PubMedID 30697691

• Association Between Sarcopenic Obesity and Falls in a Multiethnic Cohort of Postmenopausal Women JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Follis, S., Cook, A., Bea, J. W., Going, S. B., Laddu, D., Cauley, J. A., Shadyab, A. H., Stefanick, M. L., Chen, Z. 2018; 66 (12): 2314–20

  View details for DOI 10.1111/jgs.15613

  View details for Web of Science ID 000454532800014

• Association Between Sarcopenic Obesity and Falls in a Multiethnic Cohort of Postmenopausal Women. Journal of the American Geriatrics Society Follis, S., Cook, A., Bea, J. W., Going, S. B., Laddu, D., Cauley, J. A., Shadyab, A. H., Stefanick, M. L., Chen, Z. 2018

  Abstract

  OBJECTIVES: To investigate associations between sarcopenia, obesity, and sarcopenic obesity and incidence of falls in a racially and ethnically diverse cohort of healthy postmenopausal women.DESIGN: Prospective cohort study.SETTING: Three Women's Health Initiative (WHI) clinical centers (Tucson-Phoenix, AZ; Pittsburgh, PA; Birmingham, AL).PARTICIPANTS: Postmenopausal women aged 50 to 79 enrolled in the WHI who underwent bone and body composition scans using dual-energy x-ray absorptiometry at baseline (N = 11,020).MEASUREMENTS: Sarcopenia was defined as the lowest 20th percentile of appendicular lean mass, correcting for height and body fat. Obesity was defined as a body fat percentage greater than 42%. Sarcopenic obesity was defined as co-occurrence of sarcopenia and obesity. The fall outcome was defined as falling 2 or more times in any year during 7 years of follow-up. The risk of falls associated with sarcopenic obesity were analyzed using log binomial regression models stratified according to age and race/ethnicity.RESULTS: Sarcopenic obesity was associated with greater risk of falls in women aged 50 to 64 (relative risk (RR) = 1.35, 95% confidence interval (CI)=1.17-1.56) and 65 to 79 (RR = 1.21, 95% CI=1.05-1.39). Sarcopenic obesity related fall risk was higher in Hispanic women (RR = 2.40, 95% CI=1.56-3.67) than non-Hispanic white women (RR = 1.24, 95% CI=1.11-1.39).CONCLUSION: In a multiethnic cohort of postmenopausal women, sarcopenic obesity-related fall risk was high in women younger than 65 and those age 65 and older. Sarcopenic obesity posed the highest risk for falls in Hispanic women. The findings support identification of causal factors and health disparities in sarcopenic obesity to customize fall prevention strategies and ameliorate this significant public health burden.

  View details for PubMedID 30375641