Childhood socioeconomic position, gender, adult body mass index, and incidence of type 2 diabetes mellitus over 34 years in the Alameda County Study

Objectives. We examined the association between childhood socioeconomic position and incidence of type 2 diabetes and the effects of gender and adult body mass index (BMI).Methods. We studied 5913 participants in the Alameda County Study from 1965 to 1999 who were diabetes free at baseline (1965). Cox proportional hazards models estimated diabetes risk associated with childhood socioeconomic position and combined childhood socioeconomic position–adult BMI categories in pooled and gender-stratified samples. Demographic confounders and potential pathway components (physical inactivity, smoking, alcohol consumption, hypertension, depression, health care access) were included as covariates.Results. Low childhood socioeconomic position was associated with excess diabetes risk, especially among women. Race and body composition accounted for some of this excess risk. The association between childhood socioeconomic position and diabetes incidence differed by adult BMI category in the pooled and women-only groups. Adjustment for race and behaviors attenuated the risk attributable to low childhood socioeconomic position among the obese group only.Conclusions. Childhood socioeconomic position was a robust predictor of incident diabetes, especially among women. A cumulative risk effect was observed for both childhood socioeconomic position and adult BMI, especially among women.In recent years, much effort has gone into characterizing biological and social exposures during gestation and childhood that may lead to adult chronic diseases. Childhood socioeconomic disadvantage has been associated with mortality1^–4 and several adult physical5^–7 and mental health5^,7^–9 outcomes.Studies investigating the relationship between childhood socioeconomic disadvantage and diabetes have shown inconsistent results. Childhood socioeconomic position (SEP) was linked to prevalent type 2 diabetes,10^–14 insulin resistance,15 higher glucose levels,16^,17 and metabolic syndrome18^,19 in some studies, yet showed no association with impaired glucose tolerance20^,21 or metabolic syndrome22 in others. Three studies investigated the association between childhood SEP and incident diabetes in adulthood and reported either modest11^,23 or no effects.12Although the evidence thus far is insufficient to establish a causal link between childhood SEP and incident type 2 diabetes, the hypothesis is plausible. Childhood disadvantage has been linked to illnesses, such as cardiovascular diseases,24 that have overlapping pathologies with diabetes. Persons exposed to socioeconomic disadvantage in childhood are more likely to be of lower socioeconomic means as adults.25^,26 Several studies have shown inverse, graded associations between different measures of adult SEP and the prevalence11^,13^,22^,27^,28 and incidence11^,12^,23^,29^–34 of type 2 diabetes. Childhood SEP also influences adult body composition35^–41 and several behaviors20^,42^–45 that are risk factors for type 2 diabetes.Obesity is a strong predictor of type 2 diabetes.46^–48 Therefore, the effect of childhood SEP on diabetes incidence may differ by body mass index (BMI; weight in kilograms divided my height in meters squared) in adulthood. For example, low childhood SEP and adult obesity together may impart a greater risk of type 2 diabetes than the risk imparted by low childhood SEP alone. Such exposure patterns may represent an accumulation of risk over time or a risk pathway. In addition, several studies have shown that the effects of childhood circumstances on adult health and risk behaviors differ by gender.37^,38^,40^,49^–52 The question remains whether childhood SEP differentially influences diabetes risk for women and men.Previous studies of childhood SEP and incident diabetes had short follow-up periods,11^,12^,23 and one was limited to women.23 Our approach complemented these studies by using 5 waves of data collected in a population-based sample from 1965 to 1999 to examine the association between childhood SEP and the incidence of type 2 diabetes and how this association may differ by gender or adult BMI.     

Identifying heterogeneity among injection drug users: a cluster analysis approach

Objectives. We used cluster analysis to subdivide a population of injection drug users and identify previously unknown behavioral heterogeneity within that population.Methods. We applied cluster analysis techniques to data collected in a cross-sectional survey of injection drug users in Winnipeg, Manitoba. The clustering variables we used were based on receptive syringe sharing, ethnicity, and types of drugs injected.Results. Seven clusters were identified for both male and female injection drug users. Some relationships previously revealed in our study setting, such as the known relationship between Talwin (pentazocine) and Ritalin (methylphenidate) use, injection in hotels, and hepatitis C virus prevalence, were confirmed through our cluster analysis approach. Also, relationships between drug use and infection risk not previously observed in our study setting were identified, an example being a cluster of female crystal methamphetamine users who exhibited high-risk behaviors but an absence or low prevalence of blood-borne pathogens.Conclusions. Cluster analysis was useful in both confirming relationships previously identified and identifying new ones relevant to public health research and interventions.Syringe sharing is a well-established mechanism for the spread of HIV and HCV.1^–3 The introduction of syringe exchange programs (SEPs) has had a substantial impact with respect to decreasing the attributable risk of infectious blood-borne pathogens such as HIV and HCV among injection drug users.4^–11 However, studies have shown variations in the effectiveness of SEPs,11^–18 in that syringe sharing behavior persists among some injection drug users.12^,18^–21Epidemiological studies in which contextual factors are used to explain syringe sharing (i.e., social network analyses22) have demonstrated that sharing behavior is not based exclusively on individual choice7^,23^–26; that is, factors other than syringe access may drive sharing among certain injection drug users.20^,26^–28 For example, syringe sharing has been demonstrated to be associated with dyadic relationships involving close friends or sexual partners12^,26^,29^,30 and partnerships in which injection drug users pool resources to obtain drugs or injection equipment.21^,24^,26^,31^,32 Thus, variation in sharing behaviors is explained by differences between high-risk groups.Some researchers suggest that designing interventions around variances seen between groups, and the context in which these variances reside, may be both efficient and efficacious,33^–38 especially in terms of public health practice. Understanding the heterogeneity in high-risk groups may be particularly relevant for those behaviors that persist despite the establishment of structural interventions such as SEPs.15^,18^–20^,28^,39^–44 Consequently, the use of nontraditional statistical methodologies (such as social network analysis) has been encouraged to capture this variance.33^,35 Cluster analysis,45^,46 “an exploratory technique that can be used to reveal unknown heterogeneity,”35^(p196) focuses on the inherent differences between cases rather than variables. It has been used in the HIV literature to develop typologies of behavior33^,37; however, its use is more widespread in the psychiatric and psychological literatures.38^,47^–50We used cluster analysis as an exploratory tool to investigate whether empirically derived clusters could help to explain heterogeneity in a sample of injection drug users. The broader applicability of this technique to public health investigations in general was also addressed.     

Project VIVA: a multilevel community-based intervention to increase influenza vaccination rates among hard-to-reach populations in New York City

Objectives. We sought to determine whether the work of a community-based participatory research partnership increased interest in influenza vaccination among hard-to-reach individuals in urban settings.Methods. A partnership of researchers and community members carried out interventions for increasing acceptance of influenza vaccination in disadvantaged urban neighborhoods, focusing on hard-to-reach populations (e.g., substance abusers, immigrants, elderly, sex workers, and homeless persons) in East Harlem and the Bronx in New York City. Activities targeted the individual, community organization, and neighborhood levels and included dissemination of information, presentations at meetings, and provision of street-based and door-to-door vaccination during 2 influenza vaccine seasons. Participants were recruited via multiple modalities. Multivariable analyses were performed to compare interest in receiving vaccination pre- and postintervention.Results. There was increased interest in receiving the influenza vaccine postintervention (P<.01). Being a member of a hard-to-reach population (P=.03), having ever received an influenza vaccine (P<.01), and being in a priority group for vaccination (P<.01) were also associated with greater interest in receiving the vaccine.Conclusions. Targeting underserved neighborhoods through a multilevel community-based participatory research intervention significantly increased interest in influenza vaccination, particularly among hard-to-reach populations. Such interventions hold promise for increasing vaccination rates annually and in pandemic situations.National guidelines recommend annual influenza vaccination for high-risk groups—specifically, persons 50 years and older and persons of any age with chronic medical conditions and their household contacts.1 Despite these guidelines and the patent benefits of influenza vaccination—including reductions in influenza-related morbidity and mortality, attendant health care costs, and productivity losses2—vaccination rates among adults in the United States remain lower than recommended levels, especially among elderly with high-risk conditions and racial/ ethnic minorities.1^,3^–5Although data are sparse, influenza vaccination rates are particularly low among marginalized hard-to-reach urban populations such as substance abusers, undocumented immigrants, and homebound elderly.6 During the 2004–2005 influenza vaccine shortage, the vaccination rate was 21% among hard-to-reach populations in designated priority groups for vaccination, compared with estimates of 42% among designated priority groups in the general population during this same period.7 Members of these hard-to-reach groups are less likely to access routine health care or have a health care provider.8^–10 Low vaccination rates combined with risk factors and barriers to accessing health care place hard-to-reach populations at particularly high risk for influenza and attendant morbidity.Additionally, the need for improvements in annual influenza coverage is coupled with recent concern for the potential of a human influenza pandemic.11^,12 Unvaccinated persons within the larger population may propagate disease, particularly in the event of a pandemic.2^,13 Consequently, public health officials face mounting pressure to vaccinate persons in all risk groups and to do so in a brief period of time.14^–16 Members of disadvantaged, urban, multiethnic communities may face additional challenges during a pandemic, including increased vulnerability and transmissibility from overcrowded living conditions, reliance on mass transportation, and limited access to health care.17Although there have been some previous efforts to vaccinate high-risk populations, few were community-based.18 Community-based programs that contributed to increased vaccination coverage have included vaccination at syringe exchange sites,19 an immunization “blitz” in a neighborhood with widespread injection drug use,20 interventions in religion-based neighborhood health centers, and public service announcements and mailings targeted to racial/ethnic minority Medicaid populations.21^,22 Interventions in medical settings have included components such as standing orders,23^,24 mailings,25^–27 education,28^–30 targeted advertising,31 and visiting nurse programs.32 Unfortunately, these efforts may have had little impact on hard-to-reach populations, because members of these groups are less likely to access routine health care.In December 2003, members of the Harlem Community and Academic Partnership,33 comprised of representatives from community and academic organizations committed to implementing interventions by using a community-based participatory research (CBPR) approach, formed an intervention working group to address challenges in vaccinating local hard-to-reach populations. Community-based participatory research is a collaborative process among researchers and community members that emphasizes building trust, equitable power sharing, capacity building, and long-term commitment from all involved in the research process.34^–36 The intervention working group, which was comprised of members representing community residents, community-based organizations (CBOs), academic institutions, and the local health department, met regularly throughout the project to develop the research agenda and study design and to guide project implementation and evaluation. Guided by the Harlem Community and Academic Partnership principles of collaboration, the working group adopted a participatory approach to decisionmaking processes. A multilevel study design was chosen to address individual, social, and contextual factors related to access to, and acceptance of, the influenza vaccine among hard-to-reach populations.37^,38 The working group developed methods to target intervention activities to 3 levels: neighborhood, CBO, and individual.The overall goal of the Project VIVA (Venue-Intensive Vaccines for Adults) intervention was to develop, implement, and assess a rapid-vaccination protocol for hard-to-reach populations that would increase interest in vaccination, provide free vaccination during 2 influenza seasons, and establish a model for the rapid vaccination of individuals that could be generalizable to other urban areas. We report the results of Project VIVA, including pre–post surveys in the 8 target areas within East Harlem and the Bronx, New York City, that evaluated whether interest in receiving influenza vaccination changed after intervention.     

Improving health behaviors in an African American community: the Charlotte Racial and Ethnic Approaches to Community Health project

Objectives. We examined the effect on 3 behavioral risk factors for heart disease and diabetes (low fruit and vegetable consumption, low physical activity, and cigarette smoking) of an intervention in an African American community in North Carolina.Methods. A community coalition, a lay health advisor program, and policy and community environment change strategies were implemented in a community of 20000 African Americans in 2001 to 2005. Health behavior questions from the Behavioral Risk Factor Surveillance System survey were administered to a cross-section of the community annually. The results were compared with African Americans’ responses from a statewide survey.Results. All 3 health behaviors improved in the study population. Improvements were statistically significant for physical activity (P= .02) and smoking (P= .03) among women and for physical activity among middle-aged adults (P=.01). Lower baseline physical activity rates improved to levels comparable to those of African Americans statewide (2001, P<.001; 2005, P=.38), and comparable fruit and vegetable consumption rates became significantly higher (2001, P=.68; 2005, P<.001).Conclusions. Our findings support the emerging role of policy and community environment change strategies and community participation as promising practices to improve health behaviors in African American communities and to reduce health disparities.Racial and ethnic health disparities have become a prominent issue in national debates about health care and civil rights. Health disparities have been demonstrated in chronic and infectious diseases and in maternal and child health. Disparities are particularly well documented for cardiovascular disease. The underlying causes of health disparities are complex and include societal issues such as institutional racism, discrimination, socioeconomic status, and poor access to health care and community resources.1^–6Community-based approaches have been used in a wide range of settings to address cardiovascular disease. Interventions ranged from large studies funded by the National Heart, Lung, and Blood Institute in the late 1980s, which sought to effect both individual and communitywide changes in risk behaviors, to smaller programs with more-focused intervention strategies.7^–9 These interventions succeeded in improving health behaviors, but they focused predominantly on White, middle-class, well-educated populations. A few studies reported community interventions that reduced cardiovascular health disparities among African Americans.10 Interventions addressing other health disparities may also be effective in reducing cardiovascular disease. Combined, they provide several promising strategies for interventions in minority communities.Community involvement is widely described as integral to reducing health disparities. Community acceptance and investment are necessary for interventions to reach sufficient saturation levels to affect population-based outcomes.8^–11 Several models exist that engage and involve community members in the planning, implementation, and evaluation of projects.12^–14 Studies have demonstrated a correlation between coalition development and improved health practices in minority communities.11 Successful interventions in trusted community institutions such as churches have become particularly widespread.10^,15^,16 Lay health advisors (LHAs) or community peers have been used to engage social networks and apply cultural practices specific to minority communities. LHA programs used in racial and ethnic community settings have effected changes in the attitudes of community members about their control over health issues, willingness to consider behavioral changes, and use of preventive services.17^–21Health behaviors are multifaceted and are part of a larger social system of behaviors and social influences. The socioecological model recognizes that lasting influence on health behaviors evolves from changes at many levels: intrapersonal factors, interpersonal processes and groups, institutional factors, community factors, and public policy.22^,23 Community-based intervention designs that work across a socioecological model to include changes in policy, community environments, and institutions are more effective and sustainable than those focused only on intra-or interpersonal change.22^–25 Changes in policy and the community environment are particularly important in racial and ethnic minority communities because of the underlying social etiologies of most health disparities. Minority communities have been found to have reduced access to healthful food and recreation resources and greater exposure to potential health risks.26 Much of the data on successful policy and environment interventions have come from tobacco control. Policy interventions such as price increases and smoking bans have led to decreased tobacco use across racial and ethnic groups.27^,28From 1999 to 2007, the Centers for Disease Control and Prevention funded community-based interventions through the Racial and Ethnic Approaches to Community Health (REACH) 2010 program to address health disparities in minority communities.29 The Charlotte REACH 2010 project was designed to apply and expand promising strategies to improve health disparities in cardiovascular disease and diabetes in an urban, African American community. Low physical activity; a high-fat, low-fiber diet; and smoking are established antecedents of cardiovascular disease and diabetes and were considered the most realistic outcome goals for the time frame of this project.7^,24 We studied the communitywide effect of the Charlotte REACH interventions on these 3 modifiable risk factors.     

Relationships between skin color, income, and blood pressure among African Americans in the CARDIA Study

Objectives. We explored how income and skin color interact to influence the blood pressure of African American adults enrolled in the longitudinal Coronary Artery Risk Development in Young Adults (CARDIA) Study.Methods. Data were derived from 1893 African American CARDIA year-15 participants who had undergone skin reflectance assessments at year 7. We adjusted for age, gender, body mass index, smoking status, and use of antihypertensive medication to examine whether year-15 self-reported family incomes, in interaction with skin reflectance, predicted blood pressure levels.Results. Mean systolic and diastolic blood pressure levels were 117.1 (±16.07) and 76.9 (±12.5) mm Hg, respectively. After adjustment, the interaction between skin reflectance and income was significantly associated with systolic blood pressure (P< .01). Among lighter-skinned African Americans, systolic pressure decreased as income increased (b= −1.15, P<.001); among those with darker skin, systolic blood pressure increased with increasing income (b=0.10, P=.75).Conclusions. The protective gradient of income on systolic blood pressure seen among African Americans with lighter skin is not observed to the same degree among those with darker skin. Psychosocial stressors, including racial discrimination, may play a role in this relationship.In the United States, marked racial disparities in morbidity and mortality exist across a wide range of health indicators.1^,2 Gaps in health between African Americans and White Americans are particularly pronounced for cardiovascular diseases and their related risk factors3^,4 and persist despite considerable advances in clinical treatment and care.5 Rates of hypertension (blood pressure above 140/90 mm Hg) are nearly twice as high among African Americans as among Whites, and the condition tends to be more severe and to have an earlier onset among African Americans.6 This racial disparity in hypertension is also the largest contributor to broader all-cause mortality differentials between African and White Americans.7Racial disparities in health are complex in terms of their underlying causes and are not completely understood, with a range of social–environmental factors implicated in the poorer cardiovascular health of African Americans. One such factor is socioeconomic status (SES), which is associated with cardiovascular disease risk in a gradient fashion in the United States and other developed nations and is lower on average among African Americans than among Whites.8^,9 However, evidence has increasingly suggested that race and class interact in complex ways to influence health, and the magnitude of association between SES and health varies according to race.10^–15Although the relationship has been less consistent, skin color is another socially significant factor that has shown a graded association with cardiovascular health, particularly blood pressure, among African Americans.16^–18 Given the social significance of skin color in United States society,19^–21 it may constitute an additional factor along which SES effects on health vary.The well-documented SES gradient in health, wherein incremental increases in economic standing are associated with improved health across the entire SES range, suggests that psychosocial stress may be an important contributor to health disparities.9^,22 Because African Americans are overrepresented at the bottom of the SES ladder, some social–environmental models of health disparities have posited that economic factors are largely responsible for race gaps in health status.12 However, it is now well demonstrated that SES alone does not account for racial health disparities, and the effects of SES on health are not uniform across race groups.10^,11^,13^,23For example, Farmer and Ferraro13 recently demonstrated that although the SES gradient is strong for White Americans, economic success does not carry the same health benefits for African Americans. They observed a pattern of “diminishing returns”13^(p192) in general health status among African Americans of higher economic standing. A similar pattern was recently observed with respect to body mass index (BMI; weight in kilograms divided by height in meters squared), an important cardiovascular risk factor. Lewis et al.14 found that, among women, racial differences in BMI were most pronounced at higher levels of education, with White women having lower BMIs than African American women.These findings highlight the complexity of interactions among race and class and suggest that additional social–environmental factors should be considered in attempts to explain racial health disparities. An example of such a social–environmental factor is skin color.19^,24 A skin color gradient in blood pressure, such that darker skin color is associated with higher average blood pressure levels, has long been observed among African Americans and other African diaspora populations.16^,19^,25 In the first observations of this gradient, during the 1970s, the relationship was largely attributed to genetic or unknown physiological causes.16^,25However, skin color has been shown to be an imperfect marker of proportional genetic ancestry in multiracial societies.26^,27 In addition, genetic components seem to explain relatively little population-level prevalence rates of common, complex diseases such as hypertension.28 Thus, skin color is not likely to be a significant marker of differences in gene-based disease susceptibility.27Skin color has long been recognized to carry considerable social significance in United States society, however, and many studies have noted the potential confounding effects of psychosocial factors on the skin color gradient in blood pressure.17^–19^,29^,30 Relative to African Americans with lighter skin, it has been shown that, on average, African Americans with darker skin are employed in occupations with lower incomes and less prestige.31^–33Studies examining the potential confounding effects of economic status on the skin color gradient in blood pressure have produced mixed findings.16^–18 Harburg et al. found that the relationship between skin color and blood pressure is independent of SES,16 whereas Keil et al. suggested that skin color differences in blood pressure are contingent on SES.17 Klag et al.18 found a moderating effect of SES on the association between skin color and blood pressure, with only individuals in lower socioeconomic tiers exhibiting the skin color gradient. The findings of these studies indicate that more research is needed regarding the interactive effects of skin color and SES on blood pressure among African Americans.Recently, Gravlee et al.24^,34 reported that, among adults in Puerto Rico, socially ascribed “color,” of which skin tone is a dimension, moderates the SES gradient in blood pressure. They found higher SES to be associated with lower blood pressure only among those of lighter ascribed color. A similar pattern may exist for skin pigmentation in the United States; whereas skin color is associated with SES, it is also a marker of other social realities and experiences that may affect health status, including discrimination and low social standing.19^,35^,36Thus, skin color may represent an additional dimension of social variation along which health varies in the United States and, as such, may complicate the effects of SES on the health of African Americans. Similar to recent findings showing that the health benefits of higher SES are more limited for African Americans than they are for Whites,13 these benefits may also be more limited depending on one’s skin color.We explored whether skin color is a significant moderator of the effects of SES on blood pressure among African Americans taking part in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. We sought to answer the following question: does the SES gradient in blood pressure vary among African Americans of darker skin color and those of lighter skin color?     

Neighborhood psychosocial hazards and cardiovascular disease: the Baltimore Memory Study

Objectives. We examined associations between cardiovascular disease and neighborhood psychosocial hazards, such as violent crime, abandoned buildings, and signs of incivility, to evaluate whether features of place are associated with older adult health.Methods. We analyzed first-visit data from the Baltimore Memory Study of randomly selected residents aged 50 to 70 years (n=1140) of 65 contiguous neighborhoods in Baltimore, Maryland. We looked for associations between self-reports of history of selected cardiovascular diseases and scores on the 12-item neighborhood psychosocial hazards scale.Results. After adjustment for established individual risk factors for cardiovascular disease, residents in neighborhoods with scores in the highest quartile of the psychosocial hazards scale had more than 4 times higher odds of a history of myocardial infarction and more than 3 times higher odds of myocardial infarction, stroke, transient ischemic attack, or intermittent claudication compared with residents living in neighborhoods scoring in the lowest quartile.Conclusions. Neighborhood psychosocial hazards were significantly associated with self-reported cardiovascular disease after adjustment for individual-level risk factors. This is consistent with the hypothesis that environmental stress plays a role in the etiology of cardiovascular disease.The effect on health of the places in which people live—apart from individual, genetic, or lifestyle characteristics—is of increasing interest to researchers.1 A new wave of research is examining the health consequences of various aspects of residential neighborhoods. Moving beyond the study of individual risk factors to the study of neighborhoods may be a key to understanding widening health disparities across racial/ethnic and sociodemographic groups.2^,3Many aspects of neighborhoods are hypothesized to influence cardiovascular disease (CVD) risk through several different and potentially interrelated mechanisms.4^–6 Health behavior has received significant attention. Some data suggest that residents of socioeconomically deprived neighborhoods are more likely to engage in high-risk health behaviors, including inactivity,7^,8 poor diet,9 illicit drug use,10^,11 and smoking.12 However, studies that found an association between neighborhood of residence and CVD after adjustment for many of these health behaviors raised doubts that behavior was the sole mechanism.13^,14Several studies have examined the relationship between neighborhood socioeconomic characteristics (such as percentage of residents living in poverty) and CVD. Living in disadvantaged neighborhoods was found to be independently associated with increased risk of subclinical CVD,15 coronary heart disease,13^,16 and stroke,17 as well as poorer prognosis and decreased survival after myocardial infarction.18 Several explanations have been suggested for this association.4Psychosocial hazards in the neighborhood may be an important link between neighborhood socioeconomic disadvantage and adverse health outcomes.5^,19 Psychosocial hazards are visible characteristics of neighborhoods—such as violent crime, abandoned buildings, and signs of incivility—that give rise to a heightened state of vigilance, alarm, or threat.6^,20 Daily exposure to psychosocial hazards in the neighborhood is known to activate a physiological stress response.21^,22 Chronic stress may in turn lead to dysregulation of either the autonomic nervous system23 or the hypothalamic–pituitary–adrenal axis, or both. Dysregulation of the latter has been linked to key CVD risk factors, including the deposition of abdominal fat,24^,25 acute and chronic elevations in blood pressure,26 and various inflammatory processes.27We tested the hypothesis that a higher level of neighborhood psychosocial hazards is associated with increased odds of self-reported myocardial infarction, stroke, transient ischemic attack, and intermittent claudication, independent of individual-level risk factors.     

Physical health complaints among lesbians, gay men, and bisexual and homosexually experienced heterosexual individuals: results from the California Quality of Life Survey

Objectives. We examined evidence that minority sexual orientation is associated with more-frequent reports of physical health complaints. We also investigated the possible role of HIV infection among gay men and higher rates of psychological distress among lesbians, gay men, and bisexually and homosexually experienced heterosexual individuals in generating these health disparities.Methods. We used data from the California Quality of Life Survey (N=2272 adults) to examine associations between sexual orientation and self-reports about physical health status, common health conditions, disabilities, and psychological distress.Results. Prevalent HIV infection was reported by nearly 18% of gay, bisexual, and homosexually experienced heterosexual men. Gay men and bisexual and homosexually experienced heterosexual individuals had higher levels of psychological distress compared with exclusively heterosexual individuals. Self-reported physical health status varied by gender and by sexual orientation.Conclusions. Lesbians and bisexual and homosexually experienced heterosexual women reported a greater variety of health conditions and limitations compared with exclusively heterosexual women; however, these differences mostly disappeared when distress levels were taken into account. Among men, differences in health complaints appeared to reflect the ongoing burden of HIV and other sexually transmitted diseases in the gay male community.Although it is well-known that men who have sex with men are at a higher risk for contracting HIV1 and other sexual transmitted infections (STIs),2 accumulating evidence shows that minority sexual orientation may also be an underrecognized risk factor for psychiatric morbidity,3^–13 alcohol14^–18 and illicit drug use,19^–21 cigarette smoking,15^,22 and problems with health care use.22^–24 This has led to speculation that, compared with exclusively heterosexual individuals, lesbians, gay men, and bisexual and homosexually experienced heterosexual men and women may also experience unrecognized disparities in general physical health that go beyond the conditions specifically associated with STIs among homosexually active men.25 These disparities may include a higher risk for cardiovascular disease,22^,23^,26 lung cancer as a possible consequence of higher rates of smoking,15^,27^–30 and a higher risk for diabetes among lesbians and bisexual women.31^,32 Indeed, a recent survey of Dutch adults found that those adults who reported predominant or exclusive same-sex preferences were more likely to report a number of health conditions compared with other respondents.33One difficulty with estimating physical health disparities that are associated with sexual orientation lies in the dearth of population-based surveys that have measured both sexual orientation and markers of physical health, including HIV infection status. The Dutch study,33 for example, did not measure HIV status, which is a critical factor for understanding health complaints by gay men. A second concern is that lesbians, gay men, and bisexual and homosexually experienced heterosexuals have higher levels of psychological distress,6^,10^,34 which has been associated with more frequent reporting of some chronic conditions, health limitations, and poorer physical health status.35^–37 Generally, psychological distress is both a consequence of physical illness and a direct predictor of self-perceived physical health status38; however, the patterns of causal relationships among distress, chronic conditions, and self-perceived physical health are complex and may at times be recursive. For example, there is good evidence that psychiatric morbidity, including subthreshold mental disorders,39 inflates reports of somatic complaints and physical disability among individuals with similar levels of physical illness.38^,40Furthermore, prospective studies have identified psychological distress as a precursor for incident pain conditions41^,42 and preexisting depression as a risk factor for disability incidence.43 Thus, associations between sexual orientation and reports of chronic health conditions—particularly pain, disability, and poor overall physical health—may in fact reflect both direct effects of factors associated with sexual orientation and confounding from preexisting levels of psychological distress. This is relevant because previous studies have shown both higher levels of perceived social discrimination among lesbians, gay men, and bisexual individuals compared with heterosexual individuals44 and a strong positive association between perceptions of discrimination and psychological morbidity.44^,45To bring clarity to these issues, we examined the associations between sexual orientation, reports of common physical health complaints, and perceptions of physical health status with data from the California Quality of Life Survey, a population-based health survey of adult Californians that was conducted in late 2004 and early 2005. This survey oversampled individuals who were likely to be lesbian, gay, or bisexual, and it measured both sexual orientation identity and genders of sexual partners since age 18 years. We hypothesized that individuals with minority sexual orientation (defined both in terms of identity and sexual behavior) would have higher levels of psychological distress compared with exclusively heterosexual men and women. We also hypothesized that prevalent HIV infection would be more common among men who were likely to have had sex with men compared with exclusively heterosexual men. Furthermore, we anticipated that individuals with minority sexual orientation would show a greater burden of physical health complaints and a greater impairment in physical health, much like the Dutch study.33 However, we hypothesized that 2 factors—higher rates of psychological distress and, among gay and bisexual men, possible concurrent HIV infection—would account for any differences in the patterns of health problems we observed.     

Perceived discrimination and mortality in a population-based study of older adults

Objectives. We examined the relation of individual-level perceived discrimination to mortality in a biracial, population-based sample.Methods. Participants were 4154 older adults from the Chicago Health and Aging Project who underwent up to 2 interviews over 4.5 years. Perceived discrimination was measured at baseline, and vital status was obtained at each follow-up and verified through the National Death Index.Results. During follow-up, 1166 deaths occurred. Participants reporting more perceived discrimination had a higher relative risk of death (hazard ratio [HR]= 1.05; 95% confidence interval [CI]=1.01, 1.09). This association was independent of differences in negative affect or chronic illness and appeared to be stronger among Whites than among Blacks (Whites: HR=1.12; 95% CI=1.04, 1.20; Blacks: HR=1.03; 95% CI=0.99, 1.07). Secondary analyses revealed that the relation to mortality was related to discriminatory experiences of a more demeaning nature and that racial differences were no longer significant when the sample was restricted to respondents interviewed by someone of the same race.Conclusions. Perceived discrimination was associated with increased mortality risk in a general population of older adults. The results suggest that subjective experience of interpersonal mistreatment is toxic in old age. This study adds to a growing literature documenting discrimination as an important social determinant of health.There is growing interest in the health effects of perceived discrimination.1^,2 Although evidence has been mixed, several studies have demonstrated that discrimination is related to poor physical and mental health, including blood pressure,3^,4 breast cancer,5 self-rated health,4^,6^–8 psychological distress,7^–10 well-being10^,11 and depressive symptoms.8^,12 Several studies have reported no or conditional associations as well.13^–18 Inconsistency in results may be because, at least in part, of the variation in the measurement of discrimination, differences in study methodologies and populations, and the variety of outcomes that have been considered.1^,2 Overall, however, it appears that the results have been stronger for mental health than for physical health outcomes. Although the mechanisms are not clear, hypotheses include restricted access to socioeconomic resources, poor health behaviors, and stress responses.6^,19^–22Few studies have focused on well-established clinical outcomes, such as hypertension. Although some studies have reported that discrimination increases the risk for hypertension,23^,24 others have not found an association.13^,14 Discrimination has also been linked with subclinical cardiovascular disease, including carotid intima-media thickness25 and coronary artery calcification.26We examined perceived discrimination in relation to all-cause mortality for 2 reasons. First, this end point has rarely been considered in relation to discrimination.27^,28 Second, mortality serves as the common end point of many disease processes that affect adult populations. Because the negative health effects of discrimination are thought to be nonspecific—that is, they are not restricted to a particular disease process—this end point may be particularly suitable to capture much of the spectrum of adverse outcomes associated with this risk factor.Racism, racial discrimination, and perceived discrimination have been used interchangeably in the research literature. We focused on perceived discrimination, defined as the subjective experience of common forms of unfair treatment,10 and its relation to mortality in a population-based study of older Blacks and Whites. Because the weight of the current evidence shows that discrimination is associated with poorer health among minorities, we hypothesize that perceived discrimination is related to an increased risk for mortality and that this risk is stronger among Blacks than among Whites.     

Disentangling the effects of racial and weight discrimination on body mass index and obesity among Asian Americans

Objectives. We examined whether racial discrimination is associated with increased body mass index (BMI) and obesity among Asian Americans. Further, we explored whether this association strengthens with increasing time in the United States.Methods. We analyzed data from the 2002 to 2003 National Latino and Asian American Study (n=1956). Regression models tested whether reports of racial discrimination were associated with BMI and obesity, after accounting for weight discrimination, age, gender, marital status, ethnicity, generation, employment, health status, and social desirability bias (the tendency to seek approval by providing the most socially desirable response to a question).Results. We found that (1) racial discrimination was associated with increased BMI and obesity after we controlled for weight discrimination, social desirability bias, and other factors and (2) the association between racial discrimination and BMI strengthened with increasing time in the United States.Conclusions. Racial discrimination may be an important factor related to weight gain among ethnic minorities.Stress caused by disadvantaged social status may be related to obesity. Two elements provide the foundation for this observation. First, stress may have adverse physiological consequences, including increased risk for obesity and allostatic load, the “wear and tear” on organ systems that contributes to health problems.1 Stressors activate the hypothalamic–pituitary–adrenal axis system, releasing cortisol and other glucocorticoids. Glucocorticoids may stimulate appetite and blunt the satiety system.2 Cortisol increases fat retention, particularly in the abdominal region.3 Moreover, stressors may selectively increase the intake of “comfort foods” over other foods among humans and other animals.4^,5Stress may also be related to abdominal and general obesity. Daily stress,6 anxiety,7 and depressed mood8^,9 are related to visceral obesity. Among monozygotic twins, stress-induced hormonal changes result in greater intra-abdominal fat deposits in the twin with higher stress.10 Further, obesity, indicated by a high body mass index (BMI), has been associated with work stress11^,12 and early childhood trauma.13 In a prospective study of British civil servants, job stress was associated with metabolic syndrome (a group of risk factors that includes abdominal obesity, elevated blood pressure, and atherogenic dyslipidemia)8 and general and visceral obesity.12Second, social disadvantage, such as experiences with racial discrimination, may produce stress.14 Self-reported discrimination appears to be related to several stress-related and obesity-related outcomes, including high blood pressure,15 depression and anxiety,16 sleep problems,17 and coronary calcification.18 Individuals may also use alcohol to cope with discrimination,19^–21 and alcohol can contribute to obesity.22 Hence, discrimination may directly produce weight gain by activating the stress system and by influencing behavior change. Discrimination also may act indirectly by hindering socioeconomic advancement23^,24 and by segregating individuals into communities with fewer healthy food options25^,26 and fewer safe places for physical activity.27^,28Consistent with these observations, several studies have suggested that discrimination is associated with weight gain and metabolic problems. Tull et al. found that reports of internalized racism were associated with greater obesity among women in Barbados.29 Similarly, Chambers et al. found associations between internalized racism and insulin resistance among girls in Barbados.30 Butler et al. found associations between internalized racism and greater waist circumference and higher fasting glucose among Dominica women.31We tested the first hypothesis that reports of discrimination are associated with higher BMI and the risk of obesity and build on previous research in 3 primary ways. First, overweight people may encounter weight discrimination,32 and associations between racial discrimination and weight might therefore be confounded by weight discrimination. To reduce the chance of spurious findings, we controlled for weight discrimination and other factors.Second, we examined whether findings from Black populations generalize to Asian Americans. Among Asian Americans, discrimination is associated with outcomes related to obesity, including cardiovascular conditions,33^,34 depression,35^–37 and substance use,19 but no study has directly examined whether discrimination is associated with BMI and obesity in this population.Third, we tested the main effects of discrimination and investigated whether discrimination is moderated by time spent in the United States. US-born Asians appear to have higher rates of obesity than their foreign-born counterparts, but the rates of obesity among the foreign born increase with years in the United States.38^–40 Additionally, immigrants often report less racial discrimination than do nonimmigrants, but reports of discrimination increase with years spent in the United States, perhaps because immigrants are more likely to encounter and recognize discrimination over time.41^–43 A recent study found that among African and Latino immigrants, the association between racial discrimination and mental health strengthened with increasing time in the United States.44 These observations motivate the second hypothesis that time spent in the United States will interact with the association between racial discrimination, such that the association between racial discrimination and BMI among immigrant Asians will strengthen with increasing time spent in the United States.     

Chronic conditions and mortality among the oldest old

Objectives. We sought to determine whether chronic conditions and functional limitations are equally predictive of mortality among older adults.Methods. Participants in the 1998 wave of the Health and Retirement Study (N=19430) were divided into groups by decades of age, and their vital status in 2004 was determined. We used multivariate Cox regression to determine the ability of chronic conditions and functional limitations to predict mortality.Results. As age increased, the ability of chronic conditions to predict mortality declined rapidly, whereas the ability of functional limitations to predict mortality declined more slowly. In younger participants (aged 50–59 years), chronic conditions were stronger predictors of death than were functional limitations (Harrell C statistic 0.78 vs. 0.73; P=.001). In older participants (aged 90–99 years), functional limitations were stronger predictors of death than were chronic conditions (Harrell C statistic 0.67 vs. 0.61; P=.004).Conclusions. The importance of chronic conditions as a predictor of death declined rapidly with increasing age. Therefore, risk-adjustment models that only consider comorbidities when comparing mortality rates across providers may be inadequate for adults older than 80 years.Numerous studies have shown that both chronic conditions and functional limitations are powerful independent predictors of mortality.1^–4 However, a growing body of research suggests that some risk factors behave differently in people at different ages.5^–10 Some researchers have found that well-established mortality risk factors among younger persons, such as hypertension,7^,8^,11 hypercholesterolemia,7^,8^,12 increased body mass index,7^,9^,13^,14 heart disease,5^,8^,9 and cancer,5^,9 may not continue to pose a risk to the oldest old, suggesting that the association between chronic conditions and mortality may be weaker in the elderly. Autopsy series have also supported this notion, showing that a definitive cause of death attributable to a single disease process is often not found among older people.15 These observations have spurred a growing recognition within the geriatrics community that our methods of measuring and accounting for the burden of disease may be inappropriate for our oldest patients.16^–18Despite these concerns, chronic disease diagnoses remain at the center of clinical care and risk adjustment for older patients.17 However, if the association between chronic conditions and mortality is weaker in the elderly, risk adjustment tools that rely solely on chronic disease diagnoses (such as the Charlson Comorbidity Index19 and the Elixhauser method20) may be suboptimal for our oldest old. Therefore, the use of these methods to compare risk-adjusted outcomes as a proxy for the quality of care21^,22 may lead to erroneous conclusions. Improved risk-adjustment methods may lead to improvements in targeting health care quality interventions, ultimately resulting in better population health outcomes.To address these issues, we examined the ability of specific types of risk factors—chronic conditions, functional limitations, and demographic variables—to differentiate between people at high and low risk of death across a range of age groups. Based on previous research, we hypothesized that chronic conditions would be less predictive of death among older people. Because functional limitations often represent a final common pathway of decline regardless of underlying etiology,23^–25 we further hypothesized that functional limitations would be a stronger predictor of mortality than chronic conditions among our oldest participants.     

Correlates of the stages of change for physical activity in a population survey

Objectives. We sought to identify variables associated with being in a particular stage of change for physical activity—a measure of behavioral intention to engage in regular physical activity. Understanding behavioral intentions can be useful in explaining why individuals are physically inactive or active.Methods. Data from the Rhode Island 2000 Behavioral Risk Factor Surveillance System were used to evaluate predictors of stage of change for physical activity. There were 3454 observations in the data set, representing a weighted population of 742636 people. Estimates were obtained from polytomous multiple logistic models.Results. Being a woman, Hispanic, non-Hispanic Black, and older than 55 years of age were associated with being in precontemplation and contemplation stages of change rather than maintenance. Self-perceived health status and rarely feeling healthy or full of energy were strongly predictive of stage of change. Having a health limitation was a dichotomous predictor, predicting being in action and precontemplation stages.Conclusions. Several sociodemographic and health variables were associated with varying patterns of stages of change for physical activity. The complexity of individual intentions for physical activity provides evidence for the potential existence of mediating, effect-modifying, and confounding variables that differ depending on individual characteristics.The Transtheoretical Model combines key social–cognitive models of health behavior change with the core construct, stages of change, reflecting behavioral intention.1^,2 The Transtheoretical Model purports that people progress through 5 stages as they change health behaviors.1 First applied to physical activity behavior by Marcus et al.,3^–6 the model has been validated against measures of physical activity behavior, physical fitness, and health,7^–16 and has been successfully applied in an array of populations and settings.17^–24Despite public health efforts, the proportion of the population engaging in healthful levels of physical activity is low.25 Between 1990 and 1998, the prevalence of adults engaging in optimal levels of physical activity in the United States increased from 24.3% to 25.4%.26 At the same time, prevalence of walking remained stable, although select subgroups showed improvement.27 These data intimate that there is a need for improved understanding of this complex behavior.28^,29Epidemiological studies have described correlates of physical activity behavior and inactivity,30^–36 but few37^,38 have studied the intentions for physical activity. To gain a better understanding of physical activity, it is important to understand not only the behavior, but also the intentions for the behavior.15 Studying the stages of change for physical activity should improve the understanding of physical activity behavior, because of its focus on intentions for behavior.There are few studies describing the stages of change for physical activity in large populations, and only limited data on factors associated with stages of change.38^–43 We sought to identify variables associated with the probability of being in a stage of change for physical activity in a population sample.     

Comparing diabetes prevalence between African Americans and Whites of similar socioeconomic status

Objectives. We investigated whether racial disparities in the prevalence of type 2 diabetes exist beyond what may be attributable to differences in socioeconomic status (SES) and other modifiable risk factors.Methods. We analyzed data from 34331 African American and 9491 White adults aged 40 to 79 years recruited into the ongoing Southern Community Cohort Study. Participants were enrolled at community health centers and had similar socioeconomic circumstances and risk factor profiles. We used logistic regression to estimate the association between race and prevalence of self-reported diabetes after taking into account age, SES, health insurance coverage, body mass index, physical activity, and hypertension.Results. Multivariate analyses accounting for several diabetes risk factors did not provide strong support for higher diabetes prevalence rates among African Americans than among Whites (men: odds ratio [OR]=1.07; 95% confidence interval [CI]=0.95, 1.20); women: OR=1.13, 95% CI=1.04, 1.22).Conclusions. Our findings suggest that major differences in diabetes prevalence between African Americans and Whites may simply reflect differences in established risk factors for the disease, such as SES, that typically vary according to race.Members of racial and ethnic minority groups in the United States, including African Americans, suffer disproportionately from many chronic diseases, including type 2 diabetes (hereafter “diabetes”).1^–3 Prevailing statistics suggest that African American adults are 50% to 100% more likely to have diabetes than are Whites,3^–8 with evidence that diabetes precursors may even be more common in African American than in White children.9^,10 Reasons for racial disparities in diabetes prevalence are not clear, but behavioral, environmental, socioeconomic, physiological, and genetic contributors have all been postulated.3^,8^,11Because of the high prevalence of diabetes in the African American community, it has been suggested that African Americans may be more susceptible to the disease compared with Whites through direct genetic propensity or unfavorable gene–environment interactions.11 The fact that diabetes prevalence rates among Whites exceeded those among African Americans through at least the first half of the 20th century12 has led to the hypothesis that modern lifestyle factors (especially those that promote obesity) may have a greater effect on African Americans than on Whites.11^,13However, treating race as an etiological factor has been the subject of debate,14^–16 and it has been argued that despite some genotypic delineations, race largely represents a complex mixture of behavioral, environmental, and social exposures.17^,18 In comparison with Whites, African Americans often are poorer, have less education, are more likely to live in distressed households and communities, are less able to access quality health care, and have a less favorable risk factor profile for many diseases.18^–20 Because socioeconomic (and associated environmental) differences between racial groups are so pervasive, attempts to isolate an effect of race will typically involve substantial confounding,16 resulting in difficulty estimating the relative contributions of genetic and environmental factors.There have been several attempts to evaluate whether the disparity between African Americans and Whites with regard to diabetes can be attributed to factors other than racial background.7^,13^,21^–27 Studies involving nationally representative sampling frames7^,21^,23^–25^,27 provided the platform for many of these analyses, which poses a challenge in that the average African American is of substantially lower socioeconomic status (SES) than the average White American. Because racial disparities persisted in these studies after adjustment for known diabetes risk factors, including some measures of SES, a possible genetic explanation has been invoked for the residual association, although the precise biological mechanisms remain speculative. Many of the studies conducted to evaluate the underlying reasons for racial disparities in diabetes prevalence have included fewer than 1000 each of African American men and women.7^,13^,21^,23^,25Using the study population from the ongoing Southern Community Cohort Study (SCCS), which includes large numbers of African Americans and members of other racial/ethnic groups from generally similar socioeconomic circumstances, we had a unique opportunity to evaluate racial disparities in diabetes in a context in which confounding by extraneous factors related to race and SES would be limited by design. If racial disparities are driven by SES, one would expect little racial difference in diabetes prevalence rates within this population. We addressed the question of whether differences in diabetes prevalence between African Americans and Whites can be fully explained by SES or by adjustment for other correlates of diabetes risk.     

Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS

Objectives. We sought to compare health status, health care use, HIV anti-retroviral medication use, and HIV medication adherence among homeless and housed people with HIV/AIDS.Methods. Data were obtained from a cross-sectional, multisite behavioral survey of adults (N=7925) recently reported to be HIV positive.Results. At the time interviews were conducted, 304 respondents (4%) were homeless. Self-ratings of mental, physical, and overall health revealed that the health status of homeless respondents was poorer than that of housed respondents. Also, homeless respondents were more likely to be uninsured, to have visited an emergency department, and to have been admitted to a hospital. Homeless respondents had lower CD4 counts, were less likely to have taken HIV anti-retroviral medications, and were less adherent to their medication regimen. Homeless respondents needed more HIV social and medical services, but nearly all respondents in both groups had received needed services. Housing status remained a significant predictor of health and medication outcomes after we controlled for potential confounding variables.Conclusions. Homeless people with HIV/AIDS are at increased risk of negative health outcomes, and housing is a potentially important mechanism for improving the health of this vulnerable group.Homeless people are at a disproportionate risk for negative health consequences. For instance, they typically have more chronic diseases and more physical and mental health problems than do the general population, and they are at greater risk for infectious diseases.1^–13 Homelessness is often coincident with poverty, mental illness, and alcohol and drug use, compounding the other health problems experienced by these individuals.14^–17Homeless people are also more likely than other groups to engage in behaviors that place them at risk for HIV infection, including risky sexual practices, injection drug use and needle sharing, and performing sexual acts in exchange for money, drugs, or a place to stay.18^–25 Perhaps not surprisingly, previous research has shown that HIV is 3 to 9 times more prevalent among homeless individuals than among individuals in stable housing situations.18^,20^,21^,26^–29It may be difficult for homeless people, who are often faced with immediate subsistence needs (e.g., finding adequate food and shelter), to obtain medical care and adhere to treatment regimens.30^,31 As a result, homeless individuals are less likely than are the general population to have stable sources of care, and they often rely on emergency departments or ambulatory care settings for their health care needs.32^,33 Delayed medical care or lack of care has negative effects such as delayed HIV diagnoses and higher rates of serious opportunistic infections.7^,31^,34People who are living with HIV/AIDS and are homeless face additional burdens not faced by homeless people without HIV/AIDS. For instance, individuals with HIV/AIDS need greater access to comprehensive health care, and barriers to care—including lack of financial resources, lack of transportation, and insufficient (or nonexistent) health insurance coverage—may be compounded among homeless people living with the disease.30^,34People with HIV/AIDS also may have difficulty adhering to prescribed HIV antiretroviral medication regimens.35^,36 These regimens can be complex and often involve restrictions on when and how the medications should be taken and stored.31^,34 In addition, these medications can have side effects, such as recurring diarrhea, that are especially problematic for homeless individuals. Medical providers may believe that homeless individuals will not be adherent, and thus they may be reluctant to prescribe antiretroviral medications for these individuals37 given that inadequate adherence can lead to drug resistance.34 Despite its importance, few studies have investigated the issue of adherence to antiretroviral medication regimens in this population.35^,36^,38^–42Overall, minimal research has been conducted on the health of homeless people living with HIV/AIDS.15^,43^,44 We used data from a large, multisite investigation to (1) assess differences between homeless and housed persons living with HIV/AIDS regarding sociodemographic, health care, and medication adherence variables and (2) examine associations between housing status and health, and medication adherence outcomes after controlling for potential confounding factors.     

Racial/ethnic differences in the development of disability among older adults

Objectives. We investigated differences in the development of disability in activities of daily living among non-Hispanic Whites, African Americans, Hispanics interviewed in Spanish, and Hispanics interviewed in English.Methods. We estimated 6-year risk for disability development among 8161 participants 65 years or older and free of baseline disability. We evaluated mediating factors amenable to clinical and public health intervention on racial/ethnic difference.Results. The risk for developing disability among Hispanics interviewed in English was similar to that among Whites (hazard ratio [HR]=0.99; 95% confidence interval [CI] = 0.6, 1.4) but was substantially higher among African Americans (HR=1.6; 95% CI=1.3, 1.9) and Hispanics interviewed in Spanish (HR=1.8; 95% CI=1.4, 2.1). Adjustment for demographics, health, and socioeconomic status reduced a large portion of those disparities (African American adjusted HR=1.1, Spanish-interviewed Hispanic adjusted HR=1.2).Conclusions. Higher risks for developing disability among older African Americans, and Hispanics interviewed in Spanish compared with Whites were largely attenuated by health and socioeconomic differences. Language- and culture-specific programs to increase physical activity and promote weight maintenance may reduce rates of disability in activities of daily living and reduce racial/ethnic disparities in disability.Disability among older adults (those 65 years or older) is a major health issue involving high personal and economic costs. The number of Americans 65 years or older with chronic disability exceeds 7 million.1 Maintaining the quality of life for older adults by delaying disability may be as important as prolonging life.2^,3 Disability is more strongly associated with medical spending than with life expectancy.4^,5 Long-term care expenditures for older people are projected to reach $161 billion per year by 2010, of which two thirds will be paid by government programs.6The composition of the US population is changing. In 2000, 18% of people in the United States spoke a language at home other than English, up from 11% in 1980.7 The fastest-growing part of the older US population comprises minority groups, particularly African Americans and Hispanics.8 As the number of older people belonging to minority groups increases, there are growing public health concerns about racial/ethnic disparities in health outcomes.9 Although overall rates of disability among older Americans have declined over time, racial/ethnic disparities persist.1^,10^–13 The literature on racial/ethnic disparities in disability mostly focuses on African Americans; national studies investigating disability among Hispanics are limited.1^,12^,14^,15Despite the common practice of conducting interviews in languages other than English to allow respondents to participate in their primary language, few national studies have considered the influence of language differences on health outcomes.16 There are known differences in health and mortality related to immigration and acculturation.16^–19 Use of an interview language other than that of the host culture may be a proxy for acculturation and a predictor of future poor health.20^–23 Insight from a broader investigation of risk factors that includes language differences in relation to disparities in the development of disability is essential to the development of population-based public health programs to help maintain independence among older adults.We investigated racial/ethnic differences in disability among people 65 years and older using 6 years of data from the Health and Retirement Study (HRS),24 Finally, we investigated whether factors amenable to public health and policy intervention mediate minority differences in the development of disability among these Medicare-aged adults.     

Being poor and coping with stress: health behaviors and the risk of death

Objectives. Individuals may cope with perceived stress through unhealthy but often pleasurable behaviors. We examined whether smoking, alcohol use, and physical inactivity moderate the relationship between perceived stress and the risk of death in the US population as a whole and across socioeconomic strata.Methods. Data were derived from the 1990 National Health Interview Survey’s Health Promotion and Disease Prevention Supplement, which involved a representative sample of the adult US population (n=40335) and was linked to prospective National Death Index mortality data through 1997. Gompertz hazard models were used to estimate the risk of death.Results. High baseline levels of former smoking and physical inactivity increased the impact of stress on mortality in the general population as well as among those of low socioeconomic status (SES), but not middle or high SES.Conclusions. The combination of high stress levels and high levels of former smoking or physical inactivity is especially harmful among low-SES individuals. Stress, unhealthy behaviors, and low SES independently increase risk of death, and they combine to create a truly disadvantaged segment of the population.Perceived stress is a negative affective state that individuals may attempt to relieve or cope with through unhealthy but often pleasurable behaviors.1^–9 High levels of perceived stress are associated with smoking initiation, increased smoking levels, less successful smoking cessation attempts, drinking alcohol more often and in heavier quantities, increased problem drinking, and reports of positive attitudes toward drinking.4^,10^–23 Some people exercise to control their stress,24 but most individuals respond to stress by exercising less frequently and at lower levels because sedentary behavior is more rewarding in the short term.4^,10^,23^,25Stress and unhealthy behaviors each increase the risk of death.15^,26^–36 Numerous social stressors and high levels of perceived stress have been shown to be positively associated with mortality.15^,26 Current and former smoking and physical inactivity are also positively associated with mortality.27^–32 Alcohol consumption has a J-shaped relationship with mortality; abstainers and heavy drinkers are at increased risk of death relative to moderate drinkers.29^,33^–36 To our knowledge, no research has examined whether unhealthy behaviors moderate the relationship between stress and mortality.Our first aim in this study was to examine whether unhealthy behaviors moderate the stress–mortality relationship in a nationally representative sample of US adults. There are 3 possible relationships between stress, health behaviors, and the risk of death. First, the “double jeopardy” perspective suggests that multiple risk factors combine to increase the risk of death more than a single risk factor alone would indicate.37^,38 Smoking, alcohol use, and physical inactivity may be pleasurable but deleterious strategies for coping with perceived stress, and they may inadvertently increase the effects of stress on mortality.39^,40 Second, unhealthy behaviors may allow individuals to cope effectively with stress.3^,5^,7^,8^,41 Unhealthy behaviors and high stress levels are each associated with increased mortality, but unhealthy behaviors may nevertheless reduce the effects of stress on mortality. Finally, the null hypothesis implies that unhealthy behaviors will not moderate the stress–mortality relationship.Our second aim was to examine whether unhealthy behaviors moderate the impact of stress on mortality differently across different socioeconomic strata. The social vulnerability hypothesis suggests that the combination of unhealthy behaviors and high stress levels may be particularly risky among individuals of low socioeconomic status (SES), who might be more vulnerable, or less resilient, to accumulating health risks.42^,43 Those who are less advantaged “experience multiple threats to their health, with each threat making the other more serious.”43^(p302)By contrast, the “Blaxter hypothesis” posits that unhealthy behaviors may be less harmful among those in low-SES groups, precisely because members of these groups already face numerous insults resulting from unsafe housing, work, and neighborhood environments.44 Improving unhealthy behaviors without ameliorating underlying socioeconomic disadvantages may yield few health benefits.3^,45^–47 Thus, if unhealthy behaviors increase the relationship between stress and mortality, their influence may be attenuated among low-SES individuals.     

Institutionalization of older adults after the death of a spouse

Objectives. We investigated the risk of entering long-term institutional care after the death of a spouse in relation to the duration of widowhood among older Finnish men and women. We also examined whether high levels of education or household income buffered the effects of bereavement on institutionalization.Methods. We used linked register-based data on Finnish adults 65 years or older who were living with a spouse at the beginning of the study period (n=140902) and were followed from January 1998 to December 2002.Results. The excess risk of institutionalization was highest during the first month following a spouse’s death compared with still living with a spouse (adjusted hazard ratio=3.31 for men, 3.62 for women). This risk decreased over time among both men and women. The relative effect of the duration of widowhood on institutionalization did not significantly vary according to the level of education or income.Conclusions. Risk of institutionalization is particularly high immediately after the death of a spouse, demonstrating the importance of loss of social and instrumental support.Previous studies showed that older adults who live alone or without a spouse have an increased probability of entering institutional care, independent of baseline health status.1^–4 These findings indicate the importance of social and instrumental support provided by a spouse in reducing the need for institutionalization. In addition, never-married, widowed, and divorced older persons have been shown to have a higher probability of institutionalization than their married counterparts.5^,6 However, few studies have analyzed how the death of a spouse affects the probability of entering institutional care.The death of a spouse has been shown to be associated with poor mental health, such as depression and anxiety,7^,8 and with poor physical health.7 Because poor mental and physical health have both been found to be associated with an increased risk of institutionalization,1^,2 it is likely that the death of a spouse also increases the need for institutional care. In addition, some studies have found an association between the death of a spouse and a decline in cognitive status (e.g., memory functioning),9 which is shown to be an important risk factor for admission to institutional care.1^,10 Because mental health may improve again after despair and disorganization diminish with time following bereavement,11 it is possible that the risk of institutionalization is highest immediately after the loss of a spouse and decreases over time.One study from the United States indicated that becoming widowed during a prospective follow-up was associated with an increased probability of nursing home admission, but the recency of widowhood, measured retrospectively at the time of the baseline interviews, was not.12 The latter finding may be misleading, especially if the effect of widowhood is short term and a large proportion of the recently widowed were already institutionalized before the baseline interviews. However, we know of no large-scale prospective studies testing whether the effect of a spouse’s death on institutionalization varies according to the duration of widowhood, and the existence and the magnitude of these effects are unknown.The effect of widowhood and widowerhood on mortality is well established: the recently bereaved have been shown to have a higher risk of death than the currently married,13^–20 especially from alcohol-related diseases, suicides, and other accidents and violence.19 Because both mortality and institutionalization are related to poor health (e.g., poor self-perceived health predicts mortality and institutionalization,3^,21 depression predicts mortality,22 and depressive symptoms predict institutionalization among men23), it is possible that the effect of the duration of widowhood is similar for both. Previous studies indicated that excess mortality is highest during the first weeks18^,24 or months13^,14^,16^,20^,25 after a spouse’s death. Some studies found that excess mortality among the bereaved decreases to the level of the married with time from bereavement among men,13 but others indicated that it continues, although at a lower level, for 10 years and longer.15The excess risk of death among the recently bereaved may be related to psychosocial mechanisms, such as emotional stress and grief, and to the loss of social, instrumental, and material support.18^,19^,26 However, previous mortality studies suggested that the bereaved gradually adapt to the loss and learn to cope in their changed social environment. Furthermore, bereaved persons with disabilities may be more likely to be institutionalized immediately after the death of the spouse because there is no longer anybody to take care of them.High levels of education and income, as well as other social and economic resources, may buffer against the harmful effect of spousal loss on institutionalization and mortality. However, persons with higher education20^,27^,28 and income27 were not found to suffer less excess mortality after a spouse’s death in previous studies. Although high socioeconomic status is associated with lower mortality, it has not been shown to prevent or even buffer the harmful effects of spousal loss. On the contrary, a study of the Israeli Jewish population indicated that the relative excess mortality among those recently bereaved was higher for men with more education.20Perhaps socioeconomic buffering of the effects of bereavement is greater on institutionalization than on mortality, because the loss of spousal support and access to substitute assistance, such as home help services, are likely to be more effective predictors of institutionalization than of death. However, empirical evidence for this hypothesis is not available. Because older adults with savings and higher incomes may be better able to afford home help services, a high household income at the beginning of a study could also buffer the harmful effects of spousal loss.We used population-based survival data with a continuous time scale of institutionalization to assess the risk of entering institutional care after the death of a spouse in relation to the duration of widowhood and widowerhood among adults 65 years or older. We analyzed Finnish register-based data containing information on each individual’s dates of first admission into long-term institutional care and death and on the spouse’s date of death during a 5-year follow-up from January 1998 to December 2002. We sought to assess (1) whether recently bereaved older adults had a higher risk of entering institutional care than did those living with a spouse, independent of sociodemographic controls and preexisting medical conditions; (2) how the duration of widowhood was associated with the risk of entering institutional care; and (3) whether the relative effects of a spouse’s death were smaller among persons with a higher level of education or a higher household income. The first 2 analyses were performed separately for men and women.     

Workplace discrimination and health among Filipinos in the United States

Objectives. We examined the association between work discrimination and morbidity among Filipinos in the United States, independent of more-global measures of discrimination.Methods. Data were collected from the Filipino American Community Epidemiological Survey. Our analysis focused on 1652 participants who were employed at the time of data collection, and we used negative binomial regression to determine the association between work discrimination and health conditions.Results. The report of workplace discrimination specific to being Filipino was associated with an increased number of health conditions. This association persisted even after we controlled for everyday discrimination, a general assessment of discrimination; job concerns, a general assessment of unpleasant work circumstances; having immigrated for employment reasons; job category; income; education; gender; and other sociodemographic factors.Conclusions. Racial discrimination in the workplace was positively associated with poor health among Filipino Americans after we controlled for reports of everyday discrimination and general concerns about one’s job. This finding shows the importance of considering the work setting as a source of discrimination and its effect on morbidity among racial minorities.Previous research suggests that social factors associated with racial/ethnic minority group status may influence health and, thus, health disparities. One such factor is racial discrimination, an important correlate of health.1^,2 Among minority groups in the United States, self-reported racial discrimination is associated with a wide range of health outcomes, including high blood pressure, depression, substance use, and other health problems.3^–6 Most studies of health and discrimination have focused on global experiences of discrimination. For example, Krieger and Sidney7 examined how a measure of discrimination at school, in getting a job, at work, in acquiring housing, in getting medical care, on the street, or by police was associated with blood pressure. Williams et al.8 reported that everyday discrimination, a measure that captured general experiences of routine unfair treatment, was associated with poor mental health. Gee et al.9 found that the everyday discrimination scale was associated with chronic health conditions among Filipino Americans. Other studies have found associations between discrimination and numerous health problems, including coronary calcification,10 alcohol dependence,11 depressive disorder,12 and low birthweight.13Given that stressors in general are known to have nonspecific effects,14^,15 it is not surprising that a range of outcomes have been associated with discrimination.1^,2^,6^,16 In fact, stress researchers have long argued that focusing on particular outcomes may underestimate the potential effect of stressors.2^,17^,18 Although these and other studies have been invaluable in advancing our understanding of discrimination, the study of discrimination in specific contexts is important and may aid the development of targeted interventions.1^,2 One such context is the workplace.Workplace discrimination may influence health both directly, as a stressor, and indirectly through income and advancement. The workplace is among the most frequently noted areas in which discrimination occurs, but there are relatively few studies of work-place discrimination and health outcomes.1^,2 Mays et al.19^,20 reported discrimination to be associated with job stress among working African American women. Jackson et al.21 found that a specific type of workplace discrimination, tokenism, was associated with depression and anxiety among African Americans. Workplace discrimination has also been associated with alcohol use among a multiracial sample of public transit operators22 and with job dissatisfaction among African Americans.23 These studies call attention to the importance of discrimination specific to the workplace aside from more-generic experiences of discrimination; however, they did not include both a measure for workplace discrimination and a measure for generic experiences of discrimination. That is, the association between workplace discrimination and health might arise from more-global experiences with discrimination. Should an association between workplace discrimination and health persist independent of more-global experiences, this would suggest that workplace-specific policies that protect against discrimination are important not only for the preservation of workers’ rights but also to promote their health. Accordingly, we examined whether workplace discrimination was associated with health, independent of a more-global measure of discrimination, in a sample of Filipino American workers.Our study focused on Filipino American workers (this includes US citizen and non—US citizen Filipinos working in America) for several compelling reasons. Filipinos have historically emigrated to America and elsewhere, providing significant numbers of workers throughout a variety of industries.24^–32 In 2000, approximately 2.4 million Filipinos resided in the United States, making them the second largest Asian ethnic group population.33 Moreover, discrimination may be particularly relevant for this population. Compared with Chinese and Vietnamese Americans, Filipino Americans appear to perceive the highest levels of discrimination, and these levels are fairly similar to those of African Americans.34 A survey of Filipino American workers found that 81% said racism was a significant or very significant barrier to their upward mobility.35Several high-profile cases feature the importance of work discrimination among Filipinos. English-only rules in workplaces have explicitly targeted immigrants and some have focused on Filipinos.36 In Carino v. University of Oklahoma Board of Regents (750 F.2d 815 [10th Cir 1984]) the court found that a Filipino man was unlawfully demoted because of his Filipino accent. Regardless of their legality, these language rules serve to remind immigrants of their secondary status and may contribute to employment outcomes that foster work stress. Also, some evidence suggests Filipinos earn less than do their White and other Asian peers.37 Moreover, Asian Americans may encounter a “bamboo ceiling” that impedes advancement into higher level positions.38 Taken together, these observations suggest that discrimination in the workplace does occur and may influence the health of Filipino Americans.     

Association between fear of crime and mental health and physical functioning

Objectives. Studies have reported an inverse association between fear of crime and subjective mental and physical health. We investigated the direction of causality and the curtailment of physical and social activities as a possible mediating pathway.Methods. We analyzed data from 2002 to 2004 of the Whitehall II study, a longitudinal study of more than 10 000 London-based civil servants aged 35 to 55 years at baseline.Results. Fear of crime was associated with poorer mental health, reduced physical functioning on objective and subjective indicators, and lower quality of life. Participants reporting greater fear were 1.93 (95% confidence interval [CI]=1.55, 2.41) times as likely to have depression as those reporting lower fear of crime and had lower mental health scores (0.9 points on the Medical Outcomes SurveyShort Form 36; 95% CI=0.4, 1.3). They exercised less, saw friends less often, and participated in fewer social activities compared with the less fearful participants. Curtailed physical and social activities helped explain the link between fear of crime and health.Conclusions. Fear of crime may be a barrier to participation in health-promoting physical and social activities. Public health practitioners should support fear-reduction initiatives.Irrespective of recorded crime levels, public perception is that crime is on the increase,1^,2 and halting crime has been the public’s priority for government spending for several years.3 Studies report an inverse association between fear of crime and subjective measures of physical, general, and mental health.4^–6 The direction of causality and linking pathways remain unclear. Although fear of crime could lead to poorer health, it is equally plausible that physical health limitations and poor mental health could increase a person’s sense of vulnerability and fear of the effect of crime.7 Longitudinal studies that control for the effect of physical or mental frailty on fear are needed to assess whether fear of crime contributes to the development of ill health.What links fear of crime to health? One behavioral response to fear of crime is avoidance: those who are worried may restrict how much they leave the home and which places they visit, reducing the number of opportunities to form social ties and participate in social activities.6^,8^–10Fear of crime may also result in mistrust of others, in turn limiting the ability to form social ties.9^,11 Social ties and social activities appear to be protective for physical and mental health and functioning.12^–14 Fear of crime may also lead to restrictions in outdoor activities, including walking and cycling,15 and to increased car use.16 Those who fear crime may therefore be less physically active, a lifestyle that increases the risk of cardiovascular disease, poor mental health, and poorer physical and cognitive functioning.17^,18 Fear of crime may have direct effects on psychological well-being.19 Finally, fear of crime may be a stressor that has direct physiological and behavioral consequences for health. It has been proposed that perceived or actual threat increases the vulnerability to pathogens20; stimulates repeated physiological responses, producing wear and tear on the nervous and immune systems4^,21; and increases the likelihood of heavy drinking.22 However, few studies have examined the evidence for the pathways linking fear of crime to health status.Our analysis of data from the Whitehall II study built on existing literature in the following ways: (1) we examined fear of crime and objective health measures as well as subjective ones, (2) we exploited longitudinal data to allow for the possible influence of frailty on subsequent fear of crime, and (3) we explored restrictions in social and physical activities as possible mediating pathways between fear of crime and health status.     

Physical education and academic achievement in elementary school: data from the early childhood longitudinal study

Objectives. We examined the association between time spent in physical education and academic achievement in a longitudinal study of students in kindergarten through fifth grade.Methods. We used data from the Early Childhood Longitudinal Study, Kindergarten Class of 1998 to 1999, which employed a multistage probability design to select a nationally representative sample of students in kindergarten (analytic sample = 5316). Time spent in physical education (minutes per week) was collected from classroom teachers, and academic achievement (mathematics and reading) was scored on an item response theory scale.Results. A small but significant benefit for academic achievement in mathematics and reading was observed for girls enrolled in higher amounts (70–300 minutes per week) of physical education (referent: 0–35 minutes per week). Higher amounts of physical education were not positively or negatively associated with academic achievement among boys.Conclusions. Among girls, higher amounts of physical education may be associated with an academic benefit. Physical education did not appear to negatively affect academic achievement in elementary school students. Concerns about adverse effects on achievement may not be legitimate reasons to limit physical education programs.Physically active youth may be less likely than physically inactive youth to experience chronic disease risk factors1 and to become obese,2 and they may be more likely to remain active throughout adolescence3 and possibly into adulthood.4 Physical activity also has beneficial influences on behavior and cognitive functioning that may result in improving students’ academic achievement.5^–7 Direct indicators of academic achievement include grade-point averages, scores on standardized tests, and grades in specific courses; measures of concentration, memory, and classroom behavior provide indirect estimates.1Several cross-sectional studies examined the association between physical activity and direct measures of academic achievement.8^–13 In addition, several intervention studies were conducted to examine the effect of introducing more physical activity and physical education programs during the school day on indirect estimates of behaviors related to academic achievement (e.g., concentration, memory, disruptive behavior) or on direct measures (e.g., standardized tests, academic record, teacher reports).6^,7^,14^–23 These studies had mixed results. Investigators observed either no association6^,8^,13^,14^,16^,18^,23 or a modest-to-moderate positive association6^,7^,9^–12^,15^,17^,19^–22 between physical activity and academic achievement.Physical education classes provide an opportunity for students to be physically active during the school day.1 School-based physical education has many benefits, including increasing physical activity and improving physical fitness and muscular endurance.24^–28 Increasing physical activity through physical education is also a proposed public health strategy to reduce childhood obesity.29 Although there has been no evidence to date to show that maintaining or increasing time in physical education class negatively affects academic achievement in other subjects, there is concern that physical education classes could take time away from those subjects.1^,28^,30 More information is needed to address this concern and support public health objectives to maintain or expand physical education programs.31We examined the influence of physical education in US elementary schools on direct measures of academic achievement in mathematics and reading from kindergarten through fifth grade. Our study was unique in at least 3 ways: first, the measurement of academic achievement was a standardized test administered at 5 time points. Second, we examined the association between physical education and academic achievement with a prospective cohort design. Finally, we examined participation in physical education as it existed in a representative sample of US students entering kindergarten in fall 1998 who were followed through spring 2004.     

Social network, cognitive function, and dementia incidence among elderly women

Objectives. We examined whether social networks had a protective association with incidence of dementia among elderly women.Methods. We prospectively studied 2249 members of a health maintenance organization who were 78 years or older, were classified as free of dementia in 2001, and had completed at least 1 follow-up interview in 2002 through 2005. We used the Telephone Interview for Cognitive Status–modified, the Telephone Dementia Questionnaire, and medical record review to assess cognitive status. We used the Lubben Social Network Scale–6 to assess social network. We estimated hazard ratios for incident dementia with Cox proportional hazards models, adjusting for age at entry, education, hormone use, cognitive status scores, and health conditions.Results. We identified 268 incident cases of dementia during follow-up. Compared with women with smaller social networks, the adjusted hazard ratio for incident dementia in women with larger social networks was 0.74 (95% confidence interval=0.57, 0.97).Conclusions. Our findings suggest that larger social networks have a protective influence on cognitive function among elderly women. Future studies should explore which aspects of social networks are associated with dementia risk and maintenance of cognitive health.Emerging evidence suggests that social support networks may have a positive influence on cognition and a protective association with the development of dementia among older adults. Although some studies found no association between social networks,1 social engagement,2 or marital status3^,4 with cognition, more-recent studies have suggested the protective effect of social engagement,5^–7 social support,8^,9 social contact,10 social network,11 and social activities12 on cognitive function.Dementia cannot be determined without assessing cognitive function and can be seen as the lowest end of the continuum of cognitive function. Some previous studies examined the association of social networks with cognitive function or with dementia. Bassuk et al.13 found, after they controlled for a variety of risk factors, that those with no social ties had a more than 2-times increase in risk of being cognitively impaired compared with those who had 5 or 6 social ties. Fratiglioni et al. found that living alone and having no close personal ties nearly doubled the risk of developing dementia over 3 years.14 Saczynski et al. found that decreased social engagement from midlife to late life was associated with dementia risk.15 Seeman et al. determined that emotional support at entry into their study was an independent predictor of better maintenance of cognitive functioning at the 7.5-year follow-up.16 Each of these studies used different cognitive tests and social network measures, making comparison of results difficult.We expanded on these previous studies by recruiting a large elderly sample population and applying widely used and validated measures of social network and cognition. Our substudy of the Women’s Memory Study gathered information annually from 2001 through 2005 to determine the relationship of social network to cognitive function and the development of dementia.