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This systematic review synthesizes research published from January 2010-July 2022 on the social determinants of ideal cardiovascular health (CVH) carried out around the world and compares trends in high-income countries (HICs) to those in low- and middle-income countries (LMICs). 41 studies met inclusion criteria (n = 28 HICs, n = 13 LMICs). Most were from the United States (n = 22) and cross-sectional (n = 33), and nearly all evaluated associations among adults. Among studies conducted in LMICs, nearly all were from middle-income countries and only one was carried out in low-income country. Education (n = 24) and income/wealth (n = 17) were the most frequently examined social determinants in both HICs and LMICs. Although most studies assessed ideal CVH using reliable and valid methods (n = 24), only 7 used criteria pre-defined by the American Heart Association to characterize ideal levels of each CVH metric. Despite heterogeneity in how outcome measures were derived and analyzed, consistent associations were evident between multiple markers of higher social status (i.e. greater education, income/wealth, socioeconomic status, racial/ethnic majority status) and greater levels of ideal CVH across both country contexts. Gaps in the literature include evidence from LMICs and HICs other than the United States, longitudinal research, and investigations of a wider array of social determinants beyond education and income/wealth.

Background and aims Adult telomere length (TL) is substantially determined by birth TL, but associations of birth TL with cardiovascular disease (CVD) are unknown. Methods We included 144 adult offspring born in 1959–1966 from the Collaborative Perinatal Project, a US birth cohort. Birth TL was measured from banked cord blood with quantitative polymerase chain reaction. Atherosclerotic lesions were predicted by the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) score that was based on blood pressure, lipids, hemoglobin A1c, and body weight at the midlife follow-up in 2003–2008 (average age: 42 years). Information on midlife CVD risk factors including the age at first diagnoses of hypertension, hypercholesterolemia, and diabetes was also collected. We used linear and logistic regression models to analyze associations of birth TL with the continuous PDAY score and categorical CVD risk factors, respectively, adjusting for prenatal confounders. Results At midlife follow-up, 31.2% and 18.7% of participants had ever been diagnosed with hypercholesterolemia and hypertension, respectively, and 8.3% met the criteria for metabolic syndrome. Short birth TL (Quartile 1, Q1) was associated with a higher PDAY score (adjusted β: 1.78, 95% CI: 0.31, 3.25), increased odds of hypercholesterolemia (adjusted odds ratio [OR]: 3.23, 95% CI: 1.28, 8.18) and the presence of any cardiometabolic abnormalities (adjusted OR: 2.54, 95% CI: 1.00, 6.48) as compared to longer birth TL (Q2-Q4) after adjusting for prenatal confounders. Conclusions People born with short TL may be at increased risk of predicted midlife atherosclerotic lesions and hypercholesterolemia. Future studies with larger sample sizes and CVD morbidities are warranted to replicate our findings.

Prior evidence links posttraumatic stress disorder (PTSD) and depression, separately, with chronic inflammation. However, whether effects are similar across each independently or potentiated when both are present is understudied. We evaluated combined measures of PTSD and depression in relation to inflammatory biomarker concentrations.Data are from women (n's ranging 628-2797) in the Nurses' Health Study II. Trauma exposure, PTSD, and depression symptoms were ascertained using validated questionnaires. We examined (a) a continuous combined psychological distress score summing symptoms for PTSD and depression, and (b) a categorical cross-classified measure of trauma/PTSD symptoms/depressed mood status (reference group: no trauma or depressed mood). Three inflammatory biomarkers (C-reactive protein [CRP], interleukin-6 [IL-6], tumor necrosis factor alpha receptor 2 [TNFR2]) were assayed from at least one of two blood samples collected 10-16 years apart. We examined associations of our exposures with levels of each biomarker concentration (log-transformed and batch-corrected) as available across the two time points (cross-sectional analyses; CRP, IL-6 and TNFR2) and with rate of change in biomarkers across time (longitudinal analyses; CRP and IL-6) using separate linear mixed effects models.In sociodemographic-adjusted models accounting for trauma exposure, a one standard deviation increase in the continuous combined psychological distress score was associated with 10.2% (95% confidence interval (CI): 5.2-15.4%) higher CRP and 1.5% (95% CI: 0.5-2.5%) higher TNFR2 concentrations cross-sectionally. For the categorical exposure, women with trauma/PTSD symptoms/ depressed mood versus those with no trauma or depressed mood had 29.5% (95% CI: 13.3-47.9%) higher CRP and 13.1% (95% CI: 5.1-21.7%) higher IL-6 cross-sectionally. In longitudinal analysis, trauma/PTSD symptoms/depressed mood was associated with increasing CRP levels over time.High psychological distress levels with trauma exposure is associated with elevated inflammation and is a potential biologic pathway by which distress can impact development of inflammatory-related chronic diseases, such as cardiovascular disease. Considering multiple forms of distress in relation to these pathways may provide greater insight into who is at risk for biologic dysregulation and later susceptibility to chronic diseases.

Earlier menopause, either natural or through gynecologic surgeries, has been associated with various negative health sequelae. While posttraumatic stress disorder (PTSD) has been linked to dysregulated biological processes, including reproductive system changes that could alter menopausal timing, little work has examined whether trauma and PTSD are associated with greater risk of early cessation of menses.Data are from 46,639 women in the Nurses' Health Study II, a prospective cohort study of women followed for up to 26 years. Lifetime trauma and PTSD symptoms were assessed with the Brief Trauma Questionnaire and a PTSD symptom screener in 2008. Age at cessation of menses and reason for cessation of menses (i.e., natural menopause, gynecologic surgery including hysterectomy and/or bilateral salpingo-oophorectomy [BSO]) were assessed. Cox proportional hazards models estimated hazards ratios (HR) of cessation of menses (separately for naturally or surgically) associated with trauma alone or PTSD symptoms, relative to no trauma, adjusting for covariates.Trauma/PTSD status was associated with earlier cessation of menses due to surgery, but not natural menopause. Women with trauma exposure, low, and high PTSD symptoms had higher hazard of cessation of menses due to surgery relative to those with no trauma exposure (HRWomen who experienced trauma and PTSD may be at elevated risk for common gynecological surgeries premenopausally, potentially due to increased clinical indications or gynecological conditions.

Introduction Optimism—the expectation that good things will happen—has emerged as a promising health asset, as it appears to be related to healthier behaviors and reduced disease risk. Growing research finds that higher optimism is associated with lower mortality, yet it is critical to understand whether this prolonged longevity is accompanied by good health. This study tested whether higher optimism was associated with increased likelihood of healthy aging. Methods Prospective data analyzed in 2018 from the Nurses’ Health Study included 33,326 women with no major chronic diseases at baseline. Poisson regression models evaluated if optimism was associated with healthy aging 8 years later, considering potential confounders (sociodemographic variables, depression) and intermediate variables (health behaviors). Optimism was assessed in 2004 by validated self-report using mailed questionnaires and healthy aging was assessed in 2012, defined as (1) remaining free of major chronic diseases; (2) having no subjective memory impairment; (3) having intact physical function; and (4) surviving through follow-up. Results Overall, 20.5% of women (n=6,823) fulfilled the definition of healthy aging in 2012. After adjusting for sociodemographic factors and depression, the most (top quartile) versus least (bottom quartile) optimistic women had a 23% greater likelihood of healthy aging (95% CI=1.16, 1.30). Associations were similar in white and black participants, although the sample of black women was small (n=354). Conclusions Higher optimism was associated with increased likelihood of healthy aging, suggesting that optimism, a potentially modifiable health asset, merits further research for its potential to improve health in aging.

Facets of positive psychological well-being, such as optimism, have been identified as positive health assets because they are prospectively associated with the 7 metrics of cardiovascular ...

Growing evidence suggests that exposure to greenness benefits health, but studies assess greenness differently. We hypothesize greenness-health associations vary by exposure assessment method. To test this, we considered four vegetation datasets (three Normalized Difference Vegetation Index datasets with different spatial resolutions and a finely-resolved land cover dataset), and six aggregation units (five radial buffer sizes and self-described neighborhoods) of each dataset. We compared associations of self-rated health and these metrics of greenness among a sample of New York City residents. Associations with self-rated health varied more by aggregation unit than by vegetation dataset; larger buffers and self-described neighborhoods showed more positive associations. Researchers should consider spatial exposure misclassification in future greenness and health research.

Facets of positive psychological well-being, such as optimism, have been identified as positive health assets because they are prospectively associated with the 7 metrics of cardiovascular health (CVH) and improved outcomes related to cardiovascular disease. Connections between psychological well-being and cardiovascular conditions may be mediated through biological, behavioral, and psychosocial pathways. Individual-level interventions, such as mindfulness-based programs and positive psychological interventions, have shown promise for modifying psychological well-being. Further, workplaces are using well-being-focused interventions to promote employee CVH, and these interventions represent a potential model for expanding psychological well-being programs to communities and societies. Given the relevance of psychological well-being to promoting CVH, this review outlines clinical recommendations to assess and promote well-being in encounters with patients. Finally, a research agenda is proposed. Additional prospective observational studies are needed to understand mechanisms underlying the connection between psychological well-being and cardiovascular outcomes. Moreover, rigorous intervention trials are needed to assess whether psychological well-being-promoting programs can improve cardiovascular outcomes.

Purpose Exposure to nature and natural environments may be beneficial for mental health; however, most population-based studies have been conducted among adults whereas few have focused on adolescents. We aimed to investigate the relationship between both greenness (vegetation) and blue space (water), and depressive symptoms among teenagers in the United States. Methods The study population included 9,385 participants ages 12–18 in the 1999 wave of the Growing Up Today Study. We characterized greenness exposure using the Normalized Difference Vegetation Index at a 250-m and 1,250-m radius around a subject's residence using data from the moderate-resolution imaging spectroradiometer onboard the National Aeronautics and Space Administration's Terra satellite. Exposure to blue space was defined as the presence of blue space within a 250-m and 1,250-m radius and distance to the nearest blue space. We used logistic regression models to examine associations with high depressive symptoms, measured using self-reported responses to the McKnight Risk Factor Survey. Results An interquartile range higher peak greenness in the 1,250-m buffer was associated with 11% lower odds of high depressive symptoms (95% confidence interval .79–.99). Although not statistically significant, this association was stronger in middle school students than in high school students. No such association was seen for blue spaces. Conclusions Surrounding greenness, but not blue space, was associated with lower odds of high depressive symptoms in this population of more than 9,000 U.S. adolescents. This association was stronger in middle school students than in high school students. Incorporating vegetation into residential areas may be beneficial for mental health.

Several forms of chronic distress including anxiety and depression are associated with adverse cardiometabolic outcomes. Metabolic alterations may underlie these associations. Whether these forms of distress are associated with metabolic alterations even after accounting for comorbid conditions and other factors remains unclear. Using an agnostic approach, this study examines a broad range of metabolites in relation to chronic distress among women. For this cross-sectional study of chronic distress and 577 plasma metabolites, data are from different substudies within the Women’s Health Initiative (WHI) and Nurses’ Health Studies (NHSI, NHSII). Chronic distress was characterized by depressive symptoms and other depression indicators in the WHI and NHSII substudies, and by combined indicators of anxiety and depressive symptoms in the NHSI substudy. We used a two-phase discovery-validation framework, with WHI (N = 1317) and NHSII (N = 218) substudies in the discovery phase (identifying metabolites associated with distress) and NHSI (N = 558) substudy in the validation phase. A differential network analysis provided a systems-level assessment of metabolomic alterations under chronic distress. Analyses adjusted for potential confounders and mediators (demographics, comorbidities, medications, lifestyle factors). In the discovery phase, 46 metabolites were significantly associated with depression measures. In validation, six of these metabolites demonstrated significant associations with chronic distress after adjustment for potential confounders. Among women with high distress, we found lower gamma-aminobutyric acid (GABA), threonine, biliverdin, and serotonin and higher C16:0 ceramide and 3-methylxanthine. Our findings suggest chronic distress is associated with metabolomic alterations and provide specific targets for future study of biological pathways in chronic diseases.

BackgroundPosttraumatic stress disorder (PTSD) has been associated with increased cardiovascular risk, however, underlying mechanisms have not been fully specified. PTSD is associated with stress-related hormones, including dysregulated glucocorticoid activity. Dysregulation of aldosterone, a mineralocorticoid activated by psychological stress and implicated in cardiovascular damage, may be a relevant pathway linking PTSD and cardiovascular risk. Few studies to date have evaluated the association between PTSD and aldosterone, none with repeated measures of aldosterone. We examined if trauma and PTSD were associated with altered aldosterone levels relative to women unexposed to trauma.MethodsThe association of trauma exposure and chronic PTSD with plasma aldosterone levels was investigated in 521 middle-aged women in the Nurses' Health Study II. Aldosterone was assessed at two time points, 10-16 years apart, and trauma exposure and PTSD were also ascertained for both time points. Regarding exposure assessment, women were characterized based on a structured diagnostic interview as: having chronic PTSD (PTSD at both time points; n=174); being trauma-exposed (trauma exposure at first time point but no PTSD; n=174); and being unexposed (no trauma exposure at either time point; reference group for all analyses; n=173). Linear mixed models examined associations of trauma and PTSD status with log-transformed aldosterone levels, adjusting for covariates and health-related variables that may confound or lie on the pathway between PTSD and altered aldosterone levels.ResultsAcross the sample, mean aldosterone concentration decreased over time. Adjusting for covariates, women with chronic PTSD had significantly lower aldosterone levels averaged over time, compared to women unexposed to trauma (β=-0.08, p=0.04). Interactions between trauma/PTSD group and time were not significant, indicating change in aldosterone over time did not differ by trauma/PTSD status. Post-hoc exploratory analyses suggested that menopausal status partially mediated the relationship between chronic PTSD status and aldosterone level, such that postmenopausal status explained 7% of the effect of PTSD on aldosterone.ConclusionsThese findings indicate that PTSD is associated with lower levels of aldosterone. Further work is needed to understand implications of this type of dysregulation in a key biological stress system for cardiovascular and other health outcomes previously linked with PTSD.

BackgroundPosttraumatic stress disorder (PTSD) may contribute to heightened cardiovascular disease risk by promoting a proinflammatory state and impaired endothelial function. Previous research has demonstrated associations of PTSD with inflammatory and endothelial function biomarkers, but most work has been cross-sectional and does not separate the effects of trauma exposure from those of PTSD.MethodsWe investigated associations of trauma exposure and chronic PTSD with biomarkers of inflammation (C-reactive protein and tumor necrosis factor alpha receptor II) and endothelial function (intercellular adhesion molecule-1 and vascular cell adhesion molecule-1) in 524 middle-aged women in the Nurses' Health Study II. Using linear mixed models, we examined associations of trauma/PTSD status with biomarkers measured twice, 10 to 16 years apart, in cardiovascular disease-free women, considering either average levels over time (cross-sectional) or change in levels over time (longitudinal). Biomarker levels were log-transformed. Trauma/PTSD status (based on structured diagnostic interviews) was defined as no trauma at either blood draw (n= 175), trauma at blood draw 1 but no PTSD at either draw (n= 175), and PTSD that persisted beyond blood draw 1 (chronic PTSD; n= 174). The reference group was women without trauma.ResultsIn models adjusted for known potential confounders, women with chronic PTSD had higher average C-reactive protein (B= 0.27, p < .05), tumor necrosis factor alpha receptor II (B= 0.07, p < .01), and intercellular adhesion molecule-1 (B= 0.04, p < .05) levels. Women with trauma but without PTSD had higher average tumor necrosis factor alpha receptor II levels (B= 0.05, p < .05). In addition, women with chronic PTSD had a greater increase in vascular cell adhesion molecule-1 over time (B= 0.003, p < .05).ConclusionsIncreased inflammation and impaired endothelial function may be pathways by which chronic PTSD increases cardiovascular disease risk.

Dysregulation of the hypothalamus-pituitary-adrenal (HPA) axis has been suggested as a potential mechanism linking sleep and cardiometabolic disorders. However, the associations of two primary outputs of the HPA axis, cortisol and its antagonist dehydroepiandrosterone (DHEA), with sleep are less well studied. In the Nurses’ Health Study II, 233 postmenopausal women provided five timed saliva samples over one day (immediately upon waking, 45 minutes, 4 hours, and 10 hours after waking, and prior to going to sleep) to measure cortisol and DHEA. Of these, 209 completed assessment of their habitual sleep patterns using the Pittsburgh Sleep Quality Index (PSQI). We used piecewise linear mixed models to compare cross-sectional associations of slopes reflecting diurnal cortisol and DHEA rhythms with overall sleep quality and with seven sub-components. Overall, we observed no differences in the diurnal patterns of cortisol or DHEA between good versus poor sleepers as assessed by the global PSQI score. However, longer sleep latency was associated with significantly reduced cortisol awakening rise (p=0.02). Poorer subjective sleep quality (p=0.02), shorter sleep duration (p=0.02), and lower sleep efficiency (p=0.03) were associated with slower rate of cortisol decline later in the day. Women reporting daytime dysfunction had a sharper cortisol decline early in the day (p=0.03) but a flattened decline later in the day (p=0.01). The differences in diurnal patterns of DHEA between good versus poor sleepers, though less pronounced, were similar in direction to those of cortisol. Self-reported sleep duration, efficiency, latency and daytime dysfunction were associated with altered diurnal rhythms of cortisol and, to a lesser extent, DHEA. These findings provide support for the interplay between sleep and the HPA axis that may contribute to cardiometabolic disease.

Both positive ( e.g. , happiness) and negative ( e.g. , anxiety) emotions have been distinctively associated with health and disease outcomes. However, whether emotion-related effects are driven by specific emotions or by shared underlying features of similar co-occurring (or mixes of) emotions is still debated. This narrative review summarizes recent scientific advances regarding whether mixed emotions and emotion regulation abilities influence physical health over the lifecourse. While behavioral and biological pathways are commonly proposed to explain these relationships, biological pathways are less well understood. As a result, here we specifically focus on known and novel biological pathways. Future directions for empirical and clinical research aimed at identifying ways to lower the risk of and burden related to chronic diseases are also discussed.

Introduction: Type 2 diabetes is a public health concern, but psychosocial factors that may protect against the disease are unknown. This study examines whether a positive psychosocial environment in childhood is associated with lower risk for Type 2 diabetes in adulthood or healthier glucose trajectories over the life course, and whether BMI mediates the associations. Methods: A cohort of 3,596 Finnish children was followed into adulthood over 32 years. An overall positive psychosocial score, consisting of six subdomains, was measured at study baseline (1980). Relative risk ratios and multilevel growth curve modeling were used to examine associations of the psychosocial score with Type 2 diabetes (2012) and glucose trajectories (1986-2012). The mediating effect by BMI was examined using mediation analysis. The analyses were conducted between June 2015 and January 2016. Results: There was a 21% decrease in the rate of Type 2 diabetes (relative risk ratio, 0.79; 95% CI = 0.66, 0.94) for each 1-SD increase in the positive psychosocial score after adjustment for childhood cardiovascular risk factors and dietary behaviors. Adult BMI mediated 52% and weight gain mediated 25% of the association. The growth curve model showed healthier glucose trajectories (age X psychosocial score interaction, b = -0.01; p = 0.010) for participants with higher versus lower positive psychosocial score in childhood. Conclusions: Positive psychosocial environment in childhood seems to have beneficial influences on the risk for Type 2 diabetes over the life span. RCTs will be required to see if interventions directed at early-life circumstances are warranted. (C) 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Background Around the world, international migration and growing economic inequality have contributed to heightened perceptions of intergroup threat (i.e., feeling that people outside of one's social group are hostile to their physical or emotional well-being). Exposures related to intergroup threat, like negative intergroup contact, are inherently stressful and may contribute to higher levels of psychological distress in the population. This longitudinal study investigated whether maternal experiences of negative intergroup contact are related to poor mental health outcomes among ethnically diverse children in The Netherlands. Methods Data are from 4025 mother-child pairs in the Generation R Study, a multi-ethnic Dutch birth cohort initiated in 2005. Mothers’ experiences of negative intergroup contact were assessed during pregnancy. Child mental health was indexed by problem behavior reported by parents and teachers using the Child Behavior Checklist. Linear mixed-effects models tested longitudinal associations of maternal-reported negative intergroup contact with child problem behavior reported by mothers at ages 3, 5, and 9 years, considering a range of potential confounders. Sensitivity analyses examined whether results were replicated using child data from other informants. Results In fully adjusted models, higher levels of negative intergroup contact were associated with more problem behavior averaged across childhood for both non-Dutch (standardized B = 0.10, 95% CI = 0.05, 0.14) and Dutch children (standardized B = 0.12, 95% CI = 0.08, 0.15). Sensitivity analyses with data from other informants largely supported primary findings. Conclusions Comparable adverse intergenerational effects on mental health were observed among both ethnic minority and majority children whose mothers experienced negative intergroup contact. These findings suggest that ethnically divisive social contexts may confer widespread risks, regardless of a child's ethnic background. To our knowledge, this study is the first to examine exposures related to intergroup threat from an epidemiologic perspective and provides proof of principle that such exposures may be informative for population health.

Introduction Anxiety and depression are linked to increased risk of cardiometabolic disease and mortality, and unhealthy behaviors may be the key mechanisms underlying these associations. Although higher levels of psychological symptoms are associated with individual unhealthy behaviors (e.g., physical activity, smoking), their roles in overall lifestyle remain understudied. Methods Midlife women ( n =55,395) from the cohort Nurses' Health Study reported anxiety and depression symptoms in 1988 and 1992, respectively. Health behaviors (i.e., physical inactivity, BMI, diet, and alcohol and tobacco consumption) were measured in self-administered questionnaires in 1988 or 1992, and every 4 years until the last assessment available (2010; follow-up, 18–22 years). Data were analyzed in 2014–2015. Women were categorized according to initial level of psychological symptoms (e.g., lower versus higher anxiety symptoms). Results Despite slight improvements in healthy lifestyle over time among women with higher versus lower anxiety (β interaction =0.002, 95% CI=0.001, 0.003), those experiencing more severe symptoms had a consistently less healthy lifestyle over time ( p pooled =−0.09, 95% CI=−0.09, −0.08). Women with higher versus lower anxiety symptoms also had decreased odds of having a healthy lifestyle in 2010 (AOR=0.78, 95% CI=0.75, 0.81), particularly among women with an initially unhealthy lifestyle ( p interaction ≤0.0001). Comparable patterns were observed with depression symptoms. Conclusions Among midlife women, anxiety and depression symptoms were associated with unhealthier lifestyle throughout follow-up and reduced odds of having a healthy lifestyle 20 years later. Treating psychological symptoms may promote healthier lifestyles.

Two concepts, positive health and cardiovascular health, have emerged recently from the respective fields of positive psychology and preventive cardiology. These parallel constructs are converging to foster positive cardiovascular health and a growing collaboration between psychologists and cardiovascular scientists to achieve significant improvements in both individual and population cardiovascular health. We explore these 2 concepts and note close similarities in the measures that define them, the health states that they aim to produce, and their intended long-term clinical and public health outcomes. We especially examine subjective health assets, such as optimism, that are a core focus of positive psychology, but have largely been neglected in preventive cardiology. We identify research to date on positive cardiovascular health, discuss its strengths and limitations thus far, and outline directions for further engagement of cardiovascular scientists with colleagues in positive psychology to advance this new field.

Objective Individuals who are satisfied and experience frequent positive emotions tend to have reduced risk for coronary heart disease (CHD). However, conflicting evidence exists and little research has investigated whether well-being is associated with early-warning indicators of biological risk that precede CHD. We investigated whether life satisfaction and positive emotions longitudinally predicted reduced risk of incident cardiometabolic conditions and healthier cardiometabolic risk scores, which may provide insight into underlying mechanisms and novel prevention targets. Methods Initially healthy men and women (N = 754–854) reported their baseline life satisfaction and positive emotions. During follow-up, presence of manifest cardiometabolic conditions was assessed and a separate cardiometabolic risk score was constructed from eight biomarkers. Poisson and linear regression analyses tested whether life satisfaction and positive emotions were associated with reduced incident disease risk and lower cardiometabolic risk scores 8–11 years later. Results Life satisfaction and positive emotions were each prospectively associated with reduced risk of manifest conditions, controlling for demographics and family history of CHD. Associations were attenuated for positive emotions after adjusting for depressive symptoms and for life satisfaction after adjusting for health behaviors. Life satisfaction was associated with lower cardiometabolic risk scores until adding health behaviors, but positive emotions were not (regardless of the included covariates). Conclusion Well-being, particularly life satisfaction, is associated with reduced risk for incident cardiometabolic conditions in minimally-adjusted models. However, accounting for underlying behavioral pathways attenuates the association. Low levels of life satisfaction (but not positive emotions) may also provide early warning of cardiometabolic risk prior to disease development.

Background Research suggests cardiovascular and metabolic diseases are influenced by psychological distress in adulthood; however, this research is often limited to adult populations and/or a snapshot measure of distress. Given emerging recognition that cardiometabolic diseases have childhood origins, an important question is whether psychological distress earlier in life influences disease development. Objectives This study sought to assess whether life course patterns of psychological distress assessed from childhood through adulthood predict biomarkers of cardiometabolic risk in adulthood and whether effects of sustained distress differ from more limited exposure. Methods The sample (n = 6,714) consists of members of the 1958 British Birth Cohort Study who completed repeated measures of psychological distress and a biomedical survey at age 45 years. Psychological distress profiles over the life course (no distress, childhood only, adulthood only, or persistent distress) were identified from 6 assessments between ages 7 and 42 years. Cardiometabolic risk was assessed by combining information on 9 biomarkers of immune, cardiovascular, and metabolic system function. Covariate adjusted linear regression models were used to assess associations between distress profiles and cardiometabolic risk. Results Compared with those with no distress, cardiometabolic risk was higher among people with psychological distress in childhood only (β = 0.11, SE = 0.03, p = 0.0002), in adulthood only (β = 0.09, SE = 0.03, p = 0.007), and persistent across the life course (β = 0.26, SE = 0.04, p Conclusions Psychological distress at any point in the life course is associated with higher cardiometabolic risk. This is the first study to suggest that even if distress appears to remit by adulthood, heightened risk of cardiometabolic disease remains. Findings suggest early emotional development may be a target for primordial prevention and for promoting lifelong cardiovascular health.

Objective This study examined the longitudinal association between parental warmth and offspring flourishing in mid-life. We also considered associations between parental warmth and a number of mental health problems and adverse health behavioral outcomes. Method Longitudinal data from the Midlife in the United States Study (N = 3,929, mean baseline age = 47.4 years) were analyzed using generalized estimating equations. Parental warmth in childhood was recalled at phase I (1995–1996), while flourishing and other outcomes were self-reported at phase II (2004–2006). Following an approach developed by Keyes, flourishing was operationalized as a combined measure incorporating assessments of three aspects of well-being, including emotional, psychological, and social well-being. Results The results suggest that parental warmth was positively associated with the continuous score of flourishing (B = 0.21, 95% CI = 0.18, 0.25). The association was not specific to any particular component (emotional, psychological, or social well-being) or subdomain of flourishing. Parental warmth was also inversely associated with several adverse health behavior outcomes such as drug use and smoking. Conclusions Parental warmth in childhood may help promote offspring functioning across multiple domains of well-being in mid-life. The findings help to strengthen the call for a public health focus on the importance of parenting for outcomes beyond childhood and well into adulthood, and suggest the value of targeting parenting practices for prevention and intervention strategies to improve population health and well-being.

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

A history of child abuse (CA) is associated with morbidity and mortality in adulthood, and one proposed mechanism is dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. Therefore, we evaluated whether a history of physical and sexual CA was associated with daily rhythms of HPA hormones (cortisol and dehydroepiandrosterone (DHEA)) among postmenopausal women (mean age: 60.6 years). In 2013, 233 participants from the Nurses’ Health Study II provided up to 5-timed saliva samples over the course of a day: immediately upon awakening, 45 min, 4 h, and 10 h after waking, and prior to going to sleep. Among these 233 participants, 217 provided ≥4 timed saliva samples. Assessment of physical and sexual CA history occurred in 2001 using the Revised Conflict Tactics Scale. Cumulative CA history was derived by combining reports of physical and sexual abuse prior to age 18. Piecewise linear mixed models compared diurnal rhythms of cortisol and DHEA between participants with none-to-moderate CA (n = 104, reference group) versus high-to-severe CA (n = 113). Models adjusted for characteristics at each saliva collection, health status, sleep quality, medications, and hormone use. Compared to those with none-to-moderate CA, women with high-to-severe CA had different diurnal rhythms in the early and evening hours, including blunted (less steep) early declines in DHEA (% difference (%D) = 10.7, 95 % Confidence Interval (CI) 4.3, 17.5), and steeper late declines in both cortisol and DHEA (cortisol %D = -2.5, 95 % CI -4.8, -0.1, and DHEA %D= -3.9, 95 % CI -6.0, -1.8). In conclusion, high-to-severe abuse history prior to age 18 was more strongly associated with differences in DHEA rather than cortisol, suggesting that early life abuse may be related to dysregulation of stress-response mechanisms later in life.

Little research has examined associations of positive psychosocial factors with the American Heart Association Life's Simple 7™ (LS7) among African Americans. This study examined the associations between positive optimistic orientation and LS7 among African Americans. Using exam 1 data (2000–2004) from the Jackson Heart Study, we examined cross-sectional associations of optimism (in tertiles) with LS7 components [smoking, physical activity, diet, body mass index, blood pressure, cholesterol, glucose] and a composite LS7 score (classified as poor, intermediate, ideal) among 4734 African Americans free of cardiovascular disease. Multivariable prevalence regression was used to estimate prevalence ratios (PR, 95% confidence interval-CI) of intermediate and ideal (vs. poor) individual LS7 components and composite LS7 score by optimism levels, adjusting for demographics, socioeconomic status, and depressive symptoms. For LS7 components with low prevalence, we estimated odds ratios. A greater percentage of participants with high vs. low optimism were younger, female, high SES, and not depressed. After full covariate adjustment, the prevalence ratio of ideal (vs. poor) composite LS7 score was 1.24 for participants who reported high (vs. low) optimism (95% CI 1.09–1.42) at exam 1. Higher levels of optimism were also associated with greater prevalence of ideal (vs. poor) physical activity and smoking. Promoting positive optimistic orientation may be an important step toward increasing the likelihood of achieving optimal cardiovascular health among African Americans.

Greater levels of psychological well-being are associated with reduced disease and mortality risk, and lifestyle habits may be potential mechanisms underlying these relationships. Prospective studies show that positive psychological factors enhance the likelihood of adopting specific health behaviors; yet, whether they promote the adoption of multiple healthy behaviors, which can have a multiplicative effect on disease and mortality risk compared to individual behaviors, is unknown. We investigated whether happiness and optimism were related to a healthy lifestyle (characterized by multiple health behaviors) over 10–22 years of follow-up; we also explored bidirectional associations, assessing if a healthy lifestyle at baseline was related to greater likelihood of experiencing higher happiness and optimism over time. Women reported levels of happiness in 1992 (N = 52,133) and optimism in 2004 (N = 36,802). Health-related behaviors (physical activity, body mass index, diet, alcohol and tobacco consumption) were self-reported and combined into a lifestyle score, every four years from baseline until 2014. Multivariable generalized estimating equations with a Poisson distribution were used. Women with moderate and higher (versus lower) happiness levels were more likely to report sustaining healthy lifestyles (RR = 1.18, CI = 1.11–1.25; RR = 1.39, CI = 1.32–1.46, respectively). In secondary analyses, the magnitude of the inverse association was somewhat smaller (likelihood of sustaining higher happiness levels for baseline healthy versus unhealthy lifestyle, RR = 1.11, CI = 1.10–1.12). Results were similar when considering optimism as the exposure and in other secondary analyses (e.g., across individual habits). While bidirectional associations are apparent, these findings suggest pursuing happiness and optimism as modifiable determinants of lifestyle deserves further consideration.

Some evidence suggests that genetic polymorphisms in oxytocin pathway genes influence various social behaviors, but findings thus far have been mixed. Many studies have been based in small samples and there is possibility of publication bias. Using data from 2 large U.S. prospective cohorts with over 11,000 individuals, we investigated 88 SNPs in OXTR, AVPR1A, and CD38, in relation to social integration (measured as social connectedness in both binary and continuous forms and being continuously married). After correction for multiple testing only one SNP in CD38 (rs12644506) was significantly associated with social integration and that SNP predicted when using a dichotomized indicator of social connectedness (adjusted p=0.02), but not a continuous measure of social connectedness or the continuously married outcome. A significant gender-heterogeneous effect was identified in one OXTR SNP on dichotomized social connectedness; specifically, rs4686302 T allele was nominally associated with social connectedness in men, whereas the association direction was opposite in women (adjusted gender heterogeneity p=0.02). Furthermore, the rs53576 A allele was significantly associated with social connectedness only in women, and the effect magnitude was stronger in a dominant genetic model (adjusted p=0.003). In summary, our findings suggested that common genetic variants of OXTR, CD38, and AVPR1A are not associated with social integration as measured in this study using the simplified Berkman-Syme Social Network Index, but these findings and other work hint that effects may be modified by gender or other social experiences. Further work considering genetic pathways in relation to social integration may be more fruitful if these additional factors can be more comprehensively evaluated.

SummaryIn this review we summarize the results and conclusions of five studies as presented in a symposium at the 42nd annual meeting of the International Society for Psychoneuroendocrinology, in New York in September 2012. Oxytocin administration has received increasing attention for its role in promoting positive social behavior and stress regulation, and its potential as a therapeutic intervention for addressing various aspects of psychiatric disorders. However, it has been noted that the observed effects are not uniformly beneficial. In this paper we present five new studies each concluding that contextual and interindividual factors moderate the effects of oxytocin, as well as peripheral oxytocin levels. These findings are in accordance with the recent idea that oxytocin administration may increase sensitivity to social salience cues and that the interpretation of these cues may be influenced by contextual (i.e. presence of a stranger versus friend) or interindividual factors (i.e. sex, attachment style, or the presence of psychiatric symptoms). When social cues in the environment are interpreted as “safe” oxytocin may promote prosociality but when the social cues are interpreted as “unsafe” oxytocin may promote more defensive and, in effect, “anti-social” emotions and behaviors. Likewise, oxytocin appears to promote such agonistic tendencies in individuals who are chronically pre-disposed to view the social milieu in uncertain and/or in negative terms (e.g., those with borderline personality disorder, severe attachment anxiety and/or childhood maltreatment). In all, these studies in pre-clinical animal, healthy humans and patients samples further reinforce the importance of considering both contextual and interindividual factors when trying to understand the role of oxytocin as a biological substrate underlying social bonding and stress regulatory processes and when studying the effects of oxytocin administration in particular in patients with (increased risk for) psychiatric disorders.

Retrospective studies show that childhood adversity is associated with systemic inflammation in adulthood. Few prospective studies have examined whether childhood adversity influences inflammation in an observable manner during childhood or adolescence and if these effects are sustained over time.Using longitudinal data from the Avon Longitudinal Study of Parents and Children, we examined associations between acute adverse events at seven time points prior to age 8 and inflammation at ages 10 and 15. Inflammatory markers at age 10 included interleukin-6 (IL-6; N=4655) and C-reactive protein (CRP; N=4647), and CRP was measured again at age 15 (N=3286). We further evaluated whether body mass index (BMI), depression, or cigarette smoking mediated associations between adverse events and inflammation.Adverse events in middle childhood (occurring between ages 6 to 8), as well as cumulative adversity from birth to 8 years, were associated with higher levels of IL-6 and CRP at age 10. Adverse events reported in early childhood (1.5years) or middle childhood, and cumulative adversity from birth through 8years predicted increased levels of CRP at age 15, and these associations persisted after adjustment for CRP at age 10. Some, but not all, of these associations were mediated by BMI.This study documents that exposure to adverse events prior to age 8 is associated with elevated inflammation at age 10 and in mid-adolescence. These findings provide prospective evidence for a biological mechanism by which early experiences may shape long-term health. Future studies with earlier assessments of inflammation are necessary in order to elucidate potential sensitive periods and mechanisms that link childhood adversity to later disease vulnerability.

Animal research indicates that oxytocin is involved in social behavior, stress regulation, and positive physiologic adaptation. This study examines whether oxytocin enhances adaptive responses to social stress and compares effects between men and women.Hypotheses were tested with a placebo-controlled, double-blind experiment. Social stress was induced. Changes in cardiovascular reactivity, affect, and behavior were assessed.Participants given oxytocin, relative to placebo, responded to social stress with a challenge orientation characterized by a benign pattern of cardiovascular reactivity. Gender differences emerged. Men given oxytocin reported less negative affect and had greater vagal rebound, while women given oxytocin reported more anger and had better math performance following social stress.Findings indicate oxytocin stimulates an approach-oriented cardiovascular profile during social stress, suggesting mechanisms by which oxytocin might improve physical health. However, before considering oxytocin as therapeutic or uniformly enhancing health, greater understanding of possible gender differences in effects is needed.

Purpose Education is inversely associated with coronary heart disease (CHD); however whether this is attributable to causal effects of schooling rather than potential confounders existing before school entry (eg, childhood intelligence, childhood economic circumstances, childhood chronic illness, parental mental health) remains unknown. We evaluated whether education is associated with 10-year CHD risk independent of 21 prospectively assessed childhood conditions, in participants ages 38–47 years. Methods Using linear regression analyses, we evaluated associations of education with 10-year CHD risk, the latter calculated by use of the validated Framingham risk algorithm incorporating diabetes, blood pressure, total and high-density lipoprotein cholesterol, smoking, age, and sex. Propensity score matching incorporated 21 early-life potential confounders. Results Regression analyses demonstrated college graduation was associated with −27.9% lower (95% CI, −36.2, −18.6%) 10-year CHD risk compared with ≤high school after matching on propensity score that included age, sex and race (n = 272); addition of 21 early life potential confounders resulted in effect size of −13.1% (95% CI, −33.4, 13.4; mean n = 110). Conclusions Participants with college degree had substantially lower risk of CHD (27.9%) after accounting for demographics; the addition of early life potential confounders resulted in a moderate effect size (13.1%), suggesting potential importance of early life factors in explaining observed associations between education and CHD risk.

Objectives We assessed the association between depression and sudden cardiac death (SCD) and cardiac events among individuals without baseline coronary heart disease (CHD). Background Depression is a risk factor for cardiac events and mortality among those with CHD, possibly from arrhythmia. Methods We studied depressive symptoms and a proxy variable for clinical depression consisting of severe symptoms and/or antidepressant medication use and their relationship to cardiac events in the Nurses9 Health Study. Questionnaires in 1992, 1996, and 2000 assessed symptoms with the Mental Health Index (MHI-5), and antidepressant use was assessed in 1996 and 2000. Primary end points included SCD, fatal CHD, and nonfatal myocardial infarction. Results Among 63,469 women without prior CHD/stroke in 1992, 7.9% had MHI-5 scores Conclusions In this cohort of women without baseline CHD, depressive symptoms were associated with fatal CHD, and a measure of clinical depression including antidepressant use was specifically associated with SCD. Although antidepressant use might be a marker of worse depression, its specific association with SCD merits further study.

Objective To provide an overview of the role of anxiety disorders in medical illness. Method The Anxiety Disorders Association of America held a multidisciplinary conference from which conference leaders and speakers reviewed presentations and discussions, considered literature on prevalence, comorbidity, etiology and treatment, and made recommendations for research. Irritable bowel syndrome (IBS), asthma, cardiovascular disease (CVD), cancer and chronic pain were reviewed. Results A substantial literature supports clinically important associations between psychiatric illness and chronic medical conditions. Most research focuses on depression, finding that depression can adversely affect self-care and increase the risk of incident medical illness, complications and mortality. Anxiety disorders are less well studied, but robust epidemiological and clinical evidence shows that anxiety disorders play an equally important role. Biological theories of the interactions between anxiety and IBS, CVD and chronic pain are presented. Available data suggest that anxiety disorders in medically ill patients should not be ignored and could be considered conjointly with depression when developing strategies for screening and intervention, particularly in primary care. Conclusions Emerging data offer a strong argument for the role of anxiety in medical illness and suggest that anxiety disorders rival depression in terms of risk, comorbidity and outcome. Research programs designed to advance our understanding of the impact of anxiety disorders on medical illness are needed to develop evidence-based approaches to improving patient care.

Religious participation can promote marital satisfaction and stability. However, current literature has mainly used cross-sectional data. We prospectively evaluated the associations between service attendance and either 1) divorce or separation; or 2) remarriage in the Nurses’ Health Study, a large prospective cohort study that consisted of US married female nurses, with repeated measures of service attendance and marital status. During 14 years of follow up, among 66,444 married nurses, frequent services attendance was associated with 50% lower risk of divorce (95% CI: 32%, 63%). Among divorced or separated women, frequent service attendance was not associated with likelihood of remarriage; however, among widowed women, frequent service attendance was associated with a 49% increased likelihood of remarriage (95% CI: 13%, 97%). The study provides evidence that frequent services attendance is associated with lower risk of becoming divorced, and increased likelihood of remarriage among widowed women, but not among divorced or separated women.

Purpose: Adolescent smoking is associated with increased perceived stress and lower social status, but past research has not explored links between lower social status, stress, and smoking risk. This study examined whether the relation between social status and perceived stress could explain the association between lower social status and increased risk of smoking. Methods: Data were collected from 1021 non-Hispanic black and white adolescents participating in a longitudinal school-based study. Students completed a questionnaire and parents provided information on their highest level of education. Hierarchical logistic regression estimated the effects of parental education, subjective social status (SSS), and stress on smoking risk. Results: At baseline, students from families without a college-educated parent were at greater risk of current smoking (odds ratio (OR) some college 1.98, 95% confidence interval (CI) 1.06- 3.67, and OR high school degree or less 3.34, 95% CI 1.67-6.60 ). Higher school SSS decreased risk of current smoking (OR .73, 95% CI .62-.87), and higher stress increased smoking risk (OR 1.05, 95% CI 1.01-1.08). There was no evidence that the effects of parental education were mediated through stress. At one-year follow-up, both lower school SSS and higher baseline stress were significantly associated with smoking initiation in preliminary models, but only baseline stress (OR 1.06, 95% CI 1.02-1.11) predicted smoking initiation in multivariable models. Discussion: These findings indicate that higher stress and lower social status increase risk of smoking, but that stress does not explain the association between lower social status and smoking. Therefore, stress reduction interventions may not alleviate social inequalities in teen smoking, but they do hold promise for youth smoking prevention. © 2006 Society for Adolescent Medicine. All rights reserved.

Even though a majority of Americans report having spiritual/religious beliefs, the role of different dimensions of spirituality/religiosity in health is not well understood. Moreover, given that the experience of spirituality/religiosity differs for men and women, it is possible that the strength of the association between spirituality/religiosity and health may also differ by gender. The purpose of this study is to examine the relationship between spirituality/religiosity and three markers of health and well-being, and any gender differences in these relationships. First, we test the hypothesis that engagement with formal religious institutions (i.e. public religious activity) will be more beneficial for men than for women and we examine the role of denominational affiliation in any observed differences. Second, we directly compare effects of three different kinds of religious activities (public and private religious activity and spiritual experience) on health and well-being. Data are from the 1998 US General Social Survey, a nationally representative sample of non-institutionalized adults. Participants were asked about the frequency of engaging in public and private religious activities and having spiritual experiences. Psychological distress, happiness and self-rated health were used as indicators of health and well-being. Results suggest that weekly public religious activity was significantly associated with better health and well-being. Furthermore, this relationship was stronger for men than women and was influenced by denominational affiliation. When public religious activity, private religious activity and spiritual experiences were considered simultaneously, public religious activity emerged as the most consistent predictor of health and well-being among men. Among women, both public religious activity and spiritual experiences maintained an independent association with the health and well-being. These results suggest that it may not be appropriate to generalize findings about the relationship between spirituality/religiosity and health from one form of spirituality/religiosity to another, across denominations, or to assume effects are uniform for men and women.

Objective Neighborhood sociodemographic characteristics may be important to the mental health of older adults who have decreased mobility and fewer resources. Our objective was to examine the association between neighborhood context and level of depressive symptomatology in older adults in a diverse geographic region of central North Carolina. Methods The sample included 2,998 adults 65 or older residing in 91 census tracts. Depressive symptoms were measured using the Center for Epidemiologic Studies–Depression scale (CES-D). Neighborhoods were characterized by five census-based characteristics: socioeconomic disadvantage, socioeconomic advantage, racial/ethnic heterogeneity, residential stability, and age structure. Results In ecologic level analyses, level of census tract socioeconomic disadvantage was associated with increased depressive symptoms. To determine whether neighborhood context was associated with depressive symptoms independently of individual characteristics, the authors used multilevel modeling. The authors examined the ability of each of five neighborhood (level 2) characteristics to predict a level 1 outcome (CES-D symptoms) controlling for the effects of individual (level 1) characteristics. Younger age, being widowed, lower income, and having some functional limitations were associated with increased depression symptoms conditional on census tract random effects. However, none of the neighborhood characteristics was significantly associated with depression symptoms, conditional on census tract random effects, either unadjusted or adjusted for individual characteristics. Conclusion Any observed association between neighborhood sociodemographic characteristics and individual depressive symptoms in our sample may reflect the characteristics of the individuals who reside in the neighborhood rather than the neighborhood characteristics themselves. The use of multilevel modeling is important to separate these effects.

The purpose of this study was to examine the prospective relation between dominance, as assessed by a Minnesota Multiphasic Personality Inventory (MMPI-2)-derived dominance scale, and incidence of coronary heart disease (CHD), independent of participants’ anger level. The study was performed in the VA Normative Aging Study, an ongoing cohort of older (mean age 61 years) men. A total of 1,225 men who were free of CHD in 1986 completed the MMPI-2. A factor analysis of selected MMPI items provided the basis for the construction of a dominance scale and an anger scale. During an average of 8 years of follow-up, 158 cases of incident CHD occurred, including 29 cases of fatal CHD, 69 cases of nonfatal myocardial infarction (MI), and 60 cases of angina pectoris (AP). Compared with men reporting the lowest levels of dominance (lower tertile), the multivariate-adjusted relative risk among men reporting the highest levels of dominance (upper tertile) was 1.80 (95% confidence interval [CI] 1.21 to 3.24) for combined nonfatal MI and fatal CHD. Additional adjustment for anger scores did not significantly alter this relation. There was no significant relation between dominance and AP. Our data suggest that dominance is an independent risk factor for CHD in older men.

Objective: Negative emotions, such as anger, anxiety, and depression, have emerged as potentially important risk factors for coronary heart disease. The purpose of this article is to consider the nature and function of emotions, to review epidemiological evidence for an association between the three negative emotions and coronary heart disease (CHD), to discuss briefly the mechanisms by which emotions may be linked to CHD, and to consider this evidence in light of theoretical insights provided by mainstream psychological research on emotions. Methods: We collected articles published between 1980 and 1998 on the relationship between each negative emotion and CHD. We also collected review articles or chapters published during the same time period that considered mechanisms by which emotions may increase CHD risk. We used a qualitative approach to review the published literature. Results: Evidence that anxiety is involved in the onset of CHD is strongest, whereas evidence for an association between anger and CHD is limited but suggestive. Although depression has consistently been linked to mortality following a myocardial infarction, evidence for its role in the onset of coronary disease is quite mixed. Numerous unresolved issues leave our current understanding of the emotion–health relationship incomplete. Psychological theories of emotion are considered to help address gaps in our knowledge. Conclusion: Growing evidence indicates that negative emotions may influence the development of CHD. The focused and specific consideration of negative emotions and their possible role in the etiology of CHD gives insight into current knowledge and suggests important directions for future research.

Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, MA 02115, USA Department of Psychiatry, UC San Francisco, San Francisco, CA 94143, USA Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA

Purpose: Smoking in adolescence has been associated with increased perceived stress and lower socioeconomic status (SES). Furthermore, stress is a plausible pathway that may explain the relationship between SES and smoking. Recent work suggests that subjective perceptions of social status (SSS) within schools may also be important predictors of health outcomes independent of SES measures. This study investigated how SES, school SSS, and perceived stress were related to risk of smoking in adolescents. Methods: Longitudinal cohort study of 841 non-Hispanic black and white 7-12 graders from a Midwestern public school district. In the 2002-2003 academic year, students completed validated survey measures assessing school SSS, cigarette smoking behaviors, and perceived stress. Parents reported their own and their partner’s educational attainment (high school graduate or less, some college, college graduate or higher reference) as a measure of SES. The highest level of parent education (PE) was used in analyses. Students who reported having smoked in the last 30 days were classified as “current” smokers. Those who reported they had never tried smoking were considered “nonsmokers.” Among baseline nonsmokers, those who became current smokers at 1 year follow-up (FU) were classified as “initiators.” Those who had smoked in the past but were not current smokers at baseline were excluded. Hierarchical logistic regression first estimated the effect of PE, school SSS, and stress on risk of baseline current smoking and smoking initiation at 1 year FU and then assessed whether stress mediated any demonstrated social status-smoking relationships. Results: 44.8% were black and 51.6% female. 77.6% did not have a college educated parent. Mean stress levels were higher among those with lower PE ( high school or less 26.6; some college 24.8; college graduate or higher 24.3, p .0001) and lower school SSS (r -.22, p .0001). At baseline, 8.8% were current smokers. Both PE and SSS were associated with baseline current smoking. For PE, having a college educated parent was protective (OR some college 2.59, 95% CI 1.44-4.66, and OR high school degree or less 2.34, 95% CI 1.35-4.07). Higher school SSS was also protective (OR .76, 95% CI .66-.88). Higher stress increased risk of smoking (OR 1.06, 95% CI 1.02-1.09). Addition of the stress variable to the regression model did not suggest mediation. At FU, 8% of nonsmokers had become current smokers. Although PE was not associated with smoking initiation, lower school SSS did predict smoking initiation (OR 1.16, 95% CI 1.01-1.35), as did higher baseline stress (OR 1.07, 95% CI 1.03-1.12). The effect of school SSS was not mediated by stress. Conclusions: Youth with lower social status, whether measured objectively by SES or subjectively by SSS, are at increased risk of current smoking, but only lower SSS in the more local school environment predicted smoking initiation. Although higher stress is associated with both baseline smoking and smoking initiation and with lower social status, there was no evidence that stress accounts for the association between social status and smoking at either time point. Support: NICHD, William T. Grant Foundation.