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We sought to assess the relationship between sleep duration, sleep disturbance and leukemia incidence among postmenopausal women. This study included 130343 postmenopausal women 50-79 years, who were enrolled in the Women’s Health Initiative during 1993-1998. Variables of self-reported, typical sleep duration and sleep disturbance were obtained at baseline by questionnaire, and the sleep disturbance level was defined according to the WHI Insomnia Rating Scale (WHIIRS). WHIIRS 0-4, 5-8 and 9-20 comprised 37.0%, 32.6% and 30.4% of all women, respectively. After an average of 16.4 years (2,135,109 cumulative person-years) of follow-up, 930 of the participants were identified with incident leukemia in this study. Compared to women with the lowest sleep disturbance (WHIIRS 0-4), women having higher sleep disturbance level (WHIIRS 5-8 or 9-20) had a 22% (95% CI: 1.04-1.43) and 18% (95% CI: 1.00-1.40) excess risk of leukemia respectively, after multivariable adjustment. A significant dose-response trend was found for sleep disturbance and leukemia risk (P for trend 0.048). In addition, women with highest sleep disturbance had a higher risk of myeloid leukemia (WHIIRS 9-20 vs WHIIRS 0-4, HR: 1.39, CI: 1.05-1.83). Higher sleep disturbance level was associated with increased risk of leukemia, especially for myeloid leukemia among postmenopausal women.

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PURPOSE: Aging associated with progressive declines in physical function is well-known; however, little is known about the trajectories of physical function before and after breast cancer diagnosis. The current study examined the trajectories in objective measures of physical function over 20 years for women with breast cancer and matched controls. METHODS: 2712 community-dwelling women (452 breast cancer cases and 1:5 matched cancer-free controls) aged 65 years or older at baseline (1986-1988) within the Study of Osteoporotic Fractures were followed for 20 years. Objective physical function was assessed up to 9 times, including hand-grip strength, timed chair stand, gait speed and quadriceps strength. Linear mixed models were used to model physical function changes in terms of secular time trend, group (cases or controls), period (pre-and post-diagnosis status), and their interaction terms. RESULTS: We observed all measures of physical function declined over time. While no differences in trends between cases and controls during the pre-diagnosis period were observed, after cancer diagnosis, grip strength and gait speed declined significantly faster in cases than controls. Quadriceps strength significantly decreased ~7 pounds shortly after breast cancer diagnosis, and then improved over time. CONCLUSION: Our prospective study revealed that older breast cancer survivors had significantly worse declines in grip strength and gait speed and a sharp, short-term drop followed by gradual improvement over time in quadriceps strength, compared to women without cancer. These findings suggest exercise training targeting muscle strength and mobility would be beneficial among older breast cancer survivors.

Table S1. Hazard ratios (HR) and 95% confidence intervals (95% CI) for the association between metabolic phenotype with varied definitions and colorectal/colon cancer among normal-weight women. Table S2. Hazard ratios (HR) and 95% confidence intervals (95% CI) for the association between metabolic phenotype and colorectal/colon cancer among normal-weight women without diabetes. Table S3. Hazard ratios (HR) and 95% confidence intervals (95% CI) for the association between metabolic phenotype and colorectal/colon cancer among WHI normal-weight women without NSAIDs use.

Background: The prevalence of metabolically unhealthy phenotype in normal-weight adults is 30%, and few studies have explored the association between metabolic phenotype and colorectal cancer incidence in normal-weight individuals. Our aim was to compare the risk of colorectal cancer in normal-weight postmenopausal women who were characterized by either the metabolically healthy phenotype or the metabolically unhealthy phenotype.Methods: A large prospective cohort, the Women's Health Initiative, was used. The analytic sample included 5,068 postmenopausal women with BMI 18.5 to 2. Metabolic phenotype was defined using the Adult Treatment Panel-III definition, excluding waist circumference; therefore, women with one or none of the four components (elevated triglycerides, low high-density lipoprotein cholesterol, elevated blood pressure, and elevated fasting glucose) were classified as metabolically healthy. Multivariable Cox proportional hazards regression was used to estimate adjusted HRs for the association between metabolic phenotype and risk of colorectal cancer.Results: Among normal-weight women, those who were metabolically unhealthy had higher risks of colorectal cancer (HR, 1.49; 95% CI, 1.02–2.18) compared with those who were metabolically healthy.Conclusions: A metabolically unhealthy phenotype was associated with higher risk of colorectal cancer among normal-weight women.Impact: Normal-weight women should still be evaluated for metabolic health and appropriate steps taken to reduce their risk of colorectal cancer. Cancer Epidemiol Biomarkers Prev; 26(2); 155–61. ©2017 AACR.

Background and aims Little is known about how weight trajectories among women during menopausal transition and beyond may be related to risk of type 2 diabetes mellitus (T2DM). The aim of this study was to examine associations between body mass index (BMI) trajectories over 20 years, age of obesity onset, cumulative obese-years and incidence of T2DM among middle-aged women. Methods and results 12,302 women enrolled in the Australian Longitudinal Study on Women's Health (ALSWH) were surveyed in 1996 (Survey 1, age 45–50), 1998 and then every three years to 2016. Self-reported weight and height were collected for up to eight time points. Incident diabetes was assessed via validated self-report of physician-diagnosed diabetes. Growth mixture models were used to identify distinct BMI trajectories. A total of 1380 (11.2%) women newly developed T2DM over an average 16 years of follow-up. Seven distinct BMI trajectories were identified with differential risk of developing T2DM. Initial BMI was positively associated with T2DM risk. We also observed that risk of T2DM was positively associated with rapid weight increase, early age of obesity onset and greater obese-years. Conclusion Slowing down weight increases, delaying the onset of obesity, or reducing cumulative exposure to obesity may substantially lower the risk of developing T2DM.

In the United States, coal consumption in the last 12 years has declined from 1,045,140 million short tons in 2007 to 539,420 million short tons in 2019, a decrease of almost 50%. During that period the number of electric power coal generators has declined from 1,470 to 738 accounting for 21% of capacity. An even more dramatic decrease in coal use has occurred in Western Europe. This significant reduction in coal use and the concomitant closure of coal mines and coal-burning power plants will result in substantially cleaner air, reductions in respiratory problems such as asthma, less heart disease, fewer hospitalizations, and other health benefits, as well as a reduction in occupational health problems such as silicosis and Coal Workers’ Pneumoconiosis (Black Lung Disease). However, in China, India, Russia and in several other Asian countries some projections indicate an increase in coal production and use. In some situations, the coal is burned in old, highly polluting power plants. In these regions the health impacts of coal use could worsen. In addition, millions of people in these regions still burn coal in their homes resulting in maximal exposure to the pollutants such as arsenic, selenium, fluorine, and mercury released from coal combustion.

Food environments are associated with diabetes, obesity and cardiovascular health, but associations to colorectal cancer incidence and mortality have not been reported. We analyzed associations bet...

Air pollution may contribute to depression risk, but prospective incidence studies of risks and resiliencies for young women have not been undertaken. We analyzed prospective cohort data from the A...

Increasing reliance on natural gas for energy has resulted in expansion of the natural gas infrastructure, including pipelines and compressor stations to transport gas. Compressor stations emit numerous particulate and gaseous pollutants including volatile organic compounds (VOCs) but studies of human health in association with compressor stations are almost completely absent from the literature. The objective of the study was to test for associations between VOC emissions from compressor stations and adjusted mortality rates. We conducted a county-level ecological study, using VOC emission data from the 2017 National Emissions Inventory, 2017 age-adjusted total mortality per 100,000 population from CDC data, and covariates from the County Health Rankings data. Results of multiple linear regression models showed that total age-adjusted mortality, controlling for covariates (race/ethnicity, education, poverty, urbanicity, smoking and obesity rates), was significantly higher in association with greater non-methane VOC emissions from compressor stations. Twelve individual VOCs were also associated with significantly higher adjusted mortality. Results provide preliminary evidence that compressor stations along natural gas pipelines are sources of pollutant exposures that may contribute to adverse human health outcomes.

It has been hypothesized that selenium (Se) can prevent cancer, and that Se deficiency may be associated with an increased risk of breast cancer. However, findings from epidemiological studies have been inconsistent. The objective of this study was to assess the association between Se intake and risk of breast cancer in the Women’s Health Initiative (WHI). This study included 145,033 postmenopausal women 50–79 years who completed baseline questionnaires between October 1993 and December 1998, which addressed dietary and supplemental Se intake and breast cancer risk factors. The association between baseline Se intake and incident breast cancer was examined in Cox proportional hazards analysis. During a mean follow-up of 15.5 years, 9487 cases of invasive breast cancer were identified. Total Se (highest versus lowest quartile: HR 1.00, 95% CI 0.92–1.09, Ptrend = 0.66), dietary Se (highest versus lowest quartile: HR 0.99, 95% CI 0.89–1.08, Ptrend = 0.61), and supplemental Se (yes versus no: HR 0.99, 95% CI 0.95–1.03) were not associated with breast cancer incidence. This study indicates that Se intake is not associated with incident breast cancer among postmenopausal women in the United States. Further studies are needed to confirm our findings by using biomarkers such as toenail Se to reduce the potential for misclassification of Se status.

This article reviews evidence for the public health impacts of coal across the extraction, processing, use, and waste disposal continuum. Surface coal mining and processing impose public health risks on residential communities through air and water pollution. Burning coal in power plants emits more nitrogen oxides, sulfur dioxide, particulate matter, and heavy metals per unit of energy than any other fuel source and impairs global public health. Coal ash disposal exposes communities to heavy metals and particulate matter waste. Use of coal in domestic households causes public health harm concentrated in developing nations. Across the coal continuum, adverse impacts are disproportionately felt by persons of poor socioeconomic status, contributing to health inequities. Despite efforts to develop renewable energy sources, coal use has not declined on a global scale. Concentrated efforts to eliminate coal as an energy source are imperative to improve public health and avert serious climate change consequences.

Background Race disparities in health outcomes including mortality risk are well known, but mediating mechanisms that link race to mortality risk have rarely been formally tested. Methods We analyzed public NHANES III data from 1988 to 1994 linked to mortality outcomes prospectively through 2015. Participants included 10,460 non-Hispanic Black (40.5%, n = 4233) and non-Hispanic White (59.5%, n = 6227) adults. Proportional hazards regression models examined mortality risk in association with race, demographics, income, and an index of risky health behaviors including smoking, poor diet and low physical activity. A mediation approach under the counterfactual framework was used to test effects of income and risky health behaviors as mediators between race and mortality risk. Results Considering only race, age and sex, Black participants had significantly higher mortality risk than Whites (HR = 1.46, 95% CI 1.35–1.58). When income and education were added, the race effect was lower but remained significant (HR = 1.15, 95% CI 1.02–1.30). In the subsequent model that also included risky behaviors the association between race and mortality was no longer significant (HR = 1.05, 95% CI 0.92–1.20); both higher income and healthier behaviors contributed to lower mortality risk. There was a significant indirect effect of race on mortality mediated through income, and the direct effect of race on mortality was not significant when the mediating effect of income was considered. Likewise, the risky behavior score significantly mediated the association between race with mortality, and the direct effect of race was not significant. In the separate models, income mediated 62% of the association between race and mortality and lifestyle mediated 61% of the relationship. Conclusions Efforts to reduce race-based mortality disparities may focus on policies to reduce income-based disparities and promote positive health behaviors that consider variations in socioeconomic resources and personal preferences., Highlights • Racial mortality disparities are mediated by lower income and poorer health behaviors. • Direct race effects are not present when formally accounting for mediators. • Interventions to reduce disparities may focus on income policies and behavior change.

Heavy metal exposures may contribute to diabetes risk but prospective studies are uncommon. We analyzed the Australian Longitudinal Study on Women's Health (three cohorts aged 18-23, 45-50, or 70-75 at baseline in 1996, N = 34,191) merged with emissions data for 10 heavy metals (As, Be, Co, Cr, Cu, Hg, Mn, Ni, Pb, Zn) from the National Pollutant Inventory. Over 20-year follow-up, 2,584 women (7.6%) reported incident diabetes. Cox proportional hazards regression models showed that women aged 45-50 at baseline had higher diabetes risk in association with exposure to total air emissions, total water emissions, all individual metals air emissions, and six individual water emissions. After correction for false discovery rate, nine of 11 air emissions and five water emissions remained significant. Associations were not observed for land-based emissions, or for younger or older cohorts. Emissions were dominated by mining, electricity generation and other metals-related industrial processes.

Cognitive impairment imposes substantial psychological, emotional, and economic burdens on affected individuals, families and society. A better understanding of potentially modifiable risk factors that may be used in the prevention of cognitive impairment is therefore a high priority in aging research.This study included 9268 community-dwelling women aged 65 years or older from the Study of Osteoporotic Fractures launched between 1986 and 1988 in the US. Participants were followed for 20 years. Modified Mini-Mental State Examination (m-MMSE) was administered up to 6 times. Six updated measurements of gait speed and handgrip strength at the same visit time when m-MMSE was administered were used. The m-MMSE score was used to define cognitive impairment states (normal, mild, and severe impairment). A multi-state model (MSM) was used to estimate the transitions between different states of cognitive function.Faster gait speed (one unit increase of meter/s) was associated with lower risk of transition from cognitively normal status to mild cognitive impairment (HR = 0.50, 95 % CI: 0.37-0.67), and from mild impairment to severe impairment (HR = 0.52, 95 % CI: 0.37-0.72). Higher gait speed was associated with increased risk of cognitive transition from severe impairment to mild impairment (HR = 2.56 95 % CI: 0.97-6.77), although the result did not reach statistical significance. Similarly, we observed greater handgrip strength (per kg increase) was associated with lower risk of transition of cognitive status from normal to mild impairment (HR = 0.96 95 % CI: 0.95-0.97), and from mild to severe impairment (HR = 0.98, 95 % CI: 0.96-0.99). Greater handgrip strength was associated with increased risk of cognitive transition from severe to mild cognitive impairment (HR = 1.05, 95 % CI: 1.01-1.09). In addition, we also observed that both faster gait speed and greater handgrip strength were associated with lower risk of transitions from normal or mild cognitive impairment status to death.Our results confirmed that screening for slow gait speed or weak handgrip strength may be useful for identifying older adults at risk for cognitive decline when they are still cognitively normal or only mildly impaired. Exercise programs to improve gait speed and muscle strength may delay or prevent transitions into cognitive impairment in older adults.

It has been suggested that higher selenium intake and consumption of supplements protect against several cancers. To our knowledge, epidemiologic evidence is rare and inconsistent on the association of selenium level and the risk for thyroid cancer. Therefore, the aim of this study was to examine the association between selenium intake and thyroid cancer risk in postmenopausal women using the Women's Health Initiative (WHI) database.The WHI recruited 161 808 postmenopausal women 50 to 79 y of age between September 1, 1993 and December 31, 1998. The present study included 147 348 women 63.15 y of age (SD = 7.21) at baseline. The main exposure was baseline total selenium intake including dietary selenium measured by food frequency questionnaire (FFQ) and supplemental selenium. The outcome was thyroid cancer, which was adjudicated by trained physicians. Cox proportional hazard models were used to analyze the association.During a mean follow-up of 16.4 y until September 30, 2020, 442 thyroid cancer cases were identified. There was no significant association between total selenium intake and thyroid cancer risk after adjusting for multiple covariates (highest versus lowest quartile: hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.60-1.29). Association between total selenium intake and the risk for papillary thyroid cancer was also not significant (highest versus lowest quartile: HR, 1.02; 95% CI, 0.66-1.52).The present data did not support that either total or dietary selenium intake was associated with the risk for thyroid cancer or the papillary subtype in postmenopausal women ages 50 to 79 y in the United States.

Social isolation associated with greater risk for mortality is well documented, however, it is unclear whether and the extent to which social isolation influences mortality through health behaviors. We therefore assessed the mediation between social isolation and mortality by health behaviors. 15,000 adults ages 18–89 years in the Third National Health and Nutrition Examination Survey in the US (NHANES III) (1988–1994) were followed through 2015. The outcomes of overall and cause-specific mortality were assessed by linking with the National Death Index. Social isolation was based on a modified Social Network Index. Mediation analyses were conducted under the counterfactual framework. Compared with participants who were not socially isolated, those who were isolated had significantly increased risk for overall mortality (HR = 1.33, 95% CI: 1.15–1.54), cardiovascular disease (CVD)-specific mortality (HR = 1.28, 95% CI: 1.01–1.62) and mortality from causes other than CVD or cancer (HR = 1.53, 95% CI: 1.22–1.90). Social isolation was not independently associated with risk for cancer-specific mortality. The association between social isolation and cancer-specific mortality was largely (74%) mediated by health behaviors, including smoking, physical activity and quality of diet. The associations between social isolation and CVD or other specific mortality were partly (about one-fifth) explained by unhealthy behaviors. In conclusion, the extent to which social isolation and mortality was mediated by healthy behaviors varies by causes of death. Given mounting evidence that social isolation is increasing in society, it is important to add social isolation to the list of public health concerns in addition to conventional risk factors.

BACKGROUND: Triple-negative breast cancer (TNBC) is disproportionately higher in Black women relative to White women. The objective of this study was to examine to what extent the association between race/ethnicity and risk of TNBC is mediated by potentially modifiable factors. METHODS: A total of 128,623 Black and White women aged 50–79 years from the Women’s Health Initiative were followed for a mean of 15.8 years. 643 incident TNBC cases (92 Black women and 551 White women) were confirmed by medical record review. Mediation analyses were conducted using an approach under a counterfactual framework. RESULTS: Black women had approximately twofold higher risk of TNBC compared with white women (HR = 1.93, 95% CI 1.52–2.45). We observed that 48% of the racial disparity was mediated by metabolic dysfunction defined by having 3 or more cardiometabolic risk factors including elevated waist circumference, having history of diabetes, high cholesterol and hypertension. The racial disparity was not significantly mediated by other factors studied, including socioeconomic, lifestyle or reproductive factors. CONCLUSION: Our study observed that approximately half of the racial disparity between postmenopausal Black and White women in TNBC incidence was driven by metabolic dysfunction.

Purpose Because rural residents, particularly those near mining sites, are susceptible to numerous environmental health hazards, it is important to gain deeper insights into their use and trust of health information, which they may employ to help recognize symptoms, learn ways to reduce exposure, or find health care. Methods We surveyed residents (N = 101) of rural Kentucky, Virginia, and West Virginia to assess predictors of health information source use and trust. A project manager administered face-to-face paper and pencil questionnaires assessing demographics, health status, smoking behavior, and health information use and source trust. Bivariate correlations and ordinary least squares regressions were used to analyze the data. Findings The data suggest that rural individuals frequently use nurses, doctors, and websites to seek health information, whereas traditional media are often not their preferred channel for health information. Media sources were not found as trustworthy as interpersonal and medical health information sources. While only 13.0% of individuals in the sample said they ever turned to county or state health departments for health information, these sources were trusted more than any media source and more than friends. Moreover, living closer to active mining sites-meaning these individuals are at a higher risk of environmental health hazards-predicted even less use of traditional media and greater trust in peer sources. Conclusions Not all sources of health information are equally used or trusted by individuals from a rural disparities population. The findings have implications for health campaign message dissemination and intervention designs targeting individuals in rural Appalachia.

Purpose Personality traits have been reported to be associated with type 2 diabetes (T2DM) risk. The objective of this study was to examine whether and to what extent the associations between personality traits (dispositional optimism, hostility, and negative emotional expressiveness) and risk of T2DM were mediated by health behaviors and obesity. Methods Postmenopausal women (n = 110,992) aged 50–79 years without diabetes at enrollment in the Women's Health Initiative study (1993–1998) were followed up to 25 years. Incident diabetes was assessed via a validated self-report of physician-diagnosed diabetes treated with insulin or other hypoglycemic medications. Mediation analyses were performed using approaches under a counterfactual framework. Results An inverse association of optimism with diabetes was significantly mediated by a factor primarily extracted from physical activity, diet quality, and sleep quality with a mediated proportion of 28%. Positive associations for hostility and negative emotional expressiveness were substantially mediated by a factor primarily composed of body mass index and waist circumference with mediated proportions of 32% and 44%, respectively. Conclusions Our data revealed that less than half of the associations between personality traits and risk of T2DM were explained by indirect health behavior pathways. Women's personality traits should be considered in prevention of diabetes in addition to promoting health behaviors.

Background: Female hormones may play roles during renal cell carcinoma (RCC) carcinogenesis. The aims of this study were to investigate associations between hysterectomy, oophorectomy, and risk of RCC and to assess whether the associations were modified by exogenous estrogen, commonly used among women who have undergone hysterectomy. Methods: Postmenopausal women (n = 144,599) ages 50–79 years at enrollment (1993–1998) in the Women's Health Initiative were followed for a mean of 15.9 years. Hysterectomy and oophorectomy were self-reported. Incident RCC cases were confirmed by physician review of medical records and pathology reports. Multivariable Cox proportional hazards modeling was used to estimate hazard ratios (HR) and 95% confidence intervals (CI), adjusting for potential confounders. Results: A total of 583 women developed RCC during follow-up. We observed that hysterectomy, regardless of oophorectomy status, was significantly associated with an increased risk of RCC (HR, 1.28; 95% CI, 1.03–1.60). The association appeared to be more pronounced in women with age at hysterectomy younger than 40 years (HR, 1.34; 95% CI, 1.01–1.80) or older than 55 years (HR, 1.52; 95% CI, 1.01–2.29). Oophorectomy was not significantly associated with risk of RCC. There was no evidence that exogenous estrogen use modified the association between hysterectomy and risk of RCC. Conclusions: In this large prospective study, we showed that women with a history of hysterectomy had 28% increased risk of RCC, and this finding was not modified by exogenous hormone use. Impact: If our findings are confirmed, women should be made aware of increased risk of RCC when considering hysterectomy.

Several studies have assessed the relationship between sleep duration and ovarian cancer risk, but the results are conflicting. Importantly, no studies addressed the relationship between sleep disturbance or sleep quality and ovarian cancer incidence. Moreover, few studies have examined the relationships between sleep measures and subtypes of ovarian cancer. This study included 109,024 postmenopausal women ages 50–79 from the Women's Health Initiative during 1993–1998 and followed through 2018. The Cox proportional hazards model was used to estimate adjusted HRs for the associations between sleep habits and the incidence of ovarian cancer and its subtypes. No association was observed between sleep duration, sleep quality, sleep disturbance, or insomnia and risk of overall ovarian cancer, serous/nonserous, or type I/type II ovarian cancer subtype. However, compared with women with average sleep quality, women with restful or very restful sleep quality had a significantly lower risk of invasive serous subtype [HR: 0.73, 95% confidence interval (CI): 0.60–0.90] while insomnia was associated with a higher risk of invasive serous subtype (HR: 1.36, 95% CI: 1.12–1.66). Associations with insomnia differed significantly by serous and nonserous subtypes, and type I and type II subtypes (Pheterogeneity = 0.001 and Pheterogeneity Prevention Relevance: This study shows no association between sleep duration, sleep quality, or insomnia with the risk of overall ovarian cancer among postmenopausal women. However, restful sleep quality was associated with a lower risk of invasive serous ovarian cancer, and insomnia was associated with a higher risk of invasive serous ovarian cancer.

We conducted latent class analyses to identify women with homogeneous combinations of lifestyle and behavioral variables and tested whether latent classes were prospectively associated with diabetes incidence for women with or without baseline obesity. A total of 64,710 postmenopausal women aged 50-79years without prevalent diabetes at baseline (years 1993-1998) were followed until 2018 with a mean follow-up of 14.6years (sd = 6.4). Lifestyle variables included smoking, diet quality, physical activity, and sleep quality. Psychosocial variables included social support, depression, and optimism. Multivariable Cox proportional hazards regression models tested associations between latent classes and diabetes incidence controlling for age, race/ethnicity, and education. During follow-up, 8076 (12.4%) women developed diabetes. For women without baseline obesity, five latent classes were identified. Compared with a lower risk referent, diabetes incidence was higher in classes characterized by high probability of multiple lifestyle and psychosocial risks (HR = 1.45; 95% CI 1.28, 1.64), poor diet and exercise (HR = 1.23; 95% CI 1.13, 1.33), and psychosocial risks alone (HR = 1.20; 95% CI 1.12, 1.29). For women with baseline obesity, four latent classes were identified. Compared with a lower risk referent, diabetes incidence was higher for women with obesity in classes characterized by high probability of multiple lifestyle and psychosocial risks (HR = 1.48; 95% CI 1.32, 1.66), poor diet and exercise (HR = 1.32; 95% CI 1.19, 1.47), and intermediate probabilities of multiple risks (HR = 1.17; 95% CI 1.05, 1.30). Diabetes prevention efforts that focus on diet and exercise may benefit from attention to how lifestyle behaviors interact with psychosocial variables to increase diabetes risks, and conversely, how psychological or social resources may be leveraged with lifestyle changes to reduce the risk for women with and without obesity.

Objectives We examined whether social relationship variables (social support, social strain, social network size, and stressful life events) were associated with risk of developing type 2 diabetes among postmenopausal women. Method 139,924 postmenopausal women aged 50–79 years without prevalent diabetes at baseline were followed for a mean of 14 years. 19,240 women developed diabetes. Multivariable Cox proportional hazard models tested associations between social relationship variables and diabetes incidence after consideration of demographics, depressive symptoms, and lifestyle behaviors. We also examined moderating effects of obesity and race/ethnicity, and we tested whether social variable associations were mediated by lifestyle or depressive symptoms. Results Compared with the lowest quartile, women in the highest social support quartile had lower risk of diabetes after adjusting for demographic factors, health behaviors, and depressive symptoms (hazard ratio [HR] = 0.93, 95% confidence interval [CI] = 0.89–0.97). Social strain (HR = 1.09, 95% CI = 1.04–1.13) and stressful life events (HR = 1.10, 95% CI = 1.05–1.15) were associated with higher diabetes risks. The association between diabetes and social strain was stronger among African American women. Social relationship variables had direct relationships to diabetes, as well as indirect effects partially mediated by lifestyle and depressive symptoms. Discussion Social support, social strain, and stressful life events were associated with diabetes risk among postmenopausal women independently of demographic factors and health behaviors. In addition to healthy behaviors such as diet and physical activity, healthy social relationships among older women may be important in the prevention of diabetes.

Objectives We studied associations between social support, social network size, social strain or stressful life events and risk of coronary heart disease (CHD) in postmenopausal women with type 2 diabetes. Research Design and Methods From the Women’s Health Initiative, 5,262 postmenopausal women with type 2 diabetes at baseline were included. Cox proportional hazards regression models adjusted for demographics, depressive symptom, anthropometric variables, and lifestyle factors were used to examine associations between social factors and CHD. Results A total of 672 cases of CHD were observed during an average 12.79 (SD 6.29) years of follow-up. There was a significant linear trend toward higher risk of CHD as number of stressful life events increased (p for trend=0.01; HR [95% CI] for the third and fourth quartiles compared with first quartile = 1.27 [1.03-1.56] and 1.30 [1.04-1.64]). Being married or in an intimate relationship was related to decreased risk of CHD [HR and 95% CI 0.82 (0.69-0.97)]. Conclusion Among postmenopausal women with type 2 diabetes, higher levels of stressful life events were associated with higher risk of CHD. Experience of stressful life events might be considered as a risk factor for CHD among women with type 2 diabetes.

Background Exposure to heavy metals may increase risk of kidney disease, but most studies have examined individual metals or two-way interactions. There is increasing recognition of the importance of studying exposure to metal mixtures and health outcomes. Objectives We used Bayesian kernel machine regression (BKMR) to examine associations between a mixture of four heavy metals and indicators of kidney function. Methods We used NHANES 2015-16 data on 1435 adults aged 40 and over to study cross-sectional associations between blood levels of four heavy metals (Co, Cr, Hg and Pb) and kidney function. Kidney function was assessed by estimated glomerular filtration rate (eGFR) and by albumin to creatinine ratio (ACR), measured continuously and dichotomized into indicators of chronic kidney disease (CKD) and albuminuria, respectively. BKMR tested for non-linearity in the exposure-specific responses to evaluate dose-response relationships between mixtures and outcomes and possible interaction effects among exposures. Interactions among continuous outcomes were identified using the NLinteraction package in R. Results A higher metals mixture was significantly associated with all four measures of kidney function in dose-response patterns. Pb had the strongest association with eGFR, albuminuria and ACR, and the second strongest association with CKD. We also observed an interaction between Pb and Co for eGFR and an interaction between Pb and Cd for ACR. Conclusions Exposure to a co-occurring heavy metals mixture was associated with indicators of poor kidney function. Within this mixture, Pb, Co and Cd considered singly and jointly made the greatest contributions to the observed effects. Future prospective study is needed to confirm the association between metal mixtures and kidney function.

Background Parabens are a group of endocrine disruptors that have been associated with health effects such as hypertension, diabetes, oxidative stress and obesity, which are associated with increased mortality risk over time. Women are exposed to higher paraben levels than men through use of consumer products. The current prospective study examines paraben exposure in association with mortality risk for women and men. Methods We analyzed 2005–2008 National Health and Nutrition Examination Survey (NHANES) data on urinary paraben analyte concentrations and covariates in adults aged 20 years and over, prospectively linked to National Center for Health Statistics (NCHS) mortality through 2015 (N = 2939). Proportional hazard regression models examined mortality risk in association with exposures, controlling for covariates for women and men. Covariates included age, race/ethnicity, smoking, education, income, body mass index, physical activity, self-reported health status and baseline health conditions. Results Women were exposed to significantly higher concentrations of all studied parabens than men. Exposures were highest for methyl paraben. Women had significantly higher mortality risk in association with higher natural log exposure to ethyl (HR = 2.048, 95% CI 1.164–3.601), methyl (HR = 1.312, 95% CI 1.013–1.700), butyl (HR = 2.719, 95% CI 1.591–4.647) and total parabens (HR = 1.292, 95% CI 1.006–1.659). Exposure concentrations were associated with higher mortality risk for men only for ethyl paraben (HR = 2.532, 95% CI 1.217–5.268). Discussion Women were found to be at greater mortality risk in association with exposure to ethyl, methyl, butyl and total parabens. These findings require confirmatory research but add to the evidence base that exposure to parabens, probably through consumer products, may have adverse effects on human health, especially for women.

We tested whether Medicaid expansion under the Affordable care Act was associated with increased screening for cervical, breast, and colorectal cancer among low-income adults.We analyzed Behavioral Risk Factor Surveillance System data, identifying 2012 as preexpansion and 2016 as postexpansion (2014 was treated as a wash-out, and 2013 and 2015 had missing screening data from most states). States (including District of Columbia) either expanded Medicaid in 2014 (n=28) or not (n=18); five states that expanded after 2014 were excluded. Participants included low-income adults aged 18-64 without dependent children. A difference-in-difference approach tested whether expansion was significantly associated with screening, controlling for time, state effects, age, sex, race/ethnicity, education, and urban/rural population. For comparison, we also conducted analyses among the low-income Medicare (aged 65 and above) population, and a higher income population.There was a significant expansion effect for women aged 18-64 for cervical cancer screening (N=29,059; odds ratio, 1.04; 95% confidence interval, 1.01-1.08), and for adults 50-64 for colorectal cancer screening (N=32,290; odds ratio, 1.12; 95% confidence interval, 1.03-1.22). Effects for mammography for women aged 40-64, or aged 50-64, were not significant. As expected, there were no significant improvements associated with expansion among the Medicare population, or among a population ineligible due to higher income.Medicaid expansion under the Affordable Care Act was associated with increased screening for cervical and colorectal cancer for low-income adults. It will be important to monitor possible adverse cancer outcomes in nonexpansion states among vulnerable populations over time.

Children are vulnerable to environmental chemical exposures, but little is known about the extent of multiple chemical exposures among children. We analyzed biomonitoring data from five cycles (2003-2012) of the National Health and Nutrition Examination Survey (NHANES) to describe multiple chemical exposures in US children, examine levels of chemical concentrations present over time, and examine differences in chemical exposures by selected demographic groups. We analyzed data for 36 chemical analytes across five chemical classes in a sample of 4299 children aged 6-18. Classes included metals, pesticides, phthalates, phenols, and polycyclic aromatic hydrocarbons. We calculated the number and percent of chemicals detected and tested for secular trends over time in chemical concentrations. We compared log concentrations among groups defined by age, sex, race/ethnicity, and poverty using multiple linear regression models and report adjusted geometric means. Among a smaller subgroup of 733 children with data across chemical classes, we calculated the linear correlations within and between classes and conducted a principal component analysis. The percentage of children with detectable concentrations of an individual chemical ranged from 26 to 100%; the average was 93%, and 29 of 36 were detected in more than 90% of children. Concentrations of most tested chemicals were either unchanged or declined from earlier to more recent years. Many differences in concentrations were present by age, sex, poverty, and race/ethnicity categories. Within and between class correlations were all significant and positive, and the principal component analysis suggested a one factor solution, indicating that children exposed to higher levels of one chemical were exposed to higher levels of other chemicals. In conclusion, children in the USA are exposed to multiple simultaneous chemicals at uneven risk across socioeconomic and demographic groups. Further efforts to understand the effects of multiple exposures on child health and development are warranted.

It has been suggested that breast and thyroid diseases may be linked. The aim of this study was to investigate the association between benign breast disease and subsequent risk of thyroid cancer. Postmenopausal women (n = 133,875) aged 50–79 years were followed up for a mean of 14 years. Benign breast disease was defined by history of biopsy. Incident thyroid cancer cases were confirmed by medical record review. Multivariable Cox proportional hazard modeling was used to estimate hazard ratios. There were 370 incident thyroid cancer cases during the follow-up period. Compared to women without BBD, women with BBD had a significant increased risk of thyroid cancer after adjusting for potential confounders (HR 1.38 95% CI 1.10–1.73), especially for women with more than two biopsies (HR 1.59 95% CI 1.10–2.26). There were no significant differences in thyroid tumor size, stage or histologic types between women with and without BBD. Our large prospective study observed that postmenopausal women with BBD had an increased risk for thyroid cancer compared with women without BBD. A more detailed investigation of thyroid cancer risk according to different subtypes of benign breast disease is needed to better understand the association observed between thyroid and benign breast diseases.

BACKGROUND Few previous studies investigating depression before the diagnosis of breast cancer and breast cancer–specific mortality have examined depression measured at more than 1 time point. This study investigated the effect of depression (combining depressive symptoms alone with antidepressant use) measured at 2 time points before the diagnosis of breast cancer on all-cause mortality and breast cancer–specific mortality among older postmenopausal women. METHODS A large prospective cohort, the Women's Health Initiative, was used. The study included 3095 women with incident breast cancer who had measures of depressive symptoms and antidepressant use before their diagnosis at the baseline and at year 3. Multivariate Cox proportional hazards regression was used to estimate adjusted hazard ratios (HRs) between depression at the baseline, depression at year 3, and combinations of depression at these time points and all-cause mortality and breast cancer–specific mortality. RESULTS Depression at year 3 before a breast cancer diagnosis was associated with higher all-cause mortality after adjustments for multiple covariates (HR, 1.35; 95% confidence interval [CI], 1.02-1.78). There was no statistically significant association of baseline depression and all-cause mortality or breast cancer–specific mortality whether or not depression was also present at year 3. In women with late-stage (regional- or distant-stage) breast cancer, newly developed depression at year 3 was significantly associated with both all-cause mortality (HR, 2.00; 95% CI, 1.13-3.56) and breast cancer–specific mortality (HR, 2.42; 95% CI, 1.24-4.70). CONCLUSIONS Women with newly developed depression before the diagnosis of breast cancer had a modestly but significantly increased risk for death from any cause and for death from breast cancer at a late stage. Cancer 2017;123:3107–15. © 2017 American Cancer Society.

INTRODUCTION:Evidence on the association between diabetes and risk of bladder cancer has been controversial. In addition, findings on the associations between duration of diabetes, diabetes treatment, and risk of bladder cancer have been inconsistent. METHODS:A total of 148,208 participants in Women's Health Initiative study were included. Information on diabetes status, diabetes duration, and treatment was collected both at baseline and during follow-up. Information on potential confounders including age, race/ethnicity, education, occupation, family history of cancer, smoking status, alcohol consumption, total physical activity, body mass index, and daily dietary intake were collected at baseline. Bladder cancer cases were collected and confirmed by a centralized review of pathology reports. Cox proportional hazard models with time-varying covariates were used to examine associations of diabetes status, duration of diabetes, and diabetes treatment with bladder cancer risk. RESULTS:During a median follow-up of 18.5years, 865 bladder cancer cases were identified. There were no significant associations of diabetes, duration of diabetes, or diabetes treatment with risk of bladder cancer. Participants with prevalent diabetes did not have significantly higher risk of bladder cancer compared with those without diabetes. CONCLUSION:Diabetes was not significantly associated with risk of bladder cancer among postmenopausal women.

Occupational exposure limits for respirable coal dust are based on exposure during working hours, but coal miners may experience additional community-based exposures during nonworking hours. We analyzed Australia National Pollutant Inventory (NPI) data for the years 2008&ndash, 2018 to estimate air pollutants (metals, nitrogen oxides, particulate matter &le, 10 micrometers (PM10) and &le, 2.5 micrometers (PM2.5)) originating from coal mines. PM10 levels from community-based air monitors in Queensland and New South Wales were also compared between mining and nonmining communities. Results indicated that tons of coal mined increased over the study period, and that levels of particulate matter, metals, and nitrogen oxides increased significantly over time as well. Coal mines accounted for 42.1% of national PM10 air emissions from NPI sites. PM2.5 from coal mines accounted for 19.5% of the national total, metals for 12.1%, and nitrogen oxides for 10.1%. Coal mining occurred in 57 different post codes, the 20 coal-mining post codes with the highest PM10 emissions were home to 160,037 people. Emissions of all studied pollutants were significantly higher from coal mining sites than from other types of NPI sites. Results from community-based air monitoring stations indicated significantly higher population PM10 exposure in coal mining communities than in nonmining communities. The health of the public at large is impacted by coal mining, but to the extent that miners also live near coal mining operations, their total exposure is underestimated by consideration of exposure only during working hours.

Background: COVID-19 may be experienced disproportionately among racial minorities but evidence is limited. The study objective was to determine whether COVID-19 prevalence and mortality rates were higher in the US population in association with race/ethnicity, racial segregation, and other population characteristics. Methods: The study used a repeated measures county-level ecological design including all US counties. Exposures included population characteristics including percent Black race, racial segregation, household income and income inequality, age, education, health insurance rates, primary care physician supply, and percent rural population. Outcomes were COVID-19 prevalence per 100,000 population, and death rates from COVID-19 per 100,000 between April 1 and April 15, 2020. Findings: Higher disease prevalence and death rates were found in association with higher racial segregation, higher percent Black population, income and income inequality, and lower percent rural population. The disparity among populations characterized by combined higher percent Black population and higher segregation significantly worsened between April 1 and April 15, 2020. Interpretation: Populations with a combination of higher percent of Black populations and greater racial segregation experienced higher COVID-19 prevalence and mortality, and this disparity increased significantly as the disease outbreak in the US worsened in the first half of April 2020. Current and future efforts to fight COVID-19 should address disproportionate risks in these communities. Funding Statement: The study received no funding from any public or private source. Declaration of Interests: None.

Coal mining activities may increase residential exposure to polycyclic aromatic hydrocarbons (PAHs), but personal PAH exposures have not been studied in mining areas. We used silicone wristbands as passive personal samplers to estimate PAH exposures in coal mining communities in Central Appalachia in the United States. Adults (N = 101) wore wristbands for one week; 51 resided in communities within approximately three miles of surface mining sites, and 50 resided 10 or more miles from mining sites. Passive indoor polyurethane foam (PUF) sampling was conducted in residents’ homes, and a sample of 16 outdoor PUF samples were also collected. Nine PAH congeners were commonly detected in wristbands (mean ± standard deviation), including phenanthrene (50.2 ± 68.7 ng/g), benz[a]anthracene (20.2 ± 58.2 ng/g), fluoranthene (19.4 ± 24.1 ng/g) and pyrene (15.2 ± 18.2 ng/g). Controlling for participant characteristics and season, participants living closer to mining sites had significantly higher levels of phenanthrene, fluorene, fluoranthene, pyrene and ∑PAHs in wristbands compared to participants living farther from mining. Indoor air showed no significant group differences except for pyrene, but outdoor air showed significant or marginally significant differences for phenanthrene, fluorene, pyrene and ∑PAHs. The results suggest that mining community residents face exposure to outdoor mining-related pollutants, and demonstrate that personal silicone wristbands can be deployed as effective passive sampling devices.

Physical activity is associated with decreased risk for many cancers. Studies on the association between physical activity and risk of bladder cancer are limited, and findings are inconsistent. Postmenopausal women (mean age = 63.3) were recruited into the Women's Health Initiative from 1993 to 1998. Self-reported baseline information on physical activity and other covariates were available in 141 288 participants. Incident bladder cancer cases were collected through 2018 and centrally adjudicated. Hazard ratios (HRs) and 95% confidence intervals (CIs) were determined by Cox proportional hazard regression models. Effect modification due to smoking was assessed. During an average of 18.5 years of follow-up, 817 bladder cancer cases were identified. Compared to physically inactive women, those who engaged in ≥15 MET-hours/week of total physical activity, ≥8.75 MET-hours/week of walking or ≥11.25 MET-hours/week of moderate to vigorous physical activity had lower risk of bladder cancer (HR = 0.74, 95% CI: 0.59-0.94, P for linear trend = .02; HR = 0.79, 95% CI: 0.63-0.98, P for linear trend = .03; and HR = 0.76, 95% CI: 0.61-0.94, P for linear trend = .02, respectively). No effect modification was found by smoking status (P for interaction = .06, 0.91 and 0.27, respectively). We found that total physical activity, walking and moderate to vigorous physical activity were inversely associated with bladder cancer incidence among postmenopausal women in a dose-response manner. Physical activity may play a potential role in the primary prevention of bladder cancer. Further studies with objective measurements of physical activity are needed to confirm these findings.

Obesity is a risk factor for type 2 diabetes, yet little is known about how timing and cumulative exposure of obesity are related to disease risk. The aim of this study was to examine the associations between BMI trajectories, age of onset of obesity and obese-years (a product of degree and duration of obesity) over early adulthood and subsequent risk of type 2 diabetes. Women aged 18–23 years at baseline (n = 11,192) enrolled in the Australian Longitudinal Study on Women’s Health (ALSWH) in 1996 were followed up about every 3 years via surveys for up to 19 years. Self-reported weights were collected up to seven times. Incident type 2 diabetes was self-reported. A growth mixture model was used to identify distinct BMI trajectories over the early adult life course. Cox proportional hazards regression models were used to examine the associations between trajectories and risk of diabetes. One hundred and sixty-two (1.5%) women were newly diagnosed with type 2 diabetes during a mean of 16 years of follow-up. Six distinct BMI trajectories were identified, varying by different initial BMI and different slopes of increase. Initial BMI was positively associated with risk of diabetes. We also observed that age at onset of obesity was negatively associated with risk of diabetes (HR 0.87 [95% CI 0.79, 0.96] per 1 year increment), and number of obese-years was positively associated with diabetes (p for trend

Author(s): Miao Jonasson, Junmei; Hendryx, Michael; Manson, JoAnn E; Dinh, Paul; Garcia, Lorena; Liu, Simin; Luo, Juhua | Abstract: OBJECTIVE:We studied the associations between personality traits and the risk of coronary heart disease (CHD) or stroke in women with diabetes. METHODS:From the Women's Health Initiative, 15,029 women aged 50 to 79 years at enrollment and with self-reported treated diabetes at baseline or follow-up, were followed for a mean of 10 years. Personality traits measured from validated scales included hostility, optimism, ambivalence over emotional expressiveness, and negative emotional expressiveness. Multivariable Cox proportional-hazards regression models were used to examine associations between personality traits and the risk of adjudicated CHD (nonfatal myocardial infarction and CHD death) or stroke outcomes. Progressively adjusted regression approach was used in the multivariable models to adjust for demographics, depression, anthropometric variables, and lifestyle factors. RESULTS:A total of 1,118 incident CHD and 710 incident stroke cases were observed. Women in the highest quartile of hostility had 22% (hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.01-1.48) increased risk for CHD compared with women in the lowest quartile of hostility. P values for trend were greater than 0.05. Stratified analysis by prevalent or incident diabetes showed that the highest quartile of hostility had 34% increased risk for CHD (HR 1.34, 95% CI 1.03-1.74) among women with incident diabetes. Other personality traits were not significantly associated with stroke or CHD. CONCLUSIONS:Hostility was associated with incidence of CHD among postmenopausal women with diabetes, especially among incident diabetes. These results provide a basis for targeted prevention programs for women with a high level of hostility and diabetes.

Silicone wristbands are being increasingly used to assess human exposure to semi-volatile organic compounds (SVOCs). However, it is unclear what exposure pathways wristbands integrate. To test the hypothesis that wristbands integrate inhalation and dermal exposures, we measured 38 chemicals from four compound groups (PAHs, PBDEs, nBFRs, and OPEs) in silicone wristbands and brooches, active air samples (Occupational Safety and Health Administration Versatile Sampler or OVS cartridge), and hand wipes from 10 adults during a 72-hour period. Phenanthrene, BDE-47, 2‑ethylhexyl 2,3,4,5‑tetrabromobenzoate (EHTBB), tris[(2R)‑1‑chloro‑2‑propyl] phosphate (TCIPP), and tris(1,3‑dichloro‑2‑propyl) phosphate (TDCIPP) were the predominant compounds in all four matrices. In a linear regression analysis, the compound levels in OVS were positively associated with those in wristbands and brooches for nBFRs and OPEs, but not for PAHs and PBDEs. The compound levels in wristbands were positively associated with those in hand wipes and brooches for all chemicals. The regressions between the levels in wristbands and OVS or brooches combined with the levels in hand wipes showed stronger, supporting the hypothesis that wristbands captured inhalation and dermal exposure pathways.

To examine associations among parity, breastfeeding history, and risk of developing type 2 diabetes among postmenopausal women.A prospective cohort study was conducted. One hundred thirty-six thousand six hundred fifty-two postmenopausal women aged 50-79 years participating in the Women's Health Initiative recruited from 40 clinical centers throughout the United States between 1993 and 1998, without baseline cancer or diabetes were followed for 14.2 years. Parity and breastfeeding data were collected by questionnaires administrated to all participants at baseline. Incident diabetes was assessed via validated self-report of physician-diagnosed diabetes treated with insulin or other hypoglycemic medications. Multivariable Cox proportional hazards regression models were used to assess associations between parity, breastfeeding and diabetes incidence, and racial-ethnic differences in the associations.During follow-up, 18,812 cases of incident diabetes were identified. Overall, a greater number of term pregnancies was associated with increased risk of diabetes (P for trend=.002), and longer duration of breastfeeding was associated with lower risk of diabetes (P for trend.01). After further adjusting for adult weight gain among a subset of the cohort (n=75,558) with 9,110 cases, the association between parity and risk of diabetes were attenuated and became nonsignificant. Also, parous women with fewer than five term pregnancies did not have increased diabetes risk when breastfeeding for 3 months or more per child, which was associated with less weight gain.The results of this large, prospective study showed that the association between parity and risk of type 2 diabetes was most likely confounded by adult weight gain among postmenopausal women.