Early life socioeconomic position contributes to adult obesity independent of adult socioeconomic factors: Findings from the sister study cohort.

Low socioeconomic position (SEP) has been associated with obesity within life stages; however, life course SEP may also alter downstream obesity risk. Research is needed to understand the impact of childhood SEP, independent of adult SEP, as well as SEP trajectories over the life course on adult obesity risk. We use data from the Sister Study, a prospective U.S. cohort of women aged 35-74 years (N = 50,884; enrollment: 2003-2009). Relative risks (RR) for adult obesity associated with childhood SEP (latent variable) and five latent life course SEP profiles were estimated in overall and race and ethnicity-stratified log binomial regression models. We estimated the direct effect of childhood SEP on adult obesity and mediation by adult SEP. Lower childhood SEP was associated with greater obesity risk (RR = 1.16, 95% CI: 1.15-1.17). In stratified models, RRs were elevated across groups though lower for Black and Hispanic/Latina participants, despite greater prevalence of obesity among Black participants. The direct effect of childhood SEP on adult obesity persisted in mediation models independent of adult SEP (RR = 1.10, 95% CI: 1.08-1.12) with adult SEP mediating approximately 40% of the total effect of childhood SEP on adult obesity. Furthermore, adult obesity risk was elevated for all life course SEP profiles compared to persistent high advantage. Life course SEP profiles indicating greater advantage in adulthood than childhood were not associated with reduced adult obesity risk among those experiencing less than high advantage in childhood. In conclusion, lower childhood SEP, independent of adult SEP, may be an important risk factor for adult obesity.

Association of Redlining and Natural Environment with Depressive Symptoms in Women in the Sister Study.

BACKGROUND: Improving mental health is recognized as an important factor for achieving global development goals. Despite strong evidence that neighborhood greenery promotes better mental health, there are environmental justice concerns over the distribution of neighborhood greenery. Underlying these concerns are present-day consequences of historical discriminatory financial investment practices, such as redlining which was established by the U.S. Federal Home Owners' Loan Corporation (HOLC) in the 1930s. The impacts of redlining on environmental and health disparities have been researched extensively. However, the influences of redlining on the associations between neighborhood environment and health outcomes have not been fully assessed. OBJECTIVES: The aim of this study was to examine whether associations between residential tree cover and depressive symptoms vary across areas subject to HOLC practices. METHODS: Depressive symptoms were defined by the 10-item Center for Epidemiologic Studies Depression Scale collected during the period 2008-2012 for 3,555 women in the Sister Study cohort residing in cities subject to HOLC practices across the United States. HOLC rating maps were obtained from the Mapping Inequality Project, University of Richmond, with neighborhoods graded as A (best for financial investment, green), B (still desirable, blue), C (declining, yellow), and D (hazardous, red-known as redlined). Tree cover within 500m and 2,000m from residences was estimated using 2011 U.S. Forest Service Percent Tree Canopy Cover. Mixed model using climate zone as the random effect was applied to evaluate the associations with adjustments for potential covariates. Analyses were stratified by HOLC grade. RESULTS: Tree cover was significantly higher in neighborhoods with better HOLC grades. A 10% increase in tree cover was associated with reduced odds of depressive symptoms for the full study population, with adjusted odds ratios (AORs) of 0.93 [95% confidence interval (CI): 0.88, 0.99], and 0.91 (0.85, 0.97) for 500-m and 2,000-m buffer, respectively. Across HOLC grades, the strongest associations were observed in redlined neighborhoods, with respective AORs of 0.72 (95% CI: 0.52, 0.99) and 0.63 (95% CI: 0.45, 0.90) for 500-m and 2,000-m buffer. DISCUSSION: Findings support a remediation strategy focused on neighborhood greenery that would address multiple public health priorities, including mental health and environmental justice. https://doi.org/10.1289/EHP12212.

High pesticide exposures events, pesticide poisoning, and shingles: A medicare-linked study of pesticide applicators in the agricultural health study.

OBJECTIVES: Self-reported shingles was associated with history of high pesticide exposure events (HPEE) in licensed pesticide applicators aged >60 years in the Agricultural Health Study (AHS). In the current study, using AHS-linked Medicare claims data, we examined incident shingles in relation to pesticide-related illness and pesticide poisoning, as well as HPEE. METHODS: We studied 22,753 licensed private pesticide applicators (97% white males, enrolled in the AHS 1993-97), aged ≥66 years with >12 consecutive months of Medicare fee-for-service hospital and outpatient coverage between 1999 and 2016. Incident shingles was identified based on having ≥1 shingles claim(s) after 12 months without claims. At AHS enrollment, participants were asked if they ever sought medical care or were hospitalized for pesticide-related illness, and a supplemental questionnaire (completed by 51%) asked about HPEE and poisoning. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox proportional hazards regression, adjusted for age, sex, race, state, and education. RESULTS: Over 192,053 person-years (PY), 2396 applicators were diagnosed with shingles (10.5%; age-standardized rate, 13.6 cases per 1,000PY), with higher rates among those reporting hospitalization for pesticide-related illness, pesticide poisoning, and HPEE (23.2, 22.5, and 16.6 per 1,000PY, respectively). In adjusted models, shingles was associated with hospitalization for pesticide-related illness (HR 1.69; 1.18, 2.39), poisoning (1.49; 1.08, 1.46), and HPEE (1.23; 95% CI = 1.03, 1.46), especially HPEE plus medical care/poisoning (1.78; 1.30, 2.43). CONCLUSION: These novel findings suggest that acute, high-level, and clinically impactful pesticide exposures may increase risk of shingles in subsequent years to decades following exposure.

Residential proximity to metal emitting industries and toenail metal concentration in the US Gulf States.

Objective: The US Gulf region is heavily reliant on metal-emitting petrochemical and manufacturing industries. We characterized the effect of residential proximity to metal-emitting sites and metal body burden in Gulf states residents with particular attention to potential differential exposure burden by race. Methods: We measured toenail concentrations of arsenic, chromium, lead, manganese, mercury, and selenium using inductively coupled plasma mass spectrometry in 413 non-smoking men from the Gulf Long-term Follow-Up Study. Point sources of industrial metal emissions were identified using the US EPA's National Emissions Inventory (NEI) database and geocoded to participant residential addresses. For each metal, we assessed associations of toenail metal concentrations with the inverse-distance weighted number of emissions sites and volume of air-metal emissions within 30 km radial buffers of participant residences using multivariable linear regression. Results were stratified by race. Results: Compared to self-identified Non-Hispanic (NH) White participants, NH Black participants lived closer to NEI sites but had 23-70% lower toenail metal concentrations adjusting for other personal/behavioral factors. Residential proximity to lead-emitting NEI sites was positively associated with toenail Pb concentration while proximity to mercury-emitting NEI sites was inversely associated with toenail Hg concentration. Findings for lead were significantly attenuated after adjustment for neighborhood-level socioeconomic factors. Conclusion: Residential proximity to lead-emitting NEI sites in the US Gulf region is associated with a higher body burden of lead. However, this relationship may be driven in part by non-NEI factors related to residence in industry-adjacent neighborhoods.

Completeness of cohort-linked U.S. Medicare data: An example from the Agricultural Health Study (1999-2016).

Medicare Fee for Service (FFS) claims data, including inpatient (Part A) and outpatient (Part B) services, provide a valuable resource for research on older adults (≥65 year) in linked U.S. cohorts. Here we describe our experience linking the Agricultural Health Study cohort, including 47,501 licensed pesticide applicators and spouses from North Carolina (NC) and Iowa (IA) to Medicare claims data from 1999 to 2016. Given increased Part C (i.e., managed care/Medicare Advantage) enrollment during this period, and a resulting lack of available Part C claims data prior to 2015, we also explored potential for informative missingness. We compared those with partial or limited/no FFS to those with complete FFS coverage (i.e., ≥11 months per year parts AB, but not C, throughout Medicare enrollment) in relation to baseline farm size, general pesticide use, and mortality, in logistic regression models adjusted for age, sex, race, education, and smoking, and stratified by state. While 46,689 participants (98%) were linked to Medicare IDs, only 33,487 (70%) had complete FFS, 9353 (20%) had partial FFS (≥1 year FFS but not complete), and 3849 (8%) had limited/no FFS (Part A or Part C-only). Incomplete FFS was more common in NC, mostly due to Part C, and was associated with farm characteristics, pesticide use, and mortality. These findings indicate that, in addition to reduced sample size in analyses limited to complete FFS, missingness may not be random. The potential impact of incomplete FFS data and changes in coverage type need to be considered when planning linked analyses and interpreting results.

Assessment of Self-reported Sense of Smell, Objective Testing, and Associated Factors in Middle-aged and Older Women.

Importance: Poor olfaction is common in older adults and signifies multiple adverse health outcomes, but it often goes unrecognized. Objective: To characterize the self-awareness of poor olfaction in women, including its prevalence, associated factors, reporting reliability, validity against an objective test, and factors associated with validity. Design, Setting, and Participants: These cross-sectional survey data and a case-control subsample were taken from the National Institute of Environmental Health Sciences' Sister Study. Of 41 118 participants (aged 41-85 years) who reported olfaction in 2014 through 2016, 3406 (aged 50-79 years) reported olfaction again in 2018 through 2019 and completed the 12-item Brief Smell Identification Test, version A, including 2353 women who self-reported poor olfaction in 2014 through 2016 and 1053 women who reported normal olfaction. Data analyses were performed between May 28, 2021, and December 23, 2021. Main Outcomes and Measures: Self-reported (yes/no) and objectively tested poor olfaction defined as a Brief Smell Identification Test score of 9 or lower. Multivariable logistic regressions were used to assess factors that might be associated with the prevalence and reporting accuracy of self-reported olfaction. In subsample analyses, the sampling strategy was accounted for to extrapolate data to eligible cohort samples. Results: Of the 41 118 women (mean [SD] age, 64.3 [8.7] years) included in the analysis, 3322 (8.1%) self-reported poor olfaction. Higher prevalence was associated with older age, not being married, current smoking status, frequent coffee drinking, overweight or obesity, less than optimal health, Parkinson disease, cognitive impairment, depression, anxiety, and seasonal allergy, whereas a lower prevalence was associated with non-Hispanic Black race and physical activity. In the subsample analyses, olfaction status reported 3 years apart showed a modest agreement (κ, 0.56; 95% CI, 0.51-0.61). The prevalence of objectively tested poor olfaction was 13.3% (95% CI, 11.5%-15.0%), and in contrast with self-reports, it was twice as high in non-Hispanic Black women as in non-Hispanic White women (24.5% vs 12.5%). Compared with objective tests, self-reports showed a low sensitivity (22.6%; 95% CI, 19.6%-25.6%), especially in non-Hispanic Black women (12.4%; 95% CI, 7.0%-17.8%). The specificity was uniformly high (>90%). Among participants who reported poor olfaction, higher odds of true vs false positives were associated with age older than 60 years (60-64 years old, 1.68; 95% CI, 1.51-1.87; 65-69 years old, 2.26; 95% CI, 2.03-2.51; 70-74 years old, 3.34; 95% CI, 3.00-3.73; ≥75 years old, 5.17; 95% CI, 4.43-6.03), non-Hispanic Black race (2.00; 95% CI, 1.70-2.36), no college education (1.34; 95% CI, 1.22-1.48), underweight (1.40; 95% CI, 1.04-1.88), fair or poor health (1.37; 95% CI, 1.22-1.54), and Parkinson disease (7.60; 95% CI, 5.60-10.32). Among those with objectively tested poor olfaction, lower odds of true positives vs false negatives were associated with Black race (0.46; 95% CI, 0.25-0.86). Conclusions and Relevance: In this case-control study, the self-awareness and reporting accuracy of poor olfaction in middle-aged and older women were low, particularly in non-Hispanic Black women. Given its potential health implications, awareness of this common sensory deficit should be raised.

Exposure Assessment Techniques Applied to the Highly Censored Deepwater Horizon Gulf Oil Spill Personal Measurements.

The GuLF Long-term Follow-up Study (GuLF STUDY) is investigating potential adverse health effects of workers involved in the Deepwater Horizon (DWH) oil spill response and cleanup (OSRC). Over 93% of the 160 000 personal air measurements taken on OSRC workers were below the limit of detection (LOD), as reported by the analytic labs. At this high level of censoring, our ability to develop exposure estimates was limited. The primary objective here was to reduce the number of measurements below the labs' reported LODs to reflect the analytic methods' true LODs, thereby facilitating the use of a relatively unbiased and precise Bayesian method to develop exposure estimates for study exposure groups (EGs). The estimates informed a job-exposure matrix to characterize exposure of study participants. A second objective was to develop descriptive statistics for relevant EGs that did not meet the Bayesian criteria of sample size ≥5 and censoring ≤80% to achieve the aforementioned level of bias and precision. One of the analytic labs recalculated the measurements using the analytic method's LOD; the second lab provided raw analytical data, allowing us to recalculate the data values that fell between the originally reported LOD and the analytical method's LOD. We developed rules for developing Bayesian estimates for EGs with >80% censoring. The remaining EGs were 100% censored. An order-based statistical method (OBSM) was developed to estimate exposures that considered the number of measurements, geometric standard deviation, and average LOD of the censored samples for N ≥ 20. For N < 20, substitution of ½ of the LOD was assigned. Recalculation of the measurements lowered overall censoring from 93.2 to 60.5% and of the THC measurements, from 83.1 to 11.2%. A total of 71% of the EGs met the ≤15% relative bias and <65% imprecision goal. Another 15% had censoring >80% but enough non-censored measurements to apply Bayesian methods. We used the OBSM for 3% of the estimates and the simple substitution method for 11%. The methods presented here substantially reduced the degree of censoring in the dataset and increased the number of EGs meeting our Bayesian method's desired performance goal. The OBSM allowed for a systematic and consistent approach impacting only the lowest of the exposure estimates. This approach should be considered when dealing with highly censored datasets.

Breast Cancer-Related Employment Disruption and Financial Hardship in the Sister Study.

Background: More than one-half of breast cancer cases are diagnosed among women aged younger than 62 years, which may result in employment challenges. This study examined whether cancer-related employment disruption was associated with increased financial hardship in a national US study of women with breast cancer. Methods: Women with breast cancer who were enrolled in the Sister or Two Sister Studies completed a survivorship survey in 2012. Employment disruption was defined as stopping work completely or working fewer hours after diagnosis. Financial hardship was defined as: 1) experiencing financial problems paying for cancer care, 2) borrowing money or incurring debt, or 3) filing for bankruptcy because of cancer. Prevalence ratios and 95% confidence intervals for the association between employment disruption and financial hardship were estimated using multivariable Poisson regression with robust variance. Results: We analyzed data from women employed at diagnosis (n = 1628). Women were a median age of 48 years at diagnosis and 5.6 years from diagnosis at survey completion. Overall, 27.3% of women reported employment disruption (15.4% stopped working; 11.9% reduced hours), and 21.0% experienced financial hardship (16.0% had difficulty paying for care; 12.6% borrowed money or incurred debt; 1.8% filed for bankruptcy). In adjusted analysis, employment disruption was associated with nearly twice the prevalence of financial hardship (prevalence ratio = 1.93, 95% confidence interval = 1.58 to 2.35). Conclusions: Women experiencing employment disruptions after breast cancer may be more vulnerable to financial hardship. Findings highlight the need to target risk factors for employment disruption, facilitate return to work or ongoing employment, and mitigate financial consequences after cancer.

Objective and subjective childhood socioeconomic disadvantage and incident depression in adulthood: a longitudinal analysis in the Sister Study.

Understanding of the role of objective versus subjective childhood socioeconomic disadvantage (SD) in depression onset in adulthood among women, independent of later life SD, and across birth cohorts, is limited. We examined the association between objective (i.e., household education level) and subjective (i.e., rank of family income and report of not enough food to eat) SD during childhood and diagnosis of clinical depression after age 30 among 47,055 women in the Sister Study. We used Cox proportional hazard models adjusting for women's race/ethnicity, childhood household composition, mother's age at her birth adulthood educational attainment, and calendar year of birth. Analyses were repeated stratified by 10-year birth group. A total of 8036 (17.1%) women were diagnosed with clinical depression over a mean follow-up of 24.0 (± 9.9) years. Those reporting being poor (versus well-off) or not having enough food to eat in childhood had a 1.28 (95% confidence interval (CI) 1.13, 1.44) and 1.30 (95% CI 1.21, 1.41) times higher rate of depression diagnosis, respectively, with consistent associations observed across birth year groups. An inverse association between low household education level and incident depression was observed at baseline (i.e., age 30) becoming positive over time in the total sample but only among women born between 1935-1954 in analyses stratified by 10-year birth group. Our findings suggest that subjective SD in childhood is a largely consistent predictor of depression onset among women in adulthood whereas the effects of household education level in childhood may vary across women born into different birth cohorts, and for some, across the lifecourse.

Racial/Ethnic Disparities in the Relationship Between Traumatic Childhood Experiences and Suboptimal Sleep Dimensions Among Adult Women: Findings from the Sister Study.

BACKGROUND: Traumatic childhood experiences (TCEs) are associated with poor adulthood sleep, but racial/ethnic disparities have not been well-studied. We investigated the TCE-adulthood sleep relationship among non-Hispanic (NH)-White, NH-Black, and Hispanic/Latina women. METHOD: Women enrolled in the Sister Study from 2003 to 2009 reported the following TCEs in a follow-up interview (2008-2012): natural disasters; major accidents; household dysfunction; and sexual, physical, and psychological/emotional abuse. Sleep characteristics included short sleep duration (< 7 h vs. 7-9 h), long sleep onset latency (SOL) (> 30 vs. ≤ 30 min), frequent night awakenings (≥ 3 times/night ≥ 3 times/week [yes vs. no]), and frequent napping (≥ 3 vs. < 3 times/week). Using log-binomial regression to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for sleep characteristics among women with vs. without TCEs, we investigated racial/ethnic-specific associations and race/ethnicity as a moderator. RESULTS: Among 40,082 participants (mean age = 55 ± 8.8 years), 55% reported ≥ 1 TCE (NH-White, 54%; NH-Black, 62%; Hispanic/Latina, 57%). NH-White, NH-Black, and Hispanic/Latina women reporting any TCE had a higher prevalence of short sleep compared with their within-race/ethnicity counterparts without TCEs. Associations were strongest among NH-Whites. Compared to NH-Whites with no TCEs, racial/ethnic minorities who reported any TCEs had a higher prevalence of short sleep (PRBlacks = 2.13 [95% CI 2.02-2.24], PRHispanics/Latinas = 1.47 [1.35-1.60]) and long SOL. When comparing racial/ethnic minorities with TCEs to NH-Whites with TCEs, PRs for short sleep (PRBlacks = 1.98 [1.88-2.08] and PRHispanics/Latinas = 1.36 [1.25-1.48]) and long SOL were weaker. CONCLUSION: TCEs were positively associated with poor sleep characteristics among women, and TCEs appear to contribute to short sleep duration and long SOL disparities.

Association of Neighborhood Deprivation With Epigenetic Aging Using 4 Clock Metrics.

Importance: Neighborhood deprivation is associated with age-related disease, mortality, and reduced life expectancy. However, biological pathways underlying these associations are not well understood. Objective: To evaluate the association between neighborhood deprivation and epigenetic measures of age acceleration and genome-wide methylation. Design, Setting, and Participants: This cross-sectional study used data from the Sister Study, a prospective cohort study comprising 50 884 women living in the US and Puerto Rico aged 35 to 74 years at enrollment who had a sister with breast cancer but had not had breast cancer themselves. Cohort enrollment occurred between July 2003 and March 2009. Participants completed a computer-assisted telephone interview on demographic, socioeconomic, lifestyle, and residential factors and provided anthropometric measures and peripheral blood samples at a home examination. DNA methylation data obtained for 2630 non-Hispanic White women selected for a case-cohort study in 2014 were used in this cross-sectional analysis. DNA methylation was measured using the HumanMethylation450 BeadChips in whole blood samples collected at baseline. Data analysis for this study was performed from October 17, 2019, to August 27, 2020. Exposures: Each participants' primary address was linked to an established index of neighborhood deprivation. Main Outcomes and Measures: Epigenetic age was estimated using 4 epigenetic clocks (Horvath, Hannum, PhenoAge, and GrimAge). Age acceleration was determined using residuals from regressing chronologic age on each of the 4 epigenetic age metrics. Linear regression was used to estimate associations between neighborhood deprivation and epigenetic age acceleration as well as DNA methylation at individual cytosine-guanine sites across the genome. Results: Mean (SD) age of the 2630 participants was 56.9 (8.7) years. Those with the greatest (>75th percentile) vs least (≤25th percentile) neighborhood deprivation had higher epigenetic age acceleration estimated by Hannum (ß = 0.23; 95% CI, 0.01-0.45), PhenoAge (ß = 0.28; 95% CI, 0.06-.50), and GrimAge (ß = 0.37; 95% CI, 0.12-0.62). Increasing US quartiles of neighborhood deprivation exhibited a trend with Hannum, PhenoAge, and GrimAge. For example, GrimAge showed a significant dose-response (P test for trend <.001) as follows: level 2 vs level 1 (ß = 0.30; 95% CI, 0.17-0.42), level 3 vs level 1 (ß = 0.35; 95% CI, 0.19-0.50), and level 4 vs level 1 (ß = 0.37; 95% CI, 0.12-0.62). Neighborhood deprivation was found to be associated with 3 cytosine-phosphate-guanine sites, with 1 of these annotated to a known gene MAOB (P = 9.71 × 10-08). Conclusions and Relevance: The findings of this study suggest that residing in a neighborhood with a higher deprivation index appears to be reflected by methylation-based markers of aging.

A joint spatial factor analysis model to accommodate data from misaligned areal units with application to Louisiana social vulnerability.

With the threat of climate change looming, the public health community has an interest in identifying communities at the highest risk of devastation based not only on geographic features but also on social characteristics. Indices of community social vulnerability can be created by applying a spatial factor analysis to a set of relevant social variables measured for each community; however, current spatial factor analysis methodology is ill-equipped to handle spatially misaligned data. We introduce a joint spatial factor analysis model that can accommodate spatial data from two distinct partitions of a geographic space and identify a common set of latent factors underlying them. By defining the latent factors over the intersection of the two partitions, the model minimizes loss of information. Using simulated data constructed to mimic the spatial structure of our real data, we confirm the reliability of the model and demonstrate its superiority over competing ad hoc methods for dealing with misaligned data in spatial factor analysis. Finally, we construct an index of community social vulnerability for each census tract in Louisiana, a state prone to environmental disasters, which could be exacerbated by climate change, by applying the joint spatial factor analysis model to a set of misaligned social indicator data from the state. To demonstrate the utility of this index, we integrate it with Louisiana flood insurance claims data to identify communities that may be at particularly high risk during natural disasters, based on both social and geographic features.

Dietary Glycemic Index and Glycemic Load Are Positively Associated with Oxidative Stress among Premenopausal Women.

Background: Diets with a high glycemic index (GI) and glycemic load (GL) have been hypothesized to increase oxidative stress, but the limited human studies are inconsistent. Objective: The aim of this cross-sectional study was to investigate associations between dietary GI, GL, and carbohydrate intake and oxidative stress, as measured by F2-isoprostanes (F2-IsoPs). Methods: Concentrations of F2-IsoP and its metabolite (15-F2t-IsoP-M) were measured in urine samples collected at enrollment from 866 premenopausal women (aged 35-54 y) participating in the Sister Study. Total carbohydrate intake and dietary GI and GL were assessed using a validated food frequency questionnaire. Urinary F2-IsoP and 15-F2t-IsoP-M concentrations were compared across quintiles of carbohydrate intake, GI, and GL using multivariable linear regression models. Results: Urinary F2-IsoP concentrations were positively associated with dietary GI (P-trend = 0.023), and both F2-IsoP and 15-F2t-IsoP-M concentrations were positively associated with GL (F2-IsoP: P-trend < 0.001; 15-F2t-IsoP-M: P-trend < 0.001) and total carbohydrate intake (F2-IsoP: P-trend = 0.012; 15-F2t-IsoP-M: P-trend < 0.001). Stratified analyses suggested that a positive association between GI and urinary 15-F2t-IsoP-M concentrations was present among women with a body mass index [BMI (in kg/m2)] ≥30.0, but not among those with a BMI of <25.0 or 25.0-29.9 (P-interaction = 0.01). Conclusions: Our cross-sectional analyses in a sample of premenopausal women support hypothesized relations between high dietary GI and GL and oxidative stress, as assessed by urinary F2-IsoP and 15-F2t-IsoP-M concentrations. Given potential associations between oxidative stress and the development of cardiovascular disease and type 2 diabetes, our findings may have important implications for reducing chronic disease risk.

Retrospective Assessment of Occupational Exposures for the GENEVA Study of ALS among Military Veterans.

OBJECTIVE: This paper describes the retrospective exposure assessment conducted to assess occupational exposures for the Genes and Environmental Exposures in Veterans (GENEVA) study, a case-control study investigating the joint contribution of genetics and environmental exposures to the risk of amyotrophic lateral sclerosis (ALS) among military veterans. METHODS: Occupational histories for 1597 study participants collected as part of the GENEVA study were the basis for this retrospective exposure assessment. The data set included 15528 jobs held from 1924 to 2010, representing 4539 unique industry and occupation (I&O) combinations. Three industrial hygiene experts were recruited to independently rate occupational exposures to specific agents previously associated with an increased risk of ALS. Utilizing information on industry, job title, tasks performed, and materials used for each job held, raters assigned exposures associated with each I&O for the 'current time' defined as the period after 1995 (post-1995). The exposure assessment targeted agents identified as potential occupational risk factors for ALS. Experts rated semi-quantitatively exposure intensity in five exposure categories (0-4) for Group A agents (lead, formaldehyde, hydrocarbon solvents, and chlorinated solvents) and qualitatively as yes/no (1/0) exposed for Group B agents (mercury, selenium, arsenic, polychlorinated biphenyls, electromagnetic field, pesticides, and viral agents). Confidence scores (0-3) were reported for every I&O rated based on raters' experience with that industry and/or job. Each I&O was assigned an average exposure score of the raters and an alternative exposure rating was developed for each I&O by excluding low confidence (<2) scores before averaging. Exposure reconstruction for jobs held pre-1995 was done by comparing exposure data extracted from the OSHA Chemical Exposure and Health Database (CEHD) during pre-1995 and post-1995. For agents with limited exposure data in the CEHD, pre-1995 exposures were determined based on raters' judgment. RESULTS: The proportion of I&O combinations determined to be 'exposed' ranged from 0.1 to 26% across different agents, with the highest values corresponding to hydrocarbon solvents and the lowest to selenium. Industries with the highest proportion of exposed records include manufacturing, utilities, healthcare, and military with non-combat jobs. Analyses for raters' reliability showed the best agreement between the raters when rating exposure to viral agents (kappa = 0.67), hydrocarbon solvents (kappa = 0.53), and lead (kappa = 0.50). The proportion of 'exposed' I&O combinations increased for hydrocarbon solvents, chlorinated solvents, and pesticides when exposure ratings were adjusted by raters' confidence. Compared to post-1995, exposures in the earlier period (pre-1995) were deemed higher or the same for most of the agents and lower for formaldehyde and electromagnetic field exposures. CONCLUSIONS: Our results indicate that using raters' confidence assessment in determining exposure scores increases both the proportion of I&O combinations regarded as exposed and the intensity scores, suggesting raters tend to be conservative in their assessment when they lack detailed knowledge of an industry or job.

Post-treatment Neurocognition and Psychosocial Care Among Breast Cancer Survivors.

INTRODUCTION: Chemotherapy for breast cancer has been associated with cognitive problems; however, the impact of adjuvant hormone therapy is less clear. No studies have explored provider discussions about cognitive concerns or factors associated with neurocognitive treatment. This study examined cognitive problems, factors associated with having a provider discussion, and receipt of neurocognitive treatment. METHODS: Female breast cancer survivors (N=2,537) from the Sister Study and the Two Sister Study who were at least 1 year post-treatment were surveyed in 2012 about their cancer therapies (confirmed by medical records); cognitive concerns; related provider discussions; and neurocognitive treatment. A total of 2,296 women were included in the current 2014 analysis. Extensive covariate information was also ascertained for predictive multivariate models. RESULTS: The prevalence of self-reported cognitive problems after treatment was 60%. Of those reporting cognitive problems, only 37% had discussed those concerns with a provider and 15% had been treated for cognitive symptoms. The odds of reported cognitive concerns that started during and after treatment were elevated for those who received only hormone therapy and no chemotherapy (OR=1.64, 95% CI=1.15, 2.33); chemotherapy and no hormone therapy (OR=5.63, 95% CI=3.52, 9.00); or both (OR=6.33, 95% CI=4.21, 9.54) compared with those reporting neither treatment. CONCLUSIONS: The high prevalence of cognitive concerns underscores the importance of monitoring breast cancer survivors for potential neurocognitive effects of hormone and chemotherapy, discussions with survivors about those concerns, and treatment referrals. Monitoring changes over time can help to evaluate both psychosocial and neurocognitive care provided for survivors.

Leisure-time physical activity in relation to occupational physical activity among women.

OBJECTIVE: The objective of this study is to examine the association between occupational physical activity and leisure-time physical activity among US women in the Sister Study. METHODS: We conducted a cross-sectional study of 26,334 women who had been employed in their current job for at least 1 year at baseline (2004-2009). Occupational physical activity was self-reported and leisure-time physical activity was estimated in metabolic equivalent hours per week. Log multinomial regression was used to evaluate associations between occupational (sitting, standing, manually active) and leisure-time (insufficient, moderate, high) activity. Models were adjusted for age, race/ethnicity, education, income, geographic region, and body mass index. RESULTS: Only 54% of women met or exceeded minimum recommended levels of leisure-time physical activity (moderate 32% and high 22%). Women who reported sitting (prevalence ratio (PR)=0.82, 95% confidence interval (CI): 0.74-0.92) or standing (PR=0.84, 95% CI: 0.75-0.94) most of the time at work were less likely to meet the requirements for high leisure-time physical activity than manually active workers. Associations were strongest among women living in the Northeast and the South. CONCLUSION: In this nationwide study, low occupational activity was associated with lower leisure-time physical activity. Women who are not active in the workplace may benefit from strategies to promote leisure-time physical activity.

Mental health service use by cleanup workers in the aftermath of the Deepwater Horizon oil spill.

High rates of mental health (MH) problems have been documented among disaster relief workers. However, few workers utilize MH services, and predictors of service use among this group remain unexplored. The purpose of this study was to explore associations between predisposing, illness-related, and enabling factors from Andersen's behavioral model of treatment-seeking and patterns of service use among participants who completed at least one full day of cleanup work after the Deepwater Horizon oil spill and participated in home visits for the NIEHS GuLF STUDY (N = 8931). Workers reported on MH symptoms and whether they had used counseling or medication for MH problems since the oil spill. Hierarchical logistic regression models explored associations between predictors and counseling and medication use in the full sample, and type of use (counseling only, medication only, both) among participants who used either service. Analyses were replicated for subsamples of participants with and without symptom inventory scores suggestive of probable post-disaster mental illness. Having a pre-spill MH diagnosis, pre-spill service use, more severe post-spill MH symptoms, and healthcare coverage were positively associated with counseling and medication use in the full sample. Among participants who used either service, non-Hispanic Black race, pre-spill counseling, lower depression, and not identifying a personal doctor or healthcare provider were predictive of counseling only, whereas older age, female gender and pre-spill medication were predictive of medication only. The results were generally consistent among participants with and without probable post-disaster mental illness. The results suggest variability in which factors within Andersen's behavioral model are predictive of different patterns of service use among disaster relief workers.

Suicide and pesticide use among pesticide applicators and their spouses in the agricultural health study.

BACKGROUND: An association may exist between pesticide exposure and suicide. OBJECTIVE: We sought to evaluate the existence of an association between pesticide use and suicide using data from the Agricultural Health Study (AHS), a prospective cohort study of licensed pesticide applicators and their spouses in Iowa and North Carolina. METHODS: Via linkage to state mortality files and the National Death Index, we identified 110 suicides occurring between enrollment in the AHS (from 1993 to 1997) and 31 May 2009, among 81,998 cohort members contributing 1,092,943 person-years of follow-up. The average length of follow-up was 13.3 years. AHS participants provided data on pesticide use and potential confounders via self-administered questionnaires at enrollment. We evaluated several measures of pesticide use: use of any pesticide, ever use of 50 specific pesticides, cumulative lifetime days of use and intensity-adjusted cumulative lifetime days of use of 22 specific pesticides, and ever use of 10 functional and chemical classes of pesticides. We used Cox proportional hazards regression models to estimate adjusted hazard ratios and 95% confidence intervals. RESULTS: After adjusting for age at enrollment, sex, number of children in family, frequency of alcohol consumption during the past 12 months, and smoking status, we found no association between prior pesticide use and suicide in applicators and their spouses. Results were the same for applicators and spouses together or for applicators alone and were consistent across several measures of pesticide use. CONCLUSIONS: Our findings do not support an association between moderate pesticide use and suicide.

Assessment of a pesticide exposure intensity algorithm in the agricultural health study.

The accuracy of the exposure assessment is a critical factor in epidemiological investigations of pesticide exposures and health in agricultural populations. However, few studies have been conducted to evaluate questionnaire-based exposure metrics. The Agricultural Health Study (AHS) is a prospective cohort study of pesticide applicators who provided detailed questionnaire information on their use of specific pesticides. A field study was conducted for a subset of the applicators enrolled in the AHS to assess a pesticide exposure algorithm through comparison of algorithm intensity scores with measured exposures. Pre- and post-application urinary biomarker measurements were made for 2,4-D (n=69) and chlorpyrifos (n=17) applicators. Dermal patch, hand wipe, and personal air samples were also collected. Intensity scores were calculated using information from technician observations and an interviewer-administered questionnaire. Correlations between observer and questionnaire intensity scores were high (Spearman's r=0.92 and 0.84 for 2,4-D and chlorpyrifos, respectively). Intensity scores from questionnaires for individual applications were significantly correlated with post-application urinary concentrations for both 2,4-D (r=0.42, P<0.001) and chlorpyrifos (r=0.53, P=0.035) applicators. Significant correlations were also found between intensity scores and estimated hand loading, estimated body loading, and air concentrations for 2,4-D applicators (r-values 0.28-0.50, P-values<0.025). Correlations between intensity scores and dermal and air measures were generally lower for chlorpyrifos applicators using granular products. A linear regression model indicated that the algorithm factors for individual applications explained 24% of the variability in post-application urinary 2,4-D concentration, which increased to 60% when the pre-application urine concentration was included. The results of the measurements support the use of the algorithm for estimating questionnaire-based exposure intensities in the AHS for liquid pesticide products. Refinement of the algorithm may be possible using the results from this and other measurement studies.

Association of lead exposure with survival in amyotrophic lateral sclerosis.

BACKGROUND: Reasons for the variability in survival among ALS cases are unknown but may include exposure to environmental neurotoxicants. OBJECTIVES: We aimed to determine whether lead exposure, assessed by measuring blood and bone lead levels, is associated with survival in amyotrophic lateral sclerosis (ALS). METHODS: We evaluated the relationship of lead exposure to ALS survival in 110 cases from a case-control study conducted in New England in 1993-1996 that included measurements of blood and bone lead. We retrieved information on date and cause of death through 31 December 2003 from the National Death Index Plus and the Social Security Administration Death Index. We evaluated the relationship of survival to lead exposure using Cox proportional hazard analysis, with adjustment for age, sex, and smoking. RESULTS: We found mortality data for 100 of 110 cases; 93 of 100 death certificates mentioned ALS. Median survival from diagnosis to death was 28 months. Shorter survival was associated with older age at diagnosis, female sex, bulbar onset, shorter interval between symptom onset and diagnosis, and reduced lung function. Shorter survival from diagnosis to death had a weak inverse association with blood lead (hazard ratio = 0.9; 95% confidence interval, 0.8-1.0) and a stronger inverse association with patella lead (0.5; 0.2-1.0) and tibia lead (0.3; 0.1-0.7); similar results were found for survival from symptom onset to death. CONCLUSIONS: These results suggest that lead exposure is associated with longer survival in ALS cases and, if confirmed, may shed light on mechanisms involved in disease progression.