A prospective study of dietary patterns and the incidence of endometriosis diagnosis.

BACKGROUND: Although endometriosis is a common condition-affecting ∼10% of premenopausal individuals-its etiology is unknown. Diet receives large patient attention, but studies of the role of diet are limited. Examining dietary patterns is essential to provide new insight. OBJECTIVE: We sought to determine whether dietary patterns are associated with laparoscopically-confirmed endometriosis diagnosis. STUDY DESIGN: We conducted a prospective cohort study among 81,997 premenopausal participants of the Nurses' Health Study II, who were followed from 1991-2015. Diet was assessed with validated food frequency questionnaires every four years. We examined six dietary patterns: Western, Prudent, Alternative Healthy Eating Index (AHEI-2010), Dietary Approaches to Stop Hypertension (DASH), an estrogen-associated pattern, and a pro-inflammatory pattern. Cox proportional hazard ratios (HR) and 95% confidence intervals (CI) were used to quantify the association between each of these patterns and laparoscopically-confirmed endometriosis diagnosis. RESULTS: 3,810 incident cases of endometriosis were diagnosed during 24 years of follow-up. Adherence to the AHEI-2010, reflecting a healthier dietary pattern, was associated with a 13% lower risk of endometriosis diagnosis (5th vs 1st quintile 95% CI=0.78-0.96; ptrend=0.02). Participants in the highest quintile of the Western dietary pattern, characterized by high intake of red meat, processed meat, refined grains, and desserts, had a 27% higher risk of endometriosis diagnosis compared to those in the lowest quintile (95% CI=1.09-1.47; ptrend=0.004). The Prudent, DASH, and estrogen-associated dietary patterns did not demonstrate clear associations with endometriosis risk, and there was the suggestion of higher risk of endometriosis diagnosis among those with a higher pro-inflammatory diet score (HR for 5th vs 1st quintile=1.10; 95% CI=0.99-1.23; ptrend=0.01). CONCLUSION: Our results suggest that consuming a dietary pattern that adheres to the AHEI-2010 recommendations lowers the risk of endometriosis diagnosis, potentially through a beneficial impact on pelvic pain. In addition, consuming a less healthy diet high in red/processed meats and refined grains may have a detrimental impact on endometriosis symptoms.

Factors associated with COVID-19 vaccination status: A cross-sectional study of California students in higher education.

To examine the factors associated with coronavirus vaccine hesitancy among students in higher education, we conducted a cross-sectional mixed-methods study between June and August 2021 among California students in higher education (n = 4444). We collected information on vaccination status, socio-demographics, and attitudes towards coronavirus vaccination. After adjusting for social demographics and social network characteristics, compared to those with household members who were vaccinated, those who had household members who were unvaccinated had 0.11 (95% CI 0.09 - 0.14) times the odds of being vaccinated. Political identification was related to vaccination status: compared to those who did not identify with any particular party, those who identified as progressive had 12.5 (95% CI 3.70 - 50.0) times the odds of being vaccinated. Asians had higher odds (OR = 1.54; 95% CI 1.08 - 2.04) of being vaccinated compared to whites and men were marginally less likely to be vaccinated (OR = 0.79; 95% CI 0.61 - 1.00). However, age, parental education, and educational status were unrelated to vaccination status. Social and demographic factors may be associated with the decision to remain vaccinated among young adults. Public health messages should utilize social networks to encourage vaccination uptake among young adults.

Mandating COVID-19 Vaccination on Campus: A Qualitative Analysis of a Cross-Sectional Study of California College Students.

The purpose of this study was to examine college student perceptions related to institutional vaccine mandates. We utilized qualitative data (n = 2,212) from five open-ended questions in a cross-sectional study of students enrolled or intending to enroll in an institute of higher education in California in fall 2021. Data were collected between June and August 2021. Thematic analysis was employed to analyze student beliefs, and four themes were developed from the data: (1) Polarizing views and language; (2) deciding who to trust; (3) conveying rights and risk; and (4) staying focused on education. The themes represented vaccinated and nonvaccinated student perspectives, capturing views about trust, rights, and risk. Many responses were polarizing and included language that was emotional and political. Despite the range of responses, most students expressed appreciation and approval of the vaccination mandate on college campuses. Findings illustrate the important contributions of qualitative research and suggest opportunities for public health practitioners to lead and engage in critical dialogue about science and public health practices as we aim to promote public perceptions of vaccination programs and health promotion practice.

Social Support and Technology Use and Their Association With Mental and Physical Health During the COVID-19 Pandemic Among Asian Americans: The COMPASS Cross-sectional Study.

BACKGROUND: The global COVID-19 pandemic disproportionately affected Asian Americans and Pacific Islanders (AAPIs) and revealed significant health disparities with reports of increased discrimination and xenophobia. Among AAPIs, the pandemic exacerbated their social, linguistic, and geographic isolation. Social support may be especially important for AAPIs given the salience of collectivism as a cultural value. Another mechanism for support among AAPIs was technology use, as it is generally widespread among this population. However, older adults may not perceive the same benefits. OBJECTIVE: We examined social support and technology use and their relationships with mental and physical health outcomes through the COVID-19 pandemic among AAPIs. METHODS: Data were drawn from the COVID-19 Effects on the Mental and Physical Health of AAPI Survey Study (COMPASS) for the time period of October 2020 to February 2021. COMPASS was a cross-sectional, multilingual, national survey conducted online, by phone, and in person with AAPI adults who were ≥18 years of age, in collaboration with academic and community partners in the United States. Data were analyzed using multivariable linear regression using the outcome variables of mental and physical health with various predictors such as social support and technology use. We tested for interactions specific to age and ethnicity. RESULTS: Among 4631 AAPIs (mean age 45.9, SD 16.3 years; 2992/4631, 63.1% female), we found that (1) increased social support was associated with better physical health, (2) total social support was positively associated with better mental health, (3) higher technology use was associated with poorer mental health and inversely associated with poorer physical health, (4) the association of technology use with mental health was weaker among those with low social support (vs those with high social support), (5) adults younger than 60 years old (vs ≥60 years old) were more negatively affected with social support and mental health, and (6) Korean Americans appeared to be a high-risk group for poor physical health with increased technology use. CONCLUSIONS: Our paper identified mental and physical health needs along with supportive therapies observed among AAPIs during the pandemic. Future research on how social support can be leveraged, especially among AAPIs younger than 60 years old, and how various types of technology are being utilized are important to guide the recovery efforts to address both mental and physical disparities across communities as a result of the COVID-19 pandemic.

Impact of COVID-19 on health risk behaviors in northern California: A cross-sectional survey.

The COVID-19 pandemic has been disruptive, unevenly impacting health behaviors in different geographical regions and population groups. We examined how COVID-19 affected perceived changes in physical activity, sleep, and diet and the impact of socio-demographic variables on a calculated health risk behavior score. In this cross-sectional study, 505 residents of northern California completed a web-based survey from August to November of 2020. Chi-square and multivariable linear regression analyses examined the association between socio-demographic variables and the health risk behavior score. Approximately 84 % of respondents experienced at least one unfavorable behavior change after the pandemic, with 49.5 % indicating a reduction in physical activity, 29.7 % a decrease in sleep, 33.1 % an increase in sugary snack consumption, and 29.3 % a decrease in fruit and vegetable intake. Multivariate analyses indicated a higher health risk behavior score (less favorable) for females compared to males (male beta = -0.815, p < 0.0001) and Hispanics compared to Whites (Hispanics beta = 0.396, p = 0.033). The negative changes in health behavior observed in females could be attributed to a higher reduction in fruit and vegetable consumption, and a larger increase in sugary and salty snacks when compared to males. A higher reduction in exercise, sleep, and fruit and vegetable intake were the main drivers of the unfavorable results seen for Hispanics when compared to Whites. Findings highlight the detrimental behavioral changes during the COVID-19 pandemic and the disproportionate impact on Hispanics and women. These results are valuable to policymakers to identify ways to support those most affected by the pandemic and its potential long-term effects.

Correction: Racial Bias Beliefs Related to COVID-19 Among Asian Americans, Native Hawaiians, and Pacific Islanders: Findings From the COVID-19 Effects on the Mental and Physical Health of Asian Americans and Pacific Islanders Survey Study (COMPASS).

[This corrects the article DOI: 10.2196/38443.].

Racial Bias Beliefs Related to COVID-19 Among Asian Americans, Native Hawaiians, and Pacific Islanders: Findings From the COVID-19 Effects on the Mental and Physical Health of Asian Americans and Pacific Islanders Survey Study (COMPASS).

BACKGROUND: During the COVID-19 pandemic, there have been increased reports of racial biases against Asian American and Native Hawaiian and Pacific Islander individuals. However, the extent to which different Asian American and Native Hawaiian and Pacific Islander groups perceive and experience (firsthand or as a witness to such experiences) how COVID-19 has negatively affected people of their race has not received much attention. OBJECTIVE: This study used data from the COVID-19 Effects on the Mental and Physical Health of Asian Americans and Pacific Islanders Survey Study (COMPASS), a nationwide, multilingual survey, to empirically examine COVID-19-related racial bias beliefs among Asian American and Native Hawaiian and Pacific Islander individuals and the factors associated with these beliefs. METHODS: COMPASS participants were Asian American and Native Hawaiian and Pacific Islander adults who were able to speak English, Chinese (Cantonese or Mandarin), Korean, Samoan, or Vietnamese and who resided in the United States during the time of the survey (October 2020 to May 2021). Participants completed the survey on the web, via phone, or in person. The Coronavirus Racial Bias Scale (CRBS) was used to assess COVID-19-related racial bias beliefs toward Asian American and Native Hawaiian and Pacific Islander individuals. Participants were asked to rate the degree to which they agreed with 9 statements on a 5-point Likert scale (ie, 1=strongly disagree to 5=strongly agree). Multivariable linear regression was used to examine the associations between demographic, health, and COVID-19-related characteristics and perceived racial bias. RESULTS: A total of 5068 participants completed the survey (mean age 45.4, SD 16.4 years; range 18-97 years). Overall, 73.97% (3749/5068) agreed or strongly agreed with ≥1 COVID-19-related racial bias belief in the past 6 months (during the COVID-19 pandemic). Across the 9 racial bias beliefs, participants scored an average of 2.59 (SD 0.96, range 1-5). Adjusted analyses revealed that compared with Asian Indians, those who were ethnic Chinese, Filipino, Hmong, Japanese, Korean, Vietnamese, and other or multicultural had significantly higher mean CRBS scores, whereas no significant differences were found among Native Hawaiian and Pacific Islander individuals. Nonheterosexual participants had statistically significant and higher mean CRBS scores than heterosexual participants. Compared with participants aged ≥60 years, those who were younger (aged <30, 30-39, 40-49, and 50-59 years) had significantly higher mean CRBS scores. US-born participants had significantly higher mean CRBS scores than foreign-born participants, whereas those with limited English proficiency (relative to those reporting no limitation) had lower mean CRBS scores. CONCLUSIONS: Many COMPASS participants reported racial bias beliefs because of the COVID-19 pandemic. Relevant sociodemographic contexts and pre-existing and COVID-19-specific factors across individual, community, and society levels were associated with the perceived racial bias of being Asian during the pandemic. The findings underscore the importance of addressing the burden of racial bias on Asian American and Native Hawaiian and Pacific Islander communities among other COVID-19-related sequelae.

Discrimination Experiences during COVID-19 among a National, Multi-Lingual, Community-Based Sample of Asian Americans and Pacific Islanders: COMPASS Findings.

Reports of escalated discrimination among Asian Americans and Pacific Islanders (AAPIs) due to COVID-19 are alarming, making this a public health priority. However, there are limited empirical studies on the scope and impact of COVID-19-related discrimination among AAPIs. Using the COVID-19 Effects on the Mental and Physical Health of AAPI Survey Study (COMPASS) data (N = 4971; survey period: October 2020-February 2021), which is a U.S.-wide multi-lingual survey, we examined the prevalence of, and factors associated with discrimination experiences attributable to being an AAPI during the COVID-19 pandemic. Overall, 60.7% reported experiencing discrimination; the group prevalence ranged from 80.0% (Hmong) to 40.5% (Native Hawaiians and Pacific Islanders). Multivariable logistic regression models revealed that COVID-19-related factors were associated with many discrimination experiences: having a shelter-in-place order of ≥1 month, living in areas with perceived similar/higher COVID-19 severity, and negative impact in family income/employment due to COVID-19. Additionally, being Asian American (versus Native Hawaiians and Pacific Islanders), females, non-heterosexuals, younger, more severe effect on family income, living in the non-West, and poorer health were significantly correlated with discrimination experiences. Findings may assist in formulating anti-AAPI-discrimination policies and programs at the local, state, and federal levels. Culturally appropriate programs and policies to combat this are urgently needed.

Differences in COVID-19 Vaccine Concerns Among Asian Americans and Pacific Islanders: The COMPASS Survey.

BACKGROUND: Understanding concerns for receiving COVID-19 vaccines is key to ensuring appropriately tailored health communications to increase vaccine uptake. However, limited data exists about vaccine concerns among Asian Americans and Pacific Islanders (AAPI). METHODS: Data from the COVID-19 Effects on the Mental and Physical Health of AAPI Survey Study (COMPASS), a cross-sectional, national survey for AAPI adults in the U.S. were used (N=1,646). Descriptive statistics were used to assess sample characteristics including proportions of AAPI with various COVID-19 vaccine concerns, categorized as none, side-effects only, unsafe only, and multiple reasons, and differences in vaccine concerns by socio-demographics. Ordinary multivariable logistic regression analyses were conducted to evaluate associations between a characteristic and having any vaccine concerns. RESULTS: Overall, 76% of the respondents reported having at ≥1 concerns about the vaccine. The most common concern was side effects (65%). Vietnamese Americans reported less concerns (vs. Chinese Americans). Those who were 30-39 and 40-49 years old (vs. <30), females (vs. males), and experienced mild negative impacts from COVID-19 on family income/employment (vs. no change) reported more concerns about the vaccine. Those who had less vaccine concerns were those who reported higher (vs. low) health status, ≥60 years old (vs. <30), and separated/divorced/widowed (vs. single). DISCUSSION: AAPI is a diverse population and this study revealed differences in vaccine concerns across AAPI groups. Findings revealed potential targets for patient education needs. Effective strategies to address various vaccine concerns across subgroups of AAPI will be crucial to ensure equity in vaccination uptake.

A Multi-Site Analysis of the Prevalence of Food Insecurity in the United States, before and during the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic profoundly affected food systems including food security. Understanding how the COVID-19 pandemic impacted food security is important to provide support and identify long-term impacts and needs. OBJECTIVE: The National Food Access and COVID research Team (NFACT) was formed to assess food security over different US study sites throughout the pandemic, using common instruments and measurements. This study presents results from 18 study sites across 15 states and nationally over the first year of the COVID-19 pandemic. METHODS: A validated survey instrument was developed and implemented in whole or part through an online survey of adults across the sites throughout the first year of the pandemic, representing 22 separate surveys. Sampling methods for each study site were convenience, representative, or high-risk targeted. Food security was measured using the USDA 6-item module. Food security prevalence was analyzed using ANOVA by sampling method to assess statistically significant differences. RESULTS: Respondents (n = 27,168) indicate higher prevalence of food insecurity (low or very low food security) since the COVID-19 pandemic, compared with before the pandemic. In nearly all study sites, there is a higher prevalence of food insecurity among Black, Indigenous, and People of Color (BIPOC), households with children, and those with job disruptions. The findings demonstrate lingering food insecurity, with high prevalence over time in sites with repeat cross-sectional surveys. There are no statistically significant differences between convenience and representative surveys, but a statistically higher prevalence of food insecurity among high-risk compared with convenience surveys. CONCLUSIONS: This comprehensive study demonstrates a higher prevalence of food insecurity in the first year of the COVID-19 pandemic. These impacts were prevalent for certain demographic groups, and most pronounced for surveys targeting high-risk populations. Results especially document the continued high levels of food insecurity, as well as the variability in estimates due to the survey implementation method.

Vaccine willingness: Findings from the COVID-19 effects on the mental and physical health of Asian Americans & Pacific Islanders survey study (COMPASS).

Willingness to get the COVID-19 vaccine is crucial to reduce the current strain on healthcare systems and increase herd immunity, but only 71% of the U.S. public said they would get the vaccine. It remains unclear whether Asian Americans and Pacific Islanders (AAPI), a population with existing inequalities in COVID-19 infection and mortality, are willing to get the vaccine, and the factors associated with vaccine willingness. Given this imperative, we used data from a national, cross-sectional, community-based survey called COVID-19 Effects on the Mental and Physical Health of AAPI Survey Study (COMPASS), an ongoing survey study that is available in English and Asian languages (i.e., Simplified or Traditional Chinese, Korean, Vietnamese) to examine vaccine willingness among AAPI. A total of 1,646 U.S. adult AAPI participants completed the survey. Self-reported vaccine willingness showed the proportion who were "unsure" or "probably/definitely no" to getting the COVID-19 vaccine was 25.4%. The odds for vaccine willingness were significantly lower for were Native Hawaiians and Pacific Islanders (vs. Asian Americans), Korean Americans (vs. Chinese and Vietnamese Americans), women (vs. men), heterosexuals (vs. non-heterosexuals), those aged 30-39 and 50-59 (vs. aged < 30), and those who reported having any vaccine concerns (vs. no concerns). AAPIs' willingness to get COVID-19 vaccine varied by groups, which underscores the need for disaggregated AAPI data. A multi-pronged approach in culturally appropriate and tailored health communication and education with AAPI is critical to achieve the goal of health equity for AAPI as it pertains to COVID-19 mortality and morbidity.

Incidence of Second Malignancy in Patients with Papillary Thyroid Cancer from Surveillance, Epidemiology, and End Results 13 Dataset.

Increased risk of second primary malignancy (SPM) in papillary thyroid cancer (PTC) has been reported. Here, we present the most updated incidence rates of second primary malignancy from original diagnosis of PTC by using the data from the Surveillance, Epidemiology, and End Results. In this cohort, 3,200 patients developed SPM, a substantially higher number than in the reference population of 2,749 with observed to expected ratio (O/E) of 1.16 (95% CI; 1.12-1.21). Bone and joint cancer had the highest O/E ratio of 4.26 (95% confidence interval [CI] 2.33-7.15) followed by salivary gland (O/E 4.15; 95% CI 2.76-6.0) and acute lymphocytic leukemia (O/E 3.98; 95% CI 2.12-6.8). Mean age at the diagnosis of SPM was 64.4 years old. Interestingly, incidence of colorectal cancer was lower in thyroid cancer survivors compared to general population (large intestine O/E 0.3; 95% CI 0.06-0.88, rectum O/E 0.6; 95% CI 0.41-0.85); however, this was not observed in patients who underwent radiation therapy. The incidence of SPM at all sites was higher during 2000-2012 compared to 1992-1999 (O/E 1.24 versus 1.10). Surprisingly, patients with micropapillary cancer had higher incidence of SPM than counterparts with a larger tumor in radiation group (O/E of 1.40 versus 1.15). O/E of all cancers were higher in males compared to females with O/E of 1.41 versus 1.17 during the period of 2000-2012. Diagnosis of PTC before age 50, especially at age 30-34, was associated with higher incidence of overall SPM (age 30-34; O/E 1.43; 95% CI; 1.19-1.71). Efficient monitoring strategies that include age at the time of thyroid cancer diagnosis, exposure to radiation, gender, and genetic susceptibility may successfully detect SPM earlier in the disease course. This is especially important given the excellent prognosis of the initial thyroid cancer itself.

Metabolomic profiles in breast cancer:a pilot case-control study in the breast cancer family registry.

BACKGROUND: Metabolomics is emerging as an important tool for detecting differences between diseased and non-diseased individuals. However, prospective studies are limited. METHODS: We examined the detectability, reliability, and distribution of metabolites measured in pre-diagnostic plasma samples in a pilot study of women enrolled in the Northern California site of the Breast Cancer Family Registry. The study included 45 cases diagnosed with breast cancer at least one year after the blood draw, and 45 controls. Controls were matched on age (within 5 years), family status, BRCA status, and menopausal status. Duplicate samples were included for reliability assessment. We used a liquid chromatography/gas chromatography mass spectrometer platform to measure metabolites. We calculated intraclass correlations (ICCs) among duplicate samples, and coefficients of variation (CVs) across metabolites. RESULTS: Of the 661 named metabolites detected, 338 (51%) were found in all samples, and 490 (74%) in more than 80% of samples. The median ICC between duplicates was 0.96 (25th - 75th percentile: 0.82-0.99). We observed a greater than 20% case-control difference in 24 metabolites (p < 0.05), although these associations were not significant after adjusting for multiple comparisons. CONCLUSIONS: These data show that assays are reproducible for many metabolites, there is a minimal laboratory variation for the same sample, and a large between-person variation. Despite small sample size, differences between cases and controls in some metabolites suggest that a well-powered large-scale study is likely to detect biological meaningful differences to provide a better understanding of breast cancer etiology.

Maternal Anthropometry and Mammographic Density in Adult Daughters.

OBJECTIVE: We examined the relation between maternal anthropometry and mammographic density in the adult daughter using prospectively collected data. METHODS: Our study included a total of 700 mother-daughter dyads participating in an adult follow-up of women born in 2 US birth cohorts: the Child Health and Development Study and the Boston, Massachusetts, and Providence, Rhode Island sites of the National Collaborative Perinatal Project. RESULTS: We observed an increased percent breast density at a mean age of 43.1 years in the daughters of mothers who gained 5 kg or less during pregnancy compared with mother-daughter pairs in which the mother gained 5 to 10 kg (ß = 4.8, 95% confidence interval: 1.0 to 8.6). The daughters of mothers who were overweight at the time of conception (prepregnancy BMI ≥25) and who gained >5 kg during pregnancy had a lower percent density (ß = -3.2, 95% confidence interval: -6.2 to -0.2) compared with mothers with a BMI <25 at conception who gained >5 kg. CONCLUSIONS: We did not find any strong and consistent patterns between maternal anthropometry and the daughter's breast density, a strong predictor of breast cancer risk. A modest association between low gestational weight gain and increased breast density 40 years later in the daughter was observed, even after accounting for adult body size, and if confirmed, possible mechanisms need to be further elucidated.

Prospective study of body size throughout the life-course and the incidence of endometrial cancer among premenopausal and postmenopausal women.

Although adult obesity is known to increase endometrial cancer risk, evidence for childhood obesity is limited. We prospectively examined the association between body fatness throughout life and endometrial cancer risk. 47,289 participants in the Nurses' Health Study (NHS) and 105,386 of the Nurses' Health Study II (NHS II) recalled their body fatness at ages 5, 10 and 20 using a pictogram. Childhood and adolescent body fatness were derived as the average at ages 5 and 10 and ages 10 and 20, respectively. We obtained adult weight from concurrent questionnaires. We calculated hazard ratios (HR) of endometrial cancer using Cox proportional hazards models. During follow-up, 757 incident cases of endometrial cancer were diagnosed. Body fatness in childhood, at age 10, in adolescence and at age 20 were positively associated with endometrial cancer risk (HR for ≥ Level 5 versus ≤ Level 2 in adolescence: 1.83 (95% CI 1.41-2.37). After adjusting for most recent BMI, none of the associations persisted. Weight change since age 18 was positively associated with endometrial cancer risk [HR for ≥ 25 kg gain versus stable: 2.54 (95% CI 1.80-3.59). Adult BMI was strongly associated with endometrial cancer risk [HR BMI ≥ 35 kg/m(2) versus BMI ≤ 25 kg/m(2) : 4.13 (95% CI 3.29-5.16)]. In postmenopausal women, the association with BMI was significantly stronger among non-users of hormone therapy. In conclusion, obesity throughout life is positively associated with endometrial cancer risk, with adult obesity one of the strongest risk factors. Maintaining a healthy weight throughout life remains important.

Serum levels of perfluorooctanoic acid and perfluorooctane sulfonate and pregnancy outcome.

The authors examined the association of serum perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) with self-reported pregnancy outcome in Mid-Ohio Valley residents (2000-2006) highly exposed to PFOA. Data on 1,845 pregnancies within the 5 years preceding exposure measurement were analyzed for PFOA, and data on 5,262 pregnancies were analyzed for PFOS. Generalized estimating equations were used to calculate adjusted odds ratios and 95% confidence intervals. Neither PFOA nor PFOS showed any association with miscarriage or preterm birth. Preeclampsia was weakly associated with PFOA (adjusted odds ratio = 1.3, 95% confidence interval: 0.9, 1.9) and PFOS (adjusted odds ratio = 1.3, 95% confidence interval: 1.1, 1.7) exposures above the median. PFOA was not associated with an increase in low birth weight, but PFOS showed an increased risk above the median (adjusted odds ratio = 1.5, 95% confidence interval: 1.1, 1.9) and a dose-response gradient. Birth defects were weakly associated with PFOA exposures above the 90th percentile (adjusted odds ratio = 1.7, 95% confidence interval: 0.8, 3.6). This study identified modest associations of PFOA with preeclampsia and birth defects and of PFOS with preeclampsia and low birth weight, but associations were small, limited in precision, and based solely on self-reported health outcomes.