A preliminary study of a composite sleep health score: associations with psychological distress, body mass index, and physical functioning in a low-income African American community.

OBJECTIVES: Although multiple individual sleep measures (eg, sleep duration, satisfaction) have been linked to a wide range of physical and mental health conditions, scant research has examined how individual sleep dimensions may act independently or additively to influence health. The current study investigates associations of 5 sleep dimensions (duration, satisfaction, efficiency, timing, and regularity), analyzed separately and simultaneously, with psychological distress, body mass index, and physical functioning among a low-income, predominantly African American population. DESIGN: We constructed a composite sleep health (SH) score from the sum of scores, representing "good' and "poor" ranges of 5 sleep measures (range 0-5). SETTING: Two low-income, predominantly African American neighborhoods in Pittsburgh. PARTICIPANTS: Participants included 738 community-dwelling adults (78% female and 98% black). MEASUREMENTS: Actigraphy-based measures of sleep duration, regularity, timing, and efficiency, and self-reported sleep satisfaction. Outcomes included self-reported psychological distress, physical functioning, and measured body mass index (BMI). RESULTS: Each 1-unit higher SH score was associated with 0.55-unit lower psychological distress score (range 0-24) and 2.23-unit higher physical functioning score. Participants with at least 2, 3, or 4 sleep dimensions in the "healthy" range, vs fewer, had lower psychological distress scores. Greater sleep satisfaction was associated with higher physical functioning, and longer sleep duration was associated with lower physical functioning. Neither the composite SH score nor any of the individual sleep dimensions were associated with BMI. CONCLUSIONS: Assessing multiple sleep dimensions may provide a more comprehensive understanding of associations of sleep with psychological distress than assessing any single sleep dimension. Although no sleep measures were related to BMI in the current sample, analyses should be replicated in other samples to determine generalizability.

One size doesn't fit all: cross-sectional associations between neighborhood walkability, crime and physical activity depends on age and sex of residents.

BACKGROUND: Low-income African American adults are disproportionately affected by obesity and are also least likely to engage in recommended levels of physical activity (Flegal et al. JAMA 303(3):235-41, 2010; Tucker et al. Am J Prev Med 40(4):454-61, 2011). Moderate-to-vigorous physical activity (MVPA) is an important factor for weight management and control, as well as for reducing disease risk (Andersen et al. Lancet 368(9532):299-304, 2006; Boreham and Riddoch J Sports Sci 19(12):915-29, 2001; Carson et al. PLoS One 8(8):e71417, 2013). While neighborhood greenspace and walkability have been associated with increased MVPA, evidence also suggests that living in areas with high rates of crime limits MVPA. Few studies have examined to what extent the confluence of neighborhood greenspace, walkability and crime might impact MVPA in low-income African American adults nor how associations may vary by age and sex. METHODS: In 2013 we collected self-reported data on demographics, functional limitations, objective measures of MVPA (accelerometry), neighborhood greenspace (geographic information system), and walkability (street audit) in 791 predominantly African-American adults (mean age 56 years) living in two United States (U.S.) low-income neighborhoods. We also acquired data from the City of Pittsburgh on all crime events within both neighborhoods. EXPOSURE: To examine cross-sectional associations of neighborhood-related variables (i.e., neighborhood greenspace, walkability and crime) with MVPA, we used zero-inflated negative binomial regression models. Additionally, we examined potential interactions by age (over 65 years) and sex on relationships between neighborhood variables and MVPA. RESULTS: Overall, residents engaged in very little to no MVPA regardless of where they lived. However, for women, but not men, under the age of 65 years, living in more walkable neighborhoods was associated with more time engaged in MVPA in (ß = 0.55, p = 0.007) as compared to their counterparts living in less walkable areas. Women and men age 65 years and over spent very little time participating in MVPA regardless of neighborhood walkability. Neither greenspace nor crime was associated with MVPA in age-sex subgroups. CONCLUSIONS: Neighborhood walkability may play a stronger role on MVPA than accessible greenspace or crime in low-income urban communities. Walkability may differentially impact residents depending on their age and sex, which suggests tailoring public health policy design and implementation according to neighborhood demographics to improve activity for all.

Loneliness, Depression, and Inflammation: Evidence from the Multi-Ethnic Study of Atherosclerosis.

OBJECTIVE: Both objective and subjective aspects of social isolation have been associated with alterations in immune markers relevant to multiple chronic diseases among older adults. However, these associations may be confounded by health status, and it is unclear whether these social factors are associated with immune functioning among relatively healthy adults. The goal of this study was to examine the associations between perceived loneliness and circulating levels of inflammatory markers among a diverse sample of adults. METHODS: Data come from a subset of the Multi-Ethnic Study of Atherosclerosis (n = 441). Loneliness was measured by three items derived from the UCLA Loneliness Scale. The association between loneliness and C-reactive protein (CRP) and fibrinogen was assessed using multivariable linear regression analyses. Models were adjusted for demographic and health characteristics. RESULTS: Approximately 50% of participants reported that they hardly ever felt lonely and 17.2% felt highly lonely. Individuals who were unmarried/unpartnered or with higher depressive symptoms were more likely to report being highly lonely. There was no relationship between perceived loneliness and ln(CRP) (ß = -0.051, p = 0.239) adjusting for demographic and health characteristics. Loneliness was inversely associated with ln(fibrinogen) (ß = -0.091, p = 0.040), although the absolute magnitude of this relationship was small. CONCLUSION: These results indicate that loneliness is not positively associated with fibrinogen or CRP among relatively healthy middle-aged adults.

Developmental origins of flatter cortisol rhythms: socioeconomic status and adult cortisol activity.

OBJECTIVE: Low socioeconomic status (SES) is associated with increased psychosocial stress among low-income persons, which could contribute to differences in activity of the HPA axis (assessed by diurnal cortisol profiles). The current article investigates associations of SES from different developmental stages with cortisol profiles. METHODS: Using data from a large, socioeconomically diverse birth cohort (N = 1,490) in Cebu, Philippines, the current study compares the relative and joint contributions of SES from five developmental periods, between the prenatal/birth period and early adulthood, to adult cortisol, and examines the effects of chronic exposure to low SES. RESULTS: Chronically low SES from infancy through early adulthood predicts the highest bedtime cortisol levels, lowest cortisol awakening responses (CARs), lowest total cortisol levels across the day (area under curve or AUC), and the flattest cortisol rhythms between wake up and bedtime, a profile associated with poorer health. Results indicate that cumulative economic strain (between the prenatal period and early adulthood) predicts flatter cortisol rhythms more consistently than SES from any particular period. CONCLUSION: Interventions focusing on the psychosocial stressors associated with economic deprivation during any period from infancy to adulthood may be helpful, but targeting interventions across multiple periods may have the greatest impact. Interventions aimed at improving economic conditions between infancy and early adulthood may have implications for long-term changes in HPA axis functioning.

Racial and ethnic differences in diurnal cortisol rhythms: are they consistent over time?

BACKGROUND: Prior research indicates that blacks and Hispanics/Latinos have flatter diurnal cortisol declines across the day, a profile associated with poorer health. The stability of racial and ethnic differences in cortisol levels over time is not well understood, and additional research is needed to establish racial and ethnic differences in psychosocial stress levels as related to changes in cortisol levels. METHODS: With data from a community-based study of 152 adults (mean age = 58 years; 53% women; 34% black, 26% Hispanic/Latino), we examined the magnitude of racial and ethnic differences over a 5-year period. Salivary cortisol samples were obtained 3 times per day for 3 days in Years 1, 3, 4, and 5. Life events and chronic stress were assessed by questionnaires in which participants reported on whether they had experienced specific types of events or stress within the past year. Depressive symptoms scales (Center for Epidemiologic Studies of Depression Scale) were also administered annually. Daily cortisol slopes were calculated by subtracting wakeup cortisol from bedtime levels and dividing by hours awake. RESULTS: Increases in psychosocial stress were associated with flatter cortisol slopes among blacks (ß = 0.010) and Hispanics/Latinos (ß = 0.014), although including cardiovascular disease risk factors attenuates associations in blacks (ß = 0.007; p = .125). Higher income predicts a steepening of cortisol rhythms across the study (ß = -0.003; p = .019). CONCLUSIONS: Racial and ethnic differences in diurnal cortisol rhythms are stable over time. However, the magnitude of changes in cortisol levels associated with chronic stress levels may vary by racial and ethnic subgroups.

Salivary cortisol protocol adherence and reliability by socio-demographic features: the Multi-Ethnic Study of Atherosclerosis.

Collection of salivary cortisol has become increasingly popular in large population-based studies. However, the impact of protocol compliance on day-to-day reliabilities of measures, and the extent to which reliabilities differ systematically according to socio-demographic characteristics, has not been well characterized in large-scale population-based studies to date. Using data on 935 men and women from the Multi-Ethnic Study of Atherosclerosis, we investigated whether sampling protocol compliance differs systematically according to socio-demographic factors and whether compliance was associated with cortisol estimates, as well as whether associations of cortisol with both compliance and socio-demographic characteristics were robust to adjustments for one another. We further assessed the day-to-day reliability for cortisol features and the extent to which reliabilities vary according to socio-demographic factors and sampling protocol compliance. Overall, we found higher compliance among persons with higher levels of income and education. Lower compliance was significantly associated with a less pronounced cortisol awakening response (CAR) but was not associated with any other cortisol features, and adjustment for compliance did not affect associations of socio-demographic characteristics with cortisol. Reliability was higher for area under the curve (AUC) and wake up values than for other features, but generally did not vary according to socio-demographic characteristics, with few exceptions. Our findings regarding intra-class correlation coefficients (ICCs) support prior research indicating that multiple day collection is preferable to single day collection, particularly for CAR and slopes, more so than wakeup and AUC. There were few differences in reliability by socio-demographic characteristics. Thus, it is unlikely that group-specific sampling protocols are warranted.

Associations of neighborhood characteristics with sleep timing and quality: the Multi-Ethnic Study Of Atherosclerosis.

STUDY OBJECTIVES: To investigate the associations of specific neighborhood features (disorder, safety, social cohesion, physical environment, and socioeconomic status) with sleep duration and quality. DESIGN: Cross-sectional. One wave of a population-based study (Multi-Ethnic Study of Atherosclerosis). SETTING: Community-dwelling participants in New York, NY and Los Angeles, CA. PARTICIPANTS: There were 1,406 participants (636 males, 770 females). INTERVENTIONS: NA. MEASUREMENTS AND RESULTS: Sleep was assessed using reported hours of sleep, the Epworth Sleepiness Scale, and insomnia symptoms. Neighborhood characteristics were assessed via questionnaires administered to neighbors of study participants and were aggregated to the neighborhood (census tract) level using empirical Bayes estimation. An adverse social environment (characterized by high disorder, and low safety and social cohesion) was associated with shorter sleep duration after adjustment for the physical environment, neighborhood and individual-level socioeconomic status (SES), and other short sleep risk factors (mean difference per standard deviation increase in summary social environment scale 0.24 h 95% confidence interval 0.08, 0.43). Adverse neighborhood social and physical environments, and neighborhood SES were associated with greater sleepiness, but associations with physical environments were no longer statistically significant after adjustment for sociodemographic characteristics. Neighborhood SES was a weaker and less consistent predictor of specific measures of neighborhood social and physical environments. Neighborhood characteristics were not associated with insomnia. CONCLUSIONS: Shortened sleep related to adverse social environments represents one potential pathway through which neighborhoods may influence health.

Diurnal salivary cortisol is associated with body mass index and waist circumference: the Multiethnic Study of Atherosclerosis.

OBJECTIVE: Neuroendocrine abnormalities, such as activation of the hypothalamic-pituitary-adrenal (HPA) axis, are associated with obesity; however, few large-scale population-based studies have examined HPA axis and markers of obesity. We examined the cross-sectional association of the cortisol awakening response (CAR) and diurnal salivary cortisol curve with obesity. DESIGN AND METHODS: The Multiethnic Study of Atherosclerosis Stress Study includes 1,002 White, Hispanic, and Black men and women (mean age 65 ± 9.8 years) who collected up to 18 salivary cortisol samples over 3 days. Cortisol profiles were modeled using regression spline models that incorporated random parameters for subject-specific effects. Cortisol curve measures included awakening cortisol, CAR (awakening to 30-min postawakening), early decline (30 min to 2-h postawakening), late decline (2-h postawakening to bedtime), and the corresponding areas under the curve (AUC). Body mass index (BMI) and waist circumference (WC) were used to estimate adiposity. RESULTS: For the entire cohort, both BMI and WC were negatively correlated with awakening cortisol (P < 0.05), AUC during awakening rise, and early decline and positively correlated to the early decline slope (P < 0.05) after adjustments for age, race/ethnicity, gender, diabetes status, socioeconomic status, ß-blockers, steroids, hormone replacement therapy, and smoking status. No heterogeneities of effects were observed by gender, age, and race/ethnicity. CONCLUSIONS: Higher BMI and WC are associated with neuroendocrine dysregulation, which is present in a large population sample, and only partially explained by other covariates.

Concordance between self-reported and objective wakeup times in ambulatory salivary cortisol research.

BACKGROUND: Hypothalamic-pituitary-adrenal (HPA) axis functioning has implications for physical and mental health. One important indicator of HPA axis functioning, the salivary cortisol awakening response (CAR), is sensitive to whether participants provide their samples at the requested times after waking. PURPOSE: To examine the extent to which adolescents report morning wakeup times accurately, test the impact of inaccurate waketime reporting on compliance with a salivary cortisol sampling protocol designed to estimate the CAR, and to examine the implications of non-compliance for CAR estimates. METHOD: In a sample of 91 late adolescents, objective waketimes determined using actigraphy were compared to self-reported waketimes. Associations between accuracy of waketimes and compliance with requested morning cortisol sampling timings (wakeup and 30 min post-awakening) were examined, as were implications of non-compliance for the size of the CAR. RESULTS: In terms of accuracy, 72% of self-reported waketimes were within 5 min and 90% were within 15 min of objective waketimes. Individuals who were more than 5 min discrepant in their waketime reporting, however, had a 90% decrease in their likelihood of being compliant-taking both morning cortisol samples within the requested time frames after waking. However, CARs were significantly lower only among individuals whose subjective and objective waketimes differed by more than 15 min. CONCLUSIONS: Self-reported waketimes were reasonably accurate when compared to objective estimates of time of waking. When available, however, estimates of compliance are improved by knowledge of objective waketimes, resulting in increased accuracy of CAR estimates.

Neuroticism and introversion are associated with salivary cortisol patterns in adolescents.

Previous studies have yielded equivocal findings on the relationship between personality and cortisol activity. The present study examined associations between personality and cortisol activity in a large, diverse adolescent sample, while partialling the effects of relevant demographic and health-related covariates. A subsample of 230 participants (57% of whom reported elevated neuroticism) was selected from a larger sample of 16-18-year olds involved in a study on risk factors for emotional disorders. Subsample participants completed a battery of personality questionnaires, and saliva collection was requested several months later on three consecutive days at six time points per day, from wakeup to bedtime. Associations between personality and cortisol rhythms were examined using multilevel growth curve modeling. Neuroticism (N) and introversion (I) were significantly and differentially associated with features of diurnal cortisol patterns. Specifically, a significant N x gender interaction was observed, demonstrating flatter cortisol rhythms across the waking day among male participants with higher N. Elevated I, however, was associated with lower cortisol awakening responses for both male and female participants, and higher cortisol at the time of waking for male participants only. The present study supports personality as a significant predictor of diurnal cortisol patterns in late adolescence, after accounting for the effects of demographic and health covariates, and suggests that gender plays a role in moderating associations between personality and cortisol.

Racial/ethnic differences in cortisol diurnal rhythms in a community sample of adolescents.

PURPOSE: To identify potential physiological pathways to racial disparities in health outcomes, this study uses cortisol data collected from a community sample of 255 adolescents to examine whether there are racial/ethnic differences in cortisol slopes and levels across the waking day in naturalistic settings. METHODS: This study uses salivary cortisol data (sampled five times per day over 3 days) to examine racial/ethnic differences in diurnal cortisol rhythms, while covarying the presence of major depressive disorder and chronic and episodic life stress (assessed by structured interviews), momentary negative emotion (reported in diaries completed with cortisol samples), and socioeconomic status, sleep, and health variables (assessed by questionnaire) previously found to be associated with cortisol levels. RESULTS: African-American and Hispanic youth were found to have flatter cortisol slopes across the waking day than their Caucasian counterparts. Differences are due to higher bedtime cortisol levels among Hispanics and to both lower wakeup and higher bedtime levels among African-Americans. Although higher levels of negative emotion were associated with flatter diurnal rhythms, the socioenvironmental factors examined failed to explain the observed racial/ethnic differences in diurnal cortisol rhythms. CONCLUSIONS: Significantly flatter diurnal cortisol slopes were found among African American and Hispanic adolescents, a pattern which has been related to negative health consequences. Further research is needed to examine how early these differences emerge and to identify their developmental origins. Although genetic contributions are possible, greater prenatal stress exposure, low birth weight, adverse early childhood experiences, experiences with racism or discrimination, and lifetime history of chronic stress are all reasonable psychosocial hypotheses to pursue.