Women's Heart Research Articles

Improvements in Time to Reperfusion

Several studies demonstrate that women have greater delays in primary percutaneous coronary intervention (PCI). To improve care for women, the Women's Heart Advantage at Yale-New Haven Hospital (YNHH) developed patient- and physician-level interventions to improve knowledge about chest pain syndromes to promote early presentation, diagnosis, and timely management of ST-elevation myocardial infarction (STEMI) in women presenting to the emergency department. Specifically, we analyzed chart-abstracted data from all patients undergoing PCI for STEMI at YNHH from January 2004 to July 2007 and assessed quality of care for STEMI and trends in time to reperfusion. Women's Heart Advantage and YNHH orchestrated several clinical initiatives and instituted hospital-wide systems to improve STEMI care over this period. Both men and women had declines in time to reperfusion (91-73 minutes for men and 120-74 minutes for women). Notably, improvements in time to reperfusion were more substantial in women; the greatest improvement was reduction in door-to-table time (50% decrease in women vs. 19% decrease in men [P < 0.05]). In this single-site study of men and women undergoing primary PCI at a large, urban teaching hospital, where ongoing interventions to increase both patient and physician awareness regarding heart disease in women were initiated, time to reperfusion for women improved to a greater degree than in men. These results are encouraging, showing that significant improvements can be made over a relatively short time frame. It is hoped these reductions in time to reperfusion are associated with improved outcomes; however, further studies are needed to verify this potential benefit.

Adherence to American Academy of Pediatrics Recommendations for Cardiac Care Among Female Carriers of Duchenne and Becker Muscular Dystrophy

The goal was to assess women's knowledge and heart health behaviors consistent with the American Academy of Pediatrics recommendations for cardiac care among female carriers of Duchenne/Becker muscular dystrophy. Using an advocacy group mailing list and working with 50 Muscular Dystrophy Association clinics, we surveyed women who had given birth to a son with Duchenne/Becker muscular dystrophy, thought that they were definitely or probably (>/=50% likelihood) a Duchenne/Becker muscular dystrophy carrier, or both. Self-report data classified respondents as carriers, noncarriers, or women with unknown status. The respondents included 833 Duchenne/Becker muscular dystrophy carriers, 376 noncarriers, and 192 women with unknown status. Carriers were more likely than noncarriers and women in the unknown-status group to have ever undergone electrocardiography or other heart testing and to have seen a cardiologist in the past year, but they were not more likely to report a recent blood pressure or cholesterol level check. Only 64.4% of the carriers had ever had a heart test; 18.3% had seen a cardiologist in the past year. Only 62.9% of the carriers were aware of their cardiomyopathy risks before participating in the survey; 69.3% had informed their health care provider of their carrier status. Among carriers who had informed their provider, 70.2% had ever had a heart test and 21.4% had seen a cardiologist in the past year. In adjusted logistic regression models, factors that significantly increased the likelihood among carriers of ever having had a heart test and seeing a cardiologist in the previous year included older age (>/=50 years), feeling informed about their cardiomyopathy risks before the survey, and having told their provider about their carrier status. More health education efforts are needed for both patients and their providers, to improve adherence to the American Academy of Pediatrics cardiac care guidelines for female Duchenne/Becker muscular dystrophy carriers.

Two British women studies replicated the association between the Val66Met polymorphism in the brain-derived neurotrophic factor (BDNF) and BMI

The goal of this study is to investigate the relationship between the Val66Met polymorphism in the brain-derived neurotrophic factor (BDNF) and body mass index (BMI) in two sizable and well-characterized populations of British women: the British Women's Heart and Health Study (BWHHS) (age 60-79 years) and the mothers from the Avon Longitudinal Study of Parents and Children (age 16-44 years). We genotyped the Val66Met polymorphism (rs6265) in these two populations, and conducted a linear regression analysis to test for an association between this polymorphism and BMI. Both study populations indicated an association between BMI and the Val66Met polymorphism, with individuals carrying the Met-Met genotype having a lower mean BMI than those with the Val-Met or Val-Val genotypes (in the BWHHS): mean BMI difference=-0.911 kg/m(2), 95% confidence interval (CI): -1.70 to -0.12, P=0.023; in the mothers from the Avon Longitudinal Study of Parents and Children (ALSPAC): mean BMI difference=-0.57 kg/m(2), 95%CI: -1.08 to -0.054, P=0.03). In a pooled analysis of these two studies, together with one further published study that provided data in a suitable format for inclusion in our meta-analysis, we found a pooled difference of -0.76 (95% CI: -1.16, -0.036) for adult women; I(2)-test for heterogeneity=51%, P=0.13. Our study indicated an association between BDNF and BMI in two general population studies of women. The exact role of BDNF in weight regulation merits further investigation.

:The Medieval Chastity Belt: A Myth-Making Process.(The New Middle Ages.)

Another nail in the coffin of the chastity belt should not be necessary. However, like the droit de seigneur, this myth refuses to die. Albrecht Classen's book ought to kill it, but as he points out, people are quite willing to go on believing demonstrably untrue things about contemporary as well as medieval culture. Classen is most successful at reviewing and rejecting the medieval evidence, especially from literature, that has been adduced for the use of chastity belts. He convincingly argues that literary references to the use of a belt as a marriage gift have nothing to do with a chastity belt (indeed, the common use of this gift in documents of practice supports his argument). References to a man wanting to put his key in a woman's lock are, he rightly claims, most convincing as coded references to sexual intercourse; and references to a man holding the key to a woman's heart need not be directly sexual at all. The belt in Marie de France's Guigemar protects the lady's fidelity by providing a means of identification for the lovers, and in this way functions like the girdle of chastity in ancient literature, which was a symbol of virginity only to be removed by the husband but which did not physically prevent intercourse. The phrase cingulum castitatis in religious texts refers to a symbol as well (and is connected with men rather than women). Texts that do refer to locked devices that prevent vaginal and anal penetration—particularly Conrad Kyeser's Bellefortis (1405), Giovanni Sercambi's Novelle (ca. 1399–1400), and Hywel o Fuallt ( sixteenth century)—do not, in Classen's persuasive analysis, describe actual practice but are satirical and ironic. Classen successfully debunks the idea that Francesco II of Carrara, duke of Padua (1389-ca 1406), invented the chastity belt.

Alanine Aminotransferase, γ-Glutamyltransferase, and Incident Diabetes

OBJECTIVETo estimate and compare associations of alanine aminotransferase (ALT) and γ-glutamyltransferase (GGT) with incident diabetes.RESEARCH DESIGN AND METHODSALT and GGT were studied as determinants of diabetes in the British Women's Heart and Health Study, a cohort of 4,286 women 60–79 years old (median follow-up 7.3 years). A systematic review and a meta-analysis of 21 prospective, population-based studies of ultrasonography, which diagnosed nonalcoholic fatty liver disease (NAFLD), ALT, and GGT as determinants of diabetes, were conducted, and associations of ALT and GGT with diabetes were compared.RESULTSUltrasonography-diagnosed NAFLD was associated with more than a doubling in the risk of incident diabetes (three studies). ALT and GGT both predicted diabetes. The fully adjusted hazard ratio (HR) for diabetes per increase in one unit of logged ALT was 1.83 (95% CI 1.57–2.14, I2 = 8%) and for GGT was 1.92 (1.66–2.21, I2 = 55%). To directly compare ALT and GGT as determinants of diabetes, the fully adjusted risk of diabetes in the top versus bottom fourth of the ALT and GGT distributions was estimated using data from studies that included results for both markers. For ALT, the HR was 2.02 (1.59–2.58, I2 = 27%), and for GGT the HR was 2.94 (1.98–3.88, I2 = 20%), suggesting that GGT may be a better predictor (P = 0.05).CONCLUSIONSFindings are consistent with the role of liver fat in diabetes pathogenesis. GGT may be a better diabetes predictor than ALT, but additional studies with directly determined liver fat content, ALT, and GGT are needed to confirm this finding.

Influence of Life Course Socioeconomic Position on Older Women's Health Behaviors: Findings From the British Women's Heart and Health Study

We examined the association between health behaviors and socioeconomic status (SES) in childhood and adult life. Self-reported diet, smoking, and physical activity were determined among 3523 women aged 60 to 79 years recruited from general practices in 23 British towns from 1999 through 2001. The most affluent women reported eating more fruit, vegetables, chicken, and fish and less red or processed meat than did less affluent women. Affluent women were less likely to smoke and more likely to exercise. Life course SES did not influence the types of fat, bread, and milk consumed. Adult SES predicted consumption of all foods considered and predicted smoking and physical activity habits independently of childhood SES. Childhood SES predicted fruit and vegetable consumption independently of adult SES and, to a lesser extent, predicted physical activity. Downward social mobility over the life course was associated with poorer diets and reduced physical activity. Among older women, healthful eating and physical activity were associated with both current and childhood SES. Interventions designed to improve social inequalities in health behaviors should be applied during both childhood and adult life.

Life‐course socio‐economic position, area deprivation and Type 2 diabetes: findings from the British Women's Heart and Health Study

We examined whether area deprivation influenced risk of Type 2 diabetes, fasting blood glucose and insulin resistance over and above the effect of individual socio-economic position (SEP) measured across the life course. A cross-sectional analysis of 4286 women aged 60 to 79 years from 457 British electoral wards in 23 towns. Area deprivation was positively associated with diagnosed [odds ratio (OR) 1.32, 95% confidence interval (CI) 1.13, 1.53, per quintile of area deprivation, n = 2895], but not undiagnosed Type 2 diabetes after adjustment for individual life-course SEP. This association was robust to adjustment for adult health behaviours and physiological risk factors. Insulin resistance [homeostasis model assessment (HOMA) score] increased by 1.90% (95% CI 0.01, 3.82, n = 2526) per quintile of area deprivation after adjustment for individual SEP, while fasting blood glucose increased by 0.69% (95% CI 0.16, 1.22, n = 2875) after adjustment for individual SEP. Area level deprivation independently influences diagnosed Type 2 diabetes, insulin resistance and fasting blood glucose. Examination of more specific characteristics of places is needed to understand the mechanisms by which these effects arise.

The Heart Truth: Using the Power of Branding and Social Marketing to Increase Awareness of Heart Disease in Women

In September 2002, the National Heart, Lung, and Blood Institute launched The Heart Truth, the first federally-sponsored national campaign aimed at increasing awareness among women about their risk of heart disease. A traditional social marketing approach, including an extensive formative research phase, was used to plan, implement, and evaluate the campaign. With the creation of the Red Dress as the national symbol for women and heart disease awareness, the campaign integrated a branding strategy into its social marketing framework. The aim was to develop and promote a women's heart disease brand that would create a strong emotional connection with women. The Red Dress brand has had a powerful appeal to a wide diversity of women and has given momentum to the campaign's three-part implementation strategy of partnership development, media relations, and community action. In addition to generating its own substantial programming, The Heart Truth became a catalyst for a host of other national and local educational initiatives, both large and small. By the campaign's fifth anniversary, surveys showed that women were increasingly aware of heart disease as their leading cause of death and that the rise in awareness was associated with increased action to reduce heart disease risk.

The Heart Truth: Applying Formative Research to Build a National Women's Heart Health Movement

<i>The Heart Truth</i>: Applying Formative Research to Build a National Women's Heart Health Movement

Genetic association study of BDNF in depression: Finding from two cohort studies and a meta‐analysis

Depression is common and a major cause of morbidity and mortality and is also known to have serious effects on quality of life. Both clinical and pharmacologic studies have implicated the role of brain-derived neurotrophic factor (BDNF) as a susceptibility locus for the development of mental illness, including depression, bipolar disorder, and schizophrenia. Population-based genetic studies have examined the association between BDNF and a variety of depression outcomes, but the results have not clearly established the role of BDNF in the development of this complex disorder. The aim of this study was to test for associations between two genetic variants in BDNF, Val66Met (rs6265) and -270 C > T, and depression measured in two independent samples. In this analysis we included 3,548 participants from British Women's Heart and Health Study (BWHHS) and 6,836 mothers from Avon Longitudinal Study of Parents and Children (ALSPAC) who had complete data on genotype and depression outcomes. We did not detect any strong evidence of associations between any of the two polymorphisms and indicators of depression in either BWHHS or ALSPAC samples. Further, we carried out a systematic review and meta-analysis of all association studies of these two BDNF polymorphisms and depression. The meta-analysis of Val66Met in depression obtained an overall summary OR of 1.06 (95% CI: 0.89-1.26, P = 0.537) comparing MM with VV genotypes and an OR of 0.97 (95% CI: 0.89-1.05, P = 0.403) comparing MV with VV genotypes. Our findings suggest that BDNF genotype does not exert a major influence on the development of depression.

Associations of circulating C-reactive protein and interleukin-6 with cancer risk: findings from two prospective cohorts and a meta-analysis

We investigated the associations of circulating C-reactive protein (CRP) and interleukin-6 (IL-6) with cancer risk. We examined the associations of CRP and IL-6 with incident cancer in two prospective cohorts, the British Women's Heart and Health Study (4,286 women aged 60-80) and the Caerphilly Cohort (2,398 men aged 45-59) using Cox regression and pooled our findings with previous prospective studies' in fixed and random effects meta-analyses. CRP and IL-6 were associated with some incident cancers in our cohorts, but the numbers of cancer cases were small. In our meta-analyses elevated CRP was associated with an increased overall risk of cancer (random effects estimate (RE): 1.10, 95% CI: 1.02, 1.18) and lung cancer (RE: 1.32, 95% CI: 1.08, 1.61). Its associations with colorectal (RE: 1.09, 95% CI: 0.98, 1.21) and breast cancer risks (RE: 1.10, 95% CI: 0.97, 1.26) were weaker. CRP appeared unrelated to prostate cancer risk (RE: 1.00 0.88, 1.13). IL-6 was associated with increased lung and breast cancer risks and decreased prostate cancer risk, and was unrelated to colorectal cancer risk. Our findings suggest an etiological role for CRP and IL-6 in some cancers. Further large prospective and genetic studies would help to better understand this role.

High Prevalence of Cardiometabolic Risk Factors in Women Considered Low Risk by Traditional Risk Assessment

Cardiovascular disease (CVD) is the leading cause of death in women in the United States. The purpose of this study was to characterize the prevalence and awareness of traditional CVD risk factors, obesity, and coronary heart disease (CHD) risk classification using the Framingham Risk Score (FRS) among women attending the 2006 Sister to Sister National Woman's Heart Day event. A total of 8936 participants (mean age 49 +/- 14 years) were evaluated. There was a modest prevalence of traditional risk factors on screening, including non-high-density lipoprotein-cholesterol (HDL-C) >160 mg/dL (27%), HDL-C <40 mg/dL (16%), random glucose level >140 mg/dL (6%), uncontrolled blood pressure > or =140/90 mm Hg (12%), current smoking (6%), and a positive family history of CHD (21%). There was a high prevalence of overweight (39%) or obese individuals (35%) (body mass index [BMI] 25-30 and > or =30 kg/m(2), respectively), as well as those with high waist circumference (> or =35 inches) (55%). Women were classified by FRS as low (85%), intermediate (6%), and high risk (9%). When cardiometabolic risk analyses included waist circumference in addition to the FRS, 59% of low-risk and 50% of intermediate-risk women had 1 or 2 risk factors, and 19% and 41% had > or =3 risk factors, respectively. Women were often unaware of risk factors on screening; among women without a previous diagnosis of dyslipidemia or hypertension, 48% and 7%, respectively, were given new diagnoses. Women participating in the 2006 Sister to Sister National Woman's Heart Day event have a high prevalence of cardiometabolic risk factors, especially dyslipidemia, obesity, and high central adiposity, that place them at higher risk for the development of CVD and other comorbidities. The newly identified multiple risk factors in this population support the value of community health screening in women.

Interleukin-6 and incident coronary heart disease: Results from the British Women's Heart and Health Study

Introduction Inflammatory mechanisms may play a role in the pathogenesis of atherosclerosis and its complications. Interleukin-6 (IL-6) is an ‘upstream’ pro-inflammatory cytokine that stimulates hepatocytes to synthesize acute phase response proteins such as C-reactive protein (CRP) and fibrinogen. The purpose of this study was to determine whether IL-6 is associated with incident coronary heart disease (CHD) events independently of established risk factors and to examine its predictive ability for future CHD events. Methods Data from the British Women's Heart and Health Study, a prospective cohort of randomly sampled British women 60–79 years old at baseline was used. Three thousand five hundred and eighty-one women had no evidence of coronary heart disease at baseline and were followed up for a median of 4.6 years. Cox proportional hazard models were used to estimate the association of IL-6 with incident CHD. Results The age-adjusted association of IL-6 with the risk of CHD (hazard ratio, HR per doubling of IL-6 = 1.26, 95% CI 1.10, 1.43) was attenuated when adjusting for established CHD risk factors (HR per doubling of IL-6 = 1.13, 95% CI 0.97, 1.31). The main confounders of the association of IL-6 and CHD risk were smoking and forced expiratory volume (FEV 1). Further attenuation was observed when additional terms for components of the metabolic syndrome were added into the model (HR = 1.08, 95% CI 0.93, 1.27). Conclusions There was no strong evidence of an association between IL-6 and incident CHD in older British women after controlling for established CHD risk factors. Studies with measures of lung function and socio-economic position are needed to further investigate the role of IL-6 in CHD etiology.

Giving Women's Hearts a Helping Hand

Giving Women's Hearts a Helping Hand

The methylenetetrahydrofolate reductase C677T genotype and the risk of obesity in three large population-based cohorts.

ObjectiveEpidemiological studies have shown that low folate levels are associated with a high body mass index (BMI). These findings have potentially important health implications and warrant further investigation to determine whether a causal relationship exists and the direction of this relationship. The methylenetetrahydrofolate reductase (MTHFR) C677T TT genotype is associated with reduced folate availability and may be a surrogate for measuring folate levels. We sought to determine whether MTHFR C677T genotype was associated with obesity.DesignWe carried out our study on four populations from three longitudinal studies based in the UK and Denmark in which DNA for genotyping was obtained along with measures of obesity.MethodsOur subjects were taken from the British Women's Heart and Health Study (BWHHS), the Avon Longitudinal Study of Parents and Children (two populations: mothers and children) and the Copenhagen City Heart Study. We performed analyses separately by population, and then carried out a meta-analysis, combining similar populations.ResultsInitial findings in the BWHHS suggested that the TT genotype may be associated with an increased risk of obesity BMI≥30, however, no association was found with BMI or central adiposity in this cohort. This genotype was not associated with obesity in our other cohorts.ConclusionsOur results suggest that the initial positive finding with obesity in the BWHHS was a chance finding. Our findings do not support a causal effect of low folate on obesity.

The association of insulin-like-growth factor 1 (IGF-1) with incident coronary heart disease in women: Findings from the prospective British Women's Heart and Health Study

Objective To examine the association of insulin-like-growth factor 1 (IGF-1) with coronary heart disease (CHD) in women. Methods Prospective (4 year) case–control study nested within the British Women's Heart and Health Study. With 167 cases and 333 controls. Serum IGF-1 concentrations (on serum stored at −80 °C for a median of 4 years) were determined using a two-site immunoenzymometric assay. Results Among both cases and controls IGF-1 was inversely correlated with waist:hip ratio, fasting insulin, HOMA-IR, CRP, triglyceride levels and systolic blood pressure, and was positively correlated with HDL-C levels. The confounder-adjusted (age, socioeconomic position, smoking and physical activity) relative risk ratio for a 1 standard deviation (S.D.) increase in IGF-1 was 0.92 (95% CI: 0.75, 1.12) and additional adjustment for metabolic risk factors (waist:hip ratio, systolic blood pressure, high-density lipoprotein cholesterol, triglycerides, glucose, insulin and C-reactive protein) attenuated this to 0.98 (95% CI: 0.80, 1.21). There was no evidence of non-linear associations and the risk of CHD was similar across quarters of the distribution of IGF-1. Conclusions Despite associations with established CHD risk factors in this, and other studies, our findings suggest that higher IGF-1 levels are not associated with CHD in older British women. The contradictory evidence to date in this area highlights the need for further large-scale prospective studies and use of genetic epidemiology studies to determine the nature of the association between IGF-1 and CHD.

My Appalachia: A Memoir (review)

Reviewed by: My Appalachia: A Memoir Mary Owens (bio) Sidney Saylor Farr . My Appalachia: A Memoir. Lexington: University Press of Kentucky, 2007. 272 pages. Hardback with dust jacket, $35.00. Sidney Saylor Farr's new memoir, My Appalachia, is a gift to any woman looking for the path out of oppression and into a self-confident life, but especially so for Appalachian women. Her depiction of life at Stoney Fork, in southeastern Kentucky, will draw those who grew up in the region back to their mountain roots. As a former editor of Appalachian Heritage (1985 through 1999) and the author of seven books, Ms. Farr has a solid reputation in Appalachian literature. Her memoir takes us to the hidden places of a woman's heart as she grows from an insecure mountain girl to a spiritually and emotionally secure woman. We understand young Sidney's life through the family stories that draw us into the book. On her family's secluded farm in Bell County ("as far back in the 'hollers' as it was possible to go"), jokes, riddles, and wild tales of relatives and haints are shared as frequently as country ham and biscuits. She hears them on the porch after supper, or around the fire at family picnics with potatoes frying in an iron skillet, or in a rowboat while fishing with her father and grandmother. As the eldest child she works gladly alongside her father, clearing new ground to plant corn, or on the other end of a cross cut saw; as the eldest grandchild she's an eager audience for her great-grandmother's scandalous stories. She draws her strength from these people, the food, and the ever-present force of the natural world around her. Her ambition to learn, and her desire to write, grow against this backdrop; but when she is eleven her mother's illness forces her to quit school and help raise nine younger children. She marries at fifteen to escape that life. Her memoir draws us into the terrible isolation she experienced—not from growing up in a remote part of Appalachia—but from the struggle to find her voice, express her creativity, and reach her academic goals. Living with an abusive husband not capable of loving her, she dreams every night of going back to school, learning to play music, and to write. Ms. Farr exposes her existential ache, [End Page 97] and honestly verbalizes her struggle to know herself. After winning freedom from her first husband, her second husband, for whom she feels life-changing passion, leaves her. Devastated, she writes in her journal: "This journey may bring death to many parts of the person that I am. I may have to be pulled, screaming, out of my shell. There may have to be fire and smoke and pain. It hurts to part with the illusions, the old security of acting like a chameleon, taking on the virtues or the vices attributed to me by others." Her story takes detours through her memories of the mountains, and conversations with relatives long gone; she pauses to give advice and pass on wisdom like a good friend over the kitchen table. And when we're ready to pick up more details of her married life, she goes on. She tells of getting her high school diploma via correspondence (despite her husband's objections), and getting her degree from Berea College one class at a time. It's with tremendous relief that we read how through counseling she finds the courage to face down her first husband, to risk a hit to the face or another ego-crushing insult. She survives being unloved in her first marriage, and being deserted in her second, and emerges intact. Her story highlights the walls oppressive relationships can build around our self confidence; it reveals how one woman broke free and followed a path into the light. Spiritual light is unmistakable in Ms. Farr's life, and shines through her memoir. She recounts meeting Tom Sawyer and discusses the two books she wrote detailing his dramatic near-death experience and later life (What Tom Sawyer Learned From Dying, 1993; and Tom Sawyer And The Spiritual Whirlwind...

High Molecular Weight Adiponectin Is Not Associated with Incident Coronary Heart Disease in Older Women: A Nested Prospective Case-Control Study

Adiponectin levels appear weakly linked to incident vascular disease, but the high molecular weight (HMW) fraction may be more relevant. Our objective was to test whether HMW adiponectin, the key biologically active fraction, is linked to incident coronary heart disease (CHD) events. DESIGN, PARTICIPANTS, AND MAIN OUTCOME MEASURES: We assessed the association between HMW adiponectin (measured by ELISA) and CHD risk in a prospective (4-yr) case-control study nested within the British Women's Heart and Health Study. All women were postmenopausal. Women were seen in a primary care setting. Among both cases (n = 167) and controls (n = 333), HMW adiponectin positively correlated with age and high-density lipoprotein cholesterol and inversely correlated with waist to hip ratio, fasting insulin, fasting glucose, homeostasis model assessment for insulin resistance scores, C-reactive protein, and triglycerides, in similar fashion to total adiponectin. The age-adjusted relative risk ratio for a doubling of HMW adiponectin was 0.96 (95% confidence interval, 0.78-1.18), and adjustment for any of the potential confounding or mediating variables did not substantively alter this. Additional adjustments for childhood social class, alcohol consumption, hormone replacement therapy use, statin, aspirin, or blood pressure medication did not alter the null association. When we examined the effect of HMW adiponectin by quarters of its distribution, there was no evidence of any associations (P trend = 0.71). There was also no association of the ratio of HMW adiponectin to total adiponectin with CHD risk; age-adjusted relative risk per doubling of the ratio was 1.10 (95% confidence interval, 0.80-1.50). Despite associations with total adiponectin and insulin resistance, our data go against any apparent association between HMW adiponectin levels and incident CHD events.

Women, environments and chronic disease: shifting the gaze from individual level to structural factors.

Chronic heart and respiratory diseases are two of the leading causes of morbidity and mortality affecting women. Patterns of and disparities in chronic diseases between sub-populations of women suggest that there are social as well as individual level factors which enhance or impede the prevention or development of chronic respiratory and cardiovascular diseases. By examining the sex, gender and diversity based dimensions of women's lung and heart health and how these overlap with environmental factors we extend analysis of preventive health beyond the individual level. We demonstrate how biological, environmental and social factors interact and operate in women's lives, structuring their opportunities for health and abilities to prevent or manage chronic cardiovascular and respiratory diseases. This commentary is based on the findings from two evidence reviews, one conducted on women's heart health, and another on women's lung health. Additional literature was also reviewed which assessed the relationship between environmental factors and chronic heart and lung diseases. This paper explores how obesogenic environments, exposure to tobacco smoke, and the experience of living in deprived areas can affect women's heart and respiratory health. We discuss the barriers which impede women's ability to engage in physical activity, consume healthy foods, or avoid smoking, tobacco smoke, and other airborne contaminants. Sex, gender and diversity clearly interact with environmental factors and shape women's promotion of health and prevention of chronic respiratory and cardiovascular diseases. The environments women live in structure their opportunities for health, and women navigate these environments in unique ways based on gender, socioeconomic status, race/ethnicity and other social factors. Future research, policy and programs relating to the prevention of chronic disease need to move beyond linear individually-oriented models and address these complexities by developing frameworks and interventions which improve environmental conditions for all groups of women. Indeed, in order to improve women's health, broad social and economic policies and initiatives are required to eliminate negative environmental impacts on women's opportunities for health.

Do the cardiovascular disease risks and benefits of oral versus transdermal estrogen therapy differ between perimenopausal and postmenopausal women?

Wake Forest University School of Medicine, Winston-Salem, NC. Tufts University School of Medicine, Molecular Cardiology Research Center, Preventive Cardiology Center, Women's Heart Center, Boston, MA Financial disclosure: Dr. Clarkson is a member of the Scientific Advisory Board for Wyeth Pharmaceuticals. Dr. Karas has received consulting fees from Wyeth Pharmaceuticals.