Research Findings

Reflections on a Decade of Experience in Implementing a Center for Women's Health at an Academic Medical Center. Giardina EG, Cassetta JA, Weiss MW, Stein M, Press R, Frassetto G. J Women’s Health. 2006;15(3):319-29

On the 10th anniversary of the establishment of a Center for Women's Health (CWH) program, the opportunity to share the successes and limitations in developing a centralized approach to women's healthcare is provided. The development of the CWH at the Columbia University Medical Center, New York-Presbyterian Hospital was prompted by concerns that the health status for women is worse than for men in terms of disability, morbidity, and chronic illness. Moreover, women move through cycles of health and illness differently from men, and gender inequalities in research design and implementation and under-representation of women in clinical studies contributed to knowledge gaps concerning women's health, possibly leading to suboptimal care. The goal in developing a program was (1) to provide outstanding medical care to women based on prevention and treatment of unique aspects of women's health, (2) to develop professional training and programs promoting knowledge, understanding, and credible scientific efforts, and (3) to foster collaborative research and communication among researchers, practitioners, policymakers, and organizations. In this paper, the clinical and educational programmatic activities and lessons learned are described.

Association of Education and Race/ethnicity with Physical Activity in Insured Urban Women. Cassetta JA, Boden-Albala B, Sciacca RR, Giardina EG. J Women’s Health 2007;16(6):902-8.

Background: Physical inactivity is a growing problem facing American women. As little as 150 minutes of moderate physical activity (PA) weekly can reduce the risk of chronic diseases, such as heart disease and stroke. We developed a survey to determine levels and predictors of PA in a diverse population of urban women with access to healthcare. Methods: Total activity time (TAT) was calculated as the sum of all activity (walking, jogging or running, dancing, calisthenics, bicycling, aerobics, swimming) recorded over the preceding 2 weeks. Analysis of variance models were used to assess the effect of different variables on TAT. Results: The survey was completed by 242 women, mean age of 43.4 years. Ninety percent were insured; 66% were non-Hispanic white, 16% were Hispanic, and 10% were African American. Seventy-six percent of women were college graduates. Only 58% of participants recorded >or=150 minutes of PA/week. TAT was related to education, with a significant difference between high school and college graduates (290 +/- 80 vs. 502 +/- 40 min [SEM], p < 0.05). Conclusions: Education was strongly associated with TAT among these insured, diverse, and well-educated women. Only 58% exercised >or=150 minutes/week, underscoring the need to target exercise programs for all women and to close the gap between women of lower and higher educational attainment.

Metabolic Syndrome and Ischemic Stroke Risk: Northern Manhattan Study.  Boden-Albala B, Sacco RL, Lee HS, Grahame-Clarke C, Rundek T, Elkind MV, Wright C, Giardina EG, DiTullio MR, Homma S, Paik MC. Stroke. 2008;39(1):30-5.

Background:  More than 47 million individuals in the United States meet the criteria for the metabolic syndrome. The relation between the metabolic syndrome and stroke risk in multiethnic populations has not been well characterized. Methods: As part of the Northern Manhattan Study, 3298 stroke-free community residents were prospectively followed up for a mean of 6.4 years. The metabolic syndrome was defined according to guidelines established by the National Cholesterol Education Program Adult Treatment Panel III. Results: More than 44% of the cohort had the metabolic syndrome (48% of women vs 38% of men, P<0.0001), which was more prevalent among Hispanics (50%) than whites (39%) or blacks (37%). The metabolic syndrome was associated with increased risk of stroke (HR=1.5; 95% CI, 1.1 to 2.2) and vascular events (HR=1.6; 95% CI, 1.3 to 2.0) after adjustment for sociodemographic and risk factors. The effect of the metabolic syndrome on stroke risk was greater among women (HR=2.0; 95% CI, 1.3 to 3.1) than men (HR=1.1; 95% CI, 0.6 to 1.9) and among Hispanics (HR=2.0; 95% CI, 1.2 to 3.4) compared with blacks and whites. Conclusions: estimates suggest that elimination of the metabolic syndrome would result in a 19% reduction in overall stroke, a 30% reduction of stroke in women; and a 35% reduction of stroke among Hispanics.

Racial/Ethnic Disparities in Time to Follow-Up After an Abnormal Mammogram. Press R, Carrasquillo O, Sciacca RR, Giardina EG.   J Womens Health. 2008;17(6):923-30.

Background: Although non-Hispanic white women have an increased risk of developing breast cancer, the disease-specific survival is lower for African American and Hispanic women. Little is known about disparities in follow-up after an abnormal mammogram. The goal of this study was to investigate potential disparities in follow-up after an abnormal mammogram. Methods: A retrospective cohort study of 6722 women with an abnormal mammogram and documented follow-up was performed at the Columbia University Medical Center, New York. The outcome was the number of days between the abnormal mammogram and follow-up imaging or biopsy. Cox proportional hazards models were used to assess the effect of race/ethnicity and other potential covariates. Results: The median number of days to diagnostic follow-up after an abnormal mammogram was greater for African American (20 days) and Hispanic (21 days) women compared with non-Hispanic white (14 days) women (p < 0.001). Conclusions: After an abnormal mammogram, African American and Hispanic women had longer times to diagnostic follow-up compared with non-Hispanic white women. Future efforts will focus on identifying barriers to follow-up so that effective interventions may be implemented.

Management of Obesity: a Challenge for Medical Training and Practice. Thande NK, Hurstak E, Sciacca R, Giardina EGV. Obesity. 2009; 17(1):107-13.

Physicians often fail to encourage patients to make healthy choices. The task of lifestyle modification counseling may be even more daunting given the cultural and socioeconomic diversity of patient populations in the United States. This study evaluated the prevalence and predictors of attending and physician-in-training weight control counseling in an urban academic internal medicine clinic serving a unique low income multiethnic high risk population.Results: Seventy nine percent of subjects were either overweight or obese; sixty five percent of obese subjects were advised to lose weight. Attending physicians were more likely than physicians-in-training to counsel subjects on weight control (p < 0.01). Factors that were significantly (p< 0.05) associated with types of weight control counseling included obesity, cardiovascular disease risk factors, female gender, non-black race, college education, married status, and attending physician. Subjects advised to lose weight were more likely to report an attempt to lose weight (p < 0.01). Rates of weight control counseling among physicians are suboptimal, particularly among physicians-in-training.Conclusions: Physician training programs need to address barriers to the provision of weight control counseling and encourage the development of these skills.

Physical Activity Participation among Caribbean Hispanic Women Living in New York: Relation to Education, Income, and Age. Giardina EGV, Laudano M, Hurstak E, Saroff A, Fleck E, Sciacca R, Boden Albala B, Cassetta J.   J Women's Health, 2009, 18(2):187-193. 

Inadequate participation in physical activity is a serious public health issue in the United States with significant disparities among population groups. In particular, there is a scarcity of information about physical activity among Caribbean Hispanics, a group on the rise. Our goal was to accumulate data on physical activity among Caribbean Hispanic women living in New York and determine the relation between physical activity and age, marital status, education, income, primary language, and children in the household. Results: Total activity time, mean 385 ± 26 minutes, and education (r=0.14, p<0.01) were significantly related.  Women who had attended some college had greater total activity time than those with some high school education (p=0.046) or < 8th grade education (p=0.022). Walking as a form of transportation was the most frequent pursuit, 285 ± 21 minutes. Age (r = -0.34, p < 0.001) and education (r=0.25, p < 0.001) correlated with non-walking activity time (leisure-time). Non-walking activity times were greater in younger, i.e., 18-29 years (p<0.001), and college educated women (p<0.001). Physical activity recommendations were met by 11%; and 17% reported no physical activity. Conclusions: Among Caribbean Hispanic women in New York, the current recommendations for physical activity are met by 11%. Our observation that education is a critical factor related to physical activity suggests that programs are needed to address the promotion of a physically active lifestyle are needed.

Metabolic Syndrome and the Burden of Cardiovascular Disease in Caribbean Hispanic Women Living in Northern Manhattan: a Red Flag for Education. Yala SM, Fleck EM, Sciacca R, Castro D, Joseph Z, Giardina EG. Metabolic Syndromes and Related Disordors. 2009 Jun 26.

Metabolic syndrome has the highest prevalence among Mexican-American women. Little information is available for Caribbean Hispanics, the largest and fastest growing ethnic minority in the United States. We sought to evaluate the frequency of metabolic syndrome and its relationship with race/ethnicity, socioeconomic position, and education in women of largely Caribbean Hispanic origin. Results: There were 204 women enrolled; mean age was 58 +/- 11 years, Hispanic 44.1% (93% Caribbean), non-Hispanic white (NHW) 38.7%, and non-Hispanic black 9.8%. Education was some high school (<HS) 33.7%, HS graduate 11.2%, some college 12.9%, college graduate 10.1%, and postgraduate 32%. Health insurance was Medicaid 47.8% and commercial 52.2%. Area of residence was urban 77.1% and suburban 22.9%. The frequency of metabolic syndrome was 42.4%, and was increased in Hispanic women (63.3%) versus NHW (29.6%), women with <HS (72.6%) versus postgraduate education (32.1%), women with Medicaid (57.9% vs. 27.4%) and urban residence (47.5% vs. 27.2%). For all comparisons, p < 0.05. Education <HS was linked to increased risk of metabolic syndrome (odds ratio [OR] = 3.5 [1.2-10.0], p = 0.02). Hispanic women had the lowest level of education (p < 0.001) and the highest frequency of individual metabolic syndrome components (p < 0.01). Conclusion: Metabolic syndrome showed an alarming rate in less educated Caribbean Hispanic women and was independently associated with lower education level.

The Office on Women's Health Initiative to Improve Women's Heart Health: Program Description, Site Characteristics, and Lessons Learned. Foody JM, Villablanca AC, Giardina EG, Gill S, Taylor AL, Leatherwood S, Haynes SG, D'Onofrio G. J Womens Health (Larchmt). 2010 Feb 16.

Improving, Enhancing and Evaluating Outcomes of Comprehensive Heart Health Care Programs for High Risk Women has funded six diverse centers to provide chronic disease risk factor screening and lifestyle interventions for women and focuses specifically on low-income, minority women. Results: This article describes the rationale for these diverse programs across the country, all focusing on improving outcomes for women with or at risk for cardiovascular disease (CVD). The six programs include College of Physicians and Surgeons at Columbia University, Christ Community Health Services in Memphis, Women's Heart Center of Fox Valley Cardiovascular Consultants, University of Minnesota, University of California Davis Women's Cardiovascular Medicine Program, and Yale-New Haven Hospital's Women's Heart Advantage. Conclusions: We present six differing approaches to women's heart programs. Based on this experience, promoting CVD prevention in women is a feasible healthcare delivery strategy for health promotion and for delivering preventive strategies for high-risk women. It is possible to deliver heart-healthy programs through existing healthcare infrastructures. These programs provide important models for public health, voluntary, and other health organizations to develop networks for population-based, targeted, relatively low cost programs that support Healthy People 2010 objectives for lifestyle changes and cardiovascular health.

Outcomes of comprehensive heart care programs in high-risk women. Villablanca AC, Beckett LA, Li Y, Leatherwood S, Gill SK, Giardina EGV, Taylor AL, Barron C, Foody JM, Haynes S, D'Onofrio G. J of Women's Health. July 2010, 19(7): 1313-1325.

The purpose was to improve the fund of knowledge, reduce cardiovascular disease (CVD) risk, and attain Healthy People 2010 objectives among women in model women's heart programs. A 6-month pre/post-longitudinal educational intervention of high-risk women (n = 1310) at six U.S. women's heart programs consisted of comprehensive heart health counseling and use of American Heart Association/American College of Cardiology (AHA/ACC) Evidence-Based Guidelines as enhancement to usual care delivered via five integrated components: education/awareness, screening/risk assessment, diagnostic testing/treatment, lifestyle modification/rehabilitation, and tracking/evaluation. Changes in fund of knowledge, awareness, and risk reduction outcomes and Healthy People 2010 objectives were determined. RESULTS: At 6 months, there were statistically significant improvements in fund of knowledge, risk awareness, and clinical outcomes. Participants attained or exceeded >90% of the Healthy People 2010 objectives. Proportions of participants showing increased knowledge and awareness of CVD as the leading killer of women, of all signs and symptoms of a heart attack, and calling 911 increased significantly (11.1%, 25.4%, and 34.6%, respectively). CONCLUSIONS: CVD prevention built around a comprehensive heart care model program and AHA/ACC Evidence-Based Guidelines can be successful in improving knowledge and awareness, CVD risk factor reduction, and attainment of Healthy People 2010 objectives in high-risk women.

The Office on Women's Health Initiative to Improve Women's Heart Health: Focus on Knowledge and Awareness Among Women with Cardiometabolic Risk Factors. Giardina EG, Sciacca RR, Foody JM, D'Onofrio G, Villablanca AC, Leatherwood S, Taylor AL, Haynes SG. J of Women's Health, 2011 Apr 14.

The diversity of the U.S. population and disparities in the burden of cardiovascular disease (CVD) require that public health education strategies must target women and racial/ethnic minority groups to reduce their CVD risk factors, particularly in high-risk communities, such as women with the metabolic syndrome (MS). The data reported here were based on four participating sites as part of the national intervention program, Improving, Enhancing and Evaluating Outcomes of Comprehensive Heart Care in High-Risk Women. Greater frequencies of MS occurred among Hispanic women (p<0.0001), those with less than a high school education (70.0%) (p<0.0001), Medicaid recipients (57.8%) (p<0.0001), and urbanites (43.3%) (p<0.001). Fewer participants with MS (62.6%) knew the leading cause of death compared to those without MS (72.1%) (p<0.0001). MS was associated with a lack of knowledge of the composite of knowing the symptoms of a heart attack plus the need to call 911 (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.17-0.97, p=0.04). Conclusions: Current strategies to decrease CVD risk are built on educating the public about traditional factors, including hypertension, smoking, and elevated low-density lipoprotein cholesterol (LDL-C). An opportunity to broaden the scope for risk reduction among women with cardiometabolic risk derives from the observation that women with the MS have lower knowledge about CVD as the leading cause of death, the symptoms of a heart attack, and the ideal option for managing a CVD emergency.

Women at Risk for Cardiovascular Disease Lack Knowledge of Heart Attack Symptoms.Flink LE, Sciacca RR, Bier ML, Rodriguez J, Giardina EG.Clinical Cardioliology. 2013 Jan 21.

It is not known whether cardiovascular disease (CVD) risk level is related to knowledge of the leading cause of death of women or heart attack symptoms. HYPOTHESIS: Women with higher CVD risk estimated by Framingham Risk Score (FRS) or metabolic syndrome (MS) have lower CVD knowledge.METHODS: Women visiting primary care clinics completed a standardized behavioral risk questionnaire. Blood pressure, weight, height, waist size, fasting glucose, and lipid profile were assessed. Women were queried regarding CVD knowledge.RESULTS: Participants (N = 823) were Hispanic women (46%), non-Hispanic white (37%), and non-Hispanic black (8%). FRS was determined in 278: low (63%), moderate (29%), and high (8%); 24% had ≥3 components of MS. The leading cause of death was answered correctly by 54%, heart attack symptoms by 67%. Knowledge was lowest among racial/ethnic minorities and those with less education (both P< 0.001). Increasing FRS was inversely associated with knowing the leading cause of death (low 72%, moderate 68%, high 45%, P = 0.045). After multivariable adjustment, moderate/high FRS was inversely associated with knowing symptoms (moderate odds ratio [OR] 0.52, 95% confidence interval [CI]: 0.28-0.98; high OR 0.29, 95% CI: 0.11-0.81), but not the leading cause of death. MS was inversely associated with knowing the leading cause of death (P< 0.001) or heart attack symptoms (P = 0.018), but not after multivariable adjustment. CONCLUSIONS: Women with higher FRS were less likely to know heart attack symptoms. Efforts to target those at higher CVD risk must persist, or the most vulnerable may suffer disproportionately, not only because of risk factors but also inadequate knowledge

Relationship Between Cardiovascular Disease Knowledge and Race/Ethnicity, Education, and Weight Status Giardina EG, Mull L, Sciacca RR, Akabas S, Flink LE, Moise N, Paul TK, Dumas NE, Bier ML, Mattina D. Clinical Cardiology, January 2012:35(1):43-48.Inadequate cardiovascular disease (CVD) knowledge has been cited to account for the imperfect decline in CVD among women over the last 2 decades. Hypothesis:Due to concerns that at-risk women might not know the leading cause of death or symptoms of a heart attack, our goal was to assess the relationship between CVD knowledge race/ethnicity, education, and body mass index (BMI).Methods:Using a structured questionnaire, CVD knowledge, socio-demographics, risk factors, and BMI were evaluated in 681 women:Participants included Hispanic, 42.1% (n = 287); non-Hispanic white (NHW), 40.2% (n = 274); non-Hispanic black (NHB), 7.3% (n = 50); and Asian/Pacific Islander (A/PI), 8.7% (n = 59). Average BMI was 26.3 ± 6.1 kg/m2. Hypertension was more frequent among overweight (45%) and obese (62%) than normal weight (24%) (P < 0.0001), elevated total cholesterol was more frequent among overweight (41%) and obese (44%) than normal weight (30%) (P < 0.05 and P < 0.01, respectively), and diabetes was more frequent among obese (25%) than normal weight (5%) (P < 0.0001). Knowledge of the leading cause of death and symptoms of a heart attack varied by race/ethnicity and education (P < 0.001) but not BMI. Concerning the leading cause of death among women in the United States, 87.6% (240/274) NHW answered correctly compared to 64% (32/50) NHB (P < 0.05), 28.3% (80/283) Hispanic (P < 0.0001), and 55.9% (33/59) A/PI (P < 0.001). Among participants with ≤12 years of education, 21.2% knew the leading cause of death and 49.3% knew heart attack symptoms vs 75.7% and 75.5%, respectively, for >12 years (both P < 0.0001).Conclusions:Effective prevention strategies for at-risk populations need to escalate CVD knowledge and awareness among the undereducated and minority women.