Major Depressive Disorder (MDD) is one of the most common psychiatric conditions affecting adults and afflicts approximately 5% of the world's population. MDD is highly co-morbid with cardiovascular disease, a major source of morbidity and mortality. Although a number of pathological changes observed in MDD may impact cardiovascular health, no single mechanism has been identified that can explain this association. Both MDD and CVD are more common in women, and pregnancy may represent a period of elevated risk for both depression and changes in cardiovascular health that may never fully resolve in the years following pregnancy. This study of 61 pregnant women during their third trimester of pregnancy investigated whether depressive symptoms (as measured by the Edinburgh Postnatal Depression Scale, or EPDS) are associated with decreased heart rate variability, a well-known marker of cardiovascular risk. Additionally, this study will investigate whether Plasminogen Activator Inhibitor-1 and 2 (PAI-1 and PAI-2) mediate this association. These pro-thrombotic proteins have long been linked to the presence and severity of cardiovascular disease, and an emerging body of evidence suggests that plasma concentrations of these proteins may also be elevated in Major Depressive Disorder. Heart rate variability was significantly reduced among participants who had clinically significant depressive symptoms during the third trimester (EPDS >14), although adjustment for age, body mass index, smoking, education level and use of psychiatric medication fully attenuated this relationship. PAI-1 and PAI-2 measured via ELISA assay in a subset of the study population (n=23) was found to not mediate this association. This study is the first of its kind to evaluate the role of PAI-1 in psychiatric illness during pregnancy, and may serve as the impetus for further research aimed at elucidating the relationship between mental health and cardiovascular risk during gestation. / Thesis / Master of Science (MSc)

In females, menopause-related reductions in estrogen may cause declines in cardiovascular health and increase the risk for stroke. In the event of stroke, cardiovascular health of postmenopausal females may be further worsened. It is well established that physical activity and exercise improves cardiovascular health in the general population and in those with chronic conditions, including stroke. However, the nature and extent of the associations between physical activity and cardiovascular health of pre- and post-menopausal females with, and without, stroke are unclear. This thesis is comprised of two studies to address this knowledge gap. The first study was a systematic review to examine the effect of aerobic exercise on cardiovascular health of postmenopausal females, and the association with different exercise intensities. Five electronic databases from inception to May 6th, 2022, were searched for randomized-controlled trials of aerobic exercise interventions reporting cardiovascular outcomes in postmenopausal females. Data was synthesized qualitatively, and random-effects meta-analyses and subgroup analyses (for light, moderate, vigorous intensity) were performed. Fifty-six studies (4134 participants;45-78 years of age) were identified. Aerobic exercise interventions varied in frequency (3-21x/week), intensity, type, time (8-60 min/session), and duration (3-52 weeks). Fifty studies (n=3730) were included in the quantitative synthesis. Aerobic exercise improved systolic blood pressure (SBP) (Mean difference(MD)=-3.67mmHg, 95%CI[-6.88,-0.46],p=0.03), resting heart rate (MD=-5.76bpm, 95%CI[-5.76,-1.61],p<0.01), body mass index (BMI)(MD=-0.65kg/m2, 95%CI[-0.99,-0.31],p<0.01), waist circumference (WC) (MD=-2.03cm, 95%CI[-2.65,-1.41],p<0.01), body fat (MD=-2.57kg, 95%CI[-3.65,-1.49],p<0.01), low-density lipoprotein cholesterol (MD=-10.46mg/dL, 95%CI[-16.31,-4.61],p<0.01), high-density lipoprotein cholesterol (MD=3.28mg/dL, 95%CI[0.20,6.36],p=0.04) and cardiorespiratory fitness (Standardized MD=1.43, 95%CI[1.17,1.70],p<0.01). Subgroup differences in exercise intensity were only present for BMI where light- and vigorous-intensities were beneficial, and moderate intensity had no effect (X2=9.79, df=2,p<0.01), and for blood triglycerides and blood glucose where light intensity showed a beneficial effect and there was no effect of moderate and vigorous intensities (triglycerides X2=7.70, df=2, p=0.02; glucose X2=20.98, df=2, p<0.01). The second study was a cross-sectional analysis of baseline data from the Canadian Longitudinal Study on Aging that examined the association between physical activity and cardiovascular health in females with stroke, and the interaction with menopause. Generalized linear models with applied sampling weights were used to examine the associations between cardiovascular health, and self-reported physical activity, while controlling for age and smoking history. Subsequent models included an interaction between physical activity and menopausal status. The sample included 1468 females with stroke (103 premenopausal). Physical activity was beneficially associated with SBP (ß = -0.02 (SE=0.01), p=0.04, 95% CI: -0.42 to -0.0005), WC (ß = -0.03 (SE=0.008), p<0.01, 95% CI: -0.05 to -0.02), waist-to-hip ratio (ß = -0.00009 (SE=0.00004), p=0.03, 95% CI: -0.0002 to -0.0000007), C-Reactive protein (ß = -0.007 (SE=0.003), p<0.02, 95% CI: -0.013 to -0.001). There were no interactions between physical activity and menopausal status for all outcomes. Together, these studies contribute to the development of future guidelines and research to improve cardiovascular health in underrepresented and high-risk populations of postmenopausal females and females with stroke. / Thesis / Master of Science Rehabilitation Science (MSc) / Exercise and physical activity are good for the health of the heart and blood vessels. We do not know how physical activity also benefits females after menopause and females with stroke. This thesis examined the association between physical activity and the health of the heart and blood vessels in females before and after menopause, with and without stroke. The first study reviewed other studies that looked at the effect of aerobic exercise on the health of the heart and blood vessels in females after menopause. We found that after menopause females might benefit from aerobic exercise. We also found that different intensities of exercise may affect the health of the heart and blood vessels better than others, but more research is needed. The second study found that physical activity is related to better health of the heart and blood vessels in females after stroke, and whether a female has undergone menopause does not change this relationship. These studies show that exercise and physical activity may help the health of heart and blood vessels in females after menopause and females with stroke. Together they may help inform future exercise and physical activity guidelines and research to improve the health of the heart and blood vessels in these populations.

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Yes / Hypertension is the leading driver of cardiovascular disease deaths in Africa. Its prevalence is highest in older populations. Yet, this group has received little attention in many African countries. We conducted a systematic review and meta-analysis (PROSPERO registration: CRD42017056474) to estimate the prevalence of hypertension in older adults living in Africa. Methods: We searched grey literature and major electronic databases including PubMed and Embase for population-based studies and published between 1 January 1980 to 28 May 2018 reporting the prevalence of hypertension for adults aged ≥50 years living in Africa. We employed a random effects model to estimate the pooled prevalence across included studies. Findings: We screened 10,719 articles and retrieved 103 full-text articles to evaluate for inclusion in the review. Thirty-four unique studies providing 37 data points on 43,025 individuals in 15 African countries were analyzed. The prevalence of hypertension ranged from 22.3% to 90.0% from the individual studies while the overall pooled prevalence was 57.0% (95% CI 52%-61%). The prevalence was not statistically significantly different by sex, residence, or African sub-region. In individual studies, older age and overweight/obesity were independently associated with hypertension. Twenty-nine (78%) data points were deemed to be of low- or moderate-risk of bias. Eliminating high-risk bias studies made little difference to the pooled estimate of hypertension. Sensitivity analyses, omitting one study at a time, identified three studies with significant but relatively small impact on the pooled estimate. We observed substantial heterogeneity (I2 = 98.9%) across the studies which was further explored by meta-regression analyses. Overall, the GRADE assessment suggested moderate quality evidence in the results. Conclusion: The persistent high prevalence of hypertension among older adults in Africa, even in rural populations warrants more attention to the cardiovascular health of this group by public health authorities

The size of the Mexican-origin population in the United States means that its health patterns have important implications for the country’s overall population health. Understanding how this population is woven into the country’s complex social patterning of health is critical to understanding current social disparities in health. Drawing on a health disparities perspective and nationally representative datasets, this dissertation addresses key gaps in the social demographic literature on the health of the Mexican-origin population through three empirical chapters that examine how multiple measures of cardiovascular health are distributed across diverse social status and temporal configurations. I first examine how the obesity epidemic has unfolded across multiple temporal (age, period, and cohort) and social dimensions (gender, nativity, and race) for the Mexican-origin population. I find that period rather than cohort forces have shaped the rise in obesity among the Mexican-origin population. Furthermore, the pronounced group differences in obesity prevalence have remained stable across periods and cohorts, with the exception of a growing nativity gap among Mexican-origin women, among whom obesity has increased faster for U.S.-born individuals compared with foreign-born individuals. I next address the intersection of two additional temporal and social determinants of health: duration of residence in the United States and educational attainment. Building on research documenting a weak relationship between education and health for Mexican immigrants, I assess whether duration of U.S. residence strengthens this association. The patterns vary by outcome, but generally indicate that negative education gradients in health are more pronounced for long-term Mexican immigrants than for recent Mexican immigrants and that the education gradients of long-term Mexican immigrants resemble those of U.S.-born Whites. I then engage the literature linking acculturation to poor health among Mexican immigrants. Acculturation models of immigrant health have come under critique for ignoring the structural determinants of health. I engage in this debate by using segmented assimilation theory—which emphasizes the role of structural factors—to examine whether education conditions the association between acculturation and health. I find support for the idea that the detrimental influence of acculturation on cardiovascular health is concentrated among Mexican immigrant adults with low levels of education. / text

The goal of this dissertation research was to better understand relationships among physical activity (PA), cardiorespiratory fitness, adiposity, and cardiovascular (CV) health in children and adolescents. The aim of the first paper was to examine whether fitness and adiposity are independently associated with CV risk factors during puberty. Study participants were 126 prepubertal Caucasian children participating in a longitudinal four-year follow-up study. Fitness level was determined by VO2 max (L/min) obtained from maximal graded exercise testing and adiposity level was determined by the sum of skinfolds. Gender-specific individual growth curve models, including both VO2 max and the sum of skinfolds simultaneously, were fit to predict CV risk factor variables. Models also included covariates such as age, height, weight, and pubertal stage by the Tanner criteria. In both boys and girls, total cholesterol, triglyceride, LDL-C, and systolic blood pressure percentile were positively associated with the sum of skinfolds (P < 0.05), but not with VO2 max (P > 0.05). In conclusion, fitness was not associated with CV risk factors, after adjusting for adiposity, among healthy adolescents. This study suggests that adiposity may play a role in the mechanism underlying the effect of fitness on CV health during puberty. The aim of the second paper was to examine whether early adiposity level is inversely associated with subsequent PA behaviors in childhood. Study participants were 326 children participating in the Iowa Bone Development Study. PA and fat mass were measured using accelerometers and dual energy X-ray absorptiometry (DXA) at approximately 5, 8, and 11 years of age. Gender-specific generalized linear models were fit to examine the association between percent body fat (BF%) at age 8 and intensity-weighted moderate- to vigorous-intensity PA (IW-MVPA) at age 11. After adjusting for IW-MVPA at age 8, an interval between the age 5 and 8 examinations, residualized change scores of BF% and IW-MVPA from age 5 to 8 and mother's education level, BF% at age 8 was inversely associated with IW-MVPA at age 11 among boys (P < 0.05). After adjusting for IW-MVPA at age 8, physical maturity, and family income, BF% at age 8 was inversely associated with IW-MVPA at age 11 among girls (P < 0.05). Categorical analysis also showed that the odd of being in the lowest quartile relative to the highest quartile of IW-MVPA at three-year follow-up for boys and girls with high BF% was approximately four times higher than the odd for those with low BF% (P < 0.05). This study suggests that adiposity levels may be a determinant of PA behavior. Specific intervention strategies for overweight children may be needed to promote PA. The aim of the third paper was to examine whether accelerometer-measured daily light-intensity PA is inversely associated with DXA-derived body fat mass during childhood. The study sample was 577 children participating in the longitudinal Iowa Bone Development Study. Fat mass and PA were measured at about 5, 8, and 11 years of age. Two PA indicators were used, applying two accelerometer count cut-points: the daily sum of accelerometer counts during light-intensity PA (IW-LPA) and the daily sums of accelerometer counts during high-light-intensity PA (IW-HLPA). Measurement time point- and gender-specific multivariable linear regression models were fit to predict fat mass based on IW-LPA and IW-HLPA, including covariates, such as age, birth weight, fat-free mass, height, IW-MVPA and maturity (only for girls). Among boys, both IW-LPA and IW-HLPA were inversely associated with fat mass at age 11 (P < 0.05), but not at ages 5 and 8. Among girls, both LPA variables were inversely associated with fat mass at ages 8 and 11 (P < 0.10 for LPA at age 11, P < 0.05 for others), but not at age 5. In conclusion, this study suggests that light-intensity PA may have a preventive effect against adiposity among older children.

Title: What explains variability in blood pressure readings? Multilevel analysis of data from 8,731 older adults in 20 Ontario Communities Objectives: Despite universal healthcare and drug coverage for adults aged 65 and over in Ontario, hypertension, a treatable condition, remains uncontrolled among many older adults. Moreover, there are geographic disparities in blood pressure and hypertension within and across Canadian provinces and territories. Using baseline data collected on 8,731 older adults participating in the Cardiovascular Health Awareness Program (CHAP) in 20 randomly selected Ontario communities, we investigated associations between systolic blood pressure (SBP) and individual- and community-level characteristics, controlling for self-reported use of blood pressure medications. Method: Older adults were recruited via invitation by local family physicians, public advertising and word of mouth to attend community pharmacy sessions. During the sessions, trained older adult volunteers assisted participants to complete a cardiovascular disease risk factor questionnaire and blood pressure assessments using an automated blood pressure measuring device. The Postal Code Conversion File Plus was used to confirm residence within one of the 20 study communities. A multilevel linear regression analysis with participants nested within communities was used to determine which individual- and/or community-level characteristics were associated with measured systolic blood pressure level controlling for self-reported use of blood pressure medication. Results: 4,706 participants (53.9%) reported the use of blood pressure medication. Mean systolic blood pressure (SBP) levels varied among the 20 communities from 128.1 mmHg to 134.7 mmHg for participants not using blood pressure medication and from 131.9 mmHg to 139.0 mmHg for participants using blood pressure medication. The intraclass correlation coefficients were very small: less than 0.2% of the total variance was between communities. Among participants not using blood pressure medication, SBP was associated with the following individual- level characteristics: age, sex, body mass index , smoking, physical activity, stress, fruit/vegetable intake, and alcohol consumption and the following community-level characteristics: community size, community growth and the Rurality Index. Among participants using blood pressure medication, SBP was associated with the following individual-level characteristics: age, sex, body mass index, diabetes, fruit/vegetable intake, alcohol intake and one community-level characteristic: community size. The significance and magnitude of these associations were modified by the use of blood pressure medication. Conclusion: The majority of the variability in blood pressure occurs at the individual-level. There are specific individual- and community-level factors that explain variability in blood pressure readings among communities. These results can be used to inform health promotion strategies to decrease mean levels of blood pressure among older adults.

Title: What explains variability in blood pressure readings? Multilevel analysis of data from 8,731 older adults in 20 Ontario Communities Objectives: Despite universal healthcare and drug coverage for adults aged 65 and over in Ontario, hypertension, a treatable condition, remains uncontrolled among many older adults. Moreover, there are geographic disparities in blood pressure and hypertension within and across Canadian provinces and territories. Using baseline data collected on 8,731 older adults participating in the Cardiovascular Health Awareness Program (CHAP) in 20 randomly selected Ontario communities, we investigated associations between systolic blood pressure (SBP) and individual- and community-level characteristics, controlling for self-reported use of blood pressure medications. Method: Older adults were recruited via invitation by local family physicians, public advertising and word of mouth to attend community pharmacy sessions. During the sessions, trained older adult volunteers assisted participants to complete a cardiovascular disease risk factor questionnaire and blood pressure assessments using an automated blood pressure measuring device. The Postal Code Conversion File Plus was used to confirm residence within one of the 20 study communities. A multilevel linear regression analysis with participants nested within communities was used to determine which individual- and/or community-level characteristics were associated with measured systolic blood pressure level controlling for self-reported use of blood pressure medication. Results: 4,706 participants (53.9%) reported the use of blood pressure medication. Mean systolic blood pressure (SBP) levels varied among the 20 communities from 128.1 mmHg to 134.7 mmHg for participants not using blood pressure medication and from 131.9 mmHg to 139.0 mmHg for participants using blood pressure medication. The intraclass correlation coefficients were very small: less than 0.2% of the total variance was between communities. Among participants not using blood pressure medication, SBP was associated with the following individual- level characteristics: age, sex, body mass index , smoking, physical activity, stress, fruit/vegetable intake, and alcohol consumption and the following community-level characteristics: community size, community growth and the Rurality Index. Among participants using blood pressure medication, SBP was associated with the following individual-level characteristics: age, sex, body mass index, diabetes, fruit/vegetable intake, alcohol intake and one community-level characteristic: community size. The significance and magnitude of these associations were modified by the use of blood pressure medication. Conclusion: The majority of the variability in blood pressure occurs at the individual-level. There are specific individual- and community-level factors that explain variability in blood pressure readings among communities. These results can be used to inform health promotion strategies to decrease mean levels of blood pressure among older adults.