Social Integration and Reduced Risk of Coronary Heart Disease in Women

Shun Chiao Chang*, Maria Glymour, Marilyn Cornelis, Stefan Walter, Eric B. Rimm, Eric Tchetgen Tchetgen, Ichiro Kawachi, Laura D. Kubzansky

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

31 Scopus citations


Rationale: Higher social integration is associated with lower cardiovascular mortality; however, whether it is associated with incident coronary heart disease (CHD), especially in women, and whether associations differ by case fatality are unclear. Objectives: This study sought to examine the associations between social integration and risk of incident CHD in a large female prospective cohort. Methods and Results: Seventy-six thousand three hundred and sixty-two women in the Nurses' Health Study, free of CHD and stroke at baseline (1992), were followed until 2014. Social integration was assessed by a simplified Berkman-Syme Social Network Index every 4 years. End points included nonfatal myocardial infarction and fatal CHD. Two thousand three hundred and seventy-two incident CHD events occurred throughout follow-up. Adjusting for demographic, health/medical risk factors, and depressive symptoms, being socially integrated was significantly associated with lower CHD risk, particularly fatal CHD. The most socially integrated women had a hazard ratio of 0.55 (95% confidence interval, 0.41-0.73) of developing fatal CHD compared with those least socially integrated (P for trend <0.0001). When additionally adjusting for lifestyle behaviors, findings for fatal CHD were maintained but attenuated (P for trend =0.02), whereas the significant associations no longer remained for nonfatal myocardial infarction. The inverse associations between social integration and nonfatal myocardial infarction risk were largely explained by health-promoting behaviors, particularly through differences in cigarette smoking; however, the association with fatal CHD risk remained after accounting for these behaviors and, thus, may involve more direct biological mechanisms. Conclusions: Social integration is inversely associated with CHD incidence in women, but is largely explained by lifestyle/behavioral pathways.

Original languageEnglish (US)
Pages (from-to)1927-1937
Number of pages11
JournalCirculation research
Issue number12
StatePublished - Jun 9 2017


  • coronary heart disease risk
  • epidemiology
  • marginal structural model
  • mediation
  • prospective cohort study
  • social integration
  • women and minorities

ASJC Scopus subject areas

  • Physiology
  • Cardiology and Cardiovascular Medicine


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