Cynical hostility is a potential pathway to cardiovascular disease by preventing a healthy response to stress over time

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Cynical hostility is a potential pathway to cardiovascular disease by preventing a healthy response to stress over time, according to a study led by Baylor University.

Hostility generally is associated with increased risk for cardiovascular disease.

But this research explored three types of hostility – emotional, behavioral and cognitive – to see whether one is more predictive of risk factors.

Cynical hostility poses the greatest risk based on stress responses, according to the study, which was published in the journal Psychophysiology.

“Cynical hostility is more cognitive, consisting of negative beliefs, thoughts and attitudes about other people’s motives, intentions and trustworthiness,” said lead author Alexandra T. Tyra, a doctoral candidate in psychology and neuroscience at Baylor University.

“It can be considered suspiciousness, lack of trust or cynical beliefs about others.

“These findings reveal that a greater tendency to engage in cynical hostility – which appears to be extremely relevant in today’s political and health climate – can be harmful not only for our short-term stress responses but also our long-term health,” Tyra said.

In contrast to cynical hostility, chronic anger is considered emotional hostility, while verbal or physical aggression is considered behavioral hostility.

“The increased risk of hostility is likely due to heightened physiological arousal to psychological stress, which can strain the cardiovascular system over time,” Tyra said.

“However, there has been a need for research to examine these physiological responses across multiple stress exposures to better resemble real-world conditions and assess adaptation over time.”

A healthy cardiovascular response to repeated stress would consist of an increase in arousal to the first stress exposure – sometimes referred to “fight or flight” – which would decrease upon subsequent exposures to that same stressor.

“Essentially, when you’re exposed to the same thing multiple times, the novelty of that situation wears off, and you don’t have as big of a response as you did the first time,” Tyra said.

“This is a healthy response. But our study demonstrates that a higher tendency for cynical hostility may prevent or inhibit this decrease in response over time. In other words, the cardiovascular system responds similarly to a second stressor as it did to the first.

“This is unhealthy because it places increased strain on our cardiovascular system over time,” Tyra said.

For the study, which consisted of stress tests of 196 participants, researchers analyzed data collected by the Laboratory for the Study of Stress, Immunity, and Disease at Carnegie Mellon University.

Throughout two lab sessions approximately seven weeks apart, each consisting of a 20-minute baseline and a 15-minute psychological stress test, participants’ heart rate and blood pressure were recorded.

Participants also completed a standard psychological scale to measure personality and temperament – specifically degrees of hostility that represent an individual’s disposition towards cynicism and chronic hate.

In the psychological stress portion of the study, participants were given five minutes to formulate a speech to defend themselves against a suspected transgression – either a traffic violation or shoplifting – and five minutes to perform the speech.

They were told their speech would be videotaped and evaluated.

“These methods of social and self-evaluation are designed to increase the experience of stress and have been validated in prior research,” Tyra said.

Participants next were asked to perform a five-minute mental arithmetic test, which varied slightly in each visit. Heart rate and blood pressure were recorded every two minutes during each phase of the stress test – speech preparation, delivery and mental arithmetic.

Participants also responded to a 20-item test to measure the emotional, behavioral and cognitive components of hostility.

An example item of the emotional component – anger or annoyance – is “people often disappoint me.”

An example item of the behavioral component (aggression) is “I would certainly enjoy beating a crook at his or her own game.” Finally, an example item of the cognitive component (cynicism) is “I think most people would lie to get ahead.”

In the study, emotional and behavioral hostility were not found to be related to stress responses, Tyra said.

“This does not imply that emotional and behavioral hostility are not bad for you, just that they may affect your health or well-being in other ways,” she said.

Future research that would be useful would be to examine cynical hostility and its health implications across the lifespan, “perhaps following individuals as they grow older to see whether a greater tendency to use cynical hostility while young is actually related to poor cardiovascular outcomes at an older age, such as a heart attack,” Tyra said.

“I would hope that this research raises awareness about the potential health implications of cynicism,” she said.

“Perhaps the next time someone thinks a negative thought about the motives, intentions or trustworthiness of their best friend, a co-worker or even a politician, they will think twice about actively engaging with that thought.”


As one of the most common chronic diseases, diabetes currently affects around 415 million people worldwide and will affect around 615 million people by 2040 1. In the US, more than 30 million people had diabetes in 2017 2 and type 2 diabetes constituted more than 90% of cases 1.

The main threats to the health and quality of life of people with diabetes are complications caused by the metabolic and vascular sequelae of diabetes 3. Cardiovascular disease (CVD) is one of the major diabetic complications and leading causes of mortality from diabetes 4.

In the general population, personality traits were reported to be related to the risks of CVD. Optimism is associated with reduced risk of CVD 5–8. Hostility and negative affectivity are psychological risk factors for CVD 9–13. Metabolic syndrome is an independent predictor of type 2 diabetes 14.

One report showed that a combination of high level hostility and metabolic syndrome increased the risk of CVD by more than 4 fold in men compared to men with low hostility and metabolic syndrome 15. However, there is lack of study on the associations between personality traits and risk of CVD among people with type 2 diabetes.

Personality traits might be related to the occurrence of CVD in people with diabetes. Good glycemic control and adherence to diabetic treatment are important in the prevention of diabetic complications and personality traits are important factors in diabetic self-management and adherence to diabetic treatment 16.

In people with diabetes, optimism is related to better diabetic control and fewer complications 17 while negative emotional states are related to poor metabolic control in people with diabetes 9. Ambivalent emotional expressiveness (AEE) could lead to distress due to emotional inhibition 18, and stress and emotional distress could lead to poor adherence to type 2 diabetic medications and to other common medications such as antihypertensive and cholesterol-lowering treatments 19, 20.

In other studies, greater levels of hostility in people with type 2 diabetes raised susceptibility to stress-induced inflammation 21 while optimism was related to better immune defense 17. Personality traits might influence risk of CVD in people with diabetes through stress-related inflammatory pathways 21.

Dysregulation of the neuroendocrine systems and increased levels of stress-related hormones, such as cortisol were more often observed in individuals with greater levels of hostility 22. The higher levels of cortisol can adversely affect blood pressure, blood glycemic control and other cardiovascular risk factors 23.

This study aims to investigate the association between personality traits and risk of developing CVD in postmenopausal women with diabetes based on a prospective cohort study in the US -Women’s Health Initiative (WHI). The personality traits that we investigated include: optimism, ambivalence over emotional expressiveness (AEE), negative emotional expressiveness (NEE), and hostility.

CVD is measured by the incidence of coronary heart disease (CHD) or stroke over follow-up. Out study hypotheses were: The personality traits: optimism, AEE, NEE, and hostility are associated with the incidence of CVD in women with diabetes.

Methods

Study population

This study was based on the Women’s Health Initiative (WHI) which is a large-scale longitudinal epidemiological study designed to investigate the major causes of morbidity and mortality in postmenopausal women 24. Detailed information on the study are described elsewhere 25–29.

In summary, 161,808 women aged 50 to 79 years were recruited from 40 clinical centers throughout the United States between 1993 and 1998. The WHI includes both clinical trials (CT) and observational study (OS) components. Participants in the OS included 93,676 women who were screened for the CT but were ineligible, unwilling to participate in the clinical trial, or were recruited through a direct invitation for the OS.

When WHI study ended in 2005, WHI Extension Studies (Extension study 1 was from year 2005 to 2010, Extension study 2 was from year 2010 to 2020) continued follow-up of all women who consented. The study was approved by Institutional Review Boards at all 40 clinical centers and at the coordinating center. All participants provided written informed consent.

Diabetes cohort

From the WHI cohort, we selected study participants who had prevalent diabetes or who were diagnosed with diabetes, i.e., incident diabetes, during the WHI follow-up and Extension Study 1. A participant was considered to have prevalent diabetes if she reported that she had ever been treated with diabetes with pills or shots, was diagnosed after age 30 and had not been hospitalized for coma.

Self-reported diabetes was assessed and found to be a valid indicator of diagnosed diabetes 30, 31. The criteria for incident diabetes during follow-up was not having prevalent diabetes at the baseline and reported being treated for diabetes (pills or insulin shots) during the follow-up.

From the WHI cohort, we selected 6837 women with prevalent diabetes at baseline and 16241 women with incident diabetes during the WHI follow-up. Among the 6837 women with prevalent diabetes at baseline, we excluded 1850 women who had CVD at baseline and 668 women who had cancer (except non-melanoma skin cancer) at baseline, and 31 women without follow-up information.

After the exclusions, 4288 women with prevalent diabetes entered the final study cohort. Among the 16241 women with incident diabetes during the WHI follow-up, we excluded 1285 women with cancer (except non-melanoma skin cancer) at baseline, 925 women who had any cancer except non melanoma skin cancer before the diagnosis of diabetes during the follow-up, 2802 women who had CVD at baseline, 442 who had CVD before the diagnosis of diabetes during follow-up, and 46 women who had the date of end of follow-up before the date of diabetes diagnosis.

After the exclusions, there were 10741 women with incident diabetes during follow-up who entered the final study cohort. Thus in total, there were 15029 with diabetes in our study cohort.

Exposure variables:

In this study, optimism, Ambivalence over Emotional Expressiveness (AEE), Negative Emotional Expressiveness (NEE), and hostility were constructed WHI variables that were selected for the measurement of personality traits at the baseline of WHI:

Optimism:

Optimism was measured by the revised version of the Life Orientation Test 32 which included six questions: 1.In unclear times, I usually expect the best; 2. If something can go wrong for me, it will; 3. I’m always hopeful about my future; 4. I hardly ever expect things to go my way; 5.

I rarely count on good things happening to me; 6. Overall, I expect more good things to happen to me than bad. Answers to each of these questions were coded from 1=strongly disagree to 5=strongly agree. The answers were reverse recoded for questions 2, 4 and 5 and a summed score found. Possible total scores ranged from 6–30 with higher scores representing greater optimism.

Ambivalence over Emotional Expressiveness (AEE):

AEE was measured based on a three-item subscale of the Ambivalent Over Emotional Expression Questionnaire 33. Questions included were: 1. After I express anger at someone, it bothers me for a long time; 2. I try to suppress my anger, but I would like other people to know how I feel; 3.

I worry that if I express negative emotions such as fear and anger, other people will not approve of me. The response values ranged from 1=“Strongly Disagree” to 5=“Strongly Agree”. The total summary score was based on the average response values of the three questions and ranged from1 to 5. A higher score indicated greater ambivalence in expressing negative emotions.

Negative Emotional Expressiveness: (NEE):

The measurement of NEE was based on 4 items of the Emotional Expressiveness Questionnaire 33 and the following questions were used: 1.When I am angry, people around me usually know; 2. People can tell from my facial expressions how I am feeling; 3. I always express disappointment when things don’t go as I’d like them to; 4. If someone makes me angry in a public place, I will “cause a scene”. The response values for each question ranged from 1=“Strongly Disagree” to 5=“Strongly Agree.” Average response values of the four questions were used as the total score where a higher score represents greater tendency in expressing negative emotions.

Hostility:

The measurement of hostility was based on the cynicism subscale of the Cook and Medley instrument 34. The following thirteen questions were asked:

1. I have often had to take orders from someone who did not know as much as I did;

2. I think a great many people make a lot of their bad luck in order to gain the sympathy and help from others;

3. It takes a lot of argument to convince most people of the truth;

4. I think most people would lie to get ahead;

5. Most people are honest mainly through fear of being caught;

6. Most people will use somewhat unfair means to gain profit or an advantage rather than to lose it;

7. No one cares much what happens to you;

8. It is safer to trust nobody;

9: Most people make friends because friends are likely to be useful to them;

10. Most people inwardly do not like putting themselves out to help other people;

11. I have often met people who were supposed to be experts who were no better than I;

12. People often demand more respect for their own rights than they are willing to allow for others;

13. A large number of people are guilty of bad sexual behavior. The responsible values were 0=“False”, 1=“True” to each of the above questions.

The sum of response values of all thirteen questions were used as the total score where a higher score represents greater hostility.

Outcome variables:

The primary outcome was first occurrence of coronary heart disease (CHD) or stroke during follow-up. CHD was defined as first occurrence of clinical myocardial infarction (MI), definite silent MI or a death due to definite CHD or possible CHD. Stroke was defined as the first occurrence of stroke or a death due to cerebrovascular event. Information on the cardiovascular outcomes were adjudicated by physicians following standard diagnostic standards for the WHI CT and OS components through 2010 35. From 2010, cardiovascular outcomes were adjudicated for the subset that included all former hormone trial participants and all African American and Hispanic participants, and self-reported for other participants.

Potential confounders:

The following potential confounders were considered: baseline information on age, race/ethnicity (American Indian or Alaska Native, Asian or Pacific Islander, Black or African-American, Hispanic/Latino, non-Hispanic white, or other), educational level (high school or less, some college/technical training, college or some post-college, and master or higher), different study cohorts (participation in OS or CTs, and different treatment assignments for all three CTs), hypertension (never, currently untreated, currently treated), high cholesterol requiring pills ever (no, yes), atrial fibrillation (for the analysis of stroke), family history of MI (for the analysis of CHD) or stroke (for the analysis of stroke).

Prior hormone therapy (never, E alone, E+P, E alone ever and E+P ever). Depressive symptoms were categorized into none, mild, or moderate based on previously established cut-points of 0.009 and 0.06 36. Additional covariates included physical activity (<5, 5-<10, 10-<20, 20-<30, 30+ metabolic equivalent task values (METs) per week), smoking habit (never, former, current), alcohol consumption (non-drinker, past drinker, current and <1 drink per week, current and 1–7 drinks/week, current and ≥7 drinks/week, current and <1 drink per month), body mass index (BMI), waist-to-hip ratio (WHR), and healthy eating index (HEI)-2005 score (quartile). HEI-2005 was a measure of diet quality that assesses conformance to the 2005 dietary guidelines for Americans 37.

Follow-up:

The study participants were followed from the first time of interview if she already had diabetes, or from the date when she first reported diabetes during WHI follow-up, until the first occurrence of CHD or stroke, date of death, or February 28, 2017 whichever occurred first.

Statistical analyses:

We performed both descriptive and inferential statistical analyses. Each personality trait exposure variable was categorized into quartiles. The baseline characteristics of exposure variables were described by mean and standard deviation (SD) for continuous variables and by number and percentage for categorical variables. Chi-square tests were applied to test differences for categorical variables and ANOVA was used to test differences for continuous variables.

In the inferential analysis, COX proportional hazards models were used to evaluate the associations (hazard ratios and 95% confidence intervals) between each of the exposures and the occurrence of CHD or stroke, respectively. The survival time was defined as the duration from the start of the follow-up to the end of follow-up as described above.

By using a progressively-adjusted regression method, multivariable proportional hazard models were adjusted for potential confounders. The first model adjusted for age, ethnicity, education, family income, family history of MI for the outcome of CHD, family history of stroke for the outcome of stroke, hypertension, high cholesterol requiring pills ever, and study cohort (CT or OS and different assignments for CTs). The second model additionally adjusted for depressive symptoms. The third model additionally adjusted for major modifiable lifestyle factors including BMI, waist-to-hip ratio, dietary quality, physical activity, smoking history, and alcohol consumption.

Trend analysis were performed by entering the main exposure variables as continuous variables in the models. We further performed stratified analysis by prevalent or incident diabetes, as well as insulin treatment within the subgroups with prevalent diabetes or incident diabetes. Interaction between prevalent or incident diabetes and exposures, as well as the interaction between insulin treatment and exposures within subgroup with incident diabetes were performed.

In the supplementary analyses, we tested the correlation between hostility score and time from menopause. We also test interaction between prior hormone use, VMS (hot flash or night sweats) symptom or prior hysterectomy and the hostility were conducted.

Results

The 15029 participants in our study were followed for a mean of 10 years with SD 5.5. A total of 1118 incident CHD and 710 incident stroke cases were observed. Table 1 shows the baseline characteristics of the study cohort by the quartile of hostility.

Compared with the lowest quartile group, the highest quartile group was younger at the baseline (p<0.001), more likely to be black women (p<0.0001), current smokers (p<0.0001), past drinkers (p<0.0001), have lower level of education (p<0.0001), higher BMI (p<0.0001), lower HEI-2005 score (p<0.0001), and lower total energy expenditure from recreational physical activity (MET-hours/week) (p<0.0001).

The highest quartile group had more hypertension (p<0.0001), more cholesterol treated requiring pills ever (p<0.05), more had never prior hormone therapy (p<0.001) than the lowest quartile group.

The incidence rate of CHD was 687.84/100000 person-years, 780.68/100000 person-years, 710.09/100000 person-years, 890.97/100000 person-years in the first, second, third and fourth quartile of hostility in women with diabetes, respectively.

Table 1. – Baseline characteristics of the study cohort by quartiles of hostility trait

Hostility
Q1Q2Q3Q4
nMean
(SD)
or
(%)
nMean
(SD)
or
(%)
nMean
(SD)
or
(%)
nMean
(SD)
or
(%)
Age at baseline (years)241068.1 (7.6)279767.9 (7.6)366167.4 (7.7)247866.8 (7.8)
Ethnicity7(0.3)17(0.6)16(0.4)32(1.3)
American Indian or Alaskan Native
Asian or Pacific Islander114(4.7)92(3.3)123(3.4)83(3.3)
Black or African-American248(10.3)365(13.0)666(18.2)620(25.0)
Hispanic/Latino109(4.5)134(4.8)201(5.5)224(9.0)
White (not of Hispanic origin)1896(78.7)2157(77.1)2606(71.2)1474(59.5)
Other36(1.5)32(1.1)49(1.3)45(1.8)
Educational levels520(21.6)661(23.6)955(26.1)884(35.7)
higher diploma or less
some college or technical training907(37.6)1096(39.2)1597(43.6)1000(40.4)
college graduate or some post-college533(22.1)578(20.7)643(17.6)365(14.7)
master degree or higher450(18.7)462(16.5)466(12.7)229(9.2)
BMI (kg/m2)238930.8 (6.3)278231.1 (6.4)363831.7 (6.6)246832.6 (6.7)
Waist/Hip Ratio (WHR)23980.9 (0.1)27870.9 (0.1)36430.9 (0.1)24730.9 (0.1)
Total energy expend from recreational phys activity (MET-hours/week)240710.6 (12.3)27959.9 (12.0)36599.4 (11.6)24759.0 (11.9)
TOTAL HEI-2005 SCORE241067.9 (10.6)279667.4 (10.8)366166.3 (10.7)247864.8 (11.1)
Smoking habit1258(52.2)1485(53.1)1906(52.1)1317(53.1)
Never Smoked
Past Smoker996(41.3)1117(39.9)1491(40.7)948(38.3)
Current Smoker156(6.5)195(7.0)264(7.2)213(8.6)
Alcohol consumption303(12.6)337(12.0)505(13.8)451(18.2)
Non drinker
Past drinker580(24.1)734(26.2)970(26.5)786(31.7)
<1 drink per month385(16.0)431(15.4)605(16.5)339(13.7)
<1 drink per week475(19.7)581(20.8)780(21.3)456(18.4)
1 to <7 drinks per week492(20.4)515(18.4)589(16.1)346(14.0)
7+ drinks per week175(7.3)199(7.1)212(5.8)100(4.0)
High cholesterol requiring pills ever1972(81.8)2291(81.9)2963(80.9)1979(79.9)
No
Yes438(18.2)506(18.1)698(19.1)499(20.1)
Hypertension1441(59.8)1600(57.2)2066(56.4)1376(55.5)
Never hypertensive
Untreated hypertensive899(37.3)1088(38.9)1473(40.2)1002(40.4)
Treated hypertensive70(2.9)109(3.9)122(3.3)100(4.0)
Relative had stroke1132(47.0)1301(46.5)1628(44.5)1125(45.4)
No
Yes1278(53.0)1496(53.5)2033(55.5)1353(54.6)
Relative had MI1349(44.8)1140(44.2)2039(45.1)1365(47.4)
No
Yes1659(55.2)1438(55.8)2479(54.9)1515(52.6)
Depressive symptoms2024(84.0)2147(76.8)2640(72.1)1512(61.0)
None
Mild264(11.0)367(13.1)528(14.4)411(16.6)
Moderate122(5.1)283(10.1)493(13.5)555(22.4)
Systolic blood pressure745(30.9)748(26.8)987(27.0)650(26.3)
<=120
120 – 1401067(44.3)1288(46.1)1707(46.7)1119(45.2)
>140597(24.8)760(27.2)964(26.4)705(28.5)
Diastolic blood pressure2198(91.2)2567(91.8)3345(91.4)2247(90.8)
<90
>=90211(8.8)229(8.2)313(8.6)227(9.2)
Prior hormone theray1060(44.8)1315(47.9)1813(50.3)1323(54.2)
never
E alone697(29.4)815(29.7)1079(29.9)703(28.8)
E+P471(19.9)499(18.2)550(15.3)323(13.2)
E alone ever or E+P ever140(5.9)117(4.3)164(4.5)91(3.7)

Table 2 shows the results from the hazard proportional regression models for the incidence of CHD. Women in the highest quartile of hostility had 24% [HR 1.24 (95% CI 1.03–1.49)] increased risk of CHD compared with women in the lowest quartile in model 1 which adjusted for age, race/ethnicity, education, family history of diabetes, family history of MI, hypertension, high cholesterol requiring pills ever, and different study cohorts.

Similar results [HR 1.25 (95% CI 1.03–1.51)] were found in model 2 which adjusted further for depressive symptoms (plus model 1 variables) and model 3 [HR 1.22 (95% CI 1.01–1.48)] which additionally adjusted for life style factors such as BMI, WHR, smoking, alcohol intake, physical activity and quality of diet (plus model 1 and model 2 variables).

P-values for trend were greater than 0.05. We did not find any statistically significant associations between optimism, Ambivalence over Emotional Expressiveness (AEE), Negative Emotional Expressiveness (NEE) and the risk of CHD.

Table 2: – Association (HR 95% CI) between personality traits and CHD in women with diabetes.

Model aModel bModel c
CasesHR (95% CI)HR (95% CI)HR (95% CI)
Optimism
1157ReferenceReferenceReference
21451.04 (0.87–1.24)1.04 (0.87–1.25)1.06 (0.89–1.28)
32140.96 (0.82–1.13)0.96 (0.82–1.14)0.98 (0.83–1.16)
41290.94 (0.78–1.13)0.94 (0.78–1.14)0.96 (0.79–1.17)
p-value for trend0.420.370.53
Ambivalence over Emotional Expressiveness (AEE)
1160ReferenceReferenceReference
22071.05 (0.89–1.23)1.05 (0.90–1.23)1.05 (0.89–1.23)
31151.01 (0.84–1.22)1.01 (0.84–1.23)1.04 (0.86–1.25)
41631.03 (0.86–1.23)1.03 (0.86–1.23)1.03 (0.86–1.23)
p-value for trend0.880.890.85
Negative Emotional Expressiveness (NEE)
1151ReferenceReferenceReference
21710.95 (0.80–1.13)0.95 (0.80–1.13)0.95 (0.80–1.13)
31890.94 (0.80–1.11)0.94 (0.80–1.11)0.93 (0.79–1.11)
41341.07 (0.89–1.29)1.07 (0.89–1.28)1.06 (0.88–1.28)
p-value for trend0.570.590.70
Hostility
1122ReferenceReferenceReference
21431.10 (0.92–1.33)1.11 (0.92–1.33)1.11 (0.93–1.34)
32251.00 (0.83–1.19)1.00 (0.84–1.19)0.99 (0.83–1.19)
41551.24 (1.03–1.49)1.25 (1.03–1.51)1.22 (1.01–1.48)
p-value for trend0.080.080.13

aadjusted for age at baseline, race/ethnicity (American Indian or Alaska Native, Asian or Pacific Islander, Black or African-American, Hispanic/Latino, non-Hispanic white, and other), education (high school or less, some college/technical training, college or some post-college, and master or higher), family history of MI (no, yes), hypertension never, currently untreated, currently treated), high cholesterol requiring pills ever (no, yes), and different study cohorts (participation in OS or CTs, and different treatment assignments for all three CTs), prior hormone usebfurther adjusted for depressive symptoms,cfurther adjusted for BMI, WHR, smoking (never, former, current), alcohol intake (non-drinker, past drinker, current and <7 drinks/week, current and ≥7 drinks/week), physical activity (<5, 5-<10, 10-<20, 20-<30, 30+ Metabolic equivalent (METs)/week), and quality of diet (quartile)

Table 3 presents the results from the hazard proportional regression models for the incidence of stroke. No statistically significant associations between optimism, AEE, NEE or hostility and the incidence of stroke were found in different models. P-values for trend analysis were greater than 0.05.

Table 3: – Association (HR 95% CI) between personality traits and stroke in women with diabetes.

Model aModel bModel c
CasesHR (95% CI)HR (95% CI)HR (95% CI)
Optimism157
1ReferenceReferenceReference
21451.04 (0.83–1.30)1.04 (0.83–1.30)1.10 (0.87–1.38)
32140.92 (0.75–1.13)0.92 (0.75–1.13)0.97 (0.79–1.20)
41290.84 (0.67–1.07)0.84 (0.66–1.07)0.90 (0.70–1.14)
P-value for trend0.100.090.23
Ambivalence over Emotional Expressiveness (AEE)160
1ReferenceReferenceReference
22070.93 (0.76–1.14)0.93 (0.76–1.14)0.92 (0.75–1.13)
31151.01 (0.80–1.28)1.01 (0.80–1.28)1.02 (0.81–1.30)
41631.14 (0.92–1.42)1.15 (0.92–1.42)1.12 (0.90–1.40)
p-value for trend0.130.130.17
Negative Emotional Expressiveness (NEE)151
1ReferenceReferenceReference
21710.95 (0.77–1.18)0.95 (0.77–1.18)0.99 (0.80–1.23)
31890.90 (0.73–1.10)0.89 (0.73–1.10)0.91 (0.74–1.13)
41340.99 (0.79–1.24)0.99 (0.79–1.24)1.02 (0.81–1.29)
p-value for trend0.710.710.89
Hostility122
1ReferenceReferenceReference
21430.97 (0.77–1.24)0.97 (0.77–1.24)0.97 (0.76–1.23)
32251.13 (0.91–1.41)1.13 (0.91–1.41)1.13 (0.91–1.42)
41551.18 (0.92–1.49)1.18 (0.92–1.50)1.14 (0.89–1.45)
p-value for trend0.110.120.20

aadjusted for age at baseline, race/ethnicity (American Indian or Alaska Native, Asian or Pacific Islander, Black or African-American, Hispanic/Latino, non-Hispanic white, and other), education (high school or less, some college/technical training, college or some post-college, and master or higher), family history of stroke (no, yes), hypertension never, currently untreated, currently treated), high cholesterol requiring pills ever (no, yes), and different study cohorts (participation in OS or CTs, and different treatment assignments for all three CTs), atrial fibrillation, prior hormone usebfurther adjusted for depressive symptoms,cfurther adjusted for BMI, WHR, smoking (never, former, current), alcohol intake (non-drinker, past drinker, current and <7 drinks/week, current and ≥7 drinks/week), physical activity (<5, 5-<10, 10-<20, 20-<30, 30+ Metabolic equivalent (METs)/week), and quality of diet (quartile)

The interactions between prevalent or incident diabetes and the exposure variables were tested and did not show any significant interaction. The score (mean and SD) on each of the personality traits for women with prevalent diabetes or incident diabetes were shown in supplementary table 1.

The mean score of optimism in women with incident diabetes were significantly higher compare with women with prevalent diabetes. The mean score of hostility in women with incident diabetes were significantly lower compare with women with prevalent diabetes.

There were no significant difference in the AEE and NEE mean scores. No statistically significant associations between personality traits and incidence of CHD or stroke were found in women with prevalent diabetes. Among women with incident diabetes, significant associations between hostility and CHD were found in model 1 [HR 1.34 95% CI 1.04–1.74)], model 2 [HR 1.35 (95% CI 1.04–1.76)] and model 3 [HR 1.34 (95% CI 1.03–1.74)] (supplementary table 2).

To exclude possible reverse causality, we further assessed the relationship between hostility and CHD by excluding the first year’s follow-up. The highest quartile of hostility was related to increased risk of CHD in model 3 [HR 1.38, 95% CI (1.04–1.82)]. Within subgroups with incident diabetes, we performed a statistical test on interactions between insulin treatment and exposure variables and did not find significant interactions.

Furthermore, we conducted stratified analyses by treatment with insulin in women with incident diabetes or prevalent diabetes. No significant associations between the hostility and the risk of CHD were observed in any of the stratified analyses. We did the similar stratified analyses for stroke by prevalent diabetes and incident diabetes and also additionally stratified by the treatment of insulin or not.

We did not find any significant associations between personality traits and the risk of stroke in the stratified analyses. In our supplementary analyses, there were no statistical difference in the time from menopause by quartile of hostility. There were no significant correlation between time from menopause and the hostility traits.

Interactions test between prior hormone use, VMS symptom, or prior hysterectomy did not reveal any significant interactions. Since age and time from menopause are highly correlated, we additionally adjusted for VMS symptom and prior hysterectomy and the association hostility and the risk of CHD remained same.

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