An Integrative Approach To Health

AN INTEGRATIVE APPROACH TO HEALTH*
KATHLEEN MULLAN HARRIS
In this article, I make the case for using an integrative approach to health, broadly defined
as social, emotional, mental, and physical well-being; for studying health among the young as an
important marker for future health and well-being across the life course; and for understanding health
disparities among the young as both causes and consequences of social stratification. An integrative
approach bridges biomedical sciences with social and behavioral sciences by understanding the
linkages between social, behavioral, psychological, and biological factors in health. It is furthermore
vital that integration occur in all steps of the research process: in theory, design, data collection, and
analysis. I use the National Longitudinal Study of Adolescent Health, or Add Health, as an example of
an integrative approach to health and of the importance of adolescence and the transition to adulthood
years for setting health trajectories into adulthood. Evidence is also presented on the linkages be-
tween health trajectories during adolescence and the transition to adulthood and social stratification
in adulthood.
H ealth is and always has been a core area of population science. Although typically
coupled with mortality and aging research, health is a key mechanism in reproduction,
family planning, sexual behavior, birth outcomes, union formation, migration, education,
and labor market behavior and outcomes. From one of the earliest demographic accounts
by Louis Dublin, Alfred Lotka, and R.J. Horton in 1937 titled Twenty-Five Years of Health
Progress, health remains central to the demographic processes, behaviors, and outcomes
we study today.
One of the great strengths of population science is that it draws from diverse areas
to solve puzzles of the time. Recently, there has been increasing scholarly interest in the
puzzles of health. One indication of this is the increasing number of paper submissions to
the Health and Mortality topic in the Call for Papers for the annual Population Association
of America (PAA) meetings. Over the past seven years, submissions to Health and
Mortality have increased by 50%—the largest growth in submissions across all topics of the
PAA. What is this new interest in health, and how did it come about? I argue that it is due
to five fairly recent trends: (1) more data on health; (2) increased funding for research on
health; (3) a broadening of the definition of health; (4) rising research and political interest
in health disparities; and (5) the aging of industrialized populations.
DATA ON HEALTH
Beginning in the 1980s, but greatly expanding in the 1990s, several demographic and
social surveys broadened collection of health data, including, for example, the Panel Study
of Income Dynamics (PSID), the National Longitudinal Survey of Youth (NLSY79), the
Indonesian Family Life Survey (IFLS), the Los Angeles Family and Neighborhood Survey
(L.A.FANS), and at the older ages, the Health and Retirement Study (HRS), the Wisconsin
Longitudinal Study (WLS), National Social Life, Health and Aging Project (NSHAP),
*Presidential Address to the Population Association of America, Detroit, MI, May 1, 2009. Please send
all correspondence to Kathleen Mullan Harris, Carolina Population Center, CB# 8120, University Square, 123
W. Franklin Street, Chapel Hill, NC 27516; e-mail: [email protected]. I gratefully acknowledge research
support from the National Institute of Child Health and Human Development through Grant P01 HD31921, the
Add Health program project that I direct. This research uses data from Add Health, a program project designed
by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris, and funded by Grant P01-HD31921 from the
National Institute of Child Health and Human Development, with cooperative funding from 17 other agencies.
Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design.
Demography, Volume 47-Number 1, February 2010: 1–22 1
2 Demography, Volume 47-Number 1, February 2010
Figure 1. Congressional Appropriations to the National Institutes of Health (real dollars in

thousands): 1980–2008
a. All NIH institutes and centers b. Selected institutes

$35,000,000 $1,400,000
$30,000,000 $1,200,000
NICHD
NIA
$25,000,000 $1,000,000
$20,000,000 $800,000
$15,000,000 $600,000
$10,000,000 $400,000
$5,000,000 $200,000
$0 $0
1980 1988 1996 2004 1980 1988 1996 2004
Source: Office of Budget, National Institutes of Health.
National Study of Midlife Development in the United States (MIDUS), and the Social
Environment and Biomarkers of Aging Study (SEBAS). And in the mid-1990s, a new
study was launched by the name of “Add Health,” or the National Longitudinal Study of
Adolescent Health, developed in response to a 1993 congressional mandate to the National
Institutes of Health (NIH) to fund a study of adolescent health.
In addition to the increasing number of studies with health information, data collected
were more diverse and comprehensive of health status and health behaviors. For example,
in addition to reports of chronic illness, disease diagnoses, and disability, Add Health col-
lected data on safe vehicle use, sun exposure, sleep, unintentional injury, body image, eating
disorders, diet and nutrition, exercise and physical activity, TV and video watching, dental
health, and height and weight, in addition to some of the standards on physical and mental
health, smoking, drinking, drug use, violence, suicide, and sexually transmitted infections.
FUNDING FOR RESEARCH ON HEALTH

Funding for health-related research increased dramatically during the 1990s and is partly
responsible for the growth in health-related data. The left panel of Figure 1 shows the in-
crease in NIH appropriations across all institutes and centers, rising from $3.4 billion in
1980 to $29.5 billion in 2008. Much of this funding is for biomedical research, but if we
focus on the two main institutes that support population research, NICHD and NIA (shown
in the right panel of Figure 1), we see a similar pattern of increasing funding, especially
during the 1990s.
Other funding sources reflect similar increases in health-focused research. The Robert
Wood Johnson Foundation is dedicated to improving the health and health care of all Amer-
icans and, in the 1990s, expanded its postdoctoral program to encourage interdisciplinary
training of young scholars in the social and health sciences with their Health and Society
and Health Policy Fellowship programs. The Hewlett and Gates Foundations have large
population programs that focus on reproductive health and global health issues.
Although funding is not necessarily critical for health research, it certainly is needed to
collect new and expanded data on health, to survey large representative samples to capture
An Integrative Approach to Health 3
the population prevalence of lesser-known health conditions and the emergence and pat-
terns of potential health problems, and to provide evidence on the basis of which health
and social policies can be developed—all strengths of the research designs that population
science brings to knowledge about health. But what do we mean by health?
DEFINITION OF HEALTH
An important change in the study of health has been a broadening of the definition of health
for research and programmatic purposes. Within the social science research community in
particular, the concept of health has broadened beyond the presence or absence of illness
to incorporate the notion of well-being—including social, economic, and psychological
well-being. This broad concept of health has roots in the World Health Organization’s 1948
definition of health: “Health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity” (WHO 1948). In 1975, Dr. Mahler, then
Director-General of WHO, argued that we must consider health in the broader context of its
contribution to social development and expanded the definition to include the ability to lead
a socially and economically productive life (Mahler 1975). In 1990, Evans and Stoddart cri-
tiqued the various frameworks that identify the fundamental elements of health and inform
health policy. They developed a framework that incorporated biological and environmental
components into the definition of health status, but focused primarily on the adult ages.
A 2004 National Research Council report that was centered on children’s health proposed
that child health is the extent to which individual children are able to develop and realize
their potential, satisfy their needs, and develop the capacities that allow them to interact
successfully with their biological, physical, and social environments.
Underlying this broadening conception of health is growing knowledge of the integral
role that physical and mental health play in the causes and consequences of social and
demographic behavior, social and emotional development, and social and economic sta-
tus across the life course (e.g., Adler et al. 1993; Bongaarts and Potter 1983; Halfon and
Hochstein 2002; Lindau et al. 2007; Palloni 2006; Waite 1995). The conceptualization of
health has also expanded beyond the individual to represent the social contexts in which
individuals live and social interactions within these contexts, such as healthy relationships,
healthy families, healthy marriage, healthy workplace, and healthy neighborhoods (e.g.,
Dion 2005; Lavoie-Tremblay 2004; Sampson 2003; Smith and Christakis 2008; Waller and
Swisher 2006). These applications of the notion of health to various levels of the social
environment have helped identify the multiple potential sources of health disparities.
HEALTH DISPARITIES
In tandem with increasing data on health, funding for health, and embracing a broad defini-
tion of health, was dramatic growth in research on health disparities. Health disparities refer
to gaps in the quality of health and health care across racial, ethnic, and socioeconomic
groups (U.S. Department of Health and Human Services 2000). More broadly, the Health
Resources and Services Administration defines health disparities as “population-specific
differences in the presence of disease, health outcomes, or access to health care” (Goldberg,
Hayes, and Huntley 2004:3).
One will quickly recognize that throughout the history of demographic scholarship,
population scholars have been studying “health disparities,” focusing in particular on the
most fundamental health outcome of all, death, with a rich and deep literature on mortality
differentials. Indeed, Dublin et al.’s Twenty-Five Years of Health Progress (1937) analyzed
deaths among the wage-earning population of the United States and Canada between
the years 1911 and 1935 by cause of death, sex, age, and race. A wealth of demographic
research has examined socioeconomic differentials—including income, educational, occu-
pational, and social class differences—in mortality, and by extension morbidity and disabil-
ity. And at the very origins of our discipline are life tables, and how life table parameters
vary by age, sex, race, ethnicity, and socioeconomic status (Glass 1973). So, what is so new
about this concept of health disparities?
Growing research interest in health disparities is due to a number of recent trends be-
ginning in the 1990s. As mentioned previously, there are now more data on health besides
death. A second important trend has been the increasing diversity of the U.S. population,
fueled by the massive waves of immigration from Latin America and Asia that exploded
in the 1990s (Alba and Nee 2005), increasing racial and ethnic diversity and bringing at-
tention to health disparities among the growing minority populations in the United States.
Finally, during the 1990s, there was increasing political awareness of persistent disparities
by race, ethnicity, gender, and socioeconomic status as a result of the previous two trends.
In the United States, large and persistent racial, ethnic, and socioeconomic disparities
in health exist across the life course (Bergner 1993; Kington and Nickens 2001; National
Center for Health Statistics 2002, 2009; Pamuk et al. 1998; Rogers 1992; Williams and
Collins 1995). As more evidence of the scope and persistence of such disparities across
an array of health and well-being indicators filtered into the public arena throughout the
1990s, the reduction and ultimate elimination of health disparities was identified as one of
the major public health goals of the decade (Satcher and Higginbotham 2008).
In 1998, President Clinton articulated this goal in the “President’s Initiative on Race”
when he committed federal funds to eliminate racial and ethnic disparities in health by
the year 2010. The Department of Health and Human Services incorporated the Presi-
dent’s Initiative in Healthy People 2010, the nation’s promotion and disease prevention
strategy for the first decade of the twenty-first century, with the goal to “eliminate health
disparities that occur by gender, race or ethnicity, education or income, disability, living
in rural localities, or sexual orientation” (U.S. Department of Health and Human Services
2000:11).
In response to the President’s Initiative, the NIH developed its own “Program of
Action to Address Health Disparities Via Research,” and by 2000, all NIH institutes had
developed a research program for addressing health disparities (U.S. Department of Health
and Human Services 2002). At the end of 2000, President Clinton also signed into law the
establishment of the National Center on Minority Health and Health Disparities to lead,
coordinate, support, and assess the NIH effort to eliminate health disparities. These cultural
and political events that brought attention to minority health and health disparities and that
created an infrastructure for research support have energized research in this area.
While there has been a long tradition of research documenting sex, race, and
socioeconomic disparities in health care, health, and risk behavior, and certainly within
population science, mortality, morbidity, and disability differentials, public attention to
health disparities and program support for understanding how to reduce them greatly
increased since the President’s Initiative. For example, a literature search on PubMed
found 29 articles on the topic of “health disparities” between 1990 and 1999 (none
before 1990), but 1,818 between 2000 and 2009, reflecting the impact of the President’s
Initiative in 1998.
One point to note about this burgeoning research on health disparities, and on health in
general, is that most of this research focuses on adult health, health among the elderly (adults
over age 50), and child health (infants and children under 10 years). Much of the focus on
adults and the elderly reflects the well-documented aging of industrialized populations and
its consequences (Uhlenberg 2009), the fifth trend behind rising research interest in health
that I noted in the introduction.1 Only about one-quarter of the articles on health disparities
published in the past nine years in the PubMed search examined health among adolescents
or during the transition to adulthood. The point in the life course when young people begin
1. I do not elaborate on this trend here because it is has been so widely documented in population science
over the past 40 years.
to make their own decisions about their health and health behavior during adolescence and
early adulthood is a much less researched area and, I argue, is critical to understanding
adult health and the development of social stratification trajectories across the life course.
With colleagues Udry, Gordon-Larsen, and Chantala, I published one such article in
which we used data from Add Health to document trends in health disparities by race and
ethnicity as young people made the transition from adolescence into young adulthood
(Harris et al. 2006). We examined 20 leading health indicators identified in Healthy People
2010 as most crucial to the healthy development of young people. We used repeated mea-
sures of health and health behavior on the same individuals across time, in adolescence
when the sample was aged 12–19 in 1995–1996, and six years later in young adulthood
when the sample was 18–26 years old. We fit longitudinal regression models to assess the
developmental trends in health indicators among racial/ethnic groups, controlling for socio-
economic status at the individual and contextual levels. This research was unique in that
the trends show changes in health for the same individuals in racial and ethnic groups over
time, as young people age from adolescence into early adulthood, rather than snapshots of
different cohorts at a point in time.
Here I show two of the more critical trends in health among young people that have
important consequences for adult health. Figure 2 shows the trends in obesity among fe-
males. Obesity is measured similarly throughout this article using body mass index (BMI),
calculated as measured weight in kilograms divided by measured height in meters squared.
To handle the discrepant obesity definitions for adolescents and adults, the International
Obesity Task Force reference is used. This reference links childhood and adolescent BMI
centiles to the adult BMI cut point of 30 to determine obesity prevalence (Cole et al. 2000).
In adolescence, black females have the highest rates of obesity, followed by Native American
and Hispanic females, with whites and Asians having the lowest rates. As adolescents age
Figure 2. Trends in Obesity From Adolescence to Young Adulthood for Females, by Race and Ethnic-
ity (N = 5,719)
40
35
Black*†
30
Native American*
Hispanic*†
25
Percentage
White*
20
15
10
Asian*†
5
0
Adolescence Young Adulthood
Ages 13–19 Ages 18–26
(Wave II) (Wave III)
Source: Based on data from Harris et al. (2006).

*The Wave III estimate is significantly different from the Wave II estimate (p < .05).
†
The change over time is significantly different from the change for whites (p < .05).
Figure 3. Trends in Regular Smoking From Adolescence to Young Adulthood for Males, by Race and
Ethnicity (N = 6,725)
35
White*
30
25
Native American*
Percentage
20
Asian*†
Hispanic*†
15
Black*†
10
0
Adolescence Young Adulthood
Ages 12–18 Ages 18–26
(Wave I) (Wave III)
Source: Based on data from Harris et al. (2006).

*The Wave III estimate is significantly different from the Wave I estimate (p < .05).
†
The change over time is significantly different from the change for whites (p < .05).
into young adulthood, obesity increases for all ethnic groups, but more so for black, Native
American, and Hispanic females than for white and especially Asian females. In addition,
the disparities increase during this transition as the lines fan out.
Trends in regular smoking, defined as smoking at least one whole cigarette daily dur-
ing the past 30 days, are shown in Figure 3. The trends reveal a dramatic rise in smoking
among young males as they transition from adolescence into young adulthood, but here
white males have the highest level of smoking in adolescence, and their rate of smoking
increases more so than that of the other racial and ethnic groups. Again, there is a widening
of the disparities over time.
These findings are indicative of a general trend of worsening health during the transition
to adulthood, a result we did not expect. On the positive side, we found levels of depression,
suicidal thoughts, violence, and self-reports of poor health to decline between adolescence
and young adulthood. The more dominant pattern, however, was declining health. As
adolescents age into their early and mid-20s, they are less likely to eat breakfast; are more
likely to eat fast food, exercise less, become obese, and have no health insurance; are more
likely not to get regular physical check-up, dental check-ups, or health care when needed;
and are more likely to have asthma, have STDs, smoke cigarettes, use marijuana, use hard
drugs, and binge drink (Harris et al. 2006). We drew two conclusions from this research.
First, the transition to adulthood may be an especially critical period for setting health tra-
jectories for the adult life course. Second, increasing disparities during this period suggest
that health may be a marker for social stratification as young people move into adulthood.
HEALTH AMONG THE YOUNG

Much of health research focuses on health at the very beginning of life and the end of life,
when health and mortality risks are greatest, shown in the familiar J-shaped mortality curve
Figure 4. Total Number of Deaths, by Age: United States, 2005
100,000
10,000
Deaths (log rate)
1,000
100
10
4
<1
14
+
–5
1–
–2
–3
–4
–6
–7
–8
85
5–
45
15
25
35
55
65
75
Age (years)
Source: National Vital Statistics System–Mortality, CDC/National Center for Health Statistics.
for all deaths in 2005 in Figure 4. This focus makes sense, but recent social, economic,
developmental, and epidemiologic changes call for a better understanding of health at the
point in life when young people begin to make their own decisions about their behavior
and begin to choose their own environments, at the point when mortality begins to turn
upward, after age 14 or so.
I want to make a case for the importance of the life stage of adolescence and the
transition to adulthood for understanding health across the life course. Adolescence is a tran-
sitional stage of physical and mental human development that occurs between childhood and
adulthood and is the point in the life course when young people begin to gain some autonomy
to make decisions that impact their health. Adolescence is characterized by establishing
independence from one’s parents and family, exploring new lifestyles and environments,
and developing new friendships and intimate relationships (Furstenberg 2000).
As parental monitoring loosens, adolescents gain more control over their environments
and select their friends and friendship networks, romantic and sexual partners, school and
community activities, cultural contexts, and educational tracks. They also begin to make
behavioral choices involving schoolwork and studying and how to spend leisure time
in both healthy (reading, exercise, arts, safe sex) and unhealthy ways (drugs, smoking,
drinking, watching TV, eating junk food, risky sex). These developmental experiences are
normative and help prepare the adolescent for adulthood. However, recent decades have
witnessed a lengthening in the transition from adolescence to adulthood, with important
implications for health.
Transitions that typically mark the onset of adulthood—leaving home, finishing
school, starting work, getting married, and having children—have been occurring at later
and later ages, and in a more diverse and disordered sequence (Rindfuss 1991; Settersten,
Furstenberg, and Rumbaut 2005). As a result, the transition from adolescence to adulthood
has continued well into the third decade of life. As this transition has lengthened, so has
the period of time during which young people continue to engage in health-risk behavior
and expose themselves to health risks, with potential health consequences in adulthood
(Bachman et al. 1997; Schulenberg, Maggs, and Hurrelmann 1997). Findings from our
research on health disparities during the transition to adulthood provide substantial evi-
dence of continuing and, in most cases, increased involvement in risk behavior and rising
health risks as adolescents transition to adulthood (Harris et al. 2006).
At the same time that we observe these health patterns during the lengthening transi-
tion to adulthood, there is evidence that disease onset has shifted down the age spectrum
into these young ages for a number of crucial health conditions. Diabetes has become more
prevalent at younger and younger ages, reflecting the dramatic rise in obesity in the United
States (Cook et al. 2003; Duncan 2006; Pinhas-Hamiel et al. 1996). In the past decade,
diabetes has increased by 63% among 20- to 39-year-olds, compared with an increase of
22% for older ages (Centers for Disease Control and Prevention 2008; National Center for
Health Statistics 2009). Hypertension and kidney disease, diseases typically associated with
aging, are becoming more common among young people (Coresh et al. 2005; Muntner et
al. 2004). In the past decade, hypertension increased by 30% among 20- to 34-year-old
males, compared with 23% for older males; and poor kidney function increased by 49% for
20- to 39-year-olds, compared with no change for those in the adjacent 40–59 age group
(National Center for Health Statistics 2009). Inactivity and lack of physical exercise histori-
cally increase with age. During the 1990s, however, the drop-off in physical exercise has
migrated into the adolescent and young adult ages (Andersen et al. 1998). These changes in
the social, behavioral, and epidemiologic contexts of young people’s lives will have impor-
tant implications for adult health and well-being, the focus of the remainder of this article.
AN INTEGRATIVE APPROACH TO HEALTH
To understand health among the young and its implications for future health and well-being
across the life course, I advocate for using an approach that bridges biomedical sciences
with social and behavioral sciences by bringing together the disciplinary strengths of each.
Biomedical scientists have monopolized the health field and much of the early research
on health disparities because health outcomes were primarily disease-focused, with more
emphasis on cure than on prevention (National Research Council 2001). As biomedical
scientists began to identify some of the proximate causes of disease, there was a growing
recognition of the importance of social and behavioral factors. Some examples are quite
obvious: smoking increases one’s risk of lung cancer, diet is related to diabetes, and stress
is an underlying factor in heart disease. Missing from biomedical science, however, were
the social, psychological, and behavioral factors that influence smoking, diet, and stress.
In parallel but separate spheres of research, social scientists were building an impres-
sive literature on the role of social factors in health. Important findings about the roles of
social support (House, Landis, and Umberson 1988), neighborhood and family disadvantage
(Marmot and Wilkinson 2005; Williams and Collins 2001), education (Kimbro et al. 2008),
and discrimination (Williams, Neighbors, and Jackson 2003) on health outcomes demon-
strate the fundamental import of the social world in health trajectories (House 2002; Marmot
2004; Williams and Jackson 2005). Missing in this research, however, are the biological
mechanisms that social factors interact with or operate through to affect health.
There are always exceptions, especially in our field. Researchers who study aging, in
particular, have been leaders in recognizing the importance of incorporating data and analy-
sis of biological processes in models of aging (National Research Council 2000, 2008). But
for the most part, researchers tend to work within the confines of their disciplinary theory,
study designs, and data, even though the topics they study are studied by researchers in
other disciplines with other but related theories and data. To break down these disciplinary
barriers, we need an integrative approach, and here I acknowledge the National Academy
of Sciences monograph on New Horizons in Health (National Research Council 2001),

edited by Burton Singer and Carol Ryff, that spells out the various themes and strategies
for achieving an integrative approach.
To understand health, broadly defined, we must understand the linkages between
social, behavioral, psychological, and biological factors in health. Within these domains,
integration should also occur at multiple levels of influence, at both the individual and con-
textual levels. To achieve these goals requires integration of these factors in all steps of the
research process: in theory, design, data collection, and analysis. Finally, integration needs
to occur across the life course. That is, to understand adult health, we need to understand
the origins of health trajectories in early life to map out predisease pathways—defined as
the biological influences and related links to behavioral, psychological, and social influ-
ences that precede morbidity and mortality.
To make my case for using an integrative approach in theory, design, data, and analysis,
I will use Add Health as an example of what can be achieved with an integrative approach
and to illustrate the importance of studying health among the young to identify the origins
of predisease pathways. Add Health is a national longitudinal study of more than 20,000
adolescents in grades 7–12 in 1995 who have been followed into young adulthood with three
follow-up waves of interviews. Waves I and II occurred in 1995–1996, when the sample was
in adolescence, the majority of whom were aged 12–19; Wave III occurred in 2001–2002,
when the Add Health cohort was aged 18–26 and making their transition to adulthood. The
recent Wave IV was completed in 2008, when the cohort was aged 24–32 and settling into
adulthood. (For more details on the design of Add Health, see Harris et al. 2009.)
THEORY AND DESIGN FOUNDATIONS OF AN INTEGRATIVE APPROACH

An integrative approach begins with theory and study design. The purpose of Add Health,
as mandated by Congress, was to explore how the social contexts of adolescent life influ-
ence the health and health behavior of young people. Theory suggested that the social
environment becomes especially important during adolescence as young people begin to
choose their environments and spend more time outside the family setting (Furstenberg
2000; National Research Council 1993). The design of Add Health captured the theoreti-
cal sources of environmental influence by measuring key factors in the social contexts of
adolescent life, including the family, peer, school, neighborhood, community, and romantic
and sexual relationship. Unique to Add Health as a social and behavioral study is that it
captured the social, psychological, and behavioral domains at these multiple levels, and it
included the biological domain in its original design. The following sections provide a few
illustrations of this integrative design.
Social
Add Health measured social, demographic, economic, and cultural factors of the individual
and his and her social environment, including the family, peer, romantic and sexual rela-
tionships, school, work, neighborhood, and government and policy contexts. Reflecting a
strength of population science, the Add Health design obtained independent measures of
characteristics of friends and peer networks, family, school, neighborhood, and the larger
community by including these clusters as part of the sampling design and not depending
on self-reports of the characteristics of these contexts.
Psychological
Add Health captured the emotional, mental, and cognitive dimensions of individuals, and
these factors can also be measured at the family, peer, school, and neighborhood levels.
Examples of factors in the psychological domain are personality, temperament, verbal
aptitude, affect, learning disabilities, future expectations, positive orientation, self-esteem,
and self-efficacy.
Behavioral
Add Health focused on health and attainment behaviors, beginning in adolescence and in-
corporating adult behaviors as the cohort aged. Coverage includes prosocial, healthy, and
health-risk behaviors; educational achievement; and demographic behavior. Behavioral
factors are also measured at multiple contextual levels of the family, school, peer network,
and neighborhood.
Biological
Because of the theoretical role that biology plays in health, the Add Health design included
the biological domain from the start by embedding a genetic sample of over 3,000 pairs of
adolescents with varying degrees of genetic resemblance, including identical and fraternal
twins, full siblings, half siblings, cousins, and adolescents growing up in the same house-
hold with no biological relationship. Theory specifies that environmental effects, such as
parenting or peer and neighborhood influences, on child outcomes are confounded with ge-
netic effects because parents and children share genes, and there is increasing evidence that
genes play a role in the selection of one’s social environments (Khoury, Beaty, and Cohen
1993; Plomin et al. 2001). When only the environmental effect is measured, the genetic
effect is included in the estimated environmental effect. The embedded genetic sample in
Add Health, however, allows researchers to parse out environmental from genetic influence
on health outcomes.
In adolescence, we also included standard indicators of physical development and
height and weight, from which we have been able to track body mass index and obesity
into adulthood. As the Add Health cohort aged, our design continued to incorporate the
biological domain that was theoretically relevant to the developmental stage of the cohort,
just as we did for factors in the social, psychological, and behavioral domains. At Wave III,
when the cohort was aged 18–26, the ages of highest risk for sexually transmitted infec-
tions, we collected biospecimens to test for sexually transmitted infections (STIs) and HIV.
To strengthen our genetic design, we collected buccal cell DNA for molecular analysis of
genetic and gene-environment interaction effects in health and health behavior.
At Wave IV, we focused on the major health risks of the cohort at this time: health-
risk behavior, obesity, and stress are the leading causes of present and future disease in
persons aged 24–32. Certain biological processes play roles in these diseases, and specific
biomarkers can be used to characterize these processes (Crimmins and Seeman 2000).
Known methods offer feasible ways of measuring these biomarkers in large, nonclinical
field settings such as Add Health, and we used these methods to greatly expand the bio-
logical domain at Wave IV to obtain objective measures of health status. For example, we
obtained markers of metabolic function (e.g., waist circumference, cholesterol, and blood
sugar), inflammation, immune function, and cardiovascular health (blood pressure and
pulse rate). We expanded our DNA collection to the entire sample and collected information
about prescription medications.
This integrative approach continues to capture the key theoretical social, behavioral,
psychological, and biological processes represented in the major health issues for
the ages of the Add Health cohort as they progress into adulthood. Moreover, the
integrative approach in theory and design allows for the integration of data to improve
measurement—two aspects we care a lot about in population research. Table 1 shows
prevalence estimates of hypertension and diabetes based on preliminary data collected in
Wave IV of Add Health, when the sample was 24–32 years old. By combining self-reports
with objective biological measures and pharmacologic data, we obtain a more valid
estimate of prevalence.
Self-reports of hypertension indicate that 10.6% of this adult population reported
receiving a diagnosis of hypertension. When we combine this report with medication use
Table 1. Prevalence Estimates of Selected Health Conditions Using Survey,

Biomarker, and Pharmacologic Data: Young Adults Aged 24–32
Health Condition Percentage
Hypertension
Use medication 3.4
Self-reported 10.6
Use medication or self-reported 11.4
Use medication, self-reported, SBP ≥ 160 or DBP ≥ 100a 13.3
Use medication, self-reported, SBP ≥ 140 or DBP ≥ 90a 24.8
Diabetes
Use medication 1.4
Self-reported 2.9
Use medication or self-reported 3.2
Use medication, self-reported, or glucose ≥ 200b 3.9
Use medication, self-reported, glucose ≥ 200, or HbA1c ≥ 6.5b 6.4
Source: National Longitudinal Study of Adolescent Health (Wave IV).
Note: Estimates are based on preliminary unweighted Wave IV data (N ranges from 200 to
15,000).
a
Stage 2 hypertension is classified as SBP ≥ 160 or DBP ≥ 100; stage 1 hypertension is classified
as SBP ≥ 140 or DBP ≥ 90 (Aram et al. 2003).
b
Random (nonfasting) glucose values ≥ 200mg/dL and HbA1c values ≥ 6.5% are cutoffs for
classification of diabetes (American Diabetes Association 2007).
for high blood pressure, prevalence rises slightly to 11.4%. When we combine these sur-
vey measures with objective biological measures from blood pressure (BP) readings and
use standard BP cutoffs recommended by the American Heart Association, the prevalence
of stage 2 hypertension rises to 13.3%; and those with stage 1 hypertension are almost
one-quarter of young people aged 24–32. We see similar gains in measuring all cases with
diabetes. Based on self-reports and medication use for diabetes, 3.2% are diabetic. Combin-
ing the survey data with objective biological measures of diabetes risk from glucose and
glycosylated hemoglobin (HbA1c) assays on a blood drop from a finger stick, the percent-
age with diabetes doubles to 6.4% in the 24- to 32-year-old population.
Self-reports severely underestimate the prevalence of these serious and growing health
conditions within the young adult population. Moreover, these health conditions lead to
future chronic illness and disease, and with an integrative design, we have the ability to
identify the social, psychological, behavioral, and biological precursors that make up pre-
disease pathways. In the next section, I show some glimpses of these early pathways with
preliminary data from Wave IV in Add Health.
PREDISEASE PATHWAYS AMONG THE YOUNG

Recent analyses of the causes of deaths in the United States indicate that the single great-
est opportunity to improve health and reduce premature deaths lies in personal behavior
(McGinnis and Foege 1993; Mokdad et al. 2004, 2005). Unhealthy behaviors account for
40% of premature deaths in the United States, with obesity, physical inactivity, and smok-
ing singled out as the most prevalent behavioral causes (Mokdad et al. 2004, 2005). I now
return to health during adolescence and young adulthood and focus on these particular
behaviors—smoking, physical inactivity, and obesity—among young people because of
their significant consequences for adult health and premature death.
Earlier, I argued that greater involvement in health-risk behavior during the prolonga-
tion of the transition to adulthood, and the creeping of health problems into the young ages,
have consequences for adulthood health in two ways. First, there is substantial evidence
that health tracks across the life course (Halfon and Hochstein 2002). Recall the worsening
trends in health status, behavior, and health care during the transition to adulthood that I
summarized earlier from our health disparities research (Harris et al. 2006). Health patterns
during the transition to adulthood may set health trajectories into adulthood. Second, health
during the transition to adulthood has important consequences for key social and economic
outcomes, including marriage, fertility, education, occupation, and income. Health in young
adulthood may increasingly become an important marker of social stratification. Below, I
show some hints of these two important consequences.
HEALTH TRACKS ACROSS THE LIFE COURSE

The next set of figures presents evidence of how health tracks across the life course.
Figure 5 extends the trajectory of obesity that I showed earlier for the adolescent and
young adulthood ages by adding the next point in adulthood at ages 24–32 for males and
females in Add Health. From adolescence into young adulthood, obesity doubled from
11% to 22% for both sexes. Over the next six years, the trajectory continued its upward
climb into adulthood, where obesity rose to 36% for males and 38% for females, with
a slightly growing and statistically significant sex gap. These aggregate patterns are the
result of both individual stability and increasing rates of entry into obesity. For example,
compared with those not obese, obese adolescents are nine times more likely to be obese
adults, and the rate of becoming obese increases 42% across these ages.
Figure 6 shows the cohort trajectory for levels of no bouts of physical activity from
adolescence into adulthood by sex. Physical activity is measured using a standard physical
activity behavior recall (Anderson et al. 1998). Lack of exercise, or no physical activity, is
Figure 5. Trends in Obesity From Adolescence to Adulthood, by Sex*
40
35
30
25 Female
Percentage
Male
20
15
10
0
Adolescence Young Adulthood Adulthood
Ages 13–19 Ages 18–26 Ages 24–32
(Wave II) (Wave III) (Wave IV)
Source: Add Health data (N∼14,000–15,000 at each wave; preliminary Wave IV data).
*The sex difference in the obesity trend is significant at p < .05.
Figure 6. Trends in No Bouts of Physical Activity From Adolescence to Adulthood, by Sex*
25
20
Percentage
15
10
Female
Male
5
0
Ages 12–18 Ages 18–26 Ages 24–32
(Wave I) (Wave III) (Wave IV)
*The sex difference in the physical inactivity trend is significant at p < .05.
defined by self-reports of no bouts of moderate to vigorous physical activity (5–8 metabolic

equivalents) per week. There is a dramatic drop-off in physical activity during the transi-
tion to young adulthood, when the percentage who get no exercise increases from 7% to
23% for females and from 5% to 15% for males. Physical activity levels improve slightly
in adulthood, and the sex gap narrows somewhat but remains significant. More importantly,
the relatively high levels of no exercise are set coming out of adolescence. Figure 7 presents
the trends for regular smoking. Again, we see that the prevalence of smoking levels off in
adulthood, but the levels are set and the significant sex disparity emerges in the transition
from adolescence into young adulthood.
Two important findings come out of these data. First, the largest increase in poor
health—as indicated by obesity, smoking, and lack of physical activity—occurred dur-
ing the transition from adolescence into young adulthood. As young people settle into
adulthood, levels of poor health behavior stabilize, with the exception of obesity, but that
level is set coming out of adolescence, a vulnerable time for health in early life. Second,
disparities by sex grow with age, and there is evidence of widening disparities in these
health behaviors across age for other population characteristics, such as race, ethnicity,
and socioeconomic status (Harris et al. 2006, 2009; Lee, Harris, and Gordon-Larsen 2009).
I have provided evidence that adolescence and the transition to adulthood can set
health trajectories into adulthood, but do these patterns matter for general health and dis-
ease risk given that young people are generally healthy, with low prevalence of disease
or chronic illness? I now turn to whether health trajectories from adolescence into young
adulthood are related to health outcomes in adulthood to further explore how health
tracks across the life course. In Figure 8, I examine the relationship between the obesity
trajectory from adolescence into young adulthood and markers of future disease in adult-
hood to begin to map predisease pathways. Markers of future disease are measured in
Wave IV, when the Add Health sample was 24–32 years old, by indicators of (1) diabetes,
(2) hypertension, (3) high cholesterol, and (4) sleep problems. Diabetes is indicated by
Figure 7. Trends in Regular Smoking From Adolescence to Adulthood, by Sex*
30
25
20
Percentage
15
Male
10 Female
0
Ages 12–18 Ages 18–26 Ages 24–32
(Wave I) (Wave III) (Wave IV)
*The sex difference in the regular smoking trend is significant at p < .05.
whether the respondent self-reported diabetes diagnosis, is taking medication for diabetes,
had a random glucose assay result of 200 or greater, or had a glycosylated hemoglobin
(HbA1c) assay result of 6.5 or greater (see Table 1). Hypertension is measured by self-re-
port of hypertension diagnosis, using medication for hypertension, having a systolic blood
pressure (SBP) reading greater than or equal to 160, or having a diastolic blood pressure
(DBP) reading of 100 or greater (i.e., stage 2 hypertension, see Table 1). Cholesterol is
measured by self-report only.2 Sleep problems are based on three questions that asked re-
spondents whether they have trouble falling asleep once per week or more; whether they
have trouble staying asleep through the night once per week or more; and whether they
snore or stop breathing during sleep. Severe sleep problems are indicated by those who
have all three of these problems (11%). Individual obesity trajectories from adolescence
(when the Add Health cohort was aged 13–19 in Wave II) to young adulthood (when they
were aged 18–26 at Wave III) are categorized into three groups: not obese (those who
were never obese or lost weight, 82%); become obese (those who became obese during
the transition to young adulthood, 10%); or always obese (those who were obese through-
out adolescence and young adulthood, 8%).
The results in Figure 8 generally show an increasing percentage that have diabetes,
hypertension, high cholesterol, and sleep problems, with increasing time obese in adoles-
cence and young adulthood. Poor metabolic function, represented by high cholesterol and
diabetes, is generally uncommon for young people aged 24–32, but those who are obese
as they enter adulthood, and especially those who begin their obesity trajectory in adoles-
cence, face much higher risks of these metabolic disorders in early adulthood. The increase
in hypertension is particularly dramatic among those in obese trajectories, doubling the
2. Blood spots were collected for assay of lipids in Add Health Wave IV, but these results were not available
at the time this article was prepared.
Figure 8. Obesity Trajectory From Adolescence to Young Adulthood Is Associated With Markers of
Future Disease in Adulthood (N∼11,600)
30
Not obese
Become obese
25
Always obese
20
Percentage
15
10
0
***Diabetes*** ***Hypertension*** High Sleep
***Cholesterol*** ***Problems***
Source: Add Health data (diabetes, hypertension, cholesterol, and sleep problems based on preliminary Wave IV data).
***The change in health outcome by obesity trajectory is significant at p < .001.
percentage of 9.2% for those not obese to 19.2% for those becoming obese in young adult-
hood, and tripling the percentage to 27.2% for those obese throughout adolescence and
young adulthood. The impact of obesity on quality of life and general health is furthermore
seen by the increase in severe sleep problems with longer obese trajectories.
Evidence indicates that cigarette smoking and sleep problems characterize predisease
pathways for cardiovascular disease risk (Young et al. 2002). Indeed, I find that smoking
during adolescence and the transition to adulthood and sleep problems in adulthood are
associated with hypertension in adulthood. Stage 1 hypertension (SBP ≥ 140 or DBP ≥ 90)
is higher in adulthood for those who smoked regularly during adolescence and young adult-
hood (25.2%) and higher for those who had sleep problems (29.7%) compared with those
who neither smoked nor had sleep problems (22.9%); but hypertension is highest for those
who both smoked throughout the transition from adolescence into young adulthood and
report sleep problems in adulthood (37.2%) (results not shown, but available on request).
These descriptive relationships between health trajectories in adolescence and the transi-
tion to adulthood and markers of future disease at such an early age in adulthood forebode
profound implications for future morbidity and chronic illness throughout adulthood, as
well as substantial medical care costs for the individual and society as a whole.
HEALTH IS A MARKER OF SOCIAL STRATIFICATION

Finally, I end with some hints of how health trajectories from adolescence into young
adulthood are associated with demographic outcomes and markers of social stratification in
adulthood. Table 2 provides descriptive data on the relationships among the three behavioral
Table 2. Health Trajectories From Adolescence Into Young Adulthood and Associated Markers of
Social Stratification in Adulthood
Wave IV Income Indicators
Wave IV Socioeconomic Status (%)
________________________________________ (mean $)
________________________________
Health Trajectory, Attended Finished Ever Own Household Personal Household
Wave I–Wave III College College Married Home Income Earnings Assets
Obesity
Not obese 69.3*** 37.1*** 48.7*** 41.2*** 65,894*** 41,484*** 93,615***
Always obese 57.4 20.2 42.2 31.7 54,064 34,525 68,916
Physical Activity
Active 68.5*** 34.8*** 49.3 41.3*** 64,237*** 40,987*** 90,551***
Never active 51.0 20.2 51.8 35.6 52,899 34,179 68,274
Smoking
Not regular smoker 71.4*** 39.4*** 48.5*** 41.1*** 64,992*** 41,561*** 91,899***
Always regular smoker 45.5 8.5 55.7 44.0 54,899 33,696 72,212
Overall Health
Gooda 76.4*** 46.5*** 48.4 43.3** 69,270 44,146 101,833***
b
Poor 58.0 21.8 48.9 37.6 57,519 35,863 74,398
N 11,445 11,445 11,432 11,427 10,714 9,029 10,285
Source: National Longitudinal Study of Adolescent Health (Waves I–III, preliminary Wave IV data).
a
None of the following characteristics throughout adolescence and into young adulthood: obese, not physically active, or
regular smoker.
b
One or more of the following characteristics throughout adolescence and into young adulthood: obese, not physically
active, or regular smoker.
**Significant difference at p < .01; ***significant difference at p < .001.
trajectories of obesity, physical activity, and regular smoking from adolescence to young
adulthood, with indicators of socioeconomic status and income at Wave IV in adulthood. In
this table, I contrast trajectories of good or improving health3 (not obese, physically active,
and not a regular smoker) with poor health (always obese, never physically active, and al-
ways a regular smoker) throughout adolescence and young adulthood. The rows for overall
health in Table 2 combine these three health behavior trajectories to characterize a “good
health” trajectory as having none of these health behaviors throughout adolescence and into
young adulthood (representing about one-half of the sample) compared with a “poor health”
trajectory with some or all of these behaviors. Social stratification measures are binary
indicators of ever attended college, finished college, ever married, and home ownership,
all measured at Wave IV. Income measures are presented as household income (respondent
income and income of everyone in the household who contributes to the household budget),
personal earnings (of those employed), and household assets (total value of respondent
assets and assets of everyone in the household who contributes to the household budget).
The overall findings show a strong and significant relationship between longitudinal
poor health trajectories in adolescence and through the transition to young adulthood and
social and economic outcomes in adulthood. For example, compared with those who were
3. An improving health trajectory includes those who have poor health in adolescence but better health
by young adulthood (e.g., obese in adolescence but not obese in young adulthood). This trajectory is relatively
uncommon.
not obese, young people who were obese during adolescence and the transition to adulthood
were significantly less likely to attend college (57.4% vs. 69.3%), finish college (20.2% vs.
37.1%), ever marry (42.2% vs. 48.7%), and own their own home (31.7% vs. 41.2%) in the
adulthood ages 24–32. Obesity is also associated with lower income; those who were obese
from adolescence into young adulthood had lower average household income ($54,064 vs.
$65,894) and personal earnings ($34,525 vs. $41,484), and substantially lower total house-
hold assets than those not obese.
Never engaging in physical activity from adolescence and into adulthood was also as-
sociated with a lower likelihood of attending college, finishing college, and owning a home,
as well as lower average household income, personal earnings, and total assets compared
with those who were physically active in adolescence and young adulthood. Adolescent
to young adulthood trajectories of regular smoking show the same negative relationship
with college attendance, college completion, and income indicators in adulthood, but have
a slightly positive association with ever married and home ownership compared with the
trajectory for not being a regular smoker.
Finally, longitudinal patterns of overall health based on the combination of these three
health trajectories shown in the rows for overall health in the table indicate higher social
status (with the exception of ever married) and income among those with “good” health
trajectories (i.e., those who were not obese, were physically active, and never smoked regu-
larly throughout adolescence and the transition to young adulthood), compared with those
who experienced any of these poor health behaviors during this life stage. The overall con-
sistency and strength of these descriptive results suggest the importance of health among
the young as a marker for social stratification early in the adult life course.
CONCLUSION
I have tried to make the case for using an integrative approach to health, broadly defined
as social, emotional, mental, and physical well-being; for studying health among the
young as an important marker for future health and well-being across the life course; and
for understanding health disparities among the young as both causes and consequences of
social stratification.
I want to encourage population scientists to embrace an integrative approach in
their research because population scientists bring strengths to this approach that other
disciplines do not. Population training and research is inherently transdisciplinary, so
these barriers are less of a problem in our field. We bring strengths in study design,
measurement, data collection, and analytic tools that are required to achieve an integra-
tive approach.
Population scientists are ideally positioned to show that behavioral and social pro-
cesses have broader significance and are fundamental to a comprehensive understanding
of disease etiology as well as the promotion of health and well-being. When behavioral
and social sciences are implicated in health, understanding becomes less disease-focused
and emphasizes the importance of “upstream” determinants of health and the opportunity
to intervene, modify risk factors, and foster prevention to promote health and well-being.
Incorporating the biological dimensions of health improves our understanding of the social
and behavioral dimensions of health and lends credibility to our findings that biomedical
scientists cannot ignore. But an integrative approach involves more than sticking biological
measures in with social, psychological, and behavioral measures in our models; it is more
than collecting biomarker data just because we can. An integrative approach brings together
biological sciences with social and behavioral sciences in its theory and design, data col-
lection, measurement, and analysis.
Many demographers have written about and conduct research that brings biology into
our models of social and behavioral phenomena, and there are two monographs on the
collection of biological data in social surveys (National Research Council 2000, 2008). In
this article, I have tried to articulate this integration as a research process and to advocate
for this integration in the study of health among the young. Research from Add Health
suggests that an especially critical time that sets health trajectories into adulthood occurs
during the transition from adolescence into young adulthood, when young people exercise
more control over the selection of their social environments and make behavioral choices
regarding their health. With an integrative foundation in theory and design, we will better
understand the social, psychological, behavioral, and biological origins and tracking of
predisease pathways that offer the promise of reducing future disease and chronic illness,
as well as social and economic inequalities.
The empirical examples I have used in this article primarily focus on individual health
trajectories over time and highlight the biological measures expanded in Wave IV of Add
Health. Other empirical evidence from Add Health illustrates the theoretical importance of
the social contexts for health trajectories that are facilitated in an integrative design. Re-
search has documented associations with obesity for peer networks (e.g., Cohen-Cole and
Fletcher 2008; Trogdon, Nonnemaker, and Pais 2008) and school context (e.g., Richmond
and Subramanian 2008). Health-risk behavior is associated with peers (e.g., Cleveland and
Wiebe 2003; Duncan, Harris and Boisjoly 2001), school context (Guilamo-Ramos et al.
2005), and neighborhood context (e.g., Nowlin and Colder 2007); and neighborhood effects
are related to sexual behavior (Cubbin et al. 2005). Moreover, exploration of the genetic
data in Add Health uncovered a gene-environment interaction of the dopamine transporter
gene, DAT1, with the proportion of the high school population who had had sex by age 16
in relation to the number of lifetime sex partners (Guo, Tong, and Cai 2008). Such evidence
of the role that peer, school, and neighborhood contexts play in health and health behavior
early in the life course emphasizes the need to track health trajectories as young people
move into and through adulthood in order to understand the enduring influence of social
context as a key element of the integrative approach to health.
Add Health is not the only study with an integrative approach, and it is not the only
study that allows population scholars to bridge biomedical and social sciences in their
research. I mentioned just a few of the rich and innovative studies breaking ground in
this area at the beginning of this article. Add Health is not the only study that begins to
examine health early in the life; the recent launching of the National Children’s Study is a
good example. The antecedents of predisease pathways likely begin before adolescence, in
childhood, at birth, in the womb, and in the health behavior and genetic profiles of parents.
To the extent that social, behavioral, psychological, and biological data can be collected
retrospectively or during these critical life stages, these rich data sources will further the
development and knowledge to be gained from an integrative approach for understanding
health trajectories of children. Inter- and intragenerational data from the biological and
extended family of origin (e.g., parents, siblings, children) will further add to the value of
the integrative design, and these data are possible in Add Health and other studies. These
and other exciting research opportunities are becoming available, and I expect population
scholars will become the leaders in this new scientific frontier.
To quote then President-Elect Obama in a 2008 address on his goals for his science
team, “The highest purpose of science is the search for knowledge, truth and a greater un-
derstanding of the world around us” (Science Team Rollout Radio Address, Chicago, IL,
December 17, 2008). Bringing it all together isn’t easy. Think big, but start small and build.
Putting the pieces together in an integrative approach from theory to design to data and
analysis will contribute more to science than the sum of its parts; it will advance knowledge
about the world around us and change the future for health research, politics, and policy.
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An Integrative Approach To Health

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AN INTEGRATIVE APPROACH TO HEALTH*

KATHLEEN MULLAN HARRIS

Figure 1. Congressional Appropriations to the National Institutes of Health (real dollars in

a. All NIH institutes and centers b. Selected institutes

Source: Oﬃce of Budget, National Institutes of Health.

FUNDING FOR RESEARCH ON HEALTH

Source: Based on data from Harris et al. (2006).

Source: Based on data from Harris et al. (2006).

HEALTH AMONG THE YOUNG

Figure 4. Total Number of Deaths, by Age: United States, 2005

of Sciences monograph on New Horizons in Health (National Research Council 2001),

THEORY AND DESIGN FOUNDATIONS OF AN INTEGRATIVE APPROACH

Table 1. Prevalence Estimates of Selected Health Conditions Using Survey,

PREDISEASE PATHWAYS AMONG THE YOUNG

HEALTH TRACKS ACROSS THE LIFE COURSE

Figure 5. Trends in Obesity From Adolescence to Adulthood, by Sex*

Figure 6. Trends in No Bouts of Physical Activity From Adolescence to Adulthood, by Sex*

defined by self-reports of no bouts of moderate to vigorous physical activity (5–8 metabolic

Figure 7. Trends in Regular Smoking From Adolescence to Adulthood, by Sex*

HEALTH IS A MARKER OF SOCIAL STRATIFICATION

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