Title: Examining Educational Attainment and Allostatic Load in Non-Hispanic Black Women
Version: 2 Date: 14 Oct 2021
Reviewer's report:
Comments to Authors
Manuscript title: Is Higher Education Worth the Stress? Differences in Black Women’s
Allostatic Load by Educational Attainment
Authors in this study analyzed data from 4,113 Black women from the National Health and
Nutrition Examination Survey (NHANES) years 1999-2018 and examined the associations
between allostatic load and education. It is an interesting study. Revisions are needed before
the publication.
Main comments
(1) I would recommend changing the title to “Educational Attainment and Allostatic Load in
Non-Hispanic Black Women”.
(2) English language editing is needed through whole manuscript.
Abstract
• Line 2: Please clarify “these” here; you may want to change to “related factors” instead of
“these factors”.
• Line 12: How about the women with education of Master degree or higher?
• Line 13: It is better to add the values of prevalence of high allostatic load and age adjusted mean
allostatic load scores in Black women with lower education attainment as the comparisons, such
as (31.8% vs XXX%) and mean=1.90 vs. mean =XXX).
• The last sentence is unclear, please rewrite.
Introduction
• Please move the sentence in the first paragraph, “This suggests Black women’s bodies
are enduring compounding stress earlier and often due to their intersecting racialized social,
economic, and positioning.”, to discussion section.
• Please clarify that do you mean of “seeking pregnancy”? Please interpret why women who
seek pregnancy had worsen situation. Black pregnant women are not the focus, aren’t they?
Please clarify.
• What is “two-to three”, is this typo?
Methods
• Please change the “cross-sectional analysis” to “statistical analysis with cross-sectional data”
• In “Outcome Variable: Allostatic Load Definition”, Please delete the word “Definition”.
• In page 8 line 2: Please consider to separate the description of covariates in another paragraph.
Results
• Line 4:  Please change to “……an associate’s degree was 35.7% (weighted);…..”?
Table 1
• Do you have women who are educated above the college graduate? Please clarify.
• Please double check for the unit of BMI.
• Please re-present the Table 1. It is hard to read the current Table 1; some of the notes can be
moved to methods section such as “(2) Allostatic load total score was calculated as sum total of
components based on high-risk thresholds: albumin, BMI, creatinine clearance, diastolic blood
pressure, glycated hemoglobin, systolic blood pressure, total cholesterol, triglycerides. Score
ranges from 0 to 8.”
• Authors may present “mean (SD) after the variable name. For example, BMI, mean (SD);
Current Smoker Status (%).
• In page 12: Not sure it is good to use the word “Prevalence” for “Prevalence of high allostatic
load”; consider using the word “proportion” instead? Please clarify.
• In page 14: How about the women with education of Master degree or higher? Please clarify.
Discussion
• Please rewrite the discussion section to more focusing on the discussions of your main finding
-the association of education and AL in Black women; compare with other previous studies; the
limitations of the current study; implications for future research etc.
• Authors stated that “The objective of this study was to elucidate whether education moderated
levels of AL among a nationally representative sample of NH-Black women. ”. Please clarify
this sentence; education moderated the levels of AL? I would recommend to delete this sentence.
• Please change the word of highest to higher
• In pages 16-17, authors stated that “Previous studies have approximated the cumulative effects
of chronic life stressors or perceived racial discrimination as allostatic load (AL) to explain the
prolonged activation of the body’s natural stress response (1). Some have examined the impact
of high AL on a secondary outcome of interest, such as disease states or mortality risk (2, 5,
17), while others have correlated demographic characteristics such as age, race, gender, and
poverty status with predicted AL scores (6). Recently, Moore et al. found age-adjusted mean
AL scores to be highest among Non-Hispanic Black women at the end of a 30-year period (4).
The feasibility of sampling NHANES with congruent component AL data allowed for further
study on the link between educational attainment and AL of a race-gender-specific subgroup.
Significant variation exists in the degree to which studies disaggregate NH-Black women from
other demographic groups.”. This sentence is unclear and I would recommend to delete it.