News of the death of Elizabeth Barrett-Connor, Distinguished Professor in the Department of Family Medicine and Public Health at University of California San Diego (UCSD) School of Medicine at her home in La Jolla, California, USA, was announced in June 2019. Described by the New York Times as a ‘scrutinizer of aging’  Elizabeth was a pioneering epidemiologist, a mentor to many younger colleagues—and much more besides.
The essentials of Elizabeth’s early career have been well chronicled [1,2]. She received her medical degree from Cornell University in 1960 and completed her internship and residency training in internal medicine at the University of Texas. As a faculty member of the University of Miami she published on the epidemiology of infectious diseases following a National Institutes of Health postdoctoral fellowship at the London School of Hygiene & Tropical Medicine. Elizabeth joined UCSD in 1970 alongside her paediatrician husband Dr James Connor. Once she was on the academic staff the eminent lipidologist Daniel Steinberg invited Elizabeth to be the epidemiologist for a population-based study in Rancho Bernardo, a planned suburban community to the northeast of San Diego .
And so Elizabeth became inextricably associated with what was to be known the Rancho Bernardo Study (RBS) of Healthy Aging. Initiated in 1972 as one of 12 Lipid Research Clinic Prevalence Study sites, this longitudinal study ran under Elizabeth’s direction for more than four decades. She assembled a world class team of investigators and expanded the scope of the RBS to include sex steroids and a range of cardiovascular and metabolic biomarkers. When adipocytokine (leptin and adiponectin) measurements became available on the RBS cohort I was pleased to find Elizabeth receptive to the idea of accommodating a visiting scholar to test hypotheses concerning polycystic ovary syndrome and cardiometabolic disease in later life. This project aligned with Elizabeth’s interest in midlife biology and the impact of the menopause on cardiometabolic biomarkers and cardiovascular risk among women.
The RBS is noteworthy for several other features. At the time of its inception, few cohort studies included female sex or hyperglycaemia as risk factors . Elizabeth ensured that exploring the associations of sex and diabetes with cardiovascular disease became central features of the RBS. Elizabeth was also credited as being among the earliest researchers to recognize the importance of considering lifestyle, eg. dietary habits, physical activity, and psycho-social factors including educational attainment. Admittedly, the homogeneity of the RBS cohort of > 6000 residents could be regarded as something of a two-edged sword. RBS enrolled 82% of residents aged 30–79 years of Rancho Bernardo. Because Rancho Bernardo was marketed as a retirement community, participants had moved there from all parts of the United States; half were aged 60 and older. The participants, who completed questionnaires and attended for research clinic visits every few years, were almost entirely White Caucasian and middle class in terms of socioeconomic status. While these characteristics may have served to facilitate the success of RBS over the decades , questions about the generalizability of the results to more diverse populations were inevitable. This caveat notwithstanding, the output of influential original papers (Elizabeth was author or co-author of > 1000 publications) has been highly influential in creating awareness of hitherto unidentified or underappreciated aspects of population health and opening new avenues of research well beyond the confines of the RBS, as confirmed in many other studies. Early RBS reports determined the relative associations of fasting and post-challenge (oral glucose tolerance tests) hyperglycaemia to subsequent cardiovascular disease, and how diabetes overrides the intrinsic cardioprotection enjoyed by women. Loss of female cardioprotection in the context of diabetes was attributed to a higher prevalence of clustering of modifiable classic cardiovascular disease risk factors, ie. high blood pressure, hypertriglyceridaemia, obesity, and smoking. Insights into the associations of altered sex steroid profiles with cardiovascular risk factor in both sexes were aided by the application of sensitive laboratory assays. Even today, several thousand RBS participants continue to be followed. Over time, the scope of the RBS extended into new areas of research such as bone metabolism, dementia, and more recently fatty liver disease (based on computed tomography scans that originally assessed coronary calcification).
All who knew Elizabeth would, I feel sure, attest to her fierce belief in rigorous scientific methodology and data interpretation. She was regarded as a formidable academic figure and this stature was reflected in numerous prestigious awards . In my experience, an intense interest in life in all its manifestations was also evident. Certainly, she was devoted to her family and took a keen interest in those under her mentorship. Moreover, alongside her intellectual prowess lay something of a mischievous sense of humour allied to a world view grounded in common sense. One anecdote has Elizabeth explaining to a prospective researcher whose background was in paediatrics that she wanted a physician to work on the public health issues of older men. In the opinion of Elizabeth, older men behaved like children so she was sure her new junior colleague would enjoy the project! She was proved right; this encounter was also a demonstration of Elizabeth’s mastery in identifying strengths and potential in new researchers.
Elizabeth’s death will be keenly felt by everyone associated with Cardiovascular Endocrinology & Metabolism; the journal was honoured when Elizabeth graciously accepted an invitation to join the international editorial board. On behalf of the journal, it is my privilege to pay tribute to an outstanding epidemiologist and, on a more personal note, to acknowledge many valued years of friendship. I learned a great deal from Elizabeth. She will be missed.
The advice, encouragement, insights, and recollections of Dr Denise von Mühlen, Dr Gail Laughlin and Dr Claudia Langenberg are gratefully acknowledged. A.J.K. was supported by a British Heart Foundation International Research Fellowship.
Conflicts of interest
A.J.K. is a Clinical Instructor at the University of California San Diego.
2. Khaw KT. Elizabeth Barrett-Connor: instrumental contributor to the understanding of midlife well-being and health in both women and men. Diabetes Care. 2019; 42:502–506
3. Barrett-Connor E. The Rancho Bernardo Study: 40 years studying why women have less heart disease than men and how diabetes modifies women’s usual cardiac protection. Glob Heart. 2013; 8. doi: 10.1016/j.gheart.2012.12.002