Neighborhood Environments and Diabetes Risk and Control

Comparing Global and Spatial Composite Measures of Neighborhood Socioeconomic Status Across US Counties

Area-level neighborhood socioeconomic status (NSES) is often measured without consideration of spatial autocorrelation and variation. In this paper, we compared a non-spatial NSES measure to a spatial NSES measure for counties in the USA using principal component analysis and geographically weighted principal component analysis (GWPCA), respectively. We assessed spatial variation in the loadings using a Monte Carlo randomization test. The results indicated that there was statistically significant variation (p = 0.004) in the loadings of the spatial index. The variability of the census variables explained by the spatial index ranged from 60 to 90%. We found that the first geographically weighted principal component explained the most variability in the census variables in counties in the Northeast and the West, and the least variability in counties in the Midwest. We also tested the two measures by assessing the associations with county-level diabetes prevalence using data from the CDC's US Diabetes Surveillance System. While associations of the two NSES measures with diabetes did not differ for this application, the descriptive results suggest that it might be important to consider a spatial index over a global index when constructing national county measures of NSES. The spatial approach may be useful in identifying what factors drive the socioeconomic status of a county and how they vary across counties. Furthermore, we offer suggestions on how a GWPCA-based NSES index may be replicated for smaller geographic scopes.

Long-term exposure to objective and perceived residential greenness and diabetes mortality: A census-based cohort study

BACKGROUND

Residing close to green spaces might reduce diabetes mellitus (DM) risk; however, evidence for diabetes mortality is limited. Moreover, individual and neighbourhood social factors may determine DM risk. Exposure to green spaces may also depend on socioeconomic position (SEP). This study examined the associations between residential greenness and diabetes-related mortality, and the role of the social environment in these associations.

METHODS

We used the 2001 Belgian census linked to mortality register data for the period 2001-2014. We included individuals aged 40-79 years old and residing in the five largest Belgian urban areas at baseline. Exposure to residential greenness was assessed with surrounding greenness using the Normalized Difference Vegetation Index (NDVI) within 500-m of residence (objective indicator), and perceived neighbourhood greenness (subjective indicator). We conducted mixed-effects Cox proportional hazards models to obtain hazard ratios (HR) for diabetes-related mortality per interquartile range (IQR) increments of residential greenness. We assessed effect modification by social factors through stratification.

RESULTS

From 2,309,236 individuals included at baseline, 1.2% died from DM during follow-up. Both residential greenness indicators were inversely associated with diabetes-related mortality after adjustment for individual social factors. After controlling for neighbourhood SEP, the beneficial association with surrounding greenness disappeared [HR 1.02 (95%CI:0.99,1.06)], but persisted with perceived neighbourhood greenness [HR 0.93 (95%CI:0.91,0.95)]. After stratification the inverse associations with perceived neighbourhood greenness were strongest for women, the lowest educated, and individuals residing in least deprived neighbourhoods.

CONCLUSIONS

Our findings suggest that an overall positive perception of neighbourhood green spaces reduces independently the risk of diabetes-related mortality, regardless of the neighbourhood social environment. Nevertheless, neighbourhood SEP may be a strong confounder in the associations between diabetes-related mortality and greenness indicators derived from satellite images. Perception factors not captured by objective measurements of green spaces are potentially relevant in the association with DM, especially among disadvantaged groups.

Neighborhood Socioeconomic Environment and Risk of Type 2 Diabetes: Associations and Mediation Through Food Environment Pathways in Three Independent Study Samples

OBJECTIVE

We examined whether relative availability of fast-food restaurants and supermarkets mediates the association between worse neighborhood socioeconomic conditions and risk of developing type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

As part of the Diabetes Location, Environmental Attributes, and Disparities Network, three academic institutions used harmonized environmental data sources and analytic methods in three distinct study samples: 1) the Veterans Administration Diabetes Risk (VADR) cohort, a national administrative cohort of 4.1 million diabetes-free veterans developed using electronic health records (EHRs); 2) Reasons for Geographic and Racial Differences in Stroke (REGARDS), a longitudinal, epidemiologic cohort with Stroke Belt region oversampling (N = 11,208); and 3) Geisinger/Johns Hopkins University (G/JHU), an EHR-based, nested case-control study of 15,888 patients with new-onset T2D and of matched control participants in Pennsylvania. A census tract-level measure of neighborhood socioeconomic environment (NSEE) was developed as a community type-specific z-score sum. Baseline food-environment mediators included percentages of 1) fast-food restaurants and 2) food retail establishments that are supermarkets. Natural direct and indirect mediating effects were modeled; results were stratified across four community types: higher-density urban, lower-density urban, suburban/small town, and rural.

RESULTS

Across studies, worse NSEE was associated with higher T2D risk. In VADR, relative availability of fast-food restaurants and supermarkets was positively and negatively associated with T2D, respectively, whereas associations in REGARDS and G/JHU geographies were mixed. Mediation results suggested that little to none of the NSEE-diabetes associations were mediated through food-environment pathways.

CONCLUSIONS

Worse neighborhood socioeconomic conditions were associated with higher T2D risk, yet associations are likely not mediated through food-environment pathways.

Impact of neighborhood socioeconomic status, income segregation, and greenness on blood biomarkers of inflammation

BACKGROUND

Neighborhood deprivation is linked with inflammation, which may explain poorer health across populations. Behavioral risk factors are assumed to largely mediate these relationships, but few studies have examined this. We examined three neighborhood contextual factors that could exert direct effects on inflammation: (1) neighborhood socioeconomic status, (2) an index of concentration at extremes (that measures segregation), and (3) surrounding vegetation (greenness).

METHODS

Using blood samples and addresses collected from prospective cohorts of 7,930 male (1990-1994) and 16,183 female (1986-1990) health professionals with at least one inflammatory marker, we prospectively linked neighborhood contextual factors to inflammatory biomarkers (adiponectin, C-reactive protein, interleukin-6, soluble tumor necrosis factor receptor-2). Log-transformed, z-scaled component measures were used to calculate an inflammation score. Neighborhood socioeconomic status and index of concentration of extremes were obtained from the 1990 decennial census and linked to participant addresses. Surrounding greenness was assessed from satellite data and focal statistics were applied to generate exposures within 270 m and 1230 m of the participants' address. We fit multiple linear regression models adjusting for demographic, clinical, and behavioral risk factors.

RESULTS

Higher neighborhood socioeconomic status was associated with lower inflammation score in women (β for interquartile range increase = -27.7%, 95% CI: -34.9%, -19.8%) and men (β = -21.2%, 95% CI: -31.0%, -10.1%). Similarly, participants in neighborhoods with higher concentrations of high-income households were associated with lower inflammation score in women (β = -27.8%, 95% CI: -35.8%, -18.7%) and men (β = -16.4%, 95% CI: -29.7%, -0.56%). Surrounding greenness within 270 m of each participant's address was associated with lower inflammation score in women (β = -18.9%, 95% CI: -28.9%, -7.4%) but not men. Results were robust to sensitivity analyses to assess unmeasured confounding and selection bias.

DISCUSSION

Our findings support the hypothesis that adverse neighborhood environments may contribute to inflammation through pathways independent of behavioral risk factors, including psychosocial stress and toxic environments.

Social Determinants of Health, Race, and Diabetes Population Health Improvement: Black/African Americans as a Population Exemplar

PURPOSE OF REVIEW

To summarize evidence of impact of social determinants of health (SDOH) on diabetes risk, morbidity, and mortality and to illustrate this impact in a population context.

RECENT FINDINGS

Key findings from the American Diabetes Association's scientific review of five SDOH domains (socioeconomic status, neighborhood and physical environment, food environment, health care, social context) are highlighted. Population-based data on Black/African American adults illustrate persisting diabetes disparities and inequities in the SDOH conditions in which this population is born, grows, lives, and ages, with historical contributors. SDOH recommendations from US national committees largely address a health sector response, including health professional education, SDOH measurement, and patient referral to services for social needs. Fewer recommendations address solutions for systemic racism and socioeconomic discrimination as root causes. SDOH are systemic, population-based, cyclical, and intergenerational, requiring extension beyond health care solutions to multi-sector and multi-policy approaches to achieve future population health improvement.

Neighbourhood characteristics related to mental health service use among adults with diabetes: a population-based cohort study in New Brunswick, Canada

Objective

It has been postulated that social and economic inequalities may shape the distributions of comorbid diabetes and mental illness. This observational cohort study using linked population-based administrative and geospatial datasets aimed to describe associations between neighbourhood socioenvironments and disorder-specific mental health service use among adults with diabetes in the province of New Brunswick, Canada.

Results

A baseline cohort of 66,275 persons aged 19 and over living with diabetes was identified. One-quarter (26.3%) had used healthcare services for mood and anxiety disorders at least once during the six-year follow-up period 2012/2013–2017/2018. Based on Cox proportional hazards models, the risk of mental health service contacts was significantly higher among those residing in the most materially deprived neighbourhoods [HR: 1.07 (95% CI: 1.01–1.14)] compared to those in the least so, and those in areas characterized with the highest residential instability [HR: 1.13 (95% CI: 1.05–1.22)] compared to those in areas with the lowest instability. Among adults with incident diabetes (N = 4410), age and sex but not neighbourhood factors were related to differential help-seeking behaviours for mental health problems. These findings underscored the gap between theoretical postulations and population-based observations in delineating the syndemics of neighbourhood socioenvironments and mental health outcomes in populations with high diabetes prevalence.

The impact of neighborhood context on telomere length: A systematic review

A growing body of research demonstrates the association between neighborhood context and health. The underlying biological mechanisms of this association are not fully understood. We conducted a systematic review of studies that investigated the association between neighborhood context and telomere length (TL), a DNA-protein complex that shortens after cell division. Short TL is linked to age-related diseases and may be impacted by chronic stress. Nineteen eligible articles identified through PubMed and Scopus met inclusion criteria. Results demonstrated inconsistent support for the relationship between neighborhood disadvantage and short TL. However, findings across several studies provide evidence for an inverse association between perceived neighborhood problems and TL, suggesting that TL may be an important factor in understanding health vulnerabilities associated specifically with negative perceptions of the neighborhood context.

Environmental risk factors of type 2 diabetes-an exposome approach

Type 2 diabetes is one of the major chronic diseases accounting for a substantial proportion of disease burden in Western countries. The majority of the burden of type 2 diabetes is attributed to environmental risks and modifiable risk factors such as lifestyle. The environment we live in, and changes to it, can thus contribute substantially to the prevention of type 2 diabetes at a population level. The 'exposome' represents the (measurable) totality of environmental, i.e. nongenetic, drivers of health and disease. The external exposome comprises aspects of the built environment, the social environment, the physico-chemical environment and the lifestyle/food environment. The internal exposome comprises measurements at the epigenetic, transcript, proteome, microbiome or metabolome level to study either the exposures directly, the imprints these exposures leave in the biological system, the potential of the body to combat environmental insults and/or the biology itself. In this review, we describe the evidence for environmental risk factors of type 2 diabetes, focusing on both the general external exposome and imprints of this on the internal exposome. Studies provided established associations of air pollution, residential noise and area-level socioeconomic deprivation with an increased risk of type 2 diabetes, while neighbourhood walkability and green space are consistently associated with a reduced risk of type 2 diabetes. There is little or inconsistent evidence on the contribution of the food environment, other aspects of the social environment and outdoor temperature. These environmental factors are thought to affect type 2 diabetes risk mainly through mechanisms incorporating lifestyle factors such as physical activity or diet, the microbiome, inflammation or chronic stress. To further assess causality of these associations, future studies should focus on investigating the longitudinal effects of our environment (and changes to it) in relation to type 2 diabetes risk and whether these associations are explained by these proposed mechanisms.

Changes in the Retail Food Environment in Mexican Cities and Their Association with Blood Pressure Outcomes

Shifting food environments in Latin America have potentially contributed to an increase in the consumption of ultra-processed foods and sugar-sweetened beverages, along with decreases in healthy foods, such as fruits and vegetables. Yet, little is known about the impact that such changes in the food environment have on blood pressure in low- and middle-income countries, including Mexico. We utilized individual-level systolic and diastolic blood pressure (SBP and DBP) measures from the 2016 Mexican Health and Nutrition Survey (ENSANUT, n = 2798 adults). Using an inventory of food stores based on the economic census for 2010 and 2016, we calculated the change in the density of fruit and vegetable stores, convenience stores, and supermarkets. Multilevel regression was used to estimate the association between the 2010–2016 food environment neighborhood-level changes with individual-level blood pressure measured in 2016. Declines in neighborhood-level density of fruit and vegetable stores were associated with higher individual SBP (2.67 mmHg, 95% CI: 0.1, 5.2) in unadjusted models, and marginally associated after controlling for individual-level and area-level covariates. Increases in the density of supermarkets were associated with higher blood pressure outcomes among adults with undiagnosed hypertension. Structural interventions targeting the retail food environment could potentially contribute to better nutrition-related health outcomes in Latin American cities.

Modeling annual elevated blood lead levels among children in Maryland in relation to neighborhood deprivation

Estimating environmental lead exposure using ecologic risk models is an inexpensive strategy to inform public health departments and to develop location-based intervention strategies such as targeted screening and mitigation. Importantly, studies in this area have not assessed temporal and spatio-temporal lead exposure risk trends. Due to lead abatement efforts and targeted screening efforts, it is anticipated that lead exposure risk has decreased over time. However, it is unknown if decreases have occurred, and if the decreases are evenly distributed across neighborhoods. Thus, the purpose of this study was to examine the association between neighborhood deprivation and risk of elevated blood lead levels (EBLLs) in both temporal and spatio-temporal contexts within the US state of Maryland in 2005-2015. To consider the temporal dimension of lead risk, we used a novel extension of Bayesian index models to estimate time-varying neighborhood deprivation indices along with time-varying index effects. The results showed that overall EBLL proportion decreased over time, from a high of 0.11 in 2006 to a low of 0.02 in 2015. The association between neighborhood deprivation and EBLL risk was positive and significant annually, but generally diminished over time. The most important variables in the neighborhood deprivation index were percent of houses built before 1940 and median household income. In summary, using Bayesian index models that can account for both temporal and spatio-temporal contexts is a promising approach to inform public health efforts to remediate lead and focus testing efforts and may be useful in studies in other geographic areas and times.

Neighborhood greenspace and risk of type 2 diabetes in a prospective cohort: the Multi-Ethncity Study of Atherosclerosis

BACKGROUND

Neighborhood greenspaces provide opportunities for increased physical activity and social interaction, and thus may reduce the risk of Type 2 diabetes. However, there is little robust research on greenspace and diabetes. In this study, we examine the longitudinal association between neighborhood greenspace and incident diabetes in the Multi-Ethnic Study of Atherosclerosis.

METHODS

A prospective cohort study (N = 6814; 2000-2018) was conducted to examine the association between greenspace, measured as annual and high vegetation season median greenness determined by satellite (Normalized Difference Vegetation Index) within 1000 m of participant homes, and incident diabetes assessed at clinician visits, defined as a fasting glucose level of at least 126 mg/dL, use of insulin or use of hypoglycemic medication, controlling for covariates in stages. Five thousand five hundred seventy-four participants free of prevalent diabetes at baseline were included in our analysis.

RESULTS

Over the study period, 886 (15.9%) participants developed diabetes. Adjusting for individual characteristics, individual and neighborhood-scale SES, additional neighborhood factors, and diabetes risk factors, we found a 21% decrease in the risk of developing diabetes per IQR increase in greenspace (HR: 0.79; 95% CI: 0.63, 0.99).

CONCLUSIONS

Overall, neighborhood greenspace provides a protective influence in the development of diabetes, suggesting that neighborhood-level urban planning that supports access to greenspace--along with healthy behaviors--may aid in diabetes prevention. Additional research is needed to better understand how an area's greenness influences diabetes risk, how to better characterize greenspace exposure and usage, and future studies should focus on robust adjustment for neighborhood-level confounders.

'Gentrification is not improving my health': a mixed-method investigation of chronic health conditions in rapidly changing urban neighborhoods in Austin, Texas

Though there are extensive studies on neighborhood effects on health, this relationship remains elusive and requires continuous empirical evidence to support existing findings. Gentrification is a process of neighborhood change that affects most longtime residents. This study examined the health impact of the rapidly changing physical and cultural environment using oral history interviews, electronic interviews, and a quantitative structured survey. The study draws on the social determinants of health framework to explain the self-reported chronic health conditions (SR-CHCs) among 331 residents in Austin, Texas. The study employed non-linear techniques suitable for Poisson distribution to estimate the association between gentrification and SR-CHCs and complemented by direct quotes from in-depth interviews (IDIs). Perceived gentrification score significantly vary by marital status (p < 0.001), educational attainment (p < 0.001), and gender (p < 0.01), while SR-CHCs only significantly varies by educational attainment, p = 0.015). Multivariate results show that gentrification was positively associated with SR-CHCs, after adjusting for socioeconomic variables. Compared to the Hispanics, blacks were 97% more likely to report multiple counts of SR-CHCs (IRR = 1.969, 95% CI 1.074-3.608), and participants with high household income were 8% less likely to report multiple CHCs (IRR = 0.920, 95% CI 0.870-0.973). Drawing from the empirical findings, this study recommends both area-based and individual-level policies to mitigate neighborhood change's impact on residents' health. Finally, this study further adds to the understanding of social determinants of health in understanding chronic health within the changing urban physical and socio-ecology systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10901-021-09847-8.

Exercise facilities and the prevalence of obesity and type 2 diabetes in the city of Madrid

AIMS/HYPOTHESIS

We aimed to study the association between the availability of exercise facilities and the likelihood of obesity and type 2 diabetes in the adult population of Madrid, Spain.

METHODS

We analysed the electronic medical records of all 1,270,512 residents of Madrid aged 40-75 years in 2017. Exercise facility availability was defined as the count of exercise facilities in a 1000 m street network buffer around each residential building entrance. Poisson regression with standard errors clustered at census tract level was used to assess prevalence ratios of exercise facility availability tertiles and obesity and type 2 diabetes. We also examined stratified results by tertiles of area-level socioeconomic status (SES) and sex.

RESULTS

People living in areas with lower availability of exercise facilities had a higher prevalence of obesity (prevalence ratio [PR] 1.22 [95% CI 1.20, 1.25]) and diabetes (PR 1.38 [95% CI 1.34, 1.43]). We observed effect modification by area-level SES (p<0.001), with stronger associations for residents living in low-SES areas and no association for residents living in high-SES areas. Associations with type 2 diabetes were stronger among women compared with men, while associations with obesity were similar by sex.

CONCLUSIONS/INTERPRETATION

People living in areas with low availability of exercise facilities had a higher prevalence of obesity and type 2 diabetes, and this association was strongest in low-SES areas and for women. Understanding the potential role of exercise facilities in driving inequities in obesity and type 2 diabetes prevalence may inform interventions to reduce health inequities.

Association Between Area-Level Socioeconomic Deprivation and Diabetes Care Quality in US Primary Care Practices

IMPORTANCE

Diabetes management operates under a complex interrelationship between behavioral, social, and economic factors that affect a patient's ability to self-manage and access care.

OBJECTIVE

To examine the association between 2 complementary area-based metrics, area deprivation index (ADI) score and rurality, and optimal diabetes care.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed the electronic health records of patients who were receiving care at any of the 75 Mayo Clinic or Mayo Clinic Health System primary care practices in Minnesota, Iowa, and Wisconsin in 2019. Participants were adults with diabetes aged 18 to 75 years. All data were abstracted and analyzed between June 1 and November 30, 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome was the attainment of all 5 components of the D5 metric of optimal diabetes care: glycemic control (hemoglobin A1c <8.0%), blood pressure (BP) control (systolic BP <140 mm Hg and diastolic BP <90 mm Hg), lipid control (use of statin therapy according to recommended guidelines), aspirin use (for patients with ischemic vascular disease), and no tobacco use. The proportion of patients receiving optimal diabetes care was calculated as a function of block group-level ADI score (a composite measure of 17 US Census indicators) and zip code-level rurality (calculated using Rural-Urban Commuting Area codes). Odds of achieving the D5 metric and its components were assessed using logistic regression that was adjusted for demographic characteristics, coronary artery disease history, and primary care team specialty.

RESULTS

Among the 31 934 patients included in the study (mean [SD] age, 59 [11.7] years; 17 645 men [55.3%]), 13 138 (41.1%) achieved the D5 metric of optimal diabetes care. Overall, 4090 patients (12.8%) resided in the least deprived quintile (quintile 1) of block groups and 1614 (5.1%) lived in the most deprived quintile (quintile 5), while 9193 patients (28.8%) lived in rural areas and 2299 (7.2%) in highly rural areas. The odds of meeting the D5 metric were lower for individuals residing in quintile 5 vs quintile 1 block groups (odds ratio [OR], 0.72; 95% CI, 0.67-0.78). Patients residing in rural (OR, 0.84; 95% CI, 0.73-0.97) and highly rural (OR, 0.81; 95% CI, 0.72-0.91) zip codes were also less likely to attain the D5 metric compared with those in urban areas.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that patients living in more deprived and rural areas were significantly less likely to attain high-quality diabetes care compared with those living in less deprived and urban areas. The results call for geographically targeted population health management efforts by health systems, public health agencies, and payers.

New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care

Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.

Identifying and Reducing Disparities in Young Adults With Diabetes

This article outlines how social and health care determinants can affect young adults with diabetes. The authors provide a detailed description of each determinant's influence on diabetes self-management and offer solutions to help mitigate these harmful effects.

What Do We Know about Inequalities in NAFLD Distribution and Outcomes? A Scoping Review

With prevalence high and rising given the close relationship with obesity and diabetes mellitus, non-alcoholic fatty liver disease (NAFLD) is progressively becoming the most common chronic liver condition worldwide. However, little is known about the health inequalities in NAFLD distribution and outcomes. This review aims to analyze health inequalities in NAFLD distribution globally and to assess the health disparities in NAFLD-related outcomes. We conducted a scoping review of global health inequalities in NAFLD distribution and outcomes according to gender/sex, ethnicity/race, and socioeconomic position from PubMed's inception to May 2021. Ultimately, 20 articles were included in the review, most (75%) of them carried out in the United States. Males were found to have a higher NAFLD prevalence (three articles), while available evidence suggests that women have an overall higher burden of advanced liver disease and complications (four articles), whereas they are less likely to be liver-transplanted once cirrhosis develops (one article). In the US, the Hispanic population had the highest NAFLD prevalence and poorer outcomes (seven articles), whereas Whites had fewer complications than other ethnicities (two articles). Patients with low socioeconomic status had higher NAFLD prevalence (four articles) and a higher likelihood of progression and complications (five articles). In conclusion, globally there is a lack of studies analyzing NAFLD prevalence and outcomes according to various axes of inequality through joint intersectional appraisals, and most studies included in our review were based on the US population. Available evidence suggests that NAFLD distribution and outcomes show large inequalities by social group. Further research on this issue is warranted.

Gendering Neighbourhood Marginalization Metrics in Mental Health Services Research: A Cross-Sectional Exploration of a Rural and Small Urban Population

Background: Little is known about the extent to which socioenvironmental characteristics may influence mental health outcomes in smaller population centres or differently among women and men. This study used a gender-based analysis approach to explore individual- and neighbourhood-level sex differences in mental health service use in a context of uniquely smaller urban and rural settlements. Methods: This cross-sectional analysis leveraged multiple person-based administrative health datasets linked with geospatial datasets among the population aged 1 and over in the province of New Brunswick, Canada. We used multinomial logistic regression to examine associations between neighbourhood characteristics with risk of service contacts for mood and anxiety disorders in 2015/2016, characterizing the areal measures among all residents (gender neutral) and by males and females separately (gender specific), and controlling for age group. Results: Among the province’s 707,575 eligible residents, 10.7% (females: 14.0%; males: 7.3%) used mental health services in the year of observation. In models adjusted for gender-neutral neighbourhood characteristics, service contacts were significantly more likely among persons residing in the most materially deprived areas compared with the least (OR = 1.09 [95% CI: 1.05–1.12]); when stratified by individuals’ sex, the risk pattern held for females (OR = 1.13 [95% CI: 1.09–1.17]) but not males (OR = 1.00 [95% CI: 0.96–1.05]). Residence in the most female-specific materially deprived neighbourhoods was independently associated with higher risk of mental health service use among individual females (OR = 1.08 [95% CI: 1.02–1.14]) but not among males (OR = 1.02 [95% CI: 0.95–1.10]). Conclusion: These findings emphasize that research needs to better integrate sex and gender in contextual measures aiming to inform community interventions and neighbourhood designs, notably in small urban and rural settings, to reduce socioeconomic inequalities in the burden of mental disorders.

Longitudinal Analysis of Neighborhood Food Environment and Diabetes Risk in the Veterans Administration Diabetes Risk Cohort

Importance

Diabetes causes substantial morbidity and mortality among adults in the US, yet its incidence varies across the country, suggesting that neighborhood factors are associated with geographical disparities in diabetes.

Objective

To examine the association between neighborhood food environment and risk of incident type 2 diabetes across different community types (high-density urban, low-density urban, suburban, and rural).

Design, Setting, and Participants

This is a national cohort study of 4 100 650 US veterans without type 2 diabetes. Participants entered the cohort between 2008 and 2016 and were followed up through 2018. The median (IQR) duration of follow-up was 5.5 (2.6-9.8) person-years. Data were obtained from Veterans Affairs electronic health records. Incident type 2 diabetes was defined as 2 encounters with type 2 diabetes International Classification of Diseases, Ninth Revision or Tenth Revision codes, a prescription for diabetes medication other than metformin or acarbose alone, or 1 encounter with type 2 diabetes International Classification of Diseases Ninth Revision or Tenth Revision codes and 2 instances of elevated hemoglobin A1c (≥6.5%). Data analysis was performed from October 2020 to March 2021.

Exposures

Five-year mean counts of fast-food restaurants and supermarkets relative to other food outlets at baseline were used to generate neighborhood food environment measures. The association between food environment and time to incident diabetes was examined using piecewise exponential models with 2-year interval of person-time and county-level random effects stratifying by community types.

Results

The mean (SD) age of cohort participants was 59.4 (17.2) years. Most of the participants were non-Hispanic White (2 783 756 participants [76.3%]) and male (3 779 555 participants [92.2%]). The relative density of fast-food restaurants was positively associated with a modestly increased risk of type 2 diabetes in all community types. The adjusted hazard ratio (aHR) was 1.01 (95% CI, 1.00-1.02) in high-density urban communities, 1.01 (95% CI, 1.01-1.01) in low-density urban communities, 1.02 (95% CI, 1.01-1.03) in suburban communities, and 1.01 (95% CI, 1.01-1.02) in rural communities. The relative density of supermarkets was associated with lower type 2 diabetes risk only in suburban (aHR, 0.97; 95% CI, 0.96-0.99) and rural (aHR, 0.99; 95% CI, 0.98-0.99) communities.

Conclusions and Relevance

These findings suggest that neighborhood food environment measures are associated with type 2 diabetes among US veterans in multiple community types and that food environments are potential avenues for action to address the burden of diabetes. Tailored interventions targeting the availability of supermarkets may be associated with reduced diabetes risk, particularly in suburban and rural communities, whereas restrictions on fast-food restaurants may help in all community types.

Association of community socioeconomic deprivation with evidence of reduced kidney function at time of type 2 diabetes diagnosis

BACKGROUND

While there are known individual-level risk factors for kidney disease at time of type 2 diabetes diagnosis, little is known regarding the role of community context. We evaluated the association of community socioeconomic deprivation (CSD) and community type with estimated glomerular filtration rate (eGFR) when type 2 diabetes is diagnosed.

METHODS

This was a retrospective cohort study of 13,144 adults with newly diagnosed type 2 diabetes in Pennsylvania. The outcome was the closest eGFR measurement within one year prior to and two weeks after type 2 diabetes diagnosis, calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-Epi) equation. We used adjusted multinomial regression models to estimate associations of CSD (quartile 1, least deprivation) and community type (township, borough, city) with eGFR and used adjusted generalized estimating equation models to evaluate whether community features were associated with the absence of diabetes screening in the years prior to type 2 diabetes diagnosis.

RESULTS

Of the participants, 1279 (9.7%) had hyperfiltration and 1377 (10.5%) had reduced eGFR. Women were less likely to have hyperfiltration and more likely to have reduced eGFR. Black (versus White) race was positively associated with hyperfiltration when the eGFR calculation was corrected for race but inversely associated without the correction. Medical Assistance (ever versus never) was positively associated with reduced eGFR. Higher CSD and living in a city were each positively associated (odds ratio [95% confidence interval]) with reduced eGFR (CSD quartiles 3 and 4 versus quartile 1, 1.23 [1.04, 1.46], 1.32 [1.11, 1.58], respectively; city versus township, 1.38 [1.15, 1.65]). These features were also positively associated with the absence of a type 2 diabetes screening measure.

CONCLUSIONS

In a population-based sample, more than twenty percent had hyperfiltration or reduced eGFR at time of type 2 diabetes diagnosis. Individual- and community-level factors were associated with these outcomes.

Urban social determinants of non-communicable diseases risk factors in Argentina

We examined associations of individual-, neighborhood- and city-level education -as proxies of SES at different levels-, with diabetes, hypertension, obesity, smoking and binge drinking (non-communicable disease risk factors -NCD/RF) among Argentinian adults. We estimated mixed models based on 21,415 individuals from the 2013 National Survey of Risk Factors, living in 2,698 neighborhoods and 33 cities. Gradients by individual-level education differed by gender and NCD/RF, and some were modified by city education. In addition, we identified contextual effects of neighborhood and city education on some NCD/RF. Urban efforts to tackle NCD/RF in Argentina should be context- and gender-sensitive, and mainly focused on socially disadvantaged groups.

Sleep and neighborhood socioeconomic status: a micro longitudinal study of chronic low-back pain and pain-free individuals

Individuals with chronic low back pain (cLBP) frequently report sleep disturbances. Living in a neighborhood characterized by low-socioeconomic status (SES) is associated with a variety of negative health outcomes, including poor sleep. Whether low-neighborhood SES exacerbates sleep disturbances of people with cLBP, relative to pain-free individuals, has not previously been observed. This study compared associations between neighborhood-level SES, pain-status (cLBP vs. pain-free), and daily sleep metrics in 117 adults (cLBP = 82, pain-free = 35). Neighborhood-level SES was gathered from Neighborhood Atlas, which provides a composite measurement of overall neighborhood deprivation (e.g. area deprivation index). Individuals completed home sleep monitoring for 7-consecutive days/nights. Neighborhood SES and pain-status were tested as predictors of actigraphic sleep variables (e.g., sleep efficiency). Analyses revealed neighborhood-level SES and neighborhood-level SES*pain-status interaction significantly impacted objective sleep quality. These findings provide initial support for the negative impact of low neighborhood-level SES and chronic pain on sleep quality.

Proximity to freshwater blue space and type 2 diabetes onset: the importance of historical and economic context

Salutogenic effects of living near aquatic areas (blue space) remain underexplored, particularly in non-coastal and non-urban areas. We evaluated associations of residential proximity to inland freshwater blue space with new onset type 2 diabetes (T2D) in central and northeast Pennsylvania, USA, using medical records to conduct a nested case-control study. T2D cases (n=15,888) were identified from diabetes diagnoses, medication orders, and laboratory test results and frequency-matched on age, sex, and encounter year to diabetes-free controls (n=79,435). We calculated distance from individual residences to the nearest lake, river, tributary, or large stream, and residence within the 100-year floodplain. Logistic regression models adjusted for community socioeconomic deprivation and other confounding variables and stratified by community type (townships [rural/suburban], boroughs [small towns], city census tracts). Compared to individuals living ≥1.25 miles from blue space, those within 0.25 miles had 8% and 17% higher odds of T2D onset in townships and boroughs, respectively. Among city residents, T2D odds were 38-39% higher for those living 0.25 to <0.75 miles from blue space. Residing within the floodplain was associated with 16% and 14% higher T2D odds in townships and boroughs. A post-hoc analysis demonstrated patterns of lower residential property values with nearer distance to the region's predominant waterbody, suggesting unmeasured confounding by socioeconomic disadvantage. This may explain our unexpected findings of higher T2D odds with closer proximity to blue space. Our findings highlight the importance of historic and economic context and interrelated factors such as flood risk and lack of waterfront development in blue space research.

Green space and cardiovascular health in people with type 2 diabetes

Associations between green space type and 9-year risk of incident cardiovascular disease (CVD) hospitalisations and deaths were analysed in 4166 people with type 2 diabetes in the Sax Institute's 45 and Up Study. Incidence of all-cause mortality, cardiovascular mortality, fatal or non-fatal CVD events and acute myocardial infarctions (AMI) were 14.67%, 7.23%, 47.36%, and 4.51%, respectively. After full adjustment, more tree canopy was associated with lower CVD mortality, lower fatal or non-fatal CVD events, and lower AMI risk. More open grass was associated with lower all-cause mortality, lower CVD mortality and lower fatal or non-fatal CVD events, but higher AMI risk.

Neighborhood social environments, healthy resources, and adult diabetes: Accounting for activity space exposures

This study broadens contextual environments to include adults' activity spaces-inside and outside the residential neighborhood-to examine how contextual exposures shape type 2 diabetes risk. We use novel longitudinal data from the Los Angeles Family and Neighborhood Survey, construct time-weighted exposure measures of adults' social-structural and healthy resource environments, and execute random effects logistic models predicting the probability of being diabetic. Results indicate that residential and activity space exposures are independently associated with adult diabetes, and that residential and activity space healthy resources combine to influence diabetes risk in synergistic ways. Living in more socioeconomically advantaged neighborhoods reduces diabetes risk, particularly when spending time in activity spaces with greater access to recreational facilities. Moreover, healthier activity space environments may compensate for living in neighborhoods devoid of healthy food options to lessen diabetes risk. Adopting an activity space framework can inform multilevel interventions aimed at alleviating type 2 diabetes and other chronic ailments.

Diabetes Risk and Control in Multi-ethnic US Immigrant Populations

PURPOSE OF REVIEW

The goal of this review is to assess current evidence on diabetes risk and control among adult immigrants in the USA.

RECENT FINDINGS

Patterns of diabetes risk in US immigrants may reflect global diabetes trends. Asian, Black, and Latinx immigrants all see a diabetes disadvantage relative to US-born Whites. Diabetes risk in Asian immigrants also surpasses US-born Asians. Relative diabetes risk among all groups increases with time in the USA. Research to explain patterns in diabetes risk and control among immigrants has broadened from lifestyle factors to include multi-level, life course influences on trajectories of risk. Some determinants are shared across groups, such as structural racism, healthcare access, and migration stress, whereas others such as diet are embedded in sending country culture. Current literature on diabetes in immigrant populations suggests a need to shift towards a transnational lens and macro-level social determinants of health framework to understand diabetes risk and potential prevention factors.

The impact of patient-centered medical home certification on quality of care for patients with diabetes

OBJECTIVE

To identify the impact of changes surrounding certification as a patient-centered medical home (PCMH) on outcomes for patients with diabetes.

STUDY SETTING

Minnesota legislation established mandatory quality reporting for patients with diabetes and statewide standards for certification as a PCMH. Patient-level quality reporting data (2008-2018) were used to study the impact of transition to a PCMH.

STUDY DESIGN

Achievement of Minnesota's optimal diabetes care standard-in aggregate and by component-was modeled for adult patients with Type 1 or Type 2 diabetes as a function of time relative to the year the patient's primary care practice achieved PCMH certification. Patients from uncertified practices were used to control for general trend. Practice-level random effects captured time-invariant characteristics of practices and the practices' average patient.

DATA COLLECTION

Electronic health record data were submitted by 695 Minnesota practices capturing components of the quality standard: blood sugar control, cholesterol control, blood pressure control, nonsmoking status, and use of aspirin.

PRINCIPAL FINDINGS

The first cohort of practices achieving PCMH certification (July 2010-June 2014) showed statistically insignificant changes in optimal care. The next cohort of practices (July 2014-June 2018) achieved larger, clinically meaningful increases in quality of care during the time prior to and following certification. Specifically, this second cohort of practices was estimated to achieve a 12.8 percentage-point improvement (P < .001) in the predicted probability of providing optimal diabetes care over the period spanning 3 years before to 3 years after certification.

CONCLUSIONS

Our results suggest that the initial cohort of certified practices was already performing at a high level before certification, perhaps requiring little change in their operations to achieve PCMH certification. The second cohort, on the other hand, made meaningful, quality-improving changes in the years surrounding certification. Differences by cohort may partially explain the inconsistent PCMH impacts found in the literature.

The Diabetes Location, Environmental Attributes, and Disparities Network: Protocol for Nested Case Control and Cohort Studies, Rationale, and Baseline Characteristics

BACKGROUND

Diabetes prevalence and incidence vary by neighborhood socioeconomic environment (NSEE) and geographic region in the United States. Identifying modifiable community factors driving type 2 diabetes disparities is essential to inform policy interventions that reduce the risk of type 2 diabetes.

OBJECTIVE

This paper aims to describe the Diabetes Location, Environmental Attributes, and Disparities (LEAD) Network, a group funded by the Centers for Disease Control and Prevention to apply harmonized epidemiologic approaches across unique and geographically expansive data to identify community factors that contribute to type 2 diabetes risk.

METHODS

The Diabetes LEAD Network is a collaboration of 3 study sites and a data coordinating center (Drexel University). The Geisinger and Johns Hopkins University study population includes 578,485 individuals receiving primary care at Geisinger, a health system serving a population representative of 37 counties in Pennsylvania. The New York University School of Medicine study population is a baseline cohort of 6,082,146 veterans who do not have diabetes and are receiving primary care through Veterans Affairs from every US county. The University of Alabama at Birmingham study population includes 11,199 participants who did not have diabetes at baseline from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a cohort study with oversampling of participants from the Stroke Belt region.

RESULTS

The Network has established a shared set of aims: evaluate mediation of the association of the NSEE with type 2 diabetes onset, evaluate effect modification of the association of NSEE with type 2 diabetes onset, assess the differential item functioning of community measures by geographic region and community type, and evaluate the impact of the spatial scale used to measure community factors. The Network has developed standardized approaches for measurement.

CONCLUSIONS

The Network will provide insight into the community factors driving geographical disparities in type 2 diabetes risk and disseminate findings to stakeholders, providing guidance on policies to ameliorate geographic disparities in type 2 diabetes in the United States.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21377.

Longitudinal changes in the retail food environment in Mexico and their association with diabetes

The retail food environment is a potential population-level determinant of diet and nutrition-related chronic diseases, yet little is known about its composition and association with diabetes in low- and middle-income countries. Our objectives were: (1) to describe changes in the composition of the retail food environment in Mexican neighborhoods from 2010 to 2016 and (2) to examine the association between these changes and diabetes cases diagnosed over the same period. Individual level data came from the 2016 Mexican Health and Nutrition Survey (N = 2808 adults). Neighborhood level retail food environment data for 2010 and 2016 came from the National Directory of Economic Units of Mexico. Multilevel logistic regression was used to examine the adjusted association between changes in the neighborhood density per km² of fruit and vegetable stores, chain convenience stores and supermarkets with diabetes. Small store formats still predominate in Mexico's food environment, however there is evidence of fast increase in chain convenience stores and supermarkets. Adults living in neighborhoods that saw a decline in fruit and vegetable store density and a simultaneous increase in chain convenience store density experienced higher odds of diabetes, compared to adults who lived in neighborhoods where fruit and vegetable and convenience stores did not change (OR 3.90, 95% CI 1.61, 9.48). Considering the complex interplay between store types, understanding the mechanisms and confirming the causal implications of these findings could inform policies that improve the quality of food environments in cities.

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We examined changes in the retail food environment in Mexican cities.

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We also examined whether those changes were associated with new diabetes cases.

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Small food stores still predominate but evidence of fast increase in chain convenience stores and supermarkets.

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Odds of diabetes were highest when fruit and vegetable stores declined and chain convenience stores increased.

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Changes in the density of supermarkets were not associated with diabetes.

Moving Diabetes Upstream: the Social Determinants of Diabetes Management and Control Among Immigrants in the US

PURPOSE OF REVIEW

Relative to the US-born population, immigrants are less likely to successfully manage and control their diabetes, leading to a host of diabetes-related complications. This review draws on the social determinants of health framework (SDoH) to summarize the multilevel factors that shape diabetes care and management among immigrants in the USA.

RECENT FINDINGS

While the diabetes literature is replete with research on individual-level risk factors and health behaviors, empirical literature linking the SDoH to diabetes management among immigrants is limited. However, housing precarity, food insecurity, poverty, uninsurance and underinsurance, and limited support for immigrants in healthcare systems are consistently shown to deter diabetes management and care. Immigrants with diabetes face a multitude of structural constraints to managing their diabetes. More research that theorizes the role of SDoH in diabetes management along with empirical qualitative and quantitative studies are needed. Interventions to address diabetes also require a more upstream approach in order to mitigate the drivers of diabetes disparities among immigrants.

Social environment and quality of life among older people with diabetes and multiple chronic illnesses in New Zealand: Intermediary effects of psychosocial support and constraints

Purpose: In older people with diabetes, multimorbidity is highly prevalent and it can lead to poor quality of life. The overall purpose of this study was to examine the association between the social environment, psychosocial support and constraints, and overall quality of life among older people with and without with diabetes and multiple chronic illnesses.Methods: Self-reported data from participants in a cohort study of older New Zealanders was analysed. Responses from 380 older people diagnosed with diabetes and multiple chronic illnesses were compared with 527 older people with no health issues on indicators related to the associations of neighbourhood, health and ageing, using structural equation modelling.Results: The final model suggests that social provision, purpose in life and capabilities mediated between the social environment and quality of life, indicate that older people with positive social environment (i.e., neighbourhood advantage, residential stability) are much less likely to experience depression due to having good social support, meaningful life purpose and opportunities to engage.Conclusions: Perceived neighbourhood advantages, such as positive neighbourhood qualities, social cohesion and housing satisfaction, along with the focus on increasing social support, enhancing purpose in life and supporting one's capability to achieve, may serve as protective factors against depression.IMPLICATIONS FOR REHABILITATIONEnvironmental and personal circumstances can contribute to quality of life among older people with diabetes and multimorbidity.By providing older people with diabetes and multiple chronic illnesses a socially just environment that challenges ageism and other forms of oppression, this could reduce social disparities in health, improve inclusion and access to resources.Social and healthcare professionals are encouraged to design clinical care guidelines and rehabilitation goals from a wholistic and person/client centred approach to support older people with diabetes and multiple chronic illnesses.

Neighborhood Environment Characteristics and Control of Hypertension and Diabetes in a Primary Care Patient Sample

BACKGROUND

Hypertension control and diabetes control are important for reducing cardiovascular disease burden. A growing body of research suggests an association between neighborhood environment and hypertension or diabetes control among patients engaged in clinical care.

OBJECTIVE

To investigate whether neighborhood conditions (i.e., healthy food availability, socioeconomic status (SES), and crime) were associated with hypertension and diabetes control.

DESIGN

Cross-sectional analyses using electronic medical record (EMR) data, U.S. Census data, and secondary data characterizing neighborhood food environments. Multivariate logistic regression analyses adjusted for potential confounders. Analyses were conducted in 2017.

PARTICIPANTS

Five thousand nine hundred seventy adults receiving primary care at three Baltimore City clinics in 2010-2011.

MAIN MEASURES

Census tract-level neighborhood healthy food availability, neighborhood SES, and neighborhood crime. Hypertension control defined as systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg. Diabetes control defined as HgbA1c < 7.

KEY RESULTS

Among patients with hypertension, neighborhood conditions were not associated with lower odds of blood pressure control after accounting for patient and physician characteristics. However, among patients with diabetes, in fully adjusted models accounting for patient and physician characteristics, we found that patients residing in neighborhoods with low and moderate SES had reduced odds of diabetes control (OR = 0.74 (95% CI = 0.57-0.97) and OR = 0.75 (95% CI = 0.57-0.98), respectively) compared to those living in high-SES neighborhoods.

CONCLUSIONS

Neighborhood disadvantage may contribute to poor diabetes control among patients in clinical care. Community-based chronic disease care management strategies to improve diabetes control may be optimally effective if they also address neighborhood SES among patients engaged in care.

Two-stage, school and community-based population screening successfully identifies individuals and families at high-risk for type 2 diabetes: the Feel4Diabetes-study

BACKGROUND

The implementation of population screening and early prevention strategies targeting individuals at high-risk for type 2 diabetes (T2D) seems to be a public health priority. The current work aimed to describe the screening procedure applied in the Feel4Diabetes-study and examine its effectiveness in identifying individuals and families at high risk, primarily for T2D and secondarily for hypertension, among vulnerable populations in low to middle-income countries (LMICs) and high-income countries (HICs) across Europe.

METHODS

A two-stage screening procedure, using primary schools as the entry-point to the community, was applied in low socioeconomic status (SES) regions in LMICs (Bulgaria-Hungary), HICs (Belgium-Finland) and HICs under austerity measures (Greece-Spain). During the first-stage screening via the school-setting, a total of 20,501 parents (mothers and/or fathers) of schoolchildren from 11,396 families completed the Finnish Diabetes Risk Score (FINDRISC) questionnaire, while their children underwent anthropometric measurements in the school setting. Parents from the identified "high-risk families" (n = 4484) were invited to participate in the second-stage screening, including the measurement of fasting plasma glucose (FPG) and blood pressure (BP). In total, 3153 parents participated in the second-stage screening (mean age 41.1 ± 5.6 years, 65.8% females).

RESULTS

Among parents who attended the second-stage screening, the prevalence of prediabetes (as defined by impaired fasting glucose; FPG 100-125 mg/dl) and T2D (FPG > 126 mg/dl) was 23.2 and 3.0% respectively, and it was found to be higher in the higher FINDRISC categories. The percentage of undiagnosed T2D among the participants identified with T2D was 53.5%. The prevalence of high normal BP (systolic BP 130-139 mmHg and/ or diastolic BP 85-89 mmHg) and hypertension (systolic BP ≥ 140 mmHg and/ or diastolic BP ≥ 90 mmHg) was 14 and 18.6% respectively, which was also higher in the higher FINDRISC categories. The percentage of cases not receiving antihypertensive treatment among the participants identified with hypertension was 80.3%.

CONCLUSION

The findings of the current study indicate that the two-stage school and community-based screening procedure followed, effectively identified high-risk individuals and families in vulnerable populations across Europe. This approach could be potentially scalable and sustainable and support initiatives for the early prevention of T2D and hypertension.

TRIAL REGISTRATION

The Feel4Diabetes-intervention is registered at https://clinicaltrials.gov/ (NCT02393872; date of trial registration: March 20, 2015).

A COMPARATIVE CASE STUDY OF WALKING ENVIRONMENT IN MADRID AND PHILADELPHIA USING MULTIPLE SAMPLING METHODS AND STREET VIRTUAL AUDITS

The objective of this study is to quantify, using virtual audits in Madrid and Philadelphia, cross-city differences in the walking environment and to test whether differences vary by sampling method. We used two sampling methods; first, a contiguous area combining census units (~15.000 population area for each setting) was selected using the Median Neighborhood Index (MNI). MNI is a summary index that averages Euclidean distances of sociodemographic and urban form features, used to select the median neighborhood for a given city. Second, we selected a population-density stratified sampling of the same number of census units as above. M-SPACES audit tool was deployed, using street virtual audits to measure function, safety, aesthetics, and destinations along each street segment. Madrid streets had lower scores for function (b=-0.29 CI95% -0.55;-0.31) and safety (b=-0.38 CI95% -0.61;-0.14). Madrid had a greater proportion of streets having at least one walking destination in the street segment (PR=1.92 95% CI 1.55; 2.39). We did not find a significant difference between Madrid and Philadelphia in aesthetics. We found an interaction between safety and sampling methods. This approach can reveal which elements of the built environment account for between-city differences, key to mass influences that operate at the city level.

Promoting access to health information

Purpose

Describe the design of a health information and technology educational intervention that promotes health information sharing and technology use for older adult African Americans to support access to health information. The paper aims to discuss this issue.

Design/methodology/approach

The study team developed a novel method to design the intervention. It drew upon three approaches: intergenerational technology transfer, participatory design and community-based participatory research.

Findings

Older adult African Americans (55+) with diabetes and young adults (18–54) connected to them via familial or naturally occurring social networks designed the intervention, which was conducted in the two study sites in Michigan, USA. In total, 29 participants helped design the intervention. Four themes emerged concerning factors that promote intergenerational information exchange in the context of technology and health. First, focus on one technology skill. Second, working together in small groups is preferred. Third, patience is essential. Last, physical capabilities (i.e., eyesight, operating on relatively small screens) and literacy levels should be considered.

Originality/value

This novel method of having participants from the sample population select the health information materials and technology exercises serves as a guide for implementing health information and education interventions aimed at technology use to support self-management for vulnerable patient populations.

Air Pollution, Oxidative Stress, and Diabetes: a Life Course Epidemiologic Perspective

PURPOSE OF REVIEW

Ambient air pollution is strongly linked to cardiovascular and respiratory diseases. We summarize available published evidence regarding similar associations with diabetes across the life course.

RECENT FINDINGS

We performed a life-course survey of the recent literature, including prenatal, gestational, childhood/adolescence, and adult exposures to air pollution. Oxidative stress is identified as a key factor in both metabolic dysfunction and the effects of air pollution exposure, especially from fossil fuel combustion products, providing a plausible mechanism for air pollution-diabetes associations. The global burden of diabetes attributed to air pollution exposure is substantial, with a recent estimate that ambient fine particulate matter (PM_2.5) exposure contributes to more than 200,000 deaths from diabetes annually. There is a growing body of literature linking air pollution exposure during childhood and adulthood with diabetes etiology and related cardiometabolic biomarkers. A small number of studies found that exposure to air pollution during pregnancy is associated with elevated gestational diabetes risk among mothers. Studies examining prenatal air pollution exposure and diabetes risk among the offspring, as well as potential transgenerational effects of air pollution exposure, are very limited thus far. This review provides insight into how air pollutants affect diabetes and other metabolic dysfunction-related diseases across the different life stages.

Identifying neighborhood characteristics associated with diabetes and hypertension control in an urban African-American population using geo-linked electronic health records

For health care providers, information on community-level social determinants of health is most valuable when it is specific to the populations and health outcomes for which they are responsible. Diabetes and hypertension are highly prevalent conditions whose management requires an interplay of clinical treatment and behavioral modifications that may be sensitive to community conditions. We used geo-linked electronic health records from 2016 of African American patients of a network of federally qualified health centers in Philadelphia, PA to examine cross-sectional associations between characteristics of patients' residential neighborhoods and hypertension and diabetes control (n = 1061 and n = 2633, respectively). Hypertension and diabetes control were defined to align with the Health Resources and Services Administration (HRSA) Uniform Data System (UDS) reporting requirements for HRSA-funded health centers. We examined associations with nine measures of neighborhood socioeconomic status (poverty, education, deprivation index), social environment (violent crime, perceived safety and social capital, racial segregation), and built environment (land-use mix, intersection density). In demographics-adjusted log-binomial regression models accounting for neighborhood-level clustering, poor diabetes and hypertension control were more common in highly segregated neighborhoods (i.e., high proportion of African American residents relative to the mean for Philadelphia; prevalence ratio = 1.27 [1.02-1.57] for diabetes, 1.22 [1.12-1.33] for hypertension) and less common in more walkable neighborhoods (i.e., higher retail land use). Neighborhood deprivation was also weakly associated with poor hypertension control. An important consideration in making geographic information actionable for providers is understanding how specific community-level determinants affect the patient population beyond individual-level determinants.

Neighborhood social and economic change and diabetes incidence: The HeartHealthyHoods study

We studied the association between neighborhood social and economic change and type 2 diabetes incidence in the city of Madrid (Spain). We followed 199,621 individuals living in 393 census tracts for diabetes incidence for 6 years using electronic health records, starting in 2009. We measured neighborhood social and economic change from 2005 to 2009 using a finite mixture model with 16 indicators that resulted in four types of neighborhood change. Adjusted results showed an association between neighborhood change and diabetes incidence: compared to those living in Aging/Stable areas, people living in Declining SES, New Housing and Improving SES areas have an 8% (HR = 0.92, 95% CI 0.87 to 0.99), 9% (HR = 0.91, 95% CI 0.81 to 1.01) and 11% (HR = 0.89, 95% CI 0.81 to 0.98) decrease in diabetes incidence. This evidence can help guide policies for diabetes prevention by focusing efforts on specific urban areas.

Diabetes and the Built Environment: Evidence and Policies

PURPOSE OF REVIEW

To explore the relationship between the built environment and type 2 diabetes, considering both risk factors and policies to reduce risk. The built environment refers to the physical characteristics of the areas in which people live including buildings, streets, open spaces, and infrastructure.

RECENT FINDINGS

A review of current literature suggests an association between the built environment and type 2 diabetes, likely driven by two key pathways-physical activity and the food environment. Other hypothesized mechanisms linking the built environment and type 2 diabetes include housing policy, but evidence in these areas is underdeveloped. Policies designed to enhance the built environment for diabetes risk reduction are mechanistically plausible, but as of yet, little direct evidence supports their effectiveness in reducing in type 2 diabetes risk. Future work should rigorously evaluate policies meant to reduce type 2 diabetes via the built environment.