Racial/Ethnic Residential Segregation, Obesity, and Diabetes Mellitus

Is Income and Racial Residential Segregation Associated with 13-Year Changes in Body Mass Index? A Longitudinal Analysis in the Brazilian Pró-Saúde Cohort Study

Neighborhoods or residential environments have physical and social attributes which may contribute to inequalities in the overweight and obesity pandemic. We examined the longitudinal associations of baseline neighborhood-level income and racial residential segregation (using the Gi* statistic: low, medium, high) with changes in body mass index (BMI in kg/m2), using geocoded data from 1821 civil servants in the municipality of Rio de Janeiro, Brazil, followed-up for approximately 13 years (baseline wave 1: 1999, wave 2: 2001-2002, wave 3: 2006-2007, wave 4: 2012-2013). Linear mixed effects models using BMI measured in all four study waves were performed, accounting for gender, race, length of residence, education and time-dependent age, and per capita family income. After adjustments, both income and racial segregation were positively associated with BMI differences (but not BMI changes) over time, in a dose-response pattern. For income segregation, mean differences in BMI for participants living in high and medium vs. low segregated neighborhoods were 1.04 kg/m2 (β = 1.04; 95% CI 0.47, 1.62) and 0.86 kg/m2 (0.86; 0.33, 1.39), respectively. For racial segregation, mean differences in BMI for participants living in high and medium vs low segregated neighborhoods were 0.71 kg/m2 (0.71; 0.14, 1.29) and 0.30 kg/m2 (0.30; - 0.24, 0.83), respectively. We also showed a moderate to strong correlation between racial and income segregation at baseline. Strategies to reduce BMI and obesity-related health inequalities should include special efforts aimed at segregated neighborhoods and its obesogenic environments.

County-level Racial/Ethnic Residential Segregation and Physical Activity Behavior among US Adults

The relationship between racial/ethnic residential segregation and physical activity (PA) remains unclear with both positive and negative associations between segregation and PA recently reported. We aimed to examine the relationship between county-level residential segregation and total daily PA and domain-specific PA and whether these associations varied by gender. Participants (N = 2625, mean age [SD] = 45.2 [15.4]) were recruited from the AmeriSpeak panel who completed up to two Activities Completed over Time in 24 Hours (ACT24) previous day recalls in 2019. PA outcomes were created for the following: (1) light PA (LPA), (2) moderate-to-vigorous PA (MVPA), (3) total active time, and (4) domain-specific PA, including leisure, work, household, transport, personal, and other activities. County-level residential segregation based on isolation. Weighted generalized linear models were used to examine the relationship between county-level segregation and each PA outcome, controlling for age, gender, race/ethnicity, income, employment, body mass index, county-level poverty, and census region. Overall, results showed no association between county-level residential segregation and LPA, MVPA, total active time, and domain-specific PA among NH Black and Hispanic populations. Among NH Black females, greater residential segregation was associated with more total hours/day of activity (β = 3.54, 95% CI [0.23, 6.85]). Only NH Black females living in segregated neighborhoods had more total active time. Additionally, it is important to acknowledge that these relationships may vary among NH Black and Hispanic populations. Future studies should examine the interaction between segregation and a broader range of individual, contextual, and environmental factors in relation to PA and domain-specific PA.

Ethnic Enclaves and Incidence of Cancer Among US Ethnic Minorities in the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Since immigrants and their descendants represent a growing proportion of the US population, there is a strong demographic imperative for scientists to better understand the cancer risk factors at multiple levels that exist for these populations. Understanding the upstream causes of cancer, including neighborhood context, may help prevention efforts. Residence in ethnic enclaves may be one such contextual cause; however, the evidence is mixed, and past research has not utilized prospective designs examining cancer incidence or mortality.

METHODS

We examined the association between residency in ethnic enclaves and cancer events among Hispanic (n = 753) and Chinese (n = 451) participants without a history of cancer in the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective cohort study that enrolled participants ages 45-84 in six US cities. Cancer events included deaths and hospitalization for any cancer diagnosis from 2000-2012. Residency in an ethnic enclave was operationalized as their geocoded baseline census tract having a concentration of residents of the same ethnicity greater than the 75th percentile (compared to non-ethnic enclave otherwise). Potential confounders were blocked into three categories: sociodemographic, acculturation, and biomedical/health behavior variables. To examine the association between ethnic enclaves and cancer, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional hazards models.

RESULTS

Among Hispanic participants, residing in ethnic enclaves (vs. not) was associated with a 39% reduction in cancer risk (HR 0.61, 95%CI: 0.31, 1.21) after adjusting for sociodemographic variables. Among Chinese participants, residing in ethnic enclaves was associated with a 2.8-fold increase in cancer risk (HR 2.86, 95%CI; 1.38, 5.94) after adjusting for sociodemographic variables.

CONCLUSIONS

Our results suggest that the association between ethnic enclaves and cancer events differs by ethnic group, suggesting that different social and contextual factors may operate in different communities.

Racial and economic segregation and diabetes mortality in the USA, 2016-2020

BACKGROUND

The purpose of this study was to examine the association between racial and economic segregation and diabetes mortality among US counties from 2016 to 2020.

METHODS

We conducted a cross-sectional ecological study that combined county-level diabetes mortality data from the National Vital Statistics System and sociodemographic information drawn from the 2016-2020 American Community Survey (n=2380 counties in the USA). Racialized economic segregation was measured using the Index Concentration at the Extremes (ICE) for income (ICEincome), race (ICErace) and combined income and race (ICEcombined). ICE measures were categorised into quintiles, Q1 representing the highest concentration and Q5 the lowest concentration of low-income, non-Hispanic (NH) black and low-income NH black households, respectively. Diabetes was ascertained as the underlying cause of death. County-level covariates included the percentage of people aged ≥65 years, metropolitan designation and population size. Multilevel Poisson regression was used to estimate the adjusted mean mortality rate and adjusted risk ratios (aRR) comparing Q1 and Q5.

RESULTS

Adjusted mean diabetes mortality rate was consistently greater in counties with higher concentrations of low-income (ICEincome) and low-income NH black households (ICEcombined). Compared with counties with the lowest concentration (Q1), counties with the highest concentration (Q5) of low-income (aRR 1.96; 95% CI 1.81 to 2.11 for ICEincome), NH black (aRR 1.32; 95% CI 1.18 to 1.47 for ICErace) and low-income NH black households (aRR 1.70; 95% CI 1.56 to 1.84 for ICEcombined) had greater diabetes mortality.

CONCLUSION

Racial and economic segregation is associated with diabetes mortality across US counties.

The African American Transplant Access Program: Mitigating Disparities in Solid Organ Transplantation

Black Americans experience end-stage kidney disease (ESKD) at a disproportionately higher rate than other racial and ethnic groups in the United States. Kidney transplantation provides the best outcomes for patients with ESKD. However, Black patients frequently have decreased access to kidney transplantation. This article summarizes the robust literature on disparities in transplantation for Black patients and presents a practical solution to this complex issue by redesigning the transplant access process for Black patients challenged by structural and institutional barriers. The authors provide a detailed overview of a novel African American Transplant Access Program (AATAP) with its pillars of cultural congruency, trust, health literacy, and psychosocial support. This overview includes a thorough description of the program's conceptualization, the process of creating the program, the preliminary results, and guidance to establish similarly culturally congruent transplant access programs.

Associations between dimensions of the social environment and cardiometabolic health outcomes: a systematic review and meta-analysis

OBJECTIVES

The social environment (SE), that is, the social relationships and social context in which groups of people live and interact, is an understudied element of the broader living environment which impacts health. We aim to summarise the available evidence on the associations between SE and cardiometabolic disease (CMD) outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Scopus and Web of Science Core Collection were searched from inception to 28 February 2024.

ELIGIBILITY CRITERIA

We included studies for which determinants were SE factors such as area-level deprivation and social network characteristics and outcomes were type 2 diabetes mellitus and cardiovascular diseases incidence and prevalence.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts and full text were screened in duplicate. Data appraisal and extraction were based on the study protocol published in PROSPERO. Methodological quality was assessed with the Newcastle-Ottawa Scale. We synthesised the data through vote counting and meta-analyses.

RESULTS

From 10 143 records screened, 281 studies reporting 1108 relevant associations are included in this review. Of the 384 associations included in vote counting, 271 (71%) suggested that a worse SE is associated with a higher risk of CMD. 14 meta-analyses based on 180 associations indicated that worse SE was associated with increased odds of CMD outcomes, with 4 of them being statistically significant. For example, more economic and social disadvantage was associated with higher heart failure risk (OR 1.58, 95% CI 1.08 to 1.61; n=18; I2=95%). With the exception of two meta-analyses for men, meta-analysed sex-specific associations consistently showed results in the same direction as the overall meta-analyses.

CONCLUSION

Worse SE seems to be associated with increased odds of CMD outcomes, although certain SE dimensions are underexplored in relation to CMD.

PROSPERO REGISTRATION NUMBER

CRD42021223035.

Household Composition, Income, and Fast-Food Consumption among Black Women and Men

Black adults are more likely to consume meals from fast-food restaurants than other racial/ethnic groups with implications for disparities in dietary quality and obesity outcomes. Family and economic characteristics are associated with fast-food consumption. The aim of this study was to determine the association between household composition, income, and fast-food consumption among Black women and men. A cross-sectional, secondary analysis of nationally representative data from the 2011-2018 National Health and Nutrition Examination Survey using multiplicative interaction terms and negative binomial regressions were used to assess whether household income moderated associations between number of children or older adults in the household and number of weekly fast-food meals consumed. Household composition was not associated with fast-food consumption among Black women overall. Yet, demonstrated by a significant interaction (incidence rate ratio (IRR) = 3.41, 95% confidence interval (CI) = 1.59-7.32), Black women with higher household income (≥ $75,000) and multiple young children consumed more fast-food compared to women with no children in the household. In contrast, Black men with one school-aged child in the home consumed fewer weekly fast-food meals than men with no school-aged children in the home (IRR = 0.69, 95% CI = 0.51-0.93). A significant interaction between number of older adults in the household and household income ≥ $75,000 (IRR = 3.56, 95% CI = 1.59-8.01) indicated that Black men with lower incomes and at least one older adult in the household consumed fewer weekly fast-food meals. These findings demonstrate that household composition and household income interact on fast-food consumption among Black women and men. Future studies should interrogate these differences, while programs and policies can be informed by the results of this study.

Physical Activity Engagement among Black Immigrants and African American Adults in the 2010 to 2018 NHIS Study

Background

High rates of physical inactivity persist in the United States, with higher rates among non-Hispanic Black adults than among their White peers. However, a comparison of physical activity engagement across nativity among Black adults in the United States has yet to be fully documented. The purpose of this cross-sectional study was to examine physical activity engagement rates among African immigrant and Afro-Caribbean immigrant adults compared with native-born African American adults using data from the 2010 to 2018 National Health Interview Survey.

Methods

Using data from the 2010 to 2018 National Health Interview Survey, we used generalized linear models to compare levels of physical activity (meeting the moderate-to-vigorous physical activity [MVPA] recommendations) by ethnic subgroups of Black adults, sequentially adjusting for sociodemographic and health-related risk factors.

Results

Data from 38,037 adults (58.8% female, 21% college/graduate degree, and 41.4% with obesity) were included. Only 41.9% of all participants met the MVPA recommendations. In the fully adjusted models across the 9 years, higher levels of MVPA were seen among African Americans (42%) than among African immigrants (38%) and Afro-Caribbean immigrants (41%). Compared with African Americans, African immigrants were less likely to engage in physical activity that met the MVPA guidelines (prevalence ratio: 0.90; 95% confidence interval: 0.85, 0.96), whereas there were no differences in meeting the guidelines between Afro-Caribbean immigrants (prevalence ratio: 0.96; 95% confidence interval:0.90, 1.02) and African Americans.

Conclusion

Culturally tailored interventions addressing socioenvironmental barriers and facilitators of physical activity may have important impacts on physical activity promotion and long-term disease burden among Black adults across nativity.

Place-Based Measures of Inequity and Vision Difficulty and Blindness

Importance

Known social risk factors associated with poor visual and systemic health in the US include segregation, income inequality, and persistent poverty.

Objective

To investigate the association of vision difficulty, including blindness, in neighborhoods with measures of inequity (Theil H index, Gini index, and persistent poverty).

Design, Setting, and Participants

This cross-sectional study used data from the 2012-2016 American Community Survey and 2010 US census tracts as well as Theil H index, Gini index, and persistent poverty measures from PolicyMap. Data analysis was completed in July 2023.

Main Outcomes and Measures

The main outcome was the number of census tract residents reporting vision difficulty and blindness (VDB) and the association with the Theil H index, Gini index, or persistent poverty, assessed using logistic regression.

Results

In total, 73 198 census tracts were analyzed. For every 0.1-unit increase in Theil H index and Gini index, there was an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size (Theil H index: odds ratio [OR], 1.14 [95% CI, 1.14-1.14; P < .001]; Gini index: OR, 1.15 [95% CI, 1.15-1.15; P < .001]). Persistent poverty was associated with an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size compared with nonpersistent poverty (OR, 1.36; 95% CI, 1.35-1.36; P < .001).

Conclusions and Relevance

In this cross-sectional study, residential measures of inequity through segregation, income inequality, or persistent poverty were associated with a greater number of residents living with VDB. It is essential to understand and address how neighborhood characteristics can impact rates of VDB.

Structural Racism, Lifestyle Behaviors, and Obesity-related Cancers among Black and Hispanic/Latino Adults in the United States: A Narrative Review

One in three adults in the United States has obesity; a chronic disease that is implicated in the etiology of at least 14 cancers. Cancer is the leading cause of death among U.S. Hispanic/Latino adults and the second most common cause of death, after cardiovascular disease, for Black adults. Our country's legacy in overt discrimination (e.g., slavery, segregation) generated inequities across all spheres in which people function as defined by the socioecological model-biological, individual, community, structural-and two of the many areas in which it manifests today are the disproportionate burden of obesity and obesity-related cancers in populations of color. Inequities due to environmental, social, and economic factors may predispose individuals to poor lifestyle behaviors by hindering an individual's opportunity to make healthy lifestyles choices. In this review, we examined the evidence on obesity and the lifestyle guidelines for cancer prevention in relation to cancer risk and outcomes for Black and Hispanic/Latino adults. We also discussed the role of structural and societal inequities on the ability of these two communities to adopt and maintain healthful lifestyle behaviors in accordance with the lifestyle guidelines for cancer prevention and control.

Interpersonal Discrimination, Neighborhood Inequities, and Children's Body Mass Index: A Descriptive, Cross-Sectional Analysis

Psychosocial stressors have been implicated in childhood obesity, but the role of racism-related stressors is less clear. This study explored associations between neighborhood inequities, discrimination/harassment, and child body mass index (BMI). Parents of children aged 5-9 years from diverse racial/ethnic backgrounds (n = 1307), completed surveys of their child's exposure to discrimination/harassment. Census tract data derived from addresses were used to construct an index of concentration at the extremes, a measure of neighborhood social polarization. Child's height and weight were obtained from medical records. Multiple regression and hierarchical models examined child's BMI and racism at the individual and census tract levels. Children residing in the most Black-homogenous census tracts had 8.2 percentage units higher BMI percentile (95% confidence interval, 1.5-14.9) compared with white-homogenous tracts (P = .03). Household income and home values were lower, poverty rates higher, and single parent households more common among Black-homogeneous census tracts. Almost 30% of children experienced discrimination/harassment in the past year, which was associated with a 5.28-unit higher BMI percentile (95% confidence interval, 1.72-8.84; P = .004). Discrimination and racial/economic segregation were correlated with higher child BMI. Longitudinal studies are needed to understand whether these factors may be related to weight gain trajectories and future health.

The Impact of Neighborhoods on Diabetes Risk and Outcomes: Centering Health Equity

Neighborhood environments significantly influence the development of diabetes risk factors, morbidity, and mortality throughout an individual's life. The social, economic, and physical environments of a neighborhood all affect the health risks of individuals and communities and also affect population health inequities. Factors such as access to healthy food, green spaces, safe housing, and transportation options can impact the health outcomes of residents. Social factors, including social cohesion and neighborhood safety, also play an important role in shaping neighborhood environments and can influence the development of diabetes. Therefore, understanding the complex relationships between neighborhood environments and diabetes is crucial for developing effective strategies to address health disparities and promote health equity. This review presents landmark findings from studies that examined associations between neighborhood socioeconomic, built and physical, and social environmental factors and diabetes-related risk and outcomes. Our framework emphasizes the historical context and structural and institutional racism as the key drivers of neighborhood environments that ultimately shape diabetes risk and outcomes. To address health inequities in diabetes, we propose future research areas that incorporate health equity principles and place-based interventions.

Remapping racial and ethnic inequities in severe maternal morbidity: The legacy of redlining in California

BACKGROUND

Historical mortgage redlining, a racially discriminatory policy designed to uphold structural racism, may have played a role in producing the persistently elevated rate of severe maternal morbidity (SMM) among racialised birthing people.

OBJECTIVE

This study examined associations between Home-Owner Loan Corporation (HOLC) redlining grades and SMM in a racially and ethnically diverse birth cohort in California.

METHODS

We leveraged a population-based cohort of all live hospital births at ≥20 weeks of gestation between 1997 and 2017 in California. SMM was defined as having one of 21 procedures and diagnoses, per an index developed by Centers for Disease Control and Prevention. We characterised census tract-level redlining using HOLC's security maps for eight California cities. We assessed bivariate associations between HOLC grades and participant characteristics. Race and ethnicity-stratified mixed effects logistic regression models assessed the risk of SMM associated with HOLC grades within non-Hispanic Black, Asian/Pacific Islander, American Indian/Alaskan Native and Hispanic groups, adjusting for sociodemographic information, pregnancy-related factors, co-morbidities and neighbourhood deprivation index.

RESULTS

The study sample included 2,020,194 births, with 24,579 cases of SMM (1.2%). Living in a census tract that was graded as "Hazardous," compared to census tracts graded "Best" and "Still Desirable," was associated with 1.15 (95% confidence interval [CI] 1.03, 1.29) and 1.17 (95% CI 1.09, 1.25) times the risk of SMM among Black and Hispanic birthing people, respectively, independent of sociodemographic factors. These associations persisted after adjusting for pregnancy-related factors and neighbourhood deprivation index.

CONCLUSIONS

Historical redlining, a tool of structural racism that influenced the trajectory of neighbourhood social and material conditions, is associated with increased risk of experiencing SMM among Black and Hispanic birthing people in California. These findings demonstrate that addressing the enduring impact of macro-level and systemic mechanisms that uphold structural racism is a vital step in achieving racial and ethnic equity in birthing people's health.

Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward

Type 2 diabetes disparities in the USA persist in both the prevalence of disease and diabetes-related complications. We conducted a literature review related to diabetes prevention, management, and complications across racial and ethnic groups in the USA. The objective of this review is to summarise the current understanding of diabetes disparities by examining differences between and within racial and ethnic groups and among young people (aged <18 years). We also examine the pathophysiology of diabetes as it relates to race and ethnic differences. We use a conceptual framework built on the socioecological model to categorise the causes of diabetes disparities across the lifespan looking at factors in five domains of health behaviours and social norms, public awareness, structural racism, economic development, and access to high-quality care. The range of disparities in diabetes prevalence and management in the USA calls for a community-engaged and multidisciplinary approach that must involve community partners, researchers, practitioners, health system administrators, and policy makers. We offer recommendations for each of these groups to help to promote equity in diabetes prevention and care in the USA.

Diversity, Equity, and Inclusion in Clinical Research: A Path Toward Precision Health for Everyone

Healthcare disparities are a persistent societal problem. One of the contributing factors to this status quo is the lack of diversity and representativeness of research efforts, which result in nongeneralizable evidence that, in turn, provides suboptimal means to enable the best possible outcomes at the individual level. There are several strategies that research teams can adopt to improve the diversity, equity, and inclusion (DEI) of their efforts; these strategies span the totality of the research path, from initial design to the shepherding of clinical data through a potential regulatory process. These strategies include more intentionality and DEI-based goal-setting, more diverse research and leadership teams, better community engagement to set study goals and approaches, better tailored outreach interventions, decentralization of study procedures and incorporation of innovative technology for more flexible data collection, and self-surveillance to identify and prevent biases. Within their remit of overlooking research efforts, regulatory authorities, as stakeholders, also have the potential for a positive effect on the DEI of emerging clinical evidence. All these are implementable tools and mechanisms that can make study participation more approachable to diverse communities, and ultimately generate evidence that is more generalizable and a conduit for better outcomes. The research community has an imperative to make DEI principles key foundational aspects in study conduct in order to pursue better personalized medicine for diverse patient populations.

Association of neighborhood segregation with 6-year incidence of metabolic syndrome in the Hispanic community health study/study of Latinos

PURPOSE

Examine the association between neighborhood segregation and 6-year incident metabolic syndrome (MetSyn) in the Hispanic Community Health Study/Study of Latinos.

METHODS

Prospective cohort of adults residing in Miami, Chicago, the Bronx, and San Diego. The analytic sample included 6,710 participants who did not have MetSyn at baseline. The evenness and exposure dimensions of neighborhood segregation, based on the Gini and Isolation indices, respectively, were categorized into quintiles (Q). Racialized economic concentration was measured with the Index of Concentration at the Extremes (continuously and Q).

RESULTS

Exposure, but not evenness, was associated with higher disease odds (Q1 (lower segregation) vs. Q4, OR = 1.53, 95% CI = 1.082.17; Q5, OR = 2.29, 95% CI = 1.493.52). Economic concentrationprivilege (continuous OR = 0.87, 95% CI = 0.770.98), racial concentrationracialized privilege (Q1 (greater concentration) vs. Q2 OR = 0.75, 95% CI = 0.541.04; Q3 OR = 0.68, 95% CI = 0.441.05; Q4 OR = 0.68, 95% CI = 0.451.01; Q5 OR = 0.64, 95% CI = 0.420.98)(continuous OR = 0.93, 95% CI = 0.821.04), and racialized economic concentrationprivilege (i.e., higher SES non-Hispanic White, continuous OR = 0.86, 95% CI = 0.760.98) were associated with lower disease odds.

CONCLUSION

Hispanics/Latino adults residing in neighborhoods with high segregation had higher risk of incident MetSyn compared to those residing in neighborhoods with low segregation. Research is needed to identify the mechanisms that link segregation to poor metabolic health.

Perspective: Acknowledging a Hierarchy of Social Needs in Diabetes Clinical Care and Prevention

The evidence of suboptimal social determinants of health (SDoH) on poor health outcomes has resulted in widespread calls for research to identify ways to measure and address social needs to improve health outcomes and reduce disparities. While assessing SDoH has become increasingly important in diabetes care and prevention research, little guidance has been offered on how to address suboptimal determinants in diabetes-related clinical care, prevention efforts, medical education and research. Not surprisingly, many patients experience multiple social needs - some that are more urgent (housing) than others (transportation/resources), therefore the order in which these needs are addressed needs to be considered in the context of diabetes care/outcomes. Here we discuss how conceptualizing diabetes related health through the lens of Maslow's hierarchy of needs has potential to help prioritize individual social needs that should be addressed to improve outcomes in the context of population-level determinants in the communities where people live.

Neighborhood segregation and cancer prevention guideline adherence in US Hispanic/Latino adults: Results from the HCHS/SOL

Background

Adherence to the American Cancer Society (ACS) guidelines for cancer prevention is associated with a lower risk of cancer and mortality. The role of neighborhood segregation on adherence to the guidelines among Hispanic/Latino adults is relatively unexplored.

Materials and methods

The Hispanic Community Health Study/Study of Latinos is a community-based prospective cohort of 16,462 Hispanic/Latino adults, ages 18-74 years enrolled in 2008-2011 from the Bronx, Chicago, Miami and San Diego. Dimensions of neighborhood segregation were measured using 2010 United States' census tracts:-evenness (the physical separation of a group), exposure (the propensity for contact between groups), and their joint effect (hypersegregation). ACS guideline adherence levels - low, moderate, high - were created from accelerometry-measured physical activity, dietary intake, alcohol intake, and body mass index. Weighted multinominal logistic regressions estimated relative risk ratios (RRR) and 95% confidence intervals (CI) for guideline adherence levels and its components.

Results

Hispanic/Latino adults were classified as low (13.7%), moderate (58.8%) or highly (27.5%) adherent to ACS guidelines. We found no evidence of an association between segregation and overall guideline adherence. Exposure segregation associated with lower likelihood of moderate adherence to alcohol recommendations (RRR_{moderate vs. low}:0.86, 95%CI:0.75-0.98) but higher likelihood for diet recommendations (RRR_{moderate vs. low}:1.07, 95%CI:1.01-1.14). Evenness segregation associated with lower likelihood of high adherence to the physical activity recommendations (RRR_{high vs. low}:0.73, 95%CI:0.57-0.94). Hypersegregation was associated with individual guideline components.

Conclusion

We found evidence of a cross-sectional relationship between neighborhood segregation and ACS cancer prevention guideline components, but not with overall ACS guideline adherence.

Racial/Ethnic Differences in Psychiatric and Medical Diagnoses Among Autistic Adults

Background

Racial/ethnic disparities in access to diagnostic services are pervasive for autistic children. However, a few studies have examined racial/ethnic health disparities among autistic adults, who commonly experience higher rates of health conditions than non-autistic adults. We aimed at examining the intersection of autism and race/ethnicity in association with psychiatric and medical diagnoses.

Methods

The study population included adult members of Kaiser Permanente Northern California enrolled from 2008 to 2012. We ascertained 1507 adults who had an autism diagnosis documented in their electronic medical records. We sampled a matched control group of adults without an autism diagnosis (N = 15,070) at a 10:1 ratio. Our sample was 46% White, 17% Hispanic, 16% Asian, 7% Black, and 14% other race/ethnicity. We compared health diagnoses (a) between autistic and non-autistic adults within strata of race/ethnicity and (b) across race/ethnicity within strata of autistic and non-autistic adults. Lastly, we examined the interaction between autism and race/ethnicity on both multiplicative and additive scales.

Results

Autistic adults were more likely to be diagnosed with most medical and psychiatric conditions compared with their non-autistic counterparts of the same race/ethnicity. Among autistic adults, Black, Hispanic, and Asian adults were less likely to be diagnosed with psychiatric conditions and Black and Hispanic autistic adults were more likely to be diagnosed with obesity than their White counterparts. In interaction models, we found that adults who were Black and autistic were disproportionately less likely to be diagnosed with psychiatric conditions and autoimmune disease and more likely to be diagnosed with hypertension than expected.

Conclusion

Health vulnerabilities may be compounded at the intersection of autism and race/ethnicity. Future research should continue to apply an intersectional lens toward understanding and addressing these disparities. Our findings likely underestimate the health disparities that exist in uninsured autistic adults and those living in other parts of the United States.

Associations of four indexes of social determinants of health and two community typologies with new onset type 2 diabetes across a diverse geography in Pennsylvania

Evaluation of geographic disparities in type 2 diabetes (T2D) onset requires multidimensional approaches at a relevant spatial scale to characterize community types and features that could influence this health outcome. Using Geisinger electronic health records (2008–2016), we conducted a nested case-control study of new onset T2D in a 37-county area of Pennsylvania. The study included 15,888 incident T2D cases and 79,435 controls without diabetes, frequency-matched 1:5 on age, sex, and year of diagnosis or encounter. We characterized patients’ residential census tracts by four dimensions of social determinants of health (SDOH) and into a 7-category SDOH census tract typology previously generated for the entire United States by dimension reduction techniques. Finally, because the SDOH census tract typology classified 83% of the study region’s census tracts into two heterogeneous categories, termed rural affordable-like and suburban affluent-like, to further delineate geographies relevant to T2D, we subdivided these two typology categories by administrative community types (U.S. Census Bureau minor civil divisions of township, borough, city). We used generalized estimating equations to examine associations of 1) four SDOH indexes, 2) SDOH census tract typology, and 3) modified typology, with odds of new onset T2D, controlling for individual-level confounding variables. Two SDOH dimensions, higher socioeconomic advantage and higher mobility (tracts with fewer seniors and disabled adults) were independently associated with lower odds of T2D. Compared to rural affordable-like as the reference group, residence in tracts categorized as extreme poverty (odds ratio [95% confidence interval] = 1.11 [1.02, 1.21]) or multilingual working (1.07 [1.03, 1.23]) were associated with higher odds of new onset T2D. Suburban affluent-like was associated with lower odds of T2D (0.92 [0.87, 0.97]). With the modified typology, the strongest association (1.37 [1.15, 1.63]) was observed in cities in the suburban affluent-like category (vs. rural affordable-like–township), followed by cities in the rural affordable-like category (1.20 [1.05, 1.36]). We conclude that in evaluating geographic disparities in T2D onset, it is beneficial to conduct simultaneous evaluation of SDOH in multiple dimensions. Associations with the modified typology showed the importance of incorporating governmentally, behaviorally, and experientially relevant community definitions when evaluating geographic health disparities.

The long shadow of residential racial segregation: Associations between childhood residential segregation trajectories and young adult health among Black US Americans

Residential racial segregation is a key manifestation of anti-Black structural racism, thought to be a fundamental cause of poor health; evidence has shown that it yields neighborhood disinvestment, institutional discrimination, and targeting of unhealthy products like tobacco and alcohol. Yet research on the long-term impacts of childhood exposure to residential racial segregation is limited. Here, we analyzed data on 1823 Black participants in the Panel Study of Income Dynamics, estimating associations between childhood segregation trajectories and young adult health. Black young adults who consistently lived in high-segregation neighborhoods throughout childhood experienced unhealthier smoking and drinking behaviors and higher odds of obesity compared to other trajectory groups, including children who moved into or out of high-segregation neighborhoods. Results were robust to controls for neighborhood and family poverty. Findings underscore that for Black children who grow up in segregated neighborhoods, the roots of structurally-determined health inequities are established early in life.

The association of residential racial segregation with health among U.S. children: A nationwide longitudinal study

Residential racial segregation in the U.S. has been hypothesized as a fundamental cause driving health disparities across racial groups. Potential mechanisms include economic and social marginalization, subsequent constrained opportunities, and high stress. Yet evidence on residential segregation's association with health among Black and White children-particularly longitudinally-is sparse. This study aims to address this gap. We used data from the Panel Study of Income Dynamics (PSID), a national longitudinal study of U.S. households, analyzing information on 1,251 Black and 1,427 White children who participated in the Child Development Supplement (CDS) at least twice (survey waves 1997, 2002, 2007, 2014). We fit individual fixed-effects models to estimate the within-person association of neighborhood-level residential segregation, measured with local Getis-Ord G* statistics, with three outcomes (general health, weight status, and behavioral problems). We examined heterogeneous effects by age and sex. We also examined associations between health and childhood segregation trajectories, i.e., the pattern of children's residential segregation exposures from birth through when their health outcomes were measured, providing additional insight on dynamic experiences of segregation. In fixed effects models, among Black children, higher segregation was associated with worse self-rated health, especially for Black children who were older (aged 11-17 years). In trajectory models, among White children, moving out of highly segregated neighborhoods was associated with a lower probability of poor self-rated health, while moving into those neighborhoods or back and forth between neighborhood types were both associated with increased behavioral problems. Our findings highlight the importance of early-life residential segregation in shaping persistent racial health disparities, as well as the costs of segregation for all children living in highly segregated neighborhoods.

Neighborhood characteristics of low radon testing activities: A longitudinal study in Atlanta, Georgia, United States

Radon testing remains low even nationwide although its exposure is the leading cause of lung cancer among non-smokers. Little has been done to examine the neighborhood characteristics with low testing prevalence. This study investigated the associations between indoor radon testing and neighborhood characteristics in an urban environment with the highest Radon potential. A total of 25 years (1990-2015) of radon tests (n = 6355) were pooled from public and private sources in DeKalb County, Georgia, United States. Neighborhoods were characterized using racial residential segregation for African Amercians in addition to other social indicators. The associations between neighborhood characteristics and radon testing rates were evaluated using Ordinary Least Squares and Spatial Regression Models, respectively. Results show that the testing rates were lower than 6.5% over the 25 years. Summers followed by early springs experienced more tests than the other seasons. Areas of low testing rates (≤1.55%) spatially matches the mostly segregated neighborhoods. Residential segregation expanded in the 25 years and was significantly correlated (P value < 0.05) with low testing rates, even after other social indicators were controlled. Associations with the other social indicators, such as income or education, were weaker. Concertedly identifying the culturally relevant interventions in segregated communities is necessary to reduce and eliminate threats from environmental radon.

A Bibliometric Analysis on Research Regarding Residential Segregation and Health Based on CiteSpace

Considerable scholarly attention has been directed to the adverse health effects caused by residential segregation. We aimed to visualize the state-of-the-art residential segregation and health research to provide a reference for follow-up studies. Employing the CiteSpace software, we uncovered popular themes, research hotspots, and frontiers based on an analysis of 1211 English-language publications, including articles and reviews retrieved from the Web of Science Core Collection database from 1998 to 2022. The results revealed: (1) The Social Science & Medicine journal has published the most studies. Roland J. Thorpe, Thomas A. LaVeist, Darrell J. Gaskin, David R. Williams, and others are the leading scholars in residential segregation and health research. The University of Michigan, Columbia University, Harvard University, the Johns Hopkins School of Public Health, and the University of North Carolina play the most important role in current research. The U.S. is the main publishing country with significant academic influence. (2) Structural racism, COVID-19, mortality, multilevel modelling, and environmental justice are the top five topic clusters. (3) The research frontier of residential segregation and health has significantly shifted from focusing on community, poverty, infant mortality, and social class to residential environmental exposure, structural racism, and health care. We recommend strengthening comparative research on the health-related effects of residential segregation on minority groups in different socio-economic and cultural contexts.

Neighborhood Conditions and Type 2 Diabetes Risk among Latino Adolescents with Obesity in Phoenix

Type 2 Diabetes (T2D) has reached epidemic levels among the pediatric population. Furthermore, disparities in T2D among youth are distributed in a manner that reflects the social inequality between population sub-groups. Here, we investigated the neighborhood determinants of T2D risk among a sample of Latino adolescents with obesity residing in Phoenix, Arizona (n = 133). In doing so we linked together four separate contextual data sources: the American Community Survey, the United States Department of Agriculture Food Access Research Atlas, the Arizona Healthy Community Map, and the National Neighborhood Data Archive to systematically analyze how and which neighborhood characteristics were associated with T2D risk factors as measured by fasting and 2-h glucose following a 75 g oral glucose tolerance test. Using linear regression models with and without individual/household covariates, we investigated how twenty-two housing and transportation sociodemographic and built and food environment characteristics were independently and jointly associated with T2D risk. The main finding from these analyses was the strong association between the density of fast food restaurants and 2-h glucose values (b = 2.42, p < 0.01). This association was independent of individual, household, and other neighborhood characteristics. Our results contribute to an increasingly robust literature demonstrating the deleterious influence of the neighborhood food environment, especially fast food, for T2D risk among Latino youth.

School Racial Segregation and the Health of Black Children

OBJECTIVES

Few researchers have evaluated whether school racial segregation, a key manifestation of structural racism, affects child health, despite its potential impacts on school quality, social networks, and stress from discrimination. We investigated whether school racial segregation affects Black children's health and health behaviors.

METHODS

We estimated the association of school segregation with child health, leveraging a natural experiment in which school districts in recent years experienced increased school segregation. School segregation was operationalized as the Black-White dissimilarity index. We used ordinary least squares models as well as quasi-experimental instrumental variables analysis, which can reduce bias from unobserved confounders. Data from the Child Development Supplement of the Panel Study of Income Dynamics (1997-2014, n = 1248 Black children) were linked with district-level school segregation measures. Multivariable regressions were adjusted for individual-, neighborhood-, and district-level covariates. We also performed subgroup analyses by child sex and age.

RESULTS

In instrumental variables models, a one standard deviation increase in school segregation was associated with increased behavioral problems (2.53 points on a 27-point scale; 95% CI, 0.26 to 4.80), probability of having ever drunk alcohol (0.23; 95% CI, 0.049 to 0.42), and drinking at least monthly (0.20; 95% CI, 0.053 to 0.35). School segregation was more strongly associated with drinking behaviors among girls.

CONCLUSIONS

School segregation was associated with worse outcomes on several measures of well-being among Black children, which may contribute to health inequities across the life span. These results highlight the need to promote school racial integration and support Black youth attending segregated schools.

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.

Spatially varying racial inequities in cardiovascular health and the contribution of individual- and neighborhood-level characteristics across the United States: The REasons for geographic and racial differences in stroke (REGARDS) study

Black-White inequities in cardiovascular health (CVH) pose a significant public health challenge, with these disparities also varying geographically across the US. There remains limited evidence of the impact of social determinants of health on these inequities. Using a national population-based cohort from the REasons for Geographic and Racial Differences in Stroke study, we assessed the spatial heterogeneity in Black-White differences in CVH and determined the extent to which individual- and neighborhood-level characteristics explain these inequities. We utilized a Bayesian hierarchical statistical framework to fit spatially varying coefficient models. Results showed overall and spatially varying inequities, where Black participants had significantly poorer CVH. The maps of the state level random effects also highlighted how inequities vary. The evidence produced in this study further highlights the importance of multilevel approaches - at the individual- and neighborhood-levels - that need to be in place to address these geographic and racial differences in CVH.

Exercise/Physical Activity in Individuals with Type 2 Diabetes: A Consensus Statement from the American College of Sports Medicine

ABSTRACT

This consensus statement is an update of the 2010 American College of Sports Medicine position stand on exercise and type 2 diabetes. Since then, a substantial amount of research on select topics in exercise in individuals of various ages with type 2 diabetes has been published while diabetes prevalence has continued to expand worldwide. This consensus statement provides a brief summary of the current evidence and extends and updates the prior recommendations. The document has been expanded to include physical activity, a broader, more comprehensive definition of human movement than planned exercise, and reducing sedentary time. Various types of physical activity enhance health and glycemic management in people with type 2 diabetes, including flexibility and balance exercise, and the importance of each recommended type or mode are discussed. In general, the 2018 Physical Activity Guidelines for Americans apply to all individuals with type 2 diabetes, with a few exceptions and modifications. People with type 2 diabetes should engage in physical activity regularly and be encouraged to reduce sedentary time and break up sitting time with frequent activity breaks. Any activities undertaken with acute and chronic health complications related to diabetes may require accommodations to ensure safe and effective participation. Other topics addressed are exercise timing to maximize its glucose-lowering effects and barriers to and inequities in physical activity adoption and maintenance.

Perceptions and Impact of a Youth-led Childhood Obesity Prevention Intervention among Youth-leaders

Objective

To evaluate the impact of a youth-led nutrition intervention on youth-leaders themselves.

Design

Mixed methods, including: in-depth interviews and a quasi-experimental quantitative study comparing youth-leaders and nonparticipant comparison youth.

Analysis

Qualitative analysis using direct content analysis. Difference-in-differences analyses assessing quantitative program impact.

Results

Youth-leaders perceived that the intervention impacted themselves, the youth-participants, and their respective social networks. Youth-leaders experienced greater increases in intentions to eat healthfully (p=0.04), and greater decreases in support for healthy eating from their friends (p=0.01), than the comparison group.

Conclusions/Implications

Youth-leaders reported multiple levels of intervention impact, and increased intentions for healthy eating; however, additional research is needed to enhance impact on behavioral outcomes.

Ecological Associations Between Inclusionary Zoning Policies and Cardiovascular Disease Risk Prevalence: An Observational Study

BACKGROUND

Providing an adequate supply of affordable housing has become an increasingly difficult challenge for US cities. Inclusionary zoning (IZ) policies have become an increasingly popular response. Substantial research has demonstrated the health benefits of stable, affordable housing. There is anecdotal but not systematic evidence that IZ policies may be associated with some health benefits of affordable housing.

METHODS

We rely on data from the 2017 500 Cities Project, the 2016 to 2017 Lincoln Institute for Land Policy survey, and the 2011 to 2015 American Community Survey. We perform bivariate tests and cluster ordinary least squares regression to examine associations at the municipal level between having inclusionary zoning (IZ) policies, the attributes of those policies, and the prevalence of several cardiovascular outcomes.

RESULTS

Cardiovascular outcomes and socioeconomic characteristics were uniformly better in cities with IZ policies. IZ policies were associated with lower blood pressure (95% CI, -0.50 to -0.13), cholesterol (CI, -0.89 to -0.31), and blood pressure medication (CI, -0.57 to -0.03) prevalence. Some characteristics of IZ programs such as being mandatory, prioritizing rental development, and allocating a larger share of affordable housing are associated with cardiovascular risk prevalence.

CONCLUSIONS

Characteristics of IZ programs that ultimately benefit low-income residents are associated with favorable municipal-level cardiovascular health. Further, IZ policies could potentially address complex health challenges among economically vulnerable households.

Intersection of social vulnerability and residential diversity: Postoperative outcomes following resection of lung and colon cancer

INTRODUCTION

While the impact of demographic factors on postoperative outcomes has been examined, little is known about the intersection between social vulnerability and residential diversity on postoperative outcomes following cancer surgery.

METHODS

Individuals who underwent a lung or colon resection for cancer were identified in the 2016-2017 Medicare database. Data were merged with the Centers for Disease Control and Prevention social vulnerability index and a residential diversity index was calculated. Logistic regression models were utilized to estimate the probability of postoperative outcomes.

RESULTS

Among 55 742 Medicare beneficiaries who underwent lung (39.4%) or colon (60.6%) resection, most were male (46.6%), White (90.2%) and had a mean age of 75.3 years. After adjustment for competing risk factors, both social vulnerability and residential diversity were associated with mortality and other postoperative outcomes. In assessing the intersection of social vulnerability and residential diversity, synergistic effects were noted as patients from counties with low social vulnerability and high residential diversity had the lowest probability of 30-day mortality (3.2%, 95% confidence interval [CI]: 3.0-3.5) while patients from counties with high social vulnerability and low diversity had a higher probability of 30-day postoperative death (5.2%, 95% CI: 4.6-5.8; odds ratio: 1.02, 95% CI: 1.01-1.03).

CONCLUSION

Social vulnerability and residential diversity were independently associated with postoperative outcomes. The intersection of these two social health determinants demonstrated a synergistic effect on the risk of adverse outcomes following lung and colon cancer surgery.

Association of County-Level Racial Diversity and Likelihood of a Textbook Outcome Following Pancreas Surgery

Introduction

Residential racial desegregation has demonstrated improved economic and education outcomes. The degree of racial community segregation relative to surgical outcomes has not been examined.

Patients and Methods

Patients undergoing pancreatic resection between 2013 and 2017 were identified from Medicare Standard Analytic Files. A diversity index for each county was calculated from the American Community Survey. Multivariable mixed-effects logistic regression with a random effect for hospital was used to measure the association of the diversity index level with textbook outcome (TO).

Results

Among the 24,298 Medicare beneficiaries who underwent a pancreatic resection, most patients were male (n = 12,784, 52.6%), White (n = 21,616, 89%), and had a median age of 72 (68–77) years. The overall incidence of TO following pancreatic surgery was 43.3%. On multivariable analysis, patients who resided in low-diversity areas had 16% lower odds of experiencing a TO following pancreatic resection compared with patients from high-diversity communities (OR 0.84, 95% CI 0.72–0.98). Compared with patients who resided in the high-diversity areas, individuals who lived in low-diversity areas had higher odds of 90-day readmission (OR 1.16, 95% CI 1.03–1.31) and had higher odds of dying within 90 days (OR 1.85, 95% CI 1.45–2.38) (both p < 0.05). Nonminority patients who resided in low-diversity areas also had a 14% decreased likelihood to achieve a TO after pancreatic resection compared with nonminority patients in high-diversity areas (OR 0.86, 95% CI 0.73–1.00).

Conclusion

Patients residing in the lowest racial/ethnic integrated counties were considerably less likely to have an optimal TO following pancreatic resection compared with patients who resided in the highest racially integrated counties.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10316-3.

Racial residential segregation and economic disparity jointly exacerbate COVID-19 fatality in large American cities

The disproportionately high rates of both infections and deaths among racial and ethnic minorities (especially Blacks and Hispanics) in the United States during the COVID-19 pandemic are consistent with the conclusion that structural inequality can produce lethal consequences. However, the nature of this structural inequality in relation to COVID-19 is poorly understood. Here, we hypothesized that two structural features, racial residential segregation and income inequality, of metropolitan areas in the United States have contributed to health-compromising conditions, which, in turn, have increased COVID-19 fatalities; moreover, that these two features, when combined, may be particularly lethal. To test this hypothesis, we examined the growth rate of confirmed COVID-19 cases and deaths in an early 30-day period of the outbreak in the counties located in each of the 100 largest metropolitan areas in the United States. The growth curves for cases and deaths were steeper in counties located in metropolitan areas where Blacks and Hispanics are residentially segregated from Whites. Moreover, the effect of racial residential segregation was augmented by income inequality within each county. These data strongly suggest that racial and economic disparities have caused a greater death toll during the current pandemic. We draw policy implications for making virus-resilient cities free from such consequences.

Does the Association Between Hemoglobin A1c and Risk of Cardiovascular Events Vary by Residential Segregation? The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

OBJECTIVE

To examine if the association between higher A1C and risk of cardiovascular disease (CVD) among adults with and without diabetes is modified by racial residential segregation.

RESEARCH DESIGN AND METHODS

The study used a case-cohort design, which included a random sample of 2,136 participants at baseline and 1,248 participants with incident CVD (i.e., stroke, coronary heart disease [CHD], and fatal CHD during 7-year follow-up) selected from 30,239 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants originally assessed between 2003 and 2007. The relationship of A1C with incident CVD, stratified by baseline diabetes status, was assessed using Cox proportional hazards models adjusting for demographics, CVD risk factors, and socioeconomic status. Effect modification by census tract-level residential segregation indices (dissimilarity, interaction, and isolation) was assessed using interaction terms.

RESULTS

The mean age of participants in the random sample was 64.2 years, with 44% African American, 59% female, and 19% with diabetes. In multivariable models, A1C was not associated with CVD risk among those without diabetes (hazard ratio [HR] per 1% [11 mmol/mol] increase, 0.94 [95% CI 0.76-1.16]). However, A1C was associated with an increased risk of CVD (HR per 1% increase, 1.23 [95% CI 1.08-1.40]) among those with diabetes. This A1C-CVD association was modified by the dissimilarity (P < 0.001) and interaction (P = 0.001) indices. The risk of CVD was increased at A1C levels between 7 and 9% (53-75 mmol/mol) for those in areas with higher residential segregation (i.e., lower interaction index). In race-stratified analyses, there was a more pronounced modifying effect of residential segregation among African American participants with diabetes.

CONCLUSIONS

Higher A1C was associated with increased CVD risk among individuals with diabetes, and this relationship was more pronounced at higher levels of residential segregation among African American adults. Additional research on how structural determinants like segregation may modify health effects is needed.

Impact of Residential Racial Integration on Postoperative Outcomes Among Medicare Beneficiaries Undergoing Resection for Cancer

INTRODUCTION

While social determinants of health may adversely affect various populations, the impact of residential segregation on surgical outcomes remains poorly defined.

OBJECTIVE

The objective of the current study was to examine the association between residential segregation and the likelihood to achieve a textbook outcome (TO) following cancer surgery.

METHODS

The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent resection of lung, esophageal, colon, or rectal cancer between 2013 and 2017. Shannon's integration index, a measure of residential segregation, was calculated at the county level and its impact on composite TO [no complications, no prolonged length of stay (LOS), no 90-day readmission, and no 90-day mortality] was examined.

RESULTS

Among 200,509 patients who underwent cancer resection, the overall incidence of TO was 56.0%. The unadjusted likelihood of achieving a TO was lower among patients in low integration areas [low integration: n = 19,978 (55.0%) vs. high integration: n = 18,953 (59.3%); p < 0.001]. On multivariable analysis, patients residing in low integration areas had higher odds of complications [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.03-1.11], extended LOS (OR 1.13, 95% CI 1.09-1.18), and 90-day mortality (OR 1.29, 95% CI 1.22-1.38) and, in turn, lower odds of achieving a TO (OR 0.87, 95% CI 0.84-0.90) versus patients from highly integrated communities.

CONCLUSION

Patients who resided in counties with a lower integration index were less likely to have an optimal TO following resection of cancer compared with patients who resided in more integrated counties. The data highlight the importance of increasing residential racial diversity and integration as a means to improve patient outcomes.

Incorporating Measures of Structural Racism into Population Studies of Reproductive Health in the United States: A Narrative Review

Purpose: Black women in the United States face poor outcomes across reproductive health measures-from pregnancy outcomes to gynecologic cancers. Racial health inequities are attributable to systemic racism, but few population studies of reproductive health outcomes integrate upstream measures of systemic racism, and those who do are limited to maternal and infant health outcomes. Advances in understanding and intervening on the pathway from racism to reproductive health outcomes are limited by a paucity of methodological guidance toward this end. We aim to fill this gap by identifying quantitative measures of systemic racism that are salient across reproductive health outcomes. Methods: We conducted a review of literature from 2000 to 2019 to identify studies that use quantitative measures of exposure to systemic racism in population reproductive health studies. We analyzed the catalog of literature to identify cohesive domains and measures that integrate data across domains. For each domain, we contextualize its use within population health research, describe metrics currently in use, and present opportunities for their application to reproductive health research. Results: We identified four domains of systemic racism that may affect reproductive health outcomes: (1) civil rights laws and legal racial discrimination, (2) residential segregation and housing discrimination, (3) police violence, and (4) mass incarceration. Multiple quantitative measures are available for each domain. In addition, a multidimensional measure exists and additional domains of systemic racism are salient for future development into distinct measures. Conclusion: There are quantitative measures of systemic racism available for incorporation into population studies of reproductive health that investigate hypotheses, including and beyond those related to maternal and infant health. There are also promising areas for future measure development, such as the child welfare system and intersectionality. Incorporating such measures is critical for appropriate assessment of and intervention in racial inequities in reproductive health outcomes.

All-cause mortality and three aspects of social relationships: an eight-year follow-up of older adults from one entire Korean village

Various aspects of social relationships have been examined as risk factors for mortality. In particular, most research has focused on either loneliness or social disengagement. We aimed to extend the current research by adding a group-level segregation measure utilizing the whole social network of one entire village in South Korea. The analyses were based on the Korean Social Life, Health and Aging Project data collected over eight years across five waves. Of the 679 old adults who participated throughout the entire project (to wave 5), 63 were confirmed as deceased. All three aspects of social relationships examined, loneliness, social disengagement, and group-level segregation, were associated with mortality in the traditional Cox proportional hazard model without considering health-related time-varying covariates. However, a Cox marginal structural model, a counterfactual statistical measure that is designed to control for censoring bias due to sample attrition over the eight years and time-varying confounding variables, revealed that only group-level segregation was associated with mortality. Our results strongly suggest that more attention is needed on group-level segregation for mortality studies, as well as on well-known individual-level risk factors, including social disengagement and loneliness. All methods were carried out in accordance with relevant guidelines and regulations.

Partnering with Churches to Conduct a Wide-Scale Health Screening of an Urban, Segregated Community

West Side Alive (WSA) is a partnership among pastors, church members and health researchers with the goal of improving health in the churches and surrounding community in the West Side of Chicago, a highly segregated African American area of Chicago with high rates of premature mortality and social disadvantage. To inform health intervention development, WSA conducted a series of health screenings that took place in seven partner churches. Key measures included social determinants of health and healthcare access, depression and PTSD screeners, and measurement of cardiometabolic risk factors, including blood pressure, weight, cholesterol and hemoglobin A1C (A1C). A total of 1106 adults were screened, consisting of WSA church members (n = 687), members of the local community served by the church (n = 339) and 80 individuals with unknown church status. Mean age was 52.8 years, 57% were female, and 67% reported at least one social risk factor (e.g. food insecurity). Almost all participants had at least one cardiovascular risk factor (92%), including 50% with obesity, 79% with elevated blood pressure and 65% with elevated A1C. A third of participants experienced ≥ 4 potentially traumatic events and 26% screened positive for depression and/or post-traumatic stress disorder. Participants were given personalized health reports and referred to services as needed. Information from the screenings will be used to inform the design of interventions targeting the West Side community and delivered in partnership with the churches. Sharing these results helped mobilize community members to improve their own health and the health of their community.

Realtors' Perceptions of Social and Physical Neighborhood Characteristics Associated with Active Living: A Canadian Perspective

Realtors match home-seekers with neighborhoods that have built and social characteristics they desire to pursue active lifestyles. Studies have yet to explore realtors’ perspectives on neighborhood design that supports active living. Using qualitative description, our study was to explore the perceptions and understandings of neighborhood design (walkability, healthy, bike-ability, vibrancy, and livability) among urban residential realtors. Nineteen (6 men; 13 women; average age 48 years) self-identified residential realtors from Calgary, Edmonton, and Lethbridge (Canada) completed semi-structured telephone interviews. Content analysis identified themes from the interview data. Specifically, walkability was described as: perceived preferences, destinations and amenities, and connections; a healthy community was described as: encourages outdoor activities, and promotes social homogeneity; bike-ability was described as: bike-ability attributes, and was controversial; vibrancy was described as: community feel, and evidence of life; and livability was described as: subjective, and preferences and necessities. Our findings can inform the refinement of universal definitions and concepts used to in neighborhood urban design.

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.

Structural racism in the built environment: Segregation and the overconcentration of alcohol outlets

Structural racism, evidenced in practices like residential racial segregation, has been linked to health inequities. We examined the relationship between an adverse environmental factor (alcohol outlet overconcentration), segregated neighborhoods, and county alcohol policy in Louisiana and Alabama to investigate this link. Multilevel analysis revealed high outlet density associated with segregated counties and predominantly black census tracts in counties with restrictive alcohol policy. This inverse association between policies designed to limit alcohol availability and overconcentration of outlets in black neighborhoods warrants consideration by policymakers given links between outlet density and health inequities. Consideration of these findings in historical context suggests these policies may function as a contemporary actualization of the historical use of alcohol policy to subjugate black people in the South, now over-concentrating instead of prohibiting access.

Diabetes management at community health centers: Examining associations with patient and regional characteristics, efficiency, and staffing patterns

A major source of primary health care for millions of Americans, community health centers (CHCs) act as a key point of access for diabetes care. The ability of a CHC to deliver high quality care, that supports patients' management of their diabetes, may be impacted by the unique set of resources and constraints it faces, both in terms of characteristics of its patient population and aspects of operations. This study examines how patient and regional characteristics, staffing patterns, and efficiency were associated with diabetes management at CHCs (percentage of patients with uncontrolled diabetes, HbA1C > 9%). Data on a sample of 1229 CHCs came from multiple sources. CHC-level information was obtained from the Uniform Data System and regional-level information from the Behavioral Risk Factor Surveillance System and the US Census American Community Survey. A clustering methodology, latent class analysis, identified seven underlying staffing patterns at CHCs. Data envelopment analysis was performed to evaluate the efficiency of CHCs, relative to centers with similar staffing patterns. Finally, generalized linear models were used to examine the association between staffing patterns, efficiency, and patient and regional-level characteristics. Findings from this study have sociological, practical, and methodological implications. Findings highlight that the intersection of patient racial composition with regional racial composition is significant; diabetes control appears to be worse at CHCs serving racial minorities living in predominantly White areas. Findings suggest that CHCs that incorporate more behavioral health care into their staffing mix have lower rates of uncontrolled diabetes among their patients. Finally, greater efficiency in CHC operations is associated with better diabetes control among patients. By identifying sociodemographic and operational characteristics associated with better hemoglobin control among diabetes patients, the current study contributes to our understanding of both health care operations and health inequalities.

Racial residential segregation, racial discrimination, and diabetes: The Coronary Artery Risk Development in Young Adults study

Although racial residential segregation and interpersonal racial discrimination are associated with cardiovascular disease, few studies have examined their link with diabetes risk or management. We used longitudinal data from 2,175 black participants in the Coronary Artery Risk Development in Young Adults (CARDIA) Study to examine associations of racial residential segregation (Gi* statistic) and experiences of racial discrimination with diabetes incidence and management. Multivariable Cox models estimated associations for incident diabetes and GEE logistic regression estimated associations with diabetes management (meeting targets for HbA1c, systolic blood pressure, and LDL cholesterol). Neither segregation nor discrimination were associated with diabetes incidence or management.

Mortgage possessions, spatial inequality, and obesity in large US metropolitan areas

OBJECTIVES

As social determinants of health, mortgage possessions (primarily foreclosures in the US context) and housing instability have been associated with certain mental and physical health outcomes at the individual level. However, individual risks of foreclosure and of poor health are spatially patterned. The objective of this study is to examine the extent to which area-specific social and economic characteristics help explain the relationship between mortgage possessions and obesity prevalence in 75 of the 100 most populous US metropolitan areas.

STUDY DESIGN

This is a cross-sectional study.

METHODS

The study relies on three sources of data: the Selected Metropolitan/Micropolitan Area Risk Trends (SMART) project, RealtyTrac foreclosure data, and the American Community Survey. Focal social and economic characteristics include foreclosure rates, levels of racial residential segregation, and poverty. Obesity prevalence and several control measures for each metropolitan area are also used. Ordinary least squares regression, weighted using the SMART project data, is used, and statistical significance is set at 0.05.

RESULTS

The results suggest that mortgage possessions are independently associated with higher obesity prevalence and that foreclosures operate through the specific channel of racial residential segregation and its tie to the racial composition of a metropolitan area. Socio-economic status of an area, and not poverty, is related to foreclosures and obesity prevalence.

CONCLUSION

Mortgage possessions not only are socio-economic but also have negative health consequences, such as obesity. The findings provide an empirical base for other researchers to uncover the relationships between segregation, mortgage possessions, and obesity at the individual level of analysis. The public health community should be engaged in addressing the issue of foreclosures in the US because the failure to engage may have broad financial and health consequences across large cities.

Investigation of the association between obesity and insulin-induced gene 1 polymorphism at 7q36.3 region in Uygur population in Xinjiang, China

Background: Obesity is a common heritable trait and a major risk factors of chronic and metabolic diseases. Insulin-induced gene 1 (INSIG1) is known to play important roles in cholesterol and triacylglycerol (TAG) metabolism. In the present study, our primary objective was to explore whether the single nucleotide polymorphisms (SNPs) in INSIG1 gene were associated with obesity in Uygur subjects, in Xinjiang, China.

Methods: We designed a case–control study including 516 obese patients and 463 age- and sex-matched control subjects. Three SNPs (rs2721, rs9767875 and rs9719268) were genotyped using TaqMan SNP genotyping assays.

Results: For rs2721, the distribution of genotypes, dominant model (GT + TT vs GG), recessive model (TT vs GT + GG) showed significant differences between obese patients and the controls (P = 0.008, P = 0.005 and P = 0.035, respectively). For rs9719268, the distribution of genotypes showed significant differences between obese patients and the controls (P = 0.004). The dominant model (GT + TT vs GG) of rs2721 and rs9719268 GT genotype remain significantly associated with obesity after adjustment for confounders (OR = 1.393, 95% CI = 1.047–1.853, P = 0.023; OR = 1.631, 95% CI = 1.059–2.512, P = 0.026). The TG levels were significantly higher in rs2721 GT/TT genotypes than that in GG genotypes (P<0.05).

Conclusions: Rs2721 and rs9719268 of INSIG1 gene are associated with obesity in Uygur subjects. Subjects with GT/TT genotype or T allele of rs2721 and GT genotype of rs9719268 were associated with an increased risk of obesity.

Together for Health: An Initiative to Access Health Services for the Hispanic/Mexican Population Living in the United States

A disproportionately small percentage of the Hispanic/Mexican population in the United States has adequate access to health services, which decreases quality of life at both the individual and community levels. In addition, it increases risk for preventable diseases through insufficient screening and management. The Mexican Section of the U.S./Mexico Border Health Commission, in efforts to address barriers to accessing preventive health care services for vulnerable populations, launched the initiative Juntos por la Salud (JPLS) that offers health promotion and disease prevention services to Hispanics living in and around 11 U.S. metropolitan cities via mobile health units. This paper presents a descriptive analysis of the JPLS initiative and potential positive impact it has had in reducing barriers faced by the Hispanic population. JPLS screens and provides referrals to primary care services to establish a medical home and has the potential to reduce health care costs in a high-risk population through education and timely health screenings.

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 Environment and Cardiovascular Disease Risk

Purpose of review

Limited physical activity (PA) and obesity are two primary risk factors for cardiovascular disease (CVD). Within a socio-ecological framework, neighborhood social environment may play a key role in influencing PA and obesity. However, the mechanisms underlying this relationship remain ambiguous. Our goals in this review are: (1) to summarize findings from the recent studies on neighborhood social environment in relation to PA and obesity as CVD risk factors, and (2) to briefly describe several innovative approaches to assessing neighborhood social environment.

Recent findings

Almost all recent studies assessed neighborhood social environment around residential areas. There were consistent associations between neighborhood social environment and PA and obesity, with some exceptions (indicating null associations or paradoxical associations). However, a focus on residential social environment may limit results because these studies did not account for any exposures occurring away from individuals' homes. Additionally, the majority of studies utilized a cross-sectional design, which limits our ability to make inferences regarding the causality of the association between social environment and PA or obesity as CV risk factors.

Summary

The majority of the studies on neighborhood social environment characterized factors around residential areas and assessed participant activity via self-reported surveys. Future research should leverage tools to account for the spatial mismatch between environmental exposures and outcomes by using global positioning systems, ecological momentary assessments, virtual neighborhood audits, and simulation modeling. These approaches can overcome major limitations by tracking individuals' daily activity and real-time perceptions of neighborhood social environments linked to CVD events.