Neighborhood disparities in access to healthy foods and their effects on environmental justice

Experiences of multiple psychosocial stressors and associations with oxidative stress biomarkers during pregnancy

BACKGROUND

Oxidative stress is hypothesized to be one mechanism linking psychosocial stressor exposure to preterm birth and other adverse pregnancy outcomes. However, prior studies have focused solely on singular psychosocial stressors, which may not reflect real world exposures as pregnant women may experience multiple stressors simultaneously.

METHODS

Participants included a subset of the Chemicals in Our Bodies cohort, a prospective birth cohort in San Francisco, California (N = 227). Self -reported psychosocial stressors were assessed via questionnaires administered during the second trimester that addressed financial strain, food insecurity, job strain, neighborhood quality, caregiving, stressful life events, unplanned pregnancy, and perceived community status. Oxidative stress biomarkers were measured during the second trimester of pregnancy and included 15-F2t-IsoP, and its two major metabolites 2,3-dinor-5,6-dihydro-15-F2t-IsoP, and 2,3-dinor-15-F2t-IsoP, and PGF2α. Linear regression models were used to examine associations between individual and pairwise combinations of psychosocial stressors in relation to each oxidative stress biomarker.

RESULTS

15-F2t-IsoP, 2,3-dinor-15-F2t-IsoP, and 2,3-dinor-5,6-dihydro-15-F2t-IsoP were elevated among participants reporting experiences of low perceived community status, job strain, poor neighborhood quality, food insecurity, and stressful life events (e.g., β = 0.36, 95 % CI = 0.00, 0.72 for food insecurity in association with 15-F2t-IsoP). In models that included pairwise combinations of stressor exposures, nearly every combination was also associated with an increase in all oxidative stress biomarkers compared to those who experienced one or neither stressor. For example, stressful life events and poor neighborhood quality was associated with statistically significant increases in all biomarkers (e.g., β = 0.94, 95 % CI = 0.17, 1.71 for 2,3-dinor-5,6-dihydro-15-F2t-IsoP).

CONCLUSIONS

Urinary oxidative stress biomarkers were elevated among pregnant women exposed to psychosocial stressors, and exposure to multiple stressors resulted in the strongest associations. These findings support oxidative stress as one potential biological pathway linking prenatal psychosocial stress to preterm birth and other adverse pregnancy outcomes.

Neighborhood Socioeconomic Status and New Hidradenitis Suppurativa Diagnoses in a Single Health System

Importance

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition. Risk factors for developing HS (eg smoking and obesity) are influenced by social drivers of health at the neighborhood level. However, the association of neighborhood-level socioeconomic status (nSES) and HS has not been adequately assessed.

Objective

To evaluate the association of nSES with new HS diagnoses among dermatology patients within a single health system.

Design, Setting, and Participants

This was a cross-sectional study of patients of the dermatology clinics at the University of California San Francisco health system between August 1, 2019, and May 31, 2024, who were also residents of the San Francisco Bay Area at index visit. Data analyses were performed from June 1, 2024, to February 11, 2025.

Exposure

Census tract-level index measure of nSES that incorporated income, poverty, housing cost, rental cost, education, occupation, and employment. Quintiles of nSES were assigned based on nSES distribution in the San Francisco Bay Area counties.

Main Outcomes and Measures

A new HS diagnosis during the study period, identified by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code, and confirmed by medical record review. Logistic regression models were constructed and fit by generalized estimating equations accounting for clustering by census tract with nSES quintile as the primary exposure (reference used was quintile 5, the highest nSES quintile); new HS diagnosis as the binary outcome; and age, sex, and race and ethnicity as confounders. In secondary analyses, smoking status, obesity, and health insurance type were assessed as possible mediators.

Results

The analyses included a total of 65 766 patients (mean [SD] age, 50.4 [18.3] years; 41.8% female), of whom 485 (0.7%) had a new HS diagnosis. Greater odds of a new HS diagnosis were observed in lower-SES neighborhoods (Q1-Q4)-after adjusting for age, sex, and race and ethnicity, odds ratio for Q1 was 3.32 (95% CI, 2.46-4.49); Q2, 2.25 (95% CI, 1.62-3.12); Q3, 1.97 (95% CI, 1.46-2.66); and Q4, 1.44 (95% CI, 1.06-1.96) (P <.001 [linear trend]). In race-stratified analyses, greater odds of a new HS diagnosis were observed among patients residing in lower-SES neighborhoods, although this pattern did not reach statistical significance at the 5% level in all racial and ethnic groups.

Conclusions and Relevance

This cross-sectional study found that nSES was independently associated with a new diagnosis of HS among dermatology patients. This finding supports the hypothesis that neighborhood-level factors may influence the development of HS.

Reporting Minority Race and Ethnicity in Trauma and Critical Care

INTRODUCTION

Race and ethnicity disparities in health care can only be understood if race and ethnicity are reported. Currently, reporting occurs only per authors' discretion without a mandatory journalistic standard. In light of the current social climate and with many medical journals setting standards regarding diversity and inclusion, we hypothesize that reporting for racial and ethnic minorities has changed in American trauma and critical care journals.

METHODS

The Journal of Trauma and Acute Care Surgery, Shock, and Critical Care Medicine were reviewed for patient outcomes research published between January 2018 and July 2024. Basic science, translational, and international studies were excluded. Manuscripts were reviewed for study type, reported race or ethnicity, and reports of specific race (e.g., White, Black, Hispanic, Asian). Data were analyzed over time using Chi-square and Cochrane-Armitage trend tests.

RESULTS

A total of 1372 papers were reviewed and 527 manuscripts were included. Of these studies, 263 (51%) reported race or ethnicity in their analyses. Of the studies that reported race, 99% reported White, 83% reported Black, 39% reported Asian, and 49% reported Hispanic ethnicity. There was a significant increase in reporting of Asian race pre-2020 versus post-2020 (P = 0.032).

CONCLUSIONS

Despite increased national attention on racial disparities in medicine, our study found that reporting of race and ethnicity in trauma and critical care research remains inconsistent. Although there has been some improvement, including increased reporting of Asian populations, most studies still predominantly report White race. Continued efforts are needed to promote inclusivity and comprehensive demographic reporting to improve the generalizability of trauma research.

Impacts of City Life on Nutrition: Evidence From Resettlement Lotteries in China

Urban environments are thought to improve food security, by offering enhanced access to markets and income opportunities. Yet this idea is hard to test empirically due to an abundance of confounding factors and selection issues. This study leverages a resettlement program in China to provide the first quasi-experimental estimate of city life on food consumption and nutrition among low-income households. Lottery-determined timing of resettlement enables causal inference. We base our empirics on a 3-year panel and a range of difference-in-differences and matching methodologies. We find that those who were resettled to towns significantly increased both food consumption and diet variety, with increased intake of several macro- and micro-nutrients. Diet quality mostly improved, but we also found signs of over-consumption, notably of carbohydrates. Our evidence further suggests that our impacts are primarily due to improved market access. This stands in contrast to recent literature that finds little or no effect of living environments on food consumption. Instead, we reveal a significant impact of urban environments in shaping diets, bolstering the notion that supply-side channels do matter in some contexts.

Built Environment and Cardiovascular Diseases - Insights from a Global Review

PURPOSE OF REVIEW

This narrative review aims to synthesize global literature on the relationship between cardiovascular diseases (CVD) and components of built environment (green spaces, walkability, food environment, accessibility and availability of recreational and healthcare facilities, and effects of air and noise pollution).

RECENT FINDINGS

Increased green space and neighborhood walkability are associated with lower CVD mortality and morbidity; however, benefits have shown differential effects by socioeconomic status (SES). Air pollution is a leading environmental risk factor contributing to CVDs, and it disproportionately impacts low SES populations and women. Findings on relationships between food environment and CVDs are inconsistent and limited. This global review reports on the multifactorial and complex relationship between built environment and higher CVD risk and poor CVD outcomes. Future research can address an unmet need to understand this relationship with further depth and breadth, and to investigate resulting health disparities.

Diverse experiences of menopause

Although the biologic underpinnings of menopause remain consistent across populations, the experience of this phase can vary. This Practice Pearl summarizes key sociocultural, behavioral, environmental, and healthcare-system factors that contribute to the menopause journey. In addition to obtaining an accurate health history, screening for social determinants of health can enhance individualized menopause care with the potential to significantly improve overall health outcomes.

Factors and Outcomes Associated With Using Scratch-Cooked, Organic, and Locally Grown Foods in School Meals in California

BACKGROUND

Incorporating scratch-cooked, organic, and locally grown foods into school meal programs can enhance meal quality and support local food systems.

METHODS

430 California school food authorities were surveyed to (1) evaluate their use of scratch-cooked, organic, and locally grown foods in their programs; (2) identify demographic and operational characteristics related to this use; and (3) analyze the relationship between serving more of these foods and perceived barriers to student meal participation. Poisson and logistic regression models, adjusted for SFAs' demographic characteristics, were used.

RESULTS

Most respondents reported using scratch-cooked (82%) and locally grown foods (80%) in their school meals, with one-third serving organic foods (34%). Receiving grants to buy local produce and having a larger enrollment of White students were associated with more frequent use of these foods. More scratch cooking was associated with higher use of organic and locally grown foods and fewer perceptions of student nonparticipation due to concerns over meal healthfulness, taste, and freshness. More frequent use of organic and locally grown foods was also associated with fewer perceptions of student nonparticipation due to concerns about meal healthfulness.

CONCLUSIONS

These findings highlight the potential benefits of integrating more scratch-cooked, organic, and/or locally grown foods into school meals.

A Multi-Level Approach to Childhood Obesity Prevention and Management: Lessons from Japan and the United States

BACKGROUND

Childhood obesity is a pressing global public health challenge, marked by significant disparities in prevalence and management across countries. Japan and the United States offer contrasting approaches to addressing this issue, presenting a valuable opportunity for comparative analysis.

OBJECTIVE

This review examines the effectiveness of public health policies, cultural dietary habits, and lifestyle factors in combating childhood obesity in Japan and the United States. It aims to identify actionable insights to inform global strategies for obesity prevention.

RESULTS

Japan exhibits one of the lowest childhood obesity rates globally, attributed to prevention-focused policies such as the food education program, stringent school lunch standards, and culturally ingrained healthy eating practices. These efforts are complemented by active lifestyle promotion through urban planning and school-based physical education programs. In contrast, the United States faces higher obesity rates due to systemic challenges, including socioeconomic disparities, reliance on processed foods, sedentary lifestyles, and inconsistent implementation of federal programs like the National School Lunch Program (NSLP) and Supplemental Nutrition Assistance Program Education (SNAP-Ed).

CONCLUSIONS

This review highlights Japan's success in aligning public health initiatives with cultural norms to achieve sustainable outcomes. In the United States, systemic barriers and cultural disconnects hinder obesity prevention efforts. Recommendations include adopting integrated, prevention-focused policies, addressing socioeconomic inequities, redesigning urban environments to promote active living, and fostering global collaboration. This comparative analysis underscores the importance of culturally tailored, multidimensional strategies for addressing childhood obesity and improving public health outcomes worldwide.

Availability of community resources reduces the association among community violence exposure, negative emotionality, and substance use disorders

BACKGROUND

Exposure to community violence is associated with increased occurrence of substance use disorders (SUD). The self-medication hypothesis states that heightened negative emotionality may underlie the link between exposure to community violence and SUD. However, it is not well-understood if access to community resources, a broader public health approach, influences the purported psychological mechanisms underlying the link between community violence exposure and SUD.

OBJECTIVE

We examined whether negative emotionality mediates the association between youth-onset community violence exposure and having a SUD and whether community resources (i.e., density of social services, health care services, healthy food) moderate the relationship between negative emotionality and having a SUD.

METHODS

Moderated mediation analyses were used to test the indirect effect of negative emotionality and the moderating role of community resources on the association between negative emotionality and having a SUD.

PARTICIPANTS AND SETTING

A sample of 376 participants was collected from New Haven (ages 18-73, 45.7% Black, 44.1% White, 7.6% Hispanic).

RESULTS

There was a significant indirect effect of negative emotionality on the association between youth-onset community violence and having a substance use disorder (indirect effect = 0.22, SE = 0.07, p = .001, 95 % CI [0.11, 0.38]; proportion mediated = 0.24). Further, increased density of community resources reduced the relationship between negative emotionality and having a substance use disorder (β = -0.23, SE = 0.07, p = .001, 95% CI[-0.36, -0.10]).

CONCLUSION

Increasing availability of community resources may play a role in alleviating the suffering resulting from violence exposure.

Hospital volume does not mitigate the impact of area socioeconomic deprivation on heart transplantation outcomes

BACKGROUND

While structural socioeconomic inequity has been linked with inferior health outcomes, some have postulated reduced access to high-quality care to be the mediator. We assessed whether treatment at high-volume centers (HVC) would mitigate the adverse impact of area deprivation on heart transplantation (HT) outcomes.

METHODS

All HT recipients ≥18 years were identified in the 2005-2022 Organ Procurement and Transplantation Network. Neighborhood socioeconomic deprivation was assessed using the previously validated Area Deprivation Index. Recipients with scores in the highest quintile were considered Most Deprived (others: Less Deprived). Hospitals in the highest quartile by cumulative center volume (≥21 transplants/year) were classified as HVC. The primary outcome was post-transplant survival.

RESULTS

Of 38,022 HT recipients, 7,579 (20%) were considered Most Deprived. Following risk adjustment, Most Deprived demonstrated inferior survival at 3 (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.06-1.21) and 5 years following transplantation (HR 1.13, CI 1.07-1.20). Similarly, Most Deprived faced greater graft failure at 3 (HR 1.14, CI 1.06-1.22) and 5 years (HR 1.13, CI 1.07-1.20). Evaluating patients transplanted at HVC, Most Deprived continued to face greater mortality at 3 (HR 1.10, CI 1.01-1.21) and 5 years (HR 1.10, CI 1.01-1.19). The interaction between Most Deprived status and care at HVC was not significant, such that transplantation at HVC did not ameliorate the survival disparity between Most and Less Deprived.

CONCLUSIONS

Area socioeconomic disadvantage is independently associated with inferior survival. Transplantation at HVC did not eliminate this inequity. Future efforts are needed to increase engagement with longitudinal follow-up care and address systemic root causes to improve outcomes.

Social and Legal Needs in Patients and Families With Cancer: Interaction With Patient-Level Financial Toxicity

Adverse financial burden and its effect on patients resulting from the costs associated with cancer care, both direct and indirect, is known as financial toxicity. This review explores the interplay between financial toxicity and key social and legal needs in cancer care. Drawing from the WHO's framework and the ASCO's policy statement on social determinants of health, we propose a conceptual model that discusses five key needs-housing insecurity, food insecurity, transportation and access barriers, employment disruptions, and psychosocial needs-which interact with, and are affected by financial toxicity, and adversely influence patients' well-being and adherence to treatment. We review literature addressing the scope of each of these key needs, their effect on patients with cancer, and how each increases the overall burden of cancer treatment. There is an emphasis on both the patient and the caregiver as one unit navigating through cancer treatment together. The aim is to guide interventions at the patient-provider, institutional, and policy levels that alleviate financial toxicity and improve overall care delivery for patients and caregivers by addressing underappreciated social and legal needs.

Control of childhood obesity and implications for policy in China

Prevention and control of childhood obesity in China is complex. Despite numerous existing policy endeavours, particularly Healthy China 2030, accompanied by multiministerial initiatives, childhood obesity persists and even exacerbates. In this paper, we review current national policies, assess progress of the existing system managing childhood weight, and identify implementation challenges. Leveraging insights from existing literature and guided by a PEDALS (ie, problem, evidence-based practice, determinants, actions, long term, and scalability) framework, we propose a strategy to refine and integrate current policies, interventions, and research into a policy framework, embedding evidence-based practices into practical solutions for childhood obesity prevention and control in China.

Census tract geospatial analysis comparing social determinants of health with tooth loss in California seniors: An ecologic study

OBJECTIVES

Individual-level social determinant of health (SDOH) measures alone may insufficiently explain disparities in edentulism among seniors. Therefore, the authors examined the correlation of census tract-level SDOH and residential racial segregation measures with edentulism in Californian adults aged ≥65 years old.

METHODS

Explanatory variables were obtained from Healthy Places Index (HPI), the National Cancer Institute and diversitydatakids.org. The edentulism outcome variable was obtained from CDC's PLACES small area estimates from the 2018 Behavioral Risk Factor Surveillance System data. Pearson and Spearman rank correlations were estimated. Multiple linear regression and multi-collinearity evaluations were performed. The Global Moran's I statistic assessed partial autocorrelation within census tracts.

RESULTS

Pearson and Spearman correlations were similar, supporting robustness. HPI, an area measure of advantage, strongly negatively correlated with edentulism prevalence [correlation coefficient: -0.87; 95% confidence interval (CI): -0.87, -0.86]. A change of 1.0 in HPI corresponded to an estimated decrease in edentulism prevalence of 5.9% (linear model adjusted R2 = 0.78). Racially segregated census tracts with Hispanics or Blacks alone were positively correlated with edentulism prevalence [0.60, 95% CI: 0.58, 0.62; and 0.33, 95% CI: 0.31, 0.35, respectively]. The converse was seen in census tracts with non-Hispanic Whites alone [-0.57, 95% CI: -0.58, -0.55]. Global Moran's I statistic for edentulism (0.13) and HPI scores (0.19) were significant (both p < .001) indicating geospatial autocorrelation.

CONCLUSIONS

Higher disadvantage and minority racial segregation within census tracts were positively correlated with edentulism prevalence. Future research and policy should consider possible interventions improving SDOH to reduce oral health inequities.

Nutritional Education in Polish Companies: Employee Needs and the Role of Employers in Health Promotion

The modern work environment is constantly evolving, and with it, the emphasis on employee health and well-being is increasing.

BACKGROUND

Nutritional education has become a key component of health promotion strategies in many companies that recognize the benefits of healthy eating habits for enhancing efficiency and job satisfaction.

OBJECTIVES

The aim of this study was to understand employees' nutritional needs at work, and to assess the support provided by employers. The analysis focused on employees' eating habits and their attitudes towards eating at work, motives and barriers to healthy eating.

METHODS

The study was conducted using an anonymous survey completed by 1.056 individuals from across Poland. A discriminant function was selected for data analysis, which examined the differences between groups.

RESULTS/CONCLUSIONS

The larger enterprises are more inclined to establish meal consumption spaces, which contributes to a more organised work culture. The larger the business, the more time employees spend eating meals, it being influenced by better-developed eating facilities, which undoubtedly encourages the workers to take longer breaks. The people with obesity were found to place the highest value on healthy food options and the people with a normal BMI are more responsive to healthy food subsidies, nutritional advice provided by a dietitian, and access to fitness facilities.

Dietary Restriction, Socioeconomic Factors, Access to Kidney Transplantation, and Waitlist Mortality

INTRODUCTION

Dietary restrictions for patients with end-stage kidney disease (ESKD) are burdensome. Kidney transplantation (KT) candidates who lack neighborhood resources and are burdened by dietary restrictions may have decreased access to KT.

METHODS

In our two-center prospective cohort study (2014-2023), 2471 ESKD patients who were evaluated for KT (candidates) reported their perceived burden of dietary restrictions (not at all, somewhat/moderately, or extremely bothered). Neighborhood-level socioeconomic factors were derived from residential ZIP codes. We quantified the association of perceived burden of the dietary restrictions with a chance of listing using Cox models and risk of waitlist mortality using competing risks models. Then we tested whether these associations differed by neighborhood-level socioeconomic factors.

RESULTS

At evaluation, 18% of KT candidates felt extremely bothered by dietary restrictions. Those who felt extremely bothered were less likely to be listed for KT (adjusted hazard ratio [aHR] = 0.75, 95% confidence interval [CI]: 0.64-0.87); this association did not differ by neighborhood-level socioeconomic factors. Overall, the burden of dietary restrictions was not associated with waitlist mortality (p = 0.62). However, among candidates living in high food insecurity neighborhoods, those who felt extremely bothered had higher waitlist mortality (adjusted subhazard ratio [aSHR] = 2.07, 95% CI: 1.14-3.75, p[interaction] = 0.02). The association between dietary burden and waitlist mortality did not differ by neighborhood-level healthy food access.

CONCLUSION

The perceived burden of dietary restrictions is associated with a lower chance of listing for KT, and higher waitlist mortality only among candidates residing in neighborhoods with high food insecurity. Transplant centers should identify vulnerable patients and support them with nutrition education and access to food assistance programs.

The impact of the COVID-19 pandemic on the socioeconomic gradient of hypertension

The COVID-19 pandemic has brought into sharp focus the impact of socioeconomic factors on hypertension outcomes. This review examines the implications of the pandemic on the socioeconomic gradient of hypertension and explores the physiological and pathophysiological processes underlying this relationship. Changes in socioeconomic factors have disproportionately affected individuals with lower socioeconomic status, leading to adverse hypertension outcomes. The pandemic-related stressors, coupled with social isolation and disrupted daily routines, have contributed to elevated stress levels among individuals, particularly those with lower socioeconomic status. Equitable access to healthcare, enhancing health literacy and patient empowerment, and addressing social determinants of health are essential components of hypertension management strategies. By recognizing the specific challenges faced by individuals with lower socioeconomic status and implementing targeted interventions, public health efforts can help reduce the socioeconomic gradient of hypertension.

Urban-Rural Disparities in Food Insecurity and Weight Status among Children in the United States

Place of residence (urban versus rural) is a contextual determinant of health that has received less attention in the food insecurity literature. The purpose of this study was to assess the urban-rural disparity in the prevalence of food insecurity and weight status among US children. Using data from the National Health and Nutrition Examination Survey (NHANES) 2013-2016 with three age groups of children (2-5, 6-11, and 12-17 years old), the associations of weight status and child and household food security status by urban-rural residence were examined using Rao-Scott Chi-square tests. Statistical significance was set at p < 0.05. Children living in urban areas were significantly more likely to experience household food insecurity (29.15%) compared to their rural counterparts (19.10%), among those aged 6-11 years. The associations between children's weight status and child and household food security status were significant for children living in urban areas overall and different age groups but not for children living in rural areas. These trends were more pronounced in older age groups. Given the link between food insecurity and higher obesity rates, particularly among urban children, this study highlights the importance of incorporating food security interventions into future obesity prevention programs.

Early impact of a new food store intervention on health-related outcomes

This study investigated the early impact of a community-based food intervention, the Good Food Junction (GFJ), a full-service grocery store (September 2012 - January 2016) in a former food desert in Saskatoon, Canada. The hypothesis tested was that frequent shopping at the GFJ improved food security and selected health-related outcomes among shoppers, and the impact was moderated by socioeconomic factors. Longitudinal data were collected from 156 GFJ shoppers, on three occasions: 12-, 18-, and 24-months post-opening. Participants were grouped into three categories based on the frequency of shopping at the GFJ: low, moderate, and high. A generalized estimating equations approach was used for model building; moderating effects were tested. Participants were predominantly female, Indigenous, low-income, and had high school or some post-secondary education. The GFJ use was associated with household food security (OR for high and moderate frequency shoppers reporting less than a high school education were 1.81 and 1.06, respectively), and mental health (OR for high and moderate frequency shoppers reporting high income were 2.82 and 0.87, respectively) exhibiting a dose-response relationship, and indicated that these outcomes were significantly moderated by participants' socioeconomic factors. Shopping at the GFJ had a positive effect on food security and mental health, but to varying levels for those with low incomes, with less than high school or high school or better levels of education.

A greening theory of change: How neighborhood greening impacts adolescent health disparities

Neighborhoods are one of the key determinants of health disparities among young people in the United States. While neighborhood deprivation can exacerbate health disparities, amenities such as quality parks and greenspace can support adolescent health. Existing conceptual frameworks of greening-health largely focus on greenspace exposures, rather than greening interventions. In this paper, we develop and propose a Greening Theory of Change that explains how greening initiatives might affect adolescent health in deprived neighborhoods. The theory situates greening activities and possible mechanisms of change in the context of their ability to modify distal social determinants of health factors, stemming from macrostructural and historical processes that lead to resource inequalities, affecting both the social and built environment in which adolescents live and develop. The framework illustrates both short- and long-term health, economic, and security effects of greening. We also describe how the theory informed the development of Project VITAL (Vacant lot Improvement to Transform Adolescent Lives) in Baltimore, MD, which aims to (1) build a citywide sharable database on vacant lot restoration activities, (2) evaluate the impact of greening initiatives on adolescent health outcomes, (3) conduct cost-effectiveness analyses, and (4) develop best practices for greening programs for improved adolescent health.

Environmental-, Climate-, and Health-Related Dietary Motivations Are Associated With Higher Diet Quality in a National Sample of US Adults With Lower Incomes

BACKGROUND

Plant-based diets can have co-benefits for human and planetary health. Associations between environmental, climate, and health concerns and dietary intake in US adults are understudied, particularly in underserved populations.

OBJECTIVE

The study objectives were to assess how dietary choices motivated by the environment, climate, and health vary by sociodemographic characteristics and how they relate to diet quality and intake frequency of different food groups in US adults with lower incomes.

DESIGN

The study design was cross-sectional.

PARTICIPANTS/SETTING

A web-based survey was fielded in December 2022 to 1,798 US adults with lower incomes (<250% of federal poverty guidelines).

MAIN OUTCOME MEASURES

Environmental-, climate-, and health-related dietary motivations and diet quality and dietary food group intake frequency were assessed.

STATISTICAL ANALYSES

Differences in mean dietary outcomes and dietary motivation ratings by sociodemographic characteristics were evaluated using analysis of variance and Kruskal-Wallis tests. Associations between dietary motivations and diet quality scores and dietary intake frequency were examined using generalized linear models adjusted for sociodemographic covariates.

RESULTS

Younger adults, women, nonbinary people, racial and ethnic minoritized groups, and adults experiencing food insecurity reported higher environmental and climate dietary motivations; older adults, higher-income adults, and food-secure adults reported higher health motivations. Agreeing with environmental- (β = 2.28, 95% CI 1.09 to 3.47), climate- (β = 2.15, 95% CI 0.90 to 3.40), and health-related (β = 5.27, 95% CI 3.98 to 6.56) dietary motivations was associated with higher diet quality scores compared with those with neutral rankings. Similarly, agreement with environmental-, climate-, and health-related dietary motivations was associated with higher intake frequency of fish, fruits and vegetables, and plant proteins, but not with red and processed meat intake frequency. Of several climate-mitigation behaviors presented, participants perceived meat reduction as least effective (P < .001).

CONCLUSIONS

Environment, climate, and health were positive motivators of several healthy dietary choices in US adults with lower incomes. Such motivators did not translate to lower intake frequency of red and processed meat.

Association of Historical Housing Discrimination and Colon Cancer Treatment and Outcomes in the United States

PURPOSE

In the 1930s, the federally sponsored Home Owners' Loan Corporation (HOLC) used racial composition in its assessment of areas worthy of receiving loans. Neighborhoods with large proportions of Black residents were mapped in red (ie, redlining) and flagged as hazardous for mortgage financing. Redlining created a platform for systemic disinvestment in these neighborhoods, leading to barriers in access to resources that persist today. We investigated the association between residing in areas with different HOLC ratings and receipt of quality cancer care and outcomes among individuals diagnosed with colon cancer-a leading cause of cancer deaths amenable to early detection and treatment.

METHODS

Individuals who resided in zip code tabulation areas in 196 cities with HOLC rating and were diagnosed with colon cancer from 2007 to 2017 were identified from the National Cancer Database and assigned a HOLC grade (A, best; B, still desirable; C, definitely declining; and D, hazardous and mapped in red). Multivariable logistic regression models investigated association of area-level HOLC grade and late stage at diagnosis and receipt of guideline-concordant care. The product-limit method evaluated differences in time to adjuvant chemotherapy. Multivariable Cox proportional hazard models investigated differences in overall survival (OS).

RESULTS

There were 149,917 patients newly diagnosed with colon cancer with a median age of 68 years. Compared with people living in HOLC A areas, people living in HOLC D areas were more likely to be diagnosed with late-stage disease (adjusted odds ratio, 1.06 [95% CI, 1.00 to 1.12]). In addition, people living in HOLC B, C, and D areas had 8%, 16%, and 24% higher odds of not receiving guideline-concordant care, including lower receipt of surgery, evaluation of ≥12 lymph nodes, and chemotherapy. People residing in HOLC B, C, or D areas also experienced delays in initiation of adjuvant chemotherapy after surgery. People residing in HOLC C (adjusted hazard ratio [aHR], 1.09 [95% CI, 1.05 to 1.13]) and D (aHR, 1.13 [95% CI, 1.09 to 1.18]) areas had worse OS, including 13% and 20% excess risk of death for individuals diagnosed with early- and 6% and 8% for late-stage disease for HOLC C and D, respectively.

CONCLUSION

Historical housing discrimination is associated with worse contemporary access to colon cancer care and outcomes.

Sodium Intake and Cause-Specific Mortality Among Predominantly Low-Income Black and White US Residents

IMPORTANCE

Epidemiologic evidence regarding the outcomes of dietary sodium intake on mortality remains limited for low-income individuals, particularly Black people.

OBJECTIVE

To investigate the associations of excessive dietary sodium with all-cause and cause-specific mortality among predominantly low-income Black and White Americans.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included participants aged 40 to 79 years from the Southern Community Cohort Study who were recruited at Community Health Centers in 12 southeastern states from 2002 to 2009. Analyses were conducted between March 2022 and June 2023.

EXPOSURES

Dietary sodium intake was assessed using a validated food frequency questionnaire at baseline.

MAIN OUTCOMES AND MEASURES

Multivariable-adjusted Cox regression was used to estimate hazard ratios (HRs) and 95% CIs for mortality outcomes (all-cause, cardiovascular disease [CVD], coronary heart disease [CHD], stroke, heart failure, cancer, and other) associated with sodium intake. Nonlinear associations and population-attributable risk (PAR) of the mortality burden associated with excess sodium were further assessed.

RESULTS

Among the 64 329 participants, 46 185 (71.8%) were Black, 18 144 (28.2%) were White, and 39 155 (60.9%) were female. The mean (SD) age at study enrollment was 51.3 (8.6) years for Black participants and 53.3 (9.3) years for White counterparts. Mean (SD) dietary sodium intake was 4512 (2632) mg/d in Black individuals and 4041 (2227) mg/d in White individuals; 37 482 Black individuals (81.2%) and 14 431 White individuals (79.5%) exceeded the current dietary recommendations of 2300 mg/d. During a median (IQR) follow-up of 13.8 (11.3-15.8) years, 17 811 deaths were documented, including 5701 from CVD. After adjustment for potential confounders, in Black individuals, HRs per 1000-mg increase in daily sodium intake were 1.07 (95% CI, 1.03-1.10) and 1.08 (95% CI, 1.02-1.14) for deaths from total CVD and CHD, respectively; while in White individuals, the corresponding HRs were 1.08 (95% CI, 1.02-1.14) and 1.13 (95% CI, 1.03-1.23). No significant associations were found for cancer mortality. PAR estimates suggest that sodium intake above the recommended threshold may account for 10% of total CVD, 13% of CHD, and 30% of heart failure deaths in this low-income southern population.

CONCLUSIONS AND RELEVANCE

In this cohort study of 64 329 low-income Americans, nearly 80% of study participants consumed sodium exceeding the current recommended daily amount, which was associated with 10% to 30% of CVD mortality. Public health programs targeted to reduce sodium intake among this underserved population may be beneficial.

Determinants of obesity in Latin America

Obesity rates are increasing almost everywhere in the world, although the pace and timing for this increase differ when populations from developed and developing countries are compared. The sharp and more recent increase in obesity rates in many Latin American countries is an example of that and results from regional characteristics that emerge from interactions between multiple factors. Aware of the complexity of enumerating these factors, we highlight eight main determinants (the physical environment, food exposure, economic and political interest, social inequity, limited access to scientific knowledge, culture, contextual behaviour and genetics) and discuss how they impact obesity rates in Latin American countries. We propose that initiatives aimed at understanding obesity and hampering obesity growth in Latin America should involve multidisciplinary, global approaches that consider these determinants to build more effective public policy and strategies, accounting for regional differences and disease complexity at the individual and systemic levels.

The role of place-based factors and other social determinants of health on adverse post-sepsis outcomes: a review of the literature

Sepsis remains a common and costly disease. With early recognition and guideline-based treatment, more patients are surviving to hospital discharge. Many survivors experience adverse health events in the months following discharge, while others suffer long-term physical and cognitive decline. Social, biological, and environmental factors affect all aspects of the disease process, from what pathogens one is exposed to, how/if disease develops, what avenues are available for treatment, as well as short- and long-term sequelae of survival. Disparities in sepsis care exist at all stages of a patient's clinical course, but increased survivorship has highlighted the extent to which Social Determinants of Health (SDoH) influence post-discharge adverse events. Despite increased interest in the last decade, a nuanced understanding of causal relationships remains elusive. This is due to several factors: the narrow range of social determinants of health (SDoH) variables typically studied, the inconsistent and non-standardized methods of documenting and reporting SDoH, and the inadequate acknowledgment of how social, environmental, and biological factors interact. Lack of clear understanding of how SDoH influence post- discharge outcomes is an obstacle to development and testing of strategies to mitigate their harms. This paper reviews the literature pertaining to the effects of SDoH on post-discharge outcomes in sepsis, highlights gaps therein, and identifies areas of greatest need for improving the quality and impact of future investigations.

The Impact of Climate Change on Global Oncology

Climate change is the greatest threat to human health of our time, with significant implications for global cancer control efforts. The changing frequency and behavior of climate-driven extreme weather events results in more frequent and increasingly unanticipated disruptions in access to cancer care. Given the significant threat that climate change poses to cancer control efforts, oncology professionals should champion initiatives that help protect the health and safety of patients with cancer, such as enhancing emergency preparedness and response efforts and reducing emissions from our own professional activities, which has health cobenefits for the entire population.

Climate change and cancer: the Environmental Justice perspective

Despite advances in cancer control-prevention, screening, diagnosis, treatment, and survivorship-racial disparities in cancer incidence and survival persist and, in some cases, are widening in the United States. Since 2020, there's been growing recognition of the role of structural racism, including structurally racist policies and practices, as the main factor contributing to historical and contemporary disparities. Structurally racist policies and practices have been present since the genesis of the United States and are also at the root of environmental injustices, which result in disproportionately high exposure to environmental hazards among communities targeted for marginalization, increased cancer risk, disruptions in access to care, and worsening health outcomes. In addition to widening cancer disparities, environmental injustices enable the development of polluting infrastructure, which contribute to detrimental health outcomes in the entire population, and to climate change, the most pressing public health challenge of our time. In this commentary, we describe the connections between climate change and cancer through an Environmental Justice perspective (defined as the fair treatment and meaningful involvement of people of all racialized groups, nationalities, or income, in all aspects, including development, implementation, and enforcement, of policies and practices that affect the environment and public health), highlighting how the expertise developed in communities targeted for marginalization is crucial for addressing health disparities, tackling climate change, and advancing cancer control efforts for the entire population.

Broadening the Environmental Lens to Include Social and Structural Determinants of Women's Health Disparities

BACKGROUND

Due to the physical, metabolic, and hormonal changes before, during, and after pregnancy, women-defined here as people assigned female at birth-are particularly susceptible to environmental insults. Racism, a driving force of social determinants of health, exacerbates this susceptibility by affecting exposure to both chemical and nonchemical stressors to create women's health disparities.

OBJECTIVES

To better understand and address social and structural determinants of women's health disparities, the National Institute of Environmental Health Sciences (NIEHS) hosted a workshop focused on the environmental impacts on women's health disparities and reproductive health in April 2022. This commentary summarizes foundational research and unique insights shared by workshop participants, who emphasized the need to broaden the definition of the environment to include upstream social and structural determinants of health. We also summarize current challenges and recommendations, as discussed by workshop participants, to address women's environmental and reproductive health disparities.

DISCUSSION

The challenges related to women's health equity, as identified by workshop attendees, included developing research approaches to better capture the social and structural environment in both human and animal studies, integrating environmental health principles into clinical care, and implementing more inclusive publishing and funding approaches. Workshop participants discussed recommendations in each of these areas that encourage interdisciplinary collaboration among researchers, clinicians, funders, publishers, and community members. https://doi.org/10.1289/EHP12996.

Store-specific grocery shopping patterns and their association with objective and perceived retail food environments

OBJECTIVE

To explore store-specific grocery shopping patterns and assess associations with the objective and perceived retail food environment (RFE).

DESIGN

This cross-sectional study used principal component analysis and hierarchical cluster analysis to identify grocery shopping patterns and logistic regression models to assess their associations with the RFE, while adjusting for household characteristics.

SETTING

The Montpellier Metropolitan Area, France.

PARTICIPANTS

To be eligible for inclusion, participants had to be 18 years of age or older and reside in the Montpellier Metropolitan Area. Analyses were carried out on 415 households.

RESULTS

Households of cluster 'Supermarket' (49 % of households) primarily shopped at supermarkets and were less likely to live near a convenience store. Households of cluster 'Diversified' (18 %) shopped mostly at organic stores, at markets, at specialised stores, and from producers and were more likely to have a market in their activity space. Households of cluster 'Discount' (12 %) primarily shopped at discounters and were less likely to perceive a producer in their activity space. Households of cluster 'Convenience' (12 %) mostly shopped online or in convenience stores. Finally, households of cluster 'Specialized' (9 %) had high expenditures in greengrocers and in other specialised food stores and were more likely to live near a specialised food store.

CONCLUSIONS

This study highlighted the importance of considering both perceived and objective RFE indicators, as well as assessments around the home and in activity space. Understanding how people buy food and interact with their RFE is crucial for policymakers seeking to improve urban food policies.

Economic Determinants of Health Disparities and the Role of the Primary Care Provider

The economic determinants of adverse personal health outcomes and population level disparities pose a daunting challenge for primary care providers in promoting health for persons experiencing poverty and neighborhood deprivation. Until they are addressed, however, the health and economic well-being of persons experiencing neighborhood deprivation is not likely to be improved. There is growing evidence of effective interventions that primary care providers can adopt to address social and economic determinants of health. Primary care providers can participate in clinic and community-based approaches that target individual, neighborhood and social level drives of health and disparities.

The longitudinal association between neighbourhood quality and cardiovascular risk factors among youth receiving obesity treatment

BACKGROUND

Neighbourhood factors are associated with cardiovascular health in adults, but these relationships are under-explored in youth.

OBJECTIVES

To characterize the associations between neighbourhood factors and child and adolescent health among youth with obesity.

METHODS

Data were drawn from patient health records at a pediatric weight management clinic (n = 2838) and the Child Opportunity Index (COI). Exposures were area-level neighbourhood factors (commute duration, walkability, greenspace and industrial pollutants). Outcomes included BMI relative to the 95th percentile (BMIp95) and blood pressure (continuous variables). Longitudinal models examined associations between COI indicators and outcomes.

RESULTS

Shorter commute duration (β = -4.31, 95% CI: -5.92, -2.71) and greater walkability (β = -4.40, 95% CI: -5.98, -2.82) were negatively associated with BMIp95. Increased greenspace availability was positively associated with BMIp95 (β = 1.93, 95% CI: 0.19, 3.67). None of the COI indicators were associated with cardiovascular outcomes in the full sample. Analyses stratified by sex and race/ethnicity showed similar patterns for BMIp95. For commute duration, there was a negative association with blood pressure for female, non-Hispanic White and other race/ethnicity youth.

CONCLUSIONS

Neighbourhood factors should be considered as contextual factors when treating youth with obesity. Additional research is needed to understand the relationship between neighbourhood factors and cardiovascular outcomes.

Food Insecurity and Food Addiction in a Large, National Sample of Lower-Income Adults

Background

Growing research has highlighted associations between food insecurity and eating-related problems. Food addiction is one important, clinically significant pattern of problematic eating, which is related to, but distinct from, eating disorders. To date, there is only one study examining the association between food insecurity and food addiction, to our knowledge. Additional research is needed to understand the complexities of this association.

Objective

We examined the association between food insecurity and food addiction in a large, national convenience sample of lower-income adults and potential heterogeneity in this association by age, gender, race, and ethnicity.

Design

A cross-sectional, web-based study was conducted among 1780 US adults (≥18 y) with household incomes <250% of the federal poverty guideline. Household food security was assessed using the Household Food Security Survey Module. Food addiction was assessed using the modified Yale Food Addiction Scale (mYFAS), version 2.0. Multivariate logistic regression models examined the associations between food insecurity and food addiction, adjusting for sociodemographic covariates.

Results

The prevalence of food addiction was 7.3%, and the prevalence of food insecurity was 51%. Compared with adults with food security, adults with food insecurity endorsed each mYFAS symptom with significantly greater frequency, including failure to fulfill major role obligations (20%), continued use despite social or interpersonal problems (18%), and craving or strong desire to use (16%). After adjustment, food insecurity was associated with 3.82-fold higher odds of food addiction (95% CI 2.36, 6.19), with no significant heterogeneity by age, gender, or race and ethnicity. The most problematic foods reported by adults with food insecurity were chips, nondiet soda, chocolate, pizza, and ice cream.

Conclusion

These findings provide additional support for the association between food insecurity and food addiction. Mechanistic studies are needed to explore the role of psychosocial factors, eating behaviors, and the food environment in contributing to these associations.

Race- and Gender-Specific Associations between Neighborhood-Level Socioeconomic Status and Body Mass Index: Evidence from the Southern Community Cohort Study

Obesity and a low socioeconomic status (SES), measured at the neighborhood level, are more common among Americans of Black race and with a low individual-level SES. We examined the association between the neighborhood SES and body mass index (BMI) using data from 80,970 participants in the Southern Community Cohort Study, a cohort that oversamples Black and low-SES participants. BMI (kg/m2) was examined both continuously and categorically using cut points defined by the CDC. Neighborhood SES was measured using a neighborhood deprivation index composed of census-tract variables in the domains of education, employment, occupation, housing, and poverty. Generally, the participants in lower-SES neighborhoods were more likely to have a higher BMI and to be considered obese. We found effect modification by race and sex, where the neighborhood-BMI association was most apparent in White female participants in all the quintiles of the neighborhood SES (ORQ2 = 1.55, 95%CI = 1.34, 1.78; ORQ3 = 1.71, 95%CI = 1.48, 1.98; ORQ4 = 1.76, 95%CI = 1.52, 2.03; ORQ5 = 1.64, 95%SE = 1.39, 1.93). Conversely, the neighborhood-BMI association was mostly null in Black male participants (ORQ2 = 0.91, 95%CI = 0.72, 1.15; ORQ3 = 1.05, 95%CI = 0.84, 1.31; βQ4 = 1.00, 95%CI = 0.81, 1.23; ORQ5 = 0.76, 95%CI = 0.63, 0.93). Within all the subgroups, the associations were attenuated or null in participants residing in the lowest-SES neighborhoods. These findings suggest that the associations between the neighborhood SES and BMI vary, and that other factors aside from the neighborhood SES may better predict the BMI in Black and low-SES groups.

Design of an innovative digital application to facilitate access to healthy foods in low-income urban settings

Background

Under-resourced urban minority communities in the United States are characterized by food environments with low access to healthy foods, high food insecurity, and high rates of diet-related chronic disease. In Baltimore, Maryland, low access to healthy food largely results from a distribution gap between small food sources (retailers) and their suppliers. Digital interventions have the potential to address this gap, while keeping costs low.

Methods

In this paper, we describe the technical (I) front-end design and (II) back-end development process of the Baltimore Urban food Distribution (BUD) application (app). We identify and detail four main phases of the process: (I) information architecture; (II) low and high-fidelity wireframes; (III) prototype; and (IV) back-end components, while considering formative research and a pre-pilot test of a preliminary version of the BUD app.

Results

Our lessons learned provide valuable insight into developing a stable app with a user-friendly experience and interface, and accessible cloud computing services for advanced technical features.

Conclusions

Next steps will involve a pilot trial of the app in Baltimore, and eventually, other urban and rural settings nationwide. Once iterative feedback is incorporated into the app, all code will be made publicly available via an open source repository to encourage adaptation for desired communities.

Trial Registration

ClinicalTrials.gov NCT05010018.

Residence in Hispanic/Latino Immigrant Neighborhoods, Away-From-Home Food Consumption, and Diet Quality: The Hispanic Community Health Study/Study of Latinos

BACKGROUND

Hispanics/Latinos are disproportionately burdened by nutrition-related diseases but immigrants appear healthier than their US-born counterparts. Neighborhoods characterized by high Hispanic/Latino immigrant segregation may provide environments to support healthier diets.

OBJECTIVE

To examine whether or not Hispanic/Latino immigrant segregation is associated with frequency of away-from-home food consumption and diet quality in a large, diverse sample of Hispanic/Latino adults.

DESIGN

Cross-sectional baseline data from the Hispanic Community Health Study/Study of Latinos were analyzed (2008-2011). Residential addresses were geocoded and linked to census tract-level 2008-2012 American Community Survey data. Hispanic/Latino immigrant segregation was characterized using the local Getis-Ord Gi∗ statistic, a spatial clustering measure that quantifies the extent to which demographically similar neighborhoods group together.

PARTICIPANTS/SETTING

Participants were 15,661 adults in the Hispanic Community Health Study/Study of Latinos, a population-based study of Hispanic/Latinos aged 18 to 74 years from 4 US regions (Bronx, NY; Chicago, IL; Miami, FL; and San Diego, CA).

MAIN OUTCOME MEASURES

Away-from-home food consumption was assessed using a modified dietary behavior questionnaire. Diet quality was assessed using the Alternate Healthy Eating Index 2010 (range = 0 to 110) from two 24-hour recalls.

STATISTICAL ANALYSIS

Multilevel linear and logistic regression with multilevel weights were used to estimate associations between Hispanic/Latino immigrant segregation (low, medium, or high) with Alternate Healthy Eating Index 2010 score, and away-from-home food consumption (≥3 vs <3 times/week) in separate models, respectively. The mediating role of neighborhood poverty and whether or not associations differed by nativity were also assessed.

RESULTS

Higher levels of segregation were associated with higher adjusted mean Alternate Healthy Eating Index 2010 scores; estimates were further magnified after accounting for neighborhood poverty (low segregation: reference category; medium segregation: β = 2.43, 95% CI 1.10 to 3.77; and high segregation: β = 1.63, 95% CI .43 to 2.82). Associations were strongest among the foreign-born compared with the US-born. There was no association between segregation and away-from-home food consumption.

CONCLUSIONS

These results highlight the potential role of Hispanic/Latino immigrant neighborhoods in supporting healthy diets among residents, especially immigrants.

SNAP Participation Moderates Fruit and Vegetable Intake Among Minority Families With Low Income

OBJECTIVE

To examine the moderation effect of Supplemental Nutrition Assistance Program (SNAP) participation on the baseline fruit and vegetable (FV) intake of Hispanic/Latino and African American children and parents participating in the Brighter Bites program.

DESIGN

Cross-sectional.

SETTING

Houston, Austin, and Dallas, TX; Washington, DC; and Southwest Florida.

PARTICIPANTS

Self-reported surveys (n = 6,037) of Hispanic/Latino and African American adult-child dyads enrolled in Brighter Bites in Fall 2018.

VARIABLES MEASURED

Dependent variable, child FV intake; Independent variable, parent FV intake, and FV shopping behavior; Effect Measure Modifier, SNAP participation.

ANALYSIS

Quantitatively used mixed effects linear regression models to test if the effect of parental baseline FV intake and shopping behavior on a child's baseline FV intake differed by SNAP participation. Analyses were performed using STATA with significance set at P < 0.05 and 95% confidence intervals (CIs).

RESULTS

For parents that consumed FV ≥ 2 times/d at baseline, there was a 0.1 times increase in child FV intake at baseline among those who participated in SNAP as compared with those who did not participate in SNAP (ß = 0.1; 95% CI, 0.1-0.2; P = 0.001), and for parents who shopped at convenience stores ≥ 2 times/wk for FV, there was 0.6 times increase in child FV intake at baseline for those who participated in SNAP as compared with those that did not participate in SNAP (ß = 0.6; 95% CI, 0.3-0.9; P < 0.001).

CONCLUSIONS AND IMPLICATIONS

Supplemental Nutrition Assistance Program participation moderated the associations between FV intake among African American and Hispanic/Latino parents and children and FV shopping at convenience stores and child FV intake. Findings indicate a need for future interventions to promote SNAP participation among those eligible and improve access to FV.

Social Risk Factors That Increase Cardiovascular and Breast Cancer Risk

PURPOSE OF REVIEW

Cardiovascular disease (CVD) and breast cancer (BC) are significant causes of mortality globally, imposing a substantial health burden. This review article aims to examine the shared risk factors and social determinants that contribute to the high prevalence of both diseases, with a focus on social risk factors.

RECENT FINDINGS

The common risk factors for CVD and BC, such as hypertension, diabetes, obesity, aging, and physical inactivity, are discussed, emphasizing their modifiability. Adhering to ideal cardiovascular health behaviors has shown a trend toward lower BC incidence. Increased risk of CVD-related mortality is significantly impacted by age and race in BC patients, especially those over 45 years old. Additionally, racial disparities in both diseases highlight the need for targeted interventions. Social determinants of health, including socioeconomic status, education, employment, and neighborhood context, significantly impact outcomes for both CVD and BC. Addressing social factors is vital in reducing the burden of both CVD and BC and improving overall health equity.

Diet and Lifestyle in the Spanish Population and Their Relationship with Sociodemographic Variables: A Descriptive Study

A healthy lifestyle and proper nutrition have a major impact on the well-being of a population. Therefore, the aim of this research is to describe the behavior of these habits in relation to sociodemographic variables to provide data on the development of effective training and awareness-raising actions.

METHODS

An observational, descriptive and cross-sectional study was carried out. To study the behavior of a series of variables related to eating habits and lifestyle, a questionnaire was designed and validated and subsequently disseminated online, by means of nonprobabilistic snowball sampling, relying on social networks. The sample collected consisted of 18,070 young adults of Spanish nationality. Bivariate comparative analyses were performed using t-test independent samples, and the effect size (ES) was calculated by determining Cohen's D coefficient. A multivariate analysis were conducted using linear regression and principal component analysis.

RESULTS

Adults eat better but have a poorer quality of rest and are more sedentary than young people. No gender differences were found in nutritional habits; however, men engage in more sports and sleep better. People with a higher educational level have better nutritional and sleep habits, but are more sedentary, as are people of a higher socioeconomic level.

CONCLUSIONS

Higher socioeconomic and educational levels seem to favor a healthier lifestyle. The Spanish population aged 18-45 years needs to make dietary changes but leads an active lifestyle.

Mediators of parental educational differences in the intake of carbonated sugar-sweetened soft drinks among adolescents, and the moderating role of neighbourhood income

BACKGROUND

Existing evidence suggests that the intake of sugar-sweetened beverages (SSB) among adolescents remains a public health concern and that socioeconomic differences in intake exist. Tackling these challenges requires identifying the factors associated with SSB intake and the mediators of socioeconomic differences in SSB intake among adolescents. Thus, this study aimed to explore (i) factors at different levels of the ecological model associated with the intake of carbonated soft drinks with added sugar (hereafter called soft drinks), (ii) mediators of the association between parental education and the intake of soft drinks(iii) whether neighbourhood income moderates the indirect effect of parental education on adolescents' soft drink intake through potential mediators.

METHODS

Data from 826 7th graders in Oslo, Norway, who participated in the TACKLE cross-sectional study conducted in 2020 were used. The association between factors at the individual, interpersonal and neighbourhood food environment levels and the intake of soft drinks among adolescents was assessed, as well as the mediating roles of these factors for the differences in intake by parental education, using multiple logistic regression and mediation analysis, respectively. Moderated mediation analyses were used to explore whether an indirect effect of parental education on adolescents' soft drink intake through potential mediators varies across neighbourhood income areas.

RESULTS

Higher perceived accessibility of SSB at home, increased parental modelling for SSB intake, and increased frequency of food/drink purchased from the neighbourhood store were associated with a higher intake of soft drinks among adolescents and mediated the differences in intake by parental education. Neighbourhood food environment factors were neither statistically significantly associated with adolescents' higher intake of soft drinks nor explained the differences in intake by parental education. Moderated mediation analysis showed that the mediating effect of perceived accessibility of SSB at home on the association between parental education and adolescent soft drink intake was stronger among those living in low neighbourhood income.

CONCLUSIONS

Our study identified modifiable factors at the intrapersonal level (perceived accessibility of SSB at home and frequency of food/drink purchased from neighbourhood shops) and interpersonal levels (parental modelling for SSB intake) associated with a higher intake of soft drinks among adolescents and mediated the differences in the intake by parental education. The modifiable factors identified in this study could be targeted in public health initiatives among adolescents aimed at reducing the intake of soft drinks and the related differences by parental education.

The Myth of Zero-Sum Responsibility: Towards Scaffolded Responsibility for Health

Some people argue that the distribution of medical resources should be sensitive to agents' responsibility for their ill-health. In contrast, others point to the social determinants of health to argue that the collective agents that control the conditions in which agents act should bear responsibility. To a large degree, this is a debate in which those who hold individuals responsible currently have the upper hand: warranted appeals to individual responsibility effectively block allocation of any significant degree of responsibility to collective agents. We suggest that a different understanding of individual responsibility might lead to a fairer allocation of blame. Scaffolded agency is individual agency exercised in a context in which opportunities and affordances are structured by others. Appeals to scaffolded agency at once recognize the role of the individual and of the collective agents who have put the scaffolds in place.

School-Level Socioeconomic Status and Nutrient Content of Outdoor Food/Beverage Advertisements

We examined if areas around schools with more students of lower socioeconomic status (SES) have more total food/beverage advertisements and/or more advertisements with poorer nutritional content as compared to areas around schools with fewer students with lower SES. All outdoor food/beverage advertisements within a half-mile radius of 47 middle and high schools in the United States were objectively documented in 2012 and coded for nutritional content. The total number of advertisements and the macronutrient and micronutrient contents (total calories, fat (g), protein (g), carbohydrate (g), sugar (g), and sodium (mg)) of food and beverage items depicted in the advertisements were calculated. In total, 9132 unique advertisements were recorded, with 3153 ads displaying food and beverages that could be coded for nutrient content. Schools located in areas of lower SES (≥60% students receiving free/reduced-price lunch) had significantly more advertisements displaying food and beverages that could be coded for nutrient content (z = 2.01, p = 0.04), as well as advertisements that contained more sodium (z = 2.20, p = 0.03), as compared to schools located in areas of higher SES. There were no differences in calorie, fat, protein, carbohydrate, or sugar content. Policies to reduce the prevalence of outdoor food and beverage advertising are warranted.

Supplemental Nutrition Assistance Program Education reductions during COVID-19 may have exacerbated health inequities

OBJECTIVE

Describe, and assess disparities in, the changes in Supplemental Nutrition Assistance Program Education (SNAP-Ed) that occurred the year before vs. the year when COVID-19 restrictions were implemented.

DESIGN

Observational study comparing reach, intensity, and dose of California Local Health Department (LHD) SNAP-Ed interventions in Federal Fiscal years 2019 and 2020 (FFY19, FFY20).

ANALYSIS

Student t-tests determined significance of differences in the number of Direct Education (DE) programs, Policy, Systems and Environmental change (PSE) sites, people reached, and intervention intensity and dose between FFY19 and FFY20 using data reported online by LHDs. Linear regression assessed associations between census tract-level characteristics (urbanicity; percentages of population with income <185% of federal poverty level, under 18 years of age, and belonging to various racial/ethnic groups; and California Healthy Places Index) and changes in number of DE programs, PSE sites, people reached, and intervention dose between FFY19 and FFY20.

RESULTS

From FFY19 to FFY20, the number of DE programs, PSE sites, people reached, and census tract-level intervention intensity and dose decreased. Higher census tract poverty, higher proportions of Black and Latino residents, and less healthy neighborhood conditions were associated with greater decreases in some intervention characteristics including PSE sites, PSE reach, DE programs, and DE dose.

CONCLUSIONS AND IMPLICATIONS

These reductions in LHD SNAP-Ed interventions indicate reduced access to education and environments that support healthy eating and obesity prevention during a time when this support was especially needed to reduce risk of COVID-19 infection and complications. Disproportionately reduced access, may have worsened health disparities in already-disadvantaged communities. Assuring maintenance of SNAP-Ed interventions, especially in disadvantaged communities, should be a priority during public health emergencies.

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Structural racism and geographic access to food retailers in the United States: A scoping review

This scoping review summarized findings and key measures from U.S.-based studies that 1) examined associations between geographic indicators of structural racism (e.g., redlining, racial segregation) and access to food retailers (e.g., supermarkets, convenience stores) or 2) documented disparities in access by neighborhood racial/ethnic composition. In 2022, relevant scientific literature was reviewed using Covidence software. Independent reviewers examined 13,069 citations; 163 citations advanced to the full-text review stage and 70 were selected for inclusion. Twenty-one studies (30%) linked one or more indicator of structural racism to food retailer access while 49 (70%) solely examined differences in access by neighborhood racial/ethnic composition. All studies featuring indicators of structural racism reported significant findings; however, indicators varied across studies making it difficult to make direct comparisons. Key indicators of structural racism in the food access literature included redlining (n = 3), gentrification (n = 3), and racial segregation (n = 4). Many U.S.-based studies have evaluated food retailer access by neighborhood racial/ethnic composition. Moving forward, studies should model indicators of structural racism and determine their influence on geographic access to large and small food retailers.

Indices/Indicators Developed to Evaluate the "Creating Supportive Environments" Mechanism of the Ottawa Charter for Health Promotion: A Setting-Based Review on Healthy Environment Indices/ Indicators

This study aimed to identify the indices/indicators used for evaluating the "creating supportive environments" mechanism of the Ottawa Charter for Health Promotion, with a focus on built environments, in different settings. A search for literature with no time limit constraint was performed across Medline (via PubMed), Scopus, and Embase databases. Search terms included "Ottawa Charter," "health promotion," "supportive environments," "built environments," "index," and "indicator." we included the studies conducted on developing, identifying, and/or measuring health promotion indices/indicators associated with "built environments" in different settings. The review articles were excluded. Extracted data included the type of instrument used for measuring the index/indicator, the number of items, participants, settings, the purpose of indices/indicators, and a minimum of two associated examples of the indices domains/indicators. The key definitions and summarized information from studies are presented in tables. In total, 281 studies were included in the review, within which 36 indices/indicators associated with "built environment" were identified. The majority of the studies (77%) were performed in developed countries. Based on their application in different settings, the indices/indicators were categorized into seven groups: (1) Healthy Cities (n=5), (2) Healthy Municipalities and Communities (n=18), (3) Healthy Markets (n=3), (4) Healthy Villages (n=1), (5) Healthy Workplaces (n=4), (6) Health-Promoting Schools (n=3), and (7) Healthy Hospitals (n=3). Health promotion specialists, health policymakers, and social health researchers can use this collection of indices/indicators while designing/evaluating interventions to create supportive environments for health in various settings.

The Influence of Socio-Economic Factors on Diet and Active Lifestyle in the Spanish Female Population

A balanced diet and healthy social habits are two pillars on which the health of the population is based. Therefore, the efforts of the health system should be aimed at prevention. To this end, it is important to know the prevalence of these habits in different population groups and how they vary according to socioeconomic variables. This is an observational, descriptive, cross-sectional study using surveys. A questionnaire was designed to explore a set of variables related to diet and an active lifestyle and was validated through a pilot study and a nominal group. Dissemination was carried out online through social networks by means of non-probabilistic snowball sampling, obtaining a sample of 14.784 women aged between 18 and 45 years. Bivariate comparative analyses were performed using the Mann-Whitney method and the principal component analysis (PCA) method of dimensionality reduction was used to study the relationships between ordinal numerical variables. Results indicate that nutrition was influenced by the age of the sample; adult women have better nutrition than younger women, although they are more sedentary and do less sport. Women with higher education and a medium-high income have better nutrition and healthier lifestyles and a lower BMI and higher self-perceived health status than women with basic education and a lower income. It was concluded that a higher level of income and a higher level of education generally lead to a healthier lifestyle. Spanish women aged 18-45 years need to make changes in their nutrition and lead a more active life.

Geospatial Associations between Female Breast Cancer Mortality Rates and Environmental Socioeconomic Indicators for North Carolina

In North Carolina, over 6000 women will be diagnosed with breast cancer yearly, and over 1000 will die. It is well known that environmental conditions contribute greatly to health outcomes, and many of these factors include a geographic component. Using death data records from 2003-2019 extracted from North Carolina Vital Statistics Dataverse, a spatial database was developed to map and analyze female breast cancer mortality rates at the ZIP code scale in North Carolina. Thirty-nine hot spots and thirty cold spots of age-adjusted death rates were identified using the Getis-Ord analysis. Two-tailed t-tests were run between each cohort for environmental socioeconomic-related factors associated with breast cancer progression and mortality. The median age and household income of individuals who resided in ZIP codes with the highest breast cancer mortality were significantly lower than those who lived in ZIP codes with lower breast cancer mortality. The poverty rate, percentage of SNAP benefits, and the percentage of minorities were all significantly higher (p < 0.05, p < 0.001, and p < 0.001) in ZIP codes with high breast cancer rates. High-quality (ZIP code) granular cancer data were developed for which detailed analysis can be performed for future studies.

Combining crowd-sourcing, census data, and public review forums for real-time, high-resolution food desert estimation

BACKGROUND

It has been hypothesized that low access to healthy and nutritious food increases health disparities. Low-accessibility areas, called food deserts, are particularly commonplace in lower-income neighborhoods. The metrics for measuring the food environment's health, called food desert indices, are primarily based on decadal census data, limiting their frequency and geographical resolution to that of the census. We aimed to create a food desert index with finer geographic resolution than census data and better responsiveness to environmental changes.

MATERIALS AND METHODS

We augmented decadal census data with real-time data from platforms such as Yelp and Google Maps and crowd-sourced answers to questionnaires by the Amazon Mechanical Turks to create a real-time, context-aware, and geographically refined food desert index. Finally, we used this refined index in a concept application that suggests alternative routes with similar ETAs between a source and destination in the Atlanta metropolitan area as an intervention to expose a traveler to better food environments.

RESULTS

We made 139,000 pull requests to Yelp, analyzing 15,000 unique food retailers in the metro Atlanta area. In addition, we performed 248,000 walking and driving route analyses on these retailers using Google Maps' API. As a result, we discovered that the metro Atlanta food environment creates a strong bias towards eating out rather than preparing a meal at home when access to vehicles is limited. Contrary to the food desert index that we started with, which changed values only at neighborhood boundaries, the food desert index that we built on top of it captured the changing exposure of a subject as they walked or drove through the city. This model was also sensitive to the changes in the environment that occurred after the census data was collected.

CONCLUSIONS

Research on the environmental components of health disparities is flourishing. New machine learning models have the potential to augment various information sources and create fine-tuned models of the environment. This opens the way to better understanding the environment and its effects on health and suggesting better interventions.

Enhanced Measurement of Sugar-Sweetened Beverage Marketing to Young Immigrant Children in Grocery Store Environments

The marketing of Sugar-Sweetened Beverages (SSBs) within grocers is an obesogenic factor that negatively impacts children's nutritional behavior, specifically for people from racial and ethnic minority groups, such as immigrants. We aimed to develop and employ a methodology that more precisely assesses the availability, price, and promotion of SSBs to young immigrant children within independently owned grocery stores. A case comparison design was used to explore the differences in the grocery store landscape of SSB marketing by conducting an enhanced Nutrition Environment Measures Survey-SSB (NEMS-SSB) within 30 grocery stores in the Hispanic and Latino enclaves in Southwest Detroit, in the Arab and Chaldean enclaves in North-central Detroit, and in Warren, Hamtramck, and Dearborn, in comparison with 48 grocers in Metro Detroit. Unsweetened, plant-based, and organic toddler and infant beverages, as well as questions about marketing, were added to the original NEMS to capture the promotion tactics used in marketing SSBs. NEMS-SSB scores revealed that, in the immigrant enclaves, there was a significantly higher availability of SSBs in grocery stores (-2.38), and they had lower prices than those in the comparison group (-0.052). Unsweetened, plant-based, and organic beverages were unavailable in 97% of all participating grocery stores across both groups. Signage featuring cartoon characters was the most frequent in-store SSB marketing tactic across both groups. Widespread SSB marketing toward toddlers within the grocery stores in immigrant enclaves could be linked with the higher early childhood obesity prevalence among the immigrant population. Our findings can assist local and national organizations in developing and implementing healthy eating interventions. This study must be repeated in other immigrant enclaves across states to provide comparable results.