Income Inequality, Gender Disparities, and Ethnic Differences: Investigating Allostatic Load in American Adults

AIM

To estimate the association between income inequality and allostatic load score (AL) in adults ages 20 years and older, with a particular focus on the differential impacts across racial and gender groups. By examining this association, the study seeks to inform targeted policy interventions to mitigate health disparities exacerbated by economic inequality.

METHODS

Utilizing data from the 1999-2016 National Health and Nutrition Examination Survey (NHANES), we assessed AL through eight biomarkers: systolic blood pressure (mm Hg), diastolic blood pressure (mm Hg), pulse rate (beats/min), body mass index (kg/m2), glycohemoglobin (%), direct HDL cholesterol (mg/dL), total cholesterol (mg/dL), and serum albumin (g/dL). Employing negative binomial regression (NBRG), we estimated incidence rate ratios (IRR) for a sample comprising 7367 men and 7814 women, adjusting for age, race/ethnicity, marital status, education, health insurance, comorbidity, and mental health professional utilization. Gini coefficients (GC) were calculated to assess income inequality among men and women.

RESULTS

Findings revealed that men exhibited a higher poverty-to-income ratio (PIR) compared to women (3.12 vs. 2.86, p < 0.01). Yet, women experienced higher rates of elevated AL (AL > 4) (31.8% vs. 29.0%) and were more adversely affected by income inequality (GC: 0.280 vs. 0.333). NBRG results indicated that high PIR individuals had a lower IRR (0.96; CI:0.92-0.95) compared to their low PIR counterparts, a trend observed in women but not men. High PIR was notably protective among White non-Hispanic (WNH) men and women. Additionally, vigorous and moderate physical activity engagement was associated with lower AL (IRR: 0.89, CI: 0.85-0.93).

CONCLUSION

The study emphasizes the importance of implementing policies that target AL in low-income populations across all racial groups, with a specific focus on Black non-Hispanic (BNH) and Hispanic communities. By prioritizing these groups, policies can more effectively target the nexus of income inequality, health disparities, and allostatic load, contributing to the reduction of health inequities.

Neighborhood Racial and Ethnic Segregation and the Risk of Dementia in Older Adults Living with Kidney Failure

BACKGROUND

Dementia disproportionately impacts older minoritized adults with kidney failure. To better understand the mechanism of this disparity, we studied the role of racial and ethnic segregation (segregation hereafter), a form of structural racism recently identified as a mechanism in numerous other health disparities.

METHODS

We identified 901,065 older adults (age ≥55) with kidney failure from 2003 to 2019 using the United States Renal Data System (USRDS). We quantified dementia risk across tertiles of residential neighborhood segregation score using cause-specific hazard models, adjusting for individual and neighborhood-level factors. We included an interaction term to quantify the differential effect of segregation on dementia diagnosis by race and ethnicity.

RESULTS

We identified 79,851 older adults with kidney failure diagnosed with dementia between 2003 and 2019 (median follow-up: 2.2 years). Compared to those in low-segregation neighborhoods, older adults with kidney failure in high-segregation neighborhoods had a 1.63-fold (95% confidence interval (CI):1.60-1.66) higher risk of dementia diagnosis, an association that differed by race and ethnicity (Asian: adjusted hazard ratio [aHR]=1.26, 95%CI:1.15-1.38; Black: aHR=1.66, 95%CI:1.61-1.71; Hispanic: aHR=2.05, 95%CI:1.93-2.18; White: aHR=1.59, 95%CI:1.55-1.64;Pinteraction<0.001). Notably, older Asian (aHR=1.76, 95%CI:1.64-1.89), Black (aHR=2.65, 95%CI:2.54-2.77), Hispanic (aHR=2.15, 95%CI:2.04-2.26), and White (aHR=2.20, 95%CI:2.09-2.31) adults with kidney failure residing in minority-predominant high-segregation neighborhoods had a higher risk of dementia diagnosis compared to older White adults with kidney failure in White-predominant high-segregation neighborhoods. Moreover, older adults with kidney failure receiving care at dialysis facilities located in high-segregation neighborhoods also experienced a higher risk of dementia diagnosis (aHR=1.53, 95%CI:1.50-1.56); this association differed by race and ethnicity (Pinteraction<0.001).

CONCLUSIONS

Residing in or receiving care at dialysis facilities located in high-segregation neighborhoods was associated with a higher risk of dementia diagnosis among older individuals with kidney failure, particularly minoritized individuals.

"Hang Ups, Let Downs, Bad Breaks, Setbacks": Impact of Structural Socioeconomic Racism and Resilience on Cognitive Change Over Time for Persons Racialized as Black

Introduction

Older adults racialized as Black experience higher rates of dementia than those racialized as White. Structural racism produces socioeconomic challenges, described by artist Marvin Gaye as "hang ups, let downs, bad breaks, setbacks" that likely contribute to dementia disparities. Robust dementia literature suggests socioeconomic factors may also be key resiliencies.

Methods

We linked state-level data reflecting the racialized landscape of economic opportunity across the 20th Century from the U.S. Census (1930-2010) with individual-level data on cognitive outcomes from the U.S. Health and Retirement Study participants racialized as Black. A purposive sample of participants born after the Brown v. Board ruling (born 1954-59) were selected who completed the modified Telephone Interview for Cognitive Status between 2010 and 2020 (N=1381). We tested associations of exposure to structural racism and resilience before birth, and during childhood, young-adulthood, and midlife with cognitive trajectories in mid-late life using mixed-effects regression models.

Results

Older adults born in places with higher state-level structural socioeconomic racism experienced a more rapid cognitive decline in later life compared to those with lower levels of exposure. In addition, participants born in places with higher levels of state-level structural socioeconomic resilience experienced slower cognitive change over time than their counterparts.

Discussion

These findings reveal the impact of racist U.S. policies enacted in the past that influence cognitive health over time and dementia risk later in life.

Neighborhood Segregation and Access to Live Donor Kidney Transplantation

Importance

Identifying the mechanisms of structural racism, such as racial and ethnic segregation, is a crucial first step in addressing the persistent disparities in access to live donor kidney transplantation (LDKT).

Objective

To assess whether segregation at the candidate's residential neighborhood and transplant center neighborhood is associated with access to LDKT.

Design, Setting, and Participants

In this cohort study spanning January 1995 to December 2021, participants included non-Hispanic Black or White adult candidates for first-time LDKT reported in the US national transplant registry. The median (IQR) follow-up time for each participant was 1.9 (0.6-3.0) years.

Main Outcome and Measures

Segregation, measured using the Theil H method to calculate segregation tertiles in zip code tabulation areas based on the American Community Survey 5-year estimates, reflects the heterogeneity in neighborhood racial and ethnic composition. To quantify the likelihood of LDKT by neighborhood segregation, cause-specific hazard models were adjusted for individual-level and neighborhood-level factors and included an interaction between segregation tertiles and race.

Results

Among 162 587 candidates for kidney transplant, the mean (SD) age was 51.6 (13.2) years, 65 141 (40.1%) were female, 80 023 (49.2%) were Black, and 82 564 (50.8%) were White. Among Black candidates, living in a high-segregation neighborhood was associated with 10% (adjusted hazard ratio [AHR], 0.90 [95% CI, 0.84-0.97]) lower access to LDKT relative to residence in low-segregation neighborhoods; no such association was observed among White candidates (P for interaction = .01). Both Black candidates (AHR, 0.94 [95% CI, 0.89-1.00]) and White candidates (AHR, 0.92 [95% CI, 0.88-0.97]) listed at transplant centers in high-segregation neighborhoods had lower access to LDKT relative to their counterparts listed at centers in low-segregation neighborhoods (P for interaction = .64). Within high-segregation transplant center neighborhoods, candidates listed at predominantly minority neighborhoods had 17% lower access to LDKT relative to candidates listed at predominantly White neighborhoods (AHR, 0.83 [95% CI, 0.75-0.92]). Black candidates residing in or listed at transplant centers in predominantly minority neighborhoods had significantly lower likelihood of LDKT relative to White candidates residing in or listed at transplant centers located in predominantly White neighborhoods (65% and 64%, respectively).

Conclusions

Segregated residential and transplant center neighborhoods likely serve as a mechanism of structural racism, contributing to persistent racial disparities in access to LDKT. To promote equitable access, studies should assess targeted interventions (eg, community outreach clinics) to improve support for potential candidates and donors and ultimately mitigate the effects of segregation.

Whole-exome sequencing of Nigerian benign prostatic hyperplasia reveals increased alterations in apoptotic pathways

BACKGROUND

Through whole-exome sequencing of 60 formalin-fixed paraffin-embedded Nigerian (NGRn) benign prostatic hyperplasia (BPH) samples, we identified germline and somatic alterations in apoptotic pathways impacting BPH development and progression. Prostate enlargement is a common occurrence in male aging; however, this enlargement can lead to lower urinary tract symptoms that negatively impact quality of life. This impact is disproportionately present in men of African ancestry. BPH pathophysiology is poorly understood and studies examining non-European populations are lacking.

METHODS

In this study, NGRn BPH, normal prostate, and prostate cancer (PCa) tumor samples were sequenced and compared to characterize genetic alterations in NGRn BPH.

RESULTS

Two hundred and two nonbenign, ClinVar-annotated germline variants were present in NGRn BPH samples. Six genes [BRCA1 (92%), HSD3B1 (85%), TP53 (37%), PMS2 (23%), BARD1 (20%), and BRCA2 (17%)] were altered in at least 10% of samples; however, compared to NGRn normal and tumor, the frequency of alterations in BPH samples showed no significant differences at the gene or variant level. BRCA2_rs11571831 and TP53_rs1042522 germline alterations had a statistically significant co-occurrence interaction in BPH samples. In at least two BPH samples, 173 genes harbored somatic variants known to be clinically actionable. Three genes (COL18A1, KIF16B, and LRP1) showed a statistically significant (p < 0.05) higher frequency in BPH. NGRn BPH also had five gene pairs (PKD1/KIAA0100, PKHD1/PKD1, DNAH9/LRP1B, NWD1/DCHS2, and TCERG1/LMTK2) with statistically significant co-occurring interactions. Two hundred and seventy-nine genes contained novel somatic variants in NGRn BPH. Three genes (CABP1, FKBP1C, and RP11-595B24.2) had a statistically significant (p < 0.05) higher alteration frequency in NGRn BPH and three were significantly higher in NGRn tumor (CACNA1A, DMKN, and CACNA2D2). Pairwise Fisher's exact tests showed 14 gene pairs with statistically significant (p < 0.05) interactions and four interactions approaching significance (p < 0.10). Mutational patterns in NGRn BPH were similar to COSMIC (Catalog of Somatic Mutations in Cancer) signatures associated with aging and dysfunctional DNA damage repair.

CONCLUSIONS

NGRn BPH contained significant germline alteration interactions (BRCA2_rs11571831 and TP53_rs1042522) and increased somatic alteration frequencies (LMTK2, LRP1, COL18A1, CABP1, and FKBP1C) that impact apoptosis. Normal prostate development is maintained by balancing apoptotic and proliferative activity. Dysfunction in either mechanism can lead to abnormal prostate growth. This work is the first to examine genomic sequencing in NGRn BPH and provides data that fill known gaps in the understanding BPH and how it impacts men of African ancestry.

Links of Previous Incarceration with Geriatric Syndromes and Chronic Health Conditions Among Older Adults in the United States

BACKGROUND

This study investigated the association between previous incarceration and various geriatric and chronic health conditions among adults 50 and older in the United States.

METHODS

Data came from the National Longitudinal Study of Adolescent to Adult Health - Parent Study (AHPS) collected in 2015-2017, including 2,007 individuals who participated in the parent study (Parent Sample) and 976 individuals who participated in the spouse/partner study (Spouse/Partner Sample). Multiple logistic regression was used to investigate the relationship between previous incarceration and geriatric syndromes (dementia, difficulty walking, difficulty seeing, difficulty with activities of daily living) and chronic health conditions (self-reported poor/fair health, diagnosis of cancer, hypertension, diabetes, heart disease, stroke, chronic lung disease, depression, and alcohol use [4 or more drinks per week]).

RESULTS

In adjusted analyses, respondents with previous incarceration in the AHPS had significantly higher odds of reporting difficulty walking, activities of daily living difficulty, cancer diagnosis, depression diagnosis, and chronic lung disease (aORs= 2.21-2.95). Respondents in the AHPS spouse/partner study reported higher odds of difficulty seeing, cancer, depression, chronic lung disease, and heavy alcohol use (aORs= 1.02-2.15).

CONCLUSIONS

Previous incarceration may have an adverse impact on healthy aging. Findings highlight the importance of addressing the enduring health impacts of incarceration, particularly as individuals transition into older adulthood.

Risk of dementia due to Co-exposure to air pollution and neighborhood disadvantage

BACKGROUND

Co-exposure to air pollution and neighborhood disadvantage may influence cognition decline. We tested these associations in the context of dementia risk.

METHODS

We leveraged a cohort of adults ≥65 years (n = 5397) enrolled from 2011 to 2018 in the National Health and Aging Trends Study (NHATS). Particulate matter (PM) ≤ 10 μm in diameter, PM ≤ 2.5 μm in diameter, carbon monoxide, nitric oxide, and nitrogen dioxide - and neighborhood disadvantage were tested for joint associations with dementia risk. Pollutant concentrations at the 2010 census tract level were assigned using the US Environmental Protection Agency's Community Multiscale Air Quality Modeling System. Neighborhood disadvantage was defined using the tract Social Deprivation Index (SDI). Dementia was determined through self- or proxy-report or scores indicative of "probable dementia" according to NHATS screening tools. Joint effects of air pollutants and SDI were tested using quantile g-computation Cox proportional hazards models. We also stratified joint air pollution effects across SDI tertiles. Analyses adjusted for age at enrollment, sex, education, partner status, urbanicity, income, race and ethnicity, years at residence, census segregation, and census region.

RESULTS

SDI score (aHR = 1.08; 95% CI 0.96, 1.22), joint air pollution (aHR = 1.03, 95% CI 0.92, 1.16) and joint SDI with air pollution (aHR = 1.04, 95% CI 0.89, 1.22) were not associated with dementia risk. After accounting for competing risk of death, joint SDI with air pollution was not associated with dementia risk (aHR = 1.06; 95% CI 0.87, 1.29). In stratified models, joint air pollution was associated with greater risk of dementia at high (aHR = 1.19; 95% CI 0.87, 1.63), but not at medium or low SDI.

CONCLUSION

Air pollution was associated with greater dementia risk in disadvantaged areas after accounting for competing risks. Air pollution associations with dementia incidence may be attenuated when other risk factors are more prominent in disadvantaged neighborhoods.

Associations of Subjective Memory with Life Space and Neighborhood Built Environment in Older Adults in the ACTIVE Study

Objectives: To investigate the longitudinal association of life space and neighborhood and built environment (NBE) with subjective memory among individuals 65 and older, and the mediating role of depressive symptoms, a major correlate of life space mobility, NBE, and subjective memory. Methods: We examined community-dwelling participants in the Advanced Cognitive Training for Independent and Vital Elderly study (N = 2,622, Mean age = 73.7 years, 24.9% Black) across annual assessments of up to 3 years. Results: Baseline life space and NBE were positively associated with subjective memory, and these associations were partly mediated by depressive symptoms. Over time, higher baseline life space predicted a better subjective memory as one aged. Life space was concurrently associated with subjective memory across time, mediated by concurrent depressive symptoms. Discussion: Potentially modifiable environmental factors such as life space and NBE appear to influence level and change in subjective memory as we age. Interventions supporting movement in our environments may help offset subjective memory problems, a potential early sign of dementia.

Caregiving and Obesity among Black American Adults

Black American adults often report higher rates of obesity and caregiving compared with other racial or ethnic groups. Consequently, many Black American caregivers and care recipients are obese or have obesity-related chronic conditions (e.g., diabetes, hypertension). This study investigated associations between caregiving and obesity among Black Americans, including the role of health behaviors and chronic conditions. The sample included data from 2015 and 2017 Behavioral Risk Factor Surveillance System for non-Hispanic Black (NHB) or African American adult caregivers (n = 2,562) and noncaregivers (n = 7,027). The association between obesity (dependent variable) and caregiving status, fruit consumption, vegetable consumption, physical activity, and number of chronic conditions (independent variables) were evaluated using hierarchical binomial logistic regressions. Caregiving, being female, and chronic conditions were associated with higher odds of obesity, while physical activity was associated with lower odds of obesity. Physical activity, diet, and chronic conditions did not account for differences in obesity among caregiving and noncaregiving Black Americans. Increasing understanding of health behaviors and chronic disease burden of NHB caregivers has implications for programs aiming to improve obesity-related outcomes for caregivers and recipients. Future research should investigate multilevel factors that contribute to observed differences.

Does Consumer Credit Precede or Follow Health Among Older Adults? An Investigation in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Trial

Background and Objectives

Consumer credit has shown increasing relevance to the health of older adults; however, studies have not been able to assess the extent to which creditworthiness influences future health or health influences future creditworthiness. We assessed the relationships between 4-year pre and postmorbid consumer credit history and self-rated physical and mental health outcomes among older adults.

Research Design and Methods

Generalized estimating equations models assessed pre and postmorbid credit history (credit scores, derogatory accounts, and unpaid accounts in collections) and the onset of poor self-rated health (SF-36 score <50) among 1,740 participants aged 65+ in the Advanced Cognitive Training for Independent and Vital Elderly study from 2001 to 2017, linked to TransUnion consumer credit data.

Results

In any given year, up to 1/4 of participants had a major derogatory, unpaid, or collections account, and up to 13% of the sample had poor health. Each 50-point increase in credit score trended toward a 5% lower odds of poor health in the next 1 year, a 6% lower odds in the next 2 years, and a statistically significant finding of 13% lower odds by 3 years. A drop in credit score was associated with a 10% greater odds of poor health in the next year, and having a major derogatory account was associated with an 86% greater odds of poor health in the next 3 years. After poor health onset, credit scores continued to see significant losses up to the 3 years, with larger decrements over time.

Discussion and Implications

Having a major derogatory account or a sudden loss in credit may be a time to monitor older adults for changes in health. After a downturn in health, supporting older adults to manage their debt may help stabilize their credit.

Adherence to the healthy eating index-2010 and alternative healthy eating index-2010 in relation to metabolic syndrome among African Americans in the Jackson heart study

OBJECTIVE

The primary objective of this study was to determine whether Healthy Eating Index (HEI) and Alternative Healthy Eating Index (AHEI) scores were associated with incident metabolic syndrome.

DESIGN

This study is a secondary analysis of data from the Jackson Heart Study. HEI and AHEI scores were divided into quintiles and Cox proportional hazards regression models were analysed for 1864 African American adults free from metabolic syndrome at Exam 1 to examine the incidence of metabolic syndrome by quintile of dietary quality score.

SETTING

Hinds, Madison and Rankin counties, Mississippi, USA.

PARTICIPANTS

African American adults, ages 21-94 years, 60·9 % female.

RESULTS

Over a mean follow-up time of 6·7 years, we observed 932 incident cases of metabolic syndrome. After adjusting for multiple covariates, a higher HEI score at Exam 1 was not associated with the risk of incident metabolic syndrome, except when looking at the trend analysis for the subgroup of adults with two metabolic syndrome components at Exam 1 (P-trend = 0·03). A higher AHEI score at Exam 1 was associated with the risk of incident metabolic syndrome (hazard ratio for those in the highest quintile compared to the lowest: 0·80 (95 % CI: 0·65, 0·99), P-trend = 0·03).

CONCLUSION

These findings suggest that a dietary pattern that scores higher on the AHEI may help reduce the risk of metabolic syndrome, even for adults who already have two of the minimum of three components required for a diagnosis of metabolic syndrome.

Acceptability and Feasibility of a Smartphone-Based Real-Time Assessment of Suicide Among Black Men: Mixed Methods Pilot Study

BACKGROUND

Suicide rates in the United States have increased recently among Black men. To address this public health crisis, smartphone-based ecological momentary assessment (EMA) platforms are a promising way to collect dynamic, real-time data that can help improve suicide prevention efforts. Despite the promise of this methodology, little is known about its suitability in detecting experiences related to suicidal thoughts and behavior (STB) among Black men.

OBJECTIVE

This study aims to clarify the acceptability and feasibility of using smartphone-based EMA through a pilot study that assesses the user experience among Black men.

METHODS

We recruited Black men aged 18 years and older using the MyChart patient portal messaging (the patient-facing side of the Epic electronic medical record system) or outpatient provider referrals. Eligible participants self-identified as Black men with a previous history of STB and ownership of an Android or iOS smartphone. Eligible participants completed a 7-day smartphone-based EMA study. They received a prompt 4 times per day to complete a brief survey detailing their STB, as well as proximal risk factors, such as depression, social isolation, and feeling like a burden to others. At the conclusion of each day, participants also received a daily diary survey detailing their sleep quality and their daily experiences of everyday discrimination. Participants completed a semistructured exit interview of 60-90 minutes at the study's conclusion.

RESULTS

In total, 10 participants completed 166 EMA surveys and 39 daily diary entries. A total of 4 of the 10 participants completed 75% (21/28) or more of the EMA surveys, while 9 (90%) out of 10 completed 25% (7/28) or more. The average completion rate of all surveys was 58% (20.3/35), with a minimum of 17% (6/35) and maximum of 100% (35/35). A total of 4 (40%) out of 10 participants completed daily diary entries for the full pilot study. No safety-related incidents were reported. On average, participants took 2.08 minutes to complete EMA prompts and 2.72 minutes for daily diary surveys. Our qualitative results generally affirm the acceptability and feasibility of the study procedures, but the participants noted difficulties with the technology and the redundancy of the survey questions. Emerging themes also addressed issues such as reduced EMA survey compliance and diminished mood related to deficit-framed questions related to suicide.

CONCLUSIONS

Findings from this study will be used to clarify the suitability of EMA for Black men. Overall, our EMA pilot study demonstrated mixed feasibility and acceptability when delivered through smartphone-based apps to Black men. Specific recommendations are provided for managing safety within these study designs and for refinements in future intervention and implementation science research.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/31241.

The Association of eHealth Literacy Skills and mHealth Application Use Among US Adults With Obesity: Analysis of Health Information National Trends Survey Data

BACKGROUND

Physical inactivity and a poor diet are modifiable behaviors that contribute to obesity. Obesity is a well-recognized risk factor for chronic diseases, including diabetes. Mobile health (mHealth) apps can play an important adjuvant role in preventing and treating chronic diseases and promoting positive health behavior change among people with obesity, and eHealth literacy skills have the potential to impact mHealth app use.

OBJECTIVE

The purpose of this study was to explore the associations between the 2 dimensions, access and application, of eHealth literacy skills and mHealth app use among US adults (≥18 years of age) with obesity (BMI ≥30 kg/m2).

METHODS

Data were obtained from February to June 2020 using the Health Information National Trends Survey 5. A total of 1079 respondents met the inclusion criteria of adults with obesity and owners of smartphones. Individual associations between mHealth app use and sociodemographic variables were explored using weighted chi-square and 2-tailed t tests. A multivariable weighted logistic regression model was fitted, and adjusted odds ratios (ORs) of using mHealth apps with corresponding 95% CIs were reported across multiple sociodemographic variables. An Ising model-weighted network visualization was produced. A receiver operating characteristic curve was calculated, and the area under the curve was reported with the corresponding Delong 95% CI.

RESULTS

A majority of respondents were female (550/923, 59.6%) or non-Hispanic White (543/923, 58.8%). Individuals in households earning less than US $50,000 comprised 41.4% (382/923) of the sample. All sociodemographic variables were found to be univariately significant at the 5% level, except employment and region. Results from the multivariable weighted logistic regression model showed that the adjusted odds of using an mHealth app are 3.13 (95% CI 1.69-5.80) and 2.99 (95% CI 1.67-5.37) times higher among those with an access eHealth literacy skill of using an electronic device to look for health or medical information for themselves and an application eHealth literacy skill of using electronic communications with a doctor or doctor's office, respectively. Several sociodemographic variables were found to be significant, such as education, where adjusted ORs comparing subgroups to the lowest educational attainment were substantial (ORs ≥7.77). The network visualization demonstrated that all eHealth literacy skills and the mHealth app use variable were positively associated to varying degrees.

CONCLUSIONS

This work provides an initial understanding of mHealth app use and eHealth literacy skills among people with obesity, identifying people with obesity subpopulations who are at risk of a digital health divide. Future studies should identify equitable solutions for people with obesity (as well as other groups) and their use of mHealth apps.

The Association of Oncology Provider Density With Black-White Disparities in Cancer Mortality in US Counties

BACKGROUND

Black-White racial disparities in cancer mortality are well-documented in the US. Given the estimated shortage of oncologists over the next decade, understanding how access to oncology care might influence cancer disparities is of considerable importance. We aim to examine the association between oncology provider density in a county and Black-White cancer mortality disparities.

METHODS

An ecological study of 1048 US counties was performed. Oncology provider density was estimated using the 2013 National Plan and Provider Enumeration System data. Black:White cancer mortality ratio was calculated using 2014-2018 age-standardized cancer mortality rates from State Cancer Profiles. Linear regression with covariate adjustment was constructed to assess the association of provider density with (1) Black:White cancer mortality ratio, and (2) cancer mortality rates overall, and separately among Black and White persons.

RESULTS

The mean Black:White cancer mortality ratio was 1.12, indicating that cancer mortality rate among Black persons was on average 12% higher than that among White persons. Oncology provider density was significantly associated with greater cancer mortality disparities: every 5 additional oncology providers per 100 000 in a county was associated with a .02 increase in the Black:White cancer mortality ratio (95% CI: .007 to .03); however, the unexpected finding may be explained by further analysis showing that the relationship between oncology provider density and cancer mortality was different by race group. Every 5 additional oncologists per 100 000 was associated with a 1.6 decrease per 100 000 in cancer mortality rates among White persons (95% CI: -3.0 to -.2), whereas oncology provider density was not associated with cancer mortality among Black persons.

CONCLUSION

Greater oncology provider density was associated with significantly lower cancer mortality among White persons, but not among Black persons. Higher oncology provider density alone may not resolve cancer mortality disparities, thus attention to ensuring equitable care is critical.

Race Disparities in Hypertension Prevalence Among Older Men

This study aimed to examine whether hypertension prevalence varies by race/ethnicity and within age groups in a nationally representative sample of men in the United States. Hypertension was defined as blood pressure (BP) readings of 140 mm Hg and higher for systolic BP, 90 mm Hg and higher for diastolic BP, or self-reports of taking medication for hypertension. Modified Poisson models estimated prevalence ratios (PRs) and 95% confidence intervals (CI) for race and age group associations with hypertension. The prevalence of hypertension was 38% overall and 46% of the men were aged 50 and older. Analyses that focused on older men (50 years of age or older) found that non-Hispanic Black men had a higher prevalence of hypertension (PR  =  1.28, 95% CI: 1.19 - 1.37) compared to non-Hispanic White men. We suggest future research utilize life course perspectives to better identify which cumulative experiences impact hypertension disparities.

Structural Racism as a Contributor to Lung Cancer Incidence and Mortality Rates Among Black Populations in the United States

BACKGROUND

Although racial disparities in lung cancer incidence and mortality have diminished in recent years, lung cancer remains the second most diagnosed cancer among US Black populations. Many factors contributing to disparities in lung cancer are rooted in structural racism. To quantify this relationship, we examined associations between a multidimensional measure of county-level structural racism and county lung cancer incidence and mortality rates among Black populations, while accounting for county levels of environmental quality.

METHODS

We merged 2016-2020 data from the United States Cancer Statistics Data Visualization Tool, a pre-existing county-level structural racism index, the Environmental Protection Agency's 2006-2010 Environmental Quality Index (EQI), 2023 County Health Rankings, and the 2021 United States Census American Community Survey. We conducted multivariable linear regressions to examine associations between county-level structural racism and county-level lung cancer incidence and mortality rates.

RESULTS

Among Black males and females, each standard deviation increase in county-level structural racism score was associated with an increase in county-level lung cancer incidence of 6.4 (95% CI: 4.4, 8.5) cases per 100,000 and an increase of 3.3 (95% CI: 2.0, 4.6) lung cancer deaths per 100,000. When examining these associations stratified by sex, larger associations between structural racism and lung cancer rates were observed among Black male populations than among Black females.

CONCLUSION

Structural racism contributes to both the number of new lung cancer cases and the number of deaths caused by lung cancer among Black populations. Those aiming to reduce lung cancer cases and deaths should consider addressing racism as a root-cause.

Ours to eat and own: assessing the feasibility of a cooperative meal-kit service to improve food access

OBJECTIVE

Although typically serving higher income and younger demographic groups, meal-kit subscription services have the potential to improve food availability and dietary quality in communities experiencing low food access due to systemic discrimination. This study describes the development and characteristics of a pilot community-led meal-kit service (SouthEats) and evaluates key implementation outcomes of adoption, acceptability, and feasibility among households experiencing less income.

DESIGN

We utilised a mixed methods study design, including data from administrative records, customer surveys and worker interviews. Thematic qualitative analyses and descriptive quantitative analyses were conducted to illuminate the characteristics and extent the pilot meal-kit service was adopted, acceptable, and financially feasible among the target populations.

SETTING

The study took place in Washington DC, USA.

PARTICIPANTS

Study participants included SouthEats consumers (n 35) and workers (n 3).

RESULTS

During the pilot period, sixty-seven community members signed up for the meal-kit service, with 52 % making recurring purchases. Our results suggest that the meal-kit service is acceptable among people living in low food access areas. Our feasibility analysis indicates that, although not without challenges, the SouthEats model could be financially feasible.

CONCLUSION

These preliminary insights can inform the scalability and potential replication of this service and provide foundational evidence for an approach that may be used to improve food access.

Older Black Americans' Perspectives on Structural Racism-Resilience as a Form of Resistance

PURPOSE

The purpose of this study was to develop a deep understanding of the lived experiences of structural racism and discrimination among older Black Americans' and their perceptions of structural racism across their lives. We also considered individual and community resilience capacity and response in the face of systemic racism.

METHODS

In-depth interviews were conducted with Black community-dwelling adults aged 55 and older in and around Baltimore City. The interview guide used nine contexts to explore perceptions and experiences with structural racism over the life course. Two researchers used reflexive thematic analysis to code and analyze the data.

RESULTS

Participants endorsed structural racism to varying degrees across contexts of education, employment, neighborhood, healthcare, and income/wealth. Participants who denied structural racism placed blame for Black underachievement on factors such as personal and community deficiencies, unsafe neighborhoods, and institutional indifference. There was broad agreement about the existence of structural racism within the domains of policing and violence but participants were largely ambivalent about other domains such as environment, media, and civics. Resilience factors that helped individuals to resist and rebound from racism emerged as an unexpected and important theme.

CONCLUSIONS

We used Public Health Critical Race Praxis and the Cells to Society frameworks to contextualize these findings. Due to the ubiquitous nature of racism, individuals may not fully appreciate the impact of structural racism and its impact on Black well-being. This ordinariness of racism is harmful but may simultaneously contribute to resilience within Baltimore's Black community.

Life Space and Activity Space Measurement: Making 'Room' for Structural Racism

As we age, the ability to move is foundational to health. Life space is one measure of a person's ability to move and engage in activity beyond the home. A separate but related concept is activity space, a measurement of a person's spatial behaviors and visited locations that include social networks, neighborhoods, and institutions. In this article, we integrate the literature on life space and activity space discussing how physical function is not only determined by individual capabilities, but also by the surrounding social and environmental factors which may limit their agency. We show how structural racism contributes to inequities within this paradigm linking related concepts of movement, agency, belonging, and timing. We also explore implications for research and theory for mobility, social connection, and activity.

Health Care Expenditures for Black and White US Adults Living Under Similar Conditions

Importance

Evidence suggests that racial disparities in health outcomes disappear or diminish when Black and White adults in the US live under comparable living conditions; however, whether racial disparities in health care expenditures concomitantly disappear or diminish is unknown.

Objective

To examine whether disparities in health care expenditures are minimized when Black and White US adults live in similar areas of racial composition and economic condition.

Design, Setting, and Participants

This cross-sectional study used a nationally representative sample of 7062 non-Hispanic Black or White adults who live in 2238 of 2275 US census tracts with a 5% or greater Black population and who participated in the Medical Expenditure Panel Study (MEPS) in 2016. Differences in total health care expenditures and 6 specific categories of health care expenditures were assessed. Two-part regression models compared expenditures between Black and White adults living in the same Index of Concentration at the Extremes (ICE) quintile, a measure of racialized economic segregation. Estimated dollar amount differences in expenditures were calculated. All analyses were weighted to account for the complex sampling design of the MEPS. Data analysis was performed from December 1, 2019, to August 7, 2023.

Exposure

Self-reported non-Hispanic Black or non-Hispanic White race.

Main Outcomes and Measures

Presence and amount of patient out-of-pocket and insurance payments for annual total health care expenditures; office-based, outpatient, emergency department, inpatient hospital, or dental visits; and prescription medicines. ICE quintile 5 (Q5) reflected tracts that were mostly high income with mostly White individuals, whereas Q1 reflected tracts that were mostly low income with mostly Black individuals.

Results

A total of 7062 MEPS respondents (mean [SD] age, 49 [18] years; 33.1% Black and 66.9% White; 56.1% female and 43.9% male) who lived in census tracts with a 5% or greater Black population in 2016 were studied. In Q5, Black adults had 56% reduced odds of having any health care expenditures (odds ratio, 0.44; 95% CI, 0.27-0.71) compared with White adults, at an estimated $2145 less per year, despite similar health status. Among those in Q5 with any expenditures, Black adults spent 30% less on care (cost ratio, 0.70; 95% CI, 0.56-0.86). In Q3 (most racially and economically integrated), differences in total annual health care spending were minimal ($79 annually; 95% CI, -$1187 to $1345).

Conclusions and Relevance

In this cross-sectional study of Black and White adults in the US, health care expenditure disparities diminished or disappeared under conditions of both racial and economic equity and equitable health care access; in areas that were mostly high income and had mostly White residents, Black adults spent substantially less. Results underscore the continuing need to recognize place as a contributor to race-based differences in health care spending.

Measuring Racial Differences in Obesity Risk Factors in Non-Hispanic Black and White Men Aged 20 Years or Older

Obesity prevalence in the United States has increased drastically in the last two decades. Racial differences in obesity have emerged with the increase in obesity, with temporal trends because of individual, socioeconomic, and environmental factors, eating behaviors, lack of exercise, etc., raising questions about understanding the mechanisms driving these racial differences in the prevalence of obesity among non-Hispanic Black (NHB) and non-Hispanic White (NHW) men. Although many studies have measured obesity using body mass index (BMI), little is known about waist circumference (WC). This study examines variations in obesity among NHW and NHB using BMI and WC. We used National Health and Nutrition Examination Surveys (1999-2016) with a sample of 9,000 NHW and 3,913 NHB men aged 20 years or older. To estimate the association between the prevalence of obesity (BMI ≥30) and race, we applied modified Poisson regression; to explore and decompose racial differences, we used Oaxaca-Blinder decomposition (OBD). We found that NHW had higher abdominal obesity (WC ≥102) than NHB, but NHB were more likely to be obese (BMI ≥30) during most years, with some fluctuations. Modified Poisson regression showed that NHB had a higher prevalence of obesity (prevalence ratio [PR]: 1.11, 95% confidence interval [CI] = [1.04, 1.18]) but lower abdominal obesity (PR: 0.845; 95% CI = [0.801, 0.892]) than NHW. OBD showed that age, access to health care, smoking, and drinking contributed to the differences in abdominal obesity. The study identifies a significant increase in obesity among men over the last two decades; generalized obesity (based on BMI) was more problematic for NHB men, but abdominal obesity was more problematic for NHW men.

Effects of Cognitive Training on Alzheimer's Disease and Related Dementias: The Moderating Role of Social Determinants of Health

Objective: We examined whether social determinants of health (SDoH) are associated with Alzheimer's disease and related dementias (ADRD) risk and the effects of cognitive training over a 20-year follow-up period. Methods: Data were obtained from 1605 participants in ACTIVE. SDoH measures were created using baseline data at the individual and neighborhood level. Incident ADRD was defined using administrative claims data (1999-2019). Cause-specific hazard models estimated associations between SDoH and claims-based diagnosed ADRD. Results: Higher scores on neighborhood and built environment were associated with lower ADRD risk. Trained participants obtained a greater degree of protection from ADRD when they had higher scores for SDoH domains associated with health care and education access. However, there were fewer significant SDoH moderation effects on cognitive training than expected. Discussion: Future work should continue to explore culturally tailored cognitive training interventions to reduce ADRD risk associated with SDoH that disproportionately affects racially diverse aging populations.

Food insecurity gaps in the Supplemental Nutrition Assistance Program based on disability status

BACKGROUND

Households including someone with disabilities experience disproportionately high food insecurity rates and likely face disproportionate barriers accessing Supplemental Nutrition Assistance Program (SNAP) benefits.

OBJECTIVE

This article aims to examine the role of SNAP with regard to food insecurity disparities based on disability status.

METHODS

Modified Poisson regression models examined food insecurity risk based on disability status (household includes no one with disabilities vs. those with work-limiting disabilities or non-work-limiting disabilities) among 2018 Survey of Income and Program Participation households eligible for SNAP (income ≤130% of the poverty threshold). Weighted estimates were used to account for the study design and non-response.

RESULTS

Households including someone with work-limiting disabilities were more than twice as likely to be food insecure than households including no one with disabilities (PR = 2.16, 95% CI: 1.90, 2.45); households including someone with non-work-limiting disabilities were 65% more likely (PR = 1.65, 95% CI: 1.39, 1.95). However, disparities were more pronounced among households not participating in SNAP (PR = 2.67, 95% CI: 2.22, 3.23 for work-limiting disabilities and PR = 1.86, 95% CI: 1.44, 2.40 for non-work-limiting disabilities) than SNAP-participating households (PR = 1.71, 95% CI: 1.45, 2.03 and PR = 1.46, 95% CI: 1.17, 1.82, respectively). Approximately 4.2 million low-income U.S. households including someone with disabilities are food insecure. Of these, 1.4 million were not participating in SNAP and another 2.8 million households were food insecure despite participating in SNAP.

CONCLUSIONS

Access to SNAP benefits is not proportionate to the scale of food insecurity among households that include people with disabilities. Action is needed to strengthen food assistance for those with disabilities.

Does Consumer Credit Precede or Follow Changes in Cognitive Impairment Among Older Adults? An Investigation in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Trial

OBJECTIVES

We assessed the relationships between pre- and post-morbid consumer credit history (credit scores, debts unpaid, or in collections) and classification of mild (or greater) cognitive impairment (MCI).

METHODS

Generalized Estimating Equation models assessed pre-and post-morbid credit history and MCI risk among 1740 participants aged 65+ in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study, linked to TransUnion consumer credit data.

RESULTS

Each 50-point increase in credit score was associated with up to 8% lower odds of MCI in the next 3 years. In contrast, new unpaid collections over doubled the odds of having MCI in the next 3 years. MCI was associated with subsequent credit score declines and a 47%-71% greater risk of having a new unpaid collection in the next 4 years.

DISCUSSION

Credit declines may signal risk for future MCI. MCI may lead to financial challenges that warrant credit monitoring interventions for older adults.

Perceived Neighborhood Racial Composition and Depressive Symptoms Among Black Americans Across Adulthood: Evaluating the Role of Psychosocial Risks and Resources

Objectives: To evaluate the relationships between perceived neighborhood racial composition (PNRC), psychosocial risks and resources, and depressive symptoms among young (ages 22-35), middle-aged (ages 36-49), and older (ages 50+) Black Americans. Methods: Full sample and age-stratified linear regression models estimated the PNRC-depressive symptoms association and the extent to which it persisted after accounting for psychosocial risks (i.e., neighborhood disorder, other social stressors) and resources (i.e., mastery, social support, racial identity) among 627 Black Americans in the Nashville Stress and Health Study. Results: Living in racially integrated and predominately White neighborhoods was associated with elevated depressive symptoms. While psychosocial risks and resources explained a substantial portion of these associations, patterns varied across age groups. Discussion: PNRC impacts depressive symptoms among Black Americans by shaping psychosocial risks and resources. Findings underscore interconnections between contextual and psychosocial factors, as well as the distinct mental health significance of these processes across stages of adulthood.

The Relationship Between Cognition and Mortality Among Older Black and White Men in Advanced Cognitive Training for Independent and Vital Elderly

Objective: To determine the association between baseline cognition and all-cause mortality among Black men and White men. Methods: Data were from 614 Black and White men aged ≥65 years at baseline in the Advanced Cognitive Training for Independent and Vital Elderly trial and their linked mortality information. Cox proportional hazards models were used to determine the association between baseline cognition (memory, reasoning, speed of processing, Mini Mental State Exam) and mortality risk over 20 years, adjusting for covariates. Results: Among White men, higher performance on the memory composite measure was associated with a decreased risk of all-cause mortality (HR: 0.93; 95% CI: 0.89-0.98), whereas the other cognitive measures were not associated with all-cause mortality risk. Among Black men, none of the cognitive measures was associated with all-cause mortality risk. Discussion: There is a need for future work to recruit and retain a larger sample of older Black men to better understand the cognition-mortality relationship.

Neighborhood factors and survival to old age: The Jackson Heart Study

Few studies have evaluated environmental factors that predict survival to old age. Our study included 913 African American participants in the Jackson Heart Study (JHS) who resided in the tri-county area of the Jackson, MS metropolitan area and were 65-80 years at baseline. Participants were followed from 2000 through 2019 for the outcome of survival to 85 years old. We evaluated each of the following census tract-level measures of the social/physical environment as exposures: socioeconomic status, cohesion, violence, disorder, healthy food stores, residential land use, and walkability. We assessed mediation by physical activity and chronic conditions. As a complementary ecologic analysis, we used census-tract data to examine factors associated with a greater life expectancy. A total of 501 (55%) JHS participants survived to age 85 years or older. Higher social cohesion and greater residential land use were modestly associated with survival to old age (risk difference = 25%, 95% CI: 0-49%; and 4%, 95% CI: 1-7%, respectively). These neighborhood effects were modestly mediated through leisure time physical activity; additionally, social cohesion was mediated through home and yard activity. In our ecologic analysis, a greater percentage of homeowners and a greater proportion of people living in partnered families were associated with higher census-tract level life expectancy. African American older adults living in residential neighborhoods or neighborhoods with high social cohesion were more likely to survive to old age.

The ACTIVE Study: Association of Race and Social Determinants of Health (SDoH) with Long-Term Outcomes and Cognitive Training Effects

Objective: The purpose of this article is to introduce a special issue on the ACTIVE project examining the association between race and social determinants of health (SDoH) and long-term participant outcomes and training effectiveness for older Black/African Americans and Whites in the ACTIVE (for Advanced Cognitive Training for Independent and Vital Elderly) Trial on cognitive abilities, everyday functioning, and incidence of dementia. The ACTIVE study is the largest randomized clinical trial (N = 2802) of the efficacy of three types of cognitive training (memory, reasoning, speed of processing) in improving cognitive and everyday functioning in normal older adults, with follow-ups extending through 5 and 10 years post-intervention. Method: We provide background and context for studying the multiple domains of SDoH in understanding long-term participant outcomes in the ACTIVE trial and racial disparities in the efficacy of cognitive training and summarize the 11 articles in this special issue. Results: Articles in this special issue address several cross-cutting themes. These include 1) a focus on SDoH and race in relation to three cognitive abilities and driving; 2) cognitive training outcomes in older Black/African Americans (B/AA); 3) race differences in everyday function; and 4) associations of various risk factors (e.g., cardiovascular disease, obesity, depression) and protective factors (e.g., occupational complexity) for cognitive decline with health disparities in incident dementia and mortality. Conclusion: In cognitive training studies with cognitively healthy older adults, it is important to consider how factors such as race and SDoH relate to long-term participant outcomes and how they moderate intervention effects.

Self-Employment, Working Hours, and Hypertension by Race/Ethnicity in the USA

There is a large literature on work-related characteristics and hypertension, but studies on self-employment, longer working hours, and hypertension are mixed. Assessments of self-employment should be extended to account for people with part-time self-employment (i.e., employees also earning income from self-employment). The aim of this study was to determine the association of different types of self-employment with hypertension among adults by race/ethnicity and to assess whether longer working hours moderated these associations. Using data from the 2007-2018 National Health and Nutrition Examination Survey, measured hypertension (blood pressure ≥ 140/90 mm Hg) was assessed and employment categories included employees, part-time self-employment (i.e., employee with self-employment income), or full-time self-employment. Modified Poisson regressions and multiplicative interaction terms were used. Having full-time self-employment was associated with lower relative risk (RR) of hypertension compared to employees among Black (RR = 0.77, 95% confidence interval (CI) = 0.61-0.96) and White men (RR = 0.77, 0.65-0.93) compared to employees. Full-time self-employment was associated with higher risk of hypertension (RR = 1.36, 95% CI = 1.01-1.82) compared to employees among Hispanic women, while part-time self-employment was associated with lower risk (RR = 0.69, 95% CI = 0.48-0.98). Among White women, part-time self-employment was associated with higher relative risk of hypertension (RR = 1.27, 95% CI = 1.05-1.53) compared to employees. There were significant interactions between employment categories and longer working hours among Hispanic women as well as Black women and men. The results suggest that self-employment categories and longer working hours impact hypertension by race/ethnicity and sex. Because the number of full-time and part-time self-employed adults has increased, the health of this particular subgroup of workers should be further addressed.

Evaluating Social Determinants of Health Domains and Their Predictive Validity Within Black/African American and White Older Adults From the ACTIVE Trial

OBJECTIVE

To assess domains of social determinants of health (SDoH) and their associations with cognition and quality of life.

METHOD

This investigation uses baseline data from individuals participating in the ACTIVE trial (n = 2505) to reproduce the SDoH domains described in Healthy People 2030 (economic stability, health care, education, neighborhood and built environment, and social and community context). Results: Results support using data from the ACTIVE trial to assess all five SDoH domains, and the ability of the composites to predict baseline performance on measures of cognition and self-reported quality of life within a sample of older adults. Additionally, higher SDoH domain scores were associated with better functioning on composite measures of cognition and higher scores for mental and general health-related quality of life with Access to Healthcare associated with all outcomes. Discussion: These findings can inform investigators interested in assessing multiple domains of SDoH and highlight the importance of access to health care within older Black/African American and White older adults.

Associations Between Body Mass Index and Cognitive Change in the ACTIVE Study: Variations by Race and Social Determinants of Health

Objectives: The current study examines relationships between Body Mass Index (BMI) and cognitive performance and change in processing speed, memory, and reasoning, while accounting for variations by race and the influence of social determinants of health. Methods: Secondary data analysis of the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study, which included participants who self-identified as African American or Black (n = 728) and White (n = 2028). Latent growth curve modeling was used to assess study aims. Results: Increases in BMI were associated with less cognitive decline over 10 years across each cognition domain. Race moderation effects were noted for speed and memory. Relationships between BMI and cognitive trajectories were mediated by economic stability for speed and reasoning. Discussion: Overall, these findings are consistent with the "obesity paradox." Further research is needed to elucidate patterns of results by race.

Acceptability and Feasibility of a Pain and Depressive Symptoms Management Intervention in Middle-Aged and Older African American Women

Background and Objectives

The intersection of race, gender, and age puts older African American women at high risk of experiencing comorbid pain and depressive symptoms. The purpose of this study was to assess the feasibility and acceptability of a 12-week behavioral activation intervention to target self-selected goals related to pain and depressive symptoms in middle-aged and older African American women.

Research Design and Methods

This randomized waitlist control study included 34 self-identified African American women, 50 years of age or older, with moderate-to-severe chronic pain and depressive symptoms. The intervention consisted of 8 in-person or virtual 1-hour visits with a nurse. Follow-up acceptability assessments were conducted with 10 participants.

Results

The average age of the participants was 64.8 (standard deviation [SD] 10.5). They reported an average pain intensity score of 7.0 (SD 1.9) out of 10 and an average Patient Health Questionnaire-9 depressive symptoms score of 11.9 (SD 4.0) at baseline. Of the 34 participants who consented, 28 (82.4%) women started the intervention and 23 (82.1%) completed the intervention. Participants described the study as useful and beneficial. Participants recommended including a group component in future iterations. Effect sizes at 12 weeks were -0.95 for depressive symptoms indicating a substantial decrease in experienced depressive symptoms, but pain intensity was virtually unchanged (+0.09).

Discussion and Implications

The findings of this study demonstrate that the intervention is acceptable among middle-aged and older African American women and their personal goals were met. Including a group component and identifying effective ways to decrease attrition rates will be key in the next steps of development for this intervention. It is crucial to provide tailored, nonpharmacological approaches to pain, and depression symptom management in older adult populations who experience inequities in pain and mental health outcomes. This study emphasizes the importance of participant-driven goal-setting interventions.

Integrative blood-based characterization of oxidative mitochondrial DNA damage variants implicates Mexican American's metabolic risk for developing Alzheimer's disease

Alzheimer's Disease (AD) continues to be a leading cause of death in the US. As the US aging population (ages 65 +) expands, the impact will disproportionately affect vulnerable populations, e.g., Hispanic/Latino population, due to their AD-related health disparities. Age-related regression in mitochondrial activity and ethnic-specific differences in metabolic burden could potentially explain in part the racial/ethnic distinctions in etiology that exist for AD. Oxidation of guanine (G) to 8-oxo-guanine (8oxoG) is a prevalent lesion and an indicator of oxidative stress and mitochondrial dysfunction. Damaged mtDNA (8oxoG) can serve as an important marker of age-related systemic metabolic dysfunction and upon release into peripheral circulation may exacerbate pathophysiology contributing to AD development and/or progression. Analyzing blood samples from Mexican American (MA) and non-Hispanic White (NHW) participants enrolled in the Texas Alzheimer's Research & Care Consortium, we used blood-based measurements of 8oxoG from both buffy coat PBMCs and plasma to determine associations with population, sex, type-2 diabetes, and AD risk. Our results show that 8oxoG levels in both buffy coat and plasma were significantly associated with population, sex, years of education, and reveal a potential association with AD. Furthermore, MAs are significantly burdened by mtDNA oxidative damage in both blood fractions, which may contribute to their metabolic vulnerability to developing AD.

Associations of polygenic risk scores for smoking heaviness and lifetime cannabis use with tobacco and cannabis co-use trajectories among African Americans

BACKGROUND

We aimed to identify distinct trajectories of tobacco, cannabis, and their co-use among African Americans, and to investigate whether these patterns were associated with polygenic risk scores (PRS) for tobacco and cannabis use.

METHOD

Participants (N=428 participants; 50.9% male) were initially recruited for an elementary school-based prevention in a Mid-Atlantic city when they were in first grade. From ages 14-26, participants reported on their frequency of tobacco and cannabis use in the past year during annual assessments. DNA was collected from participants at age 21. PRS for smoking heaviness (i.e., cigarettes per day) and lifetime cannabis use were created based on genome-wide association study results derived from Liu et al. (2019) and Pasman et al. (2018), respectively.

RESULTS

We identified five distinct trajectories of tobacco and cannabis co-use, including (1) Low Tobacco and Cannabis Use, (2) Adolescent Limited Tobacco and Cannabis Use, (3) Experimental Cannabis, Young Adult Increasing Tobacco, (4) Experimental Tobacco, Young Adult Increasing Cannabis, and (5) High, Chronic Tobacco and Cannabis Use. Compared to the Low Tobacco and Cannabis Use subgroup, individuals in the High, Chronic Tobacco and Cannabis Use subgroup had greater PRS for smoking heaviness, and individuals in the Experimental Cannabis, Young Adult Increasing Tobacco subgroup had higher PRS for lifetime cannabis use.

CONCLUSIONS

Polygenic risk for lifetime cannabis use and smoking heaviness is associated with the developmental progression of tobacco and cannabis co-use among African Americans, furthering knowledge on the etiology of co-use in this population.

A protocol for a wait list control trial of an intervention to improve pain and depressive symptoms among middle-aged and older African American women

BACKGROUND

Pain and depression frequently co-occur among older adults with comorbidities and can exacerbate one another. The intersection of race, gender and age puts older African American women at high risk of experiencing comorbid pain and depression. The purpose of this study is to test the feasibility and acceptability of a 12-week behavioral activation intervention called DAPPER (Depression and Pain Perseverance through Empowerment and Recovery) that uses non-pharmacological, tailored strategies to target pain and mood symptoms. We will measure pain intensity and depressive symptoms as outcomes, although we are not powered to test differences.

METHODS

We describe the protocol for this study that uses a randomized waitlist control design to examine acceptability and feasibility of an intervention. The study population is comprised of self-identified African American women, 50 years of age or older with chronic pain and who self-report of depressive symptoms. Participants must also be pre-frail or frail and have an ADL or IADL limitation. The intervention consists of eight 1-2-h visits with a nurse interventionist via in-person or virtual telecommunication methods and two visits for non-invasive specimen collection. The primary outcomes include goal attainment, pain and depressive symptoms. Secondary outcomes include stress, frailty, and communication with providers. Follow-up qualitative interviews are conducted with participants to assess intervention acceptability.

DISCUSSION

Findings from this pilot study will provide further evidence supporting the use of non-pharmacological techniques to intervene in the cycle of pain and depression among an at-risk sub-population.

Barriers and solutions to Alzheimer's disease clinical trial participation for Black Americans

Introduction

Black Americans are disproportionately burdened by Alzheimer's disease (AD) relative to other racial groups in the United States and continue to be underrepresented in AD clinical trials. This review explores the primary barriers for participation in clinical trials among Black Americans and provides literature-based recommendations to improve the inclusion of Black Americans in AD clinical trials.

Methods

We searched electronic databases and gray literature for articles published in the United States through January 1, 2023, ultimately identifying 26 key articles for inclusion.

Results

Barriers to participation in clinical trials for Black Americans are rooted in social determinants of health, including access to quality education and information, access to health care, economic stability, built environment, and community context. Best practices to improve the inclusion of Black Americans in clinical trials require pharmaceutical companies to adopt a multifaceted approach, investing in innovative strategies for site selection, development of local partnerships, outreach, and education.

Discussion

While multisectoral action must occur to effectively address the disproportionate burden of AD on Black Americans, the pharmaceutical industry has an important part to play in this space due to their central role in product development and clinical trials.

Urinary Cytokines as Potential Biomarkers of Mild Cognitive Impairment and Alzheimer's Disease: A Pilot Study

Background

Alzheimer's disease (AD) is the most common form of dementia, accounting for 80% of all cases. Mild cognitive impairment (MCI) is a transitional state between normal aging and AD. Early detection is crucial, as irreversible brain damage occurs before symptoms manifest.

Objective

This study aimed to identify potential biomarkers for early detection of AD by analyzing urinary cytokine concentrations. We investigated 37 cytokines in AD, MCI, and cognitively normal individuals (NC), assessing their associations with AD development.

Methods

Urinary cytokine concentrations were measured in AD (n = 25), MCI (n = 25), and NC (n = 26) patients. IL6ST and MMP-2 levels were compared between AD and NC, while TNFRSF8, IL6ST, and IL-19 were assessed in AD versus MCI. Diagnostic models distinguished AD from NC, and in-silico analysis explored molecular mechanisms related to AD.

Results

Significant perturbations in IL6ST and MMP-2 concentrations were observed in AD urine compared to NC, suggesting their potential as biomarkers. TNFRSF8, IL6ST, and IL-19 differed significantly between AD and MCI, implicating them in disease progression. Diagnostic models exhibited promising performance (AUC: 0.59-0.79, sensitivity: 0.72-0.80, specificity: 0.56-0.78) in distinguishing AD from NC. In-silico analysis revealed molecular insights, including relevant non-coding RNAs, microRNAs, and transcription factors.

Conclusion

This study establishes significant associations between urinary cytokine concentrations and AD and MCI. IL6ST, MMP-2, TNFRSF8, IL6ST, and IL-19 emerge as potential biomarkers for early detection of AD. In-silico analysis enhances understanding of molecular mechanisms in AD. Further validation and exploration of these biomarkers in larger cohorts are warranted to assess their clinical utility.

Supplemental Nutrition Assistance Program Access and Racial Disparities in Food Insecurity

Importance

Racially minoritized people experience disproportionately high rates of food insecurity. The Supplemental Nutrition Assistance Program (SNAP) reduces food insecurity.

Objective

To evaluate SNAP access with regard to racial disparities in food insecurity.

Design, Setting, and Participants

This cross-sectional study used data from the 2018 Survey of Income and Program Participation (SIPP). On the basis of random sampling strategies, 44 870 households were eligible for the SIPP, and 26 215 (58.4%) participated. Sampling weights accounted for survey design and nonresponse. Data were analyzed from February 25 to December 12, 2022.

Exposures

This study examined disparities based on household racial composition (entirely Asian, entirely Black, entirely White, and multiple races or multirace based on SIPP categories).

Main Outcomes and Measures

Food insecurity during the prior year was measured using the validated 6-item US Department of Agriculture Food Security Survey Module. SNAP participation during the prior year was classified based on whether anyone in the household received SNAP benefits. Modified Poisson regression tested hypothesized disparities in food insecurity.

Results

A total of 4974 households that were eligible for SNAP (income ≤130% of the poverty threshold) were included in this study. A total of 218 households (5%) were entirely Asian, 1014 (22%) were entirely Black, 3313 (65%) were entirely White, and 429 (8%) were multiracial or of other racial groups. Adjusting for household characteristics, households that were entirely Black (prevalence rate [PR], 1.18; 95% CI, 1.04-1.33) or multiracial (PR, 1.25; 95% CI, 1.06-1.46) were more likely to be food insecure than entirely White households, but associations differed depending on SNAP participation. Among households that did not participate in SNAP, those that were entirely Black (PR, 1.52; 97.5% CI, 1.20-1.93) or multiracial (PR, 1.42; 97.5% CI, 1.04-1.94) were more likely to be food insecure than White households; however, among SNAP participants, Black households were less likely than White households to be food insecure (PR, 0.84; 97.5% CI, 0.71-0.99).

Conclusions and Relevance

In this cross-sectional study, racial disparities in food insecurity were found among low-income households that do not participate in SNAP but not among those that do, suggesting that access to SNAP should be improved. These results also highlight the need to examine the structural and systemic racism in food systems and in access to food assistance that may contribute to disparities.

"At least we finally found out what it was": Dementia diagnosis in minoritized populations

BACKGROUND

Disparities in diagnosis persist among persons living with dementia (PLWD); most research on delayed diagnosis relies on medical records or administrative claims. This study aimed to identify factors that delay or facilitate dementia diagnoses in racial or ethnic minoritized PLWD and elicit care partner perspectives on timing and effects of diagnosis.

METHODS

Maryland-based participants cared for a PLWD age 60 or older, self-identified as Black/African/African-American, Asian, or Hispanic/Latino, and spoke English. Nineteen care partner in-depth, semi-structured interviews were conducted and analyzed using conventional qualitative content analysis methods.

RESULTS

Biological, sociocultural, and environmental factors delayed dementia diagnosis. Memory loss was the most common early symptom, but the onset was often subtle or perceived as normal aging. Stigma and secrecy surrounding dementia influenced recognition and discussion of dementia among families and communities. Diagnoses were family-initiated and started in primary care. Care partners were divided in their perceptions of diagnosis timeliness and whether earlier diagnosis would have changed outcomes. Family reactions to dementia diagnoses varied; most participants expressed a strong sentiment of service and duty to care for older family members. Participants overwhelmingly felt the benefits of obtaining a dementia diagnosis outweighed harms.

CONCLUSIONS

Numerous factors affect dementia diagnosis in racial and ethnic minoritized PLWD. Normalization of brain health discussions and systematic, proactive discussion and detection of dementia in primary care may address multilevel barriers and facilitators to diagnosis. Systems-level and community-led public health interventions may also help address disparities in brain health education and dementia diagnosis.

Achieving mental health equity in Black male suicide prevention

Despite a steady decrease in suicide rates in the United States, the rate among Black males has increased in recent decades. Moreover, suicide is now positioned as the third leading cause of death in this population, signaling a public health crisis. Enhancing the ability for future suicide prevention scholars to fully characterize and intervene on suicide risk factors is an emerging health equity priority, yet there is little empirical evidence to robustly investigate the alarming trends in Black male suicide. We present fundamental areas of expansion in suicide prevention research focused on establishing culturally responsive strategies to achieve mental health equity. Notably, we identify gaps in existing research and offer future recommendation to reduce suicide death among Black males. Our perspective aims to present important and innovative solutions for ensuring the inclusion of Black males in need of suicide prevention and intervention efforts.

Integrative Blood-Based Characterization of Oxidative Mitochondrial DNA Damage Variants Implicates Mexican Americans' Metabolic Risk for Developing Alzheimer's Disease

Alzheimer's Disease (AD) continues to be a leading cause of death in the US. As the US aging population (ages 65+) expands, the impact will disproportionately affect vulnerable populations, e.g., Hispanic/Latinx population, due to their AD-related health disparities. Age-related regression in mitochondrial activity and ethnic-specific differences in metabolic burden could potentially explain in part the racial/ethnic distinctions in etiology that exist for AD. Oxidation of guanine (G) to 8-oxo-guanine (8oxoG) is a prevalent lesion and an indicator of oxidative stress and mitochondrial dysfunction. Damaged mtDNA (8oxoG) can serve as an important marker of age-related systemic metabolic dysfunction and upon release into peripheral circulation may exacerbate pathophysiology contributing to AD development and/or progression. Analyzing blood samples from Mexican American (MA) and non-Hispanic White (NHW) participants enrolled in the Texas Alzheimer's Research & Care Consortium, we used blood-based measurements of 8oxoG from both buffy coat PBMCs and plasma to determine associations with population, sex, type-2 diabetes, and AD risk. Our results show that 8oxoG levels in both buffy coat and plasma were significantly associated with population, sex, years of education, and reveal a potential association with AD. Furthermore, MAs are significantly burdened by mtDNA oxidative damage in both blood fractions, which may contribute to their metabolic vulnerability to developing AD.

Food Insecurity and Cognitive Trajectories in Community-Dwelling Medicare Beneficiaries 65 Years and Older

Importance

Food insecurity has a known association with prevalent impaired cognition. However, it is unknown whether food insecurity has a longitudinal association with cognitive decline among older adults.

Objective

To determine whether food insecurity is associated with a faster decline in cognitive function among community-dwelling older adults.

Design, Setting, and Participants

This retrospective cohort study used data from a nationally representative sample of Medicare beneficiaries 65 years and older recruited for the National Health and Aging Trends Study (NHATS). Community-dwelling NHATS participants were followed up for a maximum of 7 years (mean [SD] follow-up duration, 5.4 [1.1] years). Data were collected from January 1, 2012, to December 31, 2020, and analyzed from December 23, 2021, to December 6, 2022.

Exposures

Self-reported food insecurity assessed from 2012 to 2019.

Main Outcomes and Measures

Primary outcomes were immediate memory, delayed memory, and executive function collected from 2013 to 2020. Immediate and delayed recall were assessed by a 10-item word-list memory task (range, 0-10, with higher scores indicating more words recalled). Executive function was measured by the clock drawing test (range, 0-5, with higher scores indicating more accurate depiction of a clock). Each year's cognitive functions were linked to the prior year's food insecurity data. Linear mixed-effects models with random slopes and intercepts were used to examine the association between food insecurity and cognitive decline. Analytic weights in each year were applied to represent community-dwelling Medicare beneficiaries 65 years and older in 2011.

Results

Of 3037 participants, a weighted 57.8% (raw count, 1345) were younger than 75 years, 56.2% (raw count, 1777) were women, and most (84.9% [raw count, 2268]) were White. Over 7 years, 417 (weighted proportion, 12.1%) experienced food insecurity at least once. Food insecurity was associated with a faster decline in executive function in a fully adjusted model: the mean difference of annual change in executive function score between people exposed to and not exposed to food insecurity was -0.04 (95% CI, -0.09 to -0.003) points. However, food insecurity was not associated with changes in immediate and delayed memory (0.01 [95% CI, -0.05 to 0.08] and -0.01 [95% CI, -0.08 to 0.06], respectively).

Conclusions and Relevance

Among community-dwelling older adults, food insecurity was prevalent and associated with a decline in executive function. Interventions and policies aiming to increase healthy food access or reduce food insecurity should be assessed for their impact on older adults' cognitive outcome.

Associations Between Objectively Measured Sleep and Cognition: Main Effects and Interactions With Race in Adults Aged ≥50 Years

BACKGROUND

This study examined associations of actigraphy-estimated sleep parameters with concurrent and future cognitive performance in adults aged ≥ 50 years and explored interactions with race.

METHODS

Participants were 435 cognitively normal adults in the Baltimore Longitudinal Study of Aging who completed wrist actigraphy at baseline (mean = 6.6 nights) and underwent longitudinal testing of memory, attention, executive function, language, and visuospatial ability. On average, participants with follow-up data were followed for 3.1 years. Primary predictors were baseline mean total sleep time, sleep onset latency, sleep efficiency (SE), and wake after sleep onset (WASO). Fully adjusted linear mixed-effects models included demographics, baseline health-related characteristics, smoking status, sleep medication use, APOE e4 carrier status, and interactions of each covariate with time.

RESULTS

In adjusted models, higher SE (per 10%; B = 0.11, p = .012) and lower WASO (per 30 minutes; B = -0.12, p = .007) were associated with better memory cross-sectionally. In contrast, higher SE was associated with greater visuospatial ability decline longitudinally (B = -0.02, p = .004). Greater WASO was associated with poorer visuospatial ability cross-sectionally (B = -0.09, p = .019) but slower declines in visuospatial abilities longitudinally (B = 0.02, p = .002). Several sleep-cognition cross-sectional and longitudinal associations were stronger in, or limited to, Black participants (compared to White participants).

CONCLUSIONS

This study suggests cross-sectional sleep-cognition associations differ across distinct objective sleep parameters and cognitive domains. This study also provides preliminary evidence for racial differences across some sleep-cognition relationships. Unexpected directions of associations between baseline sleep and cognitive performance over time may be attributable to the significant proportion of participants without follow-up data and require further investigation.