The Health and Housing Study: Nutrition-Related Outcomes Among Low- to Moderate-Income Individuals Living in or Seeking to Live in New Subsidized Chinatown-Based Housing

Objectives

Housing stability, food security and healthy eating are interrelated. In 2015, a housing lottery for newly developed subsidized housing in Chinatown, Boston, MA was held for low- and moderate- income families who were randomly selected from a waitlist. Four years later (19/20), our study explores the associations between housing status (living in the new subsidized building (NSB) or being on the lottery waitlist) and Food Insecurity (FI); use of food safety net programs (SN), defined as use of SNAP, WIC and/or food pantries; weekly fruit and vegetable consumption (FV); weekly soda consumption; and monthly fast food consumption (FF).

Methods

Questionnaire links were sent to NSB (n = 95) and waitlist (n = 2498) households. Logistic regression was used to explore the association between housing status and (1) FI (2-item screener) and (2) use of SN (self-reported use in the past year). Linear regression with robust standard error estimation was used to explore the association between housing status and weekly consumption of (1) FV, (2) soda, and (3) monthly consumption of FF, (assessed through health behavior questions from the California Health Interview Survey). Models were adjusted for age, sex, ethnicity, household size, education, income, employment status and distance to grocery store.

Results

138 respondents completed the survey; NSB = 36, waitlist = 102. The two housing status groups were demographically similar. Respondents in the NSB showed non-statistically significant lower odds of experiencing FI (OR 0.65, 95% CI [0.3, 1.6]) and of using SN (OR 0.45, 95% CI [0.1, 1.6]). Respondents in the NSB showed non-statistically significant higher weekly consumption of FV (β 2.03, 95% CI [−1.5, 5.6]); lower weekly consumption of soda (β −0.39, 95% CI [−1.9, 1.1]) and lower monthly consumption of FF (β −1.19, 95% CI [−3.9, 1.5]), when compared to respondents on the waitlist.

Conclusions

In this small sample, main outcomes were not significantly different. Dietary intakes among NSB residents were consistently positive compared to waitlist residents. Future studies should continue to explore mechanisms through which living in a NSB may impact nutrition and health outcomes.

Funding Sources

Tufts Collaborates Seed Grants. Conclusions do not represent any U.S. Department of Agriculture office or Government determination. This research was not part of MI's work at USDA.

Self-Reported Changes and Perceived Barriers to Healthy Eating and Physical Activity among Global Breast Cancer Survivors: Results from an Exploratory Online Novel Survey

BACKGROUND

Despite being motivated to improve nutrition and physical activity behaviors, cancer survivors are still burdened by suboptimal dietary intake and low levels of physical activity.

OBJECTIVE

The aim of this study was to assess changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, barriers to eating a healthy diet and staying physically active, and sources for seeking nutrition advice reported by breast cancer survivors.

DESIGN

This was a cross-sectional study.

PARTICIPANTS/SETTING

The study included 315 survivors of breast cancer who were recruited through social media and provided completed responses to an online exploratory survey.

MAIN OUTCOME MEASURES

Self-reported changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, perceived barriers to healthy eating and physical activity, and sources of nutrition advice were measured.

STATISTICAL ANALYSIS

Frequency distribution of nutrition and physical activity behaviors and changes, barriers to healthy eating and physical activity, and sources of nutrition advice were estimated.

RESULTS

About 84.4% of the breast cancer survivors reported at least 1 positive behavior for improving nutrition and physical activity after cancer diagnosis or treatment. Fatigue was the top barrier to both making healthy food choices (72.1%) and staying physically active (65.7%), followed by stress (69.5%) and treatment-related changes in eating habits (eg, change in tastes, loss of appetite, and craving unhealthy food) (31.4% to 48.6%) as barriers to healthy eating, and pain or discomfort (53.7%) as barriers to being physically active. Internet search (74.9%) was the primary source for seeking nutrition advice. Fewer than half reported seeking nutrition advice from health care providers.

CONCLUSIONS

Despite making positive changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, breast cancer survivors experience treatment-related barriers to eating a healthy diet and staying physically active. Our results reinforce the need for developing tailored intervention programs and integrating nutrition into oncology care.

Potential of Using Twitter to Recruit Cancer Survivors and Their Willingness to Participate in Nutrition Research and Web-Based Interventions: A Cross-Sectional Study

BACKGROUND

Social media is rapidly changing how cancer survivors search for and share health information and can potentially serve as a cost-effective channel to reach cancer survivors and invite them to participate in nutrition intervention programs.

OBJECTIVE

This study aimed to assess the feasibility of using Twitter to recruit cancer survivors for a web-based survey and assess their willingness to complete web-based nutrition surveys, donate biospecimens, and to be contacted about web-based nutrition programs.

METHODS

We contacted 301 Twitter accounts of cancer organizations, advocates, and survivors to request assistance promoting a web-based survey among cancer survivors. The survey asked respondents whether they would be willing to complete web-based nutrition or lifestyle surveys, donate biospecimens, and be contacted about web-based nutrition programs. Survey promotion rate was assessed by the percentage of Twitter accounts that tweeted the survey link at least once. Survey response was assessed by the number of survey respondents who answered at least 85% (26/30). We compared the characteristics of cancer survivors who responded to this survey with those who participated in the National Health and Nutrition Examination Survey (NHANES) 1999-2010 and evaluated factors associated with willingness to complete web-based surveys, donate biospecimens, and be contacted to participate in web-based nutrition programs among those who responded to the social media survey.

RESULTS

Over 10 weeks, 113 Twitter account owners and 165 of their followers promoted the survey, and 444 cancer survivors provided complete responses. Two-thirds of respondents indicated that they would be willing to complete web-based nutrition or lifestyle surveys (297/444, 67.0%) and to be contacted to participate in web-based nutrition interventions (294/444, 66.2%). The percentage of respondents willing to donate biospecimens were 59.3% (263/444) for oral swab, 52.1% (231/444) for urine sample, 37.9% (168/444) for blood sample, and 35.6% (158/444) for stool sample. Compared with a nationally representative sample of 1550 cancer survivors in NHANES, those who responded to the social media survey were younger (53.1 years vs 60.8 years; P<.001), more likely to be female (93.9% [417/444] vs 58.7% [909/1550]; P<.001), non-Hispanic whites (85.4% [379/444] vs 64.0% [992/1550]; P<.001), to have completed college or graduate school (30.1 [133/444] vs 19.9% [308/444]; P<.001), and to be within 5 years of their initial diagnosis (55.2% [244/444] vs 34.1% [528/1550]; P<.001). Survivors younger than 45 years, female, and non-Hispanic whites were more willing to complete web-based nutrition surveys than older (65+ years), male, and racial or ethnic minority survivors. Non-Hispanic whites and breast cancer survivors were more willing to donate biospecimens than those with other race, ethnicity or cancer types.

CONCLUSIONS

Twitter could be a feasible approach to recruit cancer survivors into nutrition research and web-based interventions with potentially high yields. Specific efforts are needed to recruit survivors who are older, male, racial and ethnic minorities, and from socioeconomically disadvantaged groups when Twitter is used as a recruitment method.

Evaluating the impact of point- of-care decision support tools in improving diagnosis of obese children in primary care

OBJECTIVE

The purpose of this quasi-experimental study was to examine the effect of a computerized point-of-care alert with clinical decision support on the rates of diagnosis of childhood obesity in a multisite group practice in Massachusetts; Cambridge Health Alliance (CHA) which implemented an alert, relative to a separate group practice, Harvard Vanguard Medical Associates (HVMA), that did not.

DESIGN AND METHODS

Height and weight data from 19,466 children of 2-18 years with 34,908 well-child care visits in CHA and 123,446 children with 282,271 visits in HVMA between 2006 and 2008 were collected. The alert and decision support tool was activated for CHA patients with an age- and sex-specific body mass index of ≥95th percentile. The main outcome measure was documentation of an International Classification of Diseases, Ninth Revision [ICD-9] code for obesity before and after implementation of the alert at CHA in 2007.

RESULTS

Among obese children, the adjusted rate of an ICD-9 diagnosis of obesity increased from 2006-2007 to 2008 significantly more at CHA than at HVMA (P < 0.001 for time-by-provider group interaction). In 2006-2007, the rate of ICD-9 diagnosis of obesity was significantly lower at CHA than at HVMA (adjusted odds ratio [OR]: 0.57; 95% confidence interval [CI]: 0.52-0.62); but by 2008 was significantly higher at CHA than HVMA (adjusted OR: 1.25; 95% CI: 1.14-1.38).

CONCLUSION

A point-of-care alert was effective in improving obesity diagnosis in a multisite group practice, relative to a separate group practice that did not adopt an alert. Clinical decision support tools could help improve obesity diagnosis in pediatric primary care.

Vitamin D deficiency, adiposity, and cardiometabolic risk in urban schoolchildren

OBJECTIVE

To determine the relationship between serum vitamin D levels and cardiometabolic risk factors independent of adiposity in urban schoolchildren.

STUDY DESIGN

We assessed the relationships among serum 25-hydroxyvitamin D [25(OH)D], adiposity measured by body mass index (BMI) z-score (BMIz), and 6 cardiometabolic risk factors (total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, interleukin-6, and C-reactive protein [CRP]) in a cross-sectional sample of 263 racially and ethnically diverse schoolchildren from the Boston area during late winter. Multivariate regression analyses adjusting for sociodemographic characteristics and BMIz examined associations of 25(OH)D and cardiometabolic risk factors.

RESULTS

Overall, 74.6% of the children were vitamin D deficient [25(OH)D <50 nmol/L; mean, 41.8 ± 13.7 nmol/L]; 45% were overweight or obese (20% and 25%, respectively; BMIz = 0.75 ± 1.1). The 25(OH)D level was not associated with BMIz, but was positively associated with the cardiometabolic risk factor CRP (β = 0.03; P < .05). BMIz was associated with elevated triglycerides (β = 0.13), CRP (β = 0.58), and interleukin-6 (β= 0.14) and low high-density lipoprotein cholesterol (β = -0.09; all P < .01).

CONCLUSIONS

Vitamin D deficiency is highly prevalent during the late winter months in urban schoolchildren living in the northeastern United States. This widespread deficiency may contribute to the lack of associations between 25(OH)D and both BMIz and cardiometabolic risk factors. The association between 25(OH)D and CRP warrants further study.

Comfort and utility of school-based weight screening: the student perspective

BACKGROUND

Weight screening in schools has been proposed as one strategy to address childhood obesity. Students' response to such screening is unexplored, however. In this study we evaluated the perceived comfort, utility and impact of school-based weight screening from the perspective of middle school-aged students.

METHODS

A cross-sectional study of 852 ethnically diverse 5th-8th grade students. Associations were investigated between measured height and weight screening data and responses to a self-administered questionnaire completed immediately following weight screening in physical education class. BMI categories were based on the revised 2000 CDC growth chart and definitions: 5th-85th BMI percentile = healthy weight, 85th-95th BMI percentile = at risk for overweight, and >95th percentile BMI = overweight.

RESULTS

Overall, students' comfort level with weight screening varied depending on the student's own weight status. More overweight students (38.1%) reported being uncomfortable than healthy weight students (8.1%) (p < 0.001). In particular, overweight female students (54.8%) compared to healthy weight female students (21.6%) reported being uncomfortable (p < 0.01). About half (54.9%) of all students reported knowing their weight prior to screening, and 58.9% reported that it was useful to learn their height and weight. Compared to healthy weight students, overweight students were significantly more likely to report the intention to perform weight modification related activities such as visiting a doctor (Odds ratio (OR) = 2.0, 95% CI = 1.3, 3.1), eating more fruits and vegetables (OR = 2.7, 95% CI = 1.7, 4.1), and increasing physical activity (OR = 4.3, 95% CI = 2.7, 7.0).

CONCLUSION

Overall, the majority of the middle school students did not report discomfort with school-based weight screening, did report that receiving height and weight information was useful, and generally report appropriate weight control intentions. These proportions varied across weight status categories, however, with students who were at risk for overweight or overweight reporting higher levels of discomfort. For schools that conduct weight screening, it is essential that they also provide comfortable and private settings as well as education or counseling regarding healthy weight control practices.

Relationship of physical fitness to prevalence and incidence of overweight among schoolchildren

OBJECTIVES

We examined the relationship between comprehensive fitness tests and overweight using a school surveillance system in a racially diverse city in the United States.

RESEARCH METHODS AND PROCEDURES

Trained physical education teachers measured weight, height, and fitness annually from 2001 to 2003. We compiled data for a cross-sectional analysis (11,845 measurements on 6297 students, 5 to 14 years of age) and a 1-year prospective analysis (4215 measurements on 2927 students not overweight at baseline, 5 to 13 years of age). Overweight was defined as a BMI > or =95th percentile (Centers for Disease Control and Prevention 2000 growth charts), and underfit was defined as failing at least one of five fitness tests: endurance run, abdominal strength, flexibility, upper body strength, and agility (Amateur Athletic Union and Fitnessgram). Associations between fitness and overweight were examined using multivariate logistic regression models, adjusting for sociodemographic status and repeated measurements over time.

RESULTS

The mean number of fitness tests passed was lower among students with a BMI above the 80th percentile. Overweight incidence over 1 year was 7% and 2% for underfit and fit girls, respectively (odds ratio, 3.3; 95% confidence interval, 2.0 to 5.6). Not passing either the endurance run or upper body strength test was associated with overweight incidence in both boys and girls. After adjusting for baseline BMI, the endurance run remained a significant predictor of incident overweight among girls (odds ratio, 2.0; 95% confidence interval, 1.1 to 3.5).

DISCUSSION

Findings support a cross-sectional inverse relationship between physical fitness and overweight among school-aged children. The direction of causation between fitness and overweight is not clearly established and merits further study.

Incidence and remission rates of overweight among children aged 5 to 13 years in a district-wide school surveillance system

OBJECTIVES

To monitor annual changes in weight status, we determined incidence and remission rates of overweight among school-aged children with longitudinal school-based surveillance.

METHODS

We estimated 1-year changes in weight status among students enrolled in public schools in Cambridge, Mass. Physical education teachers measured height and weight annually. Adjusted odds ratios (ORs) were estimated via multivariate logistic regression, accounting for repeated observations of individual children across years.

RESULTS

The 1-year incidence of overweight was 4%, and the remission rate was 15%. Among overweight children, 85% remained overweight at a 1-year follow-up, while 18% of children at risk for overweight became overweight. Overweight incidence rates were higher among children aged 7 and 8 years than among those aged 11 to 13 years (boys: OR=1.68; 95% confidence interval [CI]=1.14, 2.47; girls: OR=1.86; 95% CI=1.25, 2.77).

CONCLUSIONS

Both incidence and remission rates were higher among younger children. Children who were at risk for overweight were more likely to change their weight status than those who were already overweight. Our results support targeting overweight prevention efforts toward younger children and children at risk for overweight.