Longitudinal Associations Between Neighborhood Physical and Social Environments and Incident Type 2 Diabetes Mellitus: The Multi-Ethnic Study of Atherosclerosis (MESA)

Residential mobility, neighborhood environment, and diabetes complications among socioeconomically disadvantaged patients in the United States

Residential mobility can affect health through changes in available resources, social support, or continuity of healthcare. This study sought to understand whether residential mobility and/or change in neighborhood environment among patients with diabetes were associated with diabetes-related complications. This retrospective study used electronic health record data from 19,853 adults aged 18-64 with a diabetes diagnosis seen in 110 safety-net clinics across the United States. Generalized estimating equations logistic regression models estimated whether moving (pre/post) and change in neighborhood environment (improving, worsening, similar) were associated with diagnoses of chronic diabetes-related complications. Post-move versus pre-move was associated with significantly higher probability of diabetes-related chronic complications (predicted probability: 13.16 vs 6.00, respectively), but no association was found by change in neighborhood environment. Those who moved had lower probability of chronic complications than those who did not move which could have been driven by pre-move circumstances among patients who moved. Residential mobility plays an important role in understanding diabetes-related complications while changes in neighborhood environment may be less important among low-income patients served by safety-net clinics. Moving may not be directly responsible for the development of diabetes-related chronic complications, but it may be an indicator for other factors of instability.

Neighborhood walkability and cardiometabolic disease in Texas

Cardiometabolic diseases (CMDs) affect significant numbers of adults in the United States, with 11% diagnosed with diabetes and 10% with cardiovascular diseases. Walking plays a crucial role in reducing health risks, particularly obesity and diabetes. We aim to explore the association between neighborhood walkability and CMD measures in Texas, while controlling for age, sex, racial/ethnic background, and family history of diabetes. We collected 1994 observations for the year 2019, merging data from the Texas Behavioral Risk Factor Surveillance System and the Environmental Protection Agency. We employed multilevel linear regression and multilevel logistic regression analyses to assess the association between CMD measures and neighborhood walkability. Our findings revealed that higher neighborhood walkability is significantly associated with a lower body mass index (BMI) (β = - 0.28, CI - 0.45 to - 0.10) and a reduced risk of diabetes (OR 0.93, CI 0.86-0.99), indicating that when walkability increases by one unit, an individual's BMI decreases by 0.28 kg/m2 and the odds of having diabetes decrease by 7%. We also found that African Americans living in communities with lower walkability scores compared to other racial/ethnic groups. Our findings highlight the need for urban planning policies promoting walkable neighborhoods, suggesting community-based approaches to health promotion.

Psychological Factors and Prevalence of Diabetes and Prediabetes in a United States-Mexico Border Community

Background

Domestic and international migrants along the United States-Mexico border are at increased risk for diabetes due to structural and psychosocial adversities.

Objectives

This study assessed the prevalence of diabetes and prediabetes in a low-income United States-Mexico border community; examined the relationships between depression, anxiety, andadverse childhood experiences (ACEs) and diabetes prevalence and glucose regulation; and explored indirect effects of social support on these relationships. Results. Participants were 220 adults ages 19-83 years (M.47.2, SD.11.9) of majority Mexican nationality (89.1%). Over 70% reported history of migration to the United States; 56.8% reported deportation from the United States to Mexico. Prevalences of clinically significant depression and anxiety symptoms were 36.9% and 33.3%, respectively. Prevalences of diabetes and prediabetes were 17.3% and 29.1%, respectively. Psychological variables were not associated with diabetes or glucose regulation. Indirect effects were found from depression and ACEs through social support to hemoglobin A1c.

Conclusions

Results suggest the need for diabetes prevention interventions with an integrated biopsychosocial approach.

Racial residential segregation is associated with ambient air pollution exposure after adjustment for multilevel sociodemographic factors: Evidence from eight US-based cohorts

Objective

We examined if racial residential segregation (RRS) - a fundamental cause of disease - is independently associated with air pollution after accounting for other neighborhood and individual-level sociodemographic factors, to better understand its potential role as a confounder of air pollution-health studies.

Methods

We compiled data from eight large cohorts, restricting to non-Hispanic Black and White urban-residing participants observed at least once between 1999 and 2005. We used 2000 decennial census data to derive a spatial RRS measure (divergence index) and neighborhood socioeconomic status (NSES) index for participants' residing Census tracts, in addition to participant baseline data, to examine associations between RRS and sociodemographic factors (NSES, education, race) and residential exposure to spatiotemporal model-predicted PM2.5 and NO2 levels. We fit random-effects meta-analysis models to pool estimates across adjusted cohort-specific multilevel models.

Results

Analytic sample included eligible participants in CHS (N = 3,605), MESA (4,785), REGARDS (22,649), NHS (90,415), NHSII (91,654), HPFS (32,625), WHI-OS (77,680), and WHI-CT (56,639). In adjusted univariate models, a quartile higher RRS was associated with 3.73% higher PM2.5 exposure (95% CI: 2.14%, 5.32%), and an 11.53% higher (95% CI: 10.83%, 12.22%) NO2 exposure on average. In fully adjusted models, higher RRS was associated with 3.25% higher PM2.5 exposure (95% CI: 1.45%, 5.05%; P < 0.05) and 10.22% higher NO2 exposure (95% CI: 6.69%, 13.74%; P < 0.001) on average.

Conclusions

Our findings indicate that RRS is associated with the differential distribution of poor air quality independent of NSES or individual race, suggesting it may be a relevant confounder to be considered in future air pollution epidemiology studies.

‎The association between cumulative exposure to neighborhood walkability (NW) and diabetes risk, a prospective cohort study

PURPOSE

To examine the association between cumulative exposure to neighborhood walkability (NW) and diabetes risk.

METHODS

A total of 11,037 women free of diabetes at enrollment were included. We constructed a 4-item NW index at baseline, and a 2-item average annual NW across years of follow-up that captured both changes in neighborhood features and residential moves. We used multivariable Cox PH regression models with robust variance to estimate the hazard ratios (HRs) of diabetes by NW scores.

RESULTS

Compared with women living in areas with lowest NW (Q1), those living in areas with highest NW (Q4) had 33 % (26 %-39 %) reduced risk of incident diabetes, using baseline NW, and 25 % (95 % CI 11 %-36 %), using average annual NW. Analysis using time-varying exposure showed that diabetes risks decreased by 13 % (10 %-16 %) per -standard deviation increase in NW. The associations remained similar when using inverse probability of attrition weights and/or competing risk models to account for the effect of censoring due to death or non-response. The associations of average annual NW with incident diabetes were stronger in postmenopausal women as compared to premenopausal women.

CONCLUSION

Long-term residence in more walkable neighborhoods may be protective against diabetes in women, especially postmenopausal women.

Structural and social determinants of health: The multi-ethnic study of atherosclerosis

BACKGROUND

Researchers have increasingly recognized the importance of structural and social determinants of health (SSDOH) as key drivers of a multitude of diseases and health outcomes. The Multi-Ethnic Study of Atherosclerosis (MESA) is an ongoing, longitudinal cohort study of subclinical cardiovascular disease (CVD) that has followed geographically and racially/ethnically diverse participants starting in 2000. Since its inception, MESA has incorporated numerous SSDOH assessments and instruments to study in relation to CVD and aging outcomes. In this paper, we describe the SSDOH data available in MESA, systematically review published papers using MESA that were focused on SSDOH and provide a roadmap for future SSDOH-related studies.

METHODS AND FINDINGS

The study team reviewed all published papers using MESA data (n = 2,125) through January 23, 2023. Two individuals systematically reviewed titles, abstracts, and full text to determine the final number of papers (n = 431) that focused on at least one SSDOH variable as an exposure, outcome, or stratifying/effect modifier variable of main interest (discrepancies resolved by a third individual). Fifty-seven percent of the papers focused on racialized/ethnic groups or other macrosocial/structural factors (e.g., segregation), 16% focused on individual-level inequalities (e.g. income), 14% focused on the built environment (e.g., walking destinations), 10% focused on social context (e.g., neighborhood socioeconomic status), 34% focused on stressors (e.g., discrimination, air pollution), and 4% focused on social support/integration (e.g., social participation). Forty-seven (11%) of the papers combined MESA with other cohorts for cross-cohort comparisons and replication/validation (e.g., validating algorithms).

CONCLUSIONS

Overall, MESA has made significant contributions to the field and the published literature, with 20% of its published papers focused on SSDOH. Future SSDOH studies using MESA would benefit by using recently added instruments/data (e.g., early life educational quality), linking SSDOH to biomarkers to determine underlying causal mechanisms linking SSDOH to CVD and aging outcomes, and by focusing on intersectionality, understudied SSDOH (i.e., social support, social context), and understudied outcomes in relation to SSDOH (i.e., sleep, respiratory health, cognition/dementia).

The built environment and its association with type 2 diabetes mellitus incidence: A systematic review and meta-analysis of longitudinal studies

This study aimed to systematically review longitudinal studies examining associations between the incidence of type 2 diabetes mellitus (T2DM) and built environmental factors. This review adhered to the 2020 PRISMA guidelines. Longitudinal studies examining associations between T2DM incidence and built environmental features were eligible. Built environment constructs corresponded to the following themes: 1) Walkability - factors such as sidewalks/footpaths, crosswalks, parks, and density of businesses and services; (2) Green/open space - size, greenness, and type of available public outdoor spaces; (3) Food environment - ratio of healthful food outlets (e.g., greengrocers, butchers, supermarkets, and health food shops) to unhealthful food outlets (e.g., fast-food outlets, sweet food retailers, and convenience stores). Five databases (e.g., Medline) were searched from inception until July 2023. Qualitative and quantitative synthesis were used to summarise key findings, including a meta-analysis of adjusted Hazard Ratios (aHR). Of 3,343 articles, 16 longitudinal studies from seven countries, published between 2015 and 2023, involving 13,403,902 baseline participants (median of 83,898), were included. In four of the five studies, unhealthful food environment was significantly associated with higher incident T2DM. Five of seven greenspace studies and two of four walkability studies showed that greater greenery and greater walkability were statistically significantly associated with lesser incident T2DM. In pooled analyses, greater T2DM incidence was associated with unhealthful relative to healthful food environments (pooled HR: 1.21; 95% CI: 1.04, 1.42), and T2DM incidence was inversely associated with green/open space environments (pooled HR: 0.82; 95% CI: 0.74, 0.92). Greater walkability was associated with a slight 2% lesser incidence of T2DM (pooled HR: 0.98; 95% CI: 0.98, 0.99). This review underscores consistency in the nature of associations between built environment features related to T2DM. We observed statistically significant inverse or "protective" associations between T2DM and walkability and healthful food environments. These results support calls for policies and guidelines that promote healthful food environments and walkability.

Patients with diabetes struggling to afford food and control their HbA1c in food-insecure areas in Bronx, NY

OBJECTIVE

To characterise the association between risk of poor glycaemic control and self-reported and area-level food insecurity among adult patients with type 2 diabetes.

DESIGN

We performed a retrospective, observational analysis of cross-sectional data routinely collected within a health system. Logistic regressions estimated the association between glycaemic control and the dual effect of self-reported and area-level measures of food insecurity.

SETTING

The health system included a network of ambulatory primary and speciality care sites and hospitals in Bronx County, NY.

PARTICIPANTS

Patients diagnosed with type 2 diabetes who completed a health-related social need (HRSN) assessment between April 2018 and December 2019.

RESULTS

5500 patients with type 2 diabetes were assessed for HRSN with 7·1 % reporting an unmet food need. Patients with self-reported food needs demonstrated higher odds of having poor glycaemic control compared with those without food needs (adjusted OR (aOR): 1·59, 95 % CI: 1·26, 2·00). However, there was no conclusive evidence that area-level food insecurity alone was a significant predictor of glycaemic control (aOR: 1·15, 95 % CI: 0·96, 1·39). Patients with self-reported food needs residing in food-secure (aOR: 1·83, 95 % CI: 1·22, 2·74) and food-insecure (aOR: 1·72, 95 % CI: 1·25, 2·37) areas showed higher odds of poor glycaemic control than those without self-reported food needs residing in food-secure areas.

CONCLUSIONS

These findings highlight the importance of utilising patient- and area-level social needs data to identify individuals for targeted interventions with increased risk of adverse health outcomes.

Social Determinants of Health and Diabetes in Pregnancy

Social determinants of health (SDOH) are the conditions in which people are born, grow, work, live, and age. SDOH are systemic factors that may explain, perpetuate, and exacerbate disparities in health outcomes for different populations and can be measured at both an individual and neighborhood or community level (iSDOH, nSDOH). In pregnancy, increasing evidence shows that adverse iSDOH and/or nSDOH are associated with a greater likelihood that diabetes develops, and that when it develops, there is worse glycemic control and a greater frequency of adverse pregnancy outcomes. Future research should not only continue to examine the relationships between SDOH and adverse pregnancy outcomes with diabetes but should determine whether multi-level interventions that seek to mitigate adverse SDOH result in equitable maternal care and improved patient health outcomes for pregnant individuals living with diabetes. KEY POINTS: · SDOH are conditions in which people are born, grow, work, live, and age.. · SDOH are systemic factors that may explain, perpetuate, and exacerbate disparities in health outcomes.. · SDOH can be measured at the individual and neighborhood level.. · Adverse SDOH are associated with worse outcomes for pregnant individuals living with diabetes.. · Interventions that mitigate adverse SDOH to improve maternal health equity and outcomes are needed..

Association between participation in the supplemental nutrition assistance program and perception of limited availability and choice of healthy foods

BACKGROUND

Nutrition security encompasses stable and equitable access, availability, affordability, and utilization of healthy foods.

AIM

To evaluate the relationship of two newly created dichotomous measures that represent aspects of nutrition security (i.e., perceived limited availability and healthfulness choice) with Supplemental Nutrition Assistance Program (SNAP) participation.

METHODS

Logistic regression models were run for each outcome separately with adjustment for age, income-to-poverty ratio, gender, education, race, and food security.

RESULTS

Adults using social services (e.g., food pantries) were enrolled (N = 402) in this cross-sectional analysis. SNAP participants (61.7%) were not different from non-SNAP participants in perceiving limited availability (aOR [95% CI]: 1.21 [0.75, 1.95]) or limited ability to choose (aOR [95% CI]: 0.69 [0.43, 1.12]) healthy foods.

CONCLUSIONS

Both SNAP and non-SNAP participants with low socioeconomic status report limited availability of healthy foods in their environment and a limited ability to choose healthy foods.

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

OBJECTIVES

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

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

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

ELIGIBILITY CRITERIA

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

DATA EXTRACTION AND SYNTHESIS

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION NUMBER

CRD42021223035.

Still Separate, Still Not Equal: An Ecological Examination of Redlining and Racial Segregation with COVID-19 Vaccination Administration in Washington D.C

Racial residential segregation has been deemed a fundamental cause of health inequities. It is a result of historical and contemporary policies such as redlining that have created a geographic separation of races and corresponds with an inequitable distribution of health-promoting resources. Redlining and racial residential segregation may have contributed to racial inequities in COVID-19 vaccine administration in the early stages of public accessibility. We use data from the National Archives (historical redlining), Home Mortgage Disclosure Act (contemporary redlining), American Community Survey from 1940 (historical racial residential segregation) and 2015-2019 (contemporary racial residential segregation), and Washington D.C. government (COVID-19 vaccination administration) to assess the relationships between redlining, racial residential segregation, and COVID-19 vaccine administration during the early stages of vaccine distribution when a tiered system was in place due to limited supply. Pearson correlation was used to assess whether redlining and racial segregation, measured both historically and contemporarily, were correlated with each other in Washington D.C. Subsequently, linear regression was used to assess whether each of these measures associate with COVID-19 vaccine administration. In both historical and contemporary analyses, there was a positive correlation between redlining and racial residential segregation. Further, redlining and racial residential segregation were each positively associated with administration of the novel COVID-19 vaccine. This study highlights the ongoing ways in which redlining and segregation contribute to racial health inequities. Eliminating racial health inequities in American society requires addressing the root causes that affect access to health-promoting resources.

Neighborhood-level social determinants of health and cardioprotective behaviors among church members in New Orleans, Louisiana

BACKGROUND

Favorable neighborhood-level social determinants of health (SDoH) are associated with lower cardiovascular disease risk. Less is known about their influence on cardioprotective behaviors. We evaluated the associations between neighborhood-level SDoH and cardioprotective behaviors among church members in Louisiana.

METHODS

Participants were surveyed between November 2021 to February 2022, and were asked about health behaviors, aspects of their neighborhood, and home address (to link to census tract and corresponding social deprivation index [SDI] data). Logistic regression models were used to assess the relation of neighborhood factors with the likelihood of engaging in cardioprotective behaviors: 1) a composite of healthy lifestyle behaviors [fruit and vegetable consumption, physical activity, and a tobacco/nicotine-free lifestyle], 2) medication adherence, and 3) receipt of routine medical care within the past year.

RESULTS

Participants (n = 302, mean age: 63 years, 77% female, 99% Black) were recruited from 12 churches in New Orleans. After adjusting for demographic and clinical factors, perceived neighborhood walkability or conduciveness to exercise (odds ratio [OR]=1.25; 95% CI: 1.03, 1.53), availability of fruits and vegetables (OR=1.23; 95% CI: 1.07, 1.42), and social cohesion (OR=1.55; 95% CI: 1.22, 1.97) were positively associated with the composite of healthy lifestyle behaviors. After multivariable adjustment, SDI was in the direction of association with all three cardioprotective behavior outcomes, but associations were not statistically significant.

CONCLUSIONS

In this predominantly Black, church-based population, neighborhood-level SDoH including the availability of fruits and vegetables, walkability or conduciveness to exercise, and social cohesion were associated with cardioprotective behaviors. Findings reiterate the need to address adverse neighborhood-level SDoH in the design and implementation of health interventions.

Neighborhood built environment, obesity, and diabetes: A Utah siblings study

Background

This study utilizes innovative computer vision methods alongside Google Street View images to characterize neighborhood built environments across Utah.

Methods

Convolutional Neural Networks were used to create indicators of street greenness, crosswalks, and building type on 1.4 million Google Street View images. The demographic and medical profiles of Utah residents came from the Utah Population Database (UPDB). We implemented hierarchical linear models with individuals nested within zip codes to estimate associations between neighborhood built environment features and individual-level obesity and diabetes, controlling for individual- and zip code-level characteristics (n = 1,899,175 adults living in Utah in 2015). Sibling random effects models were implemented to account for shared family attributes among siblings (n = 972,150) and twins (n = 14,122).

Results

Consistent with prior neighborhood research, the variance partition coefficients (VPC) of our unadjusted models nesting individuals within zip codes were relatively small (0.5%-5.3%), except for HbA1c (VPC = 23%), suggesting a small percentage of the outcome variance is at the zip code-level. However, proportional change in variance (PCV) attributable to zip codes after the inclusion of neighborhood built environment variables and covariates ranged between 11% and 67%, suggesting that these characteristics account for a substantial portion of the zip code-level effects. Non-single-family homes (indicator of mixed land use), sidewalks (indicator of walkability), and green streets (indicator of neighborhood aesthetics) were associated with reduced diabetes and obesity. Zip codes in the third tertile for non-single-family homes were associated with a 15% reduction (PR: 0.85; 95% CI: 0.79, 0.91) in obesity and a 20% reduction (PR: 0.80; 95% CI: 0.70, 0.91) in diabetes. This tertile was also associated with a BMI reduction of -0.68 kg/m2 (95% CI: -0.95, -0.40).

Conclusion

We observe associations between neighborhood characteristics and chronic diseases, accounting for biological, social, and cultural factors shared among siblings in this large population-based study.

Neighborhood Access to the Built Environment and Allostatic Load: A Systematic Review of the Use of Geographic Information Systems

Objectives: This paper systematically reviews how spatial analysis has been used to measure relationships between access to the built environment and Allostatic Load (AL) or biomarkers relevant to the stress pathway. Geographic Information Systems (GIS) facilitate objective measurement of built environment access that may explain unequal health outcomes linked to living in stressful environments. Methods: Systematic review, search date 13 July 2022 with methods published a priori. Included studies that quantitatively assessed associations between GIS measures of neighborhood attributes and biomarkers of stress. Results: 23 studies from 14 countries were included having used GIS measures to assess relationships between access to the built environment and biomarkers relevant to AL, with 17 being cross-sectional and 6 longitudinal. Just 2 studies explicitly assessed associations between GIS measures and AL, but 21 explored biomarkers relevant to the stress pathway. GIS was used to calculate density (how much of x within y) and proximity (how far from a to b) measures. Conclusion: GIS measures of greenspace, the food environment, area-level demographics, and land-use measures were found to influence biomarkers relevant to the stress pathway, highlighting the utility of this approach. GIS use is extremely limited when measuring the built environment and its influence on AL but has been widely used to consider effects on individual biomarkers of stress. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=348355], identifier [CRD42022348355].

Effect of Lockdown Period of COVID-19 Pandemic on Maternal Weight Gain, Gestational Diabetes, and Newborn Birth Weight

OBJECTIVE

This study aimed to determine whether the lockdown period of the initial novel coronavirus disease 2019 (COVID-19) surge in New York affected gestational weight gain (GWG), newborn birth weight (BW), and the frequency of gestational diabetes mellitus (GDM). Maternal and newborn outcomes during the first wave of the pandemic were compared with those during the same timeframe in the previous 2 years.

STUDY DESIGN

Retrospective cross-sectional study of all live singleton term deliveries from April 1 to July 31 between 2018 and 2020 at seven hospitals within a large academic health system in New York. Patients were excluded for missing data on: BW, GWG, prepregnancy body mass index, and gestational age at delivery. We compared GWG, GDM, and BW during the pandemic period (April-July 2020) with the same months in 2018 and 2019 (prepandemic) to account for seasonality. Linear regression was used to model the continuous outcomes of GWG and BW. Logistic regression was used to model the binary outcome of GDM.

RESULTS

A total of 20,548 patients were included in the study: 6,672 delivered during the pandemic period and 13,876 delivered during the prepandemic period. On regression analysis, after adjustment for study epoch and patient characteristics, the pandemic period was associated with lower GWG (β = -0.46, 95% confidence interval [CI]: -0.87 to -0.05), more GDM (adjusted odds ratio [aOR] = 1.24, 95% CI: 1.10-1.39), and no change in newborn BW (β = 0.03, 95% CI: -11.7 to 11.8) compared with the referent period. The largest increases in GDM between the two study epochs were noted in patients who identified as Hispanic (8.6 vs. 6.0%; p < 0.005) and multiracial/other (11.8 vs. 7.0%; p < 0.001).

CONCLUSION

The lockdown period of the pandemic was associated with a decrease in GWG and increase in GDM. Not all groups were affected equally. Hispanic and multiracial patients experienced a larger percentage change in GDM compared with non-Hispanic white patients.

KEY POINTS

· The COVID-19 lockdown was associated with decreased GWG and increased GDM.. · No change in newborn BW was seen during the lockdown.. · Overall, the lockdown did not have a large clinical effect on these pregnancy outcomes..

Identification of Spatial Clusters of Undervaccination Patterns Among Children Aged <24 Months Using Immunization Information System Data, Montana, 2015-2019

OBJECTIVE

Spatial clustering of undervaccination leads to increased risk of vaccine-preventable diseases. We identified spatial clustering of undervaccination patterns among children aged <24 months in Montana.

METHODS

We used Montana's immunization information system data to analyze deidentified vaccination records of children aged <24 months born from January 2015 through November 2017. We measured 3 outcomes that were not mutually exclusive: not completing the combined 7-vaccine series by age 24 months, having an undervaccination pattern indicative of parental hesitancy, and having an undervaccination pattern indicative of structural barriers to timely vaccination. Using geomasked residential addresses, we conducted separate Bernoulli spatial scans with a randomization P < .01 to identify spatial clusters consisting of ≥100 children for each outcome and calculated the relative risk of having the undervaccination pattern inside versus outside the cluster.

RESULTS

Of 31 201 children aged <24 months included in our study, 11 712 (37.5%) had not completed the combined 7-vaccine series by age 24 months, and we identified 5 spatial clusters of this outcome across Montana. We identified 4 clusters of undervaccination patterns indicative of parental vaccine hesitancy, all in western Montana. The cluster with the largest relative risk (2.3) had a radius of 23.7 kilometers (n = 762 children, P < .001). We also identified 4 clusters of undervaccination patterns indicative of structural barriers, with 3 of the largest clusters in eastern Montana.

CONCLUSION

In Montana, different strategies to increase routine and timely childhood vaccination are needed in distinct areas of this large and predominantly rural state. Immunization information system data can pinpoint areas where interventions to increase vaccination uptake are needed.

Serious Mental Illness, Glycemic Control, and Neighborhood Factors within an Urban Diabetes Cohort

BACKGROUND AND HYPOTHESIS

Serious mental illness (SMI) may compromise diabetes self-management. This study assessed the association between SMI and glycemic control, and explored sociodemographic predictors and geographic clustering of this outcome among patients with and without SMI.

STUDY DESIGN

We used electronic health record data for adult primary care patients with diabetes from 2 San Francisco health care delivery systems. The primary outcome was poor glycemic control (hemoglobin A1c >9.0%), which was modeled on SMI diagnosis status and sociodemographics. Geospatial analyses examined hotspots of poor glycemic control and neighborhood characteristics.

STUDY RESULTS

The study included 11 694 participants with diabetes, 21% with comorbid SMI, of whom 22% had a schizophrenia spectrum or bipolar disorder. Median age was 62 years; 52% were female and 79% were Asian, Black, or Hispanic. In adjusted models, having schizophrenia spectrum disorder or bipolar disorder was associated with greater risk for poor glycemic control (vs participants without SMI, adjusted relative risk [aRR] = 1.24; 95% confidence interval, 1.02, 1.49), but having broadly defined SMI was not. People with and without SMI had similar sociodemographic correlates of poor glycemic control including younger versus older age, Hispanic versus non-Hispanic White race/ethnicity, and English versus Chinese language preference. Hotspots for poor glycemic control were found in neighborhoods with more lower-income, Hispanic, and Black residents.

CONCLUSIONS

Poor diabetes control was significantly related to having a schizophrenia spectrum or bipolar disorder, and to sociodemographic factors and neighborhood. Community-based mental health clinics in hotspots could be targets for implementation of diabetes management services.

Neighbourhood deprivation and type 2 diabetes in patients with bipolar disorder: A nationwide follow-up study

Patients with bipolar disorder have higher rates of type 2 diabetes (T2D) compared to the general population. Neighbourhood deprivation is associated with T2D and bipolar disorder. The aim of this study was to explore the potential effect of neighbourhood deprivation on incident T2D in patients with bipolar disorder. This nationwide open cohort study (1997-2018) included adults in Sweden ≥20 years with bipolar disorder (90,780 patients) to examine the subsequent risk of T2D. The association between neighbourhood deprivation and T2D was explored using Cox regression analysis, with hazard ratios (HRs) and 95% confidence intervals (95% CIs). All models were conducted in both men and women and adjusted for individual-level sociodemographic factors and comorbidities. Neighbourhood deprivation was significantly associated with T2D in patients with bipolar disorder. The HRs were 1.61 (95% CI 1.40-1.86) for men and 1.83 (1.60-2.10) for women living in high deprivation neighbourhoods compared to those from low deprivation neighbourhoods. After adjustment, these results remained significant: 1.35 (1.17-1.56) in men and 1.39 (1.20-1.60) in women living in high deprivation neighbourhoods. The suggested graded association of higher incident T2D among patients with bipolar disorder, observed when levels of neighbourhood deprivation increased, raises important clinical and public health concerns. The results may help develop a contextual approach to prevention of T2D in patients with bipolar disorder that includes the neighbourhood environment.

Contribution of environmental determinants to the risk of developing type 2 diabetes mellitus in a life-course perspective: a systematic review protocol

BACKGROUND

Prevention policies against type 2 diabetes mellitus (T2DM) focus solely on individual healthy lifestyle behaviours, while an increasing body of research recognises the involvement of environmental determinants (ED) (cultural norms of land management and planning, local foodscape, built environment, pollution, and neighbourhood deprivation). Precise knowledge of this relationship is essential to proposing a prevention strategy integrating public health and spatial planning. Unfortunately, issues related to the consistency and synthesis of methods, and results in this field of research limit the development of preventive strategies. This systematic review aims to improve knowledge about the relationship between the risk of developing T2DM in adulthood and long-term exposure to its ED during childhood or teenage years.

METHODS

This protocol is presented according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) tools. PubMed, Embase, CINAHL, Web of Science, EBSCO, and grey literature from the Laval University Libraries databases will be used for data collection on main concepts such as 'type 2 diabetes mellitus', 'zoning' or 'regional, urban, or rural areas land uses', 'local food landscape', 'built environment', 'pollution', and 'deprivation'. The Covidence application will store the collected data for selection and extraction based on the Population Exposure Comparator Outcome and Study design approach (PECOS). Studies published until December 31, 2023, in English or French, used quantitative data about individuals aged 18 and over that report on T2DM, ED (cultural norms of land management and planning, local foodscape, built environment, and neighbourhood deprivation), and their association (involving only risk estimators) will be included. Then, study quality and risk of bias will be conducted according to the combined criteria and ratings from the ROBINS-E (Risk of Bias in Non-randomised Studies-of Exposures) tools and the 'Effective Public Health Practice Project' (EPHPP). Finally, the analytical synthesis will be produced using the 'Synthesis Without Meta-analysis' (SWiM) guidelines.

DISCUSSION

This systematic review will summarise available evidence on ED associated with T2DM. The results will contribute to improving current knowledge and developing more efficient cross-sectoral interventions in land management and public health in this field of research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023392073.

Neighborhood Disadvantage and Risk of Heart Failure: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

BACKGROUND

Heart failure (HF) affects >6 million US adults, with recent increases in HF hospitalizations. We aimed to investigate the association between neighborhood disadvantage and incident HF events and potential differences by diabetes status.

METHODS

We included 23 645 participants from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), a prospective cohort of Black and White adults aged ≥45 years living in the continental United States (baseline 2005-2007). Neighborhood disadvantage was assessed using a Z score of 6 census tract variables (2000 US Census) and categorized as quartiles. Incident HF hospitalizations or HF-related deaths through 2017 were adjudicated. Multivariable-adjusted Cox regression was used to examine the association between neighborhood disadvantage and incident HF. Heterogeneity by diabetes was assessed using an interaction term.

RESULTS

The mean age was 64.4 years, 39.5% were Black adults, 54.9% females, and 18.8% had diabetes. During a median follow-up of 10.7 years, there were 1125 incident HF events with an incidence rate of 3.3 (quartile 1), 4.7 (quartile 2), 5.2 (quartile 3), and 6.0 (quartile 4) per 1000 person-years. Compared to adults living in the most advantaged neighborhoods (quartile 1), those living in neighborhoods in quartiles 2, 3, and 4 (most disadvantaged) had 1.30 (95% CI, 1.06-1.60), 1.36 (95% CI, 1.11-1.66), and 1.45 (95% CI, 1.18-1.79) times greater hazard of incident HF even after accounting for known confounders. This association did not significantly differ by diabetes status (interaction P=0.59). For adults with diabetes, the adjusted incident HF hazards comparing those in quartile 4 versus quartile 1 was 1.34 (95% CI, 0.92-1.96), and it was 1.50 (95% CI, 1.16-1.94) for adults without diabetes.

CONCLUSIONS

In this large contemporaneous prospective cohort, neighborhood disadvantage was associated with an increased risk of incident HF events. This increase in HF risk did not differ by diabetes status. Addressing social, economic, and structural factors at the neighborhood level may impact HF prevention.

Perceptions of diabetes risk and prevention in Nairobi, Kenya: A qualitative and theory of change development study

BACKGROUND

Type 2 diabetes is increasing in Kenya, especially in urban settings, and prevention interventions based on local evidence and context are urgently needed. Therefore, this study aimed to explore diabetes risk and co-create a diabetes prevention theory of change in two socioeconomically distinct communities to inform future diabetes prevention interventions.

METHODS

In-depth interviews were conducted with middle-aged residents in two communities in Nairobi (one low-income (n = 15), one middle-income (n = 14)), and thematically analysed. The theory of change for diabetes prevention was informed by analysis of the in-depth interviews and the Behaviour Change Wheel framework, and reviewed by a sub-set (n = 13) of interviewees.

RESULTS

The key factors that influenced diabetes preventive practices in both communities included knowledge and skills for diabetes prevention, understanding of the benefits/consequences of (un)healthy lifestyle, social influences (e.g., upbringing, societal perceptions), and environmental contexts (e.g., access to (un)healthy foods and physical activity facilities). The proposed strategies for diabetes prevention included: increasing knowledge and understanding about diabetes risk and preventive measures particularly in the low-income community; supporting lifestyle modification (e.g., upskilling, goal setting, action planning) in both communities; identifying people at high risk of diabetes through screening in both communities; and creating social and physical environments for lifestyle modification (e.g., positive social influences on healthy living, access to healthy foods and physical activity infrastructure) particularly in the low-income community. Residents from both communities agreed that the strategies were broadly feasible for diabetes prevention but proposed the addition of door-to-door campaigns and community theatre for health education. However, residents from the low-income community were concerned about the lack of government prioritisation for implementing population-level interventions, e.g., improving access to healthy foods and physical activity facilities/infrastructure.

CONCLUSION

Diabetes prevention initiatives in Kenya should involve multicomponent interventions for lifestyle modification including increasing education and upskilling at individual level; promoting social and physical environments that support healthy living at population level; and are particularly needed in low-income communities.

Community-level social determinants of health and pregestational and gestational diabetes

BACKGROUND

Individual adverse social determinants of health are associated with increased risk of diabetes in pregnancy, but the relative influence of neighborhood or community-level social determinants of health is unknown.

OBJECTIVE

This study aimed to determine whether living in neighborhoods with greater socioeconomic disadvantage, food deserts, or less walkability was associated with having pregestational diabetes and developing gestational diabetes.

STUDY DESIGN

We conducted a secondary analysis of the prospective Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be. Home addresses in the first trimester were geocoded at the census tract level. The exposures (modeled separately) were the following 3 neighborhood-level measures of adverse social determinants of health: (1) socioeconomic disadvantage, defined by the Area Deprivation Index and measured in tertiles from the lowest tertile (ie, least disadvantage [T1]) to the highest (ie, most disadvantage [T3]); (2) food desert, defined by the United States Department of Agriculture Food Access Research Atlas (yes/no by low income and low access criteria); and (3) less walkability, defined by the Environmental Protection Agency National Walkability Index (most walkable score [15.26-20.0] vs less walkable score [<15.26]). Multinomial logistic regression was used to model the odds of gestational diabetes or pregestational diabetes relative to no diabetes as the reference, adjusted for age at delivery, chronic hypertension, Medicaid insurance status, and low household income (<130% of the US poverty level).

RESULTS

Among the 9155 assessed individuals, the mean Area Deprivation Index score was 39.0 (interquartile range, 19.0-71.0), 37.0% lived in a food desert, and 41.0% lived in a less walkable neighborhood. The frequency of pregestational and gestational diabetes diagnosis was 1.5% and 4.2%, respectively. Individuals living in a community in the highest tertile of socioeconomic disadvantage had increased odds of entering pregnancy with pregestational diabetes compared with those in the lowest tertile (T3 vs T1: 2.6% vs 0.8%; adjusted odds ratio, 2.52; 95% confidence interval, 1.41-4.48). Individuals living in a food desert (4.8% vs 4.0%; adjusted odds ratio, 1.37; 95% confidence interval, 1.06-1.77) and in a less walkable neighborhood (4.4% vs 3.8%; adjusted odds ratio, 1.33; 95% confidence interval, 1.04-1.71) had increased odds of gestational diabetes. There was no significant association between living in a food desert or a less walkable neighborhood and pregestational diabetes, or between socioeconomic disadvantage and gestational diabetes.

CONCLUSION

Nulliparous individuals living in a neighborhood with higher socioeconomic disadvantage were at increased odds of entering pregnancy with pregestational diabetes, and those living in a food desert or a less walkable neighborhood were at increased odds of developing gestational diabetes, after controlling for known covariates.

Food environment trajectories: a sequence analysis from the CARTaGENE cohort

OBJECTIVE

The purpose of this study was to create a typology of longitudinal exposure to food environment based on socio-economic context.

DESIGN

Food environment trajectories were modelled using a sequence analysis method, followed by a logistic regression to describe those trajectories.

SETTING

The study took place in Quebec, Canada, using food environment data from 2009, 2011 and 2018 merged with participants' demographic and socio-economic characteristics.

PARTICIPANT

At recruitment, 38 627 participants between the ages of 40 and 69 years from six urban areas in Quebec were included in the CARTaGENE cohort study. The cohort was representative of the Quebec urban population within this age range.

RESULTS

Our study revealed five trajectories of food access over time: (1) limited access to food stores throughout the study period, (2) limited access improving, (3) good access diminishing, (4) good access throughout the period and (5) low access throughout the period. Logistic regression analysis showed that participants who were unable to work (OR = 1·42, CI = 1·08-1·86), lived in households with five or more persons (OR = 1·69, CI = 1·17-2·42) and those living in low-income households (OR = 1·32, CI = 1·03-1·71) had higher odds of experiencing a disadvantaged food environment trajectory. Additionally, the level of education and age of participants were associated with the odds of experiencing a disadvantaged food environment trajectory.

CONCLUSIONS

The study demonstrates that people facing socio-economic disadvantage are more likely to experience a disadvantaged food environment trajectory over time.

Availability and Accessibility of Healthy and Unhealthy Foods in Neighborhood and their Association with Noncommunicable Diseases: A Scoping Review

ABSTRACT

Worldwide, 7 million mortalities and 187.7 million morbidities have been associated with dietary risks. Poor diets emerge because of an obesogenic environment. However, clear evidence indicating an association between food environment and noncommunicable diseases (NCDs) is inconclusive. The present review was conducted to study the associations between the availability/accessibility of healthy/unhealthy foods and the risk of NCDs among adults of the age group above 18. Studies published between 2012 and 2022 were reterived using three databases - PubMed, Google Scholar, and Science Direct. Following Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), (2018) guidelines and based on the selection criteria, 3034 studies were retrieved, of which 64 were included in this review. Maximum studies were conducted in high-income countries and adopted a cross-sectional study design. Overall, the results of the review illustrate mixed findings. Compared to healthy food, direct associations between obesity and the availability/accessibility of unhealthy foods were reported (n = 12). In case of diabetes, supermarket availability was more likely to be protective (4 positive) compared to negative association with unhealthy food stores (3 associations in 11 studies). For cardiovascular diseases, an increased number of cases with fast-food outlets (n = 6) outnumbered positive associations with healthy food (n = 3). Studies concerning multiple NCDs reported direct association with unhealthy food outlets (n = 5) while inconclusive associations with healthy food. Despite a large number of studies, a weak, inconclusive relationship between food environment and NCDs was found. The use of standardized tools and longitudinal and interventional studies are warranted to rationalize the execution of the policies related to the food environment.

Biological Age Mediates the Effects of Perceived Neighborhood Problems on Heart Failure Risk Among Black Persons

OBJECTIVE

We assessed whether biological age, measured by the epigenetic clock GrimAge, mediates the association of objective and subjective neighborhood disadvantage with incident HF among Black persons.

METHODS

Participants were 1448 self-reported Black adults (mean age (standard deviation, SD) = 64.3 (5.5)) dually enrolled in two community-based cohorts in Jackson, Mississippi, the ARIC and JHS cohorts, who were free of HF as of January 1, 2000. Incident HF events leading to hospitalization through December 31, 2017, were classified using ICD-9 discharge codes of HF. Multilevel age- and sex-adjusted Cox causal mediation models were used to examine whether biological age (at the person and neighborhood level) mediated the effects of objective (the National Area Deprivation Index, ADI) and subjective (perceived neighborhood problems) neighborhood disadvantage on incident HF.

RESULTS

A total of 334 incident hospitalized HF events occurred over a median follow-up of 18.0 years. The total effect of the ADI and perceived neighborhood problems (SD units) on HF was hazard ration (HR) = 1.26 and 95% confidence interval (CI) 0.98-1.56 and HR = 1.26 and 95% CI 1.10-1.41, respectively. GrimAge mediated a majority of the effect of perceived neighborhood problems on HF (person-level indirect effect HR = 1.07; 95% CI 1.02-1.12 and neighborhood-level indirect effect HR = 1.18; 95% CI 1.03-1.34), with the combined indirect effect explaining 94.8% of the relationship. The combined indirect effect of ADI on incident HF was comparable but not statistically significant.

CONCLUSIONS

Subjective neighborhood disadvantage may confer an increased risk of HF among Black populations.

Health-Related Social Control and Perceived Stress Among High-Risk Latina Mothers with Type 2 Diabetes and Their At-Risk Adult Daughters

BACKGROUND

Diabetes-related multi-morbidity and cultural factors place Latinas with diabetes at increased risk for stress, which can threaten illness management. Families provide an ideal focus for interventions that seek to strengthen interpersonal resources for illness management and, in the process, to reduce stress. The current study sought to examine whether participating in a dyadic intervention was associated with reduced perceived stress and, furthermore, whether this association was mediated by persuasion and pressure, two forms of health-related social control.

METHOD

Latina mothers with diabetes and their at-risk adult daughters participated in either (1) a dyadic intervention that encouraged constructive collaboration to improve health behaviors and reduce stress, or (2) a usual-care minimal control condition. Actor-partner interdependence model analysis was used to estimate the effect of the intervention on dyads' perceived stress, and mother-daughter ratings of health-related social control as potential mediators.

RESULTS

Results revealed that participating in the intervention was associated with significantly reduced perceived stress for daughters, but not for mothers (β =  - 3.00, p = 0.02; β =  - 0.57, p = 0.67, respectively). Analyses also indicated that the association between the intervention and perceived stress was mediated by persuasion, such that mothers' who experienced more health-related persuasion exhibited significantly less post-intervention perceived stress (indirect effect =  - 1.52, 95% CI = [- 3.12, - 0.39]). Pressure exerted by others, however, did not evidence a mediating mechanism for either mothers or daughters.

CONCLUSION

These findings buttress existing research suggesting that persuasion, or others' attempts to increase participants' healthy behaviors in an uncritical way, may be a driving force in reducing perceived stress levels.

Age and sex differences in the association between neighborhood socioeconomic environment and incident diabetes: Results from the diabetes location, environmental attributes and disparities (LEAD) network

Objective

Worse neighborhood socioeconomic environment (NSEE) may contribute to an increased risk of type 2 diabetes (T2D). We examined whether the relationship between NSEE and T2D differs by sex and age in three study populations.

Research design and methods

We conducted a harmonized analysis using data from three independent longitudinal study samples in the US: 1) the Veteran Administration Diabetes Risk (VADR) cohort, 2) the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, and 3) a case-control study of Geisinger electronic health records in Pennsylvania. We measured NSEE with a z-score sum of six census tract indicators within strata of community type (higher density urban, lower density urban, suburban/small town, and rural). Community type-stratified models evaluated the likelihood of new diagnoses of T2D in each study sample using restricted cubic splines and quartiles of NSEE.

Results

Across study samples, worse NSEE was associated with higher risk of T2D. We observed significant effect modification by sex and age, though evidence of effect modification varied by site and community type. Largely, stronger associations between worse NSEE and diabetes risk were found among women relative to men and among those less than age 45 in the VADR cohort. Similar modification by age group results were observed in the Geisinger sample in small town/suburban communities only and similar modification by sex was observed in REGARDS in lower density urban communities.

Conclusions

The impact of NSEE on T2D risk may differ for males and females and by age group within different community types.

The role of neighborhood inequalities on diabetes prevention care: a mini-review

An emerging research niche has focused on the link between social determinants of health and diabetes mellitus, one of the most prevalent non-communicable diseases in modern society. The aim of the present mini-review is to explore and summarize current findings in this field targeting high-income countries. In the presence of disadvantaged neighborhood factors (including socioeconomic status, food environment, walkability and neighborhood aesthetics), diabetes prevention and care are affected at a multidimensional level. The vast majority of the included studies suggest that, besides individual risk factors, aggregated neighborhood inequalities should be tackled to implement effective evidence-based policies for diabetes mellitus.

Racial and Ethnic Residential Segregation and Monocyte DNA Methylation Age Acceleration

Importance

Neighborhood segregation and poverty may be important drivers of health inequities. Epigenomic factors, including DNA methylation clocks that may mark underlying biological aging, have been implicated in the link between social factors and health.

Objective

To examine the associations of neighborhood segregation and poverty with 4 DNA methylation clocks trained to capture either chronological age or physiological dysregulation.

Design, Setting, and Participants

This cohort study uses data from the Multi-Ethnic Study of Atherosclerosis (MESA), a longitudinal study that started in 2000 to 2002, with follow-up in 2002 to 2004, 2004 to 2005, 2005 to 2007, and 2010 to 2012. In 2000 to 2002, adults who identified as White or Black race or Hispanic or Chinese ethnicity in 6 US sites (Baltimore, Maryland; Chicago, Illinois; Forsyth County, North Carolina; Los Angeles County, California; Northern Manhattan, New York; and St. Paul, Minnesota) were sampled for recruitment. A random subsample of 4 sites (Maryland, North Carolina, New York, and Minnesota) were selected for inclusion in the MESA epigenomics ancillary study at examination 5 (2010-2012). Participants who identified as White or Black race or Hispanic ethnicity, were aged 45 to 84 years, and did not have clinical cardiovascular disease were included in this analysis. Data were analyzed from May 2021 to October 2023.

Exposure

Information on 2000 census tract poverty and Getis-Ord G statistic segregation of Hispanic residents, non-Hispanic Black residents, or non-Hispanic White residents were linked to participant addresses at examination 1 (2000-2002).

Main Outcomes and Measures

At examination 5, DNA methylation was measured in purified monocytes. DNA methylation age acceleration was calculated using 4 clocks trained on either chronological age or physiological dysregulation. Linear regressions were used to test associations.

Results

A total of 1102 participants (mean [SD] age, 69.7 [9.4] years; 562 [51%] women) were included, with 348 Hispanic participants, 222 non-Hispanic Black participants, and 533 non-Hispanic White participants. For non-Hispanic Black participants, living in tracts with greater segregation of Black residents was associated with GrimAge DNA methylation age acceleration, a clock designed to capture physiological dysregulation. A 1-SD increase in segregation was associated with 0.42 (95% CI, 0.20-0.64) years age acceleration (P < .001); this association was not observed with other clocks. This association was particularly pronounced for participants living in high poverty tracts (interaction term, 0.24; 95% CI, 0.07-0.42; P = .006). In the overall sample, census tract poverty level was associated with GrimAge DNA methylation age acceleration (β = 0.45; 95% CI, 0.20-0.71; adjusted P = .005).

Conclusions and Relevance

These findings suggest that epigenomic mechanisms may play a role in the associations of segregated and poor neighborhoods with chronic conditions.

[Vulnerability and social determinants in diabetes]

Social determinants of health significantly influence the development and progression of chronic diseases such as type2 diabetes (T2DM). This article examines key social determinants including education, economic stability, neighborhood, and factors such as ethnicity, race, or religion that impact individuals with T2DM. The role of gender as a social determinant is also explored, emphasizing the need for gender-specific considerations in T2DM management and research. Additionally, the impact of poverty on health outcomes is analyzed, highlighting the bidirectional relationship between poverty and disease. Comprehensive measures addressing these determinants are crucial to improving the health and well-being of individuals with T2DM. Addressing social inequalities through targeted interventions can contribute to better treatment outcomes and equitable healthcare.

Traveling Together: A Road Map for Researching Neighborhood Effects on Population Health and Health Inequities

As evidence of the relationship between place and health mounts, more epidemiologists and clinical science researchers are becoming interested in incorporating place-based measures and analyses into their examination of population health and health inequities. Given the extensive literature on place and health, it can be challenging for researchers new to this area to develop neighborhood-effects research questions and apply the appropriate measures and methods. This paper provides a road map for guiding health researchers through the conceptual and methodological stages of incorporating various dimensions of place into their quantitative health research. Synthesizing across reviews, commentaries, and empirical investigations, the road map consists of 4 broad stages for considering place and health: 1) why?: articulating the motivation for assessing place and health and grounding the motivation in theory; 2) what?: identifying the relevant place-based characteristics and specifying their link to health to build a conceptual framework; 3) how?: determining how to operationalize the conceptual framework by defining, measuring, and assessing place-based characteristics and quantifying their effect on health; and 4) now what?: discussing the implications of neighborhood research findings for future research, policy, and practice. This road map supports efforts to develop conceptually and analytically rigorous neighborhood research projects.

Racial and Ethnic Inequities in Development of Type 2 Diabetes After Gestational Diabetes Mellitus

OBJECTIVE

To estimate racial and ethnic disparities in type 2 diabetes mellitus after gestational diabetes mellitus (GDM) and to investigate baseline pregnancy clinical and social or structural characteristics as mediators.

METHODS

We conducted a retrospective cohort of individuals with GDM using linked 2009-2011 New York City birth and hospital data and 2009-2017 New York City A1c Registry data. We ascertained GDM and pregnancy characteristics from birth and hospital records. We classified type 2 diabetes as two hemoglobin A 1c test results of 6.5% or higher. We grouped pregnancy characteristics into clinical (body mass index [BMI], chronic hypertension, gestational hypertension, preeclampsia, preterm delivery, caesarean, breastfeeding, macrosomia, shoulder dystocia) and social or structural (education, Medicaid insurance, prenatal care, and WIC [Special Supplemental Nutrition Program for Women, Infants, and Children] participation). We used Cox proportional hazards models to estimate associations between race and ethnicity and 8-year type 2 diabetes incidence, and we tested mediation of pregnancy characteristics, additionally adjusting for age and nativity (U.S.-born vs foreign-born).

RESULTS

The analytic data set included 22,338 patients with GDM. The 8-year type 2 diabetes incidence was 11.7% overall and 18.5% in Black, 16.8% in South and Southeast Asian, 14.6% in Hispanic, 5.5% in East and Central Asian, and 5.4% in White individuals with adjusted hazard ratios of 4.0 (95% CI 2.4-3.9), 2.9 (95% CI 2.4-3.3), 3.3 (95% CI 2.7-4.2), and 1.0 (95% CI 0.9-1.4) for each group compared with White individuals. Clinical and social or structural pregnancy characteristics explained 9.3% and 23.8% of Black, 31.2% and 24.7% of Hispanic, and 7.6% and 16.3% of South and Southeast Asian compared with White disparities. Associations between education, Medicaid insurance, WIC participation, and BMI and type 2 diabetes incidence were more pronounced among White than Black, Hispanic, and South and Southeast Asian individuals.

CONCLUSION

Population-based racial and ethnic inequities are substantial in type 2 diabetes after GDM. Characteristics at the time of delivery partially explain disparities, creating an opportunity to intervene on life-course cardiometabolic inequities, whereas weak associations of common social or structural measures and BMI in Black, Hispanic and South and Southeast Asian individuals demonstrate the need for greater understanding of how structural racism influences postpartum cardiometabolic risk in these groups.

Social Determinants of Health Data Improve the Prediction of Cardiac Outcomes in Females with Breast Cancer

Cardiovascular disease is the leading cause of mortality among breast cancer (BC) patients aged 50 and above. Machine Learning (ML) models are increasingly utilized as prediction tools, and recent evidence suggests that incorporating social determinants of health (SDOH) data can enhance its performance. This study included females ≥ 18 years diagnosed with BC at any stage. The outcomes were the diagnosis and time-to-event of major adverse cardiovascular events (MACEs) within two years following a cancer diagnosis. Covariates encompassed demographics, risk factors, individual and neighborhood-level SDOH, tumor characteristics, and BC treatment. Race-specific and race-agnostic Extreme Gradient Boosting ML models with and without SDOH data were developed and compared based on their C-index. Among 4309 patients, 11.4% experienced a 2-year MACE. The race-agnostic models exhibited a C-index of 0.78 (95% CI 0.76-0.79) and 0.81 (95% CI 0.80-0.82) without and with SDOH data, respectively. In non-Hispanic Black women (NHB; n = 765), models without and with SDOH data achieved a C-index of 0.74 (95% CI 0.72-0.76) and 0.75 (95% CI 0.73-0.78), respectively. Among non-Hispanic White women (n = 3321), models without and with SDOH data yielded a C-index of 0.79 (95% CI 0.77-0.80) and 0.79 (95% CI 0.77-0.80), respectively. In summary, including SDOH data improves the predictive performance of ML models in forecasting 2-year MACE among BC females, particularly within NHB.

Association of Unfavorable Social Determinants of Health With Stroke/Transient Ischemic Attack and Vascular Risk Factors in Hispanic/Latino Adults: Results From Hispanic Community Health Study/Study of Latinos

BACKGROUND AND PURPOSE

Social determinants of health (SDOH) are non-medical factors that may contribute to the development of diseases, with a higher representation in underserved populations. Our objective is to determine the association of unfavorable SDOH with self-reported stroke/transient ischemic attack (TIA) and vascular risk factors (VRFs) among Hispanic/Latino adults living in the US.

METHODS

We used cross-sectional data from the Hispanic Community Health Study/Study of Latinos. SDOH and VRFs were assessed using questionnaires and validated scales and measurements. We investigated the association between the SDOH (individually and as count: ≤1, 2, 3, 4, or ≥5 SDOH), VRFs and stroke/TIA using regression analyses.

RESULTS

For individuals with stroke/TIA (n=388), the mean age (58.9 years) differed from those without stroke/TIA (n=11,210; 46.8 years; P<0.0001). In bivariate analysis, income <$20,000, education less than high school, no health insurance, perceived discrimination, not currently employed, upper tertile for chronic stress, and lower tertiles for social support and language- and social-based acculturation were associated with stroke/TIA and retained further. A higher number of SDOH was directly associated with all individual VRFs investigated, except for at-risk alcohol, and with number of VRFs (β=0.11, 95% confidence interval [CI]=0.09-0.14). In the fully adjusted model, income, discrimination, social support, chronic stress, and employment status were individually associated with stroke/TIA; the odds of stroke/TIA were 2.3 times higher in individuals with 3 SDOH (95% CI 1.6-3.2) and 2.7 times (95% CI 1.9-3.7) for those with ≥5 versus ≤1 SDOH.

CONCLUSION

Among Hispanic/Latino adults, a higher number of SDOH is associated with increased odds for stroke/TIA and VRFs. The association remained significant after adjustment for VRFs, suggesting involvement of non-vascular mechanisms.

Geographic disparities in access to liver transplantation

Since the Final Rule regarding transplantation was published in 1999, organ distribution policies have been implemented to reduce geographic disparity. While a recent change in liver allocation, termed acuity circles, eliminated the donor service area as a unit of distribution to decrease the geographic disparity of waitlisted patients to liver transplantation, recently published results highlight the complexity of addressing geographic disparity. From geographic variation in donor supply, as well as liver disease burden and differing model for end-stage liver disease (MELD) scores of candidates and MELD scores necessary to receive liver transplantation, to the urban-rural disparity in specialty care access, and to neighborhood deprivation (community measure of socioeconomic status) in liver transplant access, addressing disparities of access will require a multipronged approach at the patient, transplant center, and national level. Herein, we review the current knowledge of these disparities-from variation in larger (regional) to smaller (census tract or zip code) levels to the common etiologies of liver disease, which are particularly affected by these geographic boundaries. The geographic disparity in liver transplant access must balance the limited organ supply with the growing demand. We must identify patient-level factors that contribute to their geographic disparity and incorporate these findings at the transplant center level to develop targeted interventions. We must simultaneously work at the national level to standardize and share patient data (including socioeconomic status and geographic social deprivation indices) to better understand the factors that contribute to the geographic disparity. The complex interplay between organ distribution policy, referral patterns, and variable waitlisting practices with the proportion of high MELD patients and differences in potential donor supply must all be considered to create a national policy strategy to address the inequities in the system.

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

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

Impact of Neighborhood on Cardiovascular Health: A Contemporary Narrative Review

PURPOSE OF REVIEW

This review summarizes approaches towards neighborhood characterization in relation to cardiovascular health; contemporary investigations relating neighborhood factors to cardiovascular risk and disease; and initiatives to support community-based interventions to address neighborhood-based social determinants related to cardiovascular health.

RECENT FINDINGS

Neighborhoods may be characterized by Census-derived measures, geospatial data, historical databases, and metrics that incorporate data from electronic medical records and health information exchange databases. Current research has examined neighborhood determinants spanning racial segregation, access to healthcare and food, educational opportunities, physical and built environment, and social environment, and their relations to cardiovascular health and associated outcomes. Community-based interventions have potential to alleviate health disparities but remain limited by implementation challenges. Consideration of neighborhood context is essential in the design of interventions to prevent cardiovascular disease (CVD) and promote health equity. Partnership with community stakeholders may enhance implementation of programs addressing neighborhood-based health determinants.

Neighborhood-Level Risk Factors for Severe Hyperglycemia among Emergency Department Patients without a Prior Diabetes Diagnosis

A person's place of residence is a strong risk factor for important diagnosed chronic diseases such as diabetes. It is unclear whether neighborhood-level risk factors also predict the probability of undiagnosed disease. The objective of this study was to identify neighborhood-level variables associated with severe hyperglycemia among emergency department (ED) patients without a history of diabetes. We analyzed patients without previously diagnosed diabetes for whom a random serum glucose value was obtained in the ED. We defined random glucose values ≥ 200 mg/dL as severe hyperglycemia, indicating probable undiagnosed diabetes. Patient addresses were geocoded and matched with neighborhood-level socioeconomic measures from the American Community Survey and claims-based surveillance estimates of diabetes prevalence. Neighborhood-level exposure variables were standardized based on z-scores, and a series of logistic regression models were used to assess the association of selected exposures and hyperglycemia adjusting for biological and social individual-level risk factors for diabetes. Of 77,882 ED patients without a history of diabetes presenting in 2021, 1,715 (2.2%) had severe hyperglycemia. Many geospatial exposures were associated with uncontrolled hyperglycemia, even after controlling for individual-level risk factors. The most strongly associated neighborhood-level variables included lower markers of educational attainment, higher percentage of households where limited English is spoken, lower rates of white-collar employment, and higher rates of Medicaid insurance. Including these geospatial factors in risk assessment models may help identify important subgroups of patients with undiagnosed disease.

The Growing Role of Technology in the Care of Older Adults With Diabetes

The integration of technologies such as continuous glucose monitors, insulin pumps, and smart pens into diabetes management has the potential to support the transformation of health care services that provide a higher quality of diabetes care, lower costs and administrative burdens, and greater empowerment for people with diabetes and their caregivers. Among people with diabetes, older adults are a distinct subpopulation in terms of their clinical heterogeneity, care priorities, and technology integration. The scientific evidence and clinical experience with these technologies among older adults are growing but are still modest. In this review, we describe the current knowledge regarding the impact of technology in older adults with diabetes, identify major barriers to the use of existing and emerging technologies, describe areas of care that could be optimized by technology, and identify areas for future research to fulfill the potential promise of evidence-based technology integrated into care for this important population.

Association of neighborhood physical activity facilities with incident cardiovascular disease

BACKGROUND

The availability of physical activity (PA) facilities in neighborhoods is hypothesized to influence cardiovascular disease (CVD), but evidence from individual-level long-term cohort studies is limited. We aimed to assess the association between neighborhood exposure to PA facilities and CVD incidence.

METHODS

A total of 4658 participants from the Chinese Multi-provincial Cohort Study without CVD at baseline (2007-2008) were followed for the incidence of CVD, coronary heart disease (CHD), and stroke. Availability of PA facilities was defined as both the presence and the density of PA facilities within a 500-m buffer zone around the participants' residential addresses. Time-dependent Cox regression models were performed to estimate the associations between the availability of PA facilities and risks of incident CVD, CHD, and stroke.

RESULTS

During a median follow-up of 12.1 years, there were 518 CVD events, 188 CHD events, and 355 stroke events. Analyses with the presence indicator revealed significantly lower risks of CVD (hazard ratio [HR] 0.80, 95% confidence interval ([CI] 0.65-0.99) and stroke (HR 0.76, 95% CI 0.60-0.97) in participants with PA facilities in the 500-m buffer zone compared with participants with no nearby facilities in fully adjusted models. In analyses with the density indicator, exposure to 2 and ≥ 3 PA facilities was associated with 35% (HR 0.65, 95% CI 0.47-0.91) and 28% (HR 0.72, 95% CI 0.56-0.92) lower risks of CVD and 40% (HR 0.60, 95% CI 0.40-0.90) and 38% (HR 0.62, 95% CI 0.46-0.84) lower risks of stroke compared with those without any PA facilities in 500-m buffer, respectively. Effect modifications between presence of PA facilities and a history of hypertension for incident stroke (P = 0.049), and a history of diabetes for incident CVD (P = 0.013) and stroke (P = 0.009) were noted.

CONCLUSIONS

Residing in neighborhoods with better availability of PA facilities was associated with a lower risk of incident CVD. Urban planning intervention policies that increase the availability of PA facilities could contribute to CVD prevention.

Socioeconomic status may affect association of vegetable intake with risk of ischemic cardio-cerebral vascular disease: a Mendelian randomization study

Background

Previous studies found that increasing vegetable intake benefits are reduced after adjustment for socioeconomic factors. Using genetic variation as an instrumental variable for vegetable intake and socioeconomic status, we investigated the relationship between vegetable intake and ischemic cardio-cerebral vascular diseases and focused on whether socioeconomic status was a possible confounder.

Methods

From three independent genome-wide association studies, we extracted instrumental variables reflecting raw and cooked vegetable intake, which were used to perform Mendelian randomization analysis. To evaluate the effects of socioeconomic factors on vegetable intake, univariate and multivariate Mendelian randomization analyses were performed using single nucleotide polymorphisms representing education attainment and household income reported in the literature. We also performed outlier assessment and a series of sensitivity analyses to confirm the results.

Results

Genetically predicted raw and cooked vegetable intake were not associated with any ischemic cardio-cerebral vascular diseases and lipid components after Bonferroni correction. Univariate Mendelian randomized analysis revealed that raw vegetable intake was positively correlated with education attainment (β = 0.04, p = 0.029) and household income (β = 0.07, p < 0.001). Multivariate Mendelian randomized model showed a positive correlation between household income and raw vegetable intake (β = 0.06, p = 0.004). Socioeconomic status was closely associated with eating habits and lifestyle related to the risk of cardiovascular diseases.

Conclusion

Genetically determined raw and cooked vegetable intake was not associated with significant benefits in terms of ischemic cardio-cerebral vascular diseases while genetically determined socioeconomic status may have an impact on vegetable intake. Socioeconomic status, which was closely associated with other eating habits and lifestyle, may affect the association between vegetable intake and ischemic cardio-cerebral vascular diseases.

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

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

Virtual Learning and Youth-Onset Type 2 Diabetes during the COVID-19 Pandemic

INTRODUCTION

Cases and severity of presentation of youth-onset type 2 diabetes (Y-T2D) increased during the COVID-19 pandemic, yet the potential drivers of this rise remain unknown. During this time public health mandates paused in-person education and limited social interactions, resulting in radical lifestyle changes. We hypothesized that the incidence and severity of presentation of Y-T2D increased during virtual learning amidst the COVID-19 pandemic.

MATERIALS AND METHODS

We conducted a single-center retrospective chart review to identify all newly diagnosed cases of Y-T2D (n = 387) at a pediatric tertiary care center in Washington, DC during three predetermined learning periods as defined by learning modality in Washington, DC Public Schools: pre-pandemic in-person learning (March 11, 2018-March 13, 2020), pandemic virtual learning (March 14, 2020-August 29, 2021), and pandemic in-person learning (August 30, 2021-March 10, 2022) periods.

RESULTS

Incident cases were stable during pre-pandemic in-person learning (3.9 cases/month, 95% CI: 2.8-5.4 cases/month), increased to a peak during virtual learning (18.7 cases/month, 95% CI: 15.9-22.1 cases/month), and declined with return to in-person learning (4.3 cases/month, 95% CI: 2.8-6.8 cases/month). Y-T2D incidence was 16.9 (95% CI: 9.8-29.1, p < 0.001) and 5.1-fold higher (95% CI: 2.9-9.1, p < 0.001) among non-Hispanic Black and Latinx youth, respectively, throughout the study period. Overall COVID-19 infection rates at diagnosis were low (2.5%) and were not associated with diabetes incidence (p = 0.26).

CONCLUSIONS

This study provides timely insights into an important and modifiable correlate of Y-T2D incidence, its disproportionate impact on underserved communities, and the need to consider the effects on long-term health outcomes and preexisting healthcare inequities when designing public policy.

Ferroptosis and Traditional Chinese Medicine for Type 2 Diabetes Mellitus

Ferroptosis, an emerging form of regulated programmed cell death, has garnered significant attention in the past decade. It is characterized by the accumulation of lipid peroxides and subsequent damage to cellular membranes, which is dependent on iron. Ferroptosis has been implicated in the pathogenesis of various diseases, including tumors and diabetes mellitus. Traditional Chinese medicine (TCM) has unique advantages in preventing and treating type 2 diabetes mellitus (T2DM) due to its anti-inflammatory, antioxidant, immunomodulatory, and intestinal flora-regulating functions. Recent studies have determined that TCM may exert therapeutic effects on T2DM and its complications by modulating the ferroptosis-related pathways. Therefore, a comprehensive and systematic understanding of the role of ferroptosis in the pathogenesis and TCM treatment of T2DM is of great significance for developing therapeutic drugs for T2DM and enriching the spectrum of effective T2DM treatment with TCM. In this review, we review the concept, mechanism, and regulatory pathways of ferroptosis and the ferroptosis mechanism of action involved in the development of T2DM. Also, we develop a search strategy, establish strict inclusion and exclusion criteria, and summarize and analyze the application of the ferroptosis mechanism in TCM studies related to T2DM and its complications. Finally, we discuss the shortcomings of current studies and propose a future research focus.

Perceived neighborhood social cohesion and type 2 diabetes mellitus by age, sex/gender, and race/ethnicity in the United States

In prior research, perceived low neighborhood social cohesion (nSC) has been associated with prevalence of type 2 diabetes mellitus (T2DM); however, few studies have investigated the nSC-T2DM relationship among a large, racially/ethnically diverse, and nationally representative sample of the U.S. population. We used National Health Interview Survey (2013-2018) data to determine overall, age-, sex/gender-, and racial/ethnic-specific associations between nSC and T2DM among 170,432 adults. Self-reported nSC was categorized as low, medium, and high. T2DM was determined by participants being told they had diabetes by a health professional. We used Poisson regression with robust variance to estimate prevalence ratios (PRs) and 95% confidence intervals (CI) while adjusting for confounders. Mean age was 47.4 ± 0.1 years, 52% were women, and 69% self-identified as Non-Hispanic (NH)-White. Low vs. high nSC was associated with a higher prevalence of T2DM (PR = 1.22 [95% CI: 1.16-1.27]), after adjustment. A higher prevalence of T2DM was observed among participants 31-49 years old who perceived low vs. high nSC (PR = 1.36 [95% CI: 1.20-1.54]) and among participants ≥50 years old (PR = 1.18 [95% CI: 1.13-1.24]). Hispanic/Latinx women 18-30 years old in neighborhoods with low vs. high social cohesion had a higher prevalence of T2DM (PR = 3.70 [95% CI: 1.40-9.80]), whereas NH-Black women 18-30 years old in neighborhoods with medium vs. high social cohesion had a lower prevalence of T2DM (PR = 0.35 [95% CI: 0.14-0.89]). Our findings support the literature by demonstrating an association between neighborhood environment and T2DM as well as extend it by identifying determinants for intervention for T2DM.

Geographic proximity to immunization providers and vaccine series completion among children ages 0-24 months

OBJECTIVES

In the U.S., vaccination coverage is lower in rural versus urban areas. Spatial accessibility to immunization services has been a suspected risk factor for undervaccination in rural children. Our objective was to identify whether geographic factors, including driving distance to immunization providers, were associated with completion of recommended childhood vaccinations.

METHODS

We analyzed records from Montana's immunization information system for children born 2015-2017. Using geolocated address data, we calculated distance in road miles from children's residences to the nearest immunization provider. A multivariable log-linked binomial mixed model was used to identify factors associated with completion of the combined 7-vaccine series by age 24 months.

RESULTS

Among 26,085 children, 16,503 (63.3%) completed the combined 7-vaccine series by age 24 months. Distance to the nearest immunization provider ranged from 0 to 81.0 miles (median = 1.7; IQR = 3.2), with the majority (92.1%) of children living within 10 miles of a provider. Long distances (>10 miles) to providers had modest associations with not completing the combined 7-vaccine series (adjusted prevalence ratio [aPR]: 0.97, 95% confidence interval [CI]: 0.96-0.99). After adjustment for other factors, children living in rural areas (measured by rural-urban commuting area) were significantly less likely to have completed the combined 7-vaccine series than children in metropolitan areas (aPR: 0.88, 95% CI: 0.85-0.92).

CONCLUSIONS

Long travel distances do not appear to be a major barrier to childhood vaccination in Montana. Other challenges, including limited resources for clinic-based strategies to promote timely vaccination and parental vaccine hesitancy, may have greater influence on rural childhood vaccination.

Associations between residential environmental health and sleep quality: Potential mechanisms

BACKGROUND

Sleep quality is an important dimension of sleep health. There are few studies on the relationship between residential environment and sleep quality in China. We validated the connection between them and explored the moderating role of spatial-geographic characteristics and the role of emotional stress and somatic function as mediators.

METHODS

Using survey data collected by the Chinese General Social Survey in 2021, 2717 respondents were included in the analysis. First, OLS regression was used for baseline analysis. Second, a generalized ordered logit model was used to analyze the more precise correlations between residential environmental health and sleep quality. Finally, the mediating role of emotional stress and somatic function was explored using the KHB method.

RESULTS

In the baseline analysis, both the positive correlations of residential natural environmental health and residential health resources on people's sleep quality were tested. Further analysis revealed that the correlation of natural environmental health was more about protecting people from poor sleep quality (having "good" and "very good" sleep quality). The residential health resources correlated with whether people reported very good sleep quality. Regional development disparities played a negative moderating role in the relationship between residential health resources and sleep quality. Also, the mediating role of emotional stress and somatic function were supported, and the mediating role of somatic function was higher in proportion.

CONCLUSION

Sleep quality was positively correlated with residential environmental health; the economic development gap between regions played a moderating role; and the correlation was generated by people's emotional stress and somatic function. In the development of public health policy, it is necessary to actively address various environmental issues, provide convenient health facilities in living spaces, and bolster the policy inclinations of less developed areas.

Mediation of an association between neighborhood socioeconomic environment and type 2 diabetes through the leisure-time physical activity environment in an analysis of three independent samples

INTRODUCTION

Inequitable access to leisure-time physical activity (LTPA) resources may explain geographic disparities in type 2 diabetes (T2D). We evaluated whether the neighborhood socioeconomic environment (NSEE) affects T2D through the LTPA environment.

RESEARCH DESIGN AND METHODS

We conducted analyses in three study samples: the national Veterans Administration Diabetes Risk (VADR) cohort comprising electronic health records (EHR) of 4.1 million T2D-free veterans, the national prospective cohort REasons for Geographic and Racial Differences in Stroke (REGARDS) (11 208 T2D free), and a case-control study of Geisinger EHR in Pennsylvania (15 888 T2D cases). New-onset T2D was defined using diagnoses, laboratory and medication data. We harmonized neighborhood-level variables, including exposure, confounders, and effect modifiers. We measured NSEE with a summary index of six census tract indicators. The LTPA environment was measured by physical activity (PA) facility (gyms and other commercial facilities) density within street network buffers and population-weighted distance to parks. We estimated natural direct and indirect effects for each mediator stratified by community type.

RESULTS

The magnitudes of the indirect effects were generally small, and the direction of the indirect effects differed by community type and study sample. The most consistent findings were for mediation via PA facility density in rural communities, where we observed positive indirect effects (differences in T2D incidence rates (95% CI) comparing the highest versus lowest quartiles of NSEE, multiplied by 100) of 1.53 (0.25, 3.05) in REGARDS and 0.0066 (0.0038, 0.0099) in VADR. No mediation was evident in Geisinger.

CONCLUSIONS

PA facility density and distance to parks did not substantially mediate the relation between NSEE and T2D. Our heterogeneous results suggest that approaches to reduce T2D through changes to the LTPA environment require local tailoring.

Impact of Contextual-Level Social Determinants of Health on Newer Antidiabetic Drug Adoption in Patients with Type 2 Diabetes

BACKGROUND

We aimed to investigate the association between contextual-level social determinants of health (SDoH) and the use of novel antidiabetic drugs (ADD), including sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1a) for patients with type 2 diabetes (T2D), and whether the association varies across racial and ethnic groups.

METHODS

Using electronic health records from the OneFlorida+ network, we assembled a cohort of T2D patients who initiated a second-line ADD in 2015-2020. A set of 81 contextual-level SDoH documenting social and built environment were spatiotemporally linked to individuals based on their residential histories. We assessed the association between the contextual-level SDoH and initiation of SGTL2i/GLP1a and determined their effects across racial groups, adjusting for clinical factors.

RESULTS

Of 28,874 individuals, 61% were women, and the mean age was 58 (±15) years. Two contextual-level SDoH factors identified as significantly associated with SGLT2i/GLP1a use were neighborhood deprivation index (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.81-0.94) and the percent of vacant addresses in the neighborhood (OR 0.91, 95% CI 0.85-0.98). Patients living in such neighborhoods are less likely to be prescribed with newer ADD. There was no interaction between race-ethnicity and SDoH on the use of newer ADD. However, in the overall cohort, the non-Hispanic Black individuals were less likely to use newer ADD than the non-Hispanic White individuals (OR 0.82, 95% CI 0.76-0.88).

CONCLUSION

Using a data-driven approach, we identified the key contextual-level SDoH factors associated with not following evidence-based treatment of T2D. Further investigations are needed to examine the mechanisms underlying these associations.