The role of neighborhood characteristics in racial/ethnic disparities in type 2 diabetes: results from the Boston Area Community Health (BACH) Survey

Food deserts exposure, density of fast-food restaurants, and park access: Exploring the association of food and recreation environments with obesity and diabetes using global and local regression models

To prevent obesity and diabetes environmental interventions such as eliminating food deserts, restricting proliferation of food swamps, and improving park access are essential. In the United States, however, studies that examine the food and park access relationship with obesity and diabetes using both global and local regression are lacking. To guide county, state, and federal policy in combating obesity and diabetes, there is a need for cross-scale analyses to identify that relationship at national and local levels. This study applied spatial regression and geographically weighted regression to the 3,108 counties in the contiguous United States. Global regression show food deserts exposure and density of fast-food restaurants have non-significant association with obesity and diabetes while park access has a significant inverse association with both diseases. Geographically weighted regression that takes into account spatial heterogeneity shows that, among southern states that show high prevalence of obesity and diabetes, Alabama and Mississippi stand out as having opportunity to improve park access. Results suggest food deserts exposure are positively associated with obesity and diabetes in counties close to Alabama, Georgia, and Tennessee while density of fast-food restaurants show positive association with two diseases in counties of western New York and northwestern Pennsylvania. These findings will help policymakers and public health agencies in determining which geographic areas need to be prioritized when implementing public interventions such as promoting healthy food access, limiting unhealthy food options, and increasing park access.

Perceived neighborhood disorder and type 2 diabetes disparities in Hispanic, Black, and White Americans

Introduction

Approximately 32 million Americans have type 2 diabetes, and that number continues to grow. Higher prevalence rates are observed among certain subgroups, including members of marginalized racial/ethnic groups as well as residents of disordered neighborhoods (i.e., those with more trash and vandalism). Institutionalized discriminatory practices have resulted in disproportionate representation of marginalized racial/ethnic groups in disordered neighborhoods compared to non-Hispanic Whites. These neighborhood disparities may partially contribute to health disparities, given that signs of neighborhood disorder often relate to a general withdrawal from the neighborhood, minimizing opportunities for both physical and social engagement. Yet, research suggests variability across racial/ethnic groups both in reporting rates of neighborhood disorder and in the extent to which neighborhood disorder is interpreted as posing a threat to health and well-being.

Methods

Using 2016-2018 Health and Retirement Study data (n = 10,419, mean age = 67 years), a representative sample of older US adults, this study examined the possibility of racial/ethnic differences in associations between perceived neighborhood disorder and type 2 diabetes risk. Participants reported their perceptions of neighborhood disorder and type 2 diabetes status. Weighted logistic regression models predicted type 2 diabetes risk by perceived neighborhood disorder, race/ethnicity, and their interaction.

Results

Non-Hispanic Blacks and Hispanics had higher type 2 diabetes risk; these two groups also reported more disorder in their neighborhoods compared to non-Hispanic Whites. Perceiving more neighborhood disorder was associated with increased type 2 diabetes risk, but the interaction between race/ethnicity and disorder was not significant.

Discussion

Findings from the current study suggest that the negative effects of perceiving neighborhood disorder, a neighborhood-level stressor, extend to increased type 2 diabetes risk.

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.

The role of exposure to per- and polyfluoroalkyl substances in racial/ethnic disparities in hypertension: Results from the study of Women's health across the nation

BACKGROUND

Racial/ethnic disparities in hypertension are a pressing public health problem. The contribution of environmental pollutants including PFAS have not been explored, even though certain PFAS are higher in Black population and have been associated with hypertension.

OBJECTIVES

We examined the extent to which racial/ethnic disparities in incident hypertension are explained by racial/ethnic differences in serum PFAS concentrations.

METHODS

We included 1058 hypertension-free midlife women with serum PFAS concentrations in 1999-2000 from the multi-racial/ethnic Study of Women's Health Across the Nation with approximately annual follow-up visits through 2017. Causal mediation analysis was conducted using accelerated failure time models. Quantile-based g-computation was used to evaluate the joint effects of PFAS mixtures.

RESULTS

During 11,722 person-years of follow-up, 470 participants developed incident hypertension (40.1 cases per 1000 person-years). Black participants had higher risks of developing hypertension (relative survival: 0.58, 95% CI: 0.45-0.76) compared with White participants, which suggests racial/ethnic disparities in the timing of hypertension onset. The percent of this difference in timing that was mediated by PFAS was 8.2% (95% CI: 0.7-15.3) for PFOS, 6.9% (95% CI: 0.2-13.8) for EtFOSAA, 12.7% (95% CI: 1.4-22.6) for MeFOSAA, and 19.1% (95% CI: 4.2, 29.0) for PFAS mixtures. The percentage of the disparities in hypertension between Black versus White women that could have been eliminated if everyone's PFAS concentrations were dropped to the 10th percentiles observed in this population was 10.2% (95% CI: 0.9-18.6) for PFOS, 7.5% (95% CI: 0.2-14.9) for EtFOSAA, and 17.5% (95% CI: 2.1-29.8) for MeFOSAA.

CONCLUSIONS

These findings suggest differences in PFAS exposure may be an unrecognized modifiable risk factor that partially accounts for racial/ethnic disparities in timing of hypertension onset among midlife women. The study calls for public policies aimed at reducing PFAS exposures that could contribute to reductions in racial/ethnic disparities in hypertension.

Assessing performance of ZCTA-level and Census Tract-level social and environmental risk factors in a model predicting hospital events

Predictive analytics are used in primary care to efficiently direct health care resources to high-risk patients to prevent unnecessary health care utilization and improve health. Social determinants of health (SDOH) are important features in these models, but they are poorly measured in administrative claims data. Area-level SDOH can be proxies for unavailable individual-level indicators, but the extent to which the granularity of risk factors impacts predictive models is unclear. We examined whether increasing the granularity of area-based SDOH features from ZIP code tabulation area (ZCTA) to Census Tract strengthened an existing clinical prediction model for avoidable hospitalizations (AH events) in Maryland Medicare fee-for-service beneficiaries. We created a person-month dataset for 465,749 beneficiaries (59.4% female; 69.8% White; 22.7% Black) with 144 features indexing medical history and demographics using Medicare claims (September 2018 through July 2021). Claims data were linked with 37 SDOH features associated with AH events from 11 publicly-available sources (e.g., American Community Survey) based on the beneficiaries' ZCTA and Census Tract of residence. Individual AH risk was estimated using six discrete time survival models with different combinations of demographic, condition/utilization, and SDOH features. Each model used stepwise variable selection to retain only meaningful predictors. We compared model fit, predictive performance, and interpretation across models. Results showed that increasing the granularity of area-based risk factors did not dramatically improve model fit or predictive performance. However, it did affect model interpretation by altering which SDOH features were retained during variable selection. Further, the inclusion of SDOH at either granularity level meaningfully reduced the risk that was attributed to demographic predictors (e.g., race, dual-eligibility for Medicaid). Differences in interpretation are critical given that this model is used by primary care staff to inform the allocation of care management resources, including those available to address drivers of health beyond the bounds of traditional health care.

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.

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.

The changing food environment and neighborhood prevalence of type 2 diabetes

In this ecological study, we used longitudinal data to assess if changes in neighborhood food environments were associated with type 2 diabetes mellitus (T2DM) prevalence, controlling for a host of neighborhood characteristics and spatial error correlation. We found that the population-adjusted prevalence of fast-food and pizza restaurants, grocery stores, and full-service restaurants along with changes in their numbers from 1990 to 2010 were associated with 2015 T2DM prevalence. The results suggested that neighborhoods where fast-food restaurants have increased and neighborhoods where full-service restaurants have decreased over time may be especially important targets for educational campaigns or other public health-related T2DM interventions.

Census Tract Demographics Associated with Libraries' Social, Economic, and Health-Related Programming

Background: Public libraries can contribute to reducing economic, social, and health inequities through their programming and practices. However, the extent to which libraries regularly provide programming that improve the social determinants of health (SDH) in underserved communities is unclear. Objective: This study explored the relationship between census tract demographic characteristics and library programming implicated in the SDH for underserved groups at risk for health disparities. Method: A stratified random sample of libraries (n = 235) who completed the 2017 Public Libraries Survey were recruited. Librarians completed surveys about their libraries' economic, social, and health-related programming. Libraries' census tract demographic characteristics were taken from the 2013-2017 American Community Survey. Linear regressions were estimated to determine the relationship between relevant census tract demographic characteristics and programming offered at libraries in the census tracts. Results: Higher proportions of racial and ethnic minorities were associated with more frequent economic and social programs, but results were mixed for health-related programs. Lower proportions of populations with no more than a high school diploma or GED were related to more frequent economic, social, and health-related programs. Conclusions: The inequitable distribution of SDH-related library programming highlights gaps in libraries' responsiveness to community needs. Libraries' programming likely perpetuate systemic inequities.

Neighborhood Socioeconomic Environment and Risk of Type 2 Diabetes: Associations and Mediation Through Food Environment Pathways in Three Independent Study Samples

OBJECTIVE

We examined whether relative availability of fast-food restaurants and supermarkets mediates the association between worse neighborhood socioeconomic conditions and risk of developing type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

As part of the Diabetes Location, Environmental Attributes, and Disparities Network, three academic institutions used harmonized environmental data sources and analytic methods in three distinct study samples: 1) the Veterans Administration Diabetes Risk (VADR) cohort, a national administrative cohort of 4.1 million diabetes-free veterans developed using electronic health records (EHRs); 2) Reasons for Geographic and Racial Differences in Stroke (REGARDS), a longitudinal, epidemiologic cohort with Stroke Belt region oversampling (N = 11,208); and 3) Geisinger/Johns Hopkins University (G/JHU), an EHR-based, nested case-control study of 15,888 patients with new-onset T2D and of matched control participants in Pennsylvania. A census tract-level measure of neighborhood socioeconomic environment (NSEE) was developed as a community type-specific z-score sum. Baseline food-environment mediators included percentages of 1) fast-food restaurants and 2) food retail establishments that are supermarkets. Natural direct and indirect mediating effects were modeled; results were stratified across four community types: higher-density urban, lower-density urban, suburban/small town, and rural.

RESULTS

Across studies, worse NSEE was associated with higher T2D risk. In VADR, relative availability of fast-food restaurants and supermarkets was positively and negatively associated with T2D, respectively, whereas associations in REGARDS and G/JHU geographies were mixed. Mediation results suggested that little to none of the NSEE-diabetes associations were mediated through food-environment pathways.

CONCLUSIONS

Worse neighborhood socioeconomic conditions were associated with higher T2D risk, yet associations are likely not mediated through food-environment pathways.

Disease-Specific Health Disparities: A Targeted Review Focusing on Race and Ethnicity

Background: Wide disparities in health status exist in the United States across race and ethnicity, broadly driven by social determinants of health—most notably race and ethnic group differences in income, education, and occupational status. However, disparities in disease frequency or severity remain underappreciated for many individual diseases whose distribution in the population varies. Such information is not readily accessible, nor emphasized in treatment guidelines or reviews used by practitioners. Specifically, a summary on disease-specific evidence of disparities from population-based studies is lacking. Our goal was to summarize the published evidence for specific disease disparities in the United States so that this knowledge becomes more widely available “at the bedside”. We hope this summary stimulates health equity research at the disease level so that these disparities can be addressed effectively. Methods: A targeted literature review of disorders in Pfizer’s current pipeline was conducted. The 38 diseases included metabolic disorders, cancers, inflammatory conditions, dermatologic disorders, rare diseases, and infectious targets of vaccines under development. Online searches in Ovid and Google were performed to identify sources focused on differences in disease rates and severity between non-Hispanic Whites and Black/African Americans, and between non-Hispanic Whites and Hispanics. As a model for how this might be accomplished for all disorders, disparities in disease rates and disease severity were scored to make the results of our review most readily accessible. After primary review of each condition by one author, another undertook an independent review. Differences between reviewers were resolved through discussion. Results: For Black/African Americans, 29 of the 38 disorders revealed a robust excess in incidence, prevalence, or severity. After sickle cell anemia, the largest excesses in frequency were identified for multiple myeloma and hidradenitis suppurativa. For Hispanics, there was evidence of disparity in 19 diseases. Most notable were metabolic disorders, including non-alcoholic steatohepatitis (NASH). Conclusions: This review summarized recent disease-specific evidence of disparities based on race and ethnicity across multiple diseases, to inform clinicians and health equity research. Our findings may be well known to researchers and specialists in their respective fields but may not be common knowledge to health care providers or public health and policy institutions. Our hope is that this effort spurs research into the causes of the many disease disparities that exist in the United States.

Perceived Stress as a Pathway for the Relationship Between Neighborhood Factors and Glycemic Control in Adults With Diabetes

PURPOSE

Neighborhood factors such as crime, discrimination, and violence are increasingly recognized as correlates of poor glycemic control. However, pathways for these relationships are unclear. This study examined stress and self-efficacy as potential pathways for the relationship between neighborhood factors and glycemic control in adults with type 2 diabetes.

DESIGN

Cross-sectional study.

SETTING

Two primary care clinics in southeastern US.

PARTICIPANTS

615 adults aged 18 years and older.

MEASURES

Validated measures were used to capture neighborhood factors, stress, and self-efficacy, while hemoglobin A1c (HbA1c) was abstracted from the electronic health record.

ANALYSIS

Path analysis was used to investigate direct and indirect relationships between neighborhood factors, stress, self-efficacy, and glycemic control.

RESULTS

In the final model, violence (r = .17, P = .024), discrimination (r = .46, P < .001), and crime (r = .36, P = .046) were directly associated with higher perceived stress. Stress (r = -.5, P < .001) was directly associated with lower self-efficacy. Self-efficacy was directly associated with better general diet (r = .12, P < .001), better specific diet (r = .04, P < .001), more exercise (r = .08, P < .001), and lower HbA1c (r = -.11, P < .001). Stress (r = .05, P < .001), crime (r = .20, P < .001), and discrimination (r = .08, P < .001) were indirectly associated with higher HbA1c.

CONCLUSION

Stress and self-efficacy are potential pathways for the relationship between neighborhood factors like violence, discrimination, and crime and glycemic control. Interventions aimed at mitigating stress and improving self-efficacy may improve self-care behaviors and glycemic control.

A Review of Interventional Trials in Youth-Onset Type 2 Diabetes: Challenges and Opportunities

INTRODUCTION

In recent decades, the dramatic rise of obesity among youth in the US has been accompanied by a rise in the prevalence of type 2 diabetes (T2D) in this population. This alarming trend underscores the importance of conducting trials to evaluate new therapies in children with T2D.

METHODS

A targeted review of peer-reviewed literature and trials registered on www.clinicaltrials.gov was conducted in January 2021 to identify pharmaceutical interventional studies in youth with T2D. Information regarding enrollment data, study design elements, subjects' baseline characteristics, and key treatment outcomes was documented.

RESULTS

Among the 16 clinical studies included in this review, only five appeared to meet projected enrollment targets in < 4 years. Although three other studies met recruitment targets, two took approximately 5 years to complete and the third took nearly 10 years.

CONCLUSIONS

Despite legislation requiring evaluation of pharmaceutical treatments in pediatric populations, surprisingly few interventional studies have been conducted in children with T2D. This review highlights that recruitment challenges may be impeding the conduct and completion of interventional studies. Consequently, few pharmaceutical treatments have been proven to be effective and approved for children with T2D. Metformin and liraglutide remain the only non-insulin treatments formally approved in the US for use in this population. More clinical research is needed to support regulatory decision-making as well as treatment decisions for children with T2D in clinical settings. Sponsors and investigators will need to implement strategies for improving trial enrollment as well as work with regulatory agencies to develop novel study designs that may require fewer patients.

The Neighborhood Environment and Hispanic/Latino Health

PURPOSE

Hispanic/Latino adults on the Texas-Mexico border have high rates of chronic disease. Neighborhoods can influence health, though there is a limited research on neighborhood environment and health in Hispanics/Latinos. The purpose of this study was to assess the relation of neighborhood environment with health variables in Hispanic/Latino adults, including physical activity [PA], depression, anxiety, and lab-assessed conditions (type 2 diabetes, metabolic syndrome, and chronic inflammation).

METHODS

Participants were randomly-selected from a Hispanic/Latino cohort on the Texas-Mexico border. Neighborhood environment, self-reported PA, anxiety, and depression were assessed through questionnaires. Laboratory values determined Type 2 diabetes, metabolic syndrome, and C-reactive protein (CRP). We conducted multivariable linear and logistic regression analyses to assess the associations of neighborhood environment and health variables, controlling for covariates.

RESULTS

Participants (n = 495) were mostly females, without insurance. After controlling for covariates, crime (Adjusted Odds Ratio [AOR] = 1.59 (95%CI 1.06-2.38), no streetlights (AOR = 1.65, 95%CI 1.06-2.57), and traffic (AOR = 1.74, 95%CI 1.16-2.62) were all significantly associated with anxiety. Only traffic was significantly associated with depression (AOR = 1.61, 95%CI1.05-2.47). A lack of nearby shops (AOR = 0.57, 95%CI 0.38-0.84) and no one out doing PA (AOR = 0.53, 95% CI 0.34-0.83) were both significantly associated with lower odds of meeting PA guidelines. A lack of nearby shops was associated with a 26% increase in the CRP value (β = 0.26, 95%CI 0.04-0.47).

DISCUSSION

Several neighborhood environment variables were significantly associated with mental health, PA and CRP, though estimates were small. The neighborhood environment is a meaningful contextual variable to consider for health-related interventions in Hispanic/Latino adults, though more study is needed regarding the magnitude of the estimates.

TRIAL REGISTRATION

NCT01168765.

Diabetes mortality across the 30 biggest U.S. cities: Assessing overall trends and racial inequities

AIMS

National data suggest that diabetes mortality disproportionately affects Blacks compared to whites. We aimed to (1) calculate diabetes mortality rates (where diabetes was an underlying cause of death) among the general population of the U.S. and the largest 30 cities; (2) calculate Black/white mortality rate ratios and rate differences; and (3) compare changes in mortality rates and inequities across two 5-year periods (2008-2012 (T1) and 2013-2017 (T2)).

METHODS

We used vital statistics mortality data and American Community Survey population estimates.

RESULTS

The U.S. diabetes mortality rate at T1 was 20.91 per 100,000, and significantly increased to 21.05 at T2. El Paso had the highest diabetes mortality rate at both time points (T1 = 33.06; T2 = 35.98), while San Francisco had the lowest rate (T1 = 11.41; T2 = 13.18). The U.S. Black mortality rate was 2.21 times higher than the white rate at T2 (95%CI [2.19-2.23]). Eleven cities had significantly higher rate ratios than the U.S. at T2. The Black:white rate ratio in Washington, D.C. was approximately three times higher than the national rate ratio.

CONCLUSIONS

This city-level data is important to inform more targeted local policy interventions and programming to promote health equity, particularly within cities with the greatest inequities.

Liver Cancer Incidence and Area-Level Geographic Disparities in Pennsylvania-A Geo-Additive Approach

Many neighborhood socioeconomic index measures (nSES) that capture neighborhood deprivation exist but the impact of measure selection on liver cancer (LC) geographic disparities remains unclear. We introduce a Bayesian geoadditive modeling approach to identify clusters in Pennsylvania (PA) with higher than expected LC incidence rates, adjusted for individual-level factors (age, sex, race, diagnosis year) and compared them to models with 7 different nSES index measures to elucidate the impact of nSES and measure selection on LC geospatial variation. LC cases diagnosed from 2007–2014 were obtained from the PA Cancer Registry and linked to nSES measures from U.S. census at the Census Tract (CT) level. Relative Risks (RR) were estimated for each CT, adjusted for individual-level factors (baseline model). Each nSES measure was added to the baseline model and changes in model fit, geographic disparity and state-wide RR ranges were compared. All 7 nSES measures were strongly associated with high risk clusters. Tract-level RR ranges and geographic disparity from the baseline model were attenuated after adjustment for nSES measures. Depending on the nSES measure selected, up to 60% of the LC burden could be explained, suggesting methodologic evaluations of multiple nSES measures may be warranted in future studies to inform LC prevention efforts.

Geographic and Racial/Ethnic Variation in Glycemic Control and Treatment in a National Sample of Veterans With Diabetes

OBJECTIVE

Geographic and racial/ethnic disparities related to diabetes control and treatment have not previously been examined at the national level.

RESEARCH DESIGN AND METHODS

A retrospective cohort study was conducted in a national cohort of 1,140,634 veterans with diabetes, defined as two or more diabetes ICD-9 codes (250.xx) across inpatient and outpatient records. Main exposures of interest included 125 Veterans Administration Medical Center (VAMC) catchment areas as well as racial/ethnic group. The main outcome measure was HbA1c level dichotomized at ≥8.0% (≥64 mmol/mol).

RESULTS

After adjustment for age, sex, racial/ethnic group, service-connected disability, marital status, and the van Walraven Elixhauser comorbidity score, the prevalence of uncontrolled diabetes varied by VAMC catchment area, with values ranging from 19.1% to 29.2%. Moreover, these differences largely persisted after further adjusting for medication use and adherence as well as utilization and access metrics. Racial/ethnic differences in diabetes control were also noted. In our final models, compared with non-Hispanic Whites, non-Hispanic Blacks (odds ratio 1.11 [95% credible interval 1.09-1.14]) and Hispanics (1.36 [1.09-1.14]) had a higher odds of uncontrolled HBA1c level.

CONCLUSIONS

In a national cohort of veterans with diabetes, we found geographic as well as racial/ethnic differences in diabetes control rates that were not explained by adjustment for demographics, comorbidity burden, use or type of diabetes medication, health care utilization, access metrics, or medication adherence. Moreover, disparities in suboptimal control appeared consistent across most, but not all, VAMC catchment areas, with non-Hispanic Black and Hispanic veterans having a higher odds of suboptimal diabetes control than non-Hispanic White veterans.

A geospatial analysis of Type 2 Diabetes Mellitus and the food environment in urban New Zealand

The aim of this research is to analyse the spatial epidemiology of Type 2 Diabetes Mellitus (T2DM) and investigate associations with the built environment in urban New Zealand. Data on T2DM was sourced from the New Zealand Virtual Diabetes Register (2016), and data on environmental variables sourced from the Ministry for Primary Industries and Territorial Authorities (2013-2016). Novel measures of the built environment using an enhanced two-step floating catchment area model were established using data on fast food outlets, takeaways, dairy/convenience stores, supermarkets and fruit/vegetable stores. Rates of T2DM per 1000 population and standardised morbidity ratios were computed and visualised for all urban areas. Getis Ord was used to assess spatial clustering, and Bayesian modelling was used to understand associations between T2DM and environmental variables. Results indicate that T2DM is influenced by demographic factors, spatially clustered and associated with accessibility to environmental exposures. Health-promoting resources, such as fruit/vegetable stores, were shown to have a consistently protective effect on T2DM while those considered detrimental to health showed varying, and largely insignificant, associations. This is the first study in New Zealand to spatially quantify the effects of multiple environmental exposures on population level T2DM for all urban areas using a geospatial approach. It has implications for both policy and future research efforts as a deeper knowledge of local environments forms a basis on which to better understand spatial associations between the built environment and health, as well as formulate policy directed toward environmental influences on chronic health conditions.

Neighborhood disorder predicts lower serum vitamin D levels in pregnant African American women: A pilot study

Pregnant African American women are more likely to live in neighborhoods with more disorder (e.g., vacant housing, littler, crime) and to have vitamin D deficiency due to their darker skin pigmentation and poor production of vitamin D [25(OH)D] from ultraviolet rays. However, no study has examined the potential link between neighborhood disorder and 25(OH)D status in African American pregnant women. Forty-one pregnant African American women completed validated questionnaires about perceived neighborhood disorder (6 items; 3-point scale; range 6-18) and with concurrent serum levels of 25-hydroxyvitamin D [25(OH)D] assessed during pregnancy at 18-24 weeks gestation. Higher levels of perceived neighborhood disorder were associated with lower levels of serum 25(OH)D. Pregnant African American women who report higher disorder in their neighborhood may spend less time outside. Health care providers should include assessment of perceived neighborhood disorder. Future research needs to evaluate the relationships among neighborhood disorder and 25(OH)D levels among pregnant African American women.

Racial Disparities in Total Knee Replacement Failure As Related to Poverty

OBJECTIVE

To determine whether racial disparities in total knee replacement (TKR) failure are explained by poverty.

METHODS

Black and white New York state residents, enrolled in a prospective single-institution TKR registry January 1, 2008 to February 6, 2012, who underwent primary unilateral TKR (n = 4,062) were linked to the New York Statewide Planning and Research Cooperative System database (January 1, 2008 to December 31, 2014) to capture revisions performed at outside institutions. Patients were linked by geocoded addresses to residential census tracts. Multivariable Cox regression was used to assess predictors of TKR revision. Multivariable logistic regression was used to analyze predictors of TKR failure, defined as TKR revision in New York state ≤2 years after surgery, or as Hospital for Special Surgery (HSS) TKR quality of life score "not improved" or "worsened" 2 years after surgery.

RESULTS

The mean ± SD age was 68.4 ± 10 years, 64% of patients were female, 8% lived in census tracts with >20% of the population under the poverty line, and 9% were black. Median follow-up time was 5.3 years. A total of 3% of patients (122 of 4,062) required revision a median 454 days (interquartile range 215-829) after surgery. TKR revision risk was higher in blacks than whites, with a hazard ratio of 1.69 (95% confidence interval 1.01-2.81), but in multivariable analysis, only younger age, male sex, and constrained prosthesis were predictors of TKR revision. TKR failure occurred in 200 of 2,832 cases (7%) with 2-year surveys. Risk factors for TKR failure were non-osteoarthritis TKR indication, low surgeon volume, and low HSS Expectations Survey score, but not black race. Community poverty was not associated with TKR revision or failure.

CONCLUSION

There was a trend toward higher TKR revision risk in blacks, but poverty did not modify the relationship between race and TKR revision or failure.

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

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

Neighborhoods to Nucleotides - Advances and gaps for an obesity disparities systems epidemiology model

Purpose of Review

Disparities in obesity rates in the US continue to increase. Here we review progress and highlight gaps in understanding disparities in obesity with a focus on the Hispanic/Latino population from a systems epidemiology framework. We review seven domains: environment, behavior, biomarkers, nutrition, microbiome, genomics, and epigenomics/transcriptomics. We focus on recent advances that include at least two or more of these domains, and then provide a real world example of data collection efforts that reflect these domains.

Recent Findings

Research into DNA methylation related to discrimination and microbiome relating to eating behaviors and food content is furthering understanding of why disparities in obesity persist. Environmental and neighborhood level research is uncovering the importance of exposures such as air and noise pollution and systematic or structural racism for obesity and related outcomes through behaviors such as sleep.

Green spaces and mortality: a systematic review and meta-analysis of cohort studies

BACKGROUND

Green spaces have been proposed to be a health determinant, improving health and wellbeing through different mechanisms. We aimed to systematically review the epidemiological evidence from longitudinal studies that have investigated green spaces and their association with all-cause mortality. We aimed to evaluate this evidence with a meta-analysis, to determine exposure-response functions for future quantitative health impact assessments.

METHODS

We did a systematic review and meta-analysis of cohort studies on green spaces and all-cause mortality. We searched for studies published and indexed in MEDLINE before Aug 20, 2019, which we complemented with an additional search of cited literature. We included studies if their design was longitudinal; the exposure of interest was measured green space; the endpoint of interest was all-cause mortality; they provided a risk estimate (ie, a hazard ratio [HR]) and the corresponding 95% CI for the association between green space exposure and all-cause mortality; and they used normalised difference vegetation index (NDVI) as their green space exposure definition. Two investigators (DR-R and DP-L) independently screened the full-text articles for inclusion. We used a random-effects model to obtain pooled HRs. This study is registered with PROSPERO, CRD42018090315.

FINDINGS

We identified 9298 studies in MEDLINE and 13 studies that were reported in the literature but not indexed in MEDLINE, of which 9234 (99%) studies were excluded after screening the titles and abstracts and 68 (88%) of 77 remaining studies were excluded after assessment of the full texts. We included nine (12%) studies in our quantitative evaluation, which comprised 8 324 652 individuals from seven countries. Seven (78%) of the nine studies found a significant inverse relationship between an increase in surrounding greenness per 0·1 NDVI in a buffer zone of 500 m or less and the risk of all-cause mortality, but two studies found no association. The pooled HR for all-cause mortality per increment of 0·1 NDVI within a buffer of 500 m or less of a participant's residence was 0·96 (95% CI 0·94-0·97; I², 95%).

INTERPRETATION

We found evidence of an inverse association between surrounding greenness and all-cause mortality. Interventions to increase and manage green spaces should therefore be considered as a strategic public health intervention.

FUNDING

World Health Organization.

Age Disparities Among Patients With Type 2 Diabetes and Associated Rates of Hospital Use and Diabetic Complications

Introduction

Although screening for diabetes is recommended at age 45, some populations may be at greater risk at earlier ages. Our objective was to quantify age disparities among patients with type 2 diabetes in New York City.

Methods

Using all-payer hospital claims data for New York City, we performed a cross-sectional analysis of patients with type 2 diabetes identified from emergency department visits during the 5-year period 2011–2015. We estimated type 2 diabetes prevalence at each year of life, the age distribution of patients stratified by decade, and the average age of patients by sex, race/ethnicity, and geographic location.

Results

We identified 576,306 unique patients with type 2 diabetes. These patients represented more than half of all people with type 2 diabetes in New York City. Patients in racial/ethnic minority groups were on average 5.5 to 8.4 years younger than non-Hispanic white patients. At age 45, type 2 diabetes prevalence was 10.9% among non-Hispanic black patients and 5.2% among non-Hispanic white patients. In our geospatial analyses, patients with type 2 diabetes were on average 6 years younger in hotspots of diabetes-related emergency department use and inpatient hospitalizations. The average age of patients with type 2 diabetes was also 1 to 2 years younger in hotspots of microvascular diabetic complications.

Conclusion

We identified profound age disparities among patients with type 2 diabetes in racial/ethnic minority groups and in neighborhoods with poor health outcomes. The younger age of these patients may be due to earlier onset of diabetes and/or earlier death from diabetic complications. Our findings demonstrate the need for geographically targeted interventions that promote earlier diagnosis and better glycemic control.

Residential self-selection, perceived built environment and type 2 diabetes incidence: A longitudinal analysis of 36,224 middle to older age adults

Much of the existing studies on the built environment and type 2 diabetes are cross-sectional and prone to residential self-selection bias. Using multilevel logistic regression analysis of 36,224 participants from a longitudinal study, we examined whether perceived built environment characteristics are associated with type 2 diabetes. We found that the odds of diabetes incidence varied geographically. Those who reported that there were no local amenities and reported day- and night-time crime rates made walking unsafe in the neighbourhood had higher odds of developing incident type 2 diabetes. These associations persisted after accounting for some predictors of residential self-selection. More longitudinal studies are needed to corroborate the findings. Changing the features of the residential built environment may be an important point of intervention for type 2 diabetes prevention.

Social Determinants of Health Assessment Tool: Implications for Healthcare Practice

Underserved populations are at risk for chronic health conditions due to social determinants. There is a gap in instrument availability in identifying individuals at risk of, or experiencing, cumulative social, environmental, economic, and cultural factors impacting health. The Social Determinants of Health Assessment Tool is a brief, cost-effective semistructured interview allowing healthcare professionals to engage in appropriate service prioritization. Phase I of this instrument development reported adequate face validity by Delphi panel consensus with experts in social work, nursing, public health, and psychology. This instrument identifies individuals at risk of social determinants to improve healthcare and social service delivery.

Characteristics of the built environment and spatial patterning of type 2 diabetes in the urban core of Durham, North Carolina

BACKGROUND

Few studies examine relationships between built environment (BE) and type 2 diabetes mellitus (T2DM) using spatial models, investigate BE domains apart from food environment or physical activity resources or conduct sensitivity analysis of methodological choices made in measuring BE. We examine geographic heterogeneity of T2DM, describe how heterogeneity in T2DM relates to BE and estimate associations of T2DM with BE.

METHODS

Individual-level electronic health records (n=41 203) from the Duke Medicine Enterprise Data Warehouse (2007-2011) were linked to BE based on census block. Data on housing damage, property disorder, territoriality, vacancy and public nuisances were used to estimate BE based on four different construction methods (CMs). We used race-stratified aspatial and spatial Bayesian models to assess geographic heterogeneity in T2DM and associations of T2DM with BE.

RESULTS

Among whites, a 1 SD increase in poor quality BE was associated with a 1.03 (95% credible interval 1.01 to 1.06) and 1.06 (95 % credible interval 1.02 to 1.11) increased risk of T2DM for poor quality BE CM1 and CM2, respectively. Among blacks/African Americans, associations between T2DM and BE overlapped with the null for all CMs. The addition of BE to white models reduced residual geographic heterogeneity in T2DM by 4%-15%, depending on CM. In black/African-American models, BE did not affect residual heterogeneity.

CONCLUSION

Associations of T2DM with BE were sensitive to CM and geographic heterogeneity in T2DM differed by race/ethnicity. Findings underscore the need to consider multiple methods of estimating BE and consider differences in relationships by race/ethnicity.

Association of neighbourhood socioeconomic status and diabetes burden using electronic health records in Madrid (Spain): the HeartHealthyHoods study

OBJECTIVE

To study the association between neighbourhood socioeconomic status and diabetes prevalence, incidence, and control in the entire population of northeastern Madrid, Spain.

SETTING

Electronic health records of the primary-care system in four districts of Madrid (Spain).

PARTICIPANTS

269 942 people aged 40 or older, followed from 2013 to 2014.

EXPOSURE

Neighbourhoodsocioeconomic status (NSES), measured using a composite index of seven indicators from four domains of education, wealth, occupation and living conditions.

PRIMARY OUTCOME MEASURES

Diagnosis of diabetes based on ICPC-2 codes and glycated haemoglobin (HbA1c %).

RESULTS

In regression analyses adjusted by age and sex and compared with individuals living in low NSES neighbourhoods, men living in medium and high NSES neighbourhoods had 10% (95% CI: 6% to 15%) and 29% (95% CI: 25% to 32%) lower prevalence of diabetes, while women had 27% (95% CI: 23% to 30%) and 50% (95% CI: 47% to 52%) lower prevalence of diabetes. Moreover, the hazard of diabetes in men living in medium and high NSES neighbourhoods was 13% (95% CI: 1% to 23%) and 20% (95% CI: 9% to 29%) lower, while the hazard of diabetes in women living in medium and high NSES neighbourhoods was 17% (95% CI: 3% to 29%) and 31% (95% CI: 20% to 41%) lower. Individuals living in medium and high SES neighbourhoods had 8% (95% CI: 2% to 15%) and 15% (95% CI: 9% to 21%) lower prevalence of lack of diabetes control, and a decrease in average HbA1c % of 0.05 (95% CI: 0.01 to 0.10) and 0.11 (95% CI: 0.06 to 0.15).

CONCLUSIONS

Diabetes prevalence, incidence and lack of control increased with decreasing NSES in a southern European city. Future studies should provide mechanistic insights and targets for intervention to address this health inequity.

Risk factors for pre-diabetes and diabetes in adolescence and their variability by race and ethnicity

Adolescent risk factors for pre-diabetes and diabetes in young adulthood were examined in three minority groups and compared to those in non-Hispanic Whites. Retrospective cohort study with data on 8337 adolescent respondents from Add Health (1994-2008). Participants included 5131 non-Hispanic Whites, 1651 non-Hispanic Blacks, 1223 Hispanics, and 332 American Indians/Alaska Natives. Diabetes was defined as: hemoglobin A1C ≥ 6.5%, glucose > 125 mg/dl, self-reported diabetes, or self-reported diabetes medication use, in Wave 4 data. Pre-diabetes was defined as hemoglobin A1C ≥ 5.7%. Relative risk regression models were used to evaluate the association between risk factors and risk of diabetes and pre-diabetes, controlling for body mass index, sedentary and physical activity habits, fast food consumption, and parental education, parental diabetes status, and financial stability. 484 participants developed diabetes; 2878 developed pre-diabetes between 1994 and 2008. Pre-diabetes and diabetes were more prevalent in non-Hispanic Blacks (55% and 12%, respectively) than in American Indians/Alaska Natives (43% and 11%), Hispanics (37% and 6%), and non-Hispanic Whites (27% and 3%). In all races, higher body mass index and parental diabetes were associated with higher risk of pre-diabetes and diabetes, while female sex was associated with lower risk of pre-diabetes. Efforts to reduce the risk of pre-diabetes and diabetes in adolescents should emphasize parental diabetes and BMI in all races, independent of physical activity, sedentary behaviors, or fast food consumption. Future interventions might be interested in targeting households, rather than individuals, to prevent pre-diabetes and diabetes in adolescents and young adults.

Using Geospatial Analysis and Emergency Claims Data to Improve Minority Health Surveillance

Traditional methods of health surveillance often under-represent racial and ethnic minorities. Our objective was to use geospatial analysis and emergency claims data to estimate local chronic disease prevalence separately for specific racial and ethnic groups. We also performed a regression analysis to identify associations between median household income and local disease prevalence among Black, Hispanic, Asian, and White adults in New York City. The study population included individuals who visited an emergency department at least once from 2009 to 2013. Our main outcomes were geospatial estimates of diabetes, hypertension, and asthma prevalence by Census tract as stratified by race and ethnicity. Using emergency claims data, we identified 4.9 million unique New York City adults with 28.5% of identifying as Black, 25.2% Hispanic, and 6.1% Asian. Age-adjusted disease prevalence was highest among Black and Hispanic adults for diabetes (13.4 and 13.1%), hypertension (28.7 and 24.1%), and asthma (9.9 and 10.1%). Correlation between disease prevalence maps demonstrated moderate overlap between Black and Hispanic adults for diabetes (0.49), hypertension (0.57), and asthma (0.58). In our regression analysis, we found that the association between low income and high disease prevalence was strongest for Hispanic adults, whereas increases in income had more modest reductions in disease prevalence for Black adults, especially for diabetes. Our geographically detailed maps of disease prevalence generate actionable evidence that can help direct health interventions to those communities with the highest health disparities. Using these novel geographic approaches, we reveal the underlying epidemiology of chronic disease for a racially and culturally diverse population.

Residential Racial Isolation and Spatial Patterning of Type 2 Diabetes Mellitus in Durham, North Carolina

Neighborhood characteristics such as racial segregation may be associated with type 2 diabetes mellitus, but studies have not examined these relationships using spatial models appropriate for geographically patterned health outcomes. We constructed a local, spatial index of racial isolation (RI) for black residents in a defined area, measuring the extent to which they are exposed only to one another, to estimate associations of diabetes with RI and examine how RI relates to spatial patterning in diabetes. We obtained electronic health records from 2007-2011 from the Duke Medicine Enterprise Data Warehouse. Patient data were linked to RI based on census block of residence. We used aspatial and spatial Bayesian models to assess spatial variation in diabetes and relationships with RI. Compared with spatial models with patient age and sex, residual geographic heterogeneity in diabetes in spatial models that also included RI was 29% and 24% lower for non-Hispanic white and black residents, respectively. A 0.20-unit increase in RI was associated with an increased risk of diabetes for white (risk ratio = 1.24, 95% credible interval: 1.17, 1.31) and black (risk ratio = 1.07, 95% credible interval: 1.05, 1.10) residents. Improved understanding of neighborhood characteristics associated with diabetes can inform development of policy interventions.

Using Indirect Measures to Identify Geographic Hot Spots of Poor Glycemic Control: Cross-sectional Comparisons With an A1C Registry

OBJECTIVE

Focusing health interventions in places with suboptimal glycemic control can help direct resources to neighborhoods with poor diabetes-related outcomes, but finding these areas can be difficult. Our objective was to use indirect measures versus a gold standard, population-based A1C registry to identify areas of poor glycemic control.

RESEARCH DESIGN AND METHODS

Census tracts in New York City (NYC) were characterized by race, ethnicity, income, poverty, education, diabetes-related emergency visits, inpatient hospitalizations, and proportion of adults with diabetes having poor glycemic control, based on A1C >9.0% (75 mmol/mol). Hot spot analyses were then performed, using the Getis-Ord Gi* statistic for all measures. We then calculated the sensitivity, specificity, positive and negative predictive values, and accuracy of using the indirect measures to identify hot spots of poor glycemic control found using the NYC A1C Registry data.

RESULTS

Using A1C Registry data, we identified hot spots in 42.8% of 2,085 NYC census tracts analyzed. Hot spots of diabetes-specific inpatient hospitalizations, diabetes-specific emergency visits, and age-adjusted diabetes prevalence estimated from emergency department data, respectively, had 88.9%, 89.6%, and 89.5% accuracy for identifying the same hot spots of poor glycemic control found using A1C Registry data. No other indirect measure tested had accuracy >80% except for the proportion of minority residents, which had 86.2% accuracy.

CONCLUSIONS

Compared with demographic and socioeconomic factors, health care utilization measures more accurately identified hot spots of poor glycemic control. In places without a population-based A1C registry, mapping diabetes-specific health care utilization may provide actionable evidence for targeting health interventions in areas with the highest burden of uncontrolled diabetes.

Neighborhood characteristics and lifestyle intervention outcomes: Results from the Special Diabetes Program for Indians

Growing evidence reveals various neighborhood conditions are associated with the risk of developing type 2 diabetes. It is unknown, however, whether the effectiveness of diabetes prevention interventions is also influenced by neighborhood characteristics. The purpose of the current study is to examine the impact of neighborhood characteristics on the outcomes of a lifestyle intervention to prevent diabetes in American Indians and Alaska Natives (AI/ANs). Year 2000 US Census Tract data were linked with those from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), an evidence-based lifestyle intervention implemented in 36 AI/AN grantee sites across the US. A total of 3394 participants started the intervention between 01/01/2006 and 07/31/2009 and were followed by 07/31/2016. In 2016-2017, data analyses were conducted to evaluate the relationships of neighborhood characteristics with intervention outcomes, controlling for individual level socioeconomic status. AI/ANs from sites located in neighborhoods with higher median household income had 38% lower risk of developing diabetes than those from sites with lower neighborhood income (adjusted hazard ratio = 0.65, 95% CI: 0.47-0.90). Further, those from sites with higher neighborhood concentrations of AI/ANs achieved less BMI reduction and physical activity increase. Meanwhile, participants from sites with higher neighborhood level of vehicle occupancy made more improvement in BMI and diet. Lifestyle intervention effectiveness was not optimal when the intervention was implemented at sites with disadvantaged neighborhood characteristics. Meaningful improvements in socioeconomic and other neighborhood disadvantages of vulnerable populations could be important in stemming the global epidemic of diabetes.

The Great Recession and Immune Function

The Great Recession precipitated unprecedented home foreclosures increases, but documentation of related neighborhood changes and population health is scant. Using the Detroit Neighborhood Health Study (N = 277), we examined associations between neighborhood-level recession indicators and thymic function, a life course immunological health indicator. In covariate-adjusted multilevel models, each 10 percentage point increase in abandoned home prevalence and 1 percentage point increase in 2009 home foreclosures was associated with 1.7-year and 3.3-year increases in thymic aging, respectively. Associations attenuated after adjustment for neighborhood-level social cohesion, suggesting community ties may buffer recession-related immune aging. Effects of neighborhood stressors were strongest in middle-income households, supporting theory of excess vulnerability in this group. Future research should assess whether ongoing foreclosure and blight reduction efforts improve health for residents of recession impacted neighborhoods.

Associations of Residential Socioeconomic, Food, and Built Environments With Glycemic Control in Persons With Diabetes in New York City From 2007-2013

In the present study, we examined the longitudinal associations between residential environmental factors and glycemic control in 182,756 adults with diabetes in New York City from 2007 to 2013. Glycemic control was defined as a hemoglobin A1c (HbA1c) level less than 7%. We constructed residential-level measures and performed principle component analysis to formulate a residential composite score. On the basis of this score, we divided residential areas into quintiles, with the lowest and highest quintiles reflecting the least and most advantaged residential environments, respectively. Several residential-level environmental characteristics, including more advantaged socioeconomic conditions, greater ratio of healthy food outlets to unhealthy food outlets, and residential walkability were associated with increased glycemic control. Individuals who lived continuously in the most advantaged residential areas took less time to achieve glycemic control compared with the individuals who lived continuously in the least advantaged residential areas (9.9 vs. 11.5 months). Moving from less advantaged residential areas to more advantaged residential areas was related to improved diabetes control (decrease in HbA1c = 0.40%, 95% confidence interval: 0.22, 0.55), whereas moving from more advantaged residential areas to less advantaged residential areas was related to worsening diabetes control (increase in HbA1c = 0.33%, 95% confidence interval: 0.24, 0.44). These results show that residential areas with greater resources to support healthy food and residential walkability are associated with improved glycemic control in persons with diabetes.

Characterization of users at risk of developing diabetes: a cross-sectional study

OBJECTIVE

To characterize the profile of users at risk of developing diabetes mellitus type 2 according to sociodemographic and clinical variables.

METHOD

Cross-sectional study, descriptive, quantitative approach conducted with 266 users of Basic Care. Inferential statistics analysis, calculating the crude prevalence ratio with confidence interval of 95% and Kruskal-Wallis test, and application of the multivariate technique simple Correspondence Analysis.

RESULTS

It was noted that 83.1% were women and 36.4% frequented the Family Health Unit from 1 to 5 years. Regarding the factors associated with diabetes mellitus type 2, 66.5% of the users were overweight and 77.9% were rated with central obesity. The great majority, 77.4%, did not practice physical activities and 21.1% had altered glycemia.

CONCLUSION

The results showed that many risk factors for developing diabetes mellitus type 2 were among the population of the study.

Environmental Risk Factors for Developing Type 2 Diabetes Mellitus: A Systematic Review

Different elements of the environment have been posited to influence type 2 diabetes mellitus (T2DM). This systematic review summarizes evidence on the environmental determinants of T2DM identified in four databases. It proposes a theoretical framework illustrating the link between environment and T2DM, and briefly discusses some methodological challenges and potential solutions, and opportunities for future research. Walkability, air pollution, food and physical activity environment and roadways proximity were the most common environmental characteristics studied. Of the more than 200 reported and extracted relationships assessed in 60 studies, 82 showed significant association in the expected direction. In general, higher levels of walkability and green space were associated with lower T2DM risk, while increased levels of noise and air pollution were associated with greater risk. Current evidence is limited in terms of volume and study quality prohibiting causal inferences. However, the evidence suggests that environmental characteristics may influence T2DM prevention, and also provides a reasonable basis for further investigation with better quality data and longitudinal studies with policy-relevant environmental measures. This pursuit of better evidence is critical to support health-orientated urban design and city planning.

Neighbourhood social and physical environment and general practitioner assessed morbidity

The aim of our study was to investigate the association between health enhancing and threatening, and social and physical aspects of the neighbourhood environment and general practitioner (GP) assessed morbidity of the people living there, in order to find out whether the effects of environmental characteristics add up or modify each other. We combined GP electronic health records with environmental data on neighbourhoods in the Netherlands. Cross-classified logistic multilevel models show the importance of taking into account several environmental characteristics and confounders, as social capital effects on the prevalence of morbidity disappear when other area characteristics are taken into account. Stratification by area socio-economic status, shows that the association between environmental characteristics and the prevalence of morbidity is stronger for people living in low SES areas. In low SES areas, green space seems to alleviate effects of air pollution on the prevalence of high blood pressure and diabetes, while the effects of green space and social capital reinforce each other.

Skin Deep: Enhanced Variable May Help Explain Racial Disparities in Type 2 Diabetes and Prediabetes

INTRODUCTION

The study refined definitions of type 2 diabetes and prediabetes (Pre-/T2D) via its four-category outcome variable. Respondents were identified as Pre-/T2D on the basis of (a) doctor's diagnosis only (i.e., managed Pre-/T2D); (b) biomarker only (i.e., undiagnosed Pre-/T2D); or (c) both diagnosis and biomarker (i.e., unmanaged Pre-/T2D). The reference was Pre-/T2D not indicated. We linked the outcome to social structural and social support factors, health care-related factors, mental disorder, and lifestyle variables, for each racial/ethnic group.

METHODS

We used the 2011-2012 and 2013-2014 National Health and Nutrition Examination Surveys to measure the four-category outcome and examine race/ethnicity's role in explaining the outcome.

RESULTS

We found Pre-/T2D to be associated with age, BMI, physical activity, income, education, receiving health services, and other factors. A moderating role for race/ethnicity was also confirmed.

CONCLUSION

The racial disparities observed in our three main categories generally resulted from high levels of undiagnosed Pre-/T2D and high levels of diagnosed but unmanaged Pre-T2D. Race/ethnicity's moderating role generally indicated that, through the factors BMI, age, and receiving health services, minority status (with its attendant disadvantages) could facilitate undiagnosed Pre-/T2D as well as Pre-/T2D indicated concurrently by diagnosis and biomarker.

Diabetes Knowledge, Management, and Prevention Among Haitian Immigrants in Philadelphia

Purpose Guided by the PEN-3 Cultural Model, the purpose of this study is to generate culturally framed insight into diabetes knowledge, management, and prevention among Haitians. Despite the disproportionate distribution of type II diabetes mellitus among US minorities, limited research explores outcomes within racial ethnic groups. It is particularly important to disaggregate the large racial-ethnic groups of black given the population growth among foreign-born blacks, such as Haitians, whose population has more than quadrupled in recent decades. Methods Focus group interviews were employed to understand diabetes knowledge, management, and prevention in the Haitian immigrant population in Philadelphia. Interviews were conducted in 2 groups: (1) people living with diabetes and (2) an at-risk sample for diabetes (defined as 30 and older with self-reported family history of diabetes). Interviews were recorded and transcribed verbatim in preparation for content analysis. Results Of the 10 participants, who were recruited through a Philadelphia church-based population, ages ranged from 41 to 91, with an average of 65. Content analysis revealed 3 emergent themes across: (1) cultural identity, including person, extended family, and neighborhood; (2) relationships and expectations, including perceptions, enablers, and nurturers; and (3) cultural empowerment, including positive, existential, and negative. Conclusions Results may inform culturally appropriate diabetes interventions for Haitians. Future research should explore compliance with food recommendations as well as the cultural competency of health care professional's information delivery.

Assessing the psychometric and ecometric properties of neighborhood scales using adolescent survey data from urban and rural Scotland

Background

Despite the well-established need for specific measurement instruments to examine the relationship between neighborhood conditions and adolescent well-being outcomes, few studies have developed scales to measure features of the neighborhoods in which adolescents reside. Moreover, measures of neighborhood features may be operationalised differently by adolescents living in different levels of urban/rurality. This has not been addressed in previous studies. The objectives of this study were to: 1) establish instruments to measure adolescent neighborhood features at both the individual and neighborhood level, 2) assess their psychometric and ecometric properties, 3) test for invariance by urban/rurality, and 4) generate neighborhood level scores for use in further analysis.

Methods

Data were from the Scottish 2010 Health Behaviour in School-aged Children Survey, which included an over-sample of rural adolescents. The survey responses of interest came from questions designed to capture different facets of the local area in which each respondent resided. Intermediate data zones were used as proxies for neighborhoods. Internal consistency was evaluated by Cronbach’s alpha. Invariance was examined using confirmatory factor analysis. Multilevel models were used to estimate ecometric properties and generate neighborhood scores.

Results

Two constructs labeled neighborhood social cohesion and neighborhood disorder were identified. Adjustment was made to the originally specified model to improve model fit and measures of invariance. At the individual level, reliability was .760 for social cohesion and .765 for disorder, and between .524 and .571 for both constructs at the neighborhood level. Individuals in rural areas experienced greater neighborhood social cohesion and lower levels of neighborhood disorder compared with those in urban areas.

Conclusion

The scales are appropriate for measuring neighborhood characteristics experienced by adolescents across urban and rural Scotland, and can be used in future studies of neighborhoods and health. However, trade-offs between neighborhood sample size and reliability must be considered.

Racial/Ethnic Residential Segregation, Obesity, and Diabetes Mellitus

Persistent racial/ethnic disparities in obesity and type 2 diabetes mellitus seen in the US are likely due to a combination of social, biological, and environmental factors. A growing number of studies have examined the role of racial/ethnic residential segregation with respect to these outcomes because this macro-level process is believed to be a fundamental cause of many of the factors that contribute to these disparities. This review provides an overview of findings from studies of racial/ethnic residential segregation with obesity and diabetes published between 2013 and 2015. Findings for obesity varied by geographic scale of the segregation measure, gender, ethnicity, and racial identity (among Hispanics/Latinos). Recent studies found no association between racial/ethnic residential segregation and diabetes prevalence, but higher segregation of Blacks was related to higher diabetes mortality. Implications of these recent studies are discussed as well as promising areas of future research.

Social Disorder in Adults with Type 2 Diabetes: Building on Race, Place, and Poverty

The recent resurgence of social and civic disquiet in the USA has contributed to increasing recognition that social conditions are meaningfully connected to disease and death. As a "lifestyle disease," control of diabetes requires modifications to daily activities, including healthy dietary practices, regular physical activity, and adherence to treatment regimens. One's ability to develop the healthy practices necessary to prevent or control type 2 diabetes may be influenced by a context of social disorder, the disruptive social and economic conditions that influence daily activity and, consequently, health status. In this paper, we report on our narrative review of the literature that explores the associations between social disorder and diabetes-related health outcomes within vulnerable communities. We also propose a multilevel ecosocial model for conceptualizing social disorder, specifically focusing on its role in racial disparities and its pathways to mediating diabetes outcomes.

Development of a comprehensive measure of spatial access to HIV provider services, with application to Atlanta, Georgia

BACKGROUND

No existing measures of HIV care access consider both spatial proximity to services and provider-related characteristics in a single measure. We developed and applied a tool to: (1) quantify spatial access to HIV care services (supply) and (2) identify underserved areas with respect to HIV cases (demand), by travel mode, in Atlanta.

METHODS

Building on a study of HIV care engagement, data from an HIV care provider database, and HIV case counts by zip code tabulation area (ZCTA) from AIDSVu.org, we fit a discrete choice model to estimate practice characteristics most salient in defining patient care access. Modified spatial gravity modeling quantified supply access based on discrete choice model results separately for travel by car and by public transportation. Relative access scores were calculated by ZCTA, and underserved areas (defined as having low supply access and high HIV case count) were identified for each travel mode.

RESULTS

Characteristics retained in the final model included: travel distance, available provider-hours, availability of ancillary services, and whether Ryan White patients were accepted. HIV provider supply was higher in urban versus suburban/rural areas for both travel modes, with lower supply access if traveling by public transportation. Underserved areas were concentrated in south and east Atlanta if traveling by public transportation, overlapping with many areas of high poverty. Approximately 7.7 %, if traveling by car, and 64.3 %, if traveling by public transportation, of Atlanta-based persons with diagnosed HIV infection resided in underserved areas.

CONCLUSION

These findings highlight underserved areas in south and east Atlanta if traveling by public transit. Conceptualizing access to medical services spatially and by travel mode may help bridge gaps between patient needs and service availability and improve HIV outcomes.

A longitudinal study of structural risk factors for obesity and diabetes among American Indian young adults, 1994-2008

Introduction

American Indian young adults have higher rates of obesity and type 2 diabetes than the general US population. They are also more likely than the general population to have higher rates of structural risk factors for obesity and diabetes, such as poverty, frequent changes of residence, and stress. The objective of this study was to investigate possible links between these 2 sets of problems.

Methods

Data from the American Indian subsample of the National Longitudinal Study of Adolescent to Adult Health (Add Health) were used to examine potential links between obesity and type 2 diabetes and structural risk factors such as neighborhood poverty, housing mobility, and stress. We used logistic regression to explore explanatory factors.

Results

American Indians in the subsample had higher rates of poor health, such as elevated hemoglobin A1c levels, self-reported high blood glucose, self-reported diabetes, and overweight or obesity. They also had higher rates of structural risk factors than non-Hispanic whites, such as residing in poorer and more transient neighborhoods and having greater levels of stress. Self-reported stress partially mediated the increased likelihood of high blood glucose or diabetes among American Indians, whereas neighborhood poverty partially mediated their increased likelihood of obesity.

Conclusion

Neighborhood poverty and stress may partially explain the higher rates of overweight, obesity, and type 2 diabetes among American Indian young adults than among non-Hispanic white young adults. Future research should explore additional neighborhood factors such as access to grocery stores selling healthy foods, proximity and safety of playgrounds or other recreational space, and adequate housing.