Race/ethnicity, gender and the SES gradient in BMI: The diminishing returns of SES for racial/ethnic minorities

Race, Social Determinants of Health, and Comorbidity Patterns Among Participants with Heart Failure in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Background

Among individuals with heart failure (HF), racial differences in comorbidities may be mediated by social determinants of health (SDOH).

Methods

Black and White US community-dwelling participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study aged ≥ 45 years with an adjudicated HF hospitalization between 2003 and 2017 were included in this cross-sectional analysis. We assessed whether higher prevalence of comorbidities in Black participants compared to White participants were mediated by SDOH in socioeconomic, environment/housing, social support, and healthcare access domains, using the inverse odds weighting method.

Results

Black (n = 240) compared to White (n = 293) participants with HF with preserved ejection fraction (HFpEF) had higher prevalence of diabetes [1.38 (95% CI: 1.18 - 1.61)], chronic kidney disease [1.21 (95% CI: 1.01 - 1.45)], and anemia [1.33 (95% CI: 1.02 - 1.75)] and lower prevalence of atrial fibrillation [0.80 (95% CI: (0.65 - 0.98)]. Black (n = 314) compared to White (n = 367) participants with HF with reduced ejection fraction (HFrEF) had higher prevalence of hypertension [1.04 (95% CI: 1.02 - 1.07)] and diabetes [1.26 (95% CI: 1.09 - 1.45)] and lower prevalence of coronary artery disease [0.86 (95% CI: 0.78 - 0.94)] and atrial fibrillation [0.70 (95% CI: 0.58 - 0.83)]. Socioeconomic status explained 14.5%, 26.5% and 40% of excess diabetes, anemia, and chronic kidney disease among Black adults with HFpEF; however; mediation was not statistically significant and no other SDOH substantially mediated differences in comorbidity prevalence.

Conclusions

Socioeconomic status partially mediated excess diabetes, anemia, and chronic kidney disease experienced by Black adults with HFpEF, but differences in other comorbidities were not explained by other SDOH examined.

Institutional Context Shapes the Physical Health of College Graduates Differently for U.S. White, Black, and Hispanic Adults

Greater educational attainment is generally associated with healthier and longer lives. However, important heterogeneity in who benefits from educational attainment, how much, and why remains underexplored. In particular, in the United States, the physical health returns to educational attainment are not as large for minoritized racial and ethnic groups compared with individuals racialized as White. Yet, our current understanding of ethnoracial differences in educational health disparities is limited by an almost exclusive focus on the quantity of education attained without sufficient attention to heterogeneity within educational attainment categories, such as different institution types among college graduates. Using biomarker data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), we test whether the physical health of college graduates in early adulthood (aged 24-32) varies by institution type and for White, Black, and Hispanic adults. In considering the role of the college context, we conceptualize postsecondary institutions as horizontally stratified and racialized institutional spaces with different implications for the health of their graduates. Finally, we quantify the role of differential attendance at and returns to postsecondary institution type in shaping ethnoracialized health disparities among college graduates in early adulthood.

Metabolic syndrome traits exhibit genotype-by-environment interaction in relation to socioeconomic status in the Mexican American family heart study

Background: Socioeconomic Status (SES) is a potent environmental determinant of health. To our knowledge, no assessment of genotype-environment interaction has been conducted to consider the joint effects of socioeconomic status and genetics on risk for metabolic disease. We analyzed data from the Mexican American Family Studies (MAFS) to evaluate the hypothesis that genotype-by-environment interaction (GxE) is an essential determinant of variation in risk factors for metabolic syndrome (MS). Methods: We employed a maximum likelihood estimation of the decomposition of variance components to detect GxE interaction. After excluding individuals with diabetes and individuals on medication for diabetes, hypertension, or dyslipidemia, we analyzed 12 MS risk factors: fasting glucose (FG), fasting insulin (FI), 2-h glucose (2G), 2-h insulin (2I), body mass index (BMI), waist circumference (WC), leptin (LP), high-density lipoprotein-cholesterol (HDL-C), triglycerides (TG), total serum cholesterol (TSC), systolic blood pressure (SBP), and diastolic blood pressure (DBP). Our SES variable used a combined score of Duncan's socioeconomic index and education years. Heterogeneity in the additive genetic variance across the SES continuum and a departure from unity in the genetic correlation coefficient were taken as evidence of GxE interaction. Hypothesis tests were conducted using standard likelihood ratio tests. Results: We found evidence of GxE for fasting glucose, 2-h glucose, 2-h insulin, BMI, and triglycerides. The genetic effects underlying the insulin/glucose metabolism component of MS are upregulated at the lower end of the SES spectrum. We also determined that the household variance for systolic blood pressure decreased with increasing SES. Conclusion: These results show a significant change in the GxE interaction underlying the major components of MS in response to changes in socioeconomic status. Further mRNA sequencing studies will identify genes and canonical gene pathways to support our molecular-level hypotheses.

How Education Shapes Indigenous Health Inequalities in the USA and Mexico

Indigenous peoples around the world face significant health disparities relative to the dominant groups in their countries, yet the magnitude and patterns of health disparities vary across countries. We use data from the National Health Interview Survey and Mexican Family Life Survey to examine the health of Indigenous peoples in Mexico and American Indians and Alaska Natives in the USA and to evaluate how they fare relative to the majority populations in their countries (non-Indigenous Mexicans and non-Hispanic Whites, respectively). We assess disparities in self-rated health and activity limitations, with a focus on how Indigenous health disparities intersect with educational gradients in health. Regression analyses reveal three primary findings. First, Indigenous health disparities are larger in the USA than in Mexico. Second, differences in educational attainment account for most of the differences between Indigenous and non-Indigenous populations in Mexico, but less than half in the USA. Third, in both countries, health is moderated by educational attainment such that between-group disparities are largest at the highest levels of education. However, for Indigenous Mexicans there is a "cross-over" in which Indigenous Mexicans report better health at the lowest level of education. Overall, this study finds a weak relationship between education and Indigenous health, and raises the question about the validity of using traditional measures of SES in Indigenous contexts.

Upward Mobility Context and Health Outcomes and Behaviors during Transition to Adulthood: The Intersectionality of Race and Sex

This study investigates how upward mobility context affects health during transition to adulthood and its variations by race and sex. Using county-level upward mobility measures and data from the Panel Study of Income Dynamics, we apply propensity score weighting techniques to examine these relationships. Results show that low upward mobility context increases the likelihood of poor self-rated health, obesity, and cigarette use but decreases alcohol consumption probability. Conversely, high upward mobility context raises the likelihood of distress, chronic conditions, and alcohol use but reduces cigarette use likelihood. In low-opportunity settings, Black individuals have lower risks of chronic conditions and cigarette use than White men. In high-opportunity settings, Black women are more likely to experience depression and chronic conditions, and Black men are likelier to smoke than White men. Our findings emphasize the complex link between upward mobility context and health for different racial and sex groups.

Disentangling Socioeconomic Status and Race in Infant Brain, Birth Weight, and Gestational Age at Birth: A Neural Network Analysis

Background

Race is commonly used as a proxy for multiple features including socioeconomic status. It is critical to dissociate these factors, to identify mechanisms that affect infant outcomes, such as birth weight, gestational age, and brain development, and to direct appropriate interventions and shape public policy.

Methods

Demographic, socioeconomic, and clinical variables were used to model infant outcomes. There were 351 participants included in the analysis for birth weight and gestational age. For the analysis using brain volumes, 280 participants were included after removing participants with missing magnetic resonance imaging scans and those matching our exclusion criteria. We modeled these three different infant outcomes, including infant brain, birth weight, and gestational age, with both linear and nonlinear models.

Results

Nonlinear models were better predictors of infant birth weight than linear models (R2 = 0.172 vs. R2 = 0.145, p = .005). In contrast to linear models, nonlinear models ranked income, neighborhood disadvantage, and experiences of discrimination higher in importance than race while modeling birth weight. Race was not an important predictor for either gestational age or structural brain volumes.

Conclusions

Consistent with the extant social science literature, the findings related to birth weight suggest that race is a linear proxy for nonlinear factors related to structural racism. Methods that can disentangle factors often correlated with race are important for policy in that they may better identify and rank the modifiable factors that influence outcomes.

Social and economic factors and black-white disparities in cardiovascular health: A decomposition analysis

Background

Cardiovascular health (CVH) in Black adults, and particularly in Black women, has lagged behind White adults for decades and contributes to higher mortality rates for Black adults. We quantified the contribution of five social and economic factors to observed racial disparities in CVH by gender.

Methods

We analyzed data from N = 8,019 adults aged ≥20 years free of cardiovascular disease assessed in the National Health and Nutrition Examination Survey, 2011-2018. Social and economic factors included self-reported education, income, employment, food security, and marital status. CVH was measured using eight behavioral and clinical indicators. We utilized Kitagawa-Blinder-Oaxaca decomposition to quantify gendered racial differences in CVH accounted for by these factors.

Results

Black women (mean CVH = 79.3) had a lower age-adjusted CVH score compared to White women (mean CVH = 82.3) (mean difference [MD] = -3.01; 95% CI: -5.18, -0.84). Social and economic factors accounted for a 3.26-point disadvantage (95% CI: -4.12, -2.40) and a 0.25-point CVH score advantage due to factors not accounted for in the model. In women, income had the largest coefficient associated with CVH score (b = -1.48; 95% CI: -2.04, -0.92). Among men, social and economic factors accounted for a 2.27-point disadvantage (95% CI: -2.97, -1.56) with educational attainment being the largest coefficient associated with CVH score (b = -1.55; 95% CI: -2.03, -1.06). However, the disadvantage in men was offset by a 1.99 CVH score advantage that was not accounted for by factors in the model resulting in no racial difference in age-adjusted CVH score (MD = -0.28; 95% CI: -3.78, 3.22).

Conclusions

Racial differences in social and economic factors may contribute a large portion to the observed disparity in CVH between U.S. Black and White women.

Parental determinants associated with early growth after the first year of life by race and ethnicity

Objective

To investigate maternal and parental factors associated with changes in children's body mass index percentile (BMI-P) from 12 to 24 months.

Methods

Data from a prospective cohort of racially and ethnically diverse mothers, fathers, and children (n = 245) were used. Changes in BMI-P from 12 to 24 months of age were examined using height and weight measurements collected at both times. Separate longitudinal mixed-effects models with maximum likelihood were introduced to examine the determinants introduced by mothers and determinants from both parents among all children, and by race and ethnicity.

Results

Models that examine maternal and parental factors showed that children's overall BMI-P decreased from 12 to 24 months [β = -4.85, 95% confidence interval (CI), -7.47 to -2.23]. Stratified tests showed that White children whose parents graduated high school or completed a 4-year college degree or higher had greater decreases in BMI-P than White children born to parents with less than high school education (β = -60.39, 95% CI, -115.05 to -5.72; β = -61.49, 95% CI, -122.44 to -0.53). Among Hispanic/Latinx children, mean BMI-P significantly decreased from 12 to 24 months (β = -7.12, 95% CI, -11.59 to -2.64). Mother's older age (β = 1.83, 95% CI, 0.29-3.36) and child female sex (β = 11.21, 95% CI, 1.61-20.82) were associated with gains in children's BMI-P, while father's older age was associated with decreases (β = -1.19, 95% CI, -2.30 to -0.08).

Conclusions

Parental determinants associated with children's early growth varied by children's sex and racial and ethnic background. Results highlight the importance of understanding racial and ethnicity-specific obesity risks and including fathers in research.

Black/white differences in the relationship between debt and risk of heart attack across cohorts

Background

Numerous studies show that increasing levels of education, income, assets, and occupational status are linked to greater improvements in White adults' health than Black adults'. Research has yet to determine, however, whether there are racial differences in the relationship between health and debt and whether this relationship varies across cohorts.

Methods

Using data from the 1992-2018 Health and Retirement Study, we use survival analyses to examine the link between debt and heart attack risk among the Prewar Cohort, born 1931-1941, and Baby Boomers, born 1948-1959.

Results

Higher unsecured debt is associated with increased heart attack risk for Black adults, especially among Baby Boomers and during economic recessions. Higher mortgage debt is associated with lower risk of heart attack for White but not Black Baby Boomers. The relationship between debt and heart attack risk remains after controlling for health behaviors, depressive symptoms, and other economic resources that are concentrated among respondents with high levels of debt.

Conclusion

Debt is predictive of heart attack risk, but the direction and strength of the relationship varies by type of debt, debtors' racial identity, and economic context.

A Decomposition Analysis of Racial Disparities in Physical Activity Among Cancer Survivors: National Health Interview Survey 2009-2018

PURPOSE

In light of the known benefits of physical activity (PA) for cancer survivors, this exploratory study sought to investigate the uptake of PA among this population in the United States.

METHODS

Using the National Health Interview Survey data from 2009 to 2018, lung, breast, colorectal, prostate, ovarian, and lymphoma cancer survivors were identified, and their PA adherence measured per the standards of the American College of Sports Medicine. Logistic regression and the Fairlie decomposition were used, respectively, to identify correlates of PA and to explain the difference in PA adherence between races.

RESULTS

Uptake of PA was significantly different between Whites and minorities. Blacks had lower odds than Whites (adjusted odds ratio: 0.77; 95% confidence interval, 0.66-0.93), whereas Mixed Race had twice the odds of Whites (adjusted odds ratio: 1.94; 95% confidence interval, 0.27-0.98) of adhering to PA recommendations. Decomposition identified education, family income-to-poverty ratio, body mass index, number of chronic conditions, alcohol use, and general health as key factors accounting for the PA disparity between cancer survivors of White and Black or Multiple/Mixed racial group.

CONCLUSION

These findings could help inform behavioral PA interventions to improve their design and targeting to different racial groups of cancer survivors.

Association of socioeconomic status with arterial stiffness in older African American and White adults: The ARIC study cohort

Objective

To examine the cross-sectional associations of individual measures of SES-educational attainment and household income-and the joint effects of SES with PWV, as well as the SES-race interaction, in a cohort of older African American and White adults.

Methods

Data from the Atherosclerosis Risk in Communities (ARIC) Study were used to evaluate the cross-sectional associations of individual and joint SES [education and income] and carotid femoral pulse wave velocity (cfPWV), a subclinical marker of arterial stiffness, and the interaction of SES and race using adjusted multivariable linear regression models in a cohort of 3342 men and women aged 67-89 years free of CVD in 2011-2013.

Results

Participants were 64% female, 23% African American, mean cfPWV (12.3±3.5-African American and 11.6±3.9-White participants). Post-graduate education compared to less than high school was significantly associated with lower cfPWV (less stiffness) in African American (β = -1.28 m/s; 95% CI, -1.97, -0.59) but not in White (β = -0.69 m/s; 95% CI, -1.39, 0.01) participants. Income ≥$50K as compared to <$25K, was associated with lower cfPWV both in African American (β = -0.82 m/s; 95% CI, -1.42, -0.22) and White (β = -0.76 m/s; 95% CI, -1.19, -0.32) participants. The interaction of race and individual measures of SES on cfPWV in African American and White adults were not statistically significant (p-value >0.10).

Conclusions

Higher SES was cross-sectionally associated with lower arterial stiffness in this cohort; the data did not support differences by race. Prospective studies of SES and cfPWV are needed to efficiently compare larger racially and regionally diverse populations with a wider range of socioeconomic profiles to better identify subgroup CVD risk.

Task analysis guidance for number of and readability of steps for individuals with intellectual disabilities

We examined the relationship of number of and readability of content of steps of task analyses with subsequent task performance. The results of the current study indicate that the number of and readability of steps were significantly associated with task performance via a non-linear, quadratic relationship. From our results, we suggest that task analyses may consider up to seven steps with a grade level of content (i.e., readability) of up to approximately 7^th grade without diminishing task performance. These results do not provide final guidance as to the suggested number of steps or readability of content for task analyses but some initial guidance, especially in the absence of well-established task analyses. We suggest results should be used for those practitioners seeking guidelines for content development in the absence of well-established task analyses for suggested values for number of and readability of steps.

Investigating the Intersections of Racial Identity and Perceived Income Adequacy in Relation to Dietary Quality Among Adults in Canada

BACKGROUND

Structural racism and economic marginalization shape dietary patterns in complex ways. Most research examining race and income inequities discount their interactions in shaping dietary intakes. An intersectional approach is needed to identify interconnected sources of social inequities and to more precisely locate dietary inequities.

OBJECTIVES

We examined whether racial identity and perceived income adequacy independently and jointly shape dietary quality, defined using the Healthy Eating Index (HEI) 2015, among a large sample of adults in Canada.

METHODS

Cross-sectional data from 2540 adults (≥18 years of age) in Canada who participated in the 2019 International Food Policy Study were analyzed. Multivariable linear regression models were executed to test the independent associations and interactions between racial identity and perceived income adequacy with HEI-2015 scores. Models were constructed to examine HEI-2015 total and component scores, adjusting for age, gender, and education.

RESULTS

Perceived income adequacy, but not racial identity, was independently associated with HEI-2015 total scores. The interaction between racial identity and perceived income adequacy was significantly associated with HEI-2015 scores. Compared to the reference group (individuals identifying as White and reporting income adequacy), those identifying as Black and reporting income adequacy were associated with lower HEI-2015 scores (β, -7.30; 95% CI, -13.07 to -1.54) and those identifying as Black and reporting income inadequacy were associated with lower HEI-2015 scores (β, -6.37; 95% CI, -12.13 to -0.60). Individuals who identified as indigenous and reported neither income adequacy nor inadequacy had lower HEI-2015 scores (β, -8.50; 95% CI, -13.82 to -3.18) compared to the reference group.

CONCLUSIONS

Findings suggest that racial identity and perceived income adequacy jointly shape dietary quality. Inequities in dietary quality may be missed when intersecting racial identities and socioeconomic positions are not explicitly investigated. To support healthier dietary patterns, strategies must reduce socioeconomic barriers that impose dietary constraints on some racialized groups.

Social determinants of obesity in American Indian and Alaska Native peoples aged ≥ 50 years

OBJECTIVE

American Indian and Alaska Native peoples (AI/ANs) have a disproportionately high rate of obesity, but little is known about the social determinants of obesity among older AI/ANs. Thus, our study assessed social determinants of obesity in AI/ANs aged ≥ 50 years.

DESIGN

We conducted a cross-sectional analysis using multivariate generalized linear mixed models to identify social determinants associated with the risk of being classified as obese (BMI ≥ 30.0 kg/m2). Analyses were conducted for the total study population and stratified by median county poverty level.

SETTING

Indian Health Service (IHS) data for AI/ANs who used IHS services in FY2013.

PARTICIPANTS

27,696 AI/ANs aged ≥ 50 years without diabetes.

RESULTS

Mean BMI was 29.8 ± 6.6 with 43% classified as obese. Women were more likely to be obese than men, and younger ages were associated with higher obesity risk. While having Medicaid coverage was associated with lower odds of obesity, private health insurance was associated with higher odds. Living in areas with lower rates of educational attainment and longer drive times to primary care services were associated with higher odds of obesity. Those who lived in a county where a larger percentage of people had low access to a grocery store were significantly less likely to be obese.

CONCLUSIONS

Our findings contribute to the understanding of social determinants of obesity among older AI/ANs and highlight the need to investigate AI/AN obesity, including longitudinal studies with a life course perspective to further examine social determinants of obesity in older AI/ANs.

Education, income, and obesity: A nationwide Chinese twin study

OBJECTIVE

This study aimed to examine the association of socioeconomic status with obesity.

METHODS

A total of 39,262 twin individuals were included from the Chinese National Twin Registry (CNTR). Generalized estimating equation models for unmatched twin individual analyses and conditional logistic regression for the co-twin matched design were used. Inference about Causation through Examination of FAmiliaL CONfounding (ICE FALCON) was used to explore the evidence of a causal relationship.

RESULTS

In general estimating equation models, high education level and income were associated with lower risk of obesity (odds ratio [OR] = 0.74 [95% CI: 0.65 to 0.84] and 0.86 [95% CI: 0.77 to 0.96]). In conditional logistic regression analysis, the association with education was significant (OR = 0.50 [95% CI: 0.34 to 0.74]) but the association with income was insignificant (OR = 0.74 [95% CI: 0.48 to 1.15]). From the ICE FALCON analysis, a twin's obesity was associated with the co-twin's education and income. After adjusting for the twin's own education, the association disappeared ( β co - twin '  = -0.10 [95% CI: -0.26 to 0.07]), whereas the twin's obesity was still associated with the co-twin's income but attenuated toward the null ( β co - twin '  = -0.21 [95% CI: -0.36 to -0.06]).

CONCLUSIONS

Socioeconomic status is negatively associated with obesity. Education may have a causal effect on obesity, whereas the association between income and obesity is confounded by familial factors.

Person-centered communication about weight and weight management: Focus group discussions in a diverse sample of women with nonmetastatic breast cancer and obesity

BACKGROUND

Women with obesity are at higher risk for high-grade and/or advanced-stage breast cancer in comparison with women without obesity. Many women with a high body mass index (BMI) at breast cancer diagnosis experience further weight gain during and after treatment. This study investigated Black and White patient perspectives on conversations with their oncologists about weight and weight management.

METHODS

Focus groups using a virtual platform (Zoom) were conducted with women after primary treatment for stage I to III breast cancer who were 21 years or older and had a BMI ≥ 30 kg/m² : 2 with Black women (n = 12) and 2 with White women (n = 14).

RESULTS

Participants asked that their oncologists be "transparent" about weight gain as a potential side effect of their cancer treatment and how excess weight might affect their prognosis and survival. They asked to be "seen as an individual" to facilitate both person-centered and culturally appropriate conversations about behavioral changes needed for weight management. Participants urged clinicians to take the lead in initiating conversations about weight to underscore its importance in cancer care and survivorship. They welcomed actionable recommendations about nutrition and exercise from either the oncology clinician or a specialist. Participants offered specific suggestions on how clinicians could initiate weight-related conversations, beginning with questions eliciting patients' perspectives on their weight and lifestyle.

CONCLUSIONS

Many women with early-stage breast cancer and obesity have concerns about weight and weight gain and urge their oncologists to use an active and personalized approach in recommending and supporting efforts at weight management.

LAY SUMMARY

Focus group discussions with Black and White women with early-stage breast cancer and obesity have elicited patient perspectives on conversations with their oncologists about weight and weight management. Many patients have concerns about weight and weight gain and urge their oncologists to use an active and personalized approach in recommending and supporting efforts at weight management.

Mediterranean Diet and Lifestyle Habits during Pregnancy: Is There an Association with Small for Gestational Age Infants? An Italian Single Centre Experience

Background. The small-for-gestational-age (SGA) in infants is related to an increased risk of developing Non-Communicable Diseases later in life. The Mediterranean diet (MD) is related to lower odds of being SGA. The study explored retrospectively the association between SGA, maternal MD adherence, lifestyle habits and other SGA risk factors during pregnancy. Methods. One hundred women (16–44 years) with a pregnancy at term were enrolled. Demographic data, parity, pre-gestational BMI, gestational weight gain, pregnancy-related diseases, and type of delivery were collected. The MD adherence (MEDI-LITE score ≥ 9), physical activity level, and smoking/alcohol consumption were registered. SGA neonates were diagnosed according to the neonatal growth curves. Results. Women were divided into “SGA group” vs. “non-SGA group”. The MD was adopted by 71% of women and its adherence was higher in the “non-SGA group” (p = 0.02). The prevalence of pregnancy-related diseases (gestational diabetes/pregnancy-induced hypertension) was higher in the “SGA group” (p = 0.01). The logistic regression showed that pregnancy-related diseases were the only independent risk factor for SGA. Conclusions. MD may indirectly reduce the risk of SGA since it prevents and exerts a positive effect on pregnancy-related diseases (e.g., gestational diabetes and hypertension). The small sample size of women in the SGA group of the study imposes a major limitation to the results and conclusions of this research, suggesting however that it is worthy of further investigation.