The Weight of Place: Built Environment Correlates of Obesity and Diabetes

Atherosclerotic Cardiovascular Disease Primary and Secondary Prevention in Latino Subgroups

BACKGROUND

Studies assessing equity in the prevention of atherosclerotic cardiovascular disease (ASCVD) for Latinos living in the USA collectively yield mixed results. Latino persons are diverse in many ways that may influence cardiovascular health. The intersection of Latino nativity and ASCVD prevention is understudied.

OBJECTIVE

To determine whether disparities in ASCVD screening, detection, and prescribing differ for US Latinos by country of birth.

DESIGN

A retrospective cohort design utilizing 2014-2020 electronic health record data from a network of 320 community health centers across 12 states. Analyses occurred October 1, 2022, to September 30, 2023.

PARTICIPANTS

Non-Hispanic White and Latino adults age 20-75 years, born in Cuba, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, and the USA.

EXPOSURES

Ethnicity and country of birth.

MAIN MEASURES

Outcome measures included prevalence of statin eligibility, of having insufficient data to establish eligibility, odds of having a documented statin prescription, and rates of statin prescriptions and refills. We used covariate-adjusted logistic and generalized estimating equations logistic and negative binomial regressions to generate absolute and relative measures.

KEY RESULTS

Among 108,672 adults, 23% (n = 25,422) were statin eligible for primary or secondary prevention of ASCVD using American College of Cardiology/American Heart Association guidelines. Latinos, born in and outside the USA were more likely eligible than Non-Hispanic White patients were (US-born Latino OR = 1.55 (95% CI = 1.37-1.75); non-US-born Latino OR = 1.63 (95% CI = 1.34-1.98)). The eligibility criteria that was met differed by ethnicity and nativity. Latinos overall were less likely missing data to establish eligibility and differences were again observed by specific non-US country of origin. Among those eligible, we observed no statistical difference in statin prescribing between US-born Latinos and non-Hispanic White persons; however, disparities varied by specific non-US country of origin.

CONCLUSION

Efforts to improve Latino health in the USA will require approaches for preventing and reversing cardiovascular risk factors, and statin initiation that are Latino subgroup specific.

Association of neighbourhood walkability and haemoglobin A1c levels among Latino and non-Hispanic White patients with diabetes

BACKGROUND

Neighbourhood walkability can benefit cardiovascular health. Latino patients are more likely than non-Hispanic White patients to have diabetes, and evidence has shown better diabetes-related outcomes for patients living in neighbourhoods conducive to physical activity. Our objective was to determine whether neighbourhood walkability was associated with haemoglobin A1c (HbA1c) levels among English- and Spanish-preferring Latino patients compared to non-Hispanic White patients.

METHODS

We used electronic health record data from patients in the OCHIN, Inc. network of community health centres (CHC) linked to public walkability data. Patients included those age ≥ 18 with ≥ 1 address recorded, with a study clinic visit from 2012 to 2020, and a type 2 diabetes diagnosis (N = 159,289). Generalized estimating equations logistic regression, adjusted for relevant covariates, was used to model the primary binary outcome of always having HbA1c < 7 by language/ethnicity and walkability score.

RESULTS

For all groups, the walkability score was not associated with higher odds and prevalence of always having HbA1c < 7. Non-Hispanic White patients were most likely to have HbA1c always < 7 (prevalence ranged from 32.8% [95%CI = 31.2-34.1] in the least walkable neighbourhoods to 33.4% [95% CI 34.4-34.7] in the most walkable), followed by English-preferring Latinos (28.6% [95%CI = 25.4-31.8]-30.7% [95% CI 29.0-32.3]) and Spanish-preferring Latinos (28.3% [95% CI 26.1-30.4]-29.3% [95% CI 28.2-30.3]).

CONCLUSIONS

While walkability score was not significantly associated with glycaemic control, control appeared to increase with walkability, suggesting other built environment factors, and their interaction with walkability and clinical care, may play key roles. Latino patients had a lower likelihood of HbA1c always < 7, demonstrating an opportunity for equity improvements in diabetes care.

Neighborhood built and food environment in relation to glycemic control in people with type 2 diabetes in the moving to health study

OBJECTIVE

To examine whether built environment and food metrics are associated with glycemic control in people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We included 14,985 patients with type 2 diabetes using electronic health records from Kaiser Permanente Washington. Patient addresses were geocoded with ArcGIS using King County and Esri reference data. Built environment exposures estimated from geocoded locations included residential unit density, transit threshold residential unit density, park access, and having supermarkets and fast food restaurants within 1600-m Euclidean buffers. Linear mixed effects models compared mean changes of HbA1c from baseline at 1, 3 (primary) and 5 years by each built environment variable.

RESULTS

Patients (mean age = 59.4 SD = 13.2, 49.5% female, 16.6% Asian, 9.8% Black, 5.5% Latino/Hispanic, 57.1% White, 20% insulin dependent, mean BMI = 32.7±7.7) had an average of 6 HbA1c measures available. Participants in the 1st tertile of residential density (lowest) had a greater decline in HbA1c (-0.42, -0.43, and -0.44 in years 1, 3, and 5 respectively) than those in the 3rd tertile (HbA1c = -0.37 at 1- and 3-years and -0.36 at 5-years; all p-values <0.05). Having any supermarkets within 1600 m of home was associated with a greater decrease in HbA1c at 1-year and 3-years compared to having none (all p-values <0.05).

CONCLUSIONS

Lower residential density and better proximity to supermarkets may benefit HbA1c control in people with people with type 2 diabetes. However, effects were small and indicate limited clinical significance.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Spatial Vision Inequalities: A Literature Review of the Impact of Place on Vision and Eye Health Outcomes

"Neighborhood and built environment" is one of the five domains of social determinants of health that has been outlined by Healthy People 2030, and this domain impacts an individual's well-being, health, and quality of life. Social risk factors (SRFs) in the neighborhood and built environment domain include unstable or unsafe housing, poor access to transportation, lack of green spaces, pollution, safety concerns, and neighborhood measures of inequity. In this narrative literature review, we assess the relationship between neighborhood and built environment SRFs and eye health and vision outcomes. We explain how mapping neighborhood-level SRFs may be used to advance health equity in the field of eye health and vision care.

Metabolic diseases and healthy aging: identifying environmental and behavioral risk factors and promoting public health

Aging is a progressive and irreversible pathophysiological process that manifests as the decline in tissue and cellular functions, along with a significant increase in the risk of various aging-related diseases, including metabolic diseases. While advances in modern medicine have significantly promoted human health and extended human lifespan, metabolic diseases such as obesity and type 2 diabetes among the older adults pose a major challenge to global public health as societies age. Therefore, understanding the complex interaction between risk factors and metabolic diseases is crucial for promoting well-being and healthy aging. This review article explores the environmental and behavioral risk factors associated with metabolic diseases and their impact on healthy aging. The environment, including an obesogenic environment and exposure to environmental toxins, is strongly correlated with the rising prevalence of obesity and its comorbidities. Behavioral factors, such as diet, physical activity, smoking, alcohol consumption, and sleep patterns, significantly influence the risk of metabolic diseases throughout aging. Public health interventions targeting modifiable risk factors can effectively promote healthier lifestyles and prevent metabolic diseases. Collaboration between government agencies, healthcare providers and community organizations is essential for implementing these interventions and creating supportive environments that foster healthy aging.

Trends in physical activity and sedentary time among U.S. adults with diabetes: 2007-2020

AIMS

To examine temporal trends in physical activity and sedentary time among U.S. adults with diabetes from 2007 to 2020.

METHODS

We performed serial cross-sectional analyses for participants aged ≥ 20 years with diagnosed diabetes from the U.S. National Health and Nutrition Examination Survey from 2007 to 2020. Participants completed the Global Physical Activity Questionnaire.

RESULTS

The analytic sample comprised 5096 adults with diabetes (mean age: 60.3 years; 48.2% females; 60.1% White people; mean body mass index: 33.0 kg/m2). From 2007-2008 through 2017-March 2020, the proportion of being physically sufficiently active increased from 41.5% (95% CI, 35.9%-47.2%) to 55.8% (95% CI, 51.3%-60.3%) (P-trend<0.001), whereas that of physical inactivity declined from 43.7% (95% CI, 38.1%-49.2%) to 31.0% (95% CI, 27.7%-34.3%) (P-trend<0.001). The decline was driven by increasing engagement in work-related and leisure-time activity. However, engagement in transportation-related activity stayed persistently low (16.7% [95% CI, 14.8%-18.8%] in 2017-March 2020) (P-trend = 0.25), and the mean daily sitting hours remained unaltered (6.2 [95% CI, 5.9-6.5] in 2017-March 2020) (P-trend = 0.60). Adults who were middle-aged or older, or with class III obesity, cardiovascular or chronic kidney concomitants were less likely to be sufficiently active and prone to prolonged sitting.

CONCLUSIONS

Physical activity levels in U.S. adults with diabetes have increased from 2007 to 2020, but about one in two remains inactive or insufficiently active. Sedentary time has not decreased. For diabetes management, nationwide efforts are needed to promote transportation-related physical activity while minimizing prolonged sitting, especially among those who are middle-aged or older, or with severe obesity or other complications.

Dietary Pattern Indicators among Healthy and Unhealthy Weight Adolescents Residing in Different Contexts across the Otago Region, New Zealand

Reported obesity rates for adolescents in different urban and rural areas are inconsistent. We examined indicators of healthy and unhealthy dietary patterns among 1863 adolescents aged 13-18 years with a healthy or excess body weight attending 23 secondary schools in four different settlement types across the Otago region, New Zealand. An online survey included demographics and dietary behaviours. Height and weight were measured, and body mass index was calculated. New Zealand defined urban and rural settlement types were used. Home addresses determined a small area-level index of deprivation. Data were analysed using Chi-square tests and ANOVA. A logistic model was fitted to estimate adjusted odds ratios of excess weight. The proportion of adolescents with a healthy weight differed (p < 0.001) between the most (64.9%) and least (76.4%) deprived neighbourhood areas. There was only indicative evidence of differences between settlement types (p = 0.087). Sugar-sweetened beverage and fast-food consumption was more frequent in the most deprived areas (p < 0.001), and in urban versus rural settlements (p < 0.001). The most important associations with excess weight were area-level deprivation and ethnicity, but not settlement type. Prioritising socioeconomic factors irrespective of settlement type is necessary when developing interventions to improve dietary patterns and body weight status among adolescents.

Association of community walkability and glycemic control among pregnant individuals with pregestational diabetes mellitus

BACKGROUND

Neighborhood walkability is a community-level social determinant of health that measures whether people who live in a neighborhood walk as a mode of transportation. Whether neighborhood walkability is associated with glycemic control among pregnant individuals with pregestational diabetes remains to be defined.

OBJECTIVE

This study aimed to evaluate the association between community-level neighborhood walkability and glycemic control as measured by hemoglobin A1c (A1C) among pregnant individuals with pregestational diabetes.

STUDY DESIGN

This was a retrospective analysis of pregnant individuals with pregestational diabetes enrolled in an integrated prenatal and diabetes care program from 2012 to 2016. Participant addresses were geocoded and linked at the census-tract level. The exposure was community walkability, defined by the US Environmental Protection Agency National Walkability Index (score range 1-20), which incorporates intersection density (design), proximity to transit stops (distance), and a mix of employment and household types (diversity). Individuals from neighborhoods that were the most walkable (score, 15.26-20.0) were compared with those from neighborhoods that were less walkable (score <15.26), as defined per national Environmental Protection Agency recommendations. The outcomes were glycemic control, including A1C <6.0% and <6.5%, measured both in early and late pregnancy, and mean change in A1C across pregnancy. Modified Poisson regression and linear regression were used, respectively, and adjusted for maternal age, body mass index at delivery, parity, race and ethnicity as a social determinant of health, insurance status, baseline A1C, gestational age at A1C measurement in early and late pregnancy, and diabetes type.

RESULTS

Among 417 pregnant individuals (33% type 1, 67% type 2 diabetes mellitus), 10% were living in the most walkable communities. All 417 individuals underwent A1C assessment in early pregnancy (median gestational age, 9.7 weeks; interquartile range, 7.4-14.1), and 376 underwent another A1C assessment in late pregnancy (median gestational age, 30.4 weeks; interquartile range, 27.8-33.6). Pregnant individuals living in the most walkable communities were more likely to have an A1C <6.0% in early pregnancy (15% vs 8%; adjusted relative risk, 1.46; 95% confidence interval, 1.00-2.16), and an A1C <6.5% in late pregnancy compared with those living in less walkable communities (13% vs 9%; adjusted relative risk, 1.33; 95% confidence interval, 1.08-1.63). For individuals living in the most walkable communities, the median A1C was 7.5 (interquartile range, 6.0-9.4) in early pregnancy and 5.9 (interquartile range, 5.4-6.4) in late pregnancy. For those living in less walkable communities, the median A1C was 7.3 (interquartile range, 6.2-9.2) in early pregnancy and 6.2 (interquartile range, 5.6-7.1) in late pregnancy. Change in A1C across pregnancy was not associated with walkability.

CONCLUSION

Pregnant individuals with pregestational diabetes mellitus living in more walkable communities had better glycemic control in both early and late pregnancy. Whether community-level interventions to enhance neighborhood walkability can improve glycemic control in pregnancy requires further study.

Linking the Urban Environment and Health: An Innovative Methodology for Measuring Individual-Level Environmental Exposures

Environmental exposures (EE) are increasingly recognised as important determinants of health and well-being. Understanding the influences of EE on health is critical for effective policymaking, but better-quality spatial data is needed. This article outlines the theoretical and technical foundations used for the construction of individual-level environmental exposure measurements for the population of a northern English city, Bradford. The work supports 'Connected Bradford', an entire population database linking health, education, social care, environmental and other local government data over a period of forty years. We argue that our current understanding of environmental effects on health outcomes is limited both by methodological shortcomings in the quantification of the environment and by a lack of consistency in the measurement of built environment features. To address these shortcomings, we measure the environmental exposure for a series of different domains including air quality, greenspace and greenness, public transport, walkability, traffic, buildings and the built form, street centrality, land-use intensity, and food environments as well as indoor dwelling qualities. We utilise general practitioners' historical patient information to identify the precise geolocation and duration of a person's residence. We model a person's local neighbourhood, and the probable routes to key urban functions aggregated across the city. We outline the specific geospatial procedure used to quantify the environmental exposure for each domain and use the example of exposure to fast-food outlets to illustrate the methodological challenges in the creation of city and nationwide environmental exposure databases. The proposed EE measures will enable critical research into the relationship and causal links between the built environment and health, informing planning and policy-making.

The Gangwon Obesity and Metabolic Syndrome Study: Methods and Initial Baseline Data

Background

The prevalence of obesity has been continuously increasing, especially in rural areas of South Korea. Therefore, it is important to examine various genetic, behavioral, and environmental factors associated with obesity in these rural areas. The Korean Society for the Study of Obesity commenced a community-based prospective cohort study of the Gangwon area called the Gangwon Obesity and Metabolic Syndrome (GOMS) study to investigate longitudinal changes in the status of obesity and its related factors.

Methods

A total of 317 adults 40-69 years of age were recruited from Hongcheon and Inje districts, Gangwon province, as part of the first wave of this cohort study. Information on participants' demographic, behavioral, psychological, dietary, and environmental factors and past medical histories were collected by self-administered questionnaires and interviewer-administered questionnaires. Anthropometric measurements, blood tests, and a hand grip strength test were performed, and skin keratin and stool samples were collected. Among the 317 enrolled subjects, two participants who did not have anthropometric data were excluded from the data analyses, resulting in an inclusion of a total of 315 participants.

Results

The mean age of the 315 participants in the GOMS initial baseline survey was 58.5 years old, 87 of them were men, and the mean body mass index was 24.7±3.7 kg/m². Among all participants, 48.9% had hypertension, 21.4% had diabetes mellitus (DM), 55.6% had dyslipidemia, and 46.0% had metabolic syndrome (MS). Both the prevalence rates of DM and MS were significantly higher in men.

Conclusion

The first baseline survey of the GOMS study was initiated, and a more detailed analysis of respondents' data is expected to be continued. Further follow-up and additional recruitment will allow the investigation of risk factors and the etiology of obesity and its comorbidities in rural areas of Gangwon province.

Neighborhood walkability and sex steroid hormone levels in women

BACKGROUND

Neighborhood walkability (NW) has been linked to increased physical activity, which in turn is associated with lower concentrations of sex hormones and higher concentration of SHBG in women. However, no study has directly examined the association of NW with female sex hormone levels.

OBJECTIVE

We conducted a cross-sectional study to evaluate the association between NW and circulating levels of sex hormones and SHBG in pre- and post-menopausal women.

METHODS

We included 797 premenopausal and 618 postmenopausal women from the New York University Women's Health Study (NYUWHS) who were healthy controls in previous nested case-control studies in which sex hormones (androstenedione, testosterone, DHEAS, estradiol and estrone) and SHBG had been measured in serum at enrollment. Baseline residential addresses were geo-coded and the Built Environment and Health Neighborhood Walkability Index (BEH-NWI) was calculated. Generalized Estimating Equations were used to assess the association between BEH-NWI and sex hormone and SHBG concentrations adjusting for individual- and neighborhood-level factors.

RESULTS

In premenopausal women, a one standard deviation (SD) increment in BEH-NWI was associated with a 3.5% (95% CI 0.9%-6.1%) lower DHEAS concentration. In postmenopausal women, a one SD increment in BEH-NWI was related to an 8.5% (95% CI 5.4%-11.5%) lower level of DHEAS, a 3.7% (95% CI 0.5%-6.8%) lower level of testosterone, a 1.8% (95% CI 0.5%-3.0%) lower level of estrone, and a 4.2% (95% CI 2.7%-5.7%) higher level of SHBG. However, the associations with respect to DHEAS and estrone became apparent only after adjusting for neighborhood-level variables. Sensitivity analyses using fixed effects meta-analysis and inverse probability weighting accounting for potential selection bias yielded similar results.

CONCLUSION

Our findings suggest that NW is associated with lower concentrations of androgens and estrone, and increased SHBG, in postmenopausal women, and lower levels of DHEAS in premenopausal women.

Impacts of a Workplace-Based Weight-Control Intervention on Objective and Perceived Physical Activity among a Subgroup of Workers

Physical activity (PA) has many benefits; however, groups facing barriers to health-promoting behaviors are less likely to be physically active. This may be addressed through workplace interventions. The current study employs objective (accelerometry) and perceived (International Physical Activity Questionnaire [IPAQ]) measures of PA among a subset of participants from the "Working for You" study, which tests a multi-level (work group and individual) workplace intervention targeted at workers with low-incomes. Linear mixed and hierarchical logistic regression models are used to determine the intervention's impact on moderate- to vigorous-PA (MVPA) and achieving the PA Guideline for Americans (≥150 minutes MVPA/week), respectively from baseline to 6- and 24-months, relative to a control group. Correlations (Spearman Rho) between perceived and objective PA are assessed. Of the 140 workers (69 control, 71 intervention) in the sub-study, 131 (94%) have valid data at baseline, 88 (63%) at 6-months, and 77 (55%) at 24-months. Changes in MVPA are not significantly different among intervention relative to control participants assessed by accelerometer or IPAQ at 6- or 24-months follow-up. The percent achieving the PA Guideline for Americans does not vary by treatment group by any measure at any time point (e.g., baseline accelerometry: [control: n=37 (57%); intervention: n=35 (53%)]). This study identifies limited agreement (correlation range: 0.04 to 0.42, all p>.05) between perceived and objective measures. Results suggest the intervention did not improve PA among the sub-study participants. Though agreement between objective and perceived MVPA is low, similar conclusions regarding intervention effectiveness are drawn.

How Impulsiveness Influences Obesity: The Mediating Effect of Resting-State Brain Activity in the dlPFC

Impulsiveness is a stable personal characteristic that contributes to obesity and may interact with it. Specifically, obesity is caused by unrestrained impulse eating that is not consciously controlled and leads to a hormonal imbalance that also can impair impulse control. However, the mechanism of this relationship is unclear. In our study, 35 obese individuals (body mass index, BMI > 28) were recruited and matched with 31 healthy controls (BMI < 24) in age and education level. All the participants underwent a resting-state fMRI and completed the Barratt Impulsiveness Scale-11. The results showed that patients with obesity had a significantly lower fractional amplitude of low-frequency fluctuations (fALFF) in the bilateral dorsolateral prefrontal cortex (dlPFC) and higher fALFF in the left fusiform cortex. In addition, non-planning impulsiveness was positively correlated with BMI. Importantly, we found that the right dlPFC completely mediated the relationship between non-planning impulsiveness and BMI. Our findings suggest that impulsivity is statistically more likely to precede obesity than to precede impulsivity and contributes to obesity by downregulating spontaneous activity in the dlPFC. This suggests that the dlPFC, which is associated with executive control, may be able a potential target for treating obesity.