Behavioral Risk Factor Surveillance System Research Articles

Trends in Sexual Orientation and Gender Identity Data Collection.

The aim of this study was to determine response patterns to sexual orientation and gender identity (SOGI) questions in the Behavioral Risk Factor Surveillance System (BRFSS) over time and to assess nonresponse and indeterminate responses by demographic characteristics. This is a secondary data analysis of the SOGI module of the BRFSS. We used data from 46 states and Guam that implemented SOGI questions between 2014 and 2022. We used weighted analyses that accounted for the sampling design, determined SOGI response patterns by year, and assessed nonresponse and indeterminate responses by demographic characteristics. Over time, increasing numbers self-reported as sexual and gender minority respondents, while heterosexual identity declined. Sexual orientation nonresponse and indeterminate responses increased with time, while respondents' reports of not knowing gender identity declined. Hispanic, older, respondents, those with lower education, and those who completed the questionnaire in Spanish had higher SOGI nonresponse and indeterminate responses. The low amount of SOGI nonresponse and indeterminate responses in the BRFSS can be instructive for the implementation of SOGI questions in medical settings. SOGI data collection in all settings requires improving procedures for the groups that have been shown to have elevated nonresponse and indeterminate response.

Medicare Eligibility and Changes in Coverage, Access to Care, and Health by Sexual Orientation and Gender Identity

Medicare provides nearly universal insurance coverage at age 65 years. However, how Medicare eligibility affects disparities in health insurance coverage, access to care, and health status among individuals by sexual orientation and gender identity is poorly understood. To assess the association of Medicare eligibility with disparities in health insurance coverage, access to care, and self-reported health status among individuals by sexual orientation and by gender identity. This cross-sectional study used the age discontinuity for Medicare eligibility at age 65 years to isolate the association of Medicare with health insurance coverage, access to care, and self-reported health status, by their sexual orientation and by their gender identity. Data were collected from the Behavioral Risk Factor Surveillance System for respondents from 51 to 79 years old from 2014 to 2021. Data analysis was performed from September 2022 to April 2023. Medicare eligibility at age 65 years. Proportions of respondents with health insurance coverage, usual source of care, cost barriers to care, influenza vaccination, and self-reported health status. The study population included 927 952 individuals (mean [SD] age, 64.4 [7.7] years; 524 972 [56.6%] females and 402 670 [43.4%] males), of whom 28 077 (3.03%) identified as a sexual minority-lesbian, gay, bisexual, or another sexual minority identity (LGB+) and 3286 (0.35%) as transgender or gender diverse. Respondents who identified as heterosexual had greater improvements at age 65 years in insurance coverage (4.2 percentage points [pp]; 95% CI, 4.0-4.4 pp) than those who identified as LGB+ (3.6 pp; 95% CI, 2.3-4.8 pp), except when the analysis was limited to a subsample of married respondents. For access to care, improvements in usual source of care, cost barriers to care, and influenza vaccination were larger at age 65 years for heterosexual respondents compared with LGB+ respondents, although confidence intervals were overlapping and less precise for LGB+ individuals. For self-reported health status, the analyses found larger improvements at age 65 years for LGB+ respondents compared with heterosexual respondents. There was considerable heterogeneity by state in disparities by sexual orientation among individuals who were nearly eligible for Medicare (close to 65 years old), with the US South and Central states demonstrating the highest disparities. Among the top-10 highest-disparities states, Medicare eligibility was associated with greater increases in coverage (6.7 pp vs 5.0 pp) and access to a usual source of care (1.4 pp vs 0.6 pp) for LGB+ respondents compared with heterosexual respondents. The findings of this cross-sectional study indicate that Medicare eligibility was not associated with consistently greater improvements in health insurance coverage and access to care among LGBTQI+ individuals compared with heterosexual and/or cisgender individuals. However, among sexual minority individuals, Medicare may be associated with closing gaps in self-reported health status, and among states with the highest disparities, it may improve health insurance coverage, access to care, and self-reported health status.

Exposure to structural racism-related state laws is associated with worse cardiovascular health among US adults, BRFSS 2011 and 2013.

The objective of this study was to determine whether exposure to structural racism-related state laws is associated with cardiovascular health among a racially and ethnically diverse sample of US adults. Data were from the Database of Structural Racism-Related State Laws and the Behavioral Risk Factor Surveillance System (BRFSS). The sample included 958,019 BRFSS 2011 and 2013 respondents aged 18+ from all 50 US states. The exposure was a summary index of 22 state laws related to the criminal legal system, economics and labor, education, healthcare, housing, immigration, and political participation. The outcome was the American Heart Association's Life's Simple 7 (LS7), a summary index of seven cardiovascular health indicators. Linear regression models included fixed effects for year and state to control for time trends and unmeasured time-invariant state-level contextual factors. In the full sample, a one standard deviation increase in the structural racism state legal index was associated with a 0.06-unit decrease in the LS7 (b=-0.06; 95% CI:-0.09, 0.02; p=0.001), controlling for individual- and state-level covariates. Contrary to expectations, stratified models revealed no statistically significant differences by race and ethnicity in the association between the structural racism state legal index and the LS7.

Adverse Childhood Experiences, Substance Use, and Poor Mental Health Among the U.S. Adult Population

Adverse childhood experiences (ACEs) are linked to various lifelong negative outcomes. However, there is little counseling literature on the effects of ACEs on adult mental health. Utilizing the 2021 Behavioral Risk Factor Surveillance System dataset, we examined individual ACEs and cumulative ACEs scores to quantify the relationship between ACEs and behavioral and mental health outcomes. Findings showed that 60.9% of the participants experienced at least one ACE, with nearly 1 in 6 participants reporting four or more ACEs. Childhood emotional abuse was the most prevalent form of ACE reported. Multiple logistic regression analyses adjusting for sociodemographic covariates showed that reporting any of the ACEs was significantly associated with heavy alcohol use, marijuana use, and poor mental health. Furthermore, a graded dose-response relationship was found between cumulative ACEs scores and outcome variables. The findings highlight the importance of consciously screening and considering ACEs to better assist clients with presenting behavioral and mental health issues.

Leveraging multivariate analysis and adjusted mutual information to improve stroke prediction and interpretability.

To develop a machine learning model to accurately predict stroke risk based on demographic and clinical data. It also sought to identify the most significant stroke risk factors and determine the optimal machine learning algorithm for stroke prediction. This cross-sectional study analyzed data on 438,693 adults from the 2021 Behavioral Risk Factor Surveillance System. Features encompassed demographics and clinical factors. Descriptive analysis profiled the dataset. Logistic regression quantified risk relationships. Adjusted mutual information evaluated feature importance. Multiple machine learning models were built and evaluated on metrics like accuracy, AUC ROC, and F1 score. Key factors significantly associated with higher stroke odds included older age, diabetes, hypertension, high cholesterol, and history of myocardial infarction or angina. Random forest model achieved the best performance with accuracy of 72.46%, AUC ROC of 0.72, and F1 score of 0.74. Cross-validation confirmed its reliability. Top features were hypertension, myocardial infarction history, angina, age, diabetes status, and cholesterol. The random forest model robustly predicted stroke risk using demographic and clinical variables. Feature importance highlighted priorities like hypertension and diabetes for clinical monitoring and intervention. This could help enable data-driven stroke prevention strategies.

A Brief Report of Lung Cancer Screening Utilization Prior to, During, and in the Later Stages of the COVID-19 Pandemic in the United States

IntroductionWhile COVID-19 has impacted healthcare and screening utilization, its impact on lung cancer screening (LCS) uptake remains unclear. Our study investigated LCS utilization and associated predictors among LCS-eligible adults before (2019), during (2020-2021), and at a later stage (2022) of COVID-19. MethodsWe used cross-sectional, nationally representative, population-based data from the Behavioral Risk Factor Surveillance System over four consecutive years: 2019 (n=4,484; weighted n=1,559,137), 2020 (n=1,239; weighted n=200,301), 2021 (n=1,673; weighted n=668,359), and 2022 (n=20,804; weighted n=9,458,907). The outcome was self-reported LCS uptake (0= did not have LCS in the past 12 months and 1=underwent LCS in the past 12 months). We conducted weighted statistics and multivariable logistic regression. ResultsOverall, out of 11,886,704 million LCS-eligible individuals, 2,129,900 received LCS in four years (2019-2022). National rates of LCS among screening-eligible individuals were 16.3% (95%CI:14.4-18.5), 19.4% (95%CI:15.3-24.3), 18.3% (95%CI:15.6-21.3) and 18.1% (95%CI:17.1-19.2) in 2019, 2020, 2021 and 2022, respectively. Respondents reporting lung disease and cancer (other than lung cancer) history were more likely to receive LCS across all four years. During the pandemic (2020), Hispanic (vs. White), and rural (vs. urban) residents have lower odds of LCS utilization. In 2022, men had increased odds of reporting LCS use relative to women. No sex differences in LCS use were observed in previous years. ConclusionOur findings indicate consistently low LCS utilization (<20%) over four years. Nationwide efforts to boost LCS awareness and utilization are essential for mitigating the lung cancer burden in the US.

Gardening and subjective cognitive decline: a cross-sectional study and mediation analyses of 136,748 adults aged 45+ years

BackgroundGiven the benefits of gardening for physical and psychological health, we explored whether gardening was associated with lower risks of subjective cognitive decline (SCD), a precursor of dementia, and SCD-related functional limitations.MethodsIncluded in this cross-sectional study were 136,748 participants aged 45 + years old from the Behavioral Risk Factor Surveillance System 2019 survey, who were then categorized into three groups according to self-reported exercise status: non-exercisers, gardeners, and other exercisers. SCD was assessed via a questionnaire, and SCD-related functional limitations were referred to as having difficulties in engaging in household or social activities due to SCD. The odds ratio (OR) and 95% confidence interval (CI) were calculated to assess the associations of gardening with SCD and SCD-related functional limitations, adjusted for age, sex, socioeconomic status, lifestyle factors, and health status. Mediation analyses were conducted to examine whether the observed association between gardening and SCD was mediated by energy expenditure (MET-hours/week), depression status, and consumption of fruits and vegetables.ResultsOverall, 11.1% and 5.4% of participants self-reported experiencing SCD and SCD-related functional limitations, respectively. The adjusted OR for gardeners vs. non-exercisers, was 0.72 (95% CI 0.62–0.83) for SCD and 0.57 (95% CI 0.44–0.73) for SCD-related functional limitations. The observed association between gardening and SCD was explained by higher energy expenditure (39.0%), lower likelihood of having depression (21.5%), and higher consumption of fruits and vegetables (3.4%) (P<0.05 for all). Similar patterns were observed for SCD-related functional limitations.ConclusionIn this nationally representative sample, gardening was associated with better cognitive status, which may be mainly attributed to better depression status and energy expenditure.

Access to Prostate-Specific Antigen Testing and Mortality Among Men With Prostate Cancer.

Prostate-specific antigen (PSA) screening for prostate cancer is controversial but may be associated with benefit for certain high-risk groups. To evaluate associations of county-level PSA screening prevalence with prostate cancer outcomes, as well as variation by sociodemographic and clinical factors. This cohort study used data from cancer registries based in 8 US states on Hispanic, non-Hispanic Black, and non-Hispanic White men aged 40 to 99 years who received a diagnosis of prostate cancer between January 1, 2000, and December 31, 2015. Participants were followed up until death or censored after 10 years or December 31, 2018, whichever end point came first. Data were analyzed between September 2023 and January 2024. County-level PSA screening prevalence was estimated using the Behavior Risk Factor Surveillance System survey data from 2004, 2006, 2008, 2010, and 2012 and weighted by population characteristics. Multivariable logistic, Cox proportional hazards regression, and competing risks models were fit to estimate adjusted odds ratios (AOR) and adjusted hazard ratios (AHR) for associations of county-level PSA screening prevalence at diagnosis with advanced stage (regional or distant), as well as all-cause and prostate cancer-specific survival. Of 814 987 men with prostate cancer, the mean (SD) age was 67.3 (9.8) years, 7.8% were Hispanic, 12.2% were non-Hispanic Black, and 80.0% were non-Hispanic White; 17.0% had advanced disease. There were 247 570 deaths over 5 716 703 person-years of follow-up. Men in the highest compared with lowest quintile of county-level PSA screening prevalence at diagnosis had lower odds of advanced vs localized stage (AOR, 0.86; 95% CI, 0.85-0.88), lower all-cause mortality (AHR, 0.86; 95% CI, 0.85-0.87), and lower prostate cancer-specific mortality (AHR, 0.83; 95% CI, 0.81-0.85). Inverse associations between PSA screening prevalence and advanced cancer were strongest among men of Hispanic ethnicity vs other ethnicities (AOR, 0.82; 95% CI, 0.78-0.87), older vs younger men (aged ≥70 years: AOR, 0.77; 95% CI, 0.75-0.79), and those in the Northeast vs other US Census regions (AOR, 0.81; 95% CI, 0.79-0.84). Inverse associations with all-cause mortality were strongest among men of Hispanic ethnicity vs other ethnicities (AHR, 0.82; 95% CI, 0.78-0.85), younger vs older men (AHR, 0.81; 95% CI, 0.77-0.85), those with advanced vs localized disease (AHR, 0.80; 95% CI, 0.78-0.82), and those in the West vs other US Census regions (AHR, 0.89; 95% CI, 0.87-0.90). This population-based cohort study of men with prostate cancer suggests that higher county-level prevalence of PSA screening was associated with lower odds of advanced disease, all-cause mortality, and prostate cancer-specific mortality. Associations varied by age, race and ethnicity, and US Census region.

Evaluating the impact of depression on self-reported quality of life measurements for patients with a history of cancer: A 2022 behavioral risk factor surveillance system questionnaire study.

e23131 Background: Patients with cancer are known to have higher rates of depression than the general population. Depression is known to impact cancer-specific outcomes. We aimed to understand if a history of depression for patients with a history of cancer impacts self-reported quality of life measurements. Methods: We identified patients with a history of cancer and patients with a history of depression using the 2022 phone based Behavioral Risk Factor Surveillance System Questionnaire. The demographics and reported outcomes for several quality-of-life questions, including perceived emotional support, social isolation, cancer-related pain, memory, and ability to complete daily activities independently, were compared using a Chi-Square analysis. Results: Of the 441,339 patients over the age of 18 who completed the 2022 survey, 72,765 (16%) reported a history of cancer, and 90,489 (21%) reported a history of depression. Of those patients who reported a history of cancer 72,443 (99.6%) answered if they had ever been diagnosed with depression, and of these 14,987 (21%) reported a history of depression. Compared to patients with cancer alone, patients with a history of cancer and depression were younger (10% vs. 4% under the age of 45, p &lt; 0.001), less often married (45% vs.59%, p &lt; 0.001), more likely to be in the lowest income bracket (8% vs. 3%, p &lt; 0.001), more likely to be obese (36% vs. 26%, p &lt; 0.001), and more often active smokers (16% vs. 7%, p &lt; 0.001). Several quality-of-life questions were asked of the participants, although not everyone answered each question. Overall, among patients with cancer, patients with a history of depression were more likely to report &gt; 14 poor mental health or physical health days (35% vs. 6% and 34% vs. 14%, respectively, p &lt; 0.001) and more likely to report their general health as fair or poor (41% vs. 21%, p &lt; 0.001). Cancer patients with depression were less likely to report always having the social or emotional support that they need (33% vs. 55%, p &lt; 0.001) and more likely to report always or usually feeling socially isolated (17% vs. 5%, p &lt; 0.001). Cancer patients with depression were more likely to report pain associated with their cancer (16% vs. 7%, p &lt; 0.001) and five times as likely to report issues with making decisions and memory (31% vs. 6%, p &lt; 0.001). Finally, patients with depression were also more likely to report an inability to run errands alone (21% vs. 7%) and report difficulty getting dressed or bathing (12% vs. 4%, p &lt; 0.001). Conclusions: Among people with a history of cancer, those with a history of depression are more likely to report worse physical and mental health, report worse social and emotional support and report less independence in activities of daily living. Further work is needed to understand the complex interactions between depression and quality-of-life measures for cancer patients.

The Association of County-level Prostate-specific Antigen Screening with Metastatic Prostate Cancer and Prostate Cancer Mortality

Background and objectiveThere exists ongoing debate about the benefits and harms of prostate-specific antigen (PSA) screening for prostate cancer. This study sought to evaluate the association of county-level PSA screening rates with county-level incidence of metastatic prostate cancer and prostate cancer mortality in the USA. MethodsThis ecological study used data from the 2004–2012 Behavioral Risk Factor Surveillance System (BRFSS) to build a multilevel mixed-effect model with poststratification using US Census data to estimate county-level PSA screening rates for all 3143 US counties adjusted for age, race, ethnicity, and county-level poverty rates. The exposure of interest was average county-level PSA screening rate from 2004 to 2012, defined as the proportion of men aged 40–79 yr who underwent PSA screening within the prior 2 yr. The primary outcomes were county-level age-adjusted incidence of regional/distant prostate cancer during 2015–2019 and age-adjusted prostate cancer mortality during 2016–2020. Key findings and limitationsA total of 416221 male BRFSS respondents aged 40–79 yr met the inclusion criteria and were used in the multilevel mixed-effect model. The model was poststratified using 63.4 million men aged 40–79 yr from all 3143 counties in the 2010 Decennial Census. County-level estimated PSA screening rates exhibited geographic variability and were pooled at the state level for internal validation with direct BRFSS state-level estimates, showing a strong correlation with Pearson correlation coefficients 0.77–0.90. A 10% higher county-level probability of PSA screening in 2004–2012 was associated with a 14% lower county-level incidence of regional/distant prostate cancer in 2015–2019 (rate ratio 0.86, 95% confidence interval [CI] 0.85–0.87, p < 0.001) and 10% lower county-level prostate cancer mortality in 2016–2020 (rate ratio 0.90, 95% CI 0.89–0.91, p < 0.001). Conclusions and clinical implicationsIn this population-based ecological study of all US counties, higher PSA screening rates were associated with a lower incidence of regional/distant prostate cancer and lower prostate cancer mortality at extended follow-up. Patient summaryUS counties with higher rates of prostate-specific antigen (PSA) screening had significantly lower rates of metastatic prostate cancer and prostate cancer mortality in subsequent years. These data may inform shared decision-making regarding PSA screening for prostate cancer.

Supplemental Nutrition Assistance Program (SNAP) policy changes and mammography use in the United States.

11033 Background: The Supplemental Nutrition Assistance Program (SNAP) alleviates food insecurity among low-income households, which has been linked to healthcare access. Several states increased SNAP eligibility by implementing policies that eliminate asset tests and/or broaden income eligibility criteria. This study investigates the associations of SNAP policy changes on mammography use within the past year among low-income females eligible for breast cancer screening. Methods: Income-eligible females ages 40-79 years were identified from the 2006-2019 Behavioral Risk Factors Surveillance System. 28 and 22 states adopted SNAP asset test elimination and income increase policies, respectively. Difference-in-differences analyses compared changes in the percentage of mammography within one year from pre- to post-SNAP policy adoption (asset test elimination or income eligibility increase) between states that did and did not adopt policies expanding SNAP eligibility. The samples were limited to females with household income &lt; 130% and &lt;200% federal poverty level for analyses of asset test elimination and income eligibility increase policies, respectively, to correspond to typical eligibility criteria. Results: A total of 171,684 and 294,647 income-eligible females were included for the asset test elimination and income eligibility increase policy analyses, respectively. Overall, 58.4% reported mammography within 1 year. Adoption of asset test elimination policies was associated with a 2.11 percentage point (95% CI = 0.07 to 4.15, P=0.043) increase in mammography, particularly for non-metropolitan residents (4.14 percentage points, 95% CI = 1.07 to 7.21, P=0.008), those with household income &lt;$25,000 (2.82 percentage points, 95% CI = 0.68 to 4.97, P=0.01), and those residing in states in the South (3.08 percentage points, 95% CI = 0.17 to 5.99, P=0.038) or in states that did not expand Medicaid under the Affordable Care Act (3.35 percentage points, 95% CI = 0.36 to 6.34, P=0.028). There was no significant association between state-level policies broadening SNAP income eligibility and mammography use (-1.07 percentage points, 95% CI = -2.64 to 0.49, P=0.18). Conclusions: This nationwide study suggests that policies eliminating the asset test for SNAP eligibility were associated with increased mammography use within one year, with the most pronounced positive impact observed in Southern states, non-expansion states, non-metropolitan areas, and households with the lowest incomes. Findings highlight the role that states policies have to both meet essential needs and promote health among vulnerable populations.

E-cigarette use and United States Preventive Services Task Force (USPSTF) lung cancer screening (LCS) eligibility.

10531 Background: Electronic cigarettes (E-cigarettes) have become frequently used as a smoking cessation tool. Emerging research has shown that e-cigarettes have similar carcinogenic effects as combustible cigarettes. While current lung cancer screening (LCS) guidelines primarily rely on individuals’ smoking history, it's becoming increasingly important to understand the prevalence of e-cigarette use among individuals, especially in the context of their LCS eligibility. Methods: Individuals aged 40-80 years were extracted from the 2022 Behavioral Risk Factor Surveillance System. Eligibility was defined using the 2021 USPSTF LCS criteria, i.e., aged 50-80 years who ever smoked, with at least a 20-pack-year smoking history, currently smoke or quit within the past 15 years. We compared the prevalence of current and ever e-cigarette use among LCS-eligible and non-eligible populations, overall and by smoking (combustible cigarettes) status using chi-square tests. All analyses were weighted. The significance level was set at a 2-sided p-value of &lt;0.05. Results: Among the 208,317 individuals included, 9.9% were eligible for LCS. Overall, 3.8% and 22.1% reported current and ever cigarette use, respectively. Fewer LCS-ineligible individuals reported currently using e-cigarettes than their LCS-eligible counterparts (Table). Among former combustible cigarette users, LCS-ineligible individuals were less likely to be current e-cigarette user than LCS-eligible individuals. However, among current combustible cigarette users, LCS-ineligible individuals were more likely to be current e-cigarettes users than LCS-eligible individuals. When examining the prevalence of ever e-cigarette use, similar findings were observed. Conclusions: Our study reveals a significant prevalence of e-cigarette usage among older adults (aged 40-80), with 1 in 5 individuals reporting ever having used e-cigarettes. Moreover, current cigarette users who were ineligible for LCS were more likely to use e-cigarette than their LCS-eligible counterparts. Future epidemiological studies are warranted to assess the risk of e-cigarette use (including intensity, duration and interactions with combustible cigarettes) and lung cancer risks. E-cigarette use may need to be considered in formulating future LCS guidelines. [Table: see text]

The use of wearable devices on physical activity levels among individuals living with diabetes: 2017 BRFSS

AimThis study aims to examine the association between wearing wearable devices and physical activity levels among people living with diabetes. Methods1298 wearable device users and nonusers living with diabetes from eight states of the 2017 Behavioral Risk Factors Surveillance System were included in the analysis. Unadjusted and adjusted linear regression was performed to determine the association between self-reported physical activity per week (min) and wearable device usage (users and nonusers) among people living with diabetes using survey analysis. Results84.97 % (95 % CI [80.39, 88.89]) of participants were nonusers of wearable devices, while 15.03 % (95 % CI [11.11, 19.61]) were users. Across the sample, the average weekly physical activity was 427.39 mins (95 % Cl [356.43, 498.35]). Nonusers had a higher physical activity per week with 433.83 mins (95 % CI [353.59, 514.07]), while users only had 392.59 mins (95 % CI [253.48, 531.69]) of physical activity per week. However, the differences between the two groups were non-statistically significant (p=.61). In both adjusted and unadjusted linear regressions between physical activity per week and wearable device usage, statistically significant associations were not found (unadjusted: β=-41.24, p=.62; adjusted: β=-56.41, p=.59). ConclusionFurther research is needed to determine the effectiveness of wearable devices in promoting physical activity among people with diabetes. Additionally, there is a need to determine how people with diabetes use wearable devices that could promote physical activity levels.

Associations of State Supplemental Nutrition Assistance Program Eligibility Policies With Mammography

PurposeThe Supplemental Nutrition Assistance Program (SNAP) addresses food insecurity for low-income households, which is associated with access to care. Many US states expanded SNAP access through policies eliminating the asset test (ie, restrictions based on SNAP applicant assets) and/or broadening income eligibility. The objective of this study was to determine whether state SNAP policies were associated with the use of mammography among women eligible for breast cancer screening. MethodsData for income-eligible women 40 to 79 years of age were obtained from the 2006 to 2019 Behavioral Risk Factor Surveillance System. Difference-in-differences analyses were conducted to compare changes in the percentage of mammography in the past year from pre- to post-SNAP policy adoption (asset test elimination or income eligibility increase) between states that and did not adopt policies expanding SNAP eligibility. ResultsIn total, 171,684 and 294,647 income-eligible female respondents were included for the asset test elimination policy and income eligibility increase policy analyses, respectively. Mammography within 1 year was reported by 58.4%. Twenty-eight and 22 states adopted SNAP asset test elimination and income increase policies, respectively. Adoption of asset test elimination policies was associated with a 2.11 (95% confidence interval [CI], 0.07-4.15; P = .043) percentage point increase in mammography received within 1 year, particularly for nonmetropolitan residents (4.14 percentage points; 95% CI, 1.07-7.21 percentage points; P = .008), those with household incomes <$25,000 (2.82 percentage points; 95% CI, 0.68-4.97 percentage points; P = .01), and those residing in states in the South (3.08 percentage points; 95% CI, 0.17-5.99 percentage points; P = .038) or that did not expand Medicaid under the Patient Protection and Affordable Care Act (3.35 percentage points; 95% CI, 0.36-6.34; P = .028). There was no significant association between mammography and state-level policies broadening of SNAP income eligibility. ConclusionsState policies eliminating asset test requirements for SNAP eligibility were associated with increased mammography among low-income women eligible for breast cancer screening, particularly for those in the lowest income bracket or residing in nonmetropolitan areas or Medicaid nonexpansion states.

How Generalizable Are Findings from a Community-Based Prospective Cohort Study? Extending Estimates from the Adult Changes in Thought Study to Its Source Population

Background: The Adult Changes in Thought (ACT) study is a cohort of Kaiser Permanente Washington members ages 65+ that began in 1994. Objective: We wanted to know how well ACT participants represented all older adults in the region, and how well ACT findings on eye disease and its relationship with Alzheimer’s disease generalized to all older adults in the Seattle Metropolitan Region. Methods: We used participation weights derived from pooling ACT and Behavioral Risk Factor Surveillance System (BRFSS) data to estimate prevalences of common eye diseases and their associations with Alzheimer’s disease incidence. Cox proportional hazards models accounted for age, education, smoking, sex, and APOE genotype. Confidence intervals for weighted analyses were bootstrapped to account for error in estimating the weights. Results: ACT participants were fairly similar to older adults in the region. The largest differences were more self-reported current cholesterol medication use in BRFSS and higher proportions with low education in ACT. Incorporating the weights had little impact on prevalence estimates for age-related macular degeneration or glaucoma. Weighted estimates were slightly higher for diabetic retinopathy (weighted 5.7% (95% Confidence Interval 4.3, 7.1); unweighted 4.1% (3.6, 4.6)) and cataract history (weighted 51.8% (49.6, 54.3); unweighted 48.6% (47.3, 49.9)). The weighted hazard ratio for recent diabetic retinopathy diagnosis and Alzheimer’s disease was 1.84 (0.34, 4.29), versus 1.32 (0.87, 2.00) in unweighted ACT. Conclusions: Most, but not all, associations were similar after participation weighting. Even in community-based cohorts, extending inferences to broader populations may benefit from evaluation with participation weights.

Cancer in people who identify as lesbian, gay, bisexual, transgender, queer, or gender-nonconforming.

Individuals who identify as lesbian, gay, bisexual, transgender, queer, intersex, or gender-nonconforming (LGBTQ+) experience discrimination and minority stress that may lead to elevated cancer risk. In the absence of population-based cancer occurrence information for this population, this article comprehensively examines contemporary, age-adjusted cancer risk factor and screening prevalence using data from the National Health Interview Survey, Behavioral Risk Factor Surveillance System, and National Youth Tobacco Survey, and provides a literature review of cancer incidence and barriers to care. Lesbian, gay, and bisexual adults are more likely to smoke cigarettes than heterosexual adults (16% compared to 12% in 2021-2022), with the largest disparity among bisexual women. For example, 34% of bisexual women aged 40-49 years and 24% of those 50 and older smoke compared to 12% and 11%, respectively, of heterosexual women. Smoking is also elevated among youth who identify as lesbian, gay, or bisexual (4%) or transgender (5%) compared to heterosexual or cisgender (1%). Excess body weight is elevated among lesbian and bisexual women (68% vs. 61% among heterosexual women), largely due to higher obesity prevalence among bisexual women (43% vs. 38% among lesbian women and 33% among heterosexual women). Bisexual women also have a higher prevalence of no leisure-time physical activity (35% vs. 28% among heterosexual women), as do transgender individuals (30%-31% vs. 21%-25% among cisgender individuals). Heavier alcohol intake among lesbian, gay, and bisexual individuals is confined to bisexual women, with 14% consuming more than 7 drinks/week versus 6% of heterosexual women. Incontrast, prevalence of cancer screening and risk reducing vaccinations in LGBTQ+ individuals is similar to or higher than their heterosexual/cisgender counterparts except for lower cervical and colorectal cancer screening among transgender men. People within the LGBTQ+ population have a higher prevalence of smoking, obesity, and alcohol consumption compared to heterosexual and cisgender people, suggesting a higher cancer burden. Health systems have an opportunity to help inform these disparities through the routine collection of information on sexual orientation and gender identity to facilitate cancer surveillance and to mitigate them through education to increase awareness of LGBTQ+ health needs.

Racial/Ethnic Disparities in HRQoL and Associated Risk Factors in Colorectal Cancer Survivors: With a Focus on Social Determinants of Health (SDOH).

This study aimed to understand how health-related quality of life (HRQoL) differs by race/ethnicity in colorectal (CRC) survivors. We aimed to 1) examine racial/ethnic disparities in HRQoL, and 2) explore the roles of social determinants of health (SDOH) risk factors for HRQoL differ by racial/ethnic groups. In 2,492 adult CRC survivors using Behavioral Risk Factor Surveillance System (BRFSS) survey data (from 2014 to 2021, excluding 2015 due to the absence of CRC data), we used the Centers for Disease Control and Prevention (CDC) HRQoL measure, categorized into "better" and "poor." Multivariate logistic regressions with prevalence risk (PR) were employed for our primary analyses. Compared with non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB) (PR = 0.61, p = .045) and Hispanics (PR = 0.32, p < .001) reported worse HRQoL in adjusted models. In adjusted models, unemployed/retired and low-income levels were common risk factors for worse HRQoL across all comparison groups (NHW, NHB, non-Hispanic other races, and Hispanics). Other SDOH associated with worse HRQoL include divorced/widowed/never married marital status (non-Hispanic other races and Hispanics), living in rural areas (NHW and NHB), and low education levels (NHB and Hispanics). Marital status, education, and employment status significantly interacted with race/ethnicity, with the strongest interaction between Hispanics and education (PR = 2.45, p = .045) in adjusted models. These findings highlight the need for culturally tailored interventions targeting modifiable factors (e.g., social and financial supports, health literacy), specifically for socially vulnerable CRC survivors, to address the disparities in HRQoL among different racial/ethnic groups.

Association Between Lifestyle Behaviors and Obesity Among Stroke Survivors.

The aim was to investigate factors influencing obesity among stroke survivors based on demographics and lifestyle behaviors. Stroke survivors are more likely to experience stroke recurrence within a few years. As obesity is a traditional risk factor for stroke, obesity should be managed in stroke survivors to prevent stroke recurrence. A cross-sectional secondary data analysis analyzed data from the 2017 United States Behavioral Risk Factor Surveillance System (BRFSS) survey. Demographics, frequency of vegetable and fruit intake, smoking, alcohol use, physical activity, and sleep were examined. Among 1032 stroke survivors, 57.8% were obese. Advanced age, female sex, veteran status, at least once-daily fruit intake, current smoking, and lack of physical activity were associated with obesity. Stroke survivors should be encouraged to pursue healthy behaviors to manage obesity. Appropriate transitional care, including diet education and tailored exercise, can be an effective strategy.

Associations between Adverse Childhood Experiences and Gambling Severity in Youth Online Gamblers: The Mediating Roles of Internalizing, Attention and Externalizing Problems.

This study examined the association between Adverse Childhood Experiences (ACEs) and Gambling Severity (gambling severity), considering the mediating roles of internalizing, externalizing, and attention among youth online gamblers. 762 youth (agemean±SD= 15.03 ± 2.40; agerange = 10-18 years; 75.3% boys) completed the Persian Gambling Disorder Screening Questionnaire (GDSQ-P), Pediatric Symptom Checklist - Youth Report (Y-PSC), and Behavioral Risk Factor Surveillance System Questionnaire (ACE's section, modified by authors). The analysis was done using the SMART PLS software. The reliability and discriminant validity of the provided model were assessed using Partial Least Squares-Structural Equation Modeling (PLS-SEM). According to the results of the PLS-SEM analysis, the present model demonstrated suitable levels of reliability and validity. Adverse Childhood Experiences (ACEs) significantly affected attention, internalizing, externalizing problems, and gambling severity. Additionally, the level of gambling was directly correlated with ACEs. Moreover, the indirect influence of the independent variable on the dependent variable via the mediators was found to be statistically significant (P < .001).These findings suggest that externalizing behaviors, attention problems, and internalizing symptoms mediate the effect of ACEs on gambling severity. Lastly, fitness indices indicated that our proposed model fit the data well (SRMR = 0.06, d_ULS = 1.15, Chi-square = 1291.461, and NFI = 0.71). Our study found that ACEs significantly influence gambling severity among youth online gamblers, with internalizing, externalizing, and attention problems mediating this relationship. Practical implications include integrating ACE screening and targeted interventions for associated mental health issues into youth gambling prevention programs to mitigate the risk of problematic gambling behavior.

Association of adverse childhood experiences with poor health condition among middle-aged and elderly adults in the United States: A nationally retrospective cohort study

BackgroundThe specific effects of adverse childhood experiences (ACEs) in adulthood and senectitude were less known. We aim to examine the relationship between early ACEs and overall health condition as well as specific dimensions in the middle-aged and elderly population. MethodsIn the 2019–2021 Behavioral Risk Factor Surveillance System Study, robust Poisson regression models were used to estimate the relationship between ACE exposure and current health status among adults aged 45 ≥ years. ResultsOf the 195,472 participants, 53.8 % were female and the mean age was 65.0 years. Compared to populations without ACE, ACE exposures were more significantly associated with depression (PR: 2.03, 95 %CI: 1.94–2.21), frequent mental health (PR: 1.85, 95 %CI: 1.74–1.97) and subject cognitive decline (PR: 1.99, 95 %CI:1.85–2.14) than with physical health (PR: 1.37, 95 %CI: 1.32–1.44), with dose-response patterns. The association with mental disorder was especially significant among the elderly population. ConclusionEarly ACEs are associated with adverse health outcomes that persist into later life, particularly mental disorders and cognitive decline. Poor mental health may indirectly influence associations with ACEs and cognitive decline as well as physical health. Our findings emphasize the importance of lifelong psychological screening and support for the ACE-exposed middle-aged and elderly population.