Behavioral Risk Factor Surveillance Survey Research Articles

Does Current General Mental Health Status Relate to Current Smoking Status in Pregnant Women?

Purpose Research shows that smoking during pregnancy is related to mental health diagnoses. The purpose of this study was to assess whether current general mental health status is related to current smoking status in pregnant women after controlling for other factors related to both mental health and tobacco use during pregnancy. Methods This cross-sectional analysis used 2017 Behavioral Risk Factor Surveillance Survey (BRFSS) data for 621 pregnant women aged 18-38 from Florida (N=136), Kansas (N=116), Minnesota (N=105), Nebraska (N=90), New York (N=78), and Utah (N=96). Multiple logistic regression analysis was used to assess the relationship between current mental health status and current tobacco use, while controlling for state, depression diagnosis, routine checkup, healthcare plan, age, marital status, ethnicity/race, education level, income level, and employment status. Results Overall, very few participants reported current smoking (6%) and about one-third reported low or moderate mental health status in the past 30 days. Adjusted results indicated that those who reported high mental health status were about 3 times less likely (OR=0.29, 95% CI=0.09, 0.88) to report current smoking status compared to those who reported low mental health status. Conclusions Overall, current mental health status was highly related to current smoking status in pregnant women. Clinicians in obstetrics may expect a very low proportion of pregnant women to report smoking and up to one-third to report low or moderate current general mental health status. Given that current mental health issues and current tobacco use may harm both mother and child, be highly related in pregnant women, and change throughout the pregnancy, pregnant women should be screened automatically for both at each visit.

Abstract 153: Predictors of Aspirin Nonadherence in Adults with Prior Myocardial Infarction

Background: Medication nonadherence is an alarming public health concern due to its effect on both individual treatment success and overall health care costs. In this study, we sought to identify the predictors of aspirin nonadherence in adults with prior myocardial infarction (MI). Methods: The 2017 Centers for Disease Control’s Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of 2,173 adults with prior MI who had reported the presence or absence of regular aspirin use. Demographic and clinical history were recorded and compared in individuals reporting the presence versus absence of aspirin adherence (defined as self-reported regular use of aspirin). Results: Among 2,173 adults with prior MI, 1623 (74.7%) reported adherence to aspirin while 550 (25.3%) reported aspirin nonadherence. Adults with aspirin nonadherence were younger, and more likely to be female (50.2% vs. 40.8%, p<0.001), Black (16.3% vs. 12.1%, p<0.001), and of Hispanic ethnicity (21.0% vs. 10.0%, p<0.001). They were also less likely to have health insurance (92.1% vs. 95.2%, p=0.007) or own a home (62.6% vs. 72.3%, p<0.001), and had lower annual incomes. Adults with aspirin nonadherence were noted to have less frequent medical checkups and lower rates of multiple comorbidities including diabetes mellitus (33.9% vs. 39.9%, p=0.012), hypertension (72.8% vs. 78.0%, p=0.013), hyperlipidemia (61.7% vs. 70.3%, p<0.001), and obesity (39.4% vs. 41.9%, p=0.013). In multivariate analysis, independent predictors of aspirin nonadherence in this population included female sex (adjusted odds ratio (OR) [95% confidence interval]) = 1.45 [1.14-1.83], Black race (1.64 [1.19-2.26]), Hispanic ethnicity (2.27 [1.61-3.21]), current employment (1.74 [1.28-2.36]), and absence of homeowner status (0.71 [0.55-0.93]). Conclusion: In this observational contemporary study of adults with prior MI, predictors of aspirin nonadherence include female sex, Black race, Hispanic ethnicity, employment status, and homeowner status. Appropriately identifying demographics of patients that may have barriers to adherence, especially at the time of initial medication recommendations, may help physicians to identify those at heightened risk for future nonadherence, thus allowing for timely and targeted educational and social work interventions to achieve treatment success through improved health outcomes and lower health care costs.

The Burden and Social Determinants of Asthma Among Children in the State of Georgia.

Asthma is one of the most common chronic health conditions in children, and social determinants are thought to be important risk factors. We used Georgia data from the Behavioral Risk Factors Surveillance Survey (BRFSS), and data from the Georgia hospital and emergency department survey for children with a diagnosis of asthma. All data were from the years 2011 to 2016. SAS and SUDAAN were used to calculate weighted prevalence estimates and to perform univariate and multivariate analysis of the association between social determinants, demographic characteristics, other potential risk factors, and asthma-related outcomes. The prevalence of asthma is higher in African-American children and when the parental income is less than $75,000 per year. A multivariate analysis adjusting for ethnicity, parental income, and sex found that the strongest independent predictor of asthma was African-American race (aOR 2.9, 95% CI 1.5-5.8). African-American and multiracial children also experienced extremely high burdens due to asthma related hospitalizations and emergency department visits, with rates two to five times higher than children in other groups. The secular trend for ED visits and hospitalizations is declining. African-American race is an independent predictor of asthma in children in Georgia, and African-American and multiracial children experience a greater burden of asthma than children of other races. Programmatic efforts at the state and national level to improve access, adherence, and knowledge about asthma are important if we are to continue to improve outcomes for these children.

Association of Medicaid Healthy Behavior Incentive Programs With Smoking Cessation, Weight Loss, and Annual Preventive Health Visits

Several states have implemented Healthy Behavior Incentive Programs (HBIPs) in Medicaid through Section 1115 demonstration waivers. These programs use financial incentives to encourage positive behavior changes, such as greater use of preventive services, smoking cessation, and weight loss. To test for an association between the introduction of HBIPs and the rates of smoking cessation, weight loss, and annual preventive health visits in states that have adopted behavior-specific programs compared with states that have not. A cohort study using a difference-in-differences analysis of the 2011-2016 Behavioral Risk Factor Surveillance Survey Interview Results data, adjusting for demographic conditions, state unemployment rates, state Medicaid expansion, national secular trends, and time invariant state-specific factors, was conducted. Two sets of participants were considered: adults aged 18 to 64 years who had a reported annual household income of less than $25 000 (n = 442 089) or adults aged 18 to 64 years who had completed high school education or less (n = 676 883). Changes in health behavior outcomes in 4 states (Florida, Indiana, Iowa, and Michigan) that implemented behavior-specific HBIPs targeting smoking, obesity, and annual health checkups through a Section 1115 waiver, against changes in control states, including Washington, DC, that did not introduce an HBIP (n = 44). Rate of smoking, obesity, and attendance at annual preventive health visits. Of Behavioral Risk Factor Surveillance Service respondents used for the less than $25 000 annual household income cohort (n = 442 089), the mean (SD) age was 43.1 (0.8) years, and the mean (SD) percentage of women was 58.4% (2.5%). For the cohort of high school education or less (n = 676 883) population, the mean (SD) age was 41.6 (1.1) years, and the mean (SD) percentage of women was 46.6% (0.9%). During a 2-year period after implementation, there were no improvements in smoking and obesity in individuals with a household income of less than $25 000 (2.49 percentage points, 95% CI, 1.75-3.23 percentage points; P < .001 and -1.94 percentage points, 95% CI, -4.42 to 0.55 percentage points; P = .12, respectively) as well as in the population holding a high school education or less (1.74 percentage points, 95% CI, 0.64-2.85 percentage points; P = .003 and -0.73 percentage points, 95% CI, -1.84 to 0.38 percentage points; P = .19). An association was noted between an increase in preventive health visit rates among states adopting behavior-specific HBIPs relative to control states in the less than $25 000 household income population (3.89 percentage points, 95% CI, 2.64-5.14 percentage points; P < .001). However, these associations were substantively small and not robust across the high school education or less population (1.8 percentage points, 95% CI, -0.12 to 3.71 percentage points; P = .07). Early postimplementation assessment may indicate that HBIPs were not associated with substantive improvements in incentivized healthy behaviors among populations likely to be Medicaid beneficiaries. The value, format, and timing of the incentive, complexity in delivery, and lack of awareness of incentives among target beneficiaries and clinicians may limit the usefulness of programs even over a longer follow-up period.

Exploring the differences between early-onset gastric cancer and traditional-onset gastric cancer.

The current study sought to explore the potential clinical, epidemiological and genetic differences between early-onset gastric cancer (E-gastric cancer: defined as 20-39 years) and traditional-onset gastric cancer (T-gastric cancer: defined as ≥40 years). Datasets from the following sources were searched: Surveillance, Epidemiology and End Results database [2000-2014], Behavioral Risk Factor Surveillance Survey and the cancer genome atlas (TCGA). Clinicopathological characteristics, trends, and genetic findings were compared between E-gastric cancer and T-gastric cancer. Moreover, correlations with relevant risk factors were sought after. A total of 95,323 gastric cancer patients were identified in the period from 2000 to 2014. While T-gastric cancer was decreasing during the study period (-1.4; P<0.05), E-gastric cancer was stable during the study period. E-gastric cancer is less prevalent in males (51.1% vs. 61.0%; P<0.0001), and white patients (68.9% vs. 71.4%; P<0.0001). E-gastric cancer patients usually present with poorly differentiated histology (55.3% vs. 48.0%; P<0.0001) as well as more aggressive histological subtypes (e.g., diffuse histology or linitis plastica). No difference can be detected with regards to risk factor correlations between E-gastric cancer and T-gastric cancer. Only four patients with E-gastric cancer were available in the provisional TCGA dataset at the time of the study. E-gastric cancer is a potentially distinct disease entity with specific clinicopathological and trend patterns compared to conventional T-gastric cancer. Further studies are needed to explore the potential etiologic basis as well as to investigate the clinical consequences of this distinction. The impact of this distinction on minority populations requires further assessment as well.

E-cigarette use and respiratory disorder in an adult sample

ObjectivesLittle evidence is available on the association of e-cigarettes with health indices. We investigated the association of e-cigarette use with diagnosed respiratory disorder among adults in data from the Behavioral Risk Factor Surveillance Survey (BRFSS). MethodsThe 2016 Hawaii BRFSS, a cross-sectional random-dial telephone survey, had 8087 participants; mean age was 55 years. Items asked about e-cigarette use, cigarette smoking, and being diagnosed by a health professional with (a) asthma or (b) chronic obstructive pulmonary disease. Multivariable analyses tested associations of e-cigarette use with the respiratory variables controlling for smoking and for demographic, physical, and psychosocial variables. ResultsControlling for the covariates and smoking there was a significant association of e-cigarette use with chronic pulmonary disorder in the total sample (AOR = 2.58, CI 1.36–4.89, p < 0.01) and a significant association with asthma among nonsmokers (AOR = 1.33, CI 1.00–1.77, p < 0.05). The associations were stronger among nonsmokers than among smokers. Results were similar for analyses based on relative risk and absolute risk. There was also a greater likelihood of respiratory disorder for smokers, females, and persons with overweight, financial stress, and secondhand smoke exposure. ConclusionsThis is the first study to show a significant independent association of e-cigarette use with chronic respiratory disorder. Several aspects of the data are inconsistent with the possibility that e-cigarettes were being used for smoking cessation by persons with existing respiratory disorder. Theoretical mechanisms that might link e-cigarettes use and respiratory symptoms are discussed.

HPV Vaccine-Related Research, Promotion and Coordination in the State of Georgia: A Systematic Review.

Human papillomavirus (HPV) vaccine was first recommended for female adolescents in the United States in 2006, and for male adolescents in 2011. In 2016, national HPV vaccine coverage was 43.4%, and slightly higher in Georgia (45.6%). Little is known about sub-state-level variation in HPV vaccination or Georgia specific research conducted to improve HPV vaccine uptake. We aimed to describe current uptake of HPV vaccination and synthesize Georgia-specific research of HPV vaccine uptake. We reviewed existing published and grey literature for different development, implementation and best practices related to vaccine uptake in adolescents. Studies measuring HPV vaccine uptake in Georgia utilizing quantitative, qualitative, or mixed-methods approaches were included alongside state-level information from National Immunization Survey-Teen, Community Health Needs Assessments, Behavioral Risk Factor Surveillance and Georgia Adolescent Immunization Surveys. Key findings across these reports were summarized. Forty-two titles and abstracts were identified through electronic database search for literature published between 2006 and 2017. Of these, five were from database sources and 37 were from additional sources. The most often mentioned barriers of HPV vaccine uptake in Georgia include cultural norms, vaccination education and a misalignment of vaccine uptake goals between the state and regional hospital community needs assessments. Increasing knowledge and uptake of HPV vaccine in Georgia requires significant research and to understand the vast socioeconomic, cultural and geographic barriers preventing uptake among adolescents. Georgia-specific efforts have been limited, however ongoing collaborations spearheaded by the Georgia Cancer Control Coalition provide opportunities for state-level support of research to address these barriers.

A Robust Health Equity Metric

Background: Progress on health equity will require a robust metric. Such a metric must: allow meaningful comparisons across time and place; be calculable using health data typically available; measure health equity across all major forms of social exclusion; and be conceptually distinct from measures of health disparity. Method: This paper proposes a simple new health equity metric that meets all of these criteria. It is justified by a concept of health disutility as the distastefulness associated with one's health falling short of potential. The value of the health equity metric in a population sums up this distastefulness over the entire population. This health equity metric is conceptually distinct from a health disparities measure. It has a stable interpretation across different health measures as long as the underlying measures themselves are comparable. And it can be calculated using health data that are available in existing surveys of population health. As an example, the health equity metric is implemented using 2015 data from the Behavioral Risk Factor Surveillance Survey to show the rankings of US States by health equity. Findings: There is substantial variation across states, with the District of Columbia, Maryland and South Dakota showing the greatest health equity, and West Virginia, Arkansas and Kentucky exhibiting the least. Health equity is weakly correlated with one measure of health disparities. Interpretation. It is feasible to use a single health equity metric for consistent and objective measurement of health equity. Doing so will facilitate more rapid progress toward health equity. Funding Statement: The authors declare N/A. Declaration of Interests: The authors declare: none. Ethics Approval Statement: This study was deemed exempt from review by the UCLA Institutional Review Board.

Minimum Wages and the Health of Hispanic Women

States are increasingly resorting to raising the minimum wage to boost the earnings of those at the bottom of the income distribution. Several policymakers have also claimed such increases may be health improving. In this paper, we examine the effects of minimum wage increases on the health of low-educated Hispanic women, who constitute a growing part of the US labor force, are disproportionately represented in minimum wage jobs, and typically have less access to health care. Using a difference-in-differences identification strategy and data drawn from the Behavior Risk Factor Surveillance Survey and the Current Population Survey from the years 1994 to 2015, we find little evidence that low-educated Hispanic women likely affected by minimum wage increases experience any changes in health status, access to care, or use of preventive care. We conclude that efforts to improve the health of low-educated Hispanic women are not likely to occur through increases in the minimum wage.

Who owns guns and how do they keep them? The influence of household characteristics on firearms ownership and storage practices in the United States

Our paper aims to describe firearm-related behavior among American households and to quantify the influence of household characteristics on the probability of firearms possession and storage practices. Applying logistic regression techniques to data from the 2004 Behavioral Risk Factor Surveillance Survey (BRFSS), we use separate models to estimate the effect of an array of respondent demographic characteristics factors on the likelihood that households will have a gun at home and, if so, whether they will keep it at either of two levels of risk. We find that rates of firearm ownership vary widely by household characteristics, including the state in which they reside. Simultaneously controlling for all of these factors scarcely diminishes variation in odds for ownership. Differences in the likelihood that owners will store guns unsafely are narrower and significant for fewer factors. Having children in the home scarcely affects the propensity to possess firearms but greatly reduces the chances a domestic firearm will be stored loaded and unsecured. Our findings support a consensus on the demographics of ownership but show more and stronger predictors of storage behavior than previous work. Differing dynamics of ownership and storage reveal the existence of two regional gun cultures. From these findings, we conclude that to mitigate mortality risks associated with guns in the home, encouraging safer storage by owners may be as effective as controlling sales. States and localities should test a range of promising but largely unproven interventions.

Abstract 252: Regional Variations in Access to Care Among U.S. Veterans With Cardiovascular Disease

Background: It is unclear whether access to health care for veterans with cardiovascular disease (CVD) vary among U.S. regions. This study sought to determine the extent of regional variations in access to medical care in a cohort of U.S. veterans with CVD. Methods: The 2016 Centers for Disease Control Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of veterans with cardiovascular disease. Participants were classified based on four U.S. regions: (1) Northeast, (2) Midwest, (3) South, and (4) West. Presence of CVD was noted with a single affirmative response to the following questions: “Has a health care professional ever told you that you had any of the following:” (1) a heart attack or myocardial infarction, (2) angina or coronary heart disease, (3) a stroke? Demographic data, baseline medical history, and access to care for veterans of each U.S. region were compared. Results: Among the 13,835 veterans with CVD, 18.3% were from the Northeast, while 23.5%, 37.1%, and 21.0% were from the Midwest, South, and West respectively. Veterans from South were more likely to be younger (21.4% vs 18.5% in the Northeast vs 18.6% in the Midwest vs 19.1% in the West, p=0.0018) and Black (9.7% vs 2% in the Northeast vs 3.3% in the Midwest vs 1.9% in the West, p&lt;.0001). Veterans from West had the highest proportion of females (4.9% vs 3.8% in the Northeast vs 3.5% in the Midwest vs 4.8% in the South) and Hispanics (4.3% vs 2.3% in the Northeast vs 1.2% in the Midwest vs 1.7 in the South, p&lt;.0001). Veterans from West were more likely to be college educated and have higher annual income compared to their counterparts. Veterans from South had highest rates of depressive disorder (20.5% vs 18.1% in the Northeast vs 18.4% in the Midwest vs 19.3% in the West, p=0.0318) were more likely to be smokers (16.4% vs 14.8% in the Northeast vs 15.4% in the Midwest vs 13.2% in the West, p&lt;.0001), obese (34.4% vs 32.8% in the Northeast vs 34.3% in the Midwest vs 29.7% in the West, p&lt;.0001) and had lowest rates of physical activity (62.3% vs 66.7% in the Northeast vs 66.3% in the Midwest vs 69.6% in the West, p&lt;.0001 ). Rates of medical checkup within the past year (91.7% vs 89.5% vs 91.4% vs 86.6%, p&lt;0.0001) differed significantly among the Northeast, Midwest, South, and West respectively. On multivariate analysis, West region (OR 0.39, 95% CI 0.22 - 0.70) was independently associated with lower rates of medical checkup within the past year compared to the Northeast. Conclusions: In this observational study involving U.S. veterans with CVD, West region was independently associated with lower rates of medical checkup within the past year. Further large-scale studies examining the prevalence of impaired access to care in U.S. veterans with CVD are warranted.

Modeling life course pathways from adverse childhood experiences to adult mental health

Although the association between adverse childhood experiences (ACEs) and adult mental health is becoming well established, less is known about the complex and multiple pathways through which ACEs exert their influence. Growing evidence suggests that adversity early in life conveys not only early impacts, but also augments risk of stress-related life course cascades that continue to undermine health. The present study aims to test pathways of stress proliferation and stress embodiment processes linking ACEs to mental health impairment in adulthood. Data are from the 2011 Behavioral Risk Factor Surveillance Survey, a representative sample of Washington State adults ages 18 and over (N = 14,001). Structural equation modeling allowed for testing of direct and indirect effects from ACEs though low income status, experiences of adversity in adulthood, and social support. The model demonstrated that adult low income, social support and adult adversity are in fact conduits through which ACEs exert their influence on mental health impairment in adulthood. Significant indirect pathways through these variables supported hypotheses that the effect of ACEs is carried through these variables. This is among the first models that demonstrates multiple stress-related life course pathways through which early life adversity compromises adult mental health. Discussion elaborates multiple service system opportunities for intervention in early and later life to interrupt direct and indirect pathways of ACE effects.

The Role of Physical Activity in the Association Between Smoking Status and Quality of Life.

Nonsmoking status and physical activity have, individually, been shown to be associated with health-related quality of life (HRQoL). The objective of this study was to assess whether the relationship between smoking status and HRQoL is modified or influenced by physical activity. Data were extracted from the 2014 Behavioral Risk Factor Surveillance Survey dataset (N = 332680) in 2015. Logistic regression models were used to address study objectives. Health-related quality of life (HRQoL), measured using eight domains (general health, physical health, mental health, activity limitations, pain, depressive symptoms, anxiety, and vitality), was regressed on smoking status without and with adjustment for age, race, gender, education, marital status, income, employment, healthcare coverage, comorbidity, body mass index, flu vaccination, alcohol use, and physical activity. Smoking status by physical activity interaction term was added to the adjusted model and evaluated for significance. There were significant smoking status by physical activity interaction effects on general health, physical health, activity limitations, and depressive symptoms domains. Among those who exercised, relative differences in the odds of a high HRQoL was smaller between former smokers and nonsmokers and larger between current smokers and nonsmokers when compared to those who did not exercise. Similarly, there were sharper relative differences between those who exercised and those who did not exercise among former smokers than among current smokers. Smokers who successfully quit smoking (former smokers) may benefit from enhanced HRQoL that tends towards that of nonsmokers if they adopt physical activity in their daily routine. Behavioral interventions that combine smoking cessation and physical activity may be more effective than either smoking cessation or physical activity alone in improving the quality of life measures such as overall, physical and mental health, and degree of limitation to activities due to poor health. Health care providers can support patients who successfully quit smoking to add exercise to their daily routine with the expectation of enhanced HRQoL.

Impact of Depressive Disorder on Access and Quality of Care in Veterans With Prevalent Cardiovascular Disease

Although depressive disorders have been associated with increased risk of worse outcomes with cardiovascular diseases (CVDs), its relation with access to and quality of cardiovascular care is not well studied. Accordingly, we sought to assess the association between depressive disorders and access and quality of care among United States veterans with CVD. The 2013 Centers for Disease Control's Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of 13,126 veterans with CVD. Demographic and clinical history were recorded in adults with and without a depressive disorder (defined as self-reported diagnosis of depression, major depression, minor depression, or dysthymia). Among 13,126 veterans studied, a total of 2,889 (22.0%) adults had a depressive disorder whereas 10,237 (78.0%) did not. The veterans with a depressive disorder were younger, more often female and non-white, and had higher rates of multiple medical co-morbidities. They were more likely to report a delay in receiving medical care and financial barriers to seeking care and taking prescription drugs. They also reported significantly lower rates of aspirin and antihypertensive drug use. In multivariate analysis, depressive disorder was independently associated with higher risk of delay in receiving medical care (OR [odds ratio] 2.07, 95% CI [confidence interval] 1.65 to 2.60), financial barriers to medical care (OR 1.96, 95% CI 1.45 to 2.65), and prescription drugs (OR 1.45, 95% CI 1.02 to 2.08). In conclusion, depressive disorders were associated with impaired access to care among United States veterans with CVD.

Referral Strategies to a Tobacco Quitline and Racial and/or Ethnic Differences in Participation.

Tobacco use inflicts a disproportionate burden of disease on people of color. We evaluated the reach among African American and Hispanic smokers in Boston of 2 referral strategies to the Massachusetts quitline: (1) a provider-referred strategy based in pediatric and dental clinics and (2) a targeted media campaign to promote self-referral to the quitline. Selected demographic characteristics of Boston quitline participants during the study period (2010-2012) were compared between strategies. Self-referred smoker characteristics were also compared in the years before and after the media campaign. Finally, the characteristics of quitline participants were compared with smokers in the 2010 Boston Behavioral Risk Factor Surveillance Survey. During the study period, 4066 smokers received cessation services from the quitline; 3722 (91.5%) were self-referred, and 344 (8.5%) were referred by pediatric and dental providers. The proportion of black (31.6%) and Hispanic (20.3%) participants referred by providers was higher than among self-referred participants (18.3% and 7.8%, respectively; P <.001). Overall, provider-referred participants were less likely to be white (17.9%) than to be people of color. Self-referred smokers were more likely to be white (68.0%) than the estimated population of Boston smokers overall (62.9%; P <.001). The large-scale media campaign, which promoted self-referral, was associated with higher quitline participation overall, but the provider-referred strategy based in community health centers yielded participation from a greater proportion of smokers of color. The 2 strategies reached different subpopulations of smokers, and their combined reach enhanced access to cessation services among smokers from different racial and ethnic backgrounds.

Using path analysis to examine the relationship between sexual abuse in childhood and diabetes in adulthood in a sample of US adults

To understand mechanisms underlying the relationship between adverse childhood experiences (ACE) and diabetes the study evaluated mediators of the relationship between childhood sexual abuse and diabetes in adulthood. This study used cross-sectional data from the 2011 Behavioral Risk Factor Surveillance Survey (BRFSS). Participants totaled 48, 526 who completed the ACE module. Based on theoretical relationships, path analysis was used to investigate depression and obesity as pathways between childhood sexual abuse, and diabetes in adulthood.Among adults with diabetes, 11.6% experienced sexual abuse. In the unadjusted model without mediation, sexual abuse was significantly associated with depression (OR=4.48, CI 4.18–4.81), obesity (OR=1.28, CI 1.19–1.38), and diabetes (OR=1.39, CI 1.25–1.53). In the unadjusted model with mediation, depression and obesity were significantly associated with diabetes (OR=1.59, CI 1.48–1.72, and OR=3.77, CI 3.45–4.11, respectively), and sexual abuse and diabetes was no longer significant (OR=1.10, CI 0.98–1.23), suggesting full mediation. After adjusting for covariates in the mediation model, significance remained between sexual abuse and depression (OR=3.04, CI 2.80–3.29); sexual abuse and obesity (OR=1.41, CI 1.29–1.53), depression and diabetes (OR=1.35, CI 1.23–1.47); and obesity and diabetes (OR=3.53, CI 3.20–3.90). The relationship between sexual abuse and diabetes remained insignificant (OR=1.09, CI 0.96–1.24).This study demonstrates that depression and obesity are significant pathways through which childhood sexual abuse may be linked to diabetes in adulthood. These results can guide intervention development, including multifaceted approaches to treat depression and increase physical activity in patients with a history of sexual abuse to prevent diabetes.

Medicaid Coverage Expansions and Cigarette Smoking Cessation Among Low-income Adults.

Expanding Medicaid coverage to low-income adults may have increased smoking cessation through improved access to evidence-based treatments. Our study sought to determine if states' decisions to expand Medicaid increased recent smoking cessation. Using pooled cross-sectional data from the Behavioral Risk Factor Surveillance Survey for the years 2011-2015, we examined the association between state Medicaid coverage and the probability of recent smoking cessation among low-income adults without dependent children who were current or former smokers (n=36,083). We used difference-in-differences estimation to examine the effects of Medicaid coverage on smoking cessation, comparing low-income adult smokers in states with Medicaid coverage to comparable adults in states without Medicaid coverage, with ages 18-64 years to those ages 65 years and above. Analyses were conducted for the full sample and stratified by sex. Residence in a state with Medicaid coverage among low-income adult smokers ages 18-64 years was associated with an increase in recent smoking cessation of 2.1 percentage points (95% confidence interval, 0.25-3.9). In the comparison group of individuals ages 65 years and above, residence in a state with Medicaid coverage expansion was not associated with a change in recent smoking cessation (-0.1 percentage point, 95% confidence interval, -2.1 to 1.8). Similar increases in smoking cessation among those ages 18-64 years were estimated for females and males (1.9 and 2.2 percentage point, respectively). Findings are consistent with the hypothesis that Medicaid coverage expansions may have increased smoking cessation among low-income adults without dependent children via greater access to preventive health care services, including evidence-based smoking cessation services.

Item Response Patterns on the Patient Health Questionnaire-8 in a Nationally Representative Sample of US Adults.

Recent studies have shown that item responses on the Center for Epidemiologic Studies Depression Scale (CES-D) and Kessler Screening Scale for Psychological Distress (K6) exhibit the same characteristic item response patterns among the general population. However, the distributional patterns of responses on the Patient Health Questionnaire-8 (PHQ-8) among the general population have not been adequately studied. Thus, we conducted a pattern analysis of PHQ-8 item responses among US adults. Data (18,446 individuals) were obtained from the 2015 Behavioral Risk Factor Surveillance Survey (BRFSS). Item responses on the BRFSS version of the PHQ-8 were scored using the number of days response set and then converted to the original 4-point scale. The patterns of item responses were analyzed through graphical analysis. Lines of item responses scored using the number of days response set showed the same pattern among the eight items, characterized by crossing at a single point between “0 days” and “1 day,” and parallel fluctuation from “1 day” to “14 days” on a semi-logarithmic scale. Lines of item responses converted to the 4-point scale also showed the same characteristic pattern among the eight items. The present results demonstrate that the item responses on the PHQ-8 show the same characteristic patterns among items, consistent with the CES-D and the K6.

Epidemiology of areca (betel) nut use in the mariana islands: Findings from the University of Guam/University of Hawai`i cancer center partnership program

BackgroundAreca (betel) nut is considered a Group 1 human carcinogen shown to be associated with other chronic diseases in addition to cancer. This paper describes the areca (betel) nut chewing trend in Guam, and health behaviors of chewers in Guam and Saipan. MethodsThe areca (betel) nut module in the Guam Behavioral Risk Factor Surveillance Survey was used to calculate the 5-year (2011–2015) chewing trend. To assess the association between areca (betel) nut chewing and health risks in the Mariana Islands, a cross-section of 300 chewers, ≥18years old, were recruited from households in Guam and Saipan. Self-reported socio-demographics, oral health behaviors, chronic disease status, diet, and physical activity were collected. Anthropometry was measured. Only areca (betel) nut-specific and demographic information were collected from youth chewers in the household. ResultsThe 5-year areca (betel) nut chewing prevalence in Guam was 11% and increased among Non-Chamorros, primarily other Micronesians, from 2011 (7%) to 2015 (13%). In the household survey, most adult chewers (46%) preferred areca nut with betel leaf, slaked lime, and tobacco. Most youth chewers (48%) preferred areca nut only. Common adult chronic conditions included diabetes (14%), hypertension (26%), and obesity (58%). ConclusionThe 5-year areca (betel) nut chewing prevalence in Guam is comparable to the world estimate (10–20%), though rising among Non-Chamorros. Adult and youth chewers may be at an increased risk for oral cancer. Adult chewers have an increased risk of other chronic health conditions. Cancer prevention and intervention strategies should incorporate all aspects of health.

Examining the relationship between the food environment and adult diabetes prevalence by county economic and racial composition: an ecological study

BackgroundInequitable access to healthy food may contribute to health disparities. This study examines the relationship between the prevalence of adult diabetes and food access in the U.S. by county economic/racial composition.MethodsAn ecological study from 2012 was used to estimate the relationship between diabetes and retail food outlet access. County diabetes prevalence was measured based on individual responses to the Behavioral Risk Factor Surveillance Survey question, “Have you ever been told by a doctor that you have diabetes?” If the answer was “yes” individuals were classified as having diabetes. Retail food outlets included grocery stores, supercenters, farmer’s markets, full-service restaurants, fast food restaurants and convenience stores. Counties were categorized as “high-poverty” or “low-poverty”. Counties were categorized as low (< 4.6%), medium (4.6%–31.0%), and high (> 31.0%) percent minority residents. Multiple linear regression models estimated the association between retail food outlets and diabetes, controlling for confounders, and testing for interactions between retail food outlets and county racial composition. Regression models were conditioned on county economic composition. Data were analyzed in 2016.ResultsDensity of retail foods outlets varied greatly by county economic and racial composition; counties with medium-minority populations had the least access to grocery stores and the highest access to fast food restaurants and convenience stores. Low poverty/low-minority population counties had the greatest access to farmer’s markets and grocery stores. For low poverty/low-minority counties, grocery stores were associated with decreased of diabetes prevalence. Supercenters were associated with an increase in diabetes prevalence for high-poverty/low-minority counties. Only low poverty/medium-minority counties had a statistically significant relationship between farmer’s markets and diabetes prevalence. Fast food restaurants were found to be positively associated with diabetes prevalence in all counties except high poverty/medium-minority. However, only low poverty/low-minority counties had a statistically significant relationship. Across all models, access to full service restaurants were significantly associated with lower prevalence of diabetes. Generally, access to convenience stores were associated with increased diabetes prevalence, except for high poverty/low-minority counties.ConclusionsThe food environment is more strongly associated with diabetes prevalence for wealthier counties with a lower proportion of minority residents. This is important given efforts to increase food access in vulnerable communities. Availability of healthier food may not be enough to change health outcomes.