National Representative Sample Research Articles

Forecasting the 20-Year Incidence of Dementia by Socioeconomic Status, Race/Ethnicity, and Region Based on Mid-Life Risk Factors in a U.S. Nationally Representative Sample.

Alzheimer's disease and related dementias (ADRD) incidence varies based on demographics, but mid-life risk factor contribution to this variability requires more research. The purpose of this study is to forecast the 20-year incidence of dementia in the U.S. overall and stratified by race/ethnicity, socioeconomic status (SES), and U.S. geographic region given prior mid-life risk factor prevalence and to examine the extent to which risk factor differences 20 years ago may explain current SES, race/ethnicity, or regional disparities in dementia incidence. We applied the Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) prediction model to the 2006 wave of the Health and Retirement Study (HRS) in participants aged 45 to 64 to estimate the 20-year risk of incident ADRD. The 20-year risk of dementia among middle-aged Americans was 3.3% (95% CI: 3.2%, 3.4%). Dementia incidence was forecast to be 1.51 (95% CI: 1.32, 1.71) and 1.27 (95% CI: 1.14, 1.44) times that in Hispanic and Non-Hispanic Black individuals respectively compared statistically to Non-Hispanic White individuals given mid-life risk factors. There was a progressive increase in dementia risk from the lowest versus highest SES quintile. For geographic region, dementia incidence was forecast to be 1.17 (95% CI: 1.06, 1.30) and 1.27 (95% CI: 1.14, 1.43) times that in Midwestern and Southern individuals respectively compared statistically to Western individuals. Some disparities in dementia incidence could be explained by differences in mid-life risk factors and may point toward policy interventions designed to lessen the ADRD disease burden through early prevention.

Regular source of primary care and health services utilisation among Brazilian elderly with mental-physical multimorbidity

BackgroundIn ageing populations, multimorbidity is a complex challenge to health systems, especially when the individuals have both mental and physical morbidities. Although a regular source of primary care (RSPC) is associated with better health outcomes, its relation with health service utilisation in elderly patients with mental-physical multimorbidity (MP-MM) is scarce.ObjectiveThis study explored the relations among health service utilisation, presence of RSPC and MP-MM among elderly Brazilians.MethodsA national cross-sectional study performed with data from national representative samples from the Brazilian National Health Research (PNS, in Portuguese; Pesquisa Nacional de Saúde) carried out in 2013 with 11,177 elderly Brazilian people. MP-MM was defined as the presence of two or more morbidities, including at least one mental morbidity, and was evaluated using a list of 16 physical and mental morbidities. The RSPC was analysed by the presence of regular font of care in primary care and health service utilisation according to the demand for health services ≤ 15 days, medical consultation ≤ 12 months, and hospitalisation ≤ 1 year. Frequency description of variables and bivariate association were performed using Stata v.15.2 software.ResultsThe majority of individuals was female (56.4%), and their mean age was 69.8 years. The observed prevalence of MP-MM was 12.2%. Individuals with MP-MM had higher utilisation of health services when compared to those without MP-MM. RSPC was present at 36.5% and was higher in women (37.8% vs. 34.9%). There was a lower occurrence of hospitalisation ≤ 1 year among MP-MM individuals with RSPC and without a private plan of health.ConclusionOur findings demonstrate that RSPC can be an important component of care in elderly individuals with MP-MM because it was associated with lower occurrence of hospitalisation, mainly in those that have not a private plan of health. Longitudinal studies are necessary to confirm these findings.

Projected volume of primary total joint arthroplasty in the USA from 2019 to 2060.

The global incidence of total joint arthroplasty (TJA) has consistently risen over time, and while various forecasts differ in magnitude, future projections suggest a continued increase in these procedures. Differences in future United States projections may arise from the modeling method selected, the nature of the national arthroplasty registry employed, or the representativeness of the specific hospital discharge records utilized. In addition, many models have not accounted for ambulatory surgery as well as all payer types. Therefore, to attempt to make a more accurate model, we utilized a national representative sample that included outpatient arthroplasties and all insurance types to predict the volumes of primary TJA in the USA from 2019 to 2060. A national, all-payer database was queried. All patients who underwent primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) from January 1, 2010, to December 31, 2019, were identified using international classification of disease Ninth Revision (9) and Tenth Revision (10) codes and current procedure terminology codes. Absolute frequencies and incidence rates were calculated per 100,000 for both THA and TKA procedures, with 95% confidence intervals. Mean growth in absolute frequency and incidence rates were calculated for each procedure from 2010 to 2014, and 2010 to 2019, with 95% confidence intervals (CI). The overall increase in THA and TKA procedures are expected to grow + 10 and + 36%, respectively, using linear regressions and + 9 and + 37%, respectively. The most positive mean growth in procedure frequency occurred from 2010 to 2014 for THA (+ 24, 95% Confidence Interval (CI): + 21, + 27) and 2010-2019 for TKA (+ 11%, 95% CI: + 9, + 14). There positive trend patterns in incidence rate growth for both procedures, with similar 2010-2019 incidence rates + 6%) for THA (+ 3%, 95% CI: + 0, + 6%) and TKA (+ 3%, 95% CI: + 1%, + 6%). Utilizing a nationally representative database, we demonstrated that TJA procedures would continue with an increased growth pattern to 2060, though slightly decreased from the surge from 2014 to 2019. While this finding applies to the representativeness of the population at hand, the inclusion of outpatient arthroplasty and all payer types validates an approach that has not been undertaken in previous projection studies.

Inflation in 2022 did not affect congressional voting, but abortion did

This study examines voting in the 2022 United States congressional elections, contests that were widely expected to produce a sizable defeat for Democratic candidates for largely economic reasons. Based on a representative national probability sample of voters interviewed in both 2020 and 2022, individuals who changed their vote from one party's congressional candidate to another party's candidate did not do so in response to the salience of inflation or declining economic conditions. Instead, we find strong evidence that views on abortion were central to shifting votes in the midterm elections. Americans who favored (opposed) legal abortions were more likely to shift from voting for Republican (Democratic) candidates in 2020 to Democratic (Republican) candidates in 2022. Since a larger number of Americans supported than opposed legal abortions, the combination of these shifts ultimately improved the electoral prospects of Democratic candidates. New voters were especially likely to weigh abortion views heavily in their vote-shifting calculus. Likewise, those respondents whose confidence in the US Supreme Court declined from 2020 to 2022 were more likely to shift from voting for Republican to Democratic congressional candidates. We provide direct empirical evidence that changes in support for the Supreme Court, a nonpartisan branch of the federal government, are implicated in partisan voting behavior in another branch of government. We explore the implications of these findings for prevalent assumptions about how economic conditions influence voting, as well as for the relationship between the judiciary and electoral politics.

Demographic Correlates of Endometriosis Diagnosis Among United States Women Aged 15-50

To compare demographic characteristics for women with and without a diagnosis of endometriosis. Data were collected from the National Survey of Family Growth - a publicly available survey designed and administered by the Centers for Disease Control, which uses a nationally-representative sample of the United States population. Univariate data were reported as survey-weighted percentages and means, and were analyzed using chi-square, t-tests, and logistic regression. Analyses accounted for complex survey design. United States PARTICIPANTS: Interviews were conducted with 6,141 female respondents, aged 15-50, between 2017 and 2019. Data were collected through in-person interviews. Nationally, 5.7% reported a diagnosis of endometriosis (95% CI 4.6-6.9%). Those with endometriosis were older, with a mean age of 39 (95% CI 38.1-39.9), compared to 31.7 (95% CI 31.2-32.2) among those without (p < 0.0005). Endometriosis diagnosis was significantly associated with race. Compared to non-Hispanic White women, Hispanic women had an adjusted odds ratio (aOR) of 0.37 (95% CI 0.21-0.65) for diagnosis of endometriosis, and non-Hispanic Black women had an aOR of 0.54 (95% CI 0.35-0.84). We also observed a difference in diagnosis by health insurance: compared to those with private insurance or Medi-Gap coverage, those with Medicare or military insurance had an aOR for endometriosis diagnosis of 2.49 (95% CI 1.36-4.55). Finally, compared to those with less than a high school education, those who had completed high school or greater had an aOR for endometriosis diagnosis of 2.84 (95% CI 1.15-6.99). These disparities in endometriosis diagnosis suggest that intersecting barriers may preclude certain groups from accessing timely endometriosis diagnosis and management. Further studies are warranted to explore these hypothesis-generating data, and to identify and address specific barriers to equitable endometriosis diagnosis and management.

Gradients in low birthweight by maternal education: A comparative perspective

BackgroundLongstanding research has shown strong inequalities in low birthweight by household income. However, most such research has focused on Anglophone countries, while evidence emerging from other developed countries suggest a stronger role of education rather than incomes in creating inequalities at birth. This paper compares gradients in low birthweight by maternal education, as well as explores underlying mechanisms contributing to these gradients, in France, the United States, and the United Kingdom. MethodsAnalyses are based on harmonized data from large, nationally-representative samples from France, UK and US. We use regression models and decomposition methods to explore the relative role of several possible mechanisms in producing birthweight inequalities. ResultsInequalities in low birth weight across maternal education groups were relatively similar in the United States, the United Kingdom and France. However, the individual-level mechanisms producing such inequalities varied substantially across the three countries, with income being most important in the US, pregnancy smoking being most evident in France, and the UK occupying an intermediate position. Differences in the mechanisms producing birth health inequalities mirror differences in the policy environment in the three countries. ConclusionWhile inequalities in health appear from the earliest moments in many countries, our results suggest research on birth health inequalities, and therefore policies, is not easily generalizable across national contexts, and call for more scholarship in uncovering the “whys” of health inequalities in a variety of contexts.

Height growth of Mexican boys by geographic region: an evaluation based on nationally representative data of ENSANUT 2012 and 2018.

Existing research on human growth in Mexico is regionally focused, creating a gap in the understanding of growth patterns of children and adolescents at national level and regional variation. The objective of the present study was to characterize the height growth curve of the Mexican population by geographic area and to cluster the states of the Mexican Republic according to their somatic maturation characteristics, based on a national representative sample of boys. Data on age, height, socioeconomic level, and geographic area of 18,219 boys were obtained from the National Health and Nutrition Survey 2012 (ENSANUT) and ENSANUT 2018, carried out in 32 Mexican states. Both surveys had representative samples. Preece-Baines 1 model was applied to fit height growth curves. Biological parameters were estimated; principal component analysis and cluster analysis were performed to group Mexican states based on these biological parameters. The estimated age at peak height velocity (PHV) was 12.3 years in the sample. Significant regional differences in the timing and tempo of PHV among Mexican boys were observed. Boys in the northern region experienced PHV at an earlier age and had a shorter duration of growth compared with boys in the central and southern regions. Boys in the central region had a longer duration of growth and a later age of PHV compared with the boys in the southern region. The cluster that included the southern states of the country showed estimated lower adult height and earlier somatic maturation. A lower height was found in the low and low-middle socioeconomic levels compared with the medium-high and high socioeconomic levels. Future research in Mexico should focus on longitudinal studies to analyse the timing and tempo of growth and maturation, considering the impacts of environmental and genetic factors. Public health strategies should account for geographic variations.

Dental Caries and Preventive Dental Visits Among Children in the U.S.: The Impact of Race/Ethnicity and Immigration

Introduction: National data on dental caries and dental service use among immigrant children in US is limited. It is not known whether race/ethnicity would interact with immigration status to increase these disparities. Using a national representative sample, we assessed the interaction effects of immigrant generation status and race/ethnicity on dental caries and dental visits among children in the US. Methods: Data were from the 2020 and 2021 National Survey of Children's Health (NSCH). All data were self-reported by parents/guardians. The two outcomes were (1) dental caries (yes/no) in the past 12 months, and (2) preventive dental visits (yes/no) in the past 12 months. Racial/ethnic groups included non-Hispanic White, Black, Hispanics, and Asian Americans. The analytical sample included 66,167children ages 2-17 years, including 1,243 first generation, 11,017 second generation immigrant children, and 53,907 non-immigrant children. We ran separate multiple logistic regression models for the two outcome variables. All analyses accounted for the survey design of NSCH. Results: First generation immigrant children were more likely to have dental caries than non-immigrant children (AOR=1.44). The interaction of race/ethnicity and immigrant generation status was significant (P =0.04) in the preventive dental visits model, indicating increased challenges in getting dental visits among minority immigrant children in comparison with non-Hispanic White immigrant children, especially among first generation immigrant children of Asian Americans (AOR=0.41) and non-Hispanic Black (AOR=0.37) immigrant children. Conclusions: We found that first generation immigrant children were less likely to see a dentist and more likely to have dental caries than non-immigrants. Moreover, first generation immigrant children from minority racial/ethnic groups were the least likely to seek dental services. To further reduce disparities in oral health and dental use among children in the U.S., culturally sensitive health promotion is warranted to improve oral health literacy and reduce barriers to dental care for immigrants, especially immigrant children of the minority groups.

The global diet quality score as an indicator of adequate nutrient intake and dietary quality – a nation-wide representative study

BackgroundThe Global Diet Quality Score (GDQS) was developed to be a simple, timely and cost-effective tool to track, simultaneously, nutritional deficiency and non-communicable disease risks from diet in diverse settings. The objective was to investigate the performance of GDQS as an indicator of adequate nutrient intake and dietary quality in a national-representative sample of the Brazilian population.MethodsNationally-representative data from 44,744 men and non-pregnant and non-lactating women aging ≥ 10 years, from the Brazilian National Dietary Survey were used. Dietary data were collected through two 24-h recalls (24HR). The GDQS was calculated and compared to a proxy indicator of nutrient adequate intake (the Minimum Dietary Diversity for Women—MDD-W) and to an indicator of high-risk diet for non-communicable diseases (caloric contribution from ultra-processed foods—UPF). To estimate the odds for overall nutrient inadequacy across MDD-W and GDQS quintiles, a multiple logistic regression was applied, and the two metrics’ performances were compared using Wald’s post-test.ResultsThe mean GDQS for Brazilians was 14.5 (0–49 possible range), and only 1% of the population had a low-risk diet (GDQS ≥ 23). The GDQS mean was higher in women, elderly individuals and in higher-income households. An inverse correlation was found between the GDQS and UPF (rho (95% CI) = -0.20(-0.21;-0.19)). The odds for nutrient inadequacy were lower as quintiles of GDQS and MDD-W were higher (p-trend < 0.001), and MDD-W had a slightly better performance than GDQS (p-diff < 0.001). Having a low-risk GDQS (≥ 23) lowered the odds for nutrient inadequacy by 74% (95% CI:63%-81%).ConclusionThe GDQS is a good indicator of overall nutrient adequacy, and correlates well with UPF in a nationally representative sample of Brazil. Future studies must investigate the relationship between the GDQS and clinical endpoints, strengthening the recommendation to use this metric to surveillance dietary risks.

Referendums as extended arms of the government: evidence from an illiberal regime

ABSTRACT Public support for referendums has been analysed extensively in established democracies, but the topic is investigated less in illiberal settings. This article aims to explain why citizens in an illiberal country (Hungary) support referendums. We argue that in such political regimes, referendums may serve as extended arms of the illiberal government rather than as providing people with direct access to decision-making. Our study uses individual-level data from a survey conducted in May 2022 on a national representative sample. The evidence indicates that those citizens in favour of referendums are characterized by anti-democratic attitudes and support for the initiator.

Discrimination in the Spotlight: The Effects of Political and Religious Bias on Consumer Behaviour and Labour Markets

There has been a surge in concern about political polarization and discrimination based on religious and political attitudes in the workplace. Using a nationally-representative sample of nearly 3,000 respondents, this paper presents new empirical evidence on the incidence of social hostilities in the workplace and the causal effects of providing information on consumer and labor market behavior across a range of indicators. Several empirical patterns emerge. First, nearly half of respondents have not shared their personal views about a social or political issue because of fear that sharing it would harm their career. Second, roughly a fifth of respondents have encountered discrimination for respectfully communicating their religious or political viewpoint. Third, these attitudes are negatively correlated with labor market and social media behavior: 40% of respondents say that perceptions of hostility against religious or political views make them much less likely to apply to a company, and 50% of respondents say that they are “very concerned” or “somewhat concerned” about adverse effects related with posting on social media about their religious and political attitudes. Finally, exposure to information about politicized topics is associated with a decline in respondents’ support for companies taking more activist stances. These results suggest that there are adverse and unintended consequences associated with religious and political discrimination, and companies could realize additional benefits by focusing on their core business activities.

Sleep Apnea Symptoms Are Associated with Memory and Cognitive Symptoms in a Nationally-representative Sample of U.S. Adults (S36.010)

Sleep Apnea Symptoms Are Associated with Memory and Cognitive Symptoms in a Nationally-representative Sample of U.S. Adults (S36.010)

Behavioral and social drivers of COVID-19 vaccination initiation in the US: a longitudinal study March─ October 2021

Many studies have examined behavioral and social drivers of COVID-19 vaccination initiation, but few have examined these drivers longitudinally. We sought to identify the drivers of COVID-19 vaccination initiation using the Behavioral and Social Drivers of Vaccination (BeSD) Framework. Participants were a nationally-representative sample of 1,563 US adults who had not received a COVID-19 vaccine by baseline. Participants took surveys online at baseline (spring 2021) and follow-up (fall 2021). The surveys assessed variables from BeSD Framework domains (i.e., thinking and feeling, social processes, and practical issues), COVID-19 vaccination initiation, and demographics at baseline and follow-up. Between baseline and follow-up, 65% of respondents reported initiating COVID-19 vaccination. Vaccination intent increased from baseline to follow-up (p < .01). Higher vaccine confidence, more positive social norms towards vaccination, and receiving vaccine recommendations at baseline predicted subsequent COVID-19 vaccine initiation (all p < .01). Among factors assessed at follow-up, social responsibility and vaccine requirements had the greatest associations with vaccine initiation (all p < .01). Baseline vaccine confidence, social norms, and vaccination recommendations were associated with subsequent vaccine initiation, all of which could be useful targets for behavioral interventions. Furthermore, interventions that highlight social responsibility to vaccinate or promote vaccination requirements could also be beneficial.

Comparing GPs according to their model of practice: are multiprofessional group practices associated with more favourable working conditions?

In the generalized context of general practitioner shortages and transitions towards team-based primary care, we investigated how the different practising models relate to general practitioners' labour supply. More precisely, we analysed the association between practice models-solo, groups of general practitioners, and multiprofessional groups-and their reported labour supply and level of satisfaction with work-life balance. We used a French cross-sectional survey from 2018 that surveyed a representative national sample of 3,032 self-employed general practitioners about their working conditions. We found that the model of practice was significantly associated with differences in physician labour supply at the intensive margin and that group practice appeared to be positively associated with general practitioners' reported satisfaction with work-life balance. In terms of weekly working time, only practice in groups of general practitioners was associated with a significantly lower labour supply. However, general practitioners in groups-whether groups of general practitioners or multiprofessional groups-reported more annual leave and seemed more willing to diversify their activity by devoting more time to secondary activities, including salaried activities. Consistently, general practitioners working in groups were also more likely than solo practitioners to report being satisfied with their work-life balance. Although group practice, whether multiprofessionnal or not, seems to be well suited to meeting the new aspirations of general practitioners, those working in multiprofessional groups are associated with a higher level of weekly work supply, which might justify special attention from the public authorities.

Factors Associated With Margin Positivity After Lung Resection Surgery

IntroductionThe purpose of this study is to utilize a representative national sample to investigate the factors associated with margin positivity after attempted surgical resection. Given the changes in surgical approaches to lung cancer for the last 10 years, margin positivity and outcomes between robotic, video assisted thoracoscopic surgery (VATS) and open surgical resections may vary. MethodsThis retrospective cohort study utilized the National Cancer Database. Patients with non–small-cell lung cancer, 18 or older and who had a surgical lung resection between 2010 and 2019 were included. Demographic data, along with patient-level clinical variables were extracted. Patient-level outcome variables including 30-day, 90-day mortality and readmission rates were analyzed. Univariable and multivariable logistic regression was utilized to assess factors associated with margin positivity. ResultsA total of 226,884 patients were identified. Of the total cohort, 9229 had positive margins (4.2%). Patients with positive margins had statistically significant increased 30-day, 90-day mortality, as well as increased readmission rate. Older age, male sex, patients undergoing an open resection, patients who underwent a wedge resection, higher clinical stage, larger tumor size, squamous and adenosquamous histologies, and higher Charlson-Deyo Comorbidity Index were all associated with having a positive margin after resection. ConclusionIn conclusion, there was no difference in margin positivity when comparing robotic and VATS resection, however, open resection had increased rates of margin positivity. Increasing tumor size, clinical stage, squamous and adenosquamous histologies, male sex, and patients undergoing a wedge resection were all associated with increased rates of margin positivity.

The shock index among children presenting to the emergency department: analysis of a nationally-representative sample

BackgroundThe Shock Index (SI) is emerging as a potentially useful measure among children with injury or with suspected sepsis. ObjectiveTo evaluate the distribution of the SI and evaluate its association with clinical outcomes among all children presenting to the emergency department (ED). MethodsWe analyzed a complex survey of nonfederal US ED encounters from 2016-2021. Among children, we evaluated the Pediatric Age-Adjusted Shock Index (SIPA), Pediatric SI (PSI), and the Temperature- and Age-Adjusted Shock Index (TAMSI). We evaluated the association of each criteria with disposition, acuity, medication administration, diagnoses and procedures. ResultsWe included a survey-weighted 81.5 million ED visits for children 4-16 years old and 117.2 million visits for children 1-12 years old. SI could be calculated for 78.6% of patients 4-16 years and 57.9% of patients 1-12 years old. An abnormal SI was present in 15.9%. 11.1%, and 31.7% when using the SIPA, PSI, and TAMSI, respectively. With all criteria, an elevated SI was associated with greater hospitalization. The SIPA and PSA were associated with triage acuity. All criteria were associated with medical interventions including provision of intravenous fluids and acquisition of blood cultures. ConclusionsAn elevated SI indicative of greater resource utilization needs among children in the ED. When using either criterion, an elevated SI was associated with clinically important outcomes. Further research is required to evaluate the distribution of the SI in children and to investigate its potential role within existing triage algorithms for children in the ED.

Adaptation Attitudes Are Guided by “Lived Experience” Rather than Electoral Interests: Evidence from a Survey Experiment in Bangladesh

After decades of presuming that climate adaptation is a private good benefitting only those receiving resources to reduce individual climate risks, respondents in a survey experiment among the climate-vulnerable in Bangladesh chose less-particularistic adaptation projects than “electoral connection” disaster relief theories predict and more “short-sighted” projects than international diplomats anticipate. This article reports on the experiment, which asked a representative national sample of Bangladeshis whether they favor spending funds on short-term particularistic solutions (disaster relief stockpiles), medium-term inclusionary and non-excludable solutions (ocean embankments), or long-term, public goods solutions (the development of flood-resistant rice seeds). More respondents chose “middle ground” embankment spending, and a statistically significant change in respondent propensities was tied to their lived experience with climate vulnerability rather than electoral incentives. The logic of their choices contradicts existing explanations, implying that a reconsideration of vulnerable community preferences, and how to address them, may be needed.

Abstract P203: Healthy Diet Perception, Cardiovascular Disease, and Risk Factors in Americans

Introduction: Healthy diet perception may influence cardiovascular (CV) outcomes. Misperceptions on the healthfulness of one’s diet can interfere with the precontemplative and contemplative stages of behavioral change if individuals overestimate their diet quality. Using a nationally-representative sample, we explored the prevalence of healthy diet misperception in the general population and in those with CV diseases, as well as whether misperceptions are associated with clinical CV risk factors. Methods: We included adults≥20 years old from the National Health and Nutrition Examination Survey 2017-2020. Using survey data on participants’ perception of their own diet and diet recall data to calculate Healthy Eating Index-2015 (HEI), we divided participants into dietary quantiles. We categorized healthy diet perception (HDP) as overestimated (perceived&gt;HEI quantile), accurate (perceived=HEI quantile), or underestimated (perceived&lt;HEI quantile). We categorized those who self-reported hypertension, coronary heart disease, myocardial infarction, congestive heart failure, and stroke as having CV disease. Clinical CV risk factor measures were body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), hemoglobin A1c, total cholesterol, low-density lipoprotein (LDL), and high-density lipoprotein (HDL). We used multiple logistic regression to measure the association between CV disease and HDP and multiple linear regression for HDP and CV risk factors, stratified by presence of CV disease. Results: Of 7,710 adults, 4,470 (57.5 weighted %) overestimated HDP; 1,924 (25.6 weighted %) underestimated HDP; and 1,316 (16.9 weighted %) correctly estimated HDP. After adjusting for age, sex, and education level, having CV disease was not associated with incorrectly estimating HDP (adjusted OR 1.08; 95% CI 0.93, 1.26) or overestimating HDP (adjusted OR 1.21; 95% CI 1.00, 1.48), compared to correctly estimating HDP. Among those with CV disease, overestimating HDP was associated with higher BMI (adjusted difference 1.9 m/kg 2 ; 95% CI 0.8, 2.9) and lower HDL (adjusted difference -2.8 mg/dL; 95% CI -5.1, -0.5). Among those without CV disease, overestimating HDP was only associated with higher BMI (adjusted difference 1.9; 95% CI 0.8, 2.9) Conclusions: More than half of Americans overestimate their diet quality, and adults with CV disease do not estimate diet quality more accuracy than those without CV disease. Among adults with CV disease, misperceptions in diet quality were associated with worse CV risk factor profiles, highlighting the need to assess and educate patients with CV disease on personal diet quality as part of healthy lifestyle promotion. Among those without CV disease, dietary misperceptions were associated with higher BMI, suggesting that increasing awareness of one's diet is also important in CV disease prevention.

Patterns of affective images of animal-sourced food in Norway: Land versus sea

To get an understanding of drivers of animal-sourced protein consumption, we explored laypeople’s affective images of animal-sourced food. A national representative sample of the Norwegian population (N = 783) provided free associations to six food products originating either from livestock, capture fishery, aquaculture, or hunting. Subsequently, participants evaluated their own free associations as either positive, negative, or neutral. We found that people show different associative patterns for animal-sourced food from land than from sea. Livestock and hunting are mostly related to traditions and food, whereas capture fishery relates to production, consequences, and evaluations. People reported to have little knowledge about food products in the aquaculture category. Livestock was the most positively evaluated category, followed by hunting and capture fishery; aquaculture elicited the most negative associations. The current findings suggest a need to consider different strategies to encourage consumption of specific categories of food products.

Enforcement and public opinion: the perceived legitimacy of rule of law sanctions

ABSTRACT The EU has powerful enforcement mechanisms to curb democratic backsliding and support the rule of law in its member states. While (the threat of) enforcement is necessary, sanctions might be difficult to accept as legitimate when they hurt a citizen's country. We study the perceived legitimacy of EU enforcement actions. We develop hypotheses about the influence of national identity, party support, procedural fairness, descriptive norm prevalence, and the likely effects of the sanctions on the future of cooperation. These hypotheses are tested with a survey experiment administered to a nationally-representative sample in Poland. The focus is on the substantial financial sanctions imposed by the EU concerning judicial independence. The results show that exclusive national identity, the perceived importance of the rule of law, support for European integration and party support are strongly associated with perceived legitimacy. Providing information about the prevalence of public support for judicial independence in the country increases significantly the perceived legitimacy of enforcement actions. We find no evidence for effects of arguments about Polexit, future deterrence effects of the sanctions or their procedural (un)fairness. EU sanctions might not lead to further backlash among the domestic public, but they are unlikely to generate public pressure for reforms.