Association between cigar use, with and without cigarettes, and incident diagnosed COPD: a longitudinal cohort study.

BACKGROUND: While regular cigar smoking is believed to carry similar health risks as regular cigarette smoking, the impact of cigar use, alone or in combination with cigarettes, on obstructive pulmonary disease (COPD) has not been well characterized. The purpose of this study was to examine the prospective association between exclusive and dual cigar and cigarette use and incident self-reported diagnosed COPD. METHODS: This study used data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative survey of U.S. adults. Longitudinal data from adults aged 40 to 79 at Wave 1, without a pre-existing COPD diagnosis who participated at follow-up interview were analyzed. A time-varying current tobacco exposure, lagged by one wave and categorized as: (a) never/non-current use; (b) exclusive cigar use; (c) exclusive cigarette use; and (d) dual cigar/cigarette use. Multivariable models adjusted for demographics (age, sex, race or ethnicity, education), clinical risk factors (asthma, obesity), and smoking-related confounders (second-hand smoke exposure, other combustible tobacco product use, e-cigarette use, time since quitting, cigarette pack-years). The incidence of self-reported diagnosed COPD was estimated using discrete-time survival models, using a general linear modeling (GLM) approach with a binomial distribution and a complementary log-log link function. RESULTS: The analytic sample consisted of 9,556 adults with a mean (SD) age of 56 (10.4), who were predominately female (52.8%) and Non-Hispanic White (70.8%). A total of 906 respondents reported a diagnosis of COPD at follow-up. In the fully adjusted model, exclusive cigar use (adjusted hazard ratio (aHR) = 1.57, 95% CI: 0.77, 3.21) was not associated with increased COPD risk compared to non-use, while exclusive cigarette use (aHR = 1.48, 95% CI: 1.13, 1.93) and dual cigar/cigarette use (aHR = 1.88, 95% CI: 1.24, 2.85) were. CONCLUSIONS: Exclusive cigarette use and dual cigar/cigarette use were associated with diagnosed incident COPD. These results suggest that cigars, when used in combination with cigarettes, may be associated with poorer COPD health outcomes. Dual use may promote a higher likelihood of inhaling cigar smoke, and future research would benefit from examining whether inhalation of cigar smoke increases COPD risk.

A longitudinal analysis of flavored cigar use and cigar smoking cessation among US adults.

BACKGROUND: Flavorings in cigars increase their appeal, mask the harsh taste of tobacco, and may hinder successful cigar smoking cessation; however, limited evidence has examined whether flavors are associated with short- or long-term cigar smoking cessation. METHODS: Using restricted data from the Population Assessment of Tobacco and Health Study Waves 1-5, we examined whether flavored cigar use was associated with 30-day-plus and 1-year-plus cigar smoking cessation among US adults. Multivariable discrete-time survival models were fit to a nationally representative sample of US adult (18+) respondents who had a current, established cigar use, smoked five or more days in the past 30 days, and did not exclusively smoke traditional premium cigars at baseline. Models adjusted for age, sex, race and ethnicity, income, cigar and cigarette smoking intensity, and blunt use. RESULTS: At baseline, 44.6% of respondents (n = 674) were 18-34 years old, 75.0% were male, 56.7% were non-Hispanic White, 78.9% had household incomes of <$50,000, and 56.2% smoked flavored cigars. In fully adjusted models, flavored cigar use was associated with a lower risk of 30-day-plus (HR = 0.76, 95% CI = 0.60, 0.97) but not 1-year-plus cigar smoking cessation (HR = 0.81, 95% = 0.62, 1.05). CONCLUSIONS: We found that flavored cigar use was associated with a lower risk of short-term but not long-term cigar smoking cessation. More work is needed to understand the dynamics of cigar smoking transitions, including initiation, cessation, and relapse, particularly in larger cohorts and among those who exclusively use cigars or dual-use cigars and cigarettes. IMPLICATIONS: As local and some state jurisdictions continue to adopt partial or complete bans of flavored cigar products and the United States Food and Drug Administration considers a national ban of all characterizing flavors in cigars, there is a need for more longitudinal work examining the associations between flavorings in cigars and short and long-term cigar smoking behaviors, including but not limited to initiation, cessation, intensity of use, and relapse, particularly in diverse cohorts.

Racial, ethnic, and gender differences in the association between higher state minimum wages and health and mental well-being in US adults with low educational attainment.

BACKGROUND: To date, research evaluating the association between minimum wage and health has been heterogenous and varies based on the specific subpopulation or health outcomes under evaluation while associations across racial, ethnic, and gender identities have been understudied. METHODS: A triple difference-in-differences strategy using modified Poisson regression was used to evaluate the associations between minimum wage and obesity, hypertension, fair or poor general health, and moderate psychological distress in 25-64-year-old adults with a high school education/GED or less. Data from the 1999-2017 Panel Study of Income Dynamics was linked to state policies and characteristics to estimate the risk ratio (RR) associated with a $1 increase in current and 2-year lagged state minimum wages overall and by race, ethnicity, and gender (non-Hispanic or non-Latino (NH) White men, NH White women, Black, indigenous, or people of color (BIPOC) men, and BIPOC women) adjusting for individual and state-level confounding. RESULTS: No associations between minimum wage and health were observed overall. Among NH White men 2-year lagged minimum wage was associated with reduced risk of obesity (RR = 0.82, 95% CI = 0.67, 0.99). Among NH White women, current minimum wage was associated lower risk of moderate psychological distress (RR = 0.73, 95% CI = 0.54, 1.00) while 2-year lagged minimum wage was associated with higher obesity risk (RR = 1.35, 95% CI = 1.12, 1.64) and lower risk of moderate psychological distress (RR = 0.75, 95% CI = 0.56, 1.00). Among BIPOC women, current minimum wage was associated with higher risk of fair or poor health (RR = 1.19, 95% CI = 1.02, 1.40). No associations were observed among BIPOC men. CONCLUSION: While no associations were observed overall, heterogeneous associations between minimum wage, obesity, and psychological distress by racial, ethnic, and gender strata warrant further study and have implications for health equity research.

Investigating the effects of rurality on stress, subjective well-being, and weight-related outcomes.

Purpose: Rates of obesity are significantly higher for those living in a rural versus urban setting. High levels of stress and low levels of subjective well-being (SWB) have been linked to poor weight-related behaviors and outcomes, but it is unclear if these relationships differ as a function of rurality. This study investigated the extent to which living in a rural versus urban county ("rurality") moderated associations between stress / subjective wellbeing (predictors) and diet quality, dietary intake of added sugars, physical activity, and BMI (outcomes). Methods: Participants were recruited from urban (n = 355) and rural (n = 347) counties in Washington State and self-reported psychological, demographic, and food frequency questionnaires while physical activity behavior was measured objectively. Findings: After controlling for relevant covariates, levels of stress were positively associated with added sugar intake for those living in the urban county while this relationship was non-significant for those residing in the rural county. Similarly, SWB was negatively associated with added sugar intake, but only for urban residents. County of residence was also found to moderate the relationship between SWB and BMI. Higher SWB was inversely associated with BMI for those living in the urban county while no relationship was observed for rural county residents. Conclusions: These findings support the hypothesis that the relationships between stress / SWB and weight function differentially based on the rurality of the residing county. This work adds to the growing body of literature highlighting the role stress and SWB play in the rural obesity disparity.

Associations between neighborhood built environment, residential property values, and adult BMI change: The Seattle Obesity Study III.

Objective: To examine associations between neighborhood built environment (BE) variables, residential property values, and longitudinal 1- and 2-year changes in body mass index (BMI). Methods: The Seattle Obesity Study III was a prospective cohort study of adults with geocoded residential addresses, conducted in King, Pierce, and Yakima Counties in Washington State. Measured heights and weights were obtained at baseline (n = 879), year 1 (n = 727), and year 2 (n = 679). Tax parcel residential property values served as proxies for individual socioeconomic status. Residential unit and road intersection density were captured using Euclidean-based SmartMaps at 800 m buffers. Counts of supermarket (0 versus. 1+) and fast-food restaurant availability (0, 1-3, 4+) were measured using network based SmartMaps at 1600 m buffers. Density measures and residential property values were categorized into tertiles. Linear mixed-effects models tested whether baseline BE variables and property values were associated with differential changes in BMI at year 1 or year 2, adjusting for age, gender, race/ethnicity, education, home ownership, and county of residence. These associations were then tested for potential disparities by age group, gender, race/ethnicity, and education. Results: Road intersection density, access to food sources, and residential property values were inversely associated with BMI at baseline. At year 1, participants in the 3rd tertile of density metrics and with 4+ fast-food restaurants nearby showed less BMI gain compared to those in the 1st tertile or with 0 restaurants. At year 2, higher residential property values were predictive of lower BMI gain. There was evidence of differential associations by age group, gender, and education but not race/ethnicity. Conclusion: Inverse associations between BE metrics and residential property values at baseline demonstrated mixed associations with 1- and 2-year BMI change. More work is needed to understand how individual-level sociodemographic factors moderate associations between the BE, property values, and BMI change.

Differences in Weight Gain Following Residential Relocation in the Moving to Health (M2H) Study.

BACKGROUND: Neighborhoods may play an important role in shaping long-term weight trajectory and obesity risk. Studying the impact of moving to another neighborhood may be the most efficient way to determine the impact of the built environment on health. We explored whether residential moves were associated with changes in body weight. METHODS: Kaiser Permanente Washington electronic health records were used to identify 21,502 members aged 18-64 who moved within King County, WA between 2005 and 2017. We linked body weight measures to environment measures, including population, residential, and street intersection densities (800 m and 1,600 m Euclidian buffers) and access to supermarkets and fast foods (1,600 m and 5,000 m network distances). We used linear mixed models to estimate associations between postmove changes in environment and changes in body weight. RESULTS: In general, moving from high-density to moderate- or low-density neighborhoods was associated with greater weight gain postmove. For example, those moving from high to low residential density neighborhoods (within 1,600 m) gained an average of 4.5 (95% confidence interval [CI] = 3.0, 5.9) lbs 3 years after moving, whereas those moving from low to high-density neighborhoods gained an average of 1.3 (95% CI = -0.2, 2.9) lbs. Also, those moving from neighborhoods without fast-food access (within 1600m) to other neighborhoods without fast-food access gained less weight (average 1.6 lbs [95% CI = 0.9, 2.4]) than those moving from and to neighborhoods with fast-food access (average 2.8 lbs [95% CI = 2.5, 3.2]). CONCLUSIONS: Moving to higher-density neighborhoods may be associated with reductions in adult weight gain.

A Multi-Site Analysis of the Prevalence of Food Insecurity in the United States, before and during the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic profoundly affected food systems including food security. Understanding how the COVID-19 pandemic impacted food security is important to provide support and identify long-term impacts and needs. OBJECTIVE: The National Food Access and COVID research Team (NFACT) was formed to assess food security over different US study sites throughout the pandemic, using common instruments and measurements. This study presents results from 18 study sites across 15 states and nationally over the first year of the COVID-19 pandemic. METHODS: A validated survey instrument was developed and implemented in whole or part through an online survey of adults across the sites throughout the first year of the pandemic, representing 22 separate surveys. Sampling methods for each study site were convenience, representative, or high-risk targeted. Food security was measured using the USDA 6-item module. Food security prevalence was analyzed using ANOVA by sampling method to assess statistically significant differences. RESULTS: Respondents (n = 27,168) indicate higher prevalence of food insecurity (low or very low food security) since the COVID-19 pandemic, compared with before the pandemic. In nearly all study sites, there is a higher prevalence of food insecurity among Black, Indigenous, and People of Color (BIPOC), households with children, and those with job disruptions. The findings demonstrate lingering food insecurity, with high prevalence over time in sites with repeat cross-sectional surveys. There are no statistically significant differences between convenience and representative surveys, but a statistically higher prevalence of food insecurity among high-risk compared with convenience surveys. CONCLUSIONS: This comprehensive study demonstrates a higher prevalence of food insecurity in the first year of the COVID-19 pandemic. These impacts were prevalent for certain demographic groups, and most pronounced for surveys targeting high-risk populations. Results especially document the continued high levels of food insecurity, as well as the variability in estimates due to the survey implementation method.

Some Ultra-Processed Foods Are Needed for Nutrient Adequate Diets: Linear Programming Analyses of the Seattle Obesity Study.

Typical diets include an assortment of unprocessed, processed, and ultra-processed foods, along with culinary ingredients. Linear programming (LP) can be used to generate nutritionally adequate food patterns that meet pre-defined nutrient guidelines. The present LP models were set to satisfy 22 nutrient standards, while minimizing deviation from the mean observed diet of the Seattle Obesity Study (SOS III) sample. Component foods from the Fred Hutch food frequency questionnaire comprised the market basket. LP models generated optimized 2000 kcal food patterns by selecting from all foods, unprocessed foods only, ultra-processed foods only, or some other combination. Optimized patterns created using all foods contained less fat, sugar, and salt, and more vegetables compared to the SOS III mean. Ultra-processed foods were the main sources of added sugar, saturated fat and sodium. Ultra-processed foods also contributed most vitamin E, thiamin, niacin, folate, and calcium, and were the main sources of plant protein. LP models failed to create optimal diets using unprocessed foods only and ultra-processed foods only: no mathematical solution was obtained. Relaxing the vitamin D criterion led to optimized diets based on unprocessed or ultra-processed foods only. However, food patterns created using unprocessed foods were significantly more expensive compared to those created using foods in the ultra-processed category. This work demonstrates that foods from all NOVA categories can contribute to a nutritionally adequate diet.

Differential associations of the built environment on weight gain by sex and race/ethnicity but not age.

OBJECTIVE: To explore the built environment (BE) and weight change relationship by age, sex, and racial/ethnic subgroups in adults. METHODS: Weight trajectories were estimated using electronic health records for 115,260 insured Kaiser Permanente Washington members age 18-64 years. Member home addresses were geocoded using ArcGIS. Population, residential, and road intersection densities and counts of area supermarkets and fast food restaurants were measured with SmartMaps (800 and 5000-meter buffers) and categorized into tertiles. Linear mixed-effect models tested whether associations between BE features and weight gain at 1, 3, and 5 years differed by age, sex, and race/ethnicity, adjusting for demographics, baseline weight, and residential property values. RESULTS: Denser urban form and greater availability of supermarkets and fast food restaurants were associated with differential weight change across sex and race/ethnicity. At 5 years, the mean difference in weight change comparing the 3rd versus 1st tertile of residential density was significantly different between males (-0.49 kg, 95% CI: -0.68, -0.30) and females (-0.17 kg, 95% CI: -0.33, -0.01) (P-value for interaction = 0.011). Across race/ethnicity, the mean difference in weight change at 5 years for residential density was significantly different among non-Hispanic (NH) Whites (-0.47 kg, 95% CI: -0.61, -0.32), NH Blacks (-0.86 kg, 95% CI: -1.37, -0.36), Hispanics (0.10 kg, 95% CI: -0.46, 0.65), and NH Asians (0.44 kg, 95% CI: 0.10, 0.78) (P-value for interaction <0.001). These findings were consistent for other BE measures. CONCLUSION: The relationship between the built environment and weight change differs across demographic groups. Careful consideration of demographic differences in associations of BE and weight trajectories is warranted for investigating etiological mechanisms and guiding intervention development.

Does the built environment have independent obesogenic power? Urban form and trajectories of weight gain.

OBJECTIVE: To determine whether selected features of the built environment can predict weight gain in a large longitudinal cohort of adults. METHODS: Weight trajectories over a 5-year period were obtained from electronic health records for 115,260 insured patients aged 18-64 years in the Kaiser Permanente Washington health care system. Home addresses were geocoded using ArcGIS. Built environment variables were population, residential unit, and road intersection densities captured using Euclidean-based SmartMaps at 800-m buffers. Counts of area supermarkets and fast food restaurants were obtained using network-based SmartMaps at 1600, and 5000-m buffers. Property values were a measure of socioeconomic status. Linear mixed effects models tested whether built environment variables at baseline were associated with long-term weight gain, adjusting for sex, age, race/ethnicity, Medicaid insurance, body weight, and residential property values. RESULTS: Built environment variables at baseline were associated with differences in baseline obesity prevalence and body mass index but had limited impact on weight trajectories. Mean weight gain for the full cohort was 0.06 kg at 1 year (95% CI: 0.03, 0.10); 0.64 kg at 3 years (95% CI: 0.59, 0.68), and 0.95 kg at 5 years (95% CI: 0.90, 1.00). In adjusted regression models, the top tertile of density metrics and frequency counts were associated with lower weight gain at 5-years follow-up compared to the bottom tertiles, though the mean differences in weight change for each follow-up year (1, 3, and 5) did not exceed 0.5 kg. CONCLUSIONS: Built environment variables that were associated with higher obesity prevalence at baseline had limited independent obesogenic power with respect to weight gain over time. Residential unit density had the strongest negative association with weight gain. Future work on the influence of built environment variables on health should also examine social context, including residential segregation and residential mobility.

Inedible Food Waste Linked to Diet Quality and Food Spending in the Seattle Obesity Study SOS III.

Americans waste about a pound of food per day. Some of this is represented by inedible food waste at the household level. Our objective was to estimate inedible food waste in relation to diet quality and participant socio-economic status (SES). Seattle Obesity Study III participants (n = 747) completed the Fred Hutch Food Frequency Questionnaire (FFQ) and socio-demographic and food expenditure surveys. Education and geo-coded tax-parcel residential property values were measures of SES. Inedible food waste was calculated from diet records. Retail prices of FFQ component foods (n = 378) were used to estimate individual-level diet costs. The NOVA classification was used to identify ultra-processed foods. Multivariable linear regressions tested associations between inedible food waste, SES, food spending, Nutrient Rich Food (NRF9.3) and Healthy Eating Index (HEI-2015) scores. Inedible food waste was estimated at 78.7 g/d, mostly from unprocessed vegetables (32.8 g), fruit (30.5 g) and meat, poultry, and fish (15.4 g). Greater inedible food waste was associated with higher HEI-2015 and NRF9.3 scores, higher food expenditures and lower percent energy from ultra-processed foods. In multivariable models, more inedible food waste was associated with higher food expenditures, education and residential property values. Higher consumption of unprocessed foods were associated with more inedible food waste and higher diet costs. Geo-located estimates of inedible food waste can provide a proxy index of neighborhood diet quality.

Association of State Minimum Wage Rates and Health in Working-Age Adults Using the National Health Interview Survey.

States adopt minimum wages to improve workers' economic circumstances and well-being. Many studies, but not all, find evidence of health benefits from higher minimum wages. This study used a rigorous "triple difference" strategy to identify the associations between state minimum wages and adult obesity, body mass index (weight (kg)/height (m)2), hypertension, diabetes, fair or poor health, and serious psychological distress. National Health Interview Survey data (United States, 2008-2015) on adults aged 25-64 years (n = 131,430) were linked to state policies to estimate the prevalence odds ratio or mean difference in these outcomes associated with a $1 increase in current and 2-year lagged minimum wage among less-educated adults overall and by sex, race/ethnicity, and age. In contrast to prior studies, there was no association between current minimum wage and health; however, 2-year lagged minimum wage was positively associated with the likelihood of obesity (prevalence odds ratio = 1.08, 95% confidence interval: 1.00, 1.16) and with elevated body mass index (mean difference = 0.27, 95% confidence interval: 0.04, 0.49). In subgroup models, current and 2-year lagged minimum wage were associated with a higher likelihood of obesity among male and non-White or Hispanic adults. The associations with hypertension also varied by sex and the timing of the exposure.

Characterising percentage energy from ultra-processed foods by participant demographics, diet quality and diet cost: findings from the Seattle Obesity Study (SOS) III.

Higher consumption of 'ultra-processed' (UP) foods has been linked to adverse health outcomes. The present paper aims to characterise percentage energy from UP foods by participant socio-economic status (SES), diet quality, self-reported food expenditure and energy-adjusted diet cost. Participants in the population-based Seattle Obesity Study III (n 755) conducted in WA in 2016-2017 completed socio-demographic and food expenditure surveys and the FFQ. Education and residential property values were measures of SES. Retail prices of FFQ component foods (n 378) were used to estimate individual-level diet cost. Healthy Eating Index (HEI-2015) and Nutrient Rich Food Index 9.3 (NRF9.3) were measures of diet quality. UP foods were identified following NOVA classification. Multivariable linear regressions were used to test associations between UP foods energy, socio-demographics, two estimates of food spending and diet quality measures. Higher percentage energy from UP foods was associated with higher energy density, lower HEI-2015 and NRF9.3 scores. The bottom decile of diet cost ($216·4/month) was associated with 67·5 % energy from UP foods; the top decile ($369·9/month) was associated with only 48·7 % energy from UP foods. Percentage energy from UP foods was inversely linked to lower food expenditures and diet cost. In multivariate analysis, percentage energy from UP foods was predicted by lower food expenditures, diet cost and education, adjusting for covariates. Percentage energy from UP foods was linked to lower food spending and lower SES. Efforts to reduce UP foods consumption, an increasingly common policy measure, need to take affordability, food expenditures and diet costs into account.

A cross-sectional analysis of physical activity and weight misreporting in diverse populations: The Seattle Obesity Study III.

BACKGROUND: In-person assessments of physical activity (PA) and body weight can be burdensome for participants and cost prohibitive for researchers. This study examined self-reported PA and weight accuracy and identified patterns of misreporting in a diverse sample. METHODS: King, Pierce and Yakima county residents, aged 21-59 years (n = 728), self-reported their moderate-to-vigorous PA (MVPA) and weight, in kilograms. Self-reports were compared with minutes of bout-level MVPA, from 3 days of accelerometer data, and measured weights. Regression models examined characteristics associated with underreporting and overreporting of MVPA and weight, the potential bias introduced using each measure and the relation between perceived and measured PA and weight. RESULTS: MVPA underreporting was higher among males and college educated participants; however, there was no differential MVPA overreporting. Weight underreporting was higher among males, those age 40-49 years and persons with obesity. Weight overreporting was higher among Hispanic participants and those reporting stress, unhappiness and fair or poor health. The estimated PA-obesity relation was similar using measured and self-reported PA but not self-reported weight. Perceived PA and weight predicted measured values. CONCLUSION: Self-reported PA and weight may be useful should objective measurement be infeasible; however, though population-specific adjustment for differential reporting should be considered.

Small increments in diet cost can improve compliance with the Dietary Guidelines for Americans.

Adherence to the Dietary Guidelines for Americans (DGA) may involve higher diet costs. This study assessed the relation between two measures of food spending and diet quality among adult participants (N = 768) in the Seattle Obesity Study (SOS III). All participants completed socio-demographic and food expenditure surveys and the Fred Hutch food frequency questionnaire. Dietary intakes were joined with local supermarket prices to estimate individual-level diet costs. Healthy Eating Index (HEI- 2015) scores measured compliance with DGA. Multiple linear regressions using Generalized Estimating Equations with robust standard errors showed that lower food spending was associated with younger age, Hispanic ethnicity, and lower socioeconomic status. Even though higher HEI-2015 scores were associated with higher diet costs per 2000 kcal, much individual variability was observed. A positive curvilinear relationship was observed in adjusted models. At lower cost diets, a $100/month increase in cost (from $150 to $250) was associated with a 20.6% increase in HEI-2015. For higher levels of diet cost (from $350 to $450) there were diminishing returns (2.8% increase in HEI- 2015). These findings indicate that increases in food spending at the lower end of the range have the most potential to improve diet quality.

The Initial Nonprofit Exposure and Response to Seattle's Minimum Wage Ordinance.

Nearly 40 local governments adopted minimum wage rates higher than the federal minimum in the last decade. Research on such laws focuses on employment and price adjustments of for-profit firms. Higher minimum wage rates, however, may pose unique challenges to community-based nonprofit organizations, many of which serve vulnerable communities and have limited ability to modify business practices. We use survey and in-depth interview data with more than 125 nonprofit executives to explore how nonprofit organizations were exposed to, understood, and responded to the initial phase-in of Seattle's $15 minimum wage ordinance. Although most nonprofits with low-wage workers do not report substantial programmatic changes in response to the minimum wage, we do find evidence nonprofits are pursuing several avenues to raise revenue to cover higher anticipated labor costs. Results suggest that the channels of adjustment available to nonprofits have a different character than those available to for-profit firms.

Obesity and the Built Environment: A Reappraisal.

The built environment (BE) has been viewed as an important determinant of health. Numerous studies have linked BE exposure, captured using a variety of methods, to diet quality and to area prevalence of obesity, diabetes, and cardiovascular disease. First-generation studies defined the neighborhood BE as the area around the home. Second-generation studies turned from home-centric to person-centric BE measures, capturing an individual's movements in space and time. Those studies made effective uses of global positioning system tracking devices and mobile phones, sometimes coupled with accelerometers and remote sensors. Activity space metrics explored travel paths, modes, and destinations to assess BE exposure that was both person and context specific. However, as measures of the contextual exposome have become ever more fine-grained and increasingly complex, connections to long-term chronic diseases with complex etiologies, such as obesity, are in danger of being lost. Furthermore, few studies on obesity and the BE have included intermediate energy balance behaviors, such as diet and physical activity, or explored the potential roles of social interactions or psychosocial pathways. Emerging survey-based applications that identify habitual destinations and associated travel patterns may become the third generation of tools to capture health-relevant BE exposures in the long term.

Low-income workers' perceptions of wages, food acquisition, and well-being.

Although studies have demonstrated an association between increased economic resources and improvements in food security and health, there is a paucity of qualitative research regarding the relationships between household resources, food security, and health. Policy changes related to increasing low wages are potential opportunities to understand changes to material resources. The aims of this analysis were to describe how low-wage workers perceive household resources in relation to food acquisition and to explore how workers in low-wage jobs connect food and diet to perceptions of health and well-being. We analyzed 190 transcripts from 55 workers in low-wage jobs who were living in households with children who were part of the Seattle Minimum Wage Study (up to three in-depth qualitative interviews and one phone survey per participant, conducted between 2015 and 2017). We coded and analyzed interviews using Campbell's food acquisition framework and best practices for qualitative research. Participants relied on a combination of wages, government assistance, and private assistance from community or family resources to maintain an adequate food supply. Strategies tended to focus more on maintaining food quality than food quantity. Restricted resources also limited food-related leisure activities, which many participants considered important to quality of life. Although many low-wage workers would like to use additional income to purchase higher quality foods or increase food-related leisure activities, they often perceive trade-offs that limit income-based adjustments to food-spending patterns. Future studies should be specifically designed to examine food choices in response to changes in income.