Spatial clustering patterns and regional variations for food and physical activity environments across the United States.

This study examined spatial patterns of obesogenic environments for US counties. We mapped the geographic dispersion of food and physical activity (PA) environments, assessed spatial clustering, and identified food and PA environment differences across U.S. regions and rurality categories. Substantial low food score clusters were located in the South and high score clusters in the Midwest and West. Low PA score clusters were located in the South and high score clusters in the Northeast and Midwest (p < .0001). For region, the South had significantly lower food and PA environment scores. For rurality, rural counties had significantly higher food environment scores and metropolitan counties had significantly higher PA environment scores (p < .0001). This study highlights geographic clustering and disparities in food and PA access nationwide. State and region-wide environmental inequalities may be targeted using structural interventions and policy initiatives to improve food and PA access.

Development of a national childhood obesogenic environment index in the United States: differences by region and rurality.

BACKGROUND: Diverse environmental factors are associated with physical activity (PA) and healthy eating (HE) among youth. However, no study has created a comprehensive obesogenic environment index for children that can be applied at a large geographic scale. The purpose of this study was to describe the development of a childhood obesogenic environment index (COEI) at the county level across the United States. METHODS: A comprehensive search of review articles (n = 20) and input from experts (n = 12) were used to identify community-level variables associated with youth PA, HE, or overweight/obesity for potential inclusion in the index. Based on strength of associations in the literature, expert ratings, expertise of team members, and data source availability, 10 key variables were identified - six related to HE (# per 1000 residents for grocery/superstores, farmers markets, fast food restaurants, full-service restaurants, and convenience stores; as well as percentage of births at baby (breastfeeding)-friendly facilities) and four related to PA (percentage of population living close to exercise opportunities, percentage of population < 1 mile from a school, a composite walkability index, and number of violent crimes per 1000 residents). Data for each variable for all counties in the U.S. (n = 3142) were collected from publicly available sources. For each variable, all counties were ranked and assigned percentiles ranging from 0 to 100. Positive environmental variables (e.g., grocery stores, exercise opportunities) were reverse scored such that higher values for all variables indicated a more obesogenic environment. Finally, for each county, a total obesogenic environment index score was generated by calculating the average percentile for all 10 variables. RESULTS: The average COEI percentile ranged from 24.5-81.0 (M = 50.02,s.d. = 9.01) across US counties and was depicted spatially on a choropleth map. Obesogenic counties were more prevalent (F = 130.43,p < .0001) in the South region of the U.S. (M = 53.0,s.d. = 8.3) compared to the Northeast (M = 43.2,s.d. = 6.9), Midwest (M = 48.1,s.d. = 8.5), and West (M = 48.4,s.d. = 9.8). When examined by rurality, there were also significant differences (F = 175.86,p < .0001) between metropolitan (M = 46.5,s.d. = 8.4), micropolitan (M = 50.3,s.d. = 8.1), and rural counties (M = 52.9,s.d. = 8.8) across the U.S. CONCLUSION: The COEI can be applied to benchmark obesogenic environments and identify geographic disparities and intervention targets. Future research can examine associations with obesity and other health outcomes.

Maternal BMI at the start of pregnancy and offspring epigenome-wide DNA methylation: findings from the pregnancy and childhood epigenetics (PACE) consortium.

Pre-pregnancy maternal obesity is associated with adverse offspring outcomes at birth and later in life. Individual studies have shown that epigenetic modifications such as DNA methylation could contribute. Within the Pregnancy and Childhood Epigenetics (PACE) Consortium, we meta-analysed the association between pre-pregnancy maternal BMI and methylation at over 450,000 sites in newborn blood DNA, across 19 cohorts (9,340 mother-newborn pairs). We attempted to infer causality by comparing the effects of maternal versus paternal BMI and incorporating genetic variation. In four additional cohorts (1,817 mother-child pairs), we meta-analysed the association between maternal BMI at the start of pregnancy and blood methylation in adolescents. In newborns, maternal BMI was associated with small (<0.2% per BMI unit (1 kg/m2), P < 1.06 × 10-7) methylation variation at 9,044 sites throughout the genome. Adjustment for estimated cell proportions greatly attenuated the number of significant CpGs to 104, including 86 sites common to the unadjusted model. At 72/86 sites, the direction of the association was the same in newborns and adolescents, suggesting persistence of signals. However, we found evidence for acausal intrauterine effect of maternal BMI on newborn methylation at just 8/86 sites. In conclusion, this well-powered analysis identified robust associations between maternal adiposity and variations in newborn blood DNA methylation, but these small effects may be better explained by genetic or lifestyle factors than a causal intrauterine mechanism. This highlights the need for large-scale collaborative approaches and the application of causal inference techniques in epigenetic epidemiology.

Overall gestational weight gain mediates the relationship between maternal and child obesity.

BACKGROUND: Approximately 17% of children in the U.S. are obese. Children that are overweight or obese are also more likely to be obese as adults and suffer from various chronic diseases and premature death. Maternal obesity can affect the weight status of her offspring through intrauterine mechanisms like excessive gestational weight gain (GWG). Current literature shows a positive association between maternal weight status and GWG on child obesity, yet the direct and indirect effects have not been decomposed or quantified. The purpose of this study was to estimate the effect of maternal obesity on child obesity, mediated by GWG, which is a modifiable risk factor. METHODS: The study participants were a birth cohort of offspring from women who received prenatal care in the Duke/Durham Regional health care system in Durham, NC between 2005 and 2009. Anthropomorphic data was collected via electronic medical records (EMRs) during each voluntary visit to a health care facility. The exposure of interest was maternal obesity, measured by pre-pregnancy body mass index, the mediator was GWG, dichotomized into excessive and not excessive based on maternal prenatal BMI, and the outcome was child obesity at age 4, measured as BMI z-scores from the last recorded height and weight. A counterfactual theory-based product method analysis estimated the mediated effects of GWG, adjusted for maternal race, socioeconomic status, and smoking status. RESULTS: Of the 766 children, 25% were overweight or obese, and among all mothers, 25 and 31% were overweight and obese, respectively. Maternal BMI was associated with an overall increase of 0.04 in offspring z-score. The proportion of the effect of maternal obesity on child age 4 obesity mediated by GWG was 8.1%. CONCLUSION: GWG, in part, mediated the relationship between maternal BMI and childhood adiposity. Even when the mediator is fixed, children are at an increased risk of a higher BMI if the mother is obese. These findings highlight an important public health education opportunity to stress the impact of a pre-pregnancy weight and excessive GWG on the risk of child obesity for all mothers.

A statewide program providing colorectal cancer screening to the uninsured of South Carolina.

BACKGROUND: Cancer screening rates are lowest in those without insurance or a regular provider. Since 2008, the Colorectal Cancer Prevention Network (CCPN) has provided open access colonoscopy to uninsured residents of South Carolina through established, statewide partnerships and patient navigation. Herein, we describe the structure, implementation, and clinical outcomes of this program. METHODS: The CCPN provides access to colonoscopy screening at no cost to uninsured, asymptomatic patients aged 50-64 years (African Americans age 45-64 years are eligible) who live at or below 150% of the poverty line and seek medical care in free medical clinics, federally qualified health centers, or hospital-based indigent practices in South Carolina. Screening is performed by board-certified gastroenterologists. Descriptive statistics and regression analysis are used to describe the population screened, and to assess compliance rates and colonoscopy quality metrics. RESULTS: Out of >4000 patients referred to the program, 1854 were deemed eligible, 1144 attended an in-person navigation visit, and 1030 completed a colonoscopy; 909 were included in the final sample. Nearly 90% of participants exhibited good-to-excellent bowel preparation. An overall cecal intubation rate of 99% was measured. The polyp detection rate and adenoma detection rate were 63% and 36%, respectively, with male sex and urban residence positively associated with adenoma detection. Over 13% of participants had an advanced polyp, and 1% had a cancer diagnosis or surgical intervention. CONCLUSION: The CCPN program is characterized by strong collaboration with clinicians statewide, low no-show rates, and high colonoscopy quality. Future work will assess the effectiveness of the navigation approach and will explore the mechanisms driving higher adenoma detection in urban participants. Cancer 2018;124:1912-20. © 2018 American Cancer Society.

Low-grade Systemic Inflammation May Increase the Risk of Periodontitis.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Longitudinal effects of systemic inflammation markers on periodontitis. Pink C, Kocher T, Meisel P, Dörr M, Markus MRP, Jablonowski L, Grotevendt A, Nauck M, Holtfreter B. J Clin Periodontol 2015;42(11):988-97. SOURCE OF FUNDING: The parent study was supported by the German Federal Ministry of Education and Research (BMBF) (grant 01ZZ96030, 01ZZ0701), the Ministry of Education, Research and Cultural Affairs, and the Ministry of Social Affairs of the Federal State of Mecklenburg-West Pomerania. GABA, Switzerland, provided an unlimited educational grant to support B.H. and C.P. This publication was made possible in part by grant number T32-GM081740 from NIH-NIGMS. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIGMS or NIH. CONFLICT OF INTEREST: The authors have no actual or potential conflicts of interest. TYPE OF STUDY/DESIGN: Prospective cohort study.

Spatial accessibility to colonoscopy and its role in predicting late-stage colorectal cancer.

OBJECTIVE: To better determine the relationship between spatial access to colonoscopy and colorectal cancer (CRC) outcomes, our objective was to examine the agreement of the classic, enhanced, and variable two-step floating catchment area (2SFCA) methods in evaluating spatial access to colonoscopy and to compare the predictive validity of each method related to late-stage CRC. 2SFCA methods simultaneously consider supply/demand of services and impedance (ie, travel time). DATA SOURCES: Colonoscopy provider locations were obtained from the South Carolina Ambulatory Surgery Database. ZIP code tabulation area (ZCTA) level population estimates and area-level poverty level were obtained from the American Community Survey. Rurality was determined by the United States Department of Agriculture's Rural-Urban Commuting Area codes. Individual-level CRC data were obtained from the South Carolina Central Cancer Registry. STUDY DESIGN: Using the classic, enhanced, and variable 2SFCA methods, we calculated ZCTA-level spatial access to colonoscopy. We assessed agreement between the three methods by calculating Spearman's rank coefficients and weighted Kappas (Κ). Global and Local Moran's I were used to assess spatial clustering of accessibility scores across 2SFCA methods. We performed multilevel logistic regression analyses to examine the association between spatial accessibility to colonoscopy, area- and individual-level factors, and late-stage CRC. PRINCIPAL FINDINGS: We found strong agreement (Weighted Κ = 0.82; 95% CI = 0.79-0.86) and identified similar clustering patterns with the classic and enhanced 2SFCA methods. There was negligible agreement among the classic/enhanced 2SFCA and the variable 2SFCA. Across all 2SFCA methods, regression models showed that spatial access to colonoscopy, rurality, and poverty level were not associated with greater odds of late-stage CRC, though Black race was associated with late-stage CRC across all models. CONCLUSIONS: None of the 2SFCA methods showed an association with late-stage CRC. Future studies should explore which elements (spatial or nonspatial) of access to care have the greatest impact on CRC outcomes.

Trends in spatial access to colonoscopy in South Carolina, 2000-2014.

BACKGROUND: Colonoscopy use has increased since Medicare began covering screening for average-risk persons. Our objective was to describe changes in spatial access to colonoscopy in South Carolina (SC) between 2000 and 2014. METHODS: Using data from the SC Ambulatory Surgery Database, we created annual ZIP Code Tabulation Area (ZCTA) spatial accessibility scores. We assessed changes in accessibility, colonoscopy supply, and potential demand, overall and by metropolitan designation. Spatial clustering was also explored. RESULTS: Spatial accessibility decreased across both small rural and metropolitan ZCTAs but was significantly higher in metropolitan areas during the first part of the study period . The proportion of persons with no access to colonoscopy within 30 min increased over time but was consistently higher in small rural areas. Clusters of low accessibility grew over time. CONCLUSIONS: The supply of colonoscopy facilities decreased relative to the potential demand, and clusters of low access increased, indicating a contraction of services.

Disparities in Utilization of Medical Specialists for Colonoscopy.

Purpose: Colonoscopy is the preferred screening modality for colorectal cancer (CRC) prevention. The quality of the procedure varies although medical specialists such as gastroenterologists and colorectal surgeons tend to have better outcomes. We aimed to determine whether there are demographic and clinical differences between those who received a colonoscopy from a specialist versus those who received a colonoscopy from a nonspecialist. Methods: Using the population-based South Carolina Outpatient Ambulatory Surgery Database, we looked retrospectively to obtain patient-level endoscopy records from 2010 to 2014. We used multilevel logistic regression to model whether patients saw a specialist for their colonoscopy. The primary variables were patient race and insurance type, and an interaction by rurality was tested. Results: Of the 392,285 patients included in the analysis, 81% saw a specialist for their colonoscopy. County of residence explained 30% of the variability in the outcome. Non-Hispanic black (OR=0.65; confidence interval [95% CI]: 0.64-0.67) and Hispanic patients (OR=0.75; 95% CI: 0.67-0.84) were significantly less likely than non-Hispanic white patients to see a specialist. Compared with commercial/HMO insurance, all other types were less likely to see a specialist, and even more so for rural patients. The interaction of race by rurality was not significant. Conclusions: Specialists play a key role in CRC screening and can affect later downstream outcomes. This study has shown that ethnic minorities and adults with public or other insurance, particularly in rural areas, are most likely not to see a specialist. These results are consistent with disparities in CRC incidence, mortality, and survival.

Should Measures of Health Care Availability Be Based on the Providers or the Procedures? A Case Study with Implications for Rural Colorectal Cancer Disparities.

PURPOSE: Patients with colorectal cancer (CRC) living in rural areas have lower survival rates than those in urban areas, potentially because of lack of access to quality CRC screening and treatment. The purpose of this study was to compare traditional physician density (ie, colonoscopy provider availability per capita) against a new physician density measure using an example case of colonoscopy volume and quality. The latter is particularly relevant for rural providers, who may have fewer patients and are more frequently nongastroenterologists. METHODS: We conducted a secondary data analysis of the 2014 Medicare Provider Utilization and Payment Database and the National Cancer Institute State Cancer Profile Database. Volume-weighted physician density scores at the state and county levels were created, accounting for (1) the physician's annual colonoscopy volume and (2) whether the physician performs ≥100 procedures per year. We compared volume-weighted versus traditional density, overall and by rurality, and examined their correlation with CRC screening, incidence, and mortality rates. FINDINGS: The difference between volume-weighted and traditional density scores was particularly large in rural parts of the West and Midwest, and it was most similar in the Northeast. Although weak, correlations with CRC outcomes were stronger for volume-weighted density, and they did not differ by rurality. CONCLUSIONS: Our new method is an improvement over traditional methods because it considers the variation of physician procedure volume, and it has a stronger correlation with population health outcomes. Weighted density scores portray a more realistic picture of physician supply, particularly in rural areas.

Rural-Urban Differences in Access to Thoracic Surgery in the United States, 2010 to 2014.

BACKGROUND: Because of recent lung cancer screening recommendations and corresponding insurance coverage, it is expected that more early stage cases will be identified that require thoracic surgery. However, these services may not be equally available in all regions. Our objective is to describe the availability of thoracic surgeons by examining geographic variation, rural-urban differences, and temporal changes before and after screening recommendation and insurance coverage policy changes. METHODS: We examined the U.S. thoracic surgery workforce using the 2010 and 2014 Area Health Resource Files. We calculated the density of thoracic surgeons per 100,000 persons for each year at the state and county level. We performed descriptive statistics and developed maps highlighting changes over time and geographic regions. RESULTS: Despite an overall increase in thoracic surgeons from 2010 to 2014, we observed declining density nationwide (1.5% change) and in sparsely populated states. The difference in thoracic surgeon density widened slightly between 2010 from 0.80 per 100,000 compared with 0.84 per 100,000 in 2014 in all rural counties compared with urban counties (P < .001 for both years). The difference in thoracic surgeon density was most pronounced between small adjacent rural and urban counties (0.95 and 0.96 per 100,000 for 2010 and 2014, respectively; P < .001 for both years). The Northeast held a disproportionate share of the thoracic surgery workforce. CONCLUSIONS: Limited access to thoracic surgeons in rural areas is a concern, given an older and retiring surgical workforce, the higher burden of lung cancer in rural areas, and recent policy changes for screening reimbursement.

The influence of social networks and the built environment on physical inactivity: A longitudinal study of urban-dwelling adults.

Policies targeting the built environment to increase physical activity may be ineffective without considering personal social networks. Physical activity and social network data came from the Montreal Neighborhood Networks and Healthy Aging Panel; built environment measures were from geolocation data on Montreal parks and businesses. Using multilevel logistic regression with repeated physical inactivity measures, we showed that adults with more favorable social network characteristics had lower odds of physical inactivity. Having more physical activity facilities nearby also lowered physical inactivity, but not in socially-isolated adults. Community programs that address social isolation may also benefit efforts to increase physical activity.

Who Performs Colonoscopy? Workforce Trends Over Space and Time.

PURPOSE: With the increased availability of colonoscopy to average risk persons due to insurance coverage benefit changes, we sought to identify changes in the colonoscopy workforce. We used outpatient discharge records from South Carolina between 2001 and 2010 to examine shifts over time and in urban versus rural areas in the types of medical providers who perform colonoscopy, and the practice settings in which they occur, and to explore variation in colonoscopy volume across facility and provider types. METHODS: Using an all-payer outpatient discharge records database from South Carolina, we conducted a retrospective analysis of all colonoscopy procedures performed between 2001 and 2010. FINDINGS: We identified a major shift in the type of facilities performing colonoscopy in South Carolina since 2001, with substantial gains in ambulatory surgery settings (2001: 15, 2010: 34, +127%) versus hospitals (2001: 58, 2010: 59, +2%), particularly in urban areas (2001: 12, 2010: 27, +125%). The number of internists (2001: 46, 2010: 76) and family physicians (2001: 34, 2010: 106) performing colonoscopies also increased (+65% and +212%, respectively), while their annual procedures volumes stayed fairly constant. Significant variation in annual colonoscopy volume was observed across medical specialties (P < .001), with nongastroenterologists having lower volumes versus gastroenterologists and colon and rectal surgeons. CONCLUSIONS: There have been substantial changes over time in the number of facilities and physicians performing colonoscopy in South Carolina since 2001, particularly in urban counties. Findings suggest nongastroenterologists are meeting a need for colonoscopies in rural areas.

Commentary: Periodontal Treatment and Inflammation in Diabetes: Association or Causation?

The causal effect of periodontal treatment on systemic outcomes is unclear because even randomized controlled trials (RCTs) have conflicting results. Two models are proposed to explain the apparently conflicting findings from RCTs evaluating the effect of periodontal treatment on inflammation and systemic outcomes among individuals with type 2 diabetes.