A Perspective Review on Diet Quality, Excess Adiposity, and Chronic Psychosocial Stress and Implications for Early-Onset Colorectal Cancer.

Colorectal cancer (CRC) is the third most common cancer worldwide. Although the overall incidence of CRC has been decreasing over the past 40 y, early-onset colorectal cancer (EOCRC), which is defined as a CRC diagnosis in patients aged >50 y has increased. In this Perspective, we highlight and summarize the association between diet quality and excess adiposity, and EOCRC. We also explore chronic psychosocial stress (CPS), a less investigated modifiable risk factor, and EOCRC. We were able to show that a poor-quality diet, characterized by a high intake of sugary beverages and a Western diet pattern (high intake of red and processed meats, refined grains, and foods with added sugars) can promote risk factors associated with EOCRC development, such as an imbalance in the composition and function of the gut microbiome, presence of chronic inflammation, and insulin resistance. Excess adiposity, particularly obesity onset in early adulthood, is a likely contributor of EOCRC. Although the research is sparse examining CPS and CRC/EOCRC, we describe likely pathways linking CPS to tumorigenesis. Although additional research is needed to understand what factors are driving the uptick in EOCRC, managing body weight, improving diet quality, and mitigating psychosocial stress, may play an important role in reducing an individual's risk of EOCRC.

Racial/ethnic disparities in chronic wounds: Perspectives on linking upstream factors to health outcomes.

This review explores the complex relationship between social determinants of health and the biology of chronic wounds associated with diabetes mellitus, with an emphasis on racial/ethnic disparities. Chronic wounds pose significant healthcare challenges, often leading to severe complications for millions of people in the United States, and disproportionally affect African American, Hispanic, and Native American individuals. Social determinants of health, including economic stability, access to healthcare, education, and environmental conditions, likely influence stress, weathering, and nutrition, collectively shaping vulnerability to chronic diseases, such as obesity and DM, and an elevated risk of chronic wounds and subsequent lower extremity amputations. Here, we review these issues and discuss the urgent need for further research focusing on understanding the mechanisms underlying racial/ethnic disparities in chronic wounds, particularly social deprivation, weathering, and nutrition, to inform interventions to address these disparities.

The association between precarious employment and stress among working aged individuals in the United States.

OBJECTIVE: Precarious employment is a plausible stressor, which may adversely affect health. We investigated the association between multidimensional precarious employment and perceived and biological stress in the U.S. METHODS: We used data from waves 4 (2008-2009) and 5 (2016-2018) of the National Longitudinal Study of Adolescent to Adult Health. Eight indicators were mapped to five dimensions of precarious employment to create a continuous score (PES, range: 0-5): material rewards, working-time arrangements, stability, workers' rights, and interpersonal relationships. Perceived stress was constructed from the four-item Cohen's perceived stress score (PSS; range: 0-16; wave 4). We measured biological stress in waves 4 and 5 via C-reactive protein (CRP). Given variability in CRP collection between waves, we treated wave 4 and 5 as cross-sectional. We employed adjusted linear regression models to estimate whether the PES was associated with the PSS in wave 4 (n = 11,510) and CRP in waves 4 (n = 10,343) and 5 (n = 3452). RESULT: Individuals were aged 28 and 37 years on average in wave 4 and 5, respectively. Half were female and most identified as non-Hispanic (NH)-White (∼73 %), followed by NH-Black (∼14 %), Hispanic (∼9 %) and NH-other (∼4 %). Average PES was inversely related to education. The PSS averaged 8.1 (Interquartile Range [IQR] = 7.0,9.0). Average CRP was 4.4 mg/L (IQR = 0.8,5.0) in wave 4 and 3.6 mg/L (IQR = 0.8,4.2) in wave 5. The PES was associated with perceived stress (ß=0.06; 95 % CI = 0.01,0.10) and CRP in wave 5 (ß=0.34; 95 % CI = 0.07,0.62). CONCLUSIONS: Given the deleterious effects of stress on health, policies to reduce precarious employment warrant consideration.

Ramifications of Precarious Employment for Health and Health Inequity: Emerging Trends from the Americas.

Precarious employment (PE), which encompasses the power relations between workers and employers, is a well-established social determinant of health that has strong ramifications for health and health inequity. In this review, we discuss advances in the measurement of this multidimensional construct and provide recommendations for overcoming continued measurement challenges. We then evaluate recent evidence of the negative health impacts of PE, with a focus on the burgeoning studies from North America and South America. We also establish the role of PE in maintaining and perpetuating health inequities and review potential policy solutions to help alleviate its health burden. Last, we discuss future research directions with a call for a better understanding of the heterogeneity within PE and for research that focuses both on upstream drivers that shape PE and its impacts on health, as well as on the mechanisms by which PE causes poor health. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Mediterranean Diet Adherence and Depressive Symptoms among a Nationally Representative Sample of Pregnant Women in the United States.

BACKGROUND: Prenatal depression affects ∼12% of pregnant women in the United States and is associated with an increased risk of adverse birth outcomes and maternal mortality. Adherence to a healthy dietary pattern may reduce and/or protect against depressive symptoms. OBJECTIVES: To investigate the relationship between adherence to a Mediterranean diet and depressive symptoms among pregnant women in the United States. METHODS: We used data from the National Health and Nutrition Examination Survey (2005-2018, N = 540) and included pregnant women aged 18-44 y with a positive urine pregnancy test. The Mediterranean diet score (aMED) was calculated from 1 24-h recall; aMED typically ranges from 0-9, but in these analyses, it ranged from 0-8 because alcohol was not included. The aMED score was dichotomized as high (>3) compared with low (≤3). The Patient Health Questionnaire-9 (PHQ-9), which measures depressive symptoms, was dichotomized as lower compared with higher (PHQ-9 score ≥10), based on the clinical cutoff for patient referral. Our primary model employed logistic regression to investigate the association between aMED adherence and high depressive symptoms when controlling for socio-demographics (age, racial/ethnicity, education, poverty, and relationship status), total calories, and prepregnancy body mass index (kg/m2). We also modeled the PHQ-9 score as a continuous variable using a random-effects model. RESULTS: About 5% of pregnant women had moderate to severe depressive symptoms, and 45% were highly adherent to a Mediterranean diet. Higher adherence to a Mediterranean diet was associated with lower odds of depressive symptoms (odds ratio: 0.31, 95% confidence interval: 0.10, 0.98). Results were not significant for the continuous PHQ-9 score (ß: -0.30; 95% confidence interval: -0.90, 0.30). CONCLUSIONS: Adherence to a Mediterranean diet may have the potential to lower depressive symptoms among pregnant women; however, these results should be interpreted with caution. Nevertheless, considering the public health significance of promoting mental wellness among pregnant women, this relationship merits further examination using experimental designs.

Maternal precarious employment and child overweight/obesity in the United States.

Precarious employment has increased in the United States and is now recognized as an important social determinant of health. Women are disproportionately employed in precarious jobs and are largely responsible for caretaking, which could deleteriously affect child weight. We utilized data from the National Longitudinal Survey of Youth adult and child cohorts (1996-2016; N = 4453) and identified 13 survey indicators to operationalize 7 dimensions of precarious employment (score range: 0-7, 7 indicating the most precarious): material rewards, working-time arrangements, stability, workers' rights, collective organization, interpersonal relations, and training. We estimated the association between maternal precarious employment and incident child overweight/obesity (BMI ≥85th percentile) using adjusted Poisson models. Between 1996 and 2016, the average age-adjusted precarious employment score among mothers was 3.7 (Standard Error [SE] = 0.02) and the average prevalence of children with overweight/obesity was 26.2% (SE = 0.5%). Higher maternal precarious employment was associated with a 10% higher incidence of children having overweight/obesity (Confidence Interval: 1.05, 1.14). A higher incidence of childhood overweight/obesity may have important implications at the population-level, due to the long-term health consequences of child obesity into adulthood. Policies to reduce employment precariousness should be considered and monitored for impacts on childhood obesity.

The Availability and Price of Healthy Food in Seattle by Neighborhood Sociodemographic Characteristics.

INTRODUCTION: Unequal access to healthy food in the local food retail environment contributes to diet quality disparities. We assessed whether in-store availability and prices of healthy foods differ by neighborhood-level income and racial and ethnic composition in a representative sample of food stores in Seattle, Washington. METHODS: We developed and validated an in-store survey tool and surveyed 134 stores. We measured availability and prices of 19 items. For each store, we calculated a healthy food availability score (range, 0-25), and mean prices within each category. Using census tract data, we identified the median household income and proportions of Black and Hispanic residents for each store's neighborhood and grouped them by tertiles of these neighborhood characteristics across Seattle census tracts. We used Wald tests to compare mean availability scores and prices between tertiles and applied postestimation weights to reflect store-type distributions within each tertile. RESULTS: Neighborhoods with lower income and a larger proportion of Black residents had lower healthy food availability scores compared with neighborhoods with higher income (8.06 [95% CI, 7.04-9.07] vs 12.40 [95% CI, 10.63-14.17], P < .001) and fewer Black residents (8.88 [95% CI, 7.79-9.98] vs 12.32 [95% CI, 10.51-14.14], P = .003). Availability did not differ by Hispanic population proportions. Mean prices of grains, eggs, and meat were lower in neighborhoods with larger proportions of Black residents. CONCLUSION: We found systematic differences in healthy food availability based on neighborhood-level income and racial composition. In-store assessments of the food retail environment can inform local, tailored strategies to improve healthy food access.

The Impact of Seattle's Sugar-Sweetened Beverage Tax on Substitution to Sweets and Salty Snacks.

BACKGROUND: Sugar-sweetened beverage (SSB) taxes may have broad effects on purchases of untaxed foods, and substitution of SSBs with untaxed sweets and/or salty snacks could offset the intended dietary and health effects of these policies. OBJECTIVES: To test whether there were changes in sales and calories sold for untaxed foods in response to the SSB tax in Seattle, Washington, at 12 and 24 months post-tax implementation. METHODS: On 1 January 2018, the City of Seattle levied a 1.75 cents per ounce excise tax on distributors selling targeted SSBs. We utilized universal product code-level store scanner data and employed a difference-in-differences approach to assess the impacts of the tax on the changes in 1) sales of sweets and salty snacks; and 2) total calories sold for sweets in Seattle relative to changes in its comparison site of Portland, Oregon, at 12 and 24 months post-tax. RESULTS: In the 12 months post-tax, sales of sweets increased by 4% [ratio of incidence rate ratios (RIRR), 1.04; 95% CI, 1.03-1.05] in Seattle relative to the changes in Portland; at 24 months post-tax, sweet sales increased by 6% (RIRR, 1.06; 95% CI, 1.05-1.07) relative to the pretax period. There was no significant change in sales of salty snacks at 12 months (RIRR, 1.00; 95% CI, 0.99-1.01) or 24 months (RIRR, 1.00; 95% CI, 0.98-1.02) post-tax. Total calories sold for sweets increased by 3% (RIRR, 1.03; 95% CI, 1.02-1.05) in Seattle compared with Portland at 12 months post-tax and by 4% (RIRR, 1.04; 95% CI, 1.02-1.05) at 24 months after implementation. CONCLUSIONS: There was modest substitution of SSBs for sweets in Seattle following tax implementation. However, this increase in sales and calories sold is not likely to offset previously identified tax-related reductions in the demand for taxed beverages in Seattle. Thus, SSB taxes are a promising policy tool to reduce caloric intake in the United States.

Potential interventions targeting adolescent nutrition in Indonesia: a literature review.

OBJECTIVE: The present study aimed to take stock of nutrition interventions that warrant consideration as a minimum package of interventions in Indonesia to improve four key nutrition indicators for adolescents: stunting, thinness, overweight and anaemia. DESIGN: We conducted a review of the peer-reviewed literature published between 1995 and 2017 on nutrition-specific and nutrition-sensitive interventions that target adolescents in Indonesia. The search to identify studies was conducted in PubMed, Google Scholar and EMBASE, using key search terms. We also explored programmatic and policy documents from the grey literature as they related to adolescents and/or Indonesia. Our search yielded thirty-five peer-reviewed articles and programmatic documents. SETTING: Indonesia. SUBJECTS: Adolescent girls and boys. RESULTS: There is very limited evidence on the impact of interventions specifically among adolescents in Indonesia. Nevertheless, findings from our review suggest the minimum package of interventions in Indonesia could include the following nutrition-specifc interventions: (i) iron-folic acid supplements, paired with antihelminths delivered at scale via school-based platforms and through health centres; and (ii) diet counselling and nutrition education provided through school-based platforms, adolescent youth centres/peer education and technology-based platforms. The minimum package could also include the following nutrition-sensitive interventions: (i) improving access to reproductive health services; and (ii) increasing the coverage of interventions designed to increase school attendance. CONCLUSIONS: Programmes and policies targeting adolescent nutrition are relatively new and coverage is low. To improve the nutritional status of this vulnerable population, additional evaluations of adolescent programming and surveillance data on adolescents are needed.

Perceptions of the possible health and economic impacts of Seattle's sugary beverage tax.

BACKGROUND: Taxes on sugary beverages are an emerging strategy to improve health by reducing consumption and raising revenues to support community wellbeing. However, taxes may have unintended consequences, and perceptions of these consequences may affect attitudes towards this policy. METHODS: In June 2017, the Seattle City Council passed an ordinance imposing a tax on sugary beverages, effective January 1, 2018. Between October and December 2017, we recruited 851 adults in Seattle to complete a survey (telephone or online) about support for the tax and their perceptions of tax-related health and economic impacts. We first analyzed data for the full sample. We then tested for differences in participants' responses by household income level (< 260% Federal Poverty Level [FPL], ≥ 260% FPL) and across race/ethnicities using chi-square tests. Analyses used population weights and adjusted for multiple comparisons, using the Holm-Bonferroni Sequential Correction (p < 0.01). RESULTS: A majority of participants supported the sugary beverage tax (59%; 95% Confidence Interval [CI]: 55, 63%) and believed that the tax would improve public health (56%; CI: 52, 60%). Most participants believed that the tax would not negatively affect small businesses (52%; CI: 48, 56%) nor result in job loss (66%; CI: 62, 70%). Most participants also perceived that the tax would not negatively impact their own finances (79%; CI: 75, 82%). However, fewer lower-income (48%; CI: 42, 53%), versus higher-income participants (61%; CI: 55, 66%), perceived that the tax would improve public health, would not result in job loss (lower-income: 58%; CI: 53, 64%; higher-income: 71%; CI: 66, 75%) and would not negatively affect their own finances (lower-income: 68%; CI: 62, 73%; higher-income: 85%; CI: 81, 88%). Compared to non-Hispanic Whites, (82%; CI: 79, 86%), a smaller proportion of non-Hispanic Blacks (63%; 95% CI: 48, 75%), and Hispanics (67%; 95% CI: 51, 79%), perceived that the tax would have negative consequences for their own family finances. CONCLUSIONS: A majority of respondents supported the sugary beverage tax in Seattle. Lower-income participants were more concerned about potential financial consequences. Further evaluation of the extent to which unintended consequences occur is needed.

Casino Ownership and Health-Related Community Resources Among Native American Tribes in California.

INTRODUCTION: Casinos are significantly associated with improved health among some Native Americans living on tribal lands. An increase in health-related community resources related to tribal ownership of casinos may be one mechanism through which the health of Native Americans is improved. However, no studies have quantitatively assessed whether casinos are associated with having more community resources. METHODS: To investigate the association between casino ownership and health-related community resources among Native Americans, we surveyed 81 of California's 110 federally recognized tribes about casino ownership and health-related community resources during 2015 and 2016. We created a total health-related community resources score (maximum of 50 points) by grouping resources into 5 subdomains (community infrastructure, health care and education, social determinants, recreational infrastructure, and recreation programs), which we scored for a maximum of 10 points each and then summed. Casino ownership was our independent variable. We used adjusted linear regression models to test the association between casino ownership and health-related community resources. RESULTS: Half (49%) of the tribes surveyed owned a casino. Compared with tribes without casinos, tribes with casinos had higher total health-related community resource scores (ß = 5.09; 90% confidence interval [CI], 1.17-9.01). Casino-owning tribes had more resources related to community infrastructure (ß = 1.81; 90% CI, 0.81-2.80), social determinants of health (ß = 1.45; 90% CI, 0.24-2.67) and recreational infrastructure (ß = 1.08; 90% CI, 0.24-1.92) compared with tribes without casinos. CONCLUSIONS: Casino ownership is significantly associated with health-related community resources. Future research should assess whether community resources mediate the relationship between economic resources and health among Native Americans.

Pathways of the association between maternal employment and weight status among women and children: Qualitative findings from Guatemala.

The double burden of malnutrition, defined by the coexistence of undernutrition and overweight, is well documented in low- and middle-income countries. However, the mechanisms by which employment may be related to maternal and child weight status in low- and middle-income countries are not well understood. We conducted in-depth interviews among 20 mothers who participated in Project MIEL, a contemporary trial which evaluated the effects of an integrated micronutrient supplement and parenting intervention in rural Guatemala. We utilized semi-structured interviews to explore the pathways by which maternal employment might influence bodyweight. Interviews were structured to explore the factors that mothers considered when deciding whether or not to participate in the labor force and how mothers perceived the influence of employment on determinants of their own bodyweight and that of their children. Themes were used to develop a conceptual framework. Mothers described four pathways through which employment could lead to changes in weight status: changes in food purchasing; improved household well-being; changes in time allocation; and psychological effects. Mothers described purchasing increased quantities and more varied types of food, as well as the purchase of energy-dense foods. Less time to devote to food preparation resulted in mothers preparing quicker meals and relying on substitute childcare. Mothers also expressed feelings of worry and neglect in relation to being employed, and perceived that these feelings would affect weight. A better understanding of these mechanisms is important for developing policies and programs to support women in the workplace and also reducing maternal and child overweight in Guatemala.

The weight of work: the association between maternal employment and overweight in low- and middle-income countries.

BACKGROUND: Maternal employment has increased in low-and middle-income countries (LMIC) and is a hypothesized risk factor for maternal overweight due to increased income and behavioral changes related to time allocation. However, few studies have investigated this relationship in LMIC. METHODS: Using cross-sectional samples from Demographic and Health Surveys, we investigated the association between maternal employment and overweight (body mass index [BMI] ≥ 25 kg/m2) among women in 38 LMIC (N = 162,768). We categorized mothers as formally employed, informally employed, or non-employed based on 4 indicators: employment status in the last 12 months; aggregate occupation category (skilled, unskilled); type of earnings (cash only, cash and in-kind, in-kind only, unpaid); and seasonality of employment (all year, seasonal/occasional employment). Formally employed women were largely employed year-round in skilled occupations and earned a wage (e.g. professional), whereas informally employed women were often irregularly employed in unskilled occupations and in some cases, were paid in-kind (e.g. domestic work). For within-country analyses, we used adjusted logistic regression models and included an interaction term to assess heterogeneity in the association by maternal education level. We then used meta-analysis and meta-regression to explore differences in the associations pooled across countries. RESULTS: Compared to non-employed mothers, formally employed mothers had higher odds of overweight (pooled odds ratio [POR] = 1.3; 95% Confidence Interval [CI] 1.2, 1.4) whereas informally employed mothers, compared to non-employed mothers, had lower odds of overweight (POR = 0.72; 95% CI: 0.64, 0.81). In 14 LMIC, the association varied by education. In these countries, the magnitude of the formal employment-overweight association was larger for women with low education (POR = 1.5; 95% CI: 1.1, 1.9) compared to those with high education (POR = 1.2; 95% CI: 1.0, 1.3). CONCLUSIONS: Formally employed mothers in LMIC have higher odds of overweight and the association varies by educational attainment in 14 countries. This knowledge highlights the importance of workplace initiatives to reduce the risk of overweight among working women in LMIC.

Maternal employment and childhood overweight in low- and middle-income countries.

OBJECTIVE: To investigate the association between maternal employment and childhood overweight in low- and middle-income countries (LMIC). Design/Setting We utilized cross-sectional data from forty-five Demographic and Health Surveys from 2010 to 2016 (n 268 763). Mothers were categorized as formally employed, informally employed or non-employed. We used country-specific logistic regression models to investigate the association between maternal employment and childhood overweight (BMI Z-score>2) and assessed heterogeneity in the association by maternal education with the inclusion of an interaction term. We used meta-analysis to pool the associations across countries. Sensitivity analyses included modelling BMI Z-score and normal weight (weight-for-age Z-score≥-2 to <2) as outcomes. SUBJECTS: Participants included children 0-5 years old and their mothers (aged 18-49 years). RESULTS: In most countries, neither formal nor informal employment was associated with childhood overweight. However, children of employed mothers, compared with children of non-employed mothers, had higher BMI Z-score and higher odds of normal weight. In countries where the association varied by education, children of formally employed women with high education, compared with children of non-employed women with high education, had higher odds of overweight (pooled OR=1·2; 95 % CI 1·0, 1·4). CONCLUSIONS: We find no clear association between employment and child overweight. However, maternal employment is associated with a modestly higher BMI Z-score and normal weight, suggesting that employment is currently associated with beneficial effects on children's weight status in most LMIC.

Scaling-up interventions to improve infant and young child feeding in India: What will it take?

We assessed India's readiness to deliver infant and young child feeding (IYCF) interventions by examining elements related to policy, implementation, financing, and evidence. We based our analysis on review of (a) nutrition policy guidance and program platforms, (b) published literature on interventions to improve IYCF in India, and (c) IYCF program models implemented between 2007 and 2012. We find that Indian policies are well aligned with global technical guidance on counselling interventions. However, guidelines for complementary food supplements (CFS) need to be reexamined. Two national programs with the operational infrastructure to deliver IYCF interventions offer great potential for scale, but more operational guidance, capacity, and monitoring are needed to actively support delivery of IYCF counselling at scale by available frontline workers. Many IYCF implementation efforts to date have experimented with approaches to improve breastfeeding and initiation of complementary feeding but not with improving diet diversity or the quality of food supplements. Financing is currently inadequate to deliver CFS at scale, and governance issues affect the quality and reach of CFS. Available evidence from Indian studies supports the use of counselling strategies to improve breastfeeding practices and initiation of complementary feeding, but limited evidence exists on improving full spectrum of IYCF practices and the impact and operational aspects of CFS in India. We conclude that India is well positioned to support the full spectrum of IYCF using existing policies and delivery platforms, but capacity, financing, and evidence gaps on critical areas of programming can limit impact at scale.

Stunting Mediates the Association between Small-for-Gestational-Age and Postneonatal Mortality.

BACKGROUND: In sub-Saharan Africa, one-third of all births are small for gestational age (SGA), and 4.4 million children are stunted; both conditions increase the risk of child mortality. SGA has also been shown to increase the risk of stunting. OBJECTIVE: We tested whether the association between SGA and postneonatal mortality is mediated by stunting. METHODS: We used longitudinal data from children aged 6 wk to 24 mo (n = 12,155) enrolled in the ZVITAMBO (Zimbabwe Vitamin A for Mothers and Babies) trial. HIV exposure was defined based on maternal HIV status at baseline. SGA was defined as birthweight <10th percentile of the INTERGROWTH-21st (International Fetal and Newborn Growth Consortium for the 21st Century) standards. We used a standard mediation approach by comparing the attenuation of the risk when the mediator was added to the model. We used Cox proportional hazards models first to regress SGA on postneonatal mortality, controlling for age. Stunting (length-for-age z score <-2) was then included in the model to test mediation. RESULTS: Approximately 20% of children were term SGA, and 23% were stunted before their last follow-up visit. In this cohort, 31% of children were exposed to HIV; the HIV-exposed group represented a pooled group of HIV-infected and HIV-exposed but uninfected children. Postneonatal mortality was significantly higher among children born SGA (HR: 1.5; 95% CI: 1.3, 1.7). This association was attenuated and not statistically significant when stunting was included in the model, suggesting a mediation effect (HR: 1.1; 95% CI: 0.91, 1.3). When stratified by HIV exposure status, we observed a significant attenuation of the risk, suggesting mediation, only among HIV-exposed children (model 1, HR: 1.3; 95% CI: 1.1, 1.6; model 2, HR: 1.1; 95% CI: 0.88, 1.3). CONCLUSIONS: This analysis aids in investigating pathways that underlie an observed SGA-mortality relation and may inform survival interventions in undernourished settings.

Impacts of casinos on key pathways to health: qualitative findings from American Indian gaming communities in California.

BACKGROUND: Three decades ago, casino gaming on sovereign American Indian lands was legalized with differential economic and social implications. While casinos have improved the incomes of tribal communities, there have been both positive and negative findings in relation to health impacts. We sought to understand the perceived pathways by which casinos impact individual and community health through voices of the community. METHODS: We conducted semi-structured, interviews with tribal leaders (n =12) and tribal members (n =24) from tribal communities (n = 23) representing different regions of California. We inductively analyzed textual data drawing from Grounded Theory, first using line-by-line coding to identify analytic categories from emergent themes in consideration of the study objective. Then, focused codes were applied to identify salient themes, which we represented through exemplar quotes and an overall conceptual framework. Data were managed and coded using Dedoose software. RESULTS: American Indian-owned casinos are perceived to influence the health of tribal communities through three pathways: 1) improving the tribal economy 2) altering the built environment, and 3) disrupting the the social landscape. Forming these pathways are a series of interrelated health determinants. Improvement of the tribal economy, through both job creation for tribal members and improved tribal cash flow, was perceived by participants to both influence health. Specifically, improved cash flow has resulted in new wellness programs, community centers, places for recreation, and improved social services. Higher disposable incomes have led to better financial stability, increased access to healthy food, and more opportunities for physical activity. Yet, higher disposable incomes were perceived to also contribute to negative health behaviors, most notably increased drug and alcohol abuse. Casinos were also perceived to alter built environments, resulting in increased availability and access to unhealthy food. And to a lesser extent, they were perceived to disrupt the social landscape of communities with impacts on tribal community value systems. CONCLUSIONS: Casino environments improve economic conditions of tribal communities, but present important social and public health challenges. Policy makers at federal, state, and tribal levels should consider the perceptions of tribal members and leaders when determining policies in light of casino development.

Food Security Status and Barriers to Fruit and Vegetable Consumption in Two Economically Deprived Communities of Oakland, California, 2013-2014.

INTRODUCTION: Food security status may moderate how people perceive barriers to fruit and vegetable consumption. This study aimed to 1) describe the association between fruit and vegetable consumption and microbarriers and mezzobarriers to consumption, and 2) test whether these associations differ by food security status. METHODS: We surveyed adults (n = 531) living in 2 economically deprived communities in Oakland, California, in 2013 and 2014. Multivariate linear regression assessed associations between microbarriers (taste, cost, busyness) and mezzobarriers (produce selection, quality, and purchase ease) and fruit and vegetable consumption, derived from a 26-item dietary screener. Interactions were tested by food security status. RESULTS: Respondents consumed a mean 2.4 (standard deviation, 1.5) servings of fruits and vegetables daily; 39% of the sample was food insecure. Being too busy to prepare healthy foods was associated with reduced fruit and vegetable consumption (ß(busyness) = -0.40; 95% confidence interval [CI], -0.52 to -0.28) among all respondents. Food security moderated the relationship between fruit and vegetable consumption and taste, cost, and perceived ease of purchase of healthy foods. Among the food secure, disliking healthy food taste (ß(taste) = -0.38; 95% CI, -0.60 to -0.15) and cost (ß(cost) = -0.29; 95% CI, -0.44 to -0.15) concerns were associated with lower consumptions of fruits and vegetables. Mezzobarriers were not significantly associated with consumption in either group. CONCLUSION: Perceived time constraints influenced fruit and vegetable consumption. Taste and cost influenced fruit and vegetable consumption among the food secure and may need to be considered when interpreting analyses that describe dietary intake and designing diet-related interventions.

Association of participation in the supplemental nutrition assistance program and psychological distress.

OBJECTIVES: We assessed whether households' participation in the Supplemental Nutrition Assistance Program (SNAP) was associated with improvements in well-being, as indicated by lower rates of psychological distress. METHODS: We used longitudinal data for 3146 households in 30 states, collected between October 2011 and September 2012 for the SNAP Food Security survey, the largest longitudinal national survey of SNAP participants to date. Analyses compared households within days of program entry to the same households approximately 6 months later. We measured psychological distress in the past 30 days on a 6-item Kessler screening scale and used multivariable regression to estimate associations between SNAP participation and psychological distress. RESULTS: A smaller percentage of household heads exhibited psychological distress after 6 months of participation in SNAP than at baseline (15.3% vs 23.2%; difference = -7.9%). In adjusted models, SNAP participation was associated with a decrease in psychological distress (adjusted relative risk = 0.72; 95% confidence interval = 0.66, 0.78). CONCLUSIONS: Continuing support for federal nutrition programs, such as SNAP, may reduce the public health burden of mental illness, thus improving well-being among vulnerable populations.