Influence of the food environment on obesity risk in a large cohort of US veterans by community type.

OBJECTIVE: The aim of this study was to examine relationships between the food environment and obesity by community type. METHODS: Using electronic health record data from the US Veterans Administration Diabetes Risk (VADR) cohort, we examined associations between the percentage of supermarkets and fast-food restaurants with obesity prevalence from 2008 to 2018. We constructed multivariable logistic regression models with random effects and interaction terms for year and food environment variables. We stratified models by community type. RESULTS: Mean age at baseline was 59.8 (SD = 16.1) years; 93.3% identified as men; and 2,102,542 (41.8%) were classified as having obesity. The association between the percentage of fast-food restaurants and obesity was positive in high-density urban areas (odds ratio [OR] = 1.033; 95% CI: 1.028-1.037), with no interaction by time (p = 0.83). The interaction with year was significant in other community types (p < 0.001), with increasing odds of obesity in each follow-up year. The associations between the percentage of supermarkets and obesity were null in high-density and low-density urban areas and positive in suburban (OR = 1.033; 95% CI: 1.027-1.039) and rural (OR = 1.007; 95% CI: 1.002-1.012) areas, with no interactions by time. CONCLUSIONS: Many healthy eating policies have been passed in urban areas; our results suggest such policies might also mitigate obesity risk in nonurban areas.

Menu Labeling and Calories Purchased in Restaurants in a US National Fast Food Chain.

Importance: Menu labeling has been implemented in restaurants in some US jurisdictions as early as 2008, but the extent to which menu labeling is associated with calories purchased is unclear. Objective: To estimate the association of menu labeling with calories and nutrients purchased and assess geographic variation in results. Design, Setting, and Participants: A cohort study was conducted with a quasi-experimental design using actual transaction data from Taco Bell restaurants from calendar years 2007 to 2014 US restaurants with menu labeling matched to comparison restaurants using synthetic control methods. Data were analyzed from May to October 2023. Exposure: Menu labeling policies in 6 US jurisdictions. Main Outcomes and Measures: The primary outcome was calories per transaction. Secondary outcomes included total and saturated fat, carbohydrates, protein, sugar, fiber, and sodium. Results: The final sample included 2329 restaurants, with menu labeling in 474 (31 468 restaurant-month observations). Most restaurants (94.3%) were located in California. Difference-in-differences model results indicated that customers purchased 24.7 (95% CI, 23.6-25.7) fewer calories per transaction from restaurants in the menu labeling group in the 3- to 24-month follow-up period vs the comparison group, including 21.9 (95% CI, 20.9-22.9) fewer calories in the 3- to 12-month follow-up period and 25.0 (95% CI, 24.0-26.1) fewer calories in the 13- to 24-month follow-up period. Changes in the nutrient content of transactions were consistent with calorie estimates. Findings in California were similar to overall estimates in magnitude and direction; yet, among restaurants outside of California, no association was observed in the 3- to 24-month period. The outcome of menu labeling also differed by item category and time of day, with a larger decrease in the number of tacos vs other items purchased and a larger decrease in calories purchased during breakfast vs other times of the day in the 3- to 24-month period. Conclusions and Relevance: In this quasi-experimental cohort study, fewer calories were purchased in restaurants with calorie labels compared with those with no labels, suggesting that consumers are sensitive to calorie information on menu boards, although associations differed by location.

Age and sex differences in the association between neighborhood socioeconomic environment and incident diabetes: Results from the diabetes location, environmental attributes and disparities (LEAD) network.

Objective: Worse neighborhood socioeconomic environment (NSEE) may contribute to an increased risk of type 2 diabetes (T2D). We examined whether the relationship between NSEE and T2D differs by sex and age in three study populations. Research design and methods: We conducted a harmonized analysis using data from three independent longitudinal study samples in the US: 1) the Veteran Administration Diabetes Risk (VADR) cohort, 2) the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, and 3) a case-control study of Geisinger electronic health records in Pennsylvania. We measured NSEE with a z-score sum of six census tract indicators within strata of community type (higher density urban, lower density urban, suburban/small town, and rural). Community type-stratified models evaluated the likelihood of new diagnoses of T2D in each study sample using restricted cubic splines and quartiles of NSEE. Results: Across study samples, worse NSEE was associated with higher risk of T2D. We observed significant effect modification by sex and age, though evidence of effect modification varied by site and community type. Largely, stronger associations between worse NSEE and diabetes risk were found among women relative to men and among those less than age 45 in the VADR cohort. Similar modification by age group results were observed in the Geisinger sample in small town/suburban communities only and similar modification by sex was observed in REGARDS in lower density urban communities. Conclusions: The impact of NSEE on T2D risk may differ for males and females and by age group within different community types.

Demographic, social and geographic factors associated with glycaemic control among US Veterans with new onset type 2 diabetes: a retrospective cohort study.

OBJECTIVES: This study evaluated whether a range of demographic, social and geographic factors had an influence on glycaemic control longitudinally after an initial diagnosis of diabetes. DESIGN, SETTING AND PARTICIPANTS: We used the US Veterans Administration Diabetes Risk national cohort to track glycaemic control among patients 20-79-year old with a new diagnosis of type 2 diabetes. PRIMARY OUTCOME AND METHODS: We modelled associations between glycaemic control at follow-up clinical assessments and geographic factors including neighbourhood race/ethnicity, socioeconomic, land use and food environment measures. We also adjusted for individual demographics, comorbidities, haemoglobin A1c (HbA1c) at diagnosis and duration of follow-up. These factors were analysed within strata of community type: high-density urban, low-density urban, suburban/small town and rural areas. RESULTS: We analysed 246 079 Veterans who developed a new type 2 diabetes diagnosis in 2008-2018 and had at least 2 years of follow-up data available. Across all community types, we found that lower baseline HbA1c and female sex were strongly associated with a higher likelihood of within-range HbA1c at follow-up. Surprisingly, patients who were older or had more documented comorbidities were more likely to have within-range follow-up HbA1c results. While there was variation by community type, none of the geographic measures analysed consistently demonstrated significant associations with glycaemic control across all community types.

Assessing the association between food environment and dietary inflammation by community type: a cross-sectional REGARDS study.

BACKGROUND: Communities in the United States (US) exist on a continuum of urbanicity, which may inform how individuals interact with their food environment, and thus modify the relationship between food access and dietary behaviors. OBJECTIVE: This cross-sectional study aims to examine the modifying effect of community type in the association between the relative availability of food outlets and dietary inflammation across the US. METHODS: Using baseline data from the REasons for Geographic and Racial Differences in Stroke study (2003-2007), we calculated participants' dietary inflammation score (DIS). Higher DIS indicates greater pro-inflammatory exposure. We defined our exposures as the relative availability of supermarkets and fast-food restaurants (percentage of food outlet type out of all food stores or restaurants, respectively) using street-network buffers around the population-weighted centroid of each participant's census tract. We used 1-, 2-, 6-, and 10-mile (~ 2-, 3-, 10-, and 16 km) buffer sizes for higher density urban, lower density urban, suburban/small town, and rural community types, respectively. Using generalized estimating equations, we estimated the association between relative food outlet availability and DIS, controlling for individual and neighborhood socio-demographics and total food outlets. The percentage of supermarkets and fast-food restaurants were modeled together. RESULTS: Participants (n = 20,322) were distributed across all community types: higher density urban (16.7%), lower density urban (39.8%), suburban/small town (19.3%), and rural (24.2%). Across all community types, mean DIS was - 0.004 (SD = 2.5; min = - 14.2, max = 9.9). DIS was associated with relative availability of fast-food restaurants, but not supermarkets. Association between fast-food restaurants and DIS varied by community type (P for interaction = 0.02). Increases in the relative availability of fast-food restaurants were associated with higher DIS in suburban/small towns and lower density urban areas (p-values < 0.01); no significant associations were present in higher density urban or rural areas. CONCLUSIONS: The relative availability of fast-food restaurants was associated with higher DIS among participants residing in suburban/small town and lower density urban community types, suggesting that these communities might benefit most from interventions and policies that either promote restaurant diversity or expand healthier food options.

Establishing the criterion validity of an adapted dietary screener for Asian Americans amongst Chinese American adults.

OBJECTIVE: To assess the criterion validity of a dietary screener questionnaire adapted for Asian Americans (ADSQ) compared to Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA-24) food diary data amongst Chinese American Adults (CHAs). The ADSQ incorporated example ethnic foods from six Asian American groups. Lessons learned with respect to translating the ADSQ from English into Simplified Chinese were also documented. DESIGN: Agreement between a two-day food diary (one weekend day and one weekday) and the ADSQ was assessed for vegetable, fruit, dairy, added sugar, fiber, calcium, and whole grain intake using paired t-tests to compare means and Spearman correlations to assess agreement between intake of food components. SETTING: Data were collected online and via phone interviews. PARTICIPANTS: Thirty-three CHAs aged 19-62 years (63.6% female). RESULTS: Mean differences were small for fruit, dairy, fiber, calcium, and whole grain intake, but were significantly different for vegetables and added sugar intake. Spearman correlations were < 0.5 and non-significant (p > 0.05) for all components. Both the ASA-24 and the ADSQ identified the same categories where CHAs intake is misaligned with dietary recommendations: whole grains, total fruit, and dairy. Difficulties were encountered in translating 13 out of 26 questions. CONCLUSIONS: The ADSQ may be a useful tool to identify intervention targets for improving dietary quality, but caution is warranted when interpreting vegetable and added sugar estimates. Differences in the English and Chinese languages underscore the need to take into account both literal translations and semantics in translating the ADSQ into other languages.

Relative validity of a Diet Risk Score (DRS) for Chinese American adults.

Objective: The objective of this study was to evaluate the relative validity of the nine-item Diet Risk Score (DRS) among Chinese American adults using Healthy Eating Index (HEI)-2015 scores. We provide insights into the application of the Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24) for this population, and report on lessons learned from carrying out participant recruitment during the COVID-19 pandemic. Methods: Thirty-three Chinese American adults (mean age=40; 36% male) were recruited from the community and through ResearchMatch. Participants completed the DRS and two 24-hour food records, which were entered into the ASA 24-Hour Dietary Assessment Tool (ASA24) by community health workers (CHWs). HEI-2015 scores were calculated from each food record and an average score was obtained for each participant. One-way analysis of variance and Spearman correlations were used to compare total and component scores between the DRS and HEI-2015. Results: Mean HEI-2015 score was 56.7/100 (SD 10.6) and mean DRS score was 11.8/27 (SD 4.7), with higher scores reflecting better and worse diets, respectively. HEI-2015 and DRS scores were inversely correlated (r=-0.43, p<0.05). The strongest correlations were between HEI-2015 Total Vegetables and DRS Vegetables (r=-0.5, p<0.01), HEI-2015 Total Vegetables and Green Vegetables (r=-0.43, p=0.01) and HEI-2015 Seafood/Plant Protein and DRS Fish (r=-0.47, p<0.01). The inability to advertise and recruit for the study in person at community centres due to pandemic restrictions impeded the recruitment of less-acculturated individuals. A lack of cultural food items in the ASA24 database made it difficult to record dietary intake as reported by participants. Conclusion: The DRS can be a valuable tool for physicians to identify and reach Chinese Americans at risk of cardiometabolic disease.

Consumer behaviour and experiences in a naturalistic online grocery store: implications for nutrition research.

Naturalistic online grocery stores could provide a novel setting for evaluating nutrition interventions. In 2021-2022, we recruited US adults (n 144, 59% low-income) to complete two weekly study visits: one in a naturalistic ('mock') online grocery store developed for research and one in a real online grocery store. Participants selected groceries and responded to survey questions. Analyses examined survey responses and expenditures on fifteen food categories (e.g., bread, sugar-sweetened beverages). Nearly all enrolled participants completed both visits (98% retention). Moreover, nearly participants all reported that their selections in the naturalistic store were similar to their usual purchases (95%) and that the naturalistic store felt like a real store (92%). Participants' spending on food categories in the naturalistic store were moderately-to-strongly correlated with their spending in the real store (range of correlation coefficients: 0⋅36-0⋅67, all P-values < 0⋅001). Naturalistic online grocery stores may offer a promising platform for conducting nutrition research.

Effect of Financial Incentives and Default Options on Food Choices of Adults With Low Income in Online Retail Settings: A Randomized Clinical Trial.

Importance: Despite recent growth in online redemption of Supplemental Nutrition Assistance Program (SNAP) benefits, no previous work has tested the impact of economic and behavioral economic strategies on food purchasing behaviors in an online grocery retail setting among adults with low income. Objective: To examine the extent to which financial incentives and default shopping cart options influence fruit and vegetable purchases. Design, Setting, and Participants: This randomized clinical trial used an experimental online grocery store for adults who currently or have ever received SNAP benefits. From October 7 to December 2, 2021, participants were instructed to shop for a week's worth of groceries for their household, with a budget tailored to household size; no payment was taken. Interventions: Random assignment to 1 of 4 conditions: no intervention, 50% discount on eligible fruits and vegetables, prefilled shopping carts with tailored fruit and vegetable items (ie, default options), or a combination of the discount and default options. Main Outcomes and Measures: The primary outcome was the percentage of nondiscounted dollars spent on eligible fruit and vegetables per basket. Results: Of 2744 participants, mean (SD) age was 46.7 (16.0) years, and 1447 (52.7%) identified as women. A total of 1842 participants (67.1%) reported currently receiving SNAP benefits and 1492 (54.4%) reported shopping online for groceries in the previous 12 months. Participants spent a mean (SD) 20.5% (23.5%) of total dollars on eligible fruits and vegetables. Compared with no intervention, those in the discount condition spent 4.7% (98.3% CI, 1.7%-7.7%) of more total dollars on eligible fruits and vegetables; those in the default condition, 7.8% (98.3% CI, 4.8%-10.7%) more; and those in the combination condition, 13.0% (98.3% CI, 10.0%-16.0%) more (P < .001 for all). There was no difference between the discount and the default conditions (P = .06), but the effect in the combination condition was significantly larger than both discount and default conditions (P < .001). Default shopping cart items were purchased by 679 participants (93.4%) in the default condition and 655 (95.5%) in the combination condition, whereas 297 (45.8%) in the control and 361 (52.9%) in the discount conditions purchased those items (P < .001). No variation was observed by age, sex, or race and ethnicity, and results were similar when those who reported never shopping online for groceries were excluded. Conclusions and Relevance: In this randomized clinical trial, financial incentives for fruits and vegetables and default options, especially in combination, led to meaningful increases in online fruit and vegetable purchases among adults with low income. Trial Registration: ClinicalTrials.gov Identifier: NCT04766034.

An Analysis of SNAP Online Purchasing Behavior in California: A Review of the First 7 Months of Program Implementation and Lessons Learned.

PURPOSE: The Supplemental Nutrition Assistance Program (SNAP) Online Purchasing Pilot (OPP) allows for the online purchase of groceries using SNAP benefits. First implemented in California in late April 2020, little is known about program usage. This study assessed initial implementation of SNAP Online in California using SNAP OPP transaction data from April - October 2020. Insights can identify usage differences by demographics, store availability, and rurality to help inform future pilot programs and nutrition initiatives. DESIGN: Using generalized estimating equations, we modeled county-level associations between transactions and county-level demographics, rurality, and retailer availability. SETTING: Transaction data from California's Department of Social Services (CDSS) was linked with publicly-available, county-level demographics. SUBJECTS: Anonymized county-level data on SNAP Online transactions and CalFresh households. MEASURES: The primary outcome was successful SNAP Online food transactions per county. ANALYSIS: Generalized estimating equation models with clustering by county was used. RESULTS: During the first 7 months, median SNAP Online transactions per county per month was 665; 2.7% of total SNAP redemptions were from SNAP Online. Counties with more female-led, disabled, Latino, or Asian CalFresh households had fewer Amazon transactions. Each additional Walmart per county corresponded to 260.7 more Walmart transactions (P < .001). Each percent increase in county zip codes covered by Amazon Fresh corresponded to 45.4 fewer Walmart transactions (P < .05) and 37.3 more Amazon transactions (P < .001). CONCLUSION: Number of stores per county was associated with greater online grocery transactions, whereas rurality was not. County-level SNAP demographics correlated with transactions at particular retailers.

Online Grocery Shopping Behaviors and Attitudes Among Asian Americans.

How online grocery shopping behaviors differ among Asian American (AA) ethnic subgroups and acculturation level is unknown. From June 9-15, 2020, we administered an online survey to a nationally-derived nonprobability sample of 2,895 AA adults, including 1,737 East, 570 South, and 587 Southeast Asian adults, assessing online grocery shopping (yes/no, frequency, reasons). We used logistic regression to compare responses by subgroup and acculturation score, controlling for sociodemographics. Thirty-percent of participants reported shopping online for groceries in a typical month, with a higher percentage among South (45%) versus East Asian adults (23%). Participants with low (vs. high) acculturation scores were more likely to report a lack of special foods (OR = 0.7; 95% CI: 0.5-0.98) and poor food quality (OR = 0.6; 95% CI: 0.4-0.7) as preventing them from shopping online. Online grocery shopping has the capacity to address inequities in health, potentially via culturally-tailored programs designed for less-acculturated AA adults.

The Health and Economic Impact of Using a Sugar Sweetened Beverage Tax to Fund Fruit and Vegetable Subsidies in New York City: A Modeling Study.

Low fruit and vegetable (FV) intake and high sugar-sweetened beverage (SSB) consumption are independently associated with an increased risk of developing cardiovascular disease (CVD). Many people in New York City (NYC) have low FV intake and high SSB consumption, partly due to high cost of fresh FVs and low cost of and easy access to SSBs. A potential implementation of an SSB tax and an FV subsidy program could result in substantial public health and economic benefits. We used a validated microsimulation model for predicting CVD events to estimate the health impact and cost-effectiveness of SSB taxes, FV subsidies, and funding FV subsidies with an SSB tax in NYC. Population demographics and health profiles were estimated using data from the NYC Health and Nutrition Examination Survey. Policy effects and price elasticity were derived from recent meta-analyses. We found that funding FV subsidies with an SSB tax was projected to be the most cost-effective policy from the healthcare sector perspective. From the societal perspective, the most cost-effective policy was SSB taxes. All policy scenarios could prevent more CVD events and save more healthcare costs among men compared to women, and among Black vs. White adults. Public health practitioners and policymakers may want to consider adopting this combination of policy actions, while weighing feasibility considerations and other unintended consequences.

Age-Specific Differences in Online Grocery Shopping Behaviors and Attitudes among Adults with Low Income in the United States in 2021.

Background: Online grocery shopping has surged in popularity, but we know little about online grocery shopping behaviors and attitudes of adults with low income, including differences by age. Methods: From October to November 2021, we used a survey research firm to recruit a convenience sample of adults who have ever received Supplemental Nutrition Assistance Program (SNAP) benefits (n = 3526). Participants completed an online survey designed to assess diet and online food shopping behaviors. Using logistic regression, we examined the relationship between participant characteristics, including age, and the likelihood of online grocery shopping, and separately examined variation in the reasons for online grocery shopping by age. Results: About 54% of the participants reported shopping online for groceries in the previous 12 months. Odds of online shopping were higher for those aged 18−33 years (OR = 1.95 (95% CI: 1.52, 2.52; p < 0.001)) and 34−44 years (OR = 1.50 (95% CI: 1.19, 1.90; p < 0.001)) than for those aged ≥65 years. Odds were also higher for those who were food insecure and those with income below USD 20,000, higher educational attainment, and higher fruit and vegetable intake. Low prices were the most popular reason for online grocery shopping (57%). Adults aged 18−33 years old had higher odds of reporting low prices as a motivating factor than older adults (OR = 2.34 (95% CI: 1.78, 3.08; p < 0.001)) and lower odds of reporting being discouraged by lack of social interaction (OR = 0.34 (95% CI: 0.25, 0.45; p < 0.001)). Conclusion: Strategies for making online grocery shopping more affordable for adults with lower income may be promising, especially online produce. For older adults, additional support may be needed to make online shopping a suitable replacement for in-store shopping, such as education on technology and combining it with opportunities for social support.

Beverage Availability and Price: Variations by Neighborhood Poverty Level in New York City.

Objective: To describe the variability in the availability and price of sugary drinks, low-calorie drinks, and water/seltzer across high- and low-poverty census tracts in the five boroughs of New York City (NYC). Design: Cross-sectional study. Our primary analysis compared the overall sample of beverages. Secondary analyses included tests for differences in the availability of beverage categories by neighborhood poverty level. Setting: We collected data from 106 stores (31 supermarkets, 29 convenience stores, 29 pharmacies, 9 Targets, and 8 Dollar Trees) in NYC. Fifty-four stores were located in high-poverty census tracts and 52 were located in low-poverty census tracts. Results: The mean Price per 0.03-liter of sugary drinks across the sample was $0.08, which was significantly higher than the price of low-calorie drinks ($0.07, p=0.01) but not different from water/seltzer ($0.08, p=0.65). Sugary drinks and water/seltzer were available in 91% of retailers, and low-calorie drinks were available in 87% of retailers. There was no statistical difference in availability of sugary drinks compared with low-calorie drinks or water/seltzer overall or within high- or low-poverty census tracts. Analyzed by store type, the mean price per ounce of sugary drinks differed significantly from water/seltzer at convenience stores, pharmacies, and Target stores (bodegas: $0.08 vs. $0.09, p=0.03; pharmacies: $0.11 vs. $0.08, p=0.02; Target stores: $0.07 vs. $0.09, p=0.01). Conclusions: Sugary drinks were available in most food retail settings in NYC, with little variation by census tract poverty level. Interventions that raise the price of sugary drinks to make healthier alternatives, such as water, the more affordable option should be considered.

Disparities in SNAP online grocery delivery and implementation: Lessons learned from California during the 2020-21 COVID pandemic.

During the COVID-19 pandemic in 2020, the Supplemental Nutrition Assistance Program (SNAP) Online Purchasing Pilot (OPP) was rapidly expanded across the US. This program, enabling direct-to-home grocery delivery, could be a transformative step towards improving fresh-food access. However, lack of information on which areas are serviced by SNAP OPP hinders the identification of potential demographic and regional disparities in access. Lessons from the initial implementation period are critical for understanding continuing inequities and informing the implementation of future programs. In California, SNAP OPP expanded food access for 85.9% of the state's SNAP households in 2020-21. Coverage was significantly greater in urban areas, covering 87.2% of CalFresh households in urban limited food access areas as compared with 29.9% of CalFresh households in rural limited food access areas. County-level COVID-19 rates did not have a meaningful association with SNAP OPP coverage.

Categorizing community type for epidemiologic evaluation of community factors and chronic disease across the United States.

Existing classifications of community type do not differentiate urban cores from surrounding non-rural areas, an important distinction for analyses of community features and their impact on health. Inappropriately classified community types can introduce serious methodologic flaws in epidemiologic studies and invalid inferences from findings. To address this, we evaluate a modification of the United States Department of Agriculture's Rural Urban Commuting Area codes at the census tract, propose a four-level categorization of community type, and compare this with existing classifications for epidemiologic analyses. Compared to existing classifications, our method resulted in clearer geographic delineations of community types within urban areas.

Impact of land use and food environment on risk of type 2 diabetes: A national study of veterans, 2008-2018.

BACKGROUND: Large-scale longitudinal studies evaluating influences of the built environment on risk for type 2 diabetes (T2D) are scarce, and findings have been inconsistent. OBJECTIVE: To evaluate whether land use environment (LUE), a proxy of neighborhood walkability, is associated with T2D risk across different US community types, and to assess whether the association is modified by food environment. METHODS: The Veteran's Administration Diabetes Risk (VADR) study is a retrospective cohort of diabetes-free US veteran patients enrolled in VA primary care facilities nationwide from January 1, 2008, to December 31, 2016, and followed longitudinally through December 31, 2018. A total of 4,096,629 patients had baseline addresses available in electronic health records that were geocoded and assigned a census tract-level LUE score. LUE scores were divided into quartiles, where a higher score indicated higher neighborhood walkability levels. New diagnoses for T2D were identified using a published computable phenotype. Adjusted time-to-event analyses using piecewise exponential models were fit within four strata of community types (higher-density urban, lower-density urban, suburban/small town, and rural). We also evaluated effect modification by tract-level food environment measures within each stratum. RESULTS: In adjusted analyses, higher LUE had a protective effect on T2D risk in rural and suburban/small town communities (linear quartile trend test p-value <0.001). However, in lower density urban communities, higher LUE increased T2D risk (linear quartile trend test p-value <0.001) and no association was found in higher density urban communities (linear quartile trend test p-value = 0.317). Particularly strong protective effects were observed for veterans living in suburban/small towns with more supermarkets and more walkable spaces (p-interaction = 0.001). CONCLUSION: Among veterans, LUE may influence T2D risk, particularly in rural and suburban communities. Food environment may modify the association between LUE and T2D.

Disentangling the roles of generational status and acculturation on dietary behaviors in disaggregated Asian American subgroups.

INTRODUCTION: Little is known on the independent effects of generational status and acculturation on the consumption of specific foods among disaggregated Asian American (AA) populations. This study explores the associations of generational status and acculturation with dietary behaviors of a nationwide non-probability sample of 3018 AAs (57.6% East Asian American (EAA), 18.9% South Asian American (SAA), 19.4% Southeast Asian American (SEAA)). METHODS: Recruited participants completed an online dietary survey designed and adapted for AAs to assess a range of diet and food purchasing behaviors. Generational status was assessed through participant and parental country of birth (1st-Gen, 2nd-Gen, 3rd-Gen); the Marin Short Acculturation Scale was adapted to measure acculturation. Linear regression models assessed the association of generational status and acculturation with consumption of 11 food/nutrient groups, adjusted for socio-economic variables. RESULTS: Compared to estimated US averages, participants reported lower fruit, dairy, and seafood intake yet lower red and processed meat, and higher whole grain, calcium, and fiber intake. Compared to EAA, SAA reported higher dairy (1.72 vs. 1.46 cups/day) and calcium (1029 vs. 954 mg/day) intakes, while SEAA reported lower vegetable intake (1.66 vs. 1.78 cups/day). In adjusted analyses, processed meat intake was higher among 2nd-Gen and 3rd-Gen vs.1st-Gen (+0.029 times/day; +0.061 times/day) participants. Higher acculturation was associated with lower vegetable, fiber, and seafood intake (-0.005 cups/day; -0.02 g/day; -0.002 times/day). CONCLUSION: Greater attention to the role of generational status and acculturation in AA dietary behaviors is needed, and findings call for further research to understand the mechanisms behind the dietary influence of different socialization and acculturative processes.

Differences in Dietary Quality by Sexual Orientation and Sex in the United States: NHANES 2011-2016.

BACKGROUND: There are persistent disparities in weight- and diet-related diseases by sexual orientation. Lesbian and bisexual females have a higher risk of obesity and cardiovascular disease compared with heterosexual females. Gay and bisexual males have a higher risk of diabetes and cardiovascular disease compared with heterosexual males. However, it remains unknown how sexual orientation groups differ in their dietary quality. OBJECTIVE: This study aimed to determine whether dietary quality differs by sexual orientation and sex among US adults. DESIGN: This was a cross-sectional study of 24-hour dietary recall data from a nationally representative sample of adults aged 20 through 65 years participating in the 2011-2016 National Health and Nutrition Examination Survey. PARTICIPANTS/SETTING: Study participants were adults (n = 8,851) with complete information on dietary intake, sexual orientation, and sex. MAIN OUTCOME MEASURES: The main outcome measures were daily energy intake from 20 specific food and beverage groups and Healthy Eating Index-2015 (HEI-2015) scores for sexual orientation groups (heterosexual vs gay/lesbian/bisexual). STATISTICAL ANALYSES PERFORMED: Ordinary least squares regressions were used to calculate adjusted means for each food and beverage group and HEI-2015, stratified by sex and controlling for covariates (eg, age and race/ethnicity) and survey cycles (2011-2012, 2013-2014, and 2015-2016). RESULTS: Among males, red and processed meat/poultry/seafood (P = .01) and sandwiches (P = .02) were smaller contributors to energy intake for gay/bisexual males compared with heterosexual males. Among females, cereals (P =.04) and mixed dishes (P = .02) were smaller contributors to energy intake for lesbian/bisexual females compared with heterosexual females. Gay/bisexual males had significantly higher total HEI-2015 scores than heterosexual males (mean ± standard deviation 53.40 ± 1.36 vs 49.29 ± 0.32, difference = 4.14; P = .004). Lesbian/bisexual females did not differ in total or component HEI-2015 scores from heterosexual females. CONCLUSIONS: Although gay/lesbian/bisexual groups were similar for a variety of dietary outcomes compared with heterosexual groups, gay and bisexual men displayed healthier dietary quality for processed meat (by consuming smaller amounts) and overall dietary quality (according to HEI-2015) compared with heterosexual males.

Longitudinal Analysis of Neighborhood Food Environment and Diabetes Risk in the Veterans Administration Diabetes Risk Cohort.

Importance: Diabetes causes substantial morbidity and mortality among adults in the US, yet its incidence varies across the country, suggesting that neighborhood factors are associated with geographical disparities in diabetes. Objective: To examine the association between neighborhood food environment and risk of incident type 2 diabetes across different community types (high-density urban, low-density urban, suburban, and rural). Design, Setting, and Participants: This is a national cohort study of 4 100 650 US veterans without type 2 diabetes. Participants entered the cohort between 2008 and 2016 and were followed up through 2018. The median (IQR) duration of follow-up was 5.5 (2.6-9.8) person-years. Data were obtained from Veterans Affairs electronic health records. Incident type 2 diabetes was defined as 2 encounters with type 2 diabetes International Classification of Diseases, Ninth Revision or Tenth Revision codes, a prescription for diabetes medication other than metformin or acarbose alone, or 1 encounter with type 2 diabetes International Classification of Diseases Ninth Revision or Tenth Revision codes and 2 instances of elevated hemoglobin A1c (≥6.5%). Data analysis was performed from October 2020 to March 2021. Exposures: Five-year mean counts of fast-food restaurants and supermarkets relative to other food outlets at baseline were used to generate neighborhood food environment measures. The association between food environment and time to incident diabetes was examined using piecewise exponential models with 2-year interval of person-time and county-level random effects stratifying by community types. Results: The mean (SD) age of cohort participants was 59.4 (17.2) years. Most of the participants were non-Hispanic White (2 783 756 participants [76.3%]) and male (3 779 555 participants [92.2%]). The relative density of fast-food restaurants was positively associated with a modestly increased risk of type 2 diabetes in all community types. The adjusted hazard ratio (aHR) was 1.01 (95% CI, 1.00-1.02) in high-density urban communities, 1.01 (95% CI, 1.01-1.01) in low-density urban communities, 1.02 (95% CI, 1.01-1.03) in suburban communities, and 1.01 (95% CI, 1.01-1.02) in rural communities. The relative density of supermarkets was associated with lower type 2 diabetes risk only in suburban (aHR, 0.97; 95% CI, 0.96-0.99) and rural (aHR, 0.99; 95% CI, 0.98-0.99) communities. Conclusions and Relevance: These findings suggest that neighborhood food environment measures are associated with type 2 diabetes among US veterans in multiple community types and that food environments are potential avenues for action to address the burden of diabetes. Tailored interventions targeting the availability of supermarkets may be associated with reduced diabetes risk, particularly in suburban and rural communities, whereas restrictions on fast-food restaurants may help in all community types.