Non-affirmation minority stress, internalized transphobia, and subjective cognitive decline among transgender and gender diverse veterans aged 45 years and older.

OBJECTIVES: To examine the associations of two measures of minority stress, non-affirmation minority stress and internalized transphobia, with subjective cognitive decline (SCD) among transgender and gender diverse (TGD) veterans. METHOD: We administered a cross-sectional survey from September 2022 to July 2023 to TGD veterans. The final analytic sample included 3,152 TGD veterans aged ≥45 years. We used a generalized linear model with quasi-Poisson distribution to calculate prevalence ratios (PR) and 95% confidence intervals (CIs) measuring the relationship between non-affirmation minority stress and internalized transphobia and past-year SCD. RESULTS: The mean age was 61.3 years (SD = 9.7) and the majority (70%) identified as trans women or women. Overall, 27.2% (n = 857) reported SCD. Adjusted models revealed that TGD veterans who reported experiencing non-affirmation minority stress or internalized transphobia had greater risk of past-year SCD compared to those who did not report either stressor (aPR: 1.09, 95% CI: 1.04-1.15; aPR: 1.19, 95% CI: 1.12-1.27). CONCLUSION: Our findings demonstrate that proximal and distal processes of stigma are associated with SCD among TGD veterans and underscore the need for addressing multiple types of discrimination. Above all, these results indicate the lasting sequelae of transphobia and need for systemic changes to prioritize the safety and welfare of TGD people.

Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration.

BACKGROUND: Transgender and gender diverse (TGD) veterans have a greater prevalence of suicide morbidity and mortality than cisgender veterans. Gender-affirming surgery (GAS) has been shown to improve mental health for TGD veterans. In 2021, the Veterans Health Administration (VHA) announced the initiation of a rulemaking process to cover GAS for TGD patients. OBJECTIVE: This study explores patients' and providers' perspectives about access to GAS and other gender-affirming medical interventions not offered in the VHA including barriers, facilitators, and clinical and policy recommendations. PARTICIPANTS: TGD patients (n = 30) and VHA providers (n = 22). APPROACH: Semi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data. KEY RESULTS: VHA policy exclusions were the most cited barrier to GAS. Additional barriers included finding information about GAS, traveling long distances to non-VHA surgeons, out-of-pocket expenses, post-surgery home care, and psychological challenges related to the procedure. Factors facilitating access included surgical care information from peers and VHA providers coordinating care with non-VHA GAS providers. Pre- and post-operative care through the VHA also facilitated receiving surgery; however, patients and providers indicated that knowledge of these services is not widespread. Respondents recommended disseminating information about GAS-related care and resources to patients and providers to help patients navigate care. Additional recommendations included expanding access to TGD mental health specialists and establishing referrals to non-VHA GAS providers through transgender care coordinators. Finally, transfeminine patients expressed the importance of facial GAS and hair removal. CONCLUSIONS: A policy change to include GAS in the VHA medical benefits package will allow the largest integrated healthcare system in the United States to provide evidence-based GAS services to TGD patients. For robust and consistent policy implementation, the VHA must better disseminate information about VHA-provided GAS-related care to TGD patients and providers while building capacity for GAS delivery.

Associations of Fatty Liver Disease With Recovery After Traumatic Injury.

INTRODUCTION: Fatty liver disease (FLD) is associated with systemic inflammation, metabolic disease, and socioeconomic risk factors for poor health outcomes. Little is known on how adults with FLD recover from traumatic injury. METHODS: We studied adults admitted to the intensive care unit of a level 1 trauma center (2016-2020), excluding severe head injury/cirrhosis (N = 510). We measured the liver-spleen attenuation difference in Hounsfield units (HUL-S) using virtual noncontrast computerized tomography scans: none (HUL-S>1), mild (-10≤HUL-S<1), moderate/severe (HUL-S < -10). We used Cox models to examine the "hazard" of recovery from systemic inflammatory response (SIRS score 2 or higher) organ dysfunction, defined as sequential organ failure assessment score 2 or higher, and lactate clearance (<2 mmol/L) in relation to FLD. RESULTS: Fifty-one participants had mild and 29 had moderate/severe FLD. The association of FLD with recovery from SIRS differed according to whether an individual had shock on admission (hazard ratio [HR] = 0.76; 95% confidence interval [CI] 0.55-1.05 with shock; HR = 1.81; 95% CI 1.43-2.28 without shock). Compared to patients with no FLD, the hazard of lactate clearance was similar for mild FLD (HR = 1.04; 95% CI 0.63-1.70) and lower for moderate/severe FLD (HR = 0.40; 95% CI 0.18-0.89). CONCLUSIONS: FLD is common among injured adults. Associations of FLD with outcomes after shock and critical illness warrant further study.

Differences in influenza vaccination by gender identity and state-level gender equity policies: Behavioral Risk Factor Surveillance System, 2015-2019.

BACKGROUND: It is estimated that there are one million transgender and over 340,000 gender non-conforming people in the United States, many of whom face significant health disparities including access to healthcare. Although previous studies have reported greater vaccine uptake in women compared to men, national-level estimates of influenza vaccine uptake among transgender and non-binary people are unknown. This study aims to characterize differences in influenza vaccine uptake by gender identity and examine associations between vaccination status and state-level gender equity policies. METHODS: We used cross-sectional data from adults participating in the 2015-2019 United States Behavioral Risk Factors Surveillance System surveys. Weighted prevalence differences (PDs) and associated confidence intervals (CIs) of being unvaccinated against influenza by self-reported gender identity were estimated using generalized linear regression models. RESULTS: Compared to cisgender women (unvaccinated prevalence = 57.3%), the prevalence of being unvaccinated was significantly higher among cisgender men (64.4%; PD = 7.0 per 100, 95% CI: 6.7-7.4), transgender women (65.4%; PD = 8.1 per 100, 95% CI 4.0-12.2), transgender men (64.6%; PD = 7.3 per 100, 95% CI: 2.7-11.8), and gender non-conforming individuals (64.6%; PD = 7.2 per 100, 95% CI: 1.3-13.2). This pattern was similar among individuals living in states with protective versus restrictive gender equity policies. CONCLUSIONS: Our results identified a disparity in influenza vaccine uptake among individuals across the gender spectrum. To improve vaccine equity, future research should explore barriers to and facilitators of vaccine uptake by gender identity, which could inform policies and health promotion interventions to improve uptake co-designed and implemented with the transgender and non-binary communities.

Association between health care access and food insecurity among lower-income older adults with multiple chronic conditions in Washington State, USA.

OBJECTIVE: Lower-income older adults with multiple chronic conditions (MCC) are highly vulnerable to food insecurity. However, few studies have considered how health care access is related to food insecurity among older adults with MCC. The aims of this study were to examine associations between MCC and food insecurity, and, among older adults with MCC, between health care access and food insecurity. DESIGN: Cross-sectional study data from the 2019 Behavioral Risk Factor Surveillance System survey. SETTING: Washington State, USA. PARTICIPANTS: Lower-income adults, aged 50 years or older (n 2118). MCC was defined as having ≥ 2 of 11 possible conditions. Health care access comprised three variables (unable to afford seeing the doctor, no health care coverage and not having a primary care provider (PCP)). Food insecurity was defined as buying food that did not last and not having money to get more. RESULTS: The overall prevalence of food insecurity was 26·0 % and was 1·50 times greater (95 % CI 1·16, 1·95) among participants with MCC compared to those without MCC. Among those with MCC (n 1580), inability to afford seeing a doctor was associated with food insecurity (prevalence ratio (PR) 1·83; 95 % CI 1·46, 2·28), but not having health insurance (PR 1·49; 95 % CI 0·98, 2·24) and not having a PCP (PR 1·10; 95 % CI 0·77, 1·57) were not. CONCLUSIONS: Inability to afford healthcare is related to food insecurity among older adults with MCC. Future work should focus on collecting longitudinal data that can clarify the temporal relationship between MCC and food insecurity.

Differences in Prosthetic Prescription Between Men and Women Veterans After Transtibial or Transfemoral Lower-Extremity Amputation: A Longitudinal Cohort Study (2005-2018).

OBJECTIVE: To evaluate whether prosthetic prescription differed by gender and the extent to which differences were mediated by measured factors. DESIGN: Retrospective longitudinal cohort study using data from Veterans Health Administration (VHA) administrative databases. SETTING: VHA patients throughout the United States. PARTICIPANTS: The sample included 20,889 men and 324 women who had an incident transtibial or transfemoral amputation between 2005 and 2018. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Time to prosthetic prescription (up to 1 year). We used parametric survival analysis (an accelerated failure time model) to assess gender differences. We estimated mediation effects of amputation level, pain comorbidity burden, medical comorbidities, depression, and marital status on time to prescription. RESULTS: In the 1 year after amputation, the proportion of women (54.3%) and men (55.7%) prescribed a prosthesis was similar. However, after we controlled for age, race, ethnicity, enrollment priority, VHA region, and service-connected disability, the time to prosthetic prescription was significantly faster among men compared with women (acceleration factor=0.73; 95% confidence interval, 0.61-0.87). The difference in time to prosthetic prescription between men and women was significantly mediated by amputation level (23%), pain comorbidity burden (-14%), and marital status (5%) but not medical comorbidities or depression. CONCLUSIONS: Although the proportion of patients with prosthetic prescription at 1-year postamputation was similar between men and women, women received prosthetic prescriptions more slowly than men, suggesting that more work is needed to understand barriers to timely prosthetic prescriptions among women, and how to intervene to reduce those barriers.

Voices of Women Veterans with Lower Limb Prostheses: a Qualitative Study.

BACKGROUND: Women Veterans with amputation are a group with unique needs whose numbers have grown over the last 5 years, accounting for nearly 3% of all Veterans with amputation in 2019. Although identified as a national priority by the Veterans Health Administration, the needs of this population have remained largely underrepresented in amputation research. OBJECTIVE: To describe the experiences of women Veterans with lower extremity amputation (LEA) related to prosthetic care provision and devices. DESIGN: National qualitative study using semi-structured individual interviews. PARTICIPANTS: Thirty women Veterans with LEA who had been prescribed a prosthesis at least 12 months prior. APPROACH: Inductive content analysis. KEY RESULTS: Four key themes emerged: (1) a sense of "feeling invisible" and lacking a connection with other women Veterans with amputation; (2) the desire for prosthetic devices that meet their biological and social needs; (3) the need for individualized assessment and a prosthetic limb prescription process that is tailored to women Veterans; the current process was often perceived as biased and either dismissive of women's concerns or failing to adequately solicit them; and (4) the desire for prosthetists who listen to and understand women's needs. CONCLUSIONS: Women Veterans with LEA articulated themes reminiscent of those previously reported by male Veterans with LEA, such as the importance of prostheses and the central role of the provider-patient relationship. However, they also articulated unique needs that could translate into specific strategies to improve prosthetic care, such as integrating formal opportunities for social support and peer interaction for women Veterans with LEA, advocating for administrative changes and research efforts to expand available prosthetic component options, and ensuring that clinical interactions are gender-sensitive and free of bias.

Risks and Risk Factors for Contralateral Amputation in Patients who have Undergone Amputation for Chronic Limb Threatening Ischaemia.

OBJECTIVE: The aim of this study was to determine the cumulative incidence of, and the risk factors associated with, contralateral amputation in patients with chronic limb threatening ischaemia (CLTI). METHODS: This was a retrospective cohort study of patients with incident unilateral transmetatarsal (TM), transtibial (TT), or transfemoral (TF) amputation secondary to CLTI, identified from the National Veterans Affairs Surgical Quality Improvement Program database (2004 - 2014). Thirteen potential pre-operative risk factors for contralateral amputation were considered. A competing risk analysis to estimate the cumulative incidence of contralateral amputation was performed using a Fine-Gray subdistribution hazard model. The effect of risk factors on contralateral amputation was estimated by computing subdistribution hazard ratios (sub-HR) with 95% confidence intervals (CI). RESULTS: From the database, 7 360 patients met the inclusion criteria. The contralateral amputation risk was 7.7% and was greatest in those who underwent a TF amputation (9.7%), followed by TT (7.4%) and TM amputation (6.6%) (p < .001). Among the 588 contralateral amputations, 50% were at the TF level, 34% at the TT level, and 16% at the TM level. The adjusted risk of contralateral amputation was greater in those who underwent an incident TF amputation or were Black or Hispanic. The factor that contributed to risk of contralateral amputation to the greatest extent was dialysis (sub-HR, 2.3; 95% CI 1.7 - 3.0; p < .001) while those who were obese (compared with underweight) were at lowest risk (0.67; 95% CI 0.46 - 0.97; p = .030). CONCLUSION: The one year risk of contralateral amputation in patients with CLTI is related to incident amputation level, medical comorbidities, correlates with race/ethnicity, and body mass index at the time of the incident amputation. The identified risk factors are largely not modifiable; however, they can be used to help identify populations at elevated risk.

A multi-state evaluation of the association between mental health and firearm storage practices.

Firearm storage method is a potentially modifiable risk factor for suicide. Using data from a large, multi-state survey, we sought to determine whether there is an association between mental health and household firearm storage practices, and characterize that association by state of residence. Participants who endorsed the presence of a household firearm and answered the mental health questions in the 2016-2017 Behavioral Risk Factor Surveillance System from eight states were included (n=26,949). Exposures were recent poor mental health (≥14 vs. 0-13 days/past month), and diagnosis of depression. Outcomes were household firearm storage practices (loaded, and both loaded and unlocked). Using Poisson regression, we calculated adjusted prevalence ratios (aPR) overall and stratified by state of residence. Of adults endorsing a household firearm, 35.1% reported storing a firearm loaded, and of those, 53.4% reported that the firearm was both loaded and unlocked. Neither recent poor mental health nor depression was associated with loaded (aPR 1.14 [95% CI: 0.95-1.37] and aPR 0.94 [95% CI 0.80-1.09], respectively) or loaded and unlocked (aPR 1.08 [95% CI 0.88-1.42] and aPR 1.04 [95% CI 0.88-1.22], respectively) firearm storage. In the setting of highly prevalent loaded firearm storage, no differences in storage practices by mental health indicators were observed across eight states despite disparate firearm policies and local culture. The lack of difference in storage practices by mental health indicators across several states highlights an opportunity to improve means safety counseling practices, and the need for dedicated evaluation of state-level firearm storage policies.

Association of Arthritis and Antihypertensive Medication Use Among Individuals With Hypertension: A Cross-Sectional Analysis of the 2017 Behavioral Risk Factor Surveillance System.

BACKGROUND: The aim of this study was to assess whether arthritis is associated with lower antihypertensive medication (AHM) use among those with hypertension and whether this relationship differs by age or cardiovascular (CV) comorbidity. METHODS: The data were from the 2017 Behavioral Risk Factor Surveillance System. We employed survey weights to account for the complex sampling design and nonresponse bias. We used generalized linear models to estimate unadjusted and adjusted prevalence ratios (PRs) and 95% confidence intervals comparing AHM use among those with severe or mild arthritis to those without arthritis, stratified by age, sex, and CV comorbidity. RESULTS: Among 173,098 adults with hypertension, 26.0% had severe arthritis and 22.3% had mild arthritis. Compared with those without arthritis, individuals with mild or severe arthritis were older, predominantly female, with lower income and more comorbidities. After adjustment for sex, race, inability to afford medications, and CV comorbidity, the prevalence ratios for AHM use were stronger for younger versus older age groups. Associations did not differ significantly by sex or CV comorbidity. Associations were similar for mild and severe arthritis, compared with no arthritis. CONCLUSIONS: Among individuals with hypertension, those with arthritis had significantly higher prevalences of AHM use compared with those without arthritis. Higher prevalences of AHM use were seen with older age categories, although a stronger association of arthritis and AHM use was found in younger age groups. Future studies on hypertension management in arthritis should examine these relationships more closely.

Impact of Caregiving During Emerging Adulthood on Frequent Mental Distress, Smoking, and Drinking Behaviors: United States, 2015-2017.

Objectives. To examine associations between caregiving mental or behavioral health outcomes among emerging US adults, defined as persons aged 18 to 25 years.Methods. The study sample included emerging adult respondents to the 2015-2017 Behavioral Risk Factor Surveillance System's caregiving module. Exposures were caregiver (n = 3087), expectant caregiver (n = 2303), and noncaregiver (n = 12 216) status. Expectant caregivers were defined as persons not currently providing care but anticipating doing so within the next 2 years. Outcomes included frequent mental distress (FMD), drinking (binge or heavy), and current smoking (cigarette or e-cigarette use). We used robust Poisson regression to calculate adjusted prevalence ratios (APRs) and corresponding 95% confidence intervals (CIs). We adjusted all models for income.Results. Caregivers had a similar prevalence of FMD when compared with both expectant caregivers (APR = 1.67; 95% CI = 1.28, 2.17) and noncaregivers (APR = 1.50; 95% CI = 1.23, 1.82). Caregivers had a higher prevalence of current cigarette smoking compared with noncaregivers (APR = 1.44; 95% CI = 1.21, 1.71).Conclusions. Among emerging adults, providing care is associated with poorer mental health. Point estimates looking at FMD were higher when we compared caregivers with expectant caregivers, suggesting a difference in exchangeability between comparison groups.Public Health Implications. This study highlights the importance of including emerging adults in caregiving research.

Association of 100% fruit juice consumption and 3-year weight change among postmenopausal women in the in the Women's Health Initiative.

The association between drinking 100% fruit juice and long-term weight gain is controversial and has been investigated in few studies. We examined whether 100% fruit juice consumption was associated with weight change in a large prospective cohort of postmenopausal women. We analyzed data from 49,106 postmenopausal women in the United States enrolled in the Women's Health Initiative between 1993 and 1998. Food frequency questionnaires at baseline and year 3 assessed food and beverage intake. Body weight was measured at in-person clinic visits. We used linear mixed effects modeling to determine the association between change in 100% fruit juice consumption and 3-year weight change over the same time period. Covariates of interest included age, demographic factors, smoking, body mass index, hormone replacement therapy, lifestyle factors, change in whole fruit intake, and change in sugar-sweetened beverage intake. The mean weight change was 3.2 lbs. over 3 years. In multivariable adjusted analyses, each 1 serving/day increase in 100% fruit juice intake was associated with a 3-year weight gain of 0.39 lbs. (95% confidence interval: 0.10, 0.69). In conclusion, an increase in 100% fruit juice consumption was associated with a small amount of long-term weight gain in postmenopausal women.

How can we get Iraq- and Afghanistan-deployed US Veterans to participate in health-related research? Findings from a national focus group study.

BACKGROUND: Research participant recruitment is often fraught with obstacles. Poor response rates can reduce statistical power, threaten both internal and external validity, and increase study costs and duration. Military personnel are socialized to a specific set of laws, norms, traditions, and values; their willingness to participate in research may differ from civilians. The aims of this study were to better understand the views of United States (US) Veterans who served in Operation Enduring Freedom (OEF)/ Operation Iraqi Freedom (OIF) on research and motivators for participating in research to inform recruitment for a planned observational study of respiratory health in OEF/OIF Veterans. METHODS: We conducted 10 focus groups in a purposive sample of OEF/OIF Veterans (n = 89) in five US cities in 2015. Key topics included: reasons for participating or declining to participate in health-related research, logistics around study recruitment and conduct, compensation, written materials, and information sharing preferences for study results. Two authors independently coded the data using template analysis. RESULTS: Participants identified three criteria that motivated a decision to participate in health-related research: 1) adequate compensation, 2) desire to help other Veterans, and 3) significance and relevance of the research topic. For many, both sufficient compensation and a sense that the study would help other Veterans were critical. The importance of transparency arose as a key theme; Veterans communicated that vague language about study aims or procedures engendered distrust. Lastly, participants expressed a desire for studies to communicate results of their specific health tests, as well as overall study findings, back to research participants. CONCLUSIONS: OEF/OIF Veterans described trust, transparent communication, and respect as essential characteristics of research in which they would be willing to participate. Additional studies are needed to determine whether our results generalize to other US Veterans; nevertheless, our results highlight precepts that have been reported as important for recruitment in other populations. Researchers may benefit from using community-engaged research methods to seek feedback on recruitment materials and strategies prior to initiating research. For costly studies targeting a large sample (i.e. in the thousands), it may be important to test a variety of recruitment strategies.

The Association Between Park Facilities and Duration of Physical Activity During Active Park Visits.

Public parks provide places for urban residents to obtain physical activity (PA), which is associated with numerous health benefits. Adding facilities to existing parks could be a cost-effective approach to increase the duration of PA that occurs during park visits. Using objectively measured PA and comprehensively measured park visit data among an urban community-dwelling sample of adults, we tested the association between the variety of park facilities that directly support PA and the duration of PA during park visits where any PA occurred. Cross-classified multilevel models were used to account for the clustering of park visits (n = 1553) within individuals (n = 372) and parks (n = 233). Each additional different PA facility at a park was independently associated with a 6.8% longer duration of PA bouts that included light-intensity activity, and an 8.7% longer duration of moderate to vigorous PA time. Findings from this study are consistent with the hypothesis that more PA facilities increase the amount of PA that visitors obtain while already active at a park.

Maternal sedentary behavior during pre-pregnancy and early pregnancy and mean offspring birth size: a cohort study.

BACKGROUND: Sedentary behavior is associated with adverse health outcomes in the general population. Whether sedentary behavior during pregnancy is associated with newborn outcomes, such as birth size, is not established, and previous studies have been inconsistent. While previous research suggests that male and female fetuses respond differently to maternal behaviors, such as physical activity, the role of infant sex in sedentary behavior-birth size associations has not been examined. METHODS: Participants in the Omega study, a cohort in Washington State (1996-2008), reported leisure time sedentary behavior (non-work time spent sitting), light intensity physical activity, and moderate/vigorous leisure time physical activity duration in the year before pregnancy (N = 1373) and in early pregnancy (N = 1535, mean 15 weeks). Offspring birth size was abstracted from delivery records. Non-parametric calibration weighting was used to assign adjustment weight (matching the distribution of sociodemographic and medical characteristics of the full cohort (N = 4128)) to participants with available sedentary behavior data. Weighted linear regression models were used to estimate mean differences in offspring birthweight, head circumference, and ponderal index (birthweight/length3) associated with leisure time sedentary behavior. Regression models were run overall and stratified by offspring sex. Isotemporal substitution modeling was used to determine mean differences in birthweight associated with replacing sedentary behavior with light or moderate/vigorous physical activity. RESULTS: On average, women spent 2.3 and 2.6 h/day in leisure time sedentary behavior during pre- and early pregnancy, respectively. There were no associations of pre-pregnancy leisure time sedentary behavior with mean birthweight, head circumference, or ponderal index (adjusted ß = - 12, 95% CI: -28, 4.1; ß = 0.0, 95% CI: -0.04, 0.1; and ß = 0.1, 95% CI: -0.2, 0.4, respectively). Early pregnancy sedentary behavior was not associated with mean birth size. Associations of sedentary behavior with mean birth size did not differ by offspring sex. Replacing sedentary time with light or moderate/vigorous physical activity was not associated with mean birthweight. CONCLUSIONS: We did not observe associations of maternal sedentary behavior during pre- or early pregnancy with mean offspring birth size. Pre-pregnancy and early pregnancy sedentary behavior may have important adverse effects on maternal health, but our results do not support associations with mean offspring birth size.

Association of Pre-pregnancy BMI and Postpartum Weight Retention Before Second Pregnancy, Washington State, 2003-2013.

Background Maternal overweight and obesity is one of the most common high-risk obstetric conditions associated with adverse birth outcomes. Smaller studies have suggested that pre-pregnancy body mass index (BMI) is associated with postpartum weight retention. Objective The primary objective of this study was to examine the association between pre-pregnancy BMI status and maternal weight retention. Study design We conducted a population-based retrospective cohort study using Washington State birth certificate data from 2003-2013. We included women who had two sequential births during this time period, with the second birth occurring within 18-36 months of the first singleton delivery date. BMI before a women's first pregnancy ("pre-pregnancy BMI") was categorized as normal (18.5-24.9 kg/m2) and overweight/obese (25-40 kg/m2). Women were classified as having returned to first pre-pregnancy BMI if their BMI before their second pregnancy was no more than 1 kg/m2 more compared to their BMI before their first pregnancy. Analyses were stratified by gestational weight gain during the first pregnancy (below, met, exceeded recommended gestational weight gain). Results A total of 49,132 mothers were included in the study. Among women who met their recommended gestational weight gain, compared to mothers with a normal BMI, obese/overweight mothers were less likely to return to their pre-pregnancy BMI (76.5 vs 72.3%; RRObese/Overweight = 0.88; 95% CI: 0.85-0.92). A similar pattern was observed among women who exceeded their recommended gestational weight gain (62.6 vs 53.2%; RRObese/Overweight = 0.79, 95% CI: 0.78-0.80). Conclusion Pre-pregnancy BMI in the overweight/obese range is associated with a decreased likelihood of returning to pre-pregnancy BMI. Further research to support women during and after their pregnancy to promote behavior changes that prevent excessive weight gain during pregnancy and weight retention after birth is needed.

The association between park facilities and the occurrence of physical activity during park visits.

Prior research has found a positive relationship between the variety of park facilities and park-based physical activity (PA), but has not provided an estimate of the effect that additional different PA facilities have on whether an individual is active during a park visit. Using objective measures of park visits and PA from an urban sample of 225 adults in King County, Washington, we compared the variety of PA facilities in parks visited where an individual was active to PA facilities in parks where the same individual was sedentary. Each additional different PA facility at a park was associated with a 6% increased probability of being active during a visit. Adding additional different PA facilities to a park appears to have a moderate effect on whether an individual is active during a park visit, which could translate into large community health impacts when scaled up to multiple park visitors.

State of the art conference on weight management in VA: Policy and research recommendations for advancing behavioral interventions.

This article summarizes outcomes of the behavioral interventions work group for the Veterans Health Administration (VHA) State of the Art Conference (SOTA) for Weight Management. Sixteen VHA and non-VHA subject matter experts, representing clinical care delivery, research, and policy arenas, participated. The work group reviewed current evidence of efficacy, effectiveness, and implementation of behavioral interventions for weight management, participated in phone- and online-based consensus processes, generated key questions to address gaps, and attended an in-person conference in March 2016. The work group agreed that there is strong evidence for efficacy and effectiveness of core behavioral intervention components and processes, but insufficient evidence to determine the comparative effectiveness of multiple clinician-delivered weight management modalities, as well as technologies that may or may not supplement clinician-delivered treatments. Effective strategies for implementation of weight management services in VHA were identified. The SOTA work group's foremost policy recommendations are to establish a system-wide culture for weight management and to identify a population-level health metric to measure the impact of weight management interventions that can be tracked and clearly communicated throughout VHA. The work group's top research recommendation is to determine how to deploy and scale the most effective behavioral weight management interventions for Veterans.

Associations of 100% fruit juice versus whole fruit with hypertension and diabetes risk in postmenopausal women: Results from the Women's Health Initiative.

The objective of this study was to determine whether consumption of 100% fruit juice as compared to whole fruit is associated with increased risk of hypertension or diabetes. We analyzed postmenopausal women in the United States enrolled in the Women's Health Initiative between 1993 and 1998. Whole fruit and 100% fruit juice intake were assessed by baseline food frequency questionnaire. Standardized questionnaires assessed outcomes every 6-12months during a mean 7.8years of follow-up. Cox regression estimated hazard ratios (HR) and 95% confidence intervals (CI) for incident hypertension (n=36,314 incident cases/80,539 total participants) and diabetes (n=11,488 incident cases/114,219 total participants). In multivariable analyses there was no significant association comparing the highest to lowest quintiles of 100% fruit juice consumption (8oz/day compared to none) and incident hypertension (HR 1.00, 95% CI 0.97-1.03) or diabetes (HR 0.96, 95% CI 0.90-1.03). There was also no significant association between whole fruit consumption (2.4servings/day compared to 0.3servings/day) and incident hypertension (HR 1.02, 95% CI 0.98-1.05) or diabetes (HR 1.03, 95% CI 0.96-1.10). Consuming moderate amounts of 100% fruit juice or whole fruit was not significantly associated with risk of hypertension or diabetes among postmenopausal US women.

Patterns of Smoking and Unhealthy Alcohol Use Following Sexual Trauma Among U.S. Service Members.

In the first known longitudinal study of the topic, we examined whether experiencing sexual assault or sexual harassment while in the military was associated with increased risk for subsequent unhealthy alcohol use and smoking among U.S. service members in the Millennium Cohort Study (2001-2012). Adjusted complementary log-log models were fit to estimate the relative risk of (a) smoking relapse among former smokers (men: n = 4,610; women: n = 1,453); (b) initiation of unhealthy alcohol use (problem drinking and/or drinking over recommended limits) among those with no known history of unhealthy alcohol use (men: n = 8,459; women: n = 4,816); and (c) relapse among those previously reporting unhealthy alcohol use (men: n = 3,487; women: n = 1,318). Men who reported experiencing sexual assault while in the military had sixfold higher risk for smoking relapse: relative risk (RR) = 6.62; 95% confidence interval (CI) [2.34, 18.73], than men who did not. Women who reported experiencing sexual assault while in the military had almost twice the risk for alcohol relapse: RR = 1.73; 95% CI [1.06, 2.83]. There were no other significant associations. These findings suggest that men and women may respond differently following sexual trauma, and support future concerted policy efforts by military leadership to prevent, detect, and intervene on sexual assault.