Methods for structural sexism and population health research: Introducing a novel analytic framework to capture life-course and intersectional effects.

Accumulating evidence links structural sexism to gendered health inequities, yet methodological challenges have precluded comprehensive examinations into life-course and/or intersectional effects. To help address this gap, we introduce an analytic framework that uses sequential conditional mean models (SCMMs) to jointly account for longitudinal exposure trajectories and moderation by multiple dimensions of social identity/position, which we then apply to study how early life-course exposure to U.S. state-level structural sexism shapes mental health outcomes within and between gender groups. Data came from the Growing Up Today Study, a cohort of 16,875 children aged 9-14 years in 1996 who we followed through 2016. Using a composite index of relevant public policies and societal conditions (e.g., abortion bans, wage gaps), we assigned each U.S. state a year-specific structural sexism score and calculated participants' cumulative exposure by averaging the scores associated with states they had lived in during the study period, weighted according to duration of time spent in each. We then fit a series of SCMMs to estimate overall and group-specific associations between cumulative exposure from baseline through a given study wave and subsequent depressive symptomology; we also fit models using simplified (i.e., non-cumulative) exposure variables for comparison purposes. Analyses revealed that cumulative exposure to structural sexism: (1) was associated with significantly increased odds of experiencing depressive symptoms by the subsequent wave; (2) disproportionately impacted multiply marginalized groups (e.g., sexual minority girls/women); and (3) was more strongly associated with depressive symptomology compared to static or point-in-time exposure operationalizations (e.g., exposure in a single year). Substantively, these findings suggest that long-term exposure to structural sexism may contribute to the inequitable social patterning of mental distress among young people living in the U.S. More broadly, the proposed analytic framework represents a promising approach to examining the complex links between structural sexism and health across the life course and for diverse social groups.

Comparative safety of adding serotonin and norepinephrine reuptake inhibitors (SNRIs) versus nonsteroidal anti-inflammatory drugs (NSAIDs) to short-acting opioids for non-malignant pain in nursing homes.

BACKGROUND: The comparative safety of serotonin and norepinephrine reuptake inhibitors (SNRIs) as adjuvants to short-acting opioids in older adults is unknown even though SNRIs are commonly used. We compared the effects of SNRIs versus nonsteroidal anti-Inflammatory drugs (NSAIDs) on delirium among nursing home residents when SNRIs or NSAIDs were added to stable regimens of short-acting opioids. METHODS: Using 2011-2016 national Minimum Data Set (MDS) 3.0 and Medicare claims data to implement a new-user design, we identified a cohort of nursing home residents receiving short-acting opioids who initiated either an SNRI or an NSAID. Delirium was defined from the Confusion Assessment Method in MDS 3.0 assessments and ICD9/10 codes using Medicare hospitalization claims. Propensity score matching balanced underlying differences for initiating treatments on 39 demographic and clinical characteristics (nSNRIs = 5350; nNSAIDs = 5350). Fine and Gray models provided hazard ratios (HRs) and 95% confidence intervals (CIs) adjusting for the competing risk of death. RESULTS: Hydrocodone was the most commonly used short-acting opioid (48%). Residents received ~23 mg daily oral morphine equivalent at the time of SNRIs/NSAIDs initiation. The majority were women, non-Hispanic White, and aged ≥75 years. There were no differences in any of the confounders after propensity matching. Over 1 year, 10.8% of SNRIs initiators and 8.9% of NSAIDs initiators developed delirium. The rate of delirium onset was similar in SNRIs and NSAID initiators (HR(delirium in nursing home or hospitalization for delirium):1.10; 95% CI: 0.97-1.24; HR(hospitalization for delirium): 1.06; 95% CI: 0.89-1.25), and were similar regardless of baseline opioid daily dosage. CONCLUSIONS: Among nursing home residents, adding SNRIs to short-acting opioids does not appear to increase risk of delirium relative to initiating NSAIDs. Understanding the comparative safety of pain regimens is needed to inform clinical decisions in a medically complex population often excluded from clinical research.

Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment.

BACKGROUND: Oral anticoagulants (OACs) are effective in reducing the risk of cardioembolic stroke due to atrial fibrillation. While most nursing home residents with atrial fibrillation qualify for anticoagulation based on clinical guidelines, the net clinical benefits of OACs may diminish as residents approach the end of life. METHODS: We conducted a cross-sectional study of 30,503 US nursing home residents with atrial fibrillation (based on Minimum Data Set 3.0 and Medicare Part A records) who used OACs in the year before enrolling in hospice care during 2012-2016. Whether residents discontinued OACs before hospice enrollment was determined using Part D claims and date of hospice enrollment. Modified Poisson models estimated adjusted prevalence ratios (aPR). RESULTS: Almost half (45.7%) of residents who had recent OAC use discontinued prior to hospice enrollment. Residents who were underweight (aPR: 1.02; 95% confidence interval [CI]: 1.01-1.03), those with high bleeding risk (aPR: 1.04, 95% CI: 1.03-1.05), and those with moderate or severe cognitive impairment (aPR: 1.02, 95% CI: 1.02-1.03) had a higher prevalence of OAC discontinuation before entering hospice. Residents with venous thromboembolism (aPR: 0.94, 95% CI: 0.93-0.96), statin users (aPR: 0.88, 95% CI: 0.87-0.89), and those on polypharmacy (≥10 medications, aPR: 0.72; 95% CI: 0.71-0.73) were less likely to discontinue OACs before enrollment in hospice. CONCLUSION: Anticoagulants are often discontinued among older nursing home residents with atrial fibrillation before hospice enrollment; it is not clear that these decisions are driven solely by net clinical benefit considerations. Further research is needed on comparative outcomes to inform resident-centered decisions regarding OAC use in older adults entering hospice.

Healthcare use in commercially insured youth with mental health disorders.

BACKGROUND: The objective of this study is to describe age-related patterns of outpatient healthcare utilization in youth and young adults with mental health disorders. METHOD: We used the IBM® MarketScan® Commercial Database to identify 359,413 youth and young adults (12-27 years) with a mental health disorder continuously enrolled in private health insurance in 2018. Exploratory analysis was used to describe patterns of outpatient healthcare use (e.g., primary, reproductive, mental health care) and therapeutic management (e.g., medication prescriptions, psychotherapy) by age. Period prevalence and median number of visits are reported. Additional analysis explored utilization patterns by mental health disorder. RESULTS: The prevalence of outpatient mental health care and primary care decreased with age, with a larger drop in primary care utilization. While 74.0-78.4% of those aged 12-17 years used both outpatient mental health care and primary care, 53.1-59.7% of those aged 18-27 years did. Most 18-19-year-olds had a visit with an internal medicine or family medicine specialist, a minority had a pediatrician visit. The prevalence of medication management increased with age, while the prevalence of psychotherapy decreased. CONCLUSIONS: Taken together, this descriptive study illustrates age-related differences in outpatient healthcare utilization among those with mental health disorders. Additionally, those with the most severe mental health disorders seem to be least connected to outpatient care. This knowledge can inform efforts to improve utilization of healthcare across the transition to adulthood.

Association of Socioeconomic Disadvantage With Long-term Mortality After Myocardial Infarction: The Mass General Brigham YOUNG-MI Registry.

Importance: Socioeconomic disadvantage is associated with poor health outcomes. However, whether socioeconomic factors are associated with post-myocardial infarction (MI) outcomes in younger patient populations is unknown. Objective: To evaluate the association of neighborhood-level socioeconomic disadvantage with long-term outcomes among patients who experienced an MI at a young age. Design, Setting, and Participants: This cohort study analyzed patients in the Mass General Brigham YOUNG-MI Registry (at Brigham and Women's Hospital and Massachusetts General Hospital in Boston, Massachusetts) who experienced an MI at or before 50 years of age between January 1, 2000, and April 30, 2016. Each patient's home address was mapped to the Area Deprivation Index (ADI) to capture higher rates of socioeconomic disadvantage. The median follow-up duration was 11.3 years. The dates of analysis were May 1, 2020, to June 30, 2020. Exposures: Patients were assigned an ADI ranking according to their home address and then stratified into 3 groups (least disadvantaged group, middle group, and most disadvantaged group). Main Outcomes and Measures: The outcomes of interest were all-cause and cardiovascular mortality. Cause of death was adjudicated from national registries and electronic medical records. Cox proportional hazards regression modeling was used to evaluate the association of ADI with all-cause and cardiovascular mortality. Results: The cohort consisted of 2097 patients, of whom 2002 (95.5%) with an ADI ranking were included (median [interquartile range] age, 45 [42-48] years; 1607 male individuals [80.3%]). Patients in the most disadvantaged neighborhoods were more likely to be Black or Hispanic, have public insurance or no insurance, and have higher rates of traditional cardiovascular risk factors such as hypertension and diabetes. Among the 1964 patients who survived to hospital discharge, 74 (13.6%) in the most disadvantaged group compared with 88 (12.6%) in the middle group and 41 (5.7%) in the least disadvantaged group died. Even after adjusting for a comprehensive set of clinical covariates, higher neighborhood disadvantage was associated with a 32% higher all-cause mortality (hazard ratio, 1.32; 95% CI, 1.10-1.60; P = .004) and a 57% higher cardiovascular mortality (hazard ratio, 1.57; 95% CI, 1.17-2.10; P = .003). Conclusions and Relevance: This study found that, among patients who experienced an MI at or before age 50 years, socioeconomic disadvantage was associated with higher all-cause and cardiovascular mortality even after adjusting for clinical comorbidities. These findings suggest that neighborhood and socioeconomic factors have an important role in long-term post-MI survival.

Physical Frailty and Cognitive Impairment in Older Adults in United States Nursing Homes.

INTRODUCTION: In older US nursing home (NH) residents, there is limited research on the prevalence of physical frailty, its potential dynamic changes, and its association with cognitive impairment in older adults' first 6 months of NH stay. METHODS: Minimum Data Set (MDS) 3.0 is the national database on residents in US Medicare-/Medicaid-certified NHs. MDS 3.0 was used to identify older adults aged ≥65 years, newly admitted to NHs during January 1, 2014, and June 30, 2016, with life expectancy ≥6 months at admission and NH length of stay ≥6 months (N = 571,139). MDS 3.0 assessments at admission, 3 months, and 6 months were used. In each assessment, physical frailty was measured by FRAIL-NH (robust, prefrail, and frail) and cognitive impairment by Brief Interview for Mental Status and Cognitive Performance Scale (none/mild, moderate, and severe). Demographic characteristics and diagnosed conditions were measured at admission, while presence of pain and receipt of psychotropic medications were at each assessment. Distribution of physical frailty and its change over time by cognitive impairment were described. A nonproportional odds model was fitted with a generalized estimation equation to longitudinally examine the association between physical frailty and cognitive impairment, adjusting for demographic and clinical characteristics. RESULTS: Around 60% of older residents were physically frail in the first 6 months. Improvement and worsening across physical frailty levels were observed. Particularly, in those who were prefrail at admission, 23% improved to robust by 3 months. At admission, 3 months, and 6 months, over 37% of older residents had severe cognitive impairment and about 70% of those with cognitive impairment were physically frail. At admission, older residents with moderate cognitive impairment were 35% more likely (adjusted odds ratio [aOR]: 1.35, 95% confidence interval [CI]: 1.33-1.37) and those with severe impairment were 74% more likely (aOR: 1.74, 95% CI: 1.72-1.77) to be frail than prefrail/robust, compared to those with none/mild impairment. The association between the 2 conditions remained positive and consistently increased over time. DISCUSSION/CONCLUSION: Physical frailty was prevalent in NHs with potential to improve and was strongly associated with cognitive impairment. Physical frailty could be a modifiable target, and interventions may include efforts to address cognitive impairment.

Geographic Variation of Statin Use Among US Nursing Home Residents With Life-limiting Illness.

BACKGROUND: Medically compromised nursing home residents continue to be prescribed statins, despite questionable benefits. OBJECTIVE: To describe regional variation in statin use among residents with life-limiting illness. RESEARCH DESIGN: Cross-sectional study using 2016 Minimum Data Set 3.0 assessments linked to Medicare administrative data and health service utilization area resource files. SETTING: Nursing homes (n=14,147) within hospital referral regions (n=306) across the United States. SUBJECTS: Long-stay residents (aged 65 y and older) with life-limiting illness (eg, serious illness, palliative care, or prognosis <6 mo to live) (n=361,170). MEASURES: Prevalent statin use was determined by Medicare Part D claims. Stratified by age (65-75, 76 y or older), multilevel logistic models provided odds ratios with 95% confidence intervals. RESULTS: Statin use was prevalent (age 65-75 y: 46.0%, 76 y or more: 31.6%). For both age groups, nearly all resident-level variables evaluated were associated with any and high-intensity statin use and 3 facility-level variables (ie, higher proportions of Black residents, skilled nursing care provided, and average number of medications per resident) were associated with increased odds of statin use. Although in residents aged 65-75 years, no associations were observed, residents aged 76 years or older located in hospital referral regions (HRRs) with the highest health care utilization had higher odds of statin use than those in nursing homes in HRRs with the lowest health care utilization. CONCLUSIONS: Our findings suggest extensive geographic variation in US statin prescribing across HRRs, especially for those aged 76 years or older. This variation may reflect clinical uncertainty given the largely absent guidelines for statin use in nursing home residents.

Disease Burden and Health-Related Quality of Life Among Women and Men with Spondyloarthritis: An Exploratory Analysis of a Population-Based Sample.

Objective: We described the burden of illness and health-related quality of life (HRQoL) in adults with spondyloarthritis (SpA) using a nationally representative sample. Materials and Methods: We identified participants with SpA using the Amor classification criteria (probable: score 5 or definite: ≥6) and complete data on HRQoL from the 2009 to 2010 National Health and Nutrition Examination Survey (n = 231). HRQoL was measured using the Healthy Days Measures including self-rated health status (excellent/very good, good, fair/poor), number of activity-restricted days, and number of unhealthy mental and physical health days in the past month (range: 0-30). Other domains including clinical assessments, comorbidities, physical functioning, and medication use were also explored. Results: Only 39% of the sample met the Amor criteria for definite SpA. Although 58% of those with definite SpA had seen a doctor >3 times in the past year, 2.5% women and 4.1% men had ever been told by a physician that they have ankylosing spondylitis. Among those with definite SpA, racial/ethnic diversity was observed in women (13.6% non-Hispanic Black, 23.2% Hispanic) and men (11.6% non-Hispanic Black, 11.2% Hispanic). Overall, 41.6% women and 49.7% men rated their health as fair/poor. For other HRQoL measures, 25.4% women and 20.4% men reported ≥15 activity-restricted days and 39.7% women and 41.4% men reported ≥15 physically unhealthy days. Conclusion: Both men and women rank health as poor with indications that it affects QoL. Although our small sample size limits definitive statements, we observed trends that warrant further confirmation in larger population-based samples.

Geographic Variation in Anticoagulant Use and Resident, Nursing Home, and County Characteristics Associated With Treatment Among US Nursing Home Residents.

OBJECTIVES: To quantify geographic variation in anticoagulant use and explore what resident, nursing home, and county characteristics were associated with anticoagulant use in a clinically complex population. DESIGN: A repeated cross-sectional design was used to estimate current oral anticoagulant use on December 31, 2014, 2015, and 2016. SETTING AND PARTICIPANTS: Secondary data for United States nursing home residents during the period 2014-2016 were drawn from the Minimum Data Set 3.0 and Medicare Parts A and D. Nursing home residents (≥65 years) with a diagnosis of atrial fibrillation and ≥6 months of Medicare fee-for-service enrollment were eligible for inclusion. Residents in a coma or on hospice were excluded. METHODS: Multilevel logistic models evaluated the extent to which variation in anticoagulant use between counties could be explained by resident, nursing home, and county characteristics and state of residence. Proportional changes in cluster variation (PCVs), intraclass correlation coefficients (ICCs), and adjusted odds ratios (aORs) were estimated. RESULTS: Among 86,736 nursing home residents from 11,860 nursing homes and 1694 counties, 45% used oral anticoagulants. The odds of oral anticoagulant use were 18% higher in 2016 than 2014 (aOR: 1.18; 95% confidence interval: 1.14-1.22). Most states had counties in the highest (51.3-58.9%) and lowest (31.1%-41.4%) deciles of anticoagulant use. Compared with the null model, adjustment for resident characteristics explained one-third of the variation between counties (PCV: 34.8%). The full model explained 65.5% of between-county variation. Within-county correlation was a small proportion (ICC < 2.2%) of total variation. CONCLUSIONS AND IMPLICATIONS: In this older adult population at high risk for ischemic stroke, less than half of the residents received treatment with anticoagulants. Variation in treatment across counties was partially attributable to the characteristics of residents, nursing homes, and counties. Comparative evidence and refinement of predictive algorithms specific to the nursing home setting may be warranted.

Statin Discontinuation and Life-Limiting Illness in Non-Skilled Stay Nursing Homes at Admission.

OBJECTIVES: To estimate 30-day statin discontinuation among newly admitted nursing home residents overall and within categories of life-limiting illness. DESIGN: Retrospective cohort using Minimum Data Set 3.0 nursing home admission assessments from 2015 to 2016 merged to Medicare administrative data files. SETTING: U.S. Medicare- and Medicaid-certified nursing home facilities (n = 13,092). PARTICIPANTS: Medicare fee-for-service beneficiaries, aged 65 years and older, newly admitted to nursing homes for non-skilled nursing facility stays on statin pharmacotherapy at the time of admission (n = 73,247). MEASUREMENTS: Residents were categorized using evidence-based criteria to identify progressive, terminal conditions or limited prognoses (<6 months). Discontinuation was defined as the absence of a new Medicare Part D claim for statin pharmacotherapy in the 30 days following nursing home admission. RESULTS: Overall, 19.9% discontinued statins within 30 days of nursing home admission, with rates that varied by life-limiting illness classification (no life-limiting illness: 20.5%; serious illness: 18.6%; receipt of palliative care consult: 34.5%; clinician designated as end-of-life: 45.0%). Relative to those with no life-limiting illness, risk of 30-day statin discontinuation increased with life-limiting illness severity (serious illness: adjusted risk ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02-1.10; palliative care index diagnosis: aRR = 1.15; 95% CI = 1.10-1.21; palliative care consultation: aRR = 1.58; 95% CI = 1.43-1.74; clinician designated as end of life: aRR = 1.59; 95% CI = 1.42-1.79). Nevertheless, most remained on statins after entering the nursing home regardless of life-limiting illness status. CONCLUSION: Statin use continues in a large proportion of Medicare beneficiaries after admission to a nursing home. Additional deprescribing research, which identifies how to engage nursing home residents and healthcare providers in a process to safely and effectively discontinue medications with questionable benefits, is warranted.

The Prevalence and Factors Associated with Antiepileptic Drug Use in US Nursing Home Residents.

BACKGROUND: Antiepileptic drugs (AEDs) are commonly used by nursing home residents, both on- and off-label. The landscape of AED use has changed over the past two decades; however, despite this, contemporaneous research on AED use in US nursing home residents is scant. OBJECTIVE: The aim of this study was to estimate the prevalence of AED use, describe prescribing patterns, identify factors associated with AED use, and assess whether these factors differ among AEDs with expanded indications in older adults (i.e. gabapentin, pregabalin, topiramate, and lamotrigine). METHODS: We conducted a cross-sectional study among 549,240 long-stay older residents who enrolled in fee-for-service Medicare and lived in 15,111 US nursing homes on 1 September 2016. Demographics and conditions associated with AED indications, epilepsy comorbidities, and safety data came from the Minimum Data Set Version 3.0 (MDS 3.0). Medicare Part D claims were used to identify AED use. Robust Poisson models and multinomial logistic models for clustered data estimated adjusted prevalence ratios (aPR), adjusted odds ratios (aOR), and 95% confidence intervals (CIs). RESULTS: Overall, 24.0% used AEDs (gabapentin [13.3%], levetiracetam [4.7%], phenytoin [1.9%], pregabalin [1.8%], and lamotrigine [1.2%]). AED use was associated with epilepsy (aPR 3.73, 95% CI 3.69-3.77), bipolar disorder (aPR 1.20, 95% CI 1.18-1.22), pain (aPRmoderate/severe vs. no pain 1.42, 95% CI 1.40-1.44), diabetes (aPR 1.27, 95% CI 1.26-1.28), anxiety (aPR 1.12, 95% CI 1.11-1.13), depression (aPR 1.17, 95% CI 1.15-1.18), or stroke (aPR 1.08, 95% CI 1.06-1.09). Residents with advancing age (aPR85+ vs. 65-74 years 0.73, 95% CI 0.73-0.74), Alzheimer's disease/dementia (aPR 0.87, 95% CI 0.86-0.88), or cognitive impairment (aPRsevere vs. no impairment 0.62, 95% CI 0.61-0.63) had decreased AED use. Gabapentinoid use was highly associated with pain (aORmoderate/severe vs. no pain 2.07, 95% CI 2.01-2.12) and diabetes (aOR 1.79, 95% CI 1.76-1.82), but not with an epilepsy indication. CONCLUSIONS: AED use was common in nursing homes, with gabapentin most commonly used (presumably for pain). That multiple comorbidities were associated with AED use underscores the need for future studies to investigate the safety and effectiveness of AED use in nursing home residents.

Reach Out Churches: A Community-Based Participatory Research Pilot Trial to Assess the Feasibility of a Mobile Health Technology Intervention to Reduce Blood Pressure Among African Americans.

Innovative strategies are needed to reduce the hypertension epidemic among African Americans. Reach Out was a faith-collaborative, mobile health, randomized, pilot intervention trial of four mobile health components to reduce high blood pressure (BP) compared to usual care. It was designed and tested within a community-based participatory research framework among African Americans recruited and randomized from churches in Flint, Michigan. The purpose of this pilot study was to assess the feasibility of the Reach Out processes. Feasibility was assessed by willingness to consent (acceptance of randomization), proportion of weeks participants texted their BP readings (intervention use), number lost to follow-up (retention), and responses to postintervention surveys and focus groups (acceptance of intervention). Of the 425 church members who underwent BP screening, 94 enrolled in the study and 73 (78%) completed the 6-month outcome assessment. Median age was 58 years, and 79% were women. Participants responded with their BPs on an average of 13.7 (SD = 10.7) weeks out of 26 weeks that the BP prompts were sent. All participants reported satisfaction with the intervention. Reach Out, a faith-collaborative, mobile health intervention was feasible. Further study of the efficacy of the intervention and additional mobile health strategies should be considered.

Stroke Quality Measures in Mexican Americans and Non-Hispanic Whites.

Mexican Americans (MAs) have been shown to have worse outcomes after stroke than non-Hispanic Whites (NHWs), but it is unknown if ethnic differences in stroke quality of care may contribute to these worse outcomes. We investigated ethnic differences in the quality of inpatient stroke care between MAs and NHWs within the population-based prospective Brain Attack Surveillance in Corpus Christi (BASIC) Project (February 2009- June 2012). Quality measures for inpatient stroke care, based on the 2008 Joint Commission Primary Stroke Center definitions were assessed from the medical record by a trained abstractor. Two summary measure of overall quality were also created (binary measure of defect-free care and the proportion of measures achieved for which the patient was eligible). 757 individuals were included (480 MAs and 277 NHWs). MAs were younger, more likely to have hypertension and diabetes, and less likely to have atrial fibrillation than NHWs. MAs were less likely than NHWs to receive tPA (RR: 0.72, 95% confidence interval (CI) 0.52, 0.98), and MAs with atrial fibrillation were less likely to receive anticoagulant medications at discharge than NHWs (RR 0.73, 95% CI 0.58, 0.94). There were no ethnic differences in the other individual quality measures, or in the two summary measures assessing overall quality. In conclusion, there were no ethnic differences in the overall quality of stroke care between MAs and NHWs, though ethnic differences were seen in the proportion of patients who received tPA and anticoagulant at discharge for atrial fibrillation.

Physical education policy compliance and Latino children's fitness: Does the association vary by school neighborhood socioeconomic advantage?

OBJECTIVES: To investigate the contribution of school neighborhood socioeconomic advantage to the association between school-district physical education policy compliance in California public schools and Latino students' physical fitness. METHODS: Cross-sectional Fitnessgram data for public-school students were linked with school- and district-level information, district-level physical education policy compliance from 2004-2005 and 2005-2006, and 2000 United States Census data. Multilevel logistic regression models examined whether income and education levels in school neighborhoods moderated the effects of district-level physical education policy compliance on Latino fifth-graders' fitness levels. RESULTS: Physical education compliance data were available for 48 California school districts, which included 64,073 Latino fifth-graders. Fewer than half (23, or 46%) of these districts were found to be in compliance, and only 16% of Latino fifth-graders attended schools in compliant districts. Overall, there was a positive association between district compliance with physical education policy and fitness (OR, 95%CI: 1.38, 1.07, 1.78) adjusted for covariates. There was no significant interaction between school neighborhood socioeconomic advantage and physical education policy compliance (p>.05): there was a positive pattern in the association between school district compliance with physical education policy and student fitness levels across levels of socioeconomic advantage, though the association was not always significant. CONCLUSIONS: Across neighborhoods with varying levels of socioeconomic advantage, increasing physical education policy compliance in elementary schools may be an effective strategy for improving fitness among Latino children.

Differential associations between the food environment near schools and childhood overweight across race/ethnicity, gender, and grade.

Epidemiologic studies have observed influences of the food environment near schools on children's overweight status but have not systematically assessed the associations by race, sex, and grade. The authors examined whether the associations between franchised fast food restaurant or convenience store density near schools and overweight varied by these factors using data for 926,018 children (31.3% white, 55.1% Hispanic, 5.7% black, and 8% Asian) in fifth, seventh, or ninth grade, nested in 6,362 schools. Cross-sectional data were from the 2007 California physical fitness test (also known as "Fitnessgram"), InfoUSA, the California Department of Education, and the 2000 US Census. In adjusted models, the overweight prevalence ratio comparing children in schools with 1 or more versus 0 fast food restaurants was 1.02 (95% confidence interval (CI): 1.01, 1.03), with a higher prevalence ratio among girls compared with boys. The association varied by student's race/ethnicity (P = 0.003): Among Hispanics, the prevalence ratio = 1.02 (95% CI: 1.01, 1.03); among blacks, the prevalence ratio = 1.03 (95% CI: 1.00, 1.06), but among Asians the prevalence ratio = 0.94 (95% CI: 0.91, 0.97). For each additional convenience store, the prevalence ratio was 1.01 (95% CI: 1.00, 1.01), with a higher prevalence ratio among fifth grade children. Nuanced understanding of the impact of food environments near schools by race/ethnicity, sex, and grade may help to elucidate the etiology of childhood overweight and related race/ethnic disparities.

Physical education policy compliance and children's physical fitness.

BACKGROUND: Physical education policies have received increased attention as a means for improving physical activity levels, enhancing physical fitness, and contributing to childhood obesity prevention. Although compliance at the school and district levels is likely to be critical for the success of physical education policies, few published studies have focused on this issue. PURPOSE: This study investigated whether school district-level compliance with California physical education policies was associated with physical fitness among 5th-grade public-school students in California. METHODS: Cross-sectional data from FITNESSGRAM(®) 2004-2006, district-level compliance with state physical education requirements for 2004-2006, school- and district-level information, and 2000 U.S. Census data were combined to examine the association between district-level compliance with physical education policies and children's fitness levels. The analysis was completed in 2010. RESULTS: Of the 55 districts with compliance data, 28 (50%) were in compliance with state physical education mandates; these districts represented 21% (216) of schools and 18% (n=16,571) of students in the overall study sample. Controlling for other student-, school-, and district-level characteristics, students in policy-compliant districts were more likely than students in noncompliant districts to meet or exceed physical fitness standards (AOR=1.29, 95% CI=1.03, 1.61). CONCLUSIONS: Policy mandates for physical education in schools may contribute to improvements in children's fitness levels, but their success is likely to depend on mechanisms to ensure compliance.