Sweetened Beverage Tax Implementation and Change in Body Mass Index Among Children in Seattle.

Importance: Sweetened beverage taxes have been associated with reduced purchasing of taxed beverages. However, few studies have assessed the association between sweetened beverage taxes and health outcomes. Objective: To evaluate the association between the Seattle sweetened beverage tax and change in body mass index (BMI) among children. Design, Setting, and Participants: In this longitudinal cohort study, anthropometric data were obtained from electronic medical records of 2 health care systems (Kaiser Permanente Washington [KP] and Seattle Children's Hospital Odessa Brown Children's Clinic [OBCC]). Children were included in the study if they were aged 2 to 18 years (between January 1, 2014, and December 31, 2019); had at least 1 weight measurement every year between 2015 and 2019; lived in Seattle or in urban areas of 3 surrounding counties (King, Pierce, and Snohomish); had not moved between taxed (Seattle) and nontaxed areas; received primary health care from KP or OBCC; did not have a recent history of cancer, bariatric surgery, or pregnancy; and had biologically plausible height and BMI (calculated as weight in kilograms divided by height in meters squared). Data analysis was conducted between August 5, 2022, and March 4, 2024. Exposure: Seattle sweetened beverage tax (1.75 cents per ounce on sweetened beverages), implemented on January 1, 2018. Main Outcomes and Measures: The primary outcome was BMIp95 (BMI expressed as a percentage of the 95th percentile; a newly recommended metric for assessing BMI change) of the reference population for age and sex, using the Centers for Disease Control and Prevention growth charts. In the primary (synthetic difference-in-differences [SDID]) model used, a comparison sample was created by reweighting the comparison sample to optimize on matching to pretax trends in outcome among 6313 children in Seattle. Secondary models were within-person change models using 1 pretax measurement and 1 posttax measurement in 22 779 children and fine stratification weights to balance baseline individual and neighborhood-level confounders. Results: The primary SDID analysis included 6313 children (3041 female [48%] and 3272 male [52%]). More than a third of children (2383 [38%]) were aged 2 to 5 years); their mean (SE) age was 7.7 (0.6) years. With regard to race and ethnicity, 789 children (13%) were Asian, 631 (10%) were Black, 649 (10%) were Hispanic, and 3158 (50%) were White. The primary model results suggested that the Seattle tax was associated with a larger decrease in BMIp95 for children living in Seattle compared with those living in the comparison area (SDID: -0.90 percentage points [95% CI, -1.20 to -0.60]; P < .001). Results from secondary models were similar. Conclusions and Relevance: The findings of this cohort study suggest that the Seattle sweetened beverage tax was associated with a modest decrease in BMIp95 among children living in Seattle compared with children living in nearby nontaxed areas who were receiving care within the same health care systems. Taken together with existing studies in the US, these results suggest that sweetened beverage taxes may be an effective policy for improving children's BMI. Future research should test this association using longitudinal data in other US cities with sweetened beverage taxes.

Sugar-sweetened beverage intake and convenience store shopping as mediators of the food insecurity-Tooth decay relationship among low-income children in Washington state.

INTRODUCTION: There are oral health disparities in the U.S. and children in food-insecure households have a higher burden of tooth decay. Identifying the mechanisms underlying the food insecurity-tooth decay relationship could inform public health interventions. This study examined how sugar-sweetened beverage (SSB) intake and frequent convenience store shopping mediated the food insecurity-tooth decay relationship for lower-income children. MATERIALS AND METHODS: Cross-sectional study data included a household survey, beverage questionnaire, and dental examination. The sample included 452 lower-income, racially-diverse, child-caregiver dyads in 2018 from King County in Washington state. The exposure was household food insecurity, the outcome was untreated decayed tooth surfaces, and the proposed mediators were SSB intake and frequent convenience store shopping (≥2 times/week). Causal mediation analyses via the potential outcomes framework was used to estimate natural indirect and direct effects. RESULTS: Fifty-five percent of participants were in food-insecure households, the mean number of decayed tooth surfaces among children was 0.87 (standard deviation [SD] = 1.99), the mean SSB intake was 17 fluid ounces (fl/oz)/day (SD = 35), and 18% of households frequently shopped at a convenience store. After adjusting for confounders, household food insecurity and log-transformed SSB intake (fluid ounces/day) were positively associated with decayed tooth surfaces, but not at the a α = 0.05 level (mean ratio [MR] 1.60; 95% confidence interval [CI] 0.89, 2.88; p = .12 and MR 1.16; 95% CI 0.93, 1.46; p = .19, respectively). Frequent convenience store shopping was associated with 2.75 times more decayed tooth surfaces (95% CI 1.61, 4.67; p < .001). SSB intake mediated 10% of the food insecurity-tooth decay relationship (p = .35) and frequent convenience store shopping mediated 22% (p = .33). CONCLUSIONS: Interventions aimed at addressing oral health disparities in children in food-insecure households could potentially focus on reducing intake of SSBs and improving access to healthful foods in lower-income communities.

Seattle's sweetened beverage tax implementation and changes in interior marketing displays.

Policymakers aim sugar-sweetened beverage (SSB) taxes at decreasing SSB consumption; however, little is known about their impact on beverage marketing in the retail environment. We assessed changes in interior marketing displays within large food stores before and after the implementation of Seattle's SSB tax. We used Poisson difference-in-difference (DID) models to estimate whether presence and variety of interior beverage marketing displays in Seattle changed from before to after the tax compared to displays in non-taxed comparison area stores, overall, and by beverage type. We found no significant changes in overall SSB or non-SSB interior marketing displays in Seattle versus the comparison area. There was less of an increase in displays for diet soda (DID 0.79, 90% CI 0.65, 0.97), and more of an increase in displays for diet energy drinks (DID 1.78, 90% CI 1.03, 3.09) in Seattle versus comparison area. There was mixed evidence that stores changed interior marketing displays in response to the SSB tax.

Changes in Precarious Employment and Health in the United States Amidst the COVID-19 Pandemic.

This study aimed to investigate the association between changes in employment precarity and changes in health amidst the COVID-19 pandemic. We conducted an online survey of 623 U.S. adults at-risk for cardiovascular disease, which queried respondents on employment, food insecurity, and blood pressure measurements in the Fall of 2020 and retrospectively, in February 2020. Respondents were also queried on perceived stress in the Fall of 2020. We created a multidimensional precarious employment score (PES) using 13 survey indicators, that operationalized the following dimensions of employment precarity (PES range: 0-13): material rewards, working time arrangements, employment stability, workers' rights, collective organization, interpersonal relations, and training opportunities. Using adjusted linear regression models, we investigated the association between a change in the PES and 1) change in systolic blood pressure, 2) change in pulse pressure, 3) change in food insecurity, and 4) perceived stress. Models controlled for race/ethnicity, age, gender, and education. Results indicated that employment precarity was 13 % higher between February and Fall 2020, particularly among women and non-Hispanic Black respondents. A change in the PES was associated with a change in food insecurity ( ß : 0.02; 95 % CI:0.01, 0.03) and higher perceived stress ( ß : 0.39; 95 % CI:0.25, 0.53). The PES was not associated with a change in systolic blood pressure ( ß : -0.22; 95 % CI:-0.76, 0.32) nor in pulse pressure ( ß : -0.33; 95 % CI: -0.73, 0.07). Policy approaches to mitigate the growth in employment precarity, and in turn food insecurity and stress, warrant consideration to prevent widening of health inequities.

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.

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

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

Evaluation of Seattle's sweetened beverage tax on tax support and perceived economic and health impacts.

It is important to understand whether the publics' attitudes towards sugary beverage taxes (SBT) change after tax implementation to ensure the long-term success of tax policies. Seattle's SBT went into effect on January 1, 2018. We administered a mixed-mode survey to adults in Seattle and comparison areas, pre- and 2-years post-tax, to evaluate the impact of the SBT on 1) tax support and 2) perceived tax impacts (N = 2,933). Using a difference-in-differences approach, we employed adjusted income-stratified modified Poisson models to test the impacts of the tax on net changes in attitudes in Seattle versus the comparison areas, pre- to post-tax. Among lower-income individuals in Seattle, support for the tax increased by 14% (PRDD: 1.14; 95% CI: 1.08, 1.21) and there was a 20% net-increase in the perception that the SBT would positively affect the economy (PRDD: 1.20; 95% CI: 1.05, 1.39), compared to changes in the comparison areas. Among higher-income individuals in Seattle, support for the tax was not different (PRDD: 0.93; 95% CI: 0.70, 1.22) pre- to post-tax, but there was a net-increase in the perception that the tax would have negative effects on small businesses (PRDD: 1.44; 95% CI: 1.03, 2.00) and family finances (PRDD: 1.86; 95% CI: 1.09, 3.19). After living with the tax for 2-years, support for the tax increased among lower-income individuals in Seattle. Tax support was high and unchanged among higher-income individuals, but overall attitudes became more negative. Policy makers should consider investing in ongoing campaigns that explain the benefits of SSB taxes and revenues.

Impacts of the Seattle Sweetened Beverage Tax on the Perceived Healthfulness of Sweetened Beverages.

Sweetened beverage taxes are associated with significant reductions in the purchase of sweetened beverages. However, it is unclear whether these taxes play a role in shifting perceptions about sweetened beverages and their health impacts. We utilized pre- and post-tax survey data collected from residents in Seattle, WA, a city that implemented a sweetened beverage tax in 2018 and from residents in an untaxed comparison area. We used income-stratified difference-in-difference linear probability models to compare net changes in the perceived healthfulness of overall sweetened beverage consumption and of different types of sugary beverages over time and across income groups. We found significant increases in the percentage of Seattle respondents with lower incomes who agreed that sweetened beverage consumption raises the risk of diabetes (DD = 9 percentage points (pp) (95% CI: 5 pp, 13 pp); p = 0.002), heart disease (DD = 7 pp (95% CI: 2 pp, 12 pp); p = 0.017), and serious health problems (DD = 12 pp (95% CI: 5 pp, 19 pp); p = 0.009), above and beyond changes in the comparison area. The most prominent changes in perceived health impacts of sweetened beverages were found among lower-income Seattle respondents, while fewer changes were found among higher-income Seattle respondents. Future work could examine the relationship between exposure to pro-tax messaging and changes in consumer perceptions of sweetened beverages.

Menu Labeling Utilization and Socioeconomic Status in West Virginia and Mississippi.

OBJECTIVE: Determine the association between socioeconomic status and self-reported noticing and using calorie menu labels in 2 states with high poverty and obesity. DESIGN: Cross-sectional study of responses to the 2016 Behavioral Risk Factor Surveillance System Menu Labeling Module. PARTICIPANTS: Representative sample of noninstitutionalized adults aged ≥ 18 years in West Virginia and Mississippi (n = 9,469). MAIN OUTCOME MEASURES: The outcomes were reported noticing and using menu labels to make decisions at fast-food restaurants. Independent variables were highest attained education and federal poverty level (% FPL). ANALYSIS: Generalized linear models estimated prevalence ratios for noticing and using menu labels. Models mutually adjusted for education, % FPL, age, sex, race/ethnicity, and body mass index. RESULTS: Eighty-six percent of respondents reported noticing, and 56% reported using menu labels. Compared with individuals with less than high school education, college graduates were 11% more likely to report noticing (95% confidence interval, 1.06-1.18; P < 0.001) and 18% more likely to report using (95% confidence interval, 1.06-1.30; P < 0.01) menu labels. Patterns were similar for % FPL. CONCLUSIONS AND IMPLICATIONS: These data support further investigation of menu labels among subgroups and a larger geographic scope. Limitations of the menu labeling module question and the cross-sectional nature of the existing literature warrant additional research.

Sweetened beverage taxes: Economic benefits and costs according to household income.

Taxing sweetened beverages has emerged as an important and effective policy for addressing their overconsumption. However, taxes may place a greater economic burden on people with lower incomes. We assess the degree to which sweetened beverage taxes in three large US cities placed an inequitable burden on populations with lower incomes by assessing spending on beverage taxes by income after taxes have been implemented, as well as any net transfer of funds towards lower income populations once allocation of tax revenue is considered. We find that while lower income populations pay a higher percentage of their income in beverage taxes, there is no difference in absolute spending on beverage taxes per capita, and that there is a sizable net transfer of funds towards programs targeting lower income populations. Thus, when considering both population-level taxes paid and sufficiently targeted allocations of tax revenues, a sweetened beverage tax may have characteristics of an equitable public policy.

Qualitative Study on Participant Perceptions of a Supermarket Fruit and Vegetable Incentive Program.

BACKGROUND: Complete Eats Rx is a fruit and vegetable prescription program designed to incentivize fruit and vegetable consumption among Supplemental Nutrition Assistance Program (SNAP) participants via $10 incentives distributed either weekly or per encounter to purchase fruits and vegetables at a mid-price supermarket chain in Washington State. OBJECTIVE: To better understand SNAP participants' experience, and to determine perceived impacts and consequences of the program. DESIGN: Qualitative analysis of nine photovoice sessions. Participants chose the topics for discussion. Sessions were audiorecorded and transcribed. Thematic content analysis was performed to identify key emergent themes using Atlas.ti. SETTING: Spokane, Seattle, and Yakima, Washington. PARTICIPANTS: Twenty-six individuals who received a fruit and vegetable prescription within the past 6 months, 23 of whom attended all three photovoice sessions offered at their site. Participants were recruited from three participating health care or public health organizations in Spokane, Seattle, and Yakima, Washington. ANALYSIS: Transcriptions were coded using inductive methods. Coded statements were organized into major themes. Coding structures and analysis were strengthened by iterative interactions between researchers. RESULTS: Participants reported Complete Eats Rx was an important resource for families and improved food security, diet quality, and the ability to purchase healthy foods, including a greater variety of fruits and vegetables. Primary barriers to food security and fruit and vegetable consumption included limited geographic accessibility and the high cost of fruits and vegetables, exacerbated by other financial constraints such as rising housing costs. Participants reported supermarket checkout difficulty because of embarrassment, stigmatization, and inability to redeem incentives. The most frequently mentioned barrier to perceived program acceptability was having only one supermarket chain as the acceptor of the incentive. CONCLUSION: Partnering with supermarkets to accept fruit and vegetable incentives is a unique strategy to increase produce purchasing that can be adopted by other localities. Focus on geographic accessibility, appropriate price points, and positive shopping experiences via expansion to local grocers, improvements in staff interactions, and a transition to an electronic system may improve incentive redemption and usability.

Impact of a sweetened beverage tax on beverage prices in Seattle, WA.

Seattle's Sweetened Beverage Tax is an excise tax of 1.75 cents per ounce on sugar-sweetened beverages and is one of the highest beverage taxes in the U.S. This study examined the impact of Seattle's tax on the prices of beverages. We conducted audits of 407 retail food stores and eating places (quick service restaurants and coffee shops) before and 6 months after the tax was implemented in Seattle and in a comparison area. Ordinary least squares difference-in-differences models with store fixed effects were used to estimate the effect of the tax on prices, stratified by beverage type and store type. In secondary analyses, we assessed the effect of the tax on the price of non-taxed beverages and foods. Results from the adjusted difference-in-differences models indicated the tax was associated with an average increase of 1.58 cents per ounce among Seattle retailers, representing 90 % of the price of the tax. By store type, price increases were highest in smaller grocery stores and drug stores. By beverage type, price increases were highest for energy beverages and soda and lowest for bottled coffee and juice drinks. Prices of some non-taxed beverages also increased while the prices of select healthy foods generally did not. The sweetened beverage tax in Seattle is higher than beverage taxes in most other cities, and nearly the full cost of the tax is being passed through to consumers for many beverage types and stores types.

Are Housing Prices Associated with Food Consumption?

OBJECTIVE: Since January 2010, the U.S. has experienced economic recovery, including a 39% increase in home prices nationally. While higher home prices represent a wealth increase for some homeowners, it may decrease real purchasing power for others. The objective of this study is to examine the relationship between local area housing values and consumption of four food categories. DESIGN: Observational study using data from the Behavioral Risk Factor Surveillance System between 2011 and 2015. Outcomes included number of times per week food was consumed and binary measures denoting consumption ≥2 times per day for four categories: vegetables, fruit, legumes and fruit juice. The primary explanatory variables were metropolitan/micropolitan statistical area home and rental price indices from Zillow. Differential associations by home ownership, age, race/ethnicity and education were examined. RESULTS: Overall, housing values were not associated with intake of vegetables or fruit juice. Among homeowners, a $10,000 increase in home price was associated with small, but statistically significant reductions in fruit and legume consumption. These inverse associations were pronounced among Hispanic and non-Hispanic Black adults. CONCLUSIONS: Lower fruit and legume consumption associated with greater housing values may represent one of several explanations including a decrease in purchasing power, given increases in home prices and limited wage growth since 2010.

Unemployment during the Great Recession and large-for-gestational age births.

BACKGROUND: Several studies have suggested that record high unemployment during the Great Recession was associated with deleterious changes in diet and weight-related health. However, studies have yet to explore whether the Great Recession was also associated with obesity-related health in utero. METHODS: We investigated whether increasing county-level unemployment was associated with large-for-gestational age (LGA) births, using repeated cross-sectional data from California birth records between 2008 and 2011 (n = 1,715,052). LGA was defined as >90th percentile, using the Oken reference. We use the annual 1-year lagged value for county-level unemployment (2007-2010) and limit our analyses to singleton, term births. Linear probability models, with county and year fixed-effects were used to examine the unemployment-LGA association. All models control for county-level foreclosure rates, child gender, and maternal age, parity, education, and race/ethnicity. RESULTS: An increase in county-level unemployment was not statistically significantly associated with the prevalence of LGA (percentage point [PP]: 0.12; 95% CI: -0.02, 0.25). But, over the period of observation, for every one standard deviation increase in unemployment, LGA prevalence increased by 5% and p = 0.08. CONCLUSIONS: These results cautiously suggest some deleterious effects of the Great Recession on obesity-related health in utero.

Differences in magnitude and rates of change in BMI distributions by socioeconomic and geographic factors in Mexico, Colombia, and Peru, 2005-2010.

BACKGROUND/OBJECTIVES: Previous studies about obesity and its associated factors in low- and middle-income countries have been based mostly on women of reproductive age. Furthermore, disproportionally changing BMI distributions have been a challenge for its appropriate modeling. In this context, we assessed the magnitude and rate of change in BMI distribution by socioeconomic and geographic factors in both sexes in Latin American countries, modeling the shape of BMI distributions. SUBJECTS/METHODS: We used data from national surveys conducted in Mexico, Colombia, and Peru at two time points between 2005 and 2013 (N = 57,414, 13,5403, and 30,811, respectively). We estimated shapes of BMI distributions for 2005 and 2010, and assessed their changes, using the generalized additive model for location, scale, and shape (GAMLSS), in which BMI was assumed to follow a Box-Cox Power Exponential (BCPE) distribution. RESULTS: In all the three countries, higher education was negatively associated with BMI in women but somewhat positive in men; and household wealth was positively associated in men but not in women. Lower household wealth was associated with higher rates of change in BMI distributions in women. CONCLUSION: Education and household wealth were associated with BMI distributions and their change over time. Observed sex differences in these associations have implications for designing relevant policies and programs to approach target populations effectively. The BCPE-GAMLSS method can provide a useful visual assessment of time-varying measures.

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

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

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

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

The neighborhood environment and obesity: Understanding variation by race/ethnicity.

Neighborhood characteristics have been associated with obesity, but less is known whether relationships vary by race/ethnicity. This study examined the relationship between soda consumption - a behavior strongly associated with obesity - and weight status with neighborhood sociodemographic, social, and built environments by race/ethnicity. We merged data on adults from the 2011-2013 California Health Interview Survey, U.S. Census data, and InfoUSA (n=62,396). Dependent variables were soda consumption and weight status outcomes (body mass index and obesity status). Main independent variables were measures of three neighborhood environments: social (social cohesion and safety), sociodemographic (neighborhood socioeconomic status, educational attainment, percent Asian, percent Hispanic, and percent black), and built environments (number of grocery stores, convenience stores, fast food restaurants, and gyms in neighborhood). We fit multi-level linear and logistic regression models, stratified by individual race/ethnicity (NH (non-Hispanic) Whites, NH African Americans, Hispanics, and NH Asians) controlling for individual-level characteristics, to estimate neighborhood contextual effects on study outcomes. Lower neighborhood educational attainment was associated with higher odds of obesity and soda consumption in all racial/ethnic groups. We found fewer associations between study outcomes and the neighborhood, especially the built environment, among NH African Americans and NH Asians. While improvements to neighborhood environment may be promising to reduce obesity, null associations among minority subgroups suggest that changes, particularly to the built environment, may alone be insufficient to address obesity in these groups.

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

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

Breakfast Consumption Frequency and Its Relationships to Overall Diet Quality, Using Healthy Eating Index 2010, and Body Mass Index among Adolescents in a Low-Income Urban Setting.

The aim of this study was to describe the relationship of breakfast frequency to diet quality and BMI among low-income, predominantly African American adolescents aged 9-15 (n = 239). Mean frequency of breakfast consumption was 5.0 ± 0.15 times per week. A significant, positive relationship was seen between HEI scores and frequency of breakfast consumption (p = .01). Dairy (p = .02) and whole grains (p < .01) HEI component scores were significantly related to breakfast frequency. No relationship was seen between breakfast frequency and BMI. Research with more rigorous designs should be conducted to assess the potential effects of breakfast consumption on diet quality in this population.