Review of measures of worksite environmental and policy supports for physical activity and healthy eating.

INTRODUCTION: Obesity prevention strategies are needed that target multiple settings, including the worksite. The objective of this study was to assess the state of science concerning available measures of worksite environmental and policy supports for physical activity (PA) and healthy eating (HE). METHODS: We searched multiple databases for instruments used to assess worksite environments and policies. Two commonly cited instruments developed by state public health departments were also included. Studies that were published from 1991 through 2013 in peer-reviewed publications and gray literature that discussed the development or use of these instruments were analyzed. Instrument administration mode and measurement properties were documented. Items were classified by general health topic, 5 domains of general worksite strategy, and 19 subdomains of worksite strategy specific to PA or HE. Characteristics of worksite measures were described including measurement properties, length, and administration mode, as well as frequencies of items by domain and subdomain. RESULTS: Seventeen instruments met inclusion criteria (9 employee surveys, 5 manager surveys, 1 observational assessment, and 2 studies that used multiple administration modes). Fourteen instruments included reliability testing. More items were related to PA than HE. Most instruments (n = 10) lacked items in the internal social environment domain. The most common PA subdomains were exercise facilities and lockers/showers; the most common HE subdomain was healthy options/vending. CONCLUSION: This review highlights gaps in measurement of the worksite social environment. The findings provide a useful resource for researchers and practitioners and should inform future instrument development.

Behavior-over-time graphs: assessing perceived trends in healthy eating and active living environments and behaviors across 49 communities.

CONTEXT: In the evaluation of the Healthy Kids, Healthy Communities initiative, investigators implemented Group Model Building (GMB) to promote systems thinking at the community level. As part of the GMB sessions held in each community partnership, participants created behavior-over-time graphs (BOTGs) to characterize their perceptions of changes over time related to policies, environments, collaborations, and social determinants in their community related to healthy eating, active living, and childhood obesity. OBJECTIVE: To describe the process of coding BOTGs and their trends. DESIGN: Descriptive study of trends among BOTGs from 11 domains (eg, active living environments, social determinants of health, funding) and relevant categories and subcategories based on the graphed variables. In addition, BOTGs were distinguished by whether the variables were positively (eg, access to healthy foods) or negatively (eg, screen time) associated with health. SETTING: The GMB sessions were held in 49 community partnerships across the United States. PARTICIPANTS: Participants in the GMB sessions (n = 590; n = 5-21 per session) included key individuals engaged in or impacted by the policy, system, or environmental changes occurring in the community. MAIN OUTCOME MEASURES: Thirty codes were developed to describe the direction (increasing, decreasing, stable) and shape (linear, reinforcing, balancing, or oscillating) of trends from 1660 graphs. RESULTS: The patterns of trends varied by domain. For example, among variables positively associated with health, the prevalence of reinforcing increasing trends was highest for active living and healthy eating environments (37.4% and 29.3%, respectively), partnership and community capacity (38.8%), and policies (30.2%). Examination of trends of specific variables suggested both convergence (eg, for cost of healthy foods) and divergence (eg, for farmers' markets) of trends across partnerships. CONCLUSIONS: Behavior-over-time graphs provide a unique data source for understanding community-level trends and, when combined with causal maps and computer modeling, can yield insights about prevention strategies to address childhood obesity.

Neighborhood-level socioeconomic deprivation predicts weight gain in a multi-ethnic population: longitudinal data from the Dallas Heart Study.

OBJECTIVE: The aim of this study is to examine a relationship between neighborhood-level socioeconomic deprivation and weight change in a multi-ethnic cohort from Dallas County, Texas and whether behavioral/psychosocial factors attenuate the relationship. METHODS: Non-movers (those in the same neighborhood throughout the study period) aged 18-65 (N=939) in Dallas Heart Study (DHS) underwent weight measurements between 2000 and 2009 (median 7-year follow-up). Geocoded home addresses defined block groups; a neighborhood deprivation index (NDI) was created (higher NDI=greater deprivation). Multi-level modeling determined weight change relative to NDI. Model fit improvement was examined with adding physical activity and neighborhood environment perceptions (higher score=more unfavorable perceptions) as covariates. A significant interaction between residence length and NDI was found (p-interaction=0.04); results were stratified by median residence length (11 years). RESULTS: Adjusting for age, sex, race/ethnicity, smoking, and education/income, those who lived in neighborhood >11 years gained 1.0 kg per one-unit increment of NDI (p=0.03), or 6 kg for those in highest NDI tertile compared with those in the lowest tertile. Physical activity improved model fit; NDI remained associated with weight gain after adjustment for physical activity and neighborhood environment perceptions. There was no significant relationship between NDI and weight change for those in their neighborhood ≤11 years. CONCLUSIONS: Living in more socioeconomically deprived neighborhoods over a longer time period was associated with weight gain in DHS.

Understanding the independent and joint associations of the home and workplace built environments on cardiorespiratory fitness and body mass index.

This observational study examined the associations of built environment features around the home and workplace with cardiorespiratory fitness (CRF) based on a treadmill test and body mass index (BMI) (weight (kg)/height (m)(2)). The study included 8,857 adults aged 20-88 years who completed a preventive medical examination in 2000-2007 while living in 12 Texas counties. Analyses examining workplace neighborhood characteristics included a subset of 4,734 participants. Built environment variables were derived around addresses by using geographic information systems. Models were adjusted for individual-level and census block group-level demographics and socioeconomic status, smoking, BMI (in CRF models), and all other home or workplace built environment variables. CRF was associated with higher intersection density, higher number of private exercise facilities around the home and workplace, larger area of vegetation around the home, and shorter distance to the closest city center. Aside from vegetation, these same built environment features around the home were also associated with BMI. Participants who lived and worked in neighborhoods in the lowest tertiles for intersection density and the number of private exercise facilities had lower CRF and higher BMI values than participants who lived and worked in higher tertiles for these variables. This study contributes new evidence to suggest that built environment features around homes and workplaces may affect health.

The 2011-2016 Transdisciplinary Research on Energetics and Cancer (TREC) initiative: rationale and design.

PURPOSE: Recognition of the complex, multidimensional relationship between excess adiposity and cancer control outcomes has motivated the scientific community to seek new research models and paradigms. METHODS: The National Cancer Institute developed an innovative concept to establish a center grant mechanism in nutrition, energetics, and physical activity, referred to as the Transdisciplinary Research on Energetics and Cancer (TREC) Initiative. This paper gives an overview of the 2011-2016 TREC Collaborative Network and the 15 research projects being conducted at the centers. RESULTS: Four academic institutions were awarded TREC center grants in 2011: Harvard University, University of California San Diego, University of Pennsylvania, and Washington University in St. Louis. The Fred Hutchinson Cancer Research Center is the Coordination Center. The TREC research portfolio includes three animal studies, three cohort studies, four randomized clinical trials, one cross-sectional study, and two modeling studies. Disciplines represented by TREC investigators include basic science, endocrinology, epidemiology, biostatistics, behavior, medicine, nutrition, physical activity, genetics, engineering, health economics, and computer science. Approximately 41,000 participants will be involved in these studies, including children, healthy adults, and breast and prostate cancer survivors. Outcomes include biomarkers of cancer risk, changes in weight and physical activity, persistent adverse treatment effects (e.g., lymphedema, urinary and sexual function), and breast and prostate cancer mortality. CONCLUSION: The NIH Science of Team Science group will evaluate the value added by this collaborative science. However, the most important outcome will be whether this transdisciplinary initiative improves the health of Americans at risk of cancer as well as cancer survivors.

Designing for dissemination among public health researchers: findings from a national survey in the United States.

OBJECTIVES: We have described the practice of designing for dissemination among researchers in the United States with the intent of identifying gaps and areas for improvement. METHODS: In 2012, we conducted a cross-sectional study of 266 researchers using a search of the top 12 public health journals in PubMed and lists available from government-sponsored research. The sample involved scientists at universities, the National Institutes of Health, and the Centers for Disease Control and Prevention in the United States. RESULTS: In the pooled sample, 73% of respondents estimated they spent less than 10% of their time on dissemination. About half of respondents (53%) had a person or team in their unit dedicated to dissemination. Seventeen percent of all respondents used a framework or theory to plan their dissemination activities. One third of respondents (34%) always or usually involved stakeholders in the research process. CONCLUSIONS: The current data and the existing literature suggest considerable room for improvement in designing for dissemination.

Development and reliability testing of the Worksite and Energy Balance Survey.

CONTEXT: Worksites represent important venues for health promotion. Development of psychometrically sound measures of worksite environments and policy supports for physical activity and healthy eating are needed for use in public health research and practice. OBJECTIVE: Assess the test-retest reliability of the Worksite and Energy Balance Survey (WEBS), a self-report instrument for assessing perceptions of worksite supports for physical activity and healthy eating. DESIGN: The WEBS included items adapted from existing surveys or new items on the basis of a review of the literature and expert review. Cognitive interviews among 12 individuals were used to test the clarity of items and further refine the instrument. A targeted random-digit-dial telephone survey was administered on 2 occasions to assess test-retest reliability (mean days between time periods = 8; minimum = 5; maximum = 14). SETTING: Five Missouri census tracts that varied by racial-ethnic composition and walkability. PARTICIPANTS: Respondents included 104 employed adults (67% white, 64% women, mean age = 48.6 years). Sixty-three percent were employed at worksites with less than 100 employees, approximately one-third supervised other people, and the majority worked a regular daytime shift (75%). MAIN OUTCOME MEASURES: Test-retest reliability was assessed using Spearman correlations for continuous variables, Cohen's κ statistics for nonordinal categorical variables, and 1-way random intraclass correlation coefficients for ordinal categorical variables. RESULTS: Test-retest coefficients ranged from 0.41 to 0.97, with 80% of items having reliability coefficients of more than 0.6. Items that assessed participation in or use of worksite programs/facilities tended to have lower reliability. Reliability of some items varied by gender, obesity status, and worksite size. Test-retest reliability and internal consistency for the 5 scales ranged from 0.84 to 0.94 and 0.63 to 0.84, respectively. CONCLUSIONS: The WEBS items and scales exhibited sound test-retest reliability and may be useful for research and surveillance. Further evaluation is needed to document the validity of the WEBS and associations with energy balance outcomes.

Perceived environmental correlates of physical activity for leisure and transportation in Curitiba, Brazil.

BACKGROUND: Physical activity (PA) has consistently been associated with perceived environmental characteristics. OBJECTIVE: To examine the association between perceived environmental attributes and various forms of PA in Curitiba, Brazil. METHODS: A cross-sectional phone survey of adults was conducted in 2008 (n=2097). The questionnaire included environmental perceptions and PA. Principal components analysis was used to identify groups of perceived environmental attributes. Multivariate methods tested the associations of PA with perceived environment characteristics. RESULTS: Perceptions of moderate and high personal safety were positively associated with walking for transportation (53.0%, 53.1% vs. 47.3%, both adjusted ORs [aOR]=1.5). Number of destinations within a 10-minute walk (4 and >6 vs. <3) was positively associated with bicycling for transportation (7.8%, 9.9% vs.4.8%, aOR=2.5). Perception of high accessibility was positively associated with MVPA during leisure time (35.1% vs. 19.1, aOR=1.7) and meeting recommendations for total PA (58.7% vs. 45.1%, aOR=1.4). Perception of high quality of the pedestrian space (57.3% vs. 46.5%, aOR=1.4) and moderate levels of personal safety (54.3% vs. 47.6%, aOR=1.3) were also positively associated with meeting recommendations for total PA. CONCLUSIONS: Different environmental attributes were associated with different PA outcomes, suggesting that these relationships are complex and may differ from those in high-income countries.

Disrupted and Restored Patient Experience With Transition to New Electronic Health Record System.

Transitioning from one electronic health record (EHR) system to another is of the most disruptive events in health care and research about its impact on patient experience for inpatient is limited. This study aimed to assess the impact of transitioning EHR on patient experience measured by the Hospital Consumer Assessment of Healthcare Providers and Systems composites and global items. An interrupted time series study was conducted to evaluate quarter-specific changes in patient experience following implementation of a new EHR at a Midwest health care system during 2017 to 2018. First quarter post-implementation was associated with statistically significant decreases in Communication with Nurses (-1.82; 95% CI, -3.22 to -0.43; P = .0101), Responsiveness of Hospital Staff (-2.73; 95% CI, -4.90 to -0.57; P = .0131), Care Transition (-2.01; 95% CI, -3.96 to -0.07; P = .0426), and Recommend the Hospital (-2.42; 95% CI, -4.36 to -0.49; P = .0142). No statistically significant changes were observed in the transition, second, or third quarters post-implementation. Patient experience scores returned to baseline level after two quarters and the impact from EHR transition appeared to be temporary.

Outcomes Associated With Social Distancing Policies in St Louis, Missouri, During the Early Phase of the COVID-19 Pandemic.

Importance: In the absence of a national strategy in response to the COVID-19 pandemic, many public health decisions fell to local elected officials and agencies. Outcomes of such policies depend on a complex combination of local epidemic conditions and demographic features as well as the intensity and timing of such policies and are therefore unclear. Objective: To use a decision analytical model of the COVID-19 epidemic to investigate potential outcomes if actual policies enacted in March 2020 (during the first wave of the epidemic) in the St Louis region of Missouri had been delayed. Design, Setting, and Participants: A previously developed, publicly available, open-source modeling platform (Local Epidemic Modeling for Management & Action, version 2.1) designed to enable localized COVID-19 epidemic projections was used. The compartmental epidemic model is programmed in R and Stan, uses bayesian inference, and accepts user-supplied demographic, epidemiologic, and policy inputs. Hospital census data for 1.3 million people from St Louis City and County from March 14, 2020, through July 15, 2020, were used to calibrate the model. Exposures: Hypothetical delays in actual social distancing policies (which began on March 13, 2020) by 1, 2, or 4 weeks. Sensitivity analyses were conducted that explored plausible spontaneous behavior change in the absence of social distancing policies. Main Outcomes and Measures: Hospitalizations and deaths. Results: A model of 1.3 million residents of the greater St Louis, Missouri, area found an initial reproductive number (indicating transmissibility of an infectious agent) of 3.9 (95% credible interval [CrI], 3.1-4.5) in the St Louis region before March 15, 2020, which fell to 0.93 (95% CrI, 0.88-0.98) after social distancing policies were implemented between March 15 and March 21, 2020. By June 15, a 1-week delay in policies would have increased cumulative hospitalizations from an observed actual number of 2246 hospitalizations to 8005 hospitalizations (75% CrI: 3973-15 236 hospitalizations) and increased deaths from an observed actual number of 482 deaths to a projected 1304 deaths (75% CrI, 656-2428 deaths). By June 15, a 2-week delay would have yielded 3292 deaths (75% CrI, 2104-4905 deaths)-an additional 2810 deaths or a 583% increase beyond what was actually observed. Sensitivity analyses incorporating a range of spontaneous behavior changes did not avert severe epidemic projections. Conclusions and Relevance: The results of this decision analytical model study suggest that, in the St Louis region, timely social distancing policies were associated with improved population health outcomes, and small delays may likely have led to a COVID-19 epidemic similar to the most heavily affected areas in the US. These findings indicate that an open-source modeling platform designed to accept user-supplied local and regional data may provide projections tailored to, and more relevant for, local settings.

Assessing physical activity in public parks in Brazil using systematic observation.

OBJECTIVES: We assessed park use in Recife, Brazil, and differences in physical activity and occupation rates in public parks with and without the Academia da Cidade Program (ACP), which provides cost-free, supervised physical activity classes. METHODS: We used the System for Observing Play and Recreation in Communities (SOPARC) in 128 targeted areas in 10 park sites (5 ACP sites, 5 non-ACP sites) to obtain data on the number of users and their physical activity levels and estimated age. Each area was assessed 4 times a day for 11 days over a 4-week period. RESULTS: A total of 32 974 people were observed during 5589 observation visits to target areas. People using ACP parks were more likely to be seen engaging in moderate-to-vigorous (64% vs 49%) and vigorous (25% vs 10%) physical activity. Relatively more participants in ACP sites than in non-ACP sites were females (45% vs 42% of park users) and older adults (14.7% vs 5.7% of park users). CONCLUSIONS: On the basis of systematic observation, ACP appears to be a useful strategy in promoting park use and physical activity among the population in Recife.

Concordance of commercial data sources for neighborhood-effects studies.

Growing evidence supports a relationship between neighborhood-level characteristics and important health outcomes. One source of neighborhood data includes commercial databases integrated with geographic information systems to measure availability of certain types of businesses or destinations that may have either favorable or adverse effects on health outcomes; however, the quality of these data sources is generally unknown. This study assessed the concordance of two commercial databases for ascertaining the presence, locations, and characteristics of businesses. Businesses in the St. Louis, Missouri area were selected based on their four-digit Standard Industrial Classification (SIC) codes and classified into 14 business categories. Business listings in the two commercial databases were matched by standardized business name within specified distances. Concordance and coverage measures were calculated using capture-recapture methods for all businesses and by business type, with further stratification by census-tract-level population density, percent below poverty, and racial composition. For matched listings, distance between listings and agreement in four-digit SIC code, sales volume, and employee size were calculated. Overall, the percent agreement was 32% between the databases. Concordance and coverage estimates were lowest for health-care facilities and leisure/entertainment businesses; highest for popular walking destinations, eating places, and alcohol/tobacco establishments; and varied somewhat by population density. The mean distance (SD) between matched listings was 108.2 (179.0) m with varying levels of agreement in four-digit SIC (percent agreement = 84.6%), employee size (weighted kappa = 0.63), and sales volume (weighted kappa = 0.04). Researchers should cautiously interpret findings when using these commercial databases to yield measures of the neighborhood environment.

Effects of a community-based, professionally supervised intervention on physical activity levels among residents of Recife, Brazil.

OBJECTIVES: We evaluated the effects of a community-based intervention, the Academia da Cidade program (ACP), on increasing leisure-time physical activity among residents of Recife, Brazil. METHODS: We used the International Physical Activity Questionnaire to assess leisure-time physical activity and transport physical activity (i.e., activities involved in traveling from place to place) levels in a random sample of 2047 Recife residents surveyed in 2007. We also examined factors related to exposure to ACP (participation in the intervention, residing near an intervention site, hearing about or seeing intervention activities). We estimated prevalence odds ratios (ORs) of moderate to high leisure-time and transport physical activity levels via intervention exposures adjusted for sociodemographic, health, and environmental variables. RESULTS: Prevalence ORs for moderate to high levels of leisure-time physical activity were higher among former (prevalence OR=2.0; 95% confidence interval [CI]=1.0, 3.9) and current (prevalence OR=11.3; 95% CI=3.5, 35.9) intervention participants and those who had heard about or seen an intervention activity (prevalence OR=1.8; 95% CI=1.3, 2.5). Transport physical activity levels were inversely associated with residing near an ACP site. CONCLUSIONS: The ACP program appears to be an effective public health strategy to increase population-level physical activity in urban developing settings.

Physical activity interventions in Latin America: a systematic review.

BACKGROUND: Recommendations for physical activity in the Guide to Community Preventive Services (the Community Guide) have not been systematically examined or applied in developing countries such as those in Latin America. The aim of this systematic review was to assess the current evidence base concerning interventions to increase physical activity in Latin America using a modified Community Guide process and to develop evidence-based recommendations for physical activity interventions. METHODS: In 2006, a literature review of both peer-reviewed and non-peer-reviewed literature in Portuguese, Spanish, and English was carried out to identify physical activity interventions conducted in community settings in Latin America. Intervention studies were identified by searching ten databases using 16 search terms related to physical activity, fitness, health promotion, and community interventions. All intervention studies related to physical activity were summarized into tables. Six reviewers independently classified the intervention studies by the categories used in the Community Guide and screened the studies for inclusion in a systematic abstraction process to assess the strength of the evidence. Five trained researchers conducted the abstractions. RESULTS: The literature search identified 903 peer-reviewed articles and 142 Brazilian theses related to physical activity, of which 19 were selected for full abstraction. Only for school-based physical education classes was the strength of the evidence from Latin America sufficient to support a practice recommendation. CONCLUSIONS: This systematic review highlights the need for rigorous evaluation of promising interventions to increase physical activity in Latin America. Implementation and maintenance of school physical education programs and policies should be strongly encouraged to promote the health of Latin American children.

Active neighborhood checklist: a user-friendly and reliable tool for assessing activity friendliness.

PURPOSE: To test the reliability of the Active Neighborhood Checklist (the Checklist), a user-friendly audit tool for assessing neighborhood environmental supports for physical activity. METHODS: Sixty-four street segments in St. Louis and southeastern Missouri were selected among diverse areas that varied with respect to socioeconomic levels, urbanization, and land use. Fifteen public health researchers and seven community stakeholders conducted audits in April 2005 following a two-hour training session. Interrater reliability was measured for the items in each section of the Checklist (land use characteristics, sidewalks, shoulders and bike lanes, street characteristics, and quality of the environment for a pedestrian) using observed agreement and the kappa statistic. RESULTS: The mean observed agreement for 57 evaluated items was 0.87 (range, 0.61-1.00). The mean kappa statistic was 0.68 (range, 0.21-1.00). DISCUSSION: With minimal training of the auditors, the Checklist demonstrated strong reliability. Future studies are needed to provide information about its usability for various stakeholders and across different settings.

Indicators of activity-friendly communities: an evidence-based consensus process.

BACKGROUND: Regular physical activity, even at modest intensities, is associated with many health benefits. Most Americans, however, do not engage in the recommended levels. As practitioners seek ways to increase population rates of physical activity, interventions and advocacy efforts are being targeted to the community level. Yet, advocates, community leaders, and researchers lack the tools needed to assess local barriers to and opportunities for more active, healthy lifestyles. Investigators used a systematic review process to identify key indicators of activity-friendly communities that can assess and improve opportunities for regular physical activity. METHODS: Investigators conducted a comprehensive literature review of both peer-reviewed literature and fugitive information (e.g., reports and websites) to generate an initial list of indicators for review (n=230). The review included a three-tiered, modified Delphi consensus-development process that incorporated input of international, national, state, and local researchers and practitioners from academic institutions, federal and state government agencies, nonprofit organizations, and funding agencies in public health, transportation, urban planning, parks and recreation, and public policy. RESULTS: Ten promising indicators of activity-friendly communities were identified: land use environment, access to exercise facilities, transportation environment, aesthetics, travel patterns, social environment, land use economics, transportation economics, institutional and organizational policies, and promotion. CONCLUSIONS: Collaborative, multidisciplinary approaches are underway to test, refine, and expand this initial list of indicators and to develop measures that communities, community leaders, and policymakers can use to design more activity-friendly community environments.

Trends in heart disease death rates in diabetic and nondiabetic Pima Indians.

BACKGROUND: Secular trends over 34 years (1965-1998) in overall and cause-specific mortality were examined in 4,623 Pima Indians >or=35 years old. METHODS: The underlying and contributing causes of the 1,363 deaths were determined from a review of all available clinical records; 540 of the deaths occurred in the 2,528 nondiabetic participants and 823 in the 2,095 participants who had diabetes during all or part of the study period. Age/sex-adjusted death rates were calculated across four 8.5-year time intervals. RESULTS: In the nondiabetic participants, the rate of death from natural causes declined gradually over time (20.4, 17.3, 17.3, and 16.0 deaths per 1,000 persons/year; P=.11); deaths from ischemic heart disease (IHD) were uncommon (n=22), and the rate did not change appreciably, remaining as the fifth leading natural cause of death. In the diabetic participants, the rate of death from natural causes was unchanged over time, but the rate of death from IHD (n=141) increased nearly twofold (3.3, 4.2, 6.4, and 6.4 deaths per 1,000 persons/year; P<.01), becoming the leading cause of death in the third and fourth time intervals. CONCLUSIONS: The rate of death from IHD remained stable in nondiabetic Pima Indians but increased among those with diabetes. This finding suggests that, in the absence of diabetes, the underlying susceptibility to IHD in this population has not changed.

Perceived and objective environmental measures and physical activity among urban adults.

BACKGROUND: Enhancing community environments to support walking and bicycling serves as a promising approach to increase population levels of physical activity. However, few studies have simultaneously assessed perceptions and objectively measured environmental factors and their relative association with transportation or recreational physical activity. METHODS: For this cross-sectional study, high- and low-income study areas were selected among census tracts in St. Louis MO ("low-walkable" city) and Savannah GA ("high-walkable" city). Between February and June 2002, a telephone survey of 1068 adults provided measures of the perceived environment and physical activity behavior. In this timeframe, objective measures were collected through environmental audits of all street segments (n =1158). These measures were summarized using 400-m buffers surrounding each respondent. Neighborhood characteristics included the land use environment, transportation environment, recreational facilities, aesthetics, and social environment. Associations were examined between neighborhood features and transportation- and recreation-based activity. RESULTS: After adjusting for age, gender, and education, transportation activity was negatively associated with objective measures of sidewalk levelness and perceived and objective neighborhood aesthetics. It was positively associated with perceived and objectively measured number of destinations and public transit, perceived access to bike lanes, and objective counts of active people in the neighborhood. Recreational activity was positively associated with perceived access to recreational facilities and objective measures of attractive features. CONCLUSIONS: These findings indicate that physical activities for transportation or recreational are associated with different perceived and objective environmental characteristics. Modifications to these features may change the physical activity behavior of residents exposed to them.

Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system.

PURPOSE: Substantial reductions in inpatient episodes of severe hypoglycemia achieved by a large healthcare system through enhanced use of technology and sustained quality-improvement initiatives are described. SUMMARY: After internal data collection and analysis revealed that severe hypoglycemia accounted for 75% of all systematically monitored adverse drug events in its hospital network, St. Louis-based BJC HealthCare designed and executed a multifaceted approach to reducing hypoglycemia events. Initiated by a pharmacist-led task force, the project entailed (1) automated event detection and creation of dashboards for comparing hypoglycemia rates among at-risk patients at 11 BJC facilities, (2) implementation of evidence-based and internal best practices in use at BJC's top-performing hospitals, (3) development of an online "Hypoglycemic Event Analysis Tool" (HEAT) to support event investigation and collection of data on causative factors, and (4) the assembly of targeted interventions at a "Hypoglycemia Facility Strategy Tracking" (H-FaST) intranet site. As a result of the launch of the HEAT and H-FaST tools and associated provider education activities, the systemwide rate of hypoglycemia events in the specified at-risk patient population declined from 6.45 per 1000 patient-days during a preimplementation baseline period (July-December 2009) to 1.32 per 1000 patient-days during a designated postimplementation period (January-June 2014), an 80% overall reduction in hypoglycemia (p < 0.01); reductions in severe hypoglycemia events ranging from 70% to 100% were observed at all 11 hospitals. CONCLUSION: A multifaceted, evidence-based, data-driven approach enabled a large healthcare system to markedly reduce the frequency of severe hypoglycemia events.

Change in Neighborhood Socioeconomic Status and Weight Gain: Dallas Heart Study.

INTRODUCTION: Despite a proposed connection between neighborhood environment and obesity, few longitudinal studies have examined the relationship between change in neighborhood socioeconomic deprivation, as defined by moving between neighborhoods, and change in body weight. The purpose of this study is to examine the longitudinal relationship between moving to more socioeconomically deprived neighborhoods and weight gain as a cardiovascular risk factor. METHODS: Weight (kilograms) was measured in the Dallas Heart Study (DHS), a multiethnic cohort aged 18-65 years, at baseline (2000-2002) and 7-year follow-up (2007-2009, N=1,835). Data were analyzed in 2013-2014. Geocoded addresses were linked to Dallas County, TX, census block groups. A block group-level neighborhood deprivation index (NDI) was created. Multilevel difference-in-difference models with random effects and a Heckman correction factor (HCF) determined weight change relative to NDI change. RESULTS: Forty-nine percent of the DHS population moved (263 to higher NDI, 586 to lower NDI, 47 within same NDI), with blacks more likely to move than whites or Hispanics (p<0.01), but similar baseline BMI and waist circumference were observed in movers versus non-movers (p>0.05). Adjusting for HCF, sex, race, and time-varying covariates, those who moved to areas of higher NDI gained more weight compared to those remaining in the same or moving to a lower NDI (0.64 kg per 1-unit NDI increase, 95% CI=0.09, 1.19). Impact of NDI change on weight gain increased with time (p=0.03). CONCLUSIONS: Moving to more-socioeconomically deprived neighborhoods was associated with weight gain among DHS participants.