Geographic differences in the magnitude of black-white disparities in having obesity.

Background: Obesity disparities in the United States are well documented, but the limited body of research suggests that geographic factors may alter the magnitude of these disparities. A growing body of evidence has identified a "rural mortality penalty" where morbidity and mortality rates are higher in rural than urban areas, even after controlling for other factors. Black-White differences in health and mortality are more pronounced in rural areas than in urban areas. Objective: Therefore, the purpose of this study was to explore how rural-urban status and region moderate Black-White health disparities in obesity. Methods: Data were abstracted from the 2012 Behavioral Risk Factor Surveillance System, with the sample being restricted to Black and White respondents (n = 403,231). Respondents' county of residence was linked to US Census information to obtain the county-level Index of Relative Rurality (IRR) and Census division. Crude and adjusted logistic regression models were utilized to assess the magnitude of Black-White disparities in having obesity (yes/no) by IRR quartile and by Census division. Results: Overall, Black-White differences in obesity were wider in rural than in urban counties, with a significant linear trend (p < 0.001). Furthermore, when stratified by US Census division, results revealed that disparities were significantly wider in rural than urban areas for respondents living in the Middle Atlantic and South Atlantic divisions. In contrast, the association was reversed for the remaining divisions (New England, East North Central, West North Central, Mountain, and Pacific), where the magnitude of the Black-White difference was the largest in urban areas. Conclusion: Findings highlight the need to understand and account for critical place-based factors that exacerbate racial obesity disparities to develop and maximize the effectiveness of policies and programs designed to reduce racial inequalities and improve population health.

Mental Health of Brazilian Immigrant Women: The Role of Discrimination, Social Support, and Community Strengths.

Little is known about the mental health status of Brazilians living in the U.S. We assessed the prevalence and correlates of depression to guide the development of culturally relevant community-based mental health interventions. An online survey was conducted between July and August 2020 among a sample of Brazilian women living in the U.S. (age 18 and over, born in Brazil, English or Portuguese speaking) recruited through Brazilian social media pages and community organizations. The survey assessed depression using the Center for Epidemiological Study Depression Scale (CES-D-10), the Everyday Discrimination Scale (EDS), the Oslo Social Support Scale (OSSS), and community strengths (CS). We first assessed the correlation between CES-D-10 scores and EDS, OSSS, and CS. We found that half of the participants (52.2%) had CES-D-10 scores of 10 or greater, indicating the presence of depressive symptomatology. In a multivariable model controlling for significant covariates (age, time lived in U.S.), EDS was positively associated with CES-D-10 scores (ß = 0.64, 95% CI = 0.45, 0.83), while OSSS was negatively associated with CES-D-10 scores (ß = -0.53, 95% C I= -0.80, -0.27). No statistically significant relationship was observed between CES-D-10 and CS scores. In this sample of Brazilian immigrant women, depressive symptomatology was highly prevalent, and experiences of discrimination were associated with increased symptoms of depression. There is a need to understand and address mental health in Brazilian immigrant women.

Tramadol utilization among patients with higher risk of adverse drug events: A claims analysis of commercially insured and Medicare Advantage members.

OBJECTIVE: To assess prescribing of tramadol among patients with contraindications and higher risks of adverse events in a large population of commercially insured and Medicare Advantage members. DESIGN: We performed a cross-sectional analysis evaluating tramadol utilization in patients with higher risk of adverse outcomes. SETTING: This study utilized 2016-2017 data from the Optum Clinformatics Data Mart. PATIENTS AND PARTICIPANTS: Patients with at least one tramadol prescription without a cancer or sickle cell diagnosis during the study period. MAIN OUTCOME MEASURES: We first determined if tramadol was prescribed among patients with contraindications or risk factors for adverse outcomes. We then determined if patient demographic or clinical factors were associated with the use of tramadol in these higher-risk scenarios using multivariable logistic regression models. RESULTS: Among patients with at least one prescription for tramadol, 19.66 percent (99 percent CI: 19.57-19.75) concurrently received an interacting cytochrome P450 isoenzyme medication, 19.24 percent (99 percent CI: 19.15-19.33) concurrently received a serotonergic medication, and 7.93 percent (99 percent CI: 7.88-8.00) concurrently received a benzodiazepine. Additionally, 1.59 percent (99 percent CI: 1.56-1.61) of patients who received tramadol also had a seizure disorder, while 0.55 percent (99 percent CI: 0.53-0.56) of patients were under the age of 18. Overall, nearly one in three patients (31.17 percent) received tramadol in the presence of at least one of these risks (99 percent CI: 31.06-31.27). CONCLUSION: Almost one in three patients prescribed tramadol had a clinically significant drug interaction or contraindication for use, suggesting that prescribers often disregard these concerns. Real-world studies are needed to better understand the likelihood of harms associated with the use of tramadol in these contexts.

Effects of an educational physical activity intervention in young women with newly diagnosed breast cancer: Findings from the Young and Strong Study.

BACKGROUND: Obesity and inactivity are poor prognostic factors in breast cancer, but less is known regarding physical activity (PA) and weight patterns in young breast cancer survivors. METHODS: The Young and Strong Study was a cluster-randomized trial evaluating education and support interventions for young women (age <45 years) with newly diagnosed breast cancer. Sites were randomized 1:1 to a Young Women's Intervention (YWI) or a contact-time control physical activity intervention (PAI). Changes in PA and weight were compared between groups using general estimating equations to evaluate clustered binary and Gaussian data. RESULTS: A total of 467 patients enrolled between July 2012 and December 2013 across 54 sites. Median age at diagnosis was 40 years (range, 22-45). At baseline, median body mass index (BMI) was 25.4 kg/m2 (range, 16.1-61.1), and participants reported a median of 0 minutes (range, 0-2190) of moderate/vigorous PA/week. PA increased significantly over time in both groups (p < .001), with no difference between groups at any time point. BMI increased modestly but significantly (p < .001) over time in both groups. Provider attention to PA was observed in 74% of participants on PAI and 61% on YWI (p = .145) and correlated with PA at 12 months (median 100 min/week of PA in participants with provider attention to PA vs. 60 min/week in those without, p = .016). CONCLUSIONS: In a cohort of young women with breast cancer, rates of obesity and inactivity were high. PA and BMI increased over time and were not impacted by an educational PA intervention. Findings provide important information for developing lifestyle interventions for young breast cancer survivors.

Income and rural-urban status moderate the association between income inequality and life expectancy in US census tracts.

BACKGROUND: A preponderance of evidence suggests that higher income inequality is associated with poorer population health, yet recent research suggests that this association may vary based on other social determinants, such as socioeconomic status (SES) and other geographic factors, such as rural-urban status. The objective of this empirical study was to assess the potential for SES and rural-urban status to moderate the association between income inequality and life expectancy (LE) at the census-tract level. METHODS: Census-tract LE values for 2010-2015 were abstracted from the US Small-area Life Expectancy Estimates Project and linked by census tract to Gini index, a summary measure of income inequality, median household income, and population density for all US census tracts with non-zero populations (n = 66,857). Partial correlation and multivariable linear regression modeling was used to examine the association between Gini index and LE using stratification by median household income and interaction terms to assess statistical significance. RESULTS: In the four lowest quintiles of income in the four most rural quintiles of census tracts, the associations between LE and Gini index were significant and negative (p between < 0.001 and 0.021). In contrast, the associations between LE and Gini index were significant and positive for the census tracts in the highest income quintiles, regardless of rural-urban status. CONCLUSION: The magnitude and direction of the association between income inequality and population health depend upon area-level income and, to a lesser extent, on rural-urban status. The rationale behind these unexpected findings remains unclear. Further research is needed to understand the mechanisms driving these patterns.

Nonresponsive Parenting Feeding Styles and Practices and Risk of Overweight and Obesity among Chinese Children Living Outside Mainland China: An Integrative Review of the Literature.

Chinese immigrants are a fast-growing population group in many parts of the world. Childhood obesity is increasingly a public health problem among Chinese living outside mainland China. Evidence suggests that parenting feeding styles and practices critically influence children's eating behaviors and risk of being overweight or obese. Therefore, the objectives of this review were to identify and synthesize the evidence from studies examining the associations between parenting feeding styles, feeding practices, and risk of overweight and obesity among children of Chinese parents outside mainland China. A systematic search of four electronic databases (CINAHL, Medline, PsycINFO, and PubMed) was conducted to identify peer-reviewed studies published in English between January 2000 and March 2022. Fifteen studies met the inclusion criteria and were included in the review. Findings of some of the reviewed studies showed that parenting feeding styles and practices varied according to children's age, gender, weight, and parents' acculturation levels. The two most identified parenting feeding styles were indulgent and authoritarian. Parents classified as having indulgent and/or authoritarian feeding styles reported using several feeding practices with unintended detrimental effects, such as pressuring children to eat and restricting or controlling child food intake (type and amount). Some of these feeding practices were associated with an increased risk of child overweight. The findings of this review provide important information that can inform the design interventions to address modifiable nonresponisve parental feeding practices such as pressuring, restricting, and controlling that meet the specific needs of Chinese parents and children outside mainland China.

Brazilian Immigrant Parents' Preferences for Content and Intervention Modalities for the Design of a Family-Based Intervention to Promote Their Preschool-Age Children's Healthful Energy Balance-Related Behaviors.

Brazilians are a rapidly growing ethnic immigrant population in the United States (U.S.), and there is a lack of childhood obesity prevention interventions addressing the needs of Brazilian preschool-age children. Using the family ecological model (FEM) as a guide, this developmental cross-sectional study assessed the preferences (content, intervention modality, and language) of 52 individual Brazilian immigrant parents (27 mothers, 25 fathers) for a family-based intervention to promote healthful energy balance-related behaviors (EBRB). Overall, 85% or more of parents reported being interested or very interested in content related to five of the seven assessed EBRBs (increasing fruits and vegetables, reducing unhealthy foods and sugar-sweetened beverages, increasing physical activity, and reducing screen time). Parent-preferred intervention modalities were group sessions delivered by community health workers (CHWs, 86.5%), email (84.6%), and messaging (78.8%), with most parents (71.2%) indicating a preference for content in Portuguese. Interventions integrating multiple components, such as group sessions offered by CHWs and text messaging using SMS and WhatsApp, should be considered. Future steps for intervention development should include investigating different communication channels and their integration into a culturally and linguistically tailored family-based intervention designed to promote healthful EBRBs of preschool-age children in Brazilian families living in the U.S.

Does Healthcare Provider Counseling for Weight Management Behaviors among Hispanic Adults Who Are Overweight/Obese Vary by Acculturation Level?

This cross-sectional study explored differences in the receipt of health care provider (HCP) counseling to control/lose weight and adopt weight-related lifestyle behavior changes among Hispanic respondents according to acculturation level. Differences in reported action regarding HCP counseling were also examined. Data from four National Health and Nutrition Examination Survey (NHANES) cycles (2011-2018) were analyzed, with the analytic sample limited to Hispanic respondents who were overweight/obese. Respondents' acculturation levels were derived from their reported country of origin and the primary language spoken at home. Respondents who reported speaking only Spanish or more Spanish than English at home were classified as primarily speaking Spanish at home. In contrast, those who reported speaking Spanish and English equally, more English than Spanish, or only English were categorized as primarily speaking English at home. Weighted multivariate logistic regression models were utilized to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) to determine if differences in acculturation levels existed regarding the likelihood of receiving HCP counseling to (1) control/lose weight, (2) increase exercise/PA, and (3) reduce fat/calorie intake. Similar analyses examined differences in reported action regarding HCP counseling according to acculturation level. The analysis found no significant differences in receiving HCP counseling according to acculturation level. However, non-US-born respondents who primarily spoke Spanish at home were less likely than US-born respondents to report acting to control/lose weight (p = 0.009) or increase exercise/PA (p = 0.048), but were more likely to report having taken action to reduce fat/calorie intake (p = 0.016). This study revealed differences between acting on recommendations of health care professionals according to acculturation level, indicating a need for interventions tailored to acculturation levels.

How do Central American Parents in the United States View the Importance of and Obtain Information About Behaviors Associated with the Risk of Early Childhood Obesity?

Background: Data suggest that Latinx preschool-age children are at increased risk of obesity. The fastest-growing Latinx population in the United States originates from El Salvador, Guatemala, and Honduras, also known as the Northern Triangle countries. Purpose: To describe how Central American parents from the Northern Triangle countries perceive the importance of energy balance-related behaviors (EBRBs), their preferred sources to obtain information about EBRBs, and to assess whether these differ by parent's gender and country of the nativity. Methods: Cross-sectional survey. Results: Seventy-four parents with at least one child between 2 and 5 years of age participated in the study. More than half were immigrants from El Salvador, Guatemala, and Honduras and were classified as having low acculturation. Mothers perceived consuming >5 fruits and vegetables daily, limiting sugar-sweetened beverages consumption, and having <2 hours daily screen time as extremely important, whereas fathers perceived these behaviors as being less important. Although a higher proportion of foreign-born than US-born parents perceived most of the assessed EBRBs (4 out of 6) as extremely important, these differences were not significant. Parents reported multiple sources to obtain EBRB-related information. Direct person-to-person interactions were the most commonly preferred sources, with pediatricians being the top source (97.3%), followed by other parents (86.5%), and WIC professionals (74.3%). Pediatricians were the preferred source to obtain information about EBRBs, irrespective of parent's gender and country of the nativity. A higher proportion of US-born than foreign-born parents reported a preference to obtain EBRB-related information from other parents. Conclusions: Findings suggest the significance of understanding how Central American parents perceive the importance of EBRBs and the sources they would prefer to obtain information for their children's EBRBs. Study findings have implications for health education and obesity prevention interventions designed to reach and deliver key evidence-based child health information to Central American parents from the Northern Triangle countries in the United States.

Aging in Rural Communities.

Purpose of Review: Population aging is occurring worldwide, particularly in developed countries such as the United States (US). However, in the US, the population is aging more rapidly in rural areas than in urban areas. Healthy aging in rural areas presents unique challenges. Understanding and addressing those challenges is essential to ensure healthy aging and promote health equity across the lifespan and all geographies. This review aims to present findings and evaluate recent literature (2019-2022) on rural aging and highlight future directions and opportunities to improve population health in rural communities. Recent Findings: The review first addresses several methodological considerations in measuring rurality, including the choice of measure used, the composition of each measure, and the limitations and drawbacks of each measure. Next, the review considers important concepts and context when describing what it means to be rural, including social, cultural, economic, and environmental conditions. The review assesses several key epidemiologic studies addressing rural-urban differences in population health among older adults. Health and social services in rural areas are then discussed in the context of healthy aging in rural areas. Racial and ethnic minorities, indigenous peoples, and informal caregivers are considered as special populations in the discussion of rural older adults and healthy aging. Lastly, the review provides evidence to support critical longitudinal, place-based research to promote healthy aging across the rural-urban divide is highlighted. Summary: Policies, programs, and interventions to reduce rural-urban differences in population health and to promote health equity and healthy aging necessitate a context-specific approach. Considering the cultural context and root causes of rural-urban differences in population health and healthy aging is essential to support the real-world effectiveness of such programs, policies, and interventions.

Maternal Experiences with Discussing Complementary Feeding in Primary Care.

Complementary feeding practices promote healthy eating habits and food preferences later in life. Little is known about how US pediatricians communicate infant feeding practices to caregivers or how caregivers respond to this information. The purpose of this study is to explore mothers' experiences and perceptions of the complementary feeding recommendations they receive in primary care settings. English- and Spanish-speaking mothers of infants were recruited from Special Supplemental Nutrition for Women, Infants, and Children offices in Rhode Island, US, and snowball sampling. Semi-structured telephone interviews were conducted to investigate mothers' discussions with pediatricians about complementary feeding and their overall impressions of wellness visits. Thematic analysis was informed by the Fundamentals of Care theoretical framework. The mean age of the sample (n = 13) was 30.5 years and 62% self-identified as Latina. Four themes emerged from the analysis: (1) wellness visits are mostly positive experiences, (2) not all infant feeding recommendations are easy to follow, (3) alternative sources of infant feeding recommendations can be just as helpful, and (4) there is room for improvement at wellness visits. Improving the content, delivery, and cultural relevance of infant feeding recommendations in primary care settings with more specific and tailored information may promote adherence to evidence-based practices.

The Longitudinal Association Between Physical Activity and Physical Function in Older Women.

Purpose: The age-related decline in physical function is ameliorated by physical activity; however, less is known about changes in physical function in active vs. inactive older women. The purpose of this study was to determine the longitudinal associations between physical activity and physical function in community-dwelling older women. Methods: 238 participants (age 79.0 ± 5.1) were dichotomized into two activity groups [inactive (IG); n = 144 or active (AG); n = 94] based on self-reported exercise at baseline. Repeated measures ANCOVA, controlling for age, measured differences in physical function between activity groups at baseline and 48-months using the Timed Up and Go, 30-s chair stand, and 30-second arm curl. Differences in Timed Up and Go classification [normal (≤ 8.23 s); preclinical limitations/limited physical function (>8.23 s)] were analyzed using chi-square tests for activity group and for activity-age group (AG, <80 years; AG, ≥ 80 years; IG, <80 years; IG, ≥ 80 years). Results: The repeated measures ANCOVA yielded a significant main effect for activity group for the Timed Up and Go (p = 0.006), 30-s chair stand (p = 0.002) and 30 s arm curl (p = 0.007) and a significant time main effect for the Timed Up and Go (p = 0.016). There were no significant group by time interactions. A larger proportion of the IG than the AG (58.2 vs. 86.5%, respectively) had Timed Up and Go scores >8.23 s (p < 0.001). At 48-months, individuals in the AG were more likely to have normal Timed Up and Go scores compared to those in the IG in both age groups [ χ ( 3 ,   N = 236 ) 2 = 42.56, p < 0.001]. Conclusion: Older women who engaged in regular exercise at baseline had higher levels of objectively measured physical function and were less likely to have abnormal Timed Up and Go scores. These findings help illustrate the long-term benefit of exercise on physical function in older women.

Moderation of the Association between Primary Language and Health by Race and Gender: An Intersectional Approach.

In the United States (US), limited English proficiency is associated with a higher risk of obesity and diabetes. "Intersectionality", or the interconnected nature of social categorizations, such as race/ethnicity and gender, creates interdependent systems of disadvantage, which impact health and create complex health inequities. How these patterns are associated with language-based health inequities is not well understood. The study objective was to assess the potential for race/ethnicity, gender, and socioeconomic status to jointly moderate the association between primary language (English/Spanish) and having obesity and diabetes. Using the 2018 Behavioral Risk Factor Surveillance System (n = 431,045), weighted generalized linear models with a logistic link were used to estimate the associations between primary language (English/Spanish) and obesity and diabetes status, adjusting for confounders using stratification for the intersections of gender and race/ethnicity (White, Black, Other). Respondents whose primary language was Spanish were 11.6% more likely to have obesity (95% CI 7.4%, 15.9%) and 15.1% more likely to have diabetes (95% CI 10.1%, 20.3%) compared to English speakers. Compared to English speakers, Spanish speakers were more likely to have both obesity (p < 0.001) and diabetes (p < 0.001) among White females. Spanish speakers were also more likely to have obesity among males and females of other races/ethnicities (p < 0.001 for both), and White females (p = 0.042). Among males of other racial/ethnic classifications, Spanish speakers were less likely to have both obesity (p = 0.011) and diabetes (p = 0.005) than English speakers. Health promotion efforts need to recognize these differences and critical systems−change efforts designed to fundamentally transform underlying conditions that lead to health inequities should also consider these critical sociodemographic factors to maximize their effectiveness.

Central American Parents' Preferences for Content and Modality for a Family-Centered Intervention to Promote Healthful Energy Balance-Related Behaviors of Their Preschool-Age Children.

This formative research used a cross-sectional survey to assess interest in informational content and intervention modalities for the design of an early childhood obesity prevention intervention for Central American families from the Northern Triangle countries (El Salvador, Guatemala, and Honduras) living in the United States. A total of 74 parents (36 mothers, 38 fathers) with a mean age of 31.6 years (SD = 5.6) completed the survey; 59.5% of whom were born outside of the United States. Although most parents reported being very interested in receiving information related to the seven assessed energy balance-related behaviors, there were significant differences by parents' gender and nativity. Most parents endorsed remote modalities for content delivery via text/SMS, WhatsApp, and e-mail. However, respondents were also receptive to in-person delivery provided by community health workers. There were also significant differences in parents' preferences for intervention modalities by parents' gender and nativity. Future steps should include investigating different intervention modalities and their integration into a linguistic and culturally sensitive family-based intervention to promote healthful energy balance-related behaviors of preschool-age children in Central American families originating from the Northern Triangle countries.

Black/White Disparities in Obesity Widen with Increasing Rurality: Evidence from a National Survey.

Background: Racial health disparities in obesity and obesity-related conditions and behaviors are well documented, although a small body of research suggests that geographic factors (e.g., socioeconomic status [SES] and rural/urban status) may alter the magnitude of these disparities. Methods: This study explored how rurality moderates black/white health disparities using a nationally representative sample from the 2012 Behavioral Risk Factor Surveillance System (n=359,157). Respondents' county of residence was linked to the U.S. Census information to obtain the county-level Index of Relative Rurality (IRR). Weighted logistic regression was used to model obesity, diabetes, and lack of physical activity (PA) on race (black/white), IRR, and an interaction term of race and IRR, including covariates (age, sex, education, marital status, employment, and income). Results: Blacks were significantly more likely to have obesity, diabetes, and a lack of PA compared with whites. Irrespective of race, rural respondents were significantly more likely to have obesity (odds ratio [OR] 1.035, confidence interval [95% CI] 1.028-1.043) and a lack of PA (OR 1.045, 95% CI 1.038-1.053) than respondents in more urban areas. For obesity and diabetes, the interaction term for black×IRR quintile was significant and positive, indicating an increase in the magnitude of the black/white disparity with increasing rurality. Discussion: These findings underscore the need for policies and programs aimed to reduce racial disparities in obesity and related conditions to consider the geographic context in which these outcomes occur.

Sleep Quality Among Informal Caregivers During the COVID-19 Pandemic: A Cross-Sectional Study.

Sleep is an integral component of health. The impact of the COVID-19 pandemic on sleep quality among informal caregivers, individuals who provide unpaid care or assistance to family members or friends, assisting older adults is not well understood. Therefore, informal caregivers in the United States providing care for individuals aged 50+ were recruited via Amazon's Mechanical Turk, an online platform for enrolling study participants into social and behavioral science research, to complete an online survey. The sample of informal caregivers (n = 835) was 69% male and 55% non-Hispanic. Multivariable linear regression models were constructed to assess the associations between sleep disturbance scores (SDS) and sleep-related impairment scores (SIS) and caregiving-related measures (hours caregiving/week, length of time spent caregiving, and caregiver burden), demographics, and region of the United States. The analysis determined that Black (ß = 2.6, 95% CI [-4.3, -0.9]) and Asian informal caregivers (ß = -1.8, 95% CI [-3.4, -0.3]) had lower mean SIS than White caregivers, the referent group. In addition, increasing caregiver burden was associated with increased SDS (ß = 0.8, 95% CI [0.6, 1.0]) and SIS (ß = 1.3, 95% CI [0.7, 1.6]). In conclusion, higher caregiver burden was associated with higher SIS and SDS, suggesting that informal caregivers' sleep should be assessed, and when needed interventions should be offered.

Healthcare Providers' Advice About Gestational Weight Gain, Diet, and Exercise: a Cross-Sectional Study with Brazilian Immigrant Women in the USA.

This study sought to quantify healthcare providers' advice about gestational weight gain (GWG), diet, and exercise among first-time pregnant Brazilian women living in the USA. This is a cross-sectional study of first-time pregnant Brazilian women living in selected cities in Massachusetts. The study sample included 86 women, nearly all (97%; n = 83) immigrants. Participants' mean age was 28.3 years and mean gestation was 27.5 weeks. Approximately 25.6% (n = 22) reported being overweight, and 1.2% (n = 1) being underweight. Only about 62% (n = 53) reported receiving advice from their healthcare provider on recommended GWG. In addition, about 83% (n = 71) and 81% (n = 70) reported receiving healthcare providers' advice on exercise and diet, respectively. Women who self-reported being overweight pre-pregnancy (OR 0.15; 95% confidence interval [CI] 0.03-0.73; p = 0.02) and women who were classified low acculturation levels (OR 0.12; 95% CI 0.02-0.08; p = 0.03) were less likely to report receiving healthcare providers' advice on GWG compared to women who self-reported being normal weight pre-pregnancy and those classified having high acculturation level, respectively. Furthermore, women who self-reported being overweight pre-pregnancy were less likely to report receiving diet-related advice (OR 0.32; 95% CI 0.10-1.02; p = 0.05) than women who self-reported being normal weight pre-pregnancy. Findings indicate the need for increased communication and counseling between healthcare providers and Brazilian immigrant women about GWG, in particular for women with low acculturation levels and language barriers suggesting the need for linguistic and culturally relevant interventions designed to improve Brazilian immigrant women's access to evidence-based information about GWG, diet, and exercise.

Rural-urban differences in informal caregiving and health-related quality of life.

OBJECTIVES: Rural-urban health disparities are pervasive among older adults. Rural US locations have a disproportionately high population of older adults, have reduced access to services, and are therefore more reliant on family and friends for care. However, little is known about rural-urban disparities among the 40+ million informal caregivers nationwide. There is a critical need to understand how rural-urban disparities impact caregiving experiences and health-related quality of life (HRQoL). The objectives of this study were to assess rural-urban differences in informal caregiving status, caregiving intensity (caregiving hours/week and types of care provided), and caregiver HRQoL. METHODS: Data were abstracted from the 2018 Behavioral Risk Factor Surveillance System. The primary measure of rural-urban status was "metropolitan status." Associations between rural-urban status and caregiving and rural-urban differences in caregiving intensity and HRQoL were examined using generalized linear models, controlling for confounding and accounting for complex sampling. RESULTS: Rural respondents were more likely to be caregivers than urban respondents (OR = 1.17, 95% CI: 1.02-1.34). After adjustment for confounders, rural caregivers were more likely than urban caregivers to provide 20 or more hours of caregiving per week (OR 1.38, 95% CI: 1.07-1.77), although the findings for health and HRQoL were somewhat mixed. CONCLUSION: Results indicate that rural older adults offer more care than urban counterparts, which may have implications for caregiver health, well-being, and quality of life. These results can inform policies designed to improve caregiver health, and facilitate the translation and adaptation of existing policies, programs, and interventions to address rural caregivers' needs.

Application of a diazepam milligram equivalency algorithm to assess benzodiazepine dose intensity in Rhode Island in 2018.

BACKGROUND: Benzodiazepines are indicated for the treatment of many conditions, such as anxiety disorders, muscle spasms, alcohol withdrawal, agitation, movement disorders, and epilepsy, and are one of the most frequently prescribed medication classes. This class of medication has important safety considerations, including an increased risk of dependence and addiction, falls, and death from opioid overdose. Although benzodiazepine safety and prescribing encompasses a rich and important research area, there is a lack of pharmacoepidemiologic literature addressing benzodiazepine dosing intensity in real-world settings. OBJECTIVE: To develop and apply a standardized benzodiazepine milligram equivalency conversion algorithm and assess the dose intensity of benzodiazepine use in Rhode Island (RI) in 2018. METHODS: A systematic literature review was conducted to identify the most commonly used benzodiazepine equivalency values. We then conducted a cross-sectional analysis of 2018 data from the RI Prescription Drug Monitoring Program (PDMP) to calculate the mean daily diazepam milligram equivalency (DME) based on a patient's most recent dispensing. A multivariable logistic regression analysis was conducted to determine the association between higher benzodiazepine doses (≥ 15 DME/day) and recipient characteristics, including concurrent use of opioids or stimulants. RESULTS: We identified 143,026 patients who received at least 1 prescription for a benzodiazepine in RI in 2018. The mean (SD) daily DME was 10.60 (9.05), and 26.2% of individuals had a mean DME per day of at least 15. Approximately 14% (n = 20,168) of patients prescribed a benzodiazepine had concurrent use with a prescription opioid, and 6.7% (n = 9,547) had concurrent use with a prescription stimulant. Females had a 28% lower adjusted odds of receiving a benzodiazepine dose of at least 15 DME per day compared with males (adjusted odds ratio [aOR] = 0.72, 95% CI = 0.70-0.73). The adjusted odds of receiving a benzodiazepine prescription of at least 15 DME per day was lower among the younger (aged 18-34 years) and older age groups (aged 65 years and older) compared with patients aged 35-64 years. Compared with commercial insurance, all other forms of payment had significantly higher adjusted odds of a daily benzodiazepine dose of at least 15 DME per day. The adjusted odds receiving a daily DME of at least 15 was 67% higher among those who also received a concurrent pharmacy dispensing for an opioid and 84% higher among those who also received a concurrent dispensing for a stimulant drug (aOR = 1.67, 95% CI = 1.61-1.72; aOR = 1.84, 95% CI = 1.76-1.93, respectively). CONCLUSIONS: Individuals aged 35-64 years with Medicaid insurance and those aged under 65 years with Medicare were more likely to be prescribed a benzodiazepine of at least 15 DME per day. Higher benzodiazepine DMEs were also dispensed to patients who concurrently used prescription opioids or stimulants who may be at increased risk of medication-related harm. We advocate for routine measurement of benzodiazepine dose intensity as a risk reduction strategy. DISCLOSURES: No funding supported this study. The authors have no conflicts of interest to disclose. The content and results of this study are solely the responsibility of the authors and do not necessarily represent the official views of the Rhode Island Department of Health. Kogut is partially supported by Institutional Development Award Numbers U54GM115677 and P20GM125507 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR) and the RI Lifespan Center of Biomedical Research Excellence (COBRE) on Opioids and Overdose, respectively. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Contents of this study were presented as a poster presentation at AMCP 2019 Nexus; October 29-November 1, 2019; National Harbor, MD.