Diet in Food Insecurity: A Mediator of Metabolic Health?

Objective: Food insecurity (FI) is associated with poor metabolic health. It is assumed that energy intake and diet quality underlie this association. We tested the hypothesis that dietary factors (quantity and quality) mediate the association of FI with excess weight, waist circumference and glycemic control [glycohemoglobin (A1C)]. Methods: A mediation analysis was performed on data from the National Health And Nutrition Examination Survey using FI as an independent variable; body mass index (BMI), waist circumference, and A1C as metabolic outcome variables and total energy intake, macronutrients, and diet quality measured by the Healthy Eating Index-2015 (HEI-2015) as potential mediators. Results: Despite a greater prevalence of obesity in participants experiencing FI, daily reported energy intake was similar in food-secure and -insecure subjects. In adjusted analyses of the overall cohort, none of the examined dietary factors mediated associations between FI and metabolic outcomes. In race-stratified analyses, total sugar consumption was a partial mediator of BMI in non-Hispanic Whites, while diet quality measures (HEI-2015 total score and added sugar subscore) were partial mediators of waist circumference and BMI, respectively, for those in the "other" ethnic group. Conclusion: Dietary factors are not the main factors underlying the association of FI with metabolic health. Future studies should investigate whether other social determinants of health commonly present in the context of FI play a role in this association.

Identifying Individuals with Highest Social Risk in Adults with Type 2 Diabetes Using Item Response Theory.

OBJECTIVE: The aim of this analysis was to create a parsimonious tool to screen for high social risk using item response theory to discriminate across social risk factors in adults with type 2 diabetes. METHODS: Cross-sectional data of 615 adults with diabetes recruited from two primary care clinics were used. Participants completed assessments including validated scales on economic instability (financial hardship), neighborhood and built environment (crime, violence, neighborhood rating), education (highest education, health literacy), food environment (food insecurity), social and community context (social isolation), and psychological risk factors (perceived stress, depression, serious psychological distress, diabetes distress). Item response theory (IRT) models were used to understand the association between a participant's underlying level of a particular social risk factor and the probability of that response. A two-parameter logistic IRT model was used with each of the 12 social determinant factors being added as a separate parameter in the model. Higher values in item discrimination indicate better ability of a specific social risk factor in differentiating participants from each other. RESULTS: Rate of crime reported in a neighborhood (discrimination 3.13, SE 0.50; item difficulty - 0.68, SE 0.07) and neighborhood rating (discrimination 4.02, SE 0.87; item difficulty - 1.04, SE 0.08) had the highest discrimination. CONCLUSIONS: Based on these findings, crime and neighborhood rating discriminate best between individuals with type 2 diabetes who have high social risk and those with low social risk. These two questions can be used as a parsimonious social risk screening tool to identify high social risk.

Sex Workers' Experiences of Screening for Intimate Partner Violence.

OBJECTIVE: To examine experiences of intimate partner violence (IPV) screening among women who sell sex. DESIGN: A qualitative descriptive study. SETTING: Telephone interviews during the COVID-19 pandemic (June 2020 to October 2020). PARTICIPANTS: Women aged 18 to 49 years who sold or traded sex for food, drugs, money, or shelter at least three times during the past 3 months before recruitment (N = 22). METHODS: We used individual, semistructured telephone interviews to collect data about participants' experiences with IPV and IPV screening during health care encounters. We used reflexive thematic analysis to examine these data. RESULTS: We identified two overarching themes related to IPV screening experiences: Preferences for IPV Screening and Barriers to Disclosure of IPV Experiences. Participants described a preference for IPV screening done face-to-face with providers who show a genuine interest in their responses. Stigma was a barrier of IPV disclosure. CONCLUSION: Health care providers are a trusted safety net for disclosure of IPV experiences. Providing screening in a trauma-informed, nonstigmatizing manner may facilitate disclosure of IPV by women who sell sex. Future research among marginalized populations is needed to examine ways to address IPV in clinical settings with a harm reduction empowerment lens.

Addressing Structural Inequalities, Structural Racism, and Social Determinants of Health: a Vision for the Future.

Significant national discourse has focused on the idea of structural inequalities and structural racism within a variety of societal sectors, including healthcare. This perspective provides an understanding of the historic and pervasive nature of structural inequalities and structural racism; uses well-known frameworks in health equity research for conceptualizing structural inequality and structural racism; offers a summary of the consequences of structural inequalities and structural racism on modern-day health outcomes; and concludes with strategies and suggestions for a way forward. Recommended strategies across different sectors of influence include (a) employment and economic empowerment sector: creating capacity for individuals to earn livable wages; (b) education sector: developing new funding structures to ensure equal opportunities are offered to all; (c) healthcare sector: prioritizing universal access to high-quality health care, including mental health treatment; (d) housing sector: improving access to affordable, safe housing through public-private partnerships; (e) criminal justice sector: focusing reform on restorative justice that is people-centric instead of punitive; and (f) environmental sector: creating sustainable systems that alleviate downstream consequences of climate change. The recommended strategies account for the mutually reinforcing and pervasive nature of structural inequalities/structural racism and target key sectors of influence to enhance overall health outcomes and achieve equity regardless of race, ethnicity, or socioeconomic status.

Prevalence and correlates of pre-diabetes in Sub-Saharan Africa using Demographic and Health Survey Data: a cross-sectional study.

OBJECTIVE: The objective is to investigate the prevalence of pre-diabetes in Namibia and South Africa and to determine sociodemographic correlates of disease using population data. DESIGN: Cross-sectional study. SETTING: Demographic and Health Survey for emerging (Namibia) and established (South Africa) economies in Sub-Saharan Africa collected laboratory data that allowed determination of pre-diabetes status. PARTICIPANTS: 3141 adults over age 18 from the 2013 Namibia survey, weighted to a population of 2176, and 4964 adults over age 18 from the 2016 South Africa survey, weighted to a population of 4627 had blood glucose/glycated haemoglobin (HbA1c) and diabetes information were included in the analysis. OUTCOME MEASURES: Pre-diabetes was defined as not being diagnosed with diabetes and having a blood sugar measurement of 100-125 mg/dL in Namibia or an HbA1c measurement of 5.7%-6.4%. Logistic models were run for each country separately, with pre-diabetes as the outcome and a series of sociodemographic variables (age, gender, urban/rural residence, number of children, employment status, wealth index, education level, and ethnicity (in South Africa) or religion (in Namibia)) entered as variables to investigate the independent relationship of each. RESULTS: The weighted prevalence of pre-diabetes was 18.7% in Namibia and 70.1% in South Africa. Rural residence was independently associated with higher odds of pre-diabetes in Namibia (1.47, 95% CI 1.05 to 2.06), while both younger age (0.98, 95% CI 0.97 to 0.99) and urban residence (0.80, 95% CI 0.66 to 0.99) were independently associated with odds of pre-diabetes in South Africa. CONCLUSIONS: The prevalence of pre-diabetes was 18.7% in Namibia and 70.1% in South Africa. Correlates of pre-diabetes differed between the two countries with rural residents having higher odds of pre-diabetes in Namibia and urban residents with higher odds in South Africa. Aggressive interventions, including population level education and awareness programmes, and individual level education and lifestyle interventions that account for country-specific contextual factors are urgently needed to prevent progression to diabetes.

Examining the Relationship between Social Determinants of Health and Adverse Pregnancy Outcomes in Black Women.

OBJECTIVE: Our objective was to examine associations between social determinants of health (cultural, neighborhood, and psychosocial factors) and adverse pregnancy outcomes (gestational age at birth [GAB], preterm birth [PTB], and preeclampsia) in Black women. STUDY DESIGN: Cross-sectional data (n = 204) comprised adult Black women aged ≥18 years who delivered between 2013 and 2022 in Milwaukee,Wisconsin. Sequential unadjusted linear and logistic regression models were run to evaluate associations between social determinants of health and pregnancy outcomes. Stepwise regressions with forward selection were run to test the contribution of the social determinants of health to adverse pregnancy outcomes, independent of the contribution of established risk factors. RESULTS: Mean GAB was 37.9 weeks, 19.6% had a PTB and 17.7% had preeclampsia. In all fully adjusted models, education (ß0.15, 95% confidence interval [CI]: 0.005, 0.29), nulliparity (ß -1.26, 95%CI: -2.08, -0.44), multifetal gestation (ß -2.67, 95% CI: -4.29, -1.05), and exposure to neighborhood violence (ß -0.13, 95%CI: -0.25, -0.005) were associated with shortened GAB. Education (adjusted odds ratio [aOR]: 0.83, 95%CI: 0.69, 0.99), provider trust (aOR: 0.94, 95%CI: 0.88, 0.99), chance health locus of control (aOR: 0.88, 95%CI: 0.78, 0.99), and anxiety (aOR: 0.81, 95%CI: 0.69, 0.95) were associated with reduced odds of PTB. Powerful others health locus of control (aOR: 1.16, 95%CI: 1.03, 1.32), depression (aOR: 1.17, 95%CI: 1.01, 1.34), nulliparity (aOR: 4.73, 95%CI: 1.79, 12.55), multifetal gestation (aOR: 17.78, 95%CI: 3.49, 90.50), diabetes (aOR: 4.71, 95%CI: 1.17, 19.00), and obstructive sleep apnea (aOR: 44.28, 95%CI: 2.50, 783.12) were associated with increased odds of PTB. Internal health locus of control (aOR: 1.13, 95%CI: 1.01, 1.25), depression (aOR: 1.09, 95%CI: 1.01, 1.17), preeclampsia in a previous pregnancy (aOR: 5.96, 95% CI: 2.22, 16.01), and kidney disease (aOR: 34.27, 95% CI: 1.54, 763.75) were associated with preeclampsia. CONCLUSION: Provider trust, health locus of control, neighborhood violence, depression, and anxiety were associated with adverse pregnancy outcomes in Black women, independent of demographic and clinical risk factors. KEY POINTS: · We identified associations between exposure to neighborhood violence and gestational age at birth.. · Trust, locus of control, depression, and anxiety were associated with preterm birth and preeclampsia.. · Future research should focus on interventions that address social and clinical factors..

Trials Informing Back Pain Guidelines Underreport Key Sociodemographic Data.

INTRODUCTION: Sociodemographic characteristics are related to low back pain (LBP) outcomes, therefore diverse representation is important when appraising clinical trials. We investigated the reporting of participant sociodemographic variables in trials informing the American College of Physicians (ACP) guidelines for the treatment of LBP. METHODS: Clinical trials supporting recommended interventions in the ACP guidelines were reviewed for reporting of participant sociodemographic data. RESULTS: Of 116 trials, 34 reported participant race and/or ethnicity. Education level, income level, and employment status were reported in 24, 10, and 31 trials, respectively; insurance coverage, marital status, and religion were reported in three, 16, and two trials, respectively. Two trials reported on duration or location of residence. Language comprehension was the most frequent exclusion criterion. CONCLUSIONS: Insufficient sociodemographic data exist in trials informing the ACP guidelines for the treatment of LBP. Investigators of LBP interventions should recruit diverse study participants and report comprehensive sociodemographic data.

Gender invariance in the relationship between social support and glycemic control.

BACKGROUND: Social support (SS) is important in diabetes self-management; however, little is known about how different types of SS influence diabetes outcomes in men and women with type 2 diabetes mellitus (T2DM). Therefore, the aims of this study were to investigate the relationships between types of SS and glycemic control and self-care behaviors and assess whether the relationships differ by gender. METHODS: Cross-sectional study of 615 adults from two primary care clinics in the southeastern U.S. Outcomes were hemoglobin A1c (HbA1c) extracted from the medical records, and self-management behaviors (general diet, specific diet, exercise, blood glucose testing, foot care) measured using the Summary of Diabetes Self-Care Activities (SDSCA). Independent variable was SS (emotional/informational, tangible, affectionate, positive social interaction) measured using the Medical Outcomes Study (MOS) SS Scale. Structural equation modeling (SEM) was used to understand pathways between SS and glycemic control based on a theoretical model. RESULTS: Tangible support was significantly associated with self-care (r = 0.16; p = 0.046) and affectionate support was marginally associated with glycemic control (r = 0.15; p = 0.08) for both men and women. Using SEM to test gender invariance, there was no statistically significant difference in the meaning of SS between men and women. However, unique invariances in responses occurred, including a stronger relationship between tangible support and self-care for women (r = 0.24; p = 0.061). CONCLUSIONS: Of the four components of SS, tangible and affectionate support had the strongest influence on glycemic control. While affectionate support will improve glycemic control in both men and women, tangible support will improve self-care management, particularly in women.

Feasibility, impact, and priority of key strategies to enhance diverse and inclusive training programs in clinical and translational research: A mixed methods study.

Background: Enhancing diversity in the scientific workforce is a long-standing issue. This study uses mixed methods to understand the feasibility, impact, and priority of six key strategies to promote diverse and inclusive training and contextualize the six key strategies across Clinical and Translational Science Awards (CTSAs) Program Institutions. Methods: Four breakout sessions were held at the NCATS 2020 CTSA Program annual meeting focused on diversity, equity, and inclusion (DEI) efforts. This paper focuses on the breakout session for Enhancing DEI in Translational Science Training Programs. Data were analyzed using a mixed methods convergent approach. The quantitative strand includes the online polling results. The qualitative strand includes the breakout session and the chat box in response to the training presentation. Results: Across feasibility, impact, and priority questions, prioritizing representation ranked number 1. Building partnerships ranked number 2 in feasibility and priority, while making it personal ranked number 2 for impact. Across each strategy, rankings supported the qualitative data findings in feasibility through shared experiences, impact in the ability to increase DEI, and priority rankings in comparison to the other strategies. No divergence was found across quantitative and qualitative data findings. Conclusion: Findings provide robust support for prioritizing representation as a number one strategy to focus on in training programs. Specifically, this strategy can be operationalized through integration of community representation, diversity advocates, and adopting a holistic approach to recruiting a diverse cadre of scholars into translational science training programs at the national level across CTSAs.

Mentoring strategies to support diversity in research-focused junior faculty: A scoping review.

Objective: The purpose of this scoping review is two-fold: to assess the literature that quantitatively measures outcomes of mentorship programs designed to support research-focused junior faculty and to identify mentoring strategies that promote diversity within academic medicine mentoring programs. Methods: Studies were identified by searching Medline using MESH terms for mentoring and academic medicine. Eligibility criteria included studies focused on junior faculty in research-focused positions, receiving mentorship, in an academic medical center in the USA, with outcomes collected to measure career success (career trajectory, career satisfaction, quality of life, research productivity, leadership positions). Data were abstracted using a standardized data collection form, and best practices were summarized. Results: Search terms resulted in 1,842 articles for title and abstract review, with 27 manuscripts meeting inclusion criteria. Two studies focused specifically on women, and four studies focused on junior faculty from racial/ethnic backgrounds underrepresented in medicine. From the initial search, few studies were designed to specifically increase diversity or capture outcomes relevant to promotion within academic medicine. Of those which did, most studies captured the impact on research productivity and career satisfaction. Traditional one-on-one mentorship, structured peer mentorship facilitated by a senior mentor, and peer mentorship in combination with one-on-one mentorship were found to be effective strategies to facilitate research productivity. Conclusion: Efforts are needed at the mentee, mentor, and institutional level to provide mentorship to diverse junior faculty on research competencies and career trajectory, create a sense of belonging, and connect junior faculty with institutional resources to support career success.

Understanding the relationship between perceived discrimination, allostatic load, and all-cause mortality in US older adults: A mediation analysis.

OBJECTIVE: To understand the relationship between perceived discrimination, allostatic load, and all-cause mortality; and to determine whether allostatic load is a mediator in the relationship between perceived discrimination and all-cause mortality among an older adult US population. METHODS: Data from the Health and Retirement Study (2006-2012) was analyzed. Cox proportional hazard models were used to investigate the relationship between all-cause mortality and perceived discrimination, and all-cause mortality and allostatic load. Linear regression models were used to investigate the relationship between perceived discrimination and allostatic load. A mediation model with perceived discrimination and allostatic loads as independent variables was used to determine the association with all-cause mortality. RESULTS: There were 5062 adults over the age of 50 included in the analysis. The relationship between perceived discrimination and allostatic load was statistically significant (b:0.14, [95%CI 0.10,0.19]; p < 0.001). The relationship between perceived discrimination and all-cause mortality was statistically significant (HR: 1.12, [95%CI 1.03,1.22]; p = 0.01). The relationship between allostatic load and all-cause mortality was statistically significant (HR: 1.11, [95%CI 1.08,1.13]; p < 0.001). The mediation model resulted in a decrease in hazard ratio and loss of statistical significance for perceived discrimination (HR: 1.09, [95%CI 0.98,1.21]; p = 0.13) when allostatic load (HR: 1.17, [95%CI 1.10,1.24]; p < 0.001) was added to the Cox regression model, indicating full mediation. CONCLUSIONS: Allostatic load fully mediates the relationship between perceived discrimination and all-cause mortality. Understanding the role of allostatic load in this relationship provides an additional implication for screening and indications for tighter control of the modifiable components of allostatic load by healthcare providers, especially among individuals who experience discrimination.

Understanding the relationship between perceived discrimination and mortality in United States adults.

OBJECTIVE: To understand the relationship between mortality and three types of perceived discrimination (lifetime, daily, chronic job) using a nationally representative sample of U.S. adults. METHODS: Data from 4562 adults in the Midlife in the United States (MIDUS) between 2004 and 2006 (MIDUS II and MIDUS African American sample) were analyzed. Unadjusted associations between primary independent discrimination variables (lifetime, chronic job, daily) and mortality were analyzed using univariate Cox's proportional hazards regression models. Covariates were added to the models by group: predisposing (sex, age, race/ethnicity, education, marital status); enabling (household income, employment status, insurance status); and need factors (body mass index, diabetes, hypertension, stroke, cancer) to estimate hazard ratios. RESULTS: After adjusting for all covariates, hazard ratios for lifetime discrimination (HR: 1.09, p = 0.034) and daily discrimination (HR: 1.03, p = 0.030) were statistically significant. There was no relationship between mortality and chronic job discrimination (HR:1.03, p = 0.15). CONCLUSIONS: Adults experiencing lifetime and daily discrimination had significantly increased risk of mortality after adjusting for predisposing, enabling, and need factors. The findings highlight the importance of screening patients during clinical encounters for experiences of discrimination and providing appropriate resources to mitigate the negative impact of discriminatory events on mortality. Future research should work to fully understand the mechanism by which discrimination increases risk of mortality. These future findings should be used to develop targets for interventions designed to decrease mortality among adults who have experienced discrimination.

Differences by race in the associations between neighborhood crime and violence and glycemic control among adults with type 2 diabetes.

BACKGROUND: Limited data exist on the differential association between neighborhood characteristics such as crime and violence and diabetes outcomes by race. OBJECTIVE: To examine racial differences in the relationship between neighborhood characteristics (crime and violence) and glycemic control in a sample of adults with type 2 diabetes (T2DM). DESIGN: A cross-sectional study. PARTICIPANTS: 601 adults with T2DM from the Southeastern United States. MEASUREMENTS: Outcome was glycemic control. Neighborhood violence and crime were the primary independent variable, and previously validated scales and indices were used to assess neighborhood crime and violence. Covariates included age, gender, education, marital status, income, hours of work per week, duration of diabetes, comorbidity, health status, and site of recruitment. Multiple linear regression was used to assess the relationship between neighborhood characteristics (violence and crime) and glycemic control adjusting for relevant covariates. RESULTS: Approximately 66% of the sample population was Black with ages ranging between 49-71 years. The unadjusted mean hemoglobin A1c (HbA1c) was significantly higher for Black adults compared to White adults (8.0 ± 2.0 vs. 7.8 ± 1.6; p = 0.002). In the fully adjusted stratified model, glycemic control was significantly associated with neighborhood crime (ß-coefficient: 0.36; 95% CI 0.07, 0.65) and neighborhood violence (ß-coefficient: 0.14; 95% CI 0.003, 0.28) for White adults in the fully adjusted model; these relationships were not significant for Black adults. CONCLUSION: In this sample of adults with T2DM, neighborhood crime and violence were significantly associated with glycemic control for White adults, but not for Black adults. Additional research is needed to understand perceptions of neighborhood crime and violence between White adults and Black adults with T2DM.

Advancing diversity, equity, and inclusion within clinical and translational science training programs: A qualitative content analysis of the training breakout session at the national CTSA program meeting.

Background: Diversity, equity, and inclusion (DEI) in clinical and translational science (CTS) are paramount to driving innovation and increasing health equity. One important area for improving diversity is among trainees in CTS programs. This paper reports on findings from a special session at the November 2020 Clinical and Translational Science Award (CTSA) national program meeting that focused on advancing diversity and inclusion within CTS training programs. Methods: Using qualitative content analysis, we identified approaches brought forth to increase DEI in KL2 career development and other training programs aimed at early-stage CTS investigators, beyond the six strategies put forth to guide the breakout session (prioritizing representation, building partnerships, making it personal, designing program structure, improving through feedback, and winning endorsement). We used an inductive qualitative content analysis approach to identify themes from a transcript of the panel of KL2 program leaders centered on DEI in training programs. Results: We identified four themes for advancing DEI within CTS training programs: 1) institutional buy-in; 2) proactive recruitment efforts; 3) an equitable application process; and 4) high-quality, diverse mentorship. Conclusion: Implementing these strategies in CTS and other training programs will be an important step for advancing DEI. However, processes need to be established to evaluate the implementation and effectiveness of these strategies through continuous quality improvement, a key component of the CTSA program. Training programs within the CTSA are well-positioned to be leaders in this critical effort to increase the diversity of the scientific workforce.

Cross-Sector Collaborations Between Health Care Systems and Community Partners That Target Health Equity/Disparities in Diabetes Care.

Evidence shows that social determinants of health (SDOH) are key drivers of diabetes outcomes and disparities in diabetes care. Targeting SDOH at the individual, organizational, and policy levels is an essential step in improving health equity for individuals living with diabetes. In addition, there is increasing recognition of the need to build collaboration across the health care system and the communities experiencing inequities to improve health equity. As a result, partnerships between health and nonhealth sectors have emerged as a crucial component for increasing health equity in diabetes care and achieving health equity. The purpose of this article is to discuss cross-sector collaborations between health care systems and nonhealth partners that target health equity in diabetes care.

Gender Differences in the Relationship Between Food Insecurity and Body Mass Index Among Adults in the USA.

BACKGROUND: In the USA, nearly 40% of adults ≥ 20 years have a body mass index (BMI) ≥ 30, and 11% of households are reported as food insecure. In adults, evidence shows women are more likely than men to be food insecure. Among adults with food insecurity, differences in BMI exist between men and women with women reporting higher BMI. Factors associated with this difference in BMI between genders are less understood. OBJECTIVE: The aim of this study was to assess gender differences in the relationship between food insecurity and BMI. DESIGN: Hierarchical models were analyzed using a general linear model by entering covariates sequentially in blocks (demographics, lifestyle behaviors, comorbidities, and dietary variables) and stratified by gender. PARTICIPANTS: The sample included 25,567 adults in the USA from the National Health and Nutrition Examination Survey (NHANES), 2005-2014. MAIN MEASURES: The dependent variable was BMI, and food insecurity was the primary predictor. KEY RESULTS: Approximately 51% of the sample was women. Food insecure women were significantly more likely to have higher BMI compared to food secure women in the fully adjusted model after controlling for demographics (ß = 1.79; 95% CI 1.17, 2.41); demographic and lifestyle factors (ß = 1.79; 95% CI 1.19, 2.38); demographic, lifestyle, and comorbidities (ß = 1.21; 95% CI 0.65, 1.77); and demographic, lifestyle, comorbidities, and dietary variables (ß = 1.23; 95% CI 0.67, 1.79). There were no significant associations between food insecure and food secure men in the fully adjusted model variables (ß = 0.36; 95% CI - 0.26, 0.98). CONCLUSION: In this sample of adults, food insecurity was significantly associated with higher BMI among women after adjusting for demographics, lifestyle factors, comorbidities, and dietary variables. This difference was not observed among men. More research is necessary to understand this relationship among women.