Social engagement and cognitive impairment among nursing home residents: The role of sensory impairment.

BACKGROUND AND OBJECTIVES: Using US national nursing home data, this cross-sectional study sought to evaluate 1) the association between lack of social engagement and level of cognitive impairment; and 2) the extent to which this association differs by hearing and visual impairment. RESEARCH DESIGN AND METHODS: Our sample included 793,846 nursing home residents aged ≥ 50 years. The Index of Social Engagement was categorized as none/lower (0, 1, 2) or higher levels (3 through 6). Cognitive Performance Scale was grouped as intact/mild (0, 1, 2), moderate (3, 4), or severe (5, 6). Multinomial models provided adjusted odds ratio (aOR) and 95 % confidence intervals (CI) between none/lower social engagement and cognitive impairment. We estimated relative excess risk due to interaction (RERI) to quantify the joint effects of social engagement and sensory impairment types. RESULTS: Overall, 12.6 % had lower social engagement, 30.3 % had hearing impairment, and 40.3 % had visual impairment. Compared to residents with high social engagement, those with lower social engagement were more likely to have moderate/severe cognitive impairment (aORmoderate = 2.21, 95 % CI 2.17-2.26; aORsevere = 6.49, 95 % CI 6.24-6.74). The impact of low social engagement on cognitive impairment was more profound among residents with hearing impairment and/or visual impairment (RERIhearing = 3.89, 95 % CI 3.62-4.17; RERIvisual = 25.2, 95 % CI 23.9-26.6)). DISCUSSION AND IMPLICATIONS: Residents with lower social engagement had higher levels of cognitive impairment. Residents with sensory impairments are potentially more susceptible to the negative impact of lower levels of social engagement on level of cognitive impairment.

Cumulative exposure to state-level structural sexism and risk of disordered eating: Results from a 20-year prospective cohort study.

BACKGROUND: Gendered inequities in disordered eating are well-documented, yet few studies have examined their structural drivers. To help fill this gap, we investigated whether cumulative exposure to state-level structural sexism from childhood through young adulthood potentiates differences in disordered eating risk between cisgender girls/women and boys/men. METHODS: Participants came from the Growing Up Today Study (N = 16,875), a cohort of children aged 9-14 years in 1996 who we followed through 2016. Using a composite index of relevant state policies and social inequalities from the Institute for Women's Policy Research, we categorized states as having high or low levels of structural sexism and summed the number of years participants had lived in a high structural sexism state during the study period to quantify their cumulative exposure. We fit sequential conditional mean models to estimate the effect of cumulative exposure on risk of four outcomes (chronic dieting, purging, binge eating, and overeating), controlling for individual- and state-level confounders via propensity scores. We then tested whether effects differed between girls/women and boys/men by including cumulative-exposure-by-gender-identity interaction terms and calculating the relative excess risk due to interaction (RERI). RESULTS: In the full sample, each additional year of living in a high structural sexism state was associated with a 5% increased risk of purging (95% confidence interval (CI): 3%, 7%), an 8% increased risk of binge eating (95% CI: 6%, 10%), and a 9% increased risk of overeating (95% CI: 8%, 11%). Risk increases were larger on average for girls/women than for boys/men, and girls/women who had lived in a high structural sexism state for four or more years had excess risk of chronic dieting (RERI: 0.64, 95% CI: 0.18, 1.10), purging (RERI: 2.64, 95% CI: 1.24, 4.30), and binge eating (RERI: 2.21, 95% CI: 0.93, 3.50). CONCLUSIONS: Structural sexism may contribute to inequities in disordered eating between cisgender girls/women and boys/men. Future research should include transgender and gender diverse participants, explore intersectional effects, and identify underlying mechanisms to inform policy-oriented interventions.

Prevalence and outcomes of hypertension in pregnancy in non-metropolitan and metropolitan communities.

OBJECTIVES: Hypertension during pregnancy is a leading cause of birthing parent mortality and adverse pregnancy outcomes. Since non-metropolitan communities face higher rates of several risk factors for hypertension in pregnancy and shortages in obstetrical services, persons residing in non-metropolitan areas may be at increased risk for adverse events compared to those living in metropolitan areas. Our study objectives were to examine by non-metropolitan vs. metropolitan birthing parent residence (1) the prevalence of chronic hypertension (cHTN) and hypertensive disorders of pregnancy (HDP), and (2) the prevalence of cesarean delivery, preterm birth, low birth weight, APGAR <7 at 5 min, NICU admission, and stillbirth/neonatal death among the group of birthing parents with cHTN and among the group of birthing parents with HDP. METHODS: Using U.S. Natality data from 2016 to 2018, we described the prevalence of cHTN and HDP and the association of each with several birthing parent and neonatal outcomes, stratified by non-metropolitan versus metropolitan county of birthing parent residence. Multivariable Poisson regression models were used to calculate adjusted prevalence ratios for these adverse outcomes. RESULTS: The prevalence of cHTN among pregnant individuals was 2.2% in non-metropolitan areas and 1.8% in metropolitan areas. For HDP, the prevalence was 7.4% in non-metropolitan areas and 6.6% in metropolitan areas. After adjusting for several sociodemographic characteristics among those with HDP, the prevalence ratio for an APGAR score < 7 at 5 min (aPR 1.34, 95% CI 1.29-1.38) and stillbirth/neonatal death (aPR 1.36, 95% CI 1.15-1.62) was increased among offspring born to birthing parents who resided in non-metropolitan counties. Similar results were seen among those with cHTN. CONCLUSIONS: The prevalence of cHTN and HDP is elevated among birthing parents residing in non-metropolitan areas. Also, the prevalence of APGAR <7 and stillbirth//neonatal death following pregnancies complicated by hypertension were higher among neonates born to birthing parents residing in non-metropolitan areas. Further research should investigate the robustness of these findings using alternate definitions of rural and urban areas and the possible link between low APGAR score, low NICU admission, and stillbirth/neonatal death among birthing parents residing in non-metropolitan counties.

Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residents.

BACKGROUND: Despite experimental evidence suggesting that pain sensitivity is not impaired by cognitive impairment, observational studies in nursing home residents have observed an inverse association between cognitive impairment and resident-reported or staff-assessed pain. Under the hypothesis that the inverse association may be partially attributable to differential misclassification due to recall and communication limitations, this study implemented a missing data approach to quantify the absolute magnitude of misclassification of pain, pain frequency, and pain intensity by level of cognitive impairment. METHODS: Using the 2016 Minimum Data Set 3.0, we conducted a cross-sectional study among newly admitted US nursing home residents. Pain presence, severity, and frequency is assessed via resident-reported measures. For residents unable to communicate their pain, nursing home staff document pain based on direct resident observation and record review. We estimate a counterfactual expected level of pain in the absence of cognitive impairment by multiply imputing modified pain indicators for which the values were retained for residents with no/mild cognitive impairment and set to missing for residents with moderate/severe cognitive impairment. Absolute differences (∆) in the presence and magnitude of pain were calculated as the difference between documented pain and the expected level of pain. RESULTS: The difference between observed and expected resident reported pain was greater in residents with severe cognitive impairment (∆ = -10.2%, 95% Confidence Interval (CI): -10.9% to -9.4%) than those with moderate cognitive impairment (∆ = -4.5%, 95% CI: -5.4% to -3.6%). For staff-assessed pain, the magnitude of apparent underreporting was similar between residents with moderate impairment (∆ = -7.2%, 95% CI: -8.3% to -6.0%) and residents with severe impairment (∆ = -7.2%, 95% CI: -8.0% to -6.3%). Pain characterized as "mild" had the highest magnitude of apparent underreporting. CONCLUSIONS: In residents with moderate to severe cognitive impairment, documentation of any pain was lower than expected in the absence of cognitive impairment. This finding supports the hypothesis that an inverse association between pain and cognitive impairment may be explained by differential misclassification. This study highlights the need to develop analytic and/or procedural solutions to correct for recall/reporter bias resulting from cognitive impairment.

Eating-related pathology at the intersection of gender identity and expression, sexual orientation, and weight status: An intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) of the Growing Up Today Study cohorts.

The objective of this study was to investigate how gender identity, the overwhelmingly prioritized dimension of social identity/position in eating-related pathology research, intersects with gender expression, sexual orientation, and weight status to structure the social patterning of eating disorders and disordered eating behaviors among young people in the U.S. Data were drawn from the 2010/2011 Growing Up Today Study (GUTS; N = 11,090-13,307). We conducted an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) by nesting participants within social strata defined by intersecting gender identity, gender expression, sexual orientation, and weight status categories in a series of multilevel logistic models for four outcomes (past-year purging, overeating, and binge eating; lifetime eating disorder diagnosis). To illustrate the advantages of intersectional MAIHDA, we compared the results to those from unitary and conventional intersectional analyses. The intersectional MAIHDA revealed a complex social patterning of eating-related pathology characterized by heterogeneity and outcome-specificity. Several multiply marginalized strata (e.g., those including gender nonconforming, sexual minority, and/or larger-bodied girls/women) had disproportionately elevated prevalence, although all estimates were driven by additive effects. Notably, these patterns were obscured within the unitary and conventional intersectional analyses. Future epidemiologic research on eating-related pathology should continue to adopt an intersectional approach through the use of appropriate methodologies.

Associations between perceived everyday discrimination, discrimination attributions, and binge eating among Latinas: results from the National Latino and Asian American Study.

PURPOSE: The aim of the study was to quantify the association between perceived everyday discrimination and binge eating among Latinas in the United States. METHODS: Participants included 1014 Latinas from the 2002-2003 National Latino and Asian American Study. Modified Poisson models with robust standard errors were used to estimate sociodemographic-adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) of binge eating associated with overall and attribution-specific discrimination. RESULTS: Approximately 7% of Latinas reported binge eating. Increased frequency of discrimination was associated with a higher prevalence of binge eating (aPR, 1.59; 95% CI, 1.23-2.06), and Latinas reporting frequencies of discrimination in the top tertile had the greatest prevalence elevation (aPR, 3.63; 95% CI, 1.32-10.00). There were important differences by discrimination attribution: Latinas experiencing primarily height/weight-based or skin color-based discrimination had the greatest prevalence elevation relative to those reporting no discrimination (aPR, 10.24; 95% CI, 2.95-35.51; and aPR, 8.83; 95% CI, 2.08-37.54, respectively), whereas Latinas reporting primarily race-based discrimination had the lowest prevalence elevation (aPR, 1.64; 95% CI, 0.47-5.69). CONCLUSIONS: Discrimination may be an important social determinant of Latinas' binge eating. Future research should incorporate expanded conceptual models that account for Latinas' complex social environment, focusing on intersecting dimensions of identity.

Risk of disordered eating at the intersection of gender and racial/ethnic identity among U.S. high school students.

BACKGROUND: Gender and racial/ethnic disparities in disordered eating among youth exist, although whether having multiple marginalized identities disproportionately increases risk is unclear. Therefore, we aimed to quantify the risk of disordered eating associated with intersecting gender and racial/ethnic identities of U.S. adolescents. METHODS: We analyzed data from 11,514 U.S. high school students identifying as White, Black/African American, or Hispanic/Latino who participated in the 2013 National Youth Risk Behavior Surveillance System. Age-adjusted relative risks (RR) of purging, fasting, diet pill use, and any disordered eating were estimated using log-binomial models. Relative excess risk due to interaction (RERI) was estimated to evaluate the degree to which the combined effect of marginalized gender and racial/ethnic identity was larger than the sum of their individual effects. RESULTS: Disordered eating was prevalent (girls: 20.4% Black/African American, 29.2% Hispanic/Latina, 21.4% White; boys: 13.4% Black/African American, 12.4% Hispanic/Latino; 8.1% Whites). Girls of all racial/ethnic identities and racial/ethnic minority boys had elevated risks of purging, fasting, and any disordered eating compared to White boys (RR range = 1.57-7.43); Hispanic/Latina and White girls also had elevated risk of diet pill use (RR range = 1.98-3.20). Among Hispanic/Latina girls, positive interaction between gender and race/ethnicity produced excess risk of any disordered eating and purging (RERI: any = 0.42 (95% confidence interval (CI) = -0.02, 0.87); purging = 1.74 (95% CI = 0.06, 3.42). CONCLUSIONS: Findings illustrate the advantages of adopting an intersectional approach to disordered eating research. Future research should investigate the mechanisms of these disparities.

CDKN2A/B T2D Genome-Wide Association Study Risk SNPs Impact Locus Gene Expression and Proliferation in Human Islets.

Genome-wide association studies link the CDKN2A/B locus with type 2 diabetes (T2D) risk, but mechanisms increasing risk remain unknown. The CDKN2A/B locus encodes cell cycle inhibitors p14, p15, and p16; MTAP; and ANRIL, a long noncoding RNA. The goal of this study was to determine whether CDKN2A/B T2D risk SNPs impact locus gene expression, insulin secretion, or ß-cell proliferation in human islets. Islets from donors without diabetes (n = 95) were tested for SNP genotype (rs10811661, rs2383208, rs564398, and rs10757283), gene expression (p14, p15, p16, MTAP, ANRIL, PCNA, KI67, and CCND2), insulin secretion (n = 61), and ß-cell proliferation (n = 47). Intriguingly, locus genes were coregulated in islets in two physically overlapping cassettes: p14-p16-ANRIL, which increased with age, and MTAP-p15, which did not. Risk alleles at rs10811661 and rs2383208 were differentially associated with expression of ANRIL, but not p14, p15, p16, or MTAP, in age-dependent fashion, such that younger homozygous risk donors had higher ANRIL expression, equivalent to older donor levels. We identified several risk SNP combinations that may impact locus gene expression, suggesting possible mechanisms by which SNPs impact locus biology. Risk allele carriers at ANRIL coding SNP rs564398 had reduced ß-cell proliferation index. In conclusion, CDKN2A/B locus SNPs may impact T2D risk by modulating islet gene expression and ß-cell proliferation.

Neighborhood Socioeconomic Status Predicts Health After Hospitalization for Acute Coronary Syndromes: Findings From TRACE-CORE (Transitions, Risks, and Actions in Coronary Events-Center for Outcomes Research and Education).

OBJECTIVE: To explore the influence of contextual factors on health-related quality of life (HRQoL), which is sometimes used as an indicator of quality of care, we examined the association of neighborhood socioeconomic status (NSES) and trajectories of HRQoL after hospitalization for acute coronary syndromes (ACS). METHODS: We studied 1481 patients hospitalized with acute coronary syndromes in Massachusetts and Georgia querying HRQoL via the mental and physical components of the 36-item short-form health survey (SF-36) (MCS and PCS) and the physical limitations and angina-related HRQoL subscales of the Seattle Angina Questionnaire (SAQ) during hospitalization and at 1-, 3-, and 6-month postdischarge. We categorized participants by tertiles of the neighborhood deprivation index (a residence-census tract-based measure) to examine the association of NSES with trajectories of HRQoL after adjusting for individual socioeconomic status (SES) and clinical characteristics. RESULTS: Participants had mean age 61.3 (SD, 11.4) years; 33% were female; 76%, non-Hispanic white; 11.2% had household income below the federal poverty level. During 6 months postdischarge, living in lower NSES neighborhoods was associated with lower mean PCS scores (1.5 points for intermediate NSES; 1.8 for low) and SAQ scores (2.4 and 4.2 points) versus living in high NSES neighborhoods. NSES was more consequential for patients with lower individual SES. Individuals living below the federal poverty level had lower average MCS and SAQ physical scores (3.7 and 7.7 points, respectively) than those above. CONCLUSIONS: Neighborhood deprivation was associated with worse health status. Using HRQoL to assess quality of care without accounting for individual SES and NSES may unfairly penalize safety-net hospitals.

Recurrent Clostridium difficile infection among Medicare patients in nursing homes: A population-based cohort study.

We explored the epidemiology and outcomes of Clostridium difficile infection (CDI) recurrence among Medicare patients in a nursing home (NH) whose CDI originated in acute care hospitals.We conducted a retrospective, population-based matched cohort combining Medicare claims with Minimum Data Set 3.0, including all hospitalized patients age ≥65 years transferred to an NH after hospitalization with CDI 1/2011-11/2012. Incident CDI was defined as ICD-9-CM code 008.45 with no others in prior 60 days. CDI recurrence was defined as (within 60 days of last day of CDI treatment): oral metronidazole, oral vancomycin, or fidaxomicin for ≥3 days in part D file; or an ICD-9-CM code for CDI (008.45) during a rehospitalization. Cox proportional hazards and linear models, adjusted for age, gender, race, and comorbidities, examined mortality within 60 days and excess hospital days and costs, in patients with recurrent CDI compared to those without.Among 14,472 survivors of index CDI hospitalization discharged to an NH, 4775 suffered a recurrence. Demographics and clinical characteristics at baseline were similar, as was the risk of death (24.2% with vs 24.4% without). Median number of hospitalizations was 2 (IQR 1-3) among those with and 0 (IQR 0-1) among those without recurrence. Adjusted excess hospital days per patient were 20.3 (95% CI 19.1-21.4) and Medicare reimbursements $12,043 (95% CI $11,469-$12,617) in the group with a recurrence.Although recurrent CDI did not increase the risk of death, it was associated with a far higher risk of rehospitalization, excess hospital days, and costs to Medicare.

On Edge: the impact of race-related vigilance on obesity status in African-Americans.

OBJECTIVE: Nearly half of African-Americans are classified as obese. Perceived racism has been associated with obesity, yet the internal experiences of racism have received little attention. African Americans who face racism may "ready themselves" to cope through survival strategies, including race-related vigilance. This study explores the association between race-related vigilance and obesity in African Americans. DESIGN AND METHODS: The Reactions to Race module of the Behavioral Risk Factor Surveillance Survey (years 2002-2010) was used. Our sample size consisted of 12,214 African-Americans. Race-related vigilance was assessed as: "How often do you think about your race?" and classified as: never, < daily, daily, and > daily. Obesity was dichotomized as body mass index (BMI) ≥30 kg/m2 vs. < 30 kg/m2 using self-reported weight and height. Multivariable logistic models assessed the association between race-related vigilance and obesity. RESULTS: Seventeen percent of respondents reported thinking about their race > daily; 14% daily; 31% < daily, and 39% reported never thinking about their race. Compared to those who reported never thinking about their race, the adjusted odds of obesity were 0.91, 95% CI: 0.72-1.15 among those thinking about their race daily. CONCLUSIONS: Frequently thinking about one's race was a risk factor for obesity in African-Americans in this study. Internalized impacts of racism captured through race-related vigilance may be particularly detrimental to African-Americans, driving their risk for obesity.