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Background: Healthcare disparities research is often limited by incomplete accounting for differences in health status by populations. In the United States, hysterectomy shows marked variation by race and geography, but it is difficult to understand what factors cause these variations without accounting for differences in the severity of gynecologic symptoms that drive the decision-making for hysterectomy., Objective: This study aimed to demonstrate a method for using electronic health record-derived data to create composite symptom severity indices to more fully capture relevant markers that influence the decision for hysterectomy., Study Design: This was a retrospective cohort study of 1993 women who underwent hysterectomy between April 4, 2014, and December 31, 2017, from 10 hospitals and >100 outpatient clinics in North Carolina. Electronic health record data, including billing, pharmacy, laboratory data, and free-text notes, were used to identify markers of 3 common indications for hysterectomy: bulk symptoms (pressure from uterine enlargement), vaginal bleeding, and pelvic pain. To develop weighted symptom indices, we finalized a scoring algorithm based on the relationship of each marker to an objective measure, in combination with clinical expertise, with the goal of composite symptom severity indices that had sufficient variation to be useful in comparing different patient groups and allow discrimination among severe symptoms of bulk, bleeding, or pain., Results: The ranges of symptom severity scores varied across the 3 indices, including composite bulk score (0-14), vaginal bleeding score (0-44), and pain score (0-30). The mean values of each composite symptom severity index were greater for those who had diagnostic codes for vaginal bleeding, bulk symptoms, or pelvic pain, respectively. However, each index demonstrated a variation across the entire group of hysterectomy cases and identified symptoms that ranged in severity among those with and without the target diagnostic codes., Conclusion: Leveraging multisource data to create composite symptom severity indices provided greater discriminatory power to assess common gynecologic indications for hysterectomy. These methods can improve the understanding in healthcare use in the setting of long-standing inequities and be applied across populations to account for previously unexplained variations across race, geography, and other social indicators., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Surgery is an important part of early stage breast cancer treatment that affects overall survival. Many studies of surgical treatment of breast cancer rely on data sources that condition on continuous insurance coverage or treatment at specified facilities and thus under-sample populations especially affected by cancer care inequities including the uninsured and rural populations. Statewide cancer registries contain data on first course of cancer treatment for all patients diagnosed with cancer but the accuracy of these data are uncertain., Methods: Patients diagnosed with stage I-III breast cancer between 2003 and 2016 were identified using the North Carolina Central Cancer Registry and linked to Medicaid, Medicare, and private insurance claims. We calculated the sensitivity, specificity, positive predictive value, negative predictive value, and Kappa statistics for receipt of surgery and type of surgery (breast conserving surgery or mastectomy) using the insurance claims as the presumed gold standard. Analyses were stratified by race, insurance type, and rurality., Results: Of 26,819 patients who met eligibility criteria, 23,125 were identified as having surgery in both the claims and registry for a sensitivity of 97.9% (95% CI 97.8%, 98.1%). There was also strong agreement for surgery type between the cancer registry and the insurance claims (Kappa: 0.91). Registry treatment data validity was lower for Medicaid insured patients than for Medicare and commercially insured patients., Conclusions: Cancer registry treatment data reliably identified receipt and type of breast cancer surgery. Cancer registries are an important source of data for understanding cancer care in underrepresented populations., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Bilateral oophorectomy before menopause, or surgical menopause, is associated with negative health outcomes, including an increased risk for stroke and other cardiovascular outcomes; however, surgical menopause also dramatically reduces ovarian cancer incidence and mortality rates. Because there are competing positive and negative sequelae associated with surgical menopause, clinical guidelines have not been definitive. Previous research indicates that White women have higher rates of surgical menopause than other racial groups. However, previous studies may have underestimated the rates of surgical menopause among Black women. Furthermore, clinical practice has changed dramatically in the past 15 years, and there are no population-based studies in which more recent data were used. Tracking actual racial differences among women with surgical menopause is important for ensuring equity in gynecologic care., Objective: This population-based surveillance study evaluated racial differences in the rates of surgical menopause in all inpatient and outpatient settings in a large, racially diverse US state with historically high rates of hysterectomy., Study Design: We evaluated all inpatient and outpatient surgeries in North Carolina from 2011 to 2014 for patients aged between 20 and 44 years. Surgical menopause was defined as a bilateral oophorectomy, with or without an accompanying hysterectomy, among North Carolina residents. International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes were used to identify inpatient and outpatient procedures, respectively, and diagnostic indications. We estimated age-, race-, and ethnicity-specific rates of surgical menopause using county-specific population estimates based on the 2010 United States census. We used Poisson regression with deviance-adjusted residuals to estimate the incidence rate ratios in the entire state population. We tested changes in surgery rates over time (reference year, 2011), differences by setting (reference, inpatient), and differences by race and ethnicity (reference, non-Hispanic White). We then described the surgery rates between non-Hispanic White and non-Hispanic Black patients., Results: Between 2011 and 2014, 11,502 surgical menopause procedures for benign indications were performed in North Carolina among reproductive-aged residents. Most (95%) of these surgeries occurred concomitant with a hysterectomy. Over the 4-year study period, there was a 39% reduction in inpatient surgeries (incidence rate ratio, 0.61) and a 100% increase in outpatient surgeries (incidence rate ratio, 2.0). Restricting the analysis to surgeries among non-Hispanic White and Black patients, the increase in outpatient surgeries was significantly higher among non-Hispanic Black women (P<.01) for year-race interaction (reference, 2011 and non-Hispanic White). The overall rates of bilateral oophorectomy for non-Hispanic Black women rose more quickly than for non-Hispanic White women (P<.01). In 2011, the rate of surgical menopause was greater among White women than among Black women (17.7 vs 13.2 per 10,000 women). By 2014, the racial trends were reversed (rate, 24.8 per 10,000 for non-Hispanic White women and 28.4 per 10,000 for non-Hispanic Black women)., Conclusion: Our findings suggest that the rates of surgical menopause increased in North Carolina in the early 2010s, especially among non-Hispanic Black women. By 2014, the rates of surgical menopause among non-Hispanic Black women had surpassed that of non-Hispanic White women. Given the long-term health consequences associated with surgical menopause, we propose potential drivers for the racially-patterned increases in the application of bilateral oophorectomy before the age of 45 years., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To investigate the intersection of race and economic context in treatment with hysterectomy among reproductive aged women with noncancerous gynecologic conditions., Data Sources: We combined administrative billing records of inpatient and outpatient hysterectomy procedures (N = 28 301) occurring in North Carolina between 2011 and 2014 with census data to calculate county-level hysterectomy rates., Study Design: Spatial analysis techniques examined the distribution of black and white hysterectomy rates across counties, and county-level black and white rate differences were compared across economic contexts., Data Collection/extraction: We restricted to those of premenopausal age identifying as non-Hispanic black or white, undergoing hysterectomy for nonemergent causes (N = 28 301 procedures)., Principal Findings: County-level hysterectomy rates were spatially patterned (Moran's I, P < .05) and similarly so for black and white women (LISA, P < .005). The black-white difference in hysterectomy rates was the largest in the high economic tier counties (22/10 000 person-years [PY], P < .05) and smallest in the mid and low economic tier counties (11/10 000 PY, P > .05 and 10/10 000 PY, P > .05, respectively)., Conclusion: Socioeconomic context is important to understand, particularly for black-white disparities in hysterectomy. Efforts should be made to understand the causes of higher rates of hysterectomy among blacks than whites, especially in counties in the highest economic tier., (© 2021 Health Research and Educational Trust.)

US Latinos, a growing, aging population, are disproportionately burdened by cognitive decline and dementia. Identification of modifiable risk factors is needed for interventions aimed at reducing risk. Broad sociocultural context may illuminate complex etiology among culturally diverse Latinos. Among 1,418 older (≥60 years), low-socioeconomic position (SEP) Latinos (predominantly of Mexican descent) in Sacramento, California, we examined whether US acculturation was associated with cognitive performance, cognitive decline, and dementia/ cognitive impairment without dementia over a 10-year period and whether education modified the associations (Sacramento Area Latino Study on Aging, 1998-2008). Analyses used linear mixed models, competing-risk regression, and inverse probability of censoring weights for attrition. Participants with high US acculturation had better cognitive performance (0.21 fewer cognitive errors at grand-mean-centered age 70 years) than those with low acculturation after adjustment for sociodemographic factors, practice effects, and survey language. Results may have been driven by cultural language use rather than identity factors (e.g., ethnic identity, interactions). Rate of cognitive decline and risk of dementia/cognitive impairment without dementia did not differ by acculturation, regardless of education (β = 0.00 (standard error, 0.00) and hazard ratio = 0.81 (95% confidence interval: 0.49, 1.35), respectively). High US acculturation was associated with better cognitive performance among these older, low-SEP Latinos. Acculturation may benefit cognition when SEP is low. Future studies should incorporate extended longitudinal assessments among more diverse groups., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Inequalities by race and ethnicity in hysterectomy for noncancerous conditions suggest that some subgroups may be shouldering an unfair burden of procedure-associated negative health impacts. We aimed to estimate race- and ethnicity-specific rates in contemporary hysterectomy incidence that address three challenges in the literature: exclusion of outpatient procedures, no hysterectomy prevalence adjustment, and paucity of non-White and non-Black estimates., Methods: We used surveillance data capturing all inpatient and outpatient hysterectomy procedures performed in North Carolina from 2011 to 2014 (N = 30,429). Integrating data from the Behavior Risk Factor Surveillance System and US Census population estimates, we calculated prevalence-corrected hysterectomy incidence rates and differences by race and ethnicity., Results: Prevalence-corrected estimates show that non-Hispanic (nH) Blacks (62, 95% confidence interval [CI] = 61, 63) and nH American Indians (85, 95% CI = 79, 93) per 10,000 person-years (PY) had higher rates, compared with nH Whites (45 [95% CI = 45, 46] per 10,000 PY), while Hispanic (20, 95% CI = 20, 21) and nH Asian/Pacific Islander rates (8, 95% CI = 8.0, 8.2) per 10,000 PY were lower than nH Whites., Conclusion: Through strategic surveillance data use and application of bias correction methods, we demonstrate wide differences in hysterectomy incidence by race and ethnicity. See video abstract at, http://links.lww.com/EDE/B657.

Purpose: In the United States, hysterectomies and oophorectomies are frequently performed before menopause for benign conditions. The procedures are associated with reduced breast cancer-specific mortality among White women. The relationship between premenopausal gynecologic surgery and mortality in Black women with breast cancer is unknown., Methods: This investigation used incident invasive cases of breast cancer from Phases 1 and 2 of the Carolina Breast Cancer Study a population-based study that recruited Black and White women in North Carolina between 1993 and 2001. Premenopausal gynecologic surgery was operationalized in three categories: no surgery; hysterectomy with bilateral oophorectomy; hysterectomy with conservation of ≥ 1 ovary. Mortality was ascertained using the National Death Index, last updated in 2016. Multivariable-adjusted Cox Proportional Hazard Models were used to estimate the effect of premenopausal surgery on breast cancer-specific and all-cause mortality RESULTS: Hysterectomy with bilateral oophorectomy was associated with reduced breast cancer-specific mortality (HR 0.68; 95% CI 0.49, 0.96). White and Black women had a similar reduction in breast cancer-specific mortality. (HR among white: 0.66; 95% CI 0.43, 1.02), (HR among Black: 0.67; 95% CI 0.37, 1.21)., Conclusions: There was a similar reduction in breast cancer-specific mortality following premenopausal, pre-diagnosis hysterectomy with bilateral oophorectomy across both Black and White women.

Objective: Despite growing evidence that discrimination may contribute to poor mental health, few studies have assessed this association among US Latinos. Furthermore, the interaction between discrimination and educational attainment in shaping Latino mental health is virtually unexplored. This study aims to examine the association between perceived discrimination and depressive symptoms and the modifying role of education among a population of Mexican-origin adults., Design: We utilized population-based data from 629 Mexican-origin adults (mean age = 52.8 years) participating the Niños Lifestyle and Diabetes Study (2013-2014). Perceived discrimination was defined as responding 'sometimes' or 'often' to at least one item on the 9-item Everyday Discrimination Scale. High depressive symptoms were defined as scoring ≥10 on the CESD-10. We used log-binomial and linear-binomial models to estimate prevalence ratios (PR) and prevalence differences (PD), respectively, of high depressive symptoms for levels of perceived discrimination. Final models were adjusted for age, sex, education, cultural orientation, and nativity. General estimating equations were employed to account for within-family clustering., Results: Prevalence of perceived discrimination and high depressive symptoms were 49.5% and 29.2%, respectively. Participants experiencing discrimination had higher depressive symptom prevalence than those never or rarely experiencing discrimination [PR = 1.94, 95% confidence interval (CI): 1.46-2.58; PD = 0.19, 95% CI: 0.12-0.27]. The strength of this association varied by education level. The association between discrimination and depressive symptoms was stronger among those with >12 years of education (PR = 2.69; PD = 0.24) compared to those with ≤12 years of education (PR = 1.36; PD = 0.09)., Conclusion: US Latinos suffer a high burden of depressive symptoms, and discrimination may be an important driver of this burden. Our results suggest that effortful coping strategies, such as achieving high education despite high perceived discrimination, may magnify discrimination's adverse effect on Latino mental health.

Acculturation may shape the disproportionate burden of poor sleep among Latinos in the United States. Existing studies are limited by unidimensional acculturation proxies that are incapable of capturing cultural complexities across generations. Understanding how acculturation relates to sleep may lead to the identification of modifiable intervention targets. We used multivariable regression and latent class methods to examine cross-sectional associations between a validated multidimensional scale of US acculturation and self-reported poor sleep measures. We analyzed an intergenerational cohort: first-generation (GEN1) older Latinos (Sacramento Area Latino Study on Aging; N = 1,716; median age: 69.5) and second-generation (GEN2) middle-aged offspring and relatives of GEN1 (Niños Lifestyle and Diabetes Study; N = 670; median age: 54.0) in Sacramento, California. GEN1 with high US acculturation, compared with high acculturation towards another origin/ancestral country, had less restless sleep (prevalence ratio [PR] [95% confidence interval (CI)]: 0.67 [0.54, 0.84]) and a higher likelihood of being in the best sleep class than the worst (OR [95% CI]: 1.62 [1.09, 2.40]), but among nonmanual occupations, high intergenerational US acculturation was associated with more general fatigue (PR [95% CI: 1.86 [1.11, 3.10]). GEN2 with high intergenerational US acculturation reported shorter sleep (PR [95% CI]: 2.86 [1.02, 7.99]). High US acculturation shaped sleep differentially by generation, socioeconomic context, and intergenerational acculturative status. High US acculturation was associated with better sleep among older, lower socioeconomic Latinos, but with shorter sleep duration among middle-aged, higher socioeconomic Latinos; results also differed by parental acculturation status. Upon replication, future studies should incorporate prospective and intergenerational designs to uncover sociobehavioral pathways by which acculturation may shape sleep to ultimately inform intervention efforts., (© Sleep Research Society 2018. Published by Oxford University Press [on behalf of the Sleep Research Society]. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: Neighborhood segregation related to cultural factors, such as language use, may influence elderly Latino depression. We examined the association between neighborhood-level Spanish language segregation and individual depressive symptoms among elderly Latinos., Methods: We linked U.S. Census language use data with geocoded population-based data from 1789 elderly Latinos (mean age = 70.6 years) participating in the Sacramento Area Latino Study on Aging (1998-2008). Neighborhood language segregation was measured with the Index of Concentration at the Extremes, which demonstrates the extent to which residents are concentrated at extremes of deprivation and privilege. We fit two-level generalized linear-mixed models with random intercepts for census tracts to quantify the association between neighborhood-level language segregation and depressive symptoms, adjusting for identified confounders., Results: After adjusting for age, sex, and nativity, residents of highly segregated Spanish-speaking neighborhoods had more depressive symptoms than those in highly segregated English-only-speaking neighborhoods (β = -4.410; 95% confidence interval [CI] = -6.851 to -1.970). This association was largely attenuated upon adjustment for individual-level education (β = -2.119; 95% CI = -4.650 to 0.413)., Conclusions: Linguistically segregated communities may benefit from targeted outreach given the high depression prevalence in these neighborhoods. Furthermore, our findings suggest that limited access to fundamental social protections, such as education, may drive the segregation-depression association among U.S. Latinos., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Few studies have collected intergenerational data to assess the association between educational mobility across multiple generations and offspring depression. Using data from the Sacramento Area Latino Study on Aging (1998-2008), we assessed the influence of intergenerational education on depressive symptoms over 10 years among 1,786 Latino individuals (mean age = 70.6 years). Educational mobility was classified as stable-low (low parental/low offspring education), upwardly mobile (low parental/high offspring education), stable-high (high parental/high offspring education), or downwardly mobile (high parental/low offspring education). Depressive symptoms were measured with the Center for Epidemiological Studies-Depression Scale (CES-D); higher scores indicated more depressive symptoms. To quantify the association between educational mobility and CES-D scores over follow-up, we used generalized estimating equations to account for repeated CES-D measurements and adjusted for identified confounders. Within individuals, depressive symptoms remained relatively stable over follow-up. Compared with stable-low education, stable-high education and upward mobility were associated with significantly lower CES-D scores (β = -2.75 and -2.18, respectively). Downwardly mobile participants had slightly lower CES-D scores than stable-low participants (β = -0.77). Our results suggest that sustained, low educational attainment across generations may have adverse mental health consequences, and improved educational opportunities in underresourced communities may counteract the adverse influence of low parental education on Latino depression.

Background: Despite 50 years since the passage of the Fair Housing Act of 1968, the majority of black Americans continue to live in highly segregated communities. Differing exposure to obesogenic environments in segregated neighborhoods may contribute to racial disparities in obesity prevalence., Methods: We used prospective data from the Coronary Artery Risk Development in Young Adults (CARDIA) study to examine associations between levels of neighborhood-level racial residential segregation and incident obesity in black men and women. Obesity, determined by measured anthropometry, and residential segregation, measured using the local Gi*statistic, were recorded at baseline and follow-up at years 7, 10, 15, 20, and 25. We used marginal structural survival models to account for time-dependent confounding and for loss to follow-up., Results: Black women living in highly segregated neighborhoods at the prior exam were 30% more likely to become obese during the follow-up period as compared with women living in neighborhoods with low levels of segregation after adjustment for sociodemographic and cardiovascular risk covariates (hazard ratio = 1.3 [95% confidence interval = 1.0, 1.7]). Cumulatively high exposure to segregation averaged across time points was associated with 50% higher hazard of obesity (hazard ratio = 1.5 [95% confidence interval = 1.0, 2.3]) among women. We observed few differences in obesity incidence among men by segregation levels., Conclusions: Fewer health-promoting resources, stressful neighborhood context, and social norms that are less stigmatizing of obesity may contribute to these findings, but more research on specific pathways leading from segregation to obesity is needed to understand differing patterns between men and women.

Background: African American breast cancer patients have lower frequency of hormone receptor-positive (HR+)/human epidermal growth factor receptor 2 (HER2)-negative disease and higher subtype-specific mortality. Racial differences in molecular subtype within clinically defined subgroups are not well understood., Methods: Using data and biospecimens from the population-based Carolina Breast Cancer Study (CBCS) Phase 3 (2008-2013), we classified 980 invasive breast cancers using RNA expression-based PAM50 subtype and recurrence (ROR) score that reflects proliferation and tumor size. Molecular subtypes (Luminal A, Luminal B, HER2-enriched, and Basal-like) and ROR scores (high vs low/medium) were compared by race (blacks vs whites) and age (≤50 years vs > 50 years) using chi-square tests and analysis of variance tests., Results: Black women of all ages had a statistically significantly lower frequency of Luminal A breast cancer (25.4% and 33.6% in blacks vs 42.8% and 52.1% in whites; younger and older, respectively). All other subtype frequencies were higher in black women (case-only odds ratio [OR] = 3.11, 95% confidence interval [CI] = 2.22 to 4.37, for Basal-like; OR = 1.45, 95% CI = 1.02 to 2.06, for Luminal B; OR = 2.04, 95% CI = 1.33 to 3.13, for HER2-enriched). Among clinically HR+/HER2- cases, Luminal A subtype was less common and ROR scores were statistically significantly higher among black women., Conclusions: Multigene assays highlight racial disparities in tumor subtype distribution that persist even in clinically defined subgroups. Differences in tumor biology (eg, HER2-enriched status) may be targetable to reduce disparities among clinically ER+/HER2- cases., (© The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: Previous US population-based studies have found that body weight may be underestimated when self-reported. However, this research may not apply to all US Hispanics/Latinos, many of whom are immigrants with distinct cultural orientations to ideal body size. We assessed the data quality and accuracy of self-reported weight in a diverse, community-based, US sample of primarily foreign-born Hispanic/Latino adults., Methods: Using baseline data (2008-2011) from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), we described the difference between contemporaneous self-reported and measured current body weight (n = 16,119) and used multivariate adjusted models to establish whether the observed trends in misreporting in potential predictors of inaccuracy persisted after adjustment for other predictors. Last, we described the weighted percentage agreement in body mass classification using either self-reported or measured weight (n = 16,110)., Results: Self-reported weight was well correlated with (r = 0.95) and on average 0.23 kg greater than measured weight. The range of this misreporting was large and several factors were associated with misreporting: age group, gender, body mass categories, nativity, study site by background, unit of self-report (kg or lb), and end-digit preference. The percentage agreement of body mass classification using self-reported versus measured weight was 86% and varied across prevalent health conditions., Conclusions: The direction of misreporting in self-reported weight, and thus the anticipated bias in obesity prevalence estimates based on self-reported weights, may differ in US Hispanic/Latinos from that found in prior studies. Future investigations using self-reported body weight in US Hispanic/Latinos should consider this information for bias analyses.See video abstract at, http://links.lww.com/EDE/B276.

Most body mass index (BMI) genetic loci have been identified in studies of primarily European ancestries. The effect of these loci in other racial/ethnic groups is less clear. Thus, we aimed to characterize the generalizability of 170 established BMI variants, or their proxies, to diverse US populations and trans-ethnically fine-map 36 BMI loci using a sample of >102,000 adults of African, Hispanic/Latino, Asian, European and American Indian/Alaskan Native descent from the Population Architecture using Genomics and Epidemiology Study. We performed linear regression of the natural log of BMI (18.5-70 kg/m 2 ) on the additive single nucleotide polymorphisms (SNPs) at BMI loci on the MetaboChip (Illumina, Inc.), adjusting for age, sex, population stratification, study site, or relatedness. We then performed fixed-effect meta-analyses and a Bayesian trans-ethnic meta-analysis to empirically cluster by allele frequency differences. Finally, we approximated conditional and joint associations to test for the presence of secondary signals. We noted directional consistency with the previously reported risk alleles beyond what would have been expected by chance (binomial p < 0.05). Nearly, a quarter of the previously described BMI index SNPs and 29 of 36 densely-genotyped BMI loci on the MetaboChip replicated/generalized in trans-ethnic analyses. We observed multiple signals at nine loci, including the description of seven loci with novel multiple signals. This study supports the generalization of most common genetic loci to diverse ancestral populations and emphasizes the importance of dense multiethnic genomic data in refining the functional variation at genetic loci of interest and describing several loci with multiple underlying genetic variants.

Background: Child obesity is a major problem in the United States. Identifying early-life risk factors is necessary for prevention. Maternal diet during pregnancy is a primary source of fetal energy and might influence risk of child obesity., Objective: We prospectively investigated the influence of maternal dietary patterns during pregnancy on child growth in the first 3 y of life in 389 mother-child pairs from the Pregnancy, Infection, and Nutrition study., Methods: Dietary patterns were derived with the use of latent class analysis (LCA) based on maternal diet, collected with the use of a food-frequency questionnaire at 26-29 wk gestation. Associations between maternal dietary patterns and child body mass index (BMI)-for-age z score and overweight or obesity were assessed with the use of linear regression and log-binomial regression, respectively. We used linear mixed models to estimate childhood growth patterns in relation to maternal dietary patterns., Results: Three patterns were identified from LCA: 1) fruits, vegetables, refined grains, red and processed meats, pizza, french fries, sweets, salty snacks, and soft drinks (latent class 1); 2) fruits, vegetables, baked chicken, whole-wheat bread, low-fat dairy, and water (latent class 2); and 3) white bread, red and processed meats, fried chicken, french fries, and vitamin C-rich drinks (latent class 3). In crude analyses, the latent class 3 diet was associated with a higher BMI-for-age z score at 1 and 3 y of age and a higher risk of overweight or obesity at 3 y of age than was the latent class 2 diet. These associations were not detectable after adjustment for confounding factors. We observed an inverse association between the latent class 3 diet and BMI-for-age z score at birth after adjustment for confounding factors that was not evident in the crude analysis (latent class 3 compared with latent class 2-β: -0.41; 95% CI: -0.79, -0.03)., Conclusion: In this prospective study, a less-healthy maternal dietary pattern was associated with early childhood weight patterns., Competing Interests: 2 Author disclosures: CL Martin, AM Siega-Riz, D Sotres-Alvarez, WR Robinson, JL Daniels, EM Perrin, and AM Stuebe, no conflicts of interest., (© 2016 American Society for Nutrition.)

Background: Few studies have comprehensively evaluated the effectiveness of multi-faceted interventions intended to improve pedestrian safety. "Watch for Me NC" is a multi-faceted, community-based pedestrian safety program that includes widespread media and public engagement in combination with enhanced law enforcement activities (i.e., police outreach and targeted pedestrian safety operations conducted at marked crosswalks) and low-cost engineering improvements at selected crossings. The purpose of this study was to estimate the effect of the law enforcement and engineering improvement components of the program on motor vehicle driver behavior, specifically in terms of increased driver yielding to pedestrians in marked crosswalks., Methods: The study used a pre-post design with a control group, comparing crossing locations receiving enforcement and low-cost engineering treatments (enhanced locations) with locations that did not (standard locations) to examine changes in driver yielding over a 6-month period from 2013 to 2014. A total of 24,941 drivers were observed in 11,817 attempted crossing events at 16 crosswalks in five municipalities that were participating in the program. Observations of real pedestrians attempting to use the crosswalks ("naturalistic" crossing) were supplemented by observations of trained research staff attempting the same crossings following an established protocol ("staged" crossings). Generalized estimating equations (GEE) were used to model driver yielding rates, accounting for repeated observations at the crossing locations and controlling other factors that affect driver behavior in yielding to pedestrians in marked crosswalks., Results: At crossings that did not receive enhancements (targeted police operations or low-cost engineering improvements), driver yielding rates did not change from before to after the Watch for Me NC program. However, yielding rates improved significantly (between 4 and 7 percentage points on average) at the enhanced locations. This was true for both naturalistic and staged crossings., Conclusions: This study provides evidence that enhanced enforcement and low-cost engineering improvements, as a part of a broader program involving community-based outreach, can increase driver yielding to pedestrians in marked crosswalks. These data are important for the staff and decision-makers involved in pedestrian safety programs to gain a better understanding of the different engineering and behavioral mechanisms that could be used to improve driver yielding rates., (Published by Elsevier Ltd.)

Background: In the literature, it has been suggested that there are race-ethnic disparities in what Americans eat. In addition, some studies have shown that residents of African American and low-income neighborhoods have less access to grocery stores and supermarkets, which tend to stock healthier foods. However, it is unclear whether differences in food shopping patterns contribute to the poorer nutrient profile of food purchases made by racial-ethnic minorities., Objectives: We examined whether the mix of food stores where people shop (i.e., food-shopping patterns) was associated with the nutrient profile of packaged food purchases (PFPs) and the types of foods and beverages purchased, and we determined whether these associations differ across racial-ethnic groups., Design: We used PFPs by US households (Nielsen National Consumer Panel) from 2007 to 2012 and implemented a cluster analysis to categorize households according to their food-shopping patterns. Longitudinal random-effects linear regression models were used to examine the association between food shopping patterns and the nutrient qualities and types of packaged foods and beverages purchased by race-ethnicity in US households., Results: Shopping primarily at grocery chains was not associated with a better nutrient profile of household PFPs or the food and beverages that households purchased than was shopping primarily at mass merchandisers (value-oriented stores that sell merchandise lines in multiple departments) or at a combination of large and small stores. These results were consistent across racial-ethnic groups. Regardless of where households shopped, non-Hispanic African American households purchased foods with higher energy, total sugar, and sodium densities than did non-Hispanic white and Hispanic households., Conclusion: Policy initiatives that focus on increasing physical access to stores or helping stores sell healthier products to encourage healthier purchases may be ineffective because other factors may be more important determinants of food and beverage purchases than where people shop or what is available in the store., (© 2016 American Society for Nutrition.)

Objective: The purpose of this study was to examine the association of intergenerational education and country of birth with waist circumference, metabolic syndrome, and type 2 diabetes among older adult Latinos in the United States., Methods: We used cross-sectional data from the Sacramento Area Latino Study on Aging, a cohort of older adult Mexican-American Latinos (mean age = 70 years). At baseline, we measured waist circumference and assessed metabolic syndrome and diabetes according to established guidelines (N = 1,789). Participants were classified as US-born or foreign-born based on self-reported birth country. Participants reported their parents' education level (≥6 vs. <6 years) and their own educational attainment (≥12 vs. <12 years)., Results: US-born participants who achieved high adult education, regardless of their parents' education, had 37% lower odds of type 2 diabetes compared to US-born participants with both low parental and personal education levels [e.g., multivariable-adjusted OR (parental low/adult high) = 0.63; 95% CI = 0.40, 0.99]. Among the foreign-born, only those with both high parental and high personal education levels had 55% lower odds of large waist circumference (OR = 0.45; 95% CI = 0.23, 0.88) compared to foreign-born participants with both low parental and personal education levels., Conclusions: Intergenerational exposure to low education levels may increase central obesity and type 2 diabetes differentially among US-born and foreign-born Latinos., (© 2015 The Obesity Society.)

Objective: Contemporary childbearing is associated with greater gestational weight gain and postpartum weight retention than in previous decades, potentially leading to a more pronounced effect of childbearing on women's long-term obesity risk. Previous work on the association of childbearing with women's long-term obesity risk mostly examined births in the 1970s and 1980s and produced mixed results. The association of childbearing and obesity incidence in a diverse, contemporary sample of 2731 US women was estimated., Methods: Propensity-score (PS) matching was used for confounding control when estimating the effect of incident parity (1996-2001) on 7-year incident obesity (BMI≥30 kg/m(2) ) (2001-2008)., Results: In the sample, 19.3% of parous women became obese, whereas 16.1% of unmatched nulliparous women did. After PS matching without and with replacement, the differences in obesity incidence were, respectively, 0.0 percentage points (ppts) (95% CI: -4.7 to 4.7) and 0.9 ppts (95% CI: -4.9 to 6.7). Results were similar in analyses of prevalent parity and obesity in 2008 (n = 6601) conducted to explore possible selection bias., Conclusions: These results imply that, in contemporary US parous women in their late 20s and early 30s, childbearing may not increase obesity incidence., (Copyright © 2013 The Obesity Society.)