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The present study investigates the spatial correlation between built and natural environments that promote physical activity (PA) and children’s fitness. Previous work has been conducted on various geographic scales such as from a county level. However, evaluations from a school attendance zone level, which are the policy and program administration units for schools, have yet to be investigated. Using a factor analysis, 24 PA-related environmental variables were reduced to six environmental factors and then run factors with geographically weighted regression (GWR) at the level of the elementary school attendance zones (ESAZ) in Georgia. The outside-school environmental factors (park, recreation, terrain, nature and camping) and inside school environmental factor (school PA time) were constructed by ESAZ. We found that of all the PA environment factors, the most highly associated with promoting PA and children’s fitness were inside-school PA environment. The outside factors of the park and terrain environment indicated strong local geographic variation in youth health. The result showed local variation in the association between PA environment and fitness among elementary school children in Georgia and highlighted the geographically customized efforts for different regions’ policy changes to improve child health.

In the United States, physical activity (PA) among adolescents is declining; 75% of high school students do not meet daily PA guidelines. Low rates of PA are more prevalent among high school girls. Schools provide an optimal environment to target and promote PA. However, school climate has not yet been studied for its importance in promoting PA among high school students, particularly girls.A cross-sectional analysis was conducted using the Georgia Student Health Survey (GSHS) 2.0 data on perceptions of different school climate measures and self-reported weekly PA levels to study gender differences in the association of PA with school climate.Data from a total of 362,926 students (48% males and 52% females) were analyzed. For both genders, the odds of being physically active increased with a more positive report of supportive school environments, school connectedness, peer social support, school physical environments, cultural acceptance, school safety, and adult social support. Peer victimization was associated with increased odds of PA among females but lower odds for males.Results suggest that improving school climate can increase PA among adolescents. As new or existing school-based interventions and policies are considered by states and local governments, improving the school climate should be part of the overall strategy. Future research is needed on peer victimization among physically active females.This study evaluated gender differences in the association between measures of school climate and PA among high school students. School climate or policies fostering positive environments including feelings of safety, connectedness, and peer support may increase adolescent PA; addressing peer victimization and fights may reduce gender disparities in PA.

Introduction: Adherence to anti-hypertensive drugs, which is sub-optimal despite public health and policy efforts, is essential in controlling high blood pressure. Medicare Advantage plans are gaining popularity, partly due to their managed care designs that held promise to improve chronic disease management. Hypothesis: We assessed the hypothesis that hypertensive patients with a managed care plan have higher adherence to antihypertensive drugs than those with a non-managed care plan. Methods: We analyzed medication adherence – measured using proportion of days covered (PDC) over 12 months for antihypertensive drugs – among 174,172 patients with a hypertension diagnosis from the medical and pharmacy claims and benefits data in the 2017-2019 IBM MarketScan Research Database. We fitted separate generalized linear regression models among monotherapy (use of one class of antihypertensive drugs) and polytherapy (combined use of at least two classes of antihypertensive drugs) users and computed postestimation margins with the best-fitted model to compare medication adherence by plan type: 1) Managed Care exclusive provider organization and health management organization (EPO/HMO) plan, 2) Managed Care point-of-service plan, 3) Managed Care preferred provider organization plan, 4) non-Managed Care comprehensive plan, 5) non-Managed Care consumer driven health plan / high deductible health plan. Other patient characteristics included in the analyses were age, age-squared, sex, comorbidities, census region, and their interaction terms. Results: The average PDC among Medicare patients on monotherapy was 0.53 and among those on polytherapy was 0.74. Patients with a managed-care EPO/HMO plan had the highest PDC (0.53, 95% confidence interval [CI]: 0.52, 0.54 among monotherapy users and 0.73, 95% CI: 0.72, 0.74 among polytherapy users, respectively) and those with a non-managed care comprehensive plan had the lowest PDC (0.42, 95% CI: 0.41, 0.43 among monotherapy users and 0.62, 95% CI: 0.61, 0.63 among polytherapy users, respectively). By census region, patients living in the North Central region with a managed care EPO/HMO plan had the highest average PDC (0.71, 95% CI: 0.70, 0.72 among monotherapy users and 0.85, 95% CI: 0.84, 0.86 among polytherapy users, respectively). Other factors such as age, sex, and number of chronic conditions were significantly associated with PDC. Conclusions: In conclusion, with an increase in the proportion of older adults enrolled in Medicare Advantage insurance, managed care models may play a more important role in influencing adherence to essential drugs such as anti-hypertensive drugs among Medicare beneficiaries. Future research should investigate factors that promote adherence to medications across different managed care plan designs.

While malaria and neglected tropical disease (NTD) morbidity and mortality rates among children5 years old have decreased through public health efforts in the United Republic of Tanzania, associations between household environments and disease outcomes are relatively unknown.We conducted latent class analysis (LCA) on 2015-2016 Tanzania Demographic Health Survey data from mothers with children5 years old (N = 10 233) to identify NTD household risk profiles. The outcome of child NTD was assessed by mothers' reports of recent diarrhoea, cough, treatment for enteric parasites, and fever symptoms. Household-built environment indicators included urban/rural designation, electricity access, water source, cooking fuel, flooring, wall, and roofing materials. External environmental covariates were considered to further differentiate profiles.Five profiles were identified in the sample: rural finished walls households (40.2%) with the lowest NTD risk; rural rudimentary households (20.9%) with intermediate-low NTD risk; finished material households (22.5%) with intermediate NTD risk; urban households (14.4%) with intermediate-high NTD risk and high likelihood of enteric parasites; rural finished roof/walls households (2.1%) with the highest overall NTD risk.This study is among the first to use LCA to examine household environment characteristics to assess child NTD risk in Tanzania. This paper serves as a framework for community-level rapid NTD risk assessment for targeted health promotion interventions.

Purpose: Limited English proficiency and increased language isolation are known to be associated with adverse health outcomes. It is not clear how neighborhood-level linguistic isolation may impact individual health and risk of death among Hispanic older adults. We examined the link between living in a linguistically isolated neighborhood and all-cause mortality among an older Mexican American cohort. Methods: Using a longitudinal sample of older Mexican Americans from the Hispanic Established Populations for the Epidemiologic Studies of the Elderly, we calculated the days from the baseline interview (1993–1994) until observed death through five waves of follow-up (until 2004–2005) using Cox regression. A linguistically isolated neighborhood was defined as a census tract with more than 30% of linguistically isolated households. Results: Our results showed that living in a neighborhood with more than 30% of linguistically isolated households predicted higher mortality (hazard ratio: 1.25; 95% confidence interval: 1.04–1.50), after adjusting for age, sex, nativity, years of education, marital status, self-reported health status, number of chronic conditions, ever smoked, ever drank, and other neighborhood-level contextual factors. Conclusion: Living in a neighborhood with a high proportion of linguistically isolated households predicted higher mortality among older Mexican Americans. Addressing the social capital shortage in linguistically isolated neighborhoods is one way to address health disparities in the United States.

Telomere length is affected by lifestyle and environmental factors and varies between racial and ethnic groups; however, studies are limited, with mixed findings. This study examined the effects of tobacco use and smoke exposure on mean telomere length to identify critical age periods by race/ethnicity. We used time-varying effect modeling on the National Health and Nutrition Examination Survey for continuous years 1999–2002 to observe the effects of active tobacco use and environmental tobacco smoke—measured through serum cotinine—and mean telomere length for adults 19 to 85 and older (N = 7826). Models were run for Mexican American, other Hispanic, non-Hispanic White, non-Hispanic Black, and other/multi-race categories to allow for time-varying group differences, and controlled for biological sex, socioeconomic status, education, and ever-smoker status. Serum cotinine was found to have an increasing effect on telomere length from age 37 to approximately age 74 among Mexican Americans. Among other/multi-race individuals serum cotinine was found to have a decreasing effect at approximately age 42, and among Blacks, it had an overall decreasing effect from age 61 to 78. Findings reveal a further need to focus additional support and resources to intervene regarding disparate health effects from tobacco use and environmental smoke exposure for already vulnerable groups at particular ages.

Background To address change in the gender gap of life expectancy (GGLE) in Shanghai from 1973 to 2018, and to identify the major causes of death and age groups associated with the change over time. Methods The temporal trend in GGLE was evaluated using retrospective demographic analysis with Joinpoint regression. Causes of death were coded in accordance with the International Classification of Diseases and mapped with the Global Burden of Disease (GBD) cause list. The life table technique and decomposition method were used to express changes in GGLE. Results The trend of GGLE in Shanghai experienced two phases, i.e., a decrease from 8.4 to 4.2 years in the descent phase (1973–1999) and a fluctuation between 4.0 and 4.9 years in the plateau phase (1999–2018). The reduced age-specific mortality rates tended to concentrate to a narrower age range, from age 0–9 and above 30 years in the descent phase to age above 55 years in the plateau phase. Gastroesophageal and liver cancer, communicable, chronic respiratory, and digestive diseases were once the major contributors to narrow GGLE in the descent phase. While, importance should be attached to a widening effect on GGLE by lung cancer, cardiovascular diseases, other neoplasms like colorectal and pancreatic cancer, and diabetes in the recent plateau phase. Conclusions Non-communicable diseases (NCDs) have made GGLE enter a plateau phase from a descent phase in Shanghai, China. Public efforts to reduce excess mortalities for male NCDs, cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes in particular and health policies focused on the middle-aged and elderly population might further narrow GGLE. This will also ensure improvements in health and health equity in Shanghai China.

Considering the importance of social and structural support and resources in recovering health, where people reside could lead to differences in health outcome in Medicare home health care. We used the 2019 Outcome and Assessment Information Set and Area Deprivation Index to examine the association between neighborhood context and successful discharge to community among older Medicare home health care users. Based on the multivariable logistic regression (OR: 0.84; 95% CI, 0.83–0.85) and conditional logistic regression models stratified by home health agency (OR: 0.95; 95% CI, 0.94–0.95), patients living in the most disadvantaged neighborhoods were less likely to experience successful discharge to community than others. Furthermore, the predicted probability of successful discharge to community decreased as the percentage of patients from the most disadvantaged neighborhoods within a home health agency increased. Policymakers should consider using area-level interventions and supports to reduce disparities in Medicare home health care.

OBJECTIVE We examine role of ACEs and pathways to risk of opioid misuse among young adults. Participants and Methods: A cross-sectional survey of validated measures of ACEs, risk of opioid misuse, and health conditions with a sample of 1,402 students from a large public university followed by multivariate logistic regression and pathway analysis. Results: Majority (61%) of participants reported at least one ACE. A dose-response relationship between numbers of ACEs with risk for opioid misuse was present. Compared to participants with no ACEs, participants with ≥4 ACEs and 0-3 ACEs were 2.93 (95% CI: 1.95, 4.39; p

To understand the design and implementation models of US produce prescription programs.In a mixed-methods study, program providers completed an online survey and an individual phone interview regarding their 2019 programming.Twenty-three programs completed surveys; 20 completed interviews. Program locations included the mid-Atlantic (26%), Northeast (9%), Midwest (30%), Southwest (17%), and Western regions (17%). Although program models varied, programs generally included a health care visit, usually at a safety-net clinic, and nutrition education, typically counseling, advice, or classes. Prescriptions tended to be farmers market vouchers worth a median of $15 a week (interquartile range, $7.81-$20.00). Transportation was a problem for nearly half of the programs.Current produce prescription program characteristics and operations can serve as a blueprint for new and existing programs. Future research should determine program best practices and the opportunity cost between program standardization and local flexibilities.

Effective COVID-19 vaccine distribution requires prioritizing locations that are accessible to high-risk target populations. However, little is known about the vaccination location preferences of individuals with underlying chronic conditions. Using data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), we grouped 162,744 respondents into high-risk and low-risk groups for COVID-19 and analyzed the odds of previous influenza vaccination at doctor’s offices, health departments, community settings, stores, or hospitals. Individuals at high risk for severe COVID-19 were more likely to be vaccinated in doctor’s offices and stores and less likely to be vaccinated in community settings.

Physician shortages are more pronounced in rural than in urban areas. The geography of medical school application and matriculation could provide insights into geographic differences in physician availability. Using data from the Association of American Medical Colleges (AAMC), we conducted geospatial analyses, and developed origin–destination (O–D) trajectories and conceptual graphs to understand the root cause of rural physician shortages. Geographic disparities exist at a significant level in medical school applications in the US. The total number of medical school applications increased by 38% from 2001 to 2015, but the number had decreased by 2% in completely rural counties. Most counties with no medical school applicants were in rural areas (88%). Rurality had a significant negative association with the application rate and explained 15.3% of the variation at the county level. The number of medical school applications in a county was disproportional to the population by rurality. Applicants from completely rural counties (2% of the US population) represented less than 1% of the total medical school applications. Our results can inform recruitment strategies for new medical school students, elucidate location decisions of new medical schools, provide recommendations to close the rural–urban gap in medical school applications, and reduce physician shortages in rural areas.

Introduction: Cardiometabolic diseases (CMDs), which include coronary heart disease (CHD), hypertension (HTN), type 2 diabetes (DM) and obesity, are an interrelated set of highly preventable conditions. Food insecurity, another pervasive public health issue, is associated with CMDs. We aim to characterize the prevalence of CMD by food security (FS) status over time. Hypothesis: Prevalence of DM and obesity increased while that of HTN and CHD decreased over time, with pervasive disparities among FS status. Methods: Adults ≥20 years from the 1999-2016 NHANES were included in this analysis. CMD outcomes included DM (prior diagnosed or FPG≥126 mg/dL or HbA1c ≥6.5%), CHD (prior diagnosis of myocardial infarction, angina or any other type of CHD), obesity (BMI ≥30 kg/m 2 ) and HTN (≥1 of the following: systolic blood pressure (BP) ≥130 mmHg, diastolic BP ≥80, or currently taking BP medications). FS status was measured through the US Household Food Security Survey Module and recategorized into three levels (full, marginal and low). All estimates were age-standardized to the 2010 US census population. All analyses accounted for the complex survey design. Logistic regressions were conducted to calculate P-values. Results: Our sample included 46,879 adults (79.5% of full, 7.67% of marginal and 12.8% of low FS). HTN prevalence decreased from 50% to 44.4% among the full FS group and from 54.9% to 50.4% among the marginal group (P-trendsFigure ). Conclusion: From 1999 to 2016, the prevalence of CMDs were lowest among participants who were in full FS group and disparities by FS status persisted or worsened.

BACKGROUND: Prostate-specific antigen (PSA) surveillance testing is a cornerstone of prostate cancer survivorship because patients with biochemical recurrence often have no symptoms. However, the investigation of guideline-concordant PSA surveillance across racial groups is limited. We examined racial differences in PSA surveillance testing 5-years post-definitive treatment for localized prostate cancer. METHODS: We created a population-based retrospective cohort from the Surveillance, Epidemiology, and End Results-Medicare linked database for men diagnosed with prostate cancer between the years 2007 to 2011 with Medicare claims through 2016 (N = 21,372). Multivariable log-binomial regression models were used to examine the effect of race on the likelihood of not receiving at least one PSA surveillance test annually 5-years post-definitive treatment. RESULTS: Black men had 90%, 71%, 44%, 34%, and 23% increased risk of not receiving at least one PSA surveillance test annually in the first, second, third, fourth, and fifth years of post-definitive treatment follow-up, respectively. The adjusted relative risk [ARR] for Black men compared to White men were 1.68 (95% Confidence Interval [CI], 1.37–2.07), 1.52 (95% CI, 1.32–1.75), 1.32 (95% CI, 1.17–1.48), and 1.16 (95% CI, 1.05–1.29) in the first, second, third, and fourth year of post-definitive treatment, respectively. CONCLUSION: Black men were more likely not to receive guideline-concordant PSA surveillance testing following definitive treatment for localized prostate cancer during the first 4 years post-treatment. This study suggest room for improvement in defining survivorship care plans for Black men to increase use of PSA surveillance testing.

OBJECTIVE: To report and examine associations with infant vitamin D intake and meeting recommendations among a national sample participating in WIC. DESIGN: Secondary analysis from the 2013–2015 WIC Infant Toddler Feeding Practices Study-2. PARTICIPANTS: US Infants. VARIABLES MEASURED: Total reported vitamin D intake from diet and supplementation at the time of data collection. ANALYSIS: Descriptive statistics and generalized estimating equations. RESULTS: The median total vitamin D intake ranged from 5.43 (95% CI: 5.40, 5.46) mcg/day at month 1 to 8.18 (95% CI: 8.11, 8.20) mcg /day at month 13, with 16–36% of infants meeting the infant vitamin D recommendation over that time. Overall 6 to 12% of all participants reported supplementation, across all time points. Although most (between 78–98%) of supplemented breastfed infants met the recommendation, very few were supplemented as a group. Hence, breastfed infants were less likely to meet the recommendation as compared to those who were formula fed across at time points except month 1 (P < 0.001 for all). Whereas infant age, feeding type, and/or their interaction were significant predictors of both receiving supplementation and meeting the recommendation, maternal nativity (P = 0.006) and parity (P = 0.01 and P < 0.001) predicted receiving supplementation, and child sex (P < 0.001) and maternal race/ethnicity (P < 0.001) predicted meeting the recommendation. CONCLUSIONS AND IMPLICATIONS: Among a national sample of infants participating in WIC between 2013–2015, a high proportion were not meeting the current vitamin D recommendation. The WIC program is one resource for promoting strategies for increasing the number of American infants meeting D recommendations yet, a coordinated approach involving other health care providers is likely needed. Future research exploring the reason for lack of supplementation, from both the perspective of parents and providers, as well as the clinical impact of low vitamin D intake is warranted.

Background: With the growing rate of obesity and associated chronic conditions in China, there is a need to assess the health and economic burdens of obesity and examine the effectiveness of pharmaceutical, medical, and comprehensive weight-loss interventions. Areas covered: This article reviewed publications retrieved from PubMed and Google Scholar during 2010–2020 on pharmacoeconomic studies related to overweight and obesity in China. We identified five cost-of-illness studies and four cost-effectiveness analyses of weight-loss interventions, including bariatric surgeries and a comprehensive intervention program. Expert opinion: There is a lack of pharmacoeconomic analyses of obesity in China. Existing studies have often taken the health system perspective without accounting for productivity loss. Cohort studies and studies based on electronic health records or claims data are needed to provide the epidemiologic parameters required for homegrown economic evaluations of the health and economic burdens of obesity in China, as well as the cost-effectiveness of interventions to reduce obesity and its sequela.

Background Bereavement is the experience of an individual following the death of a person of significance to the individual, most often referring to the spouse. Increased morbidity, health care utilization, and mortality are known to be associated with bereavement. Given China’s growing population of older adults, there is a critical need to assess the health consequences of bereavement. Method We use data from the China Health and Retirement Longitudinal Study to examine the impact of bereavement on mental health and quality of life among a sample of mid- and older-aged adults. We use propensity score matching to construct a matching sample and difference-in-differences method to estimate the impact of bereavement on mental health and self-assessed health. Results We find bereavement is associated with increased depression symptoms among women (1.542 point or 0.229 standard deviations of Center for Epidemiologic Studies Depression (CES-D) 10 score) but not consistently for men over time. No statistically significant effect of bereavement on self-assessed health is found. Conclusions Our results show a harmful impact of bereavement on mental health among older women in China and point to the need for a comprehensive policy on survivor benefits in China, particularly for rural older women.

This study aims to examine the trend in the diagnosis of obesity and the use of surgical treatment in in-patient settings as well as per person and national costs associated with the surgical treatment of obesity. We conducted cross-sectional and trend analyses of in-patient obesity diagnosis and surgical treatment for obesity using data from the National Inpatient Sample (2011-2014) of adult patients in the United States aged 18 years and older. We studied the rate of in-patient obesity diagnosis among hospitalized patients, the rate of bariatric surgery among patients diagnosed with obesity in the hospital, and the costs associated with surgical treatment. Trend analyses showed a statistically significant increase in the proportion of (a) hospitalized patients diagnosed with obesity, and (b) bariatric surgery among those diagnosed with obesity and among different socio-demographic and insurance groups. Despite the increase in the national in-patient cost, the average in-patient cost per hospitalization associated with bariatric surgery decreased from 2012 to 2014. With the increase in the rate of diagnosed obesity and bariatric surgery among hospitalized patients and the decrease in the average in-patient cost, future research should address the short- and long-term cost-effectiveness of bariatric surgery on chronic diseases.

Objective This study examines insurance coverage rates among working-age adults with low income and with or without obesity before and after Medicaid expansion under the Affordable Care Act. Methods Individual-level data on noninstitutionalized and nonpregnant adult participants aged 18 to 64 years with household income below $15,000 from the Centers for Disease Control and Prevention 2006-2017 Behavioral Risk Factor Surveillance System were used. A difference-in-differences design with logistic regression was used to examine the likelihood of insurance coverage before and after Medicaid expansion. Results Working-age adults (analytic sample N = 316,151) who were white, female, less educated, unemployed, and living in a Medicaid-expansion state were more likely to have insurance coverage. The insurance coverage rate in Medicaid-expanded states in years after expansion increased for both subgroups with and without obesity. However, the increase was slightly lower for the subpopulation with obesity (5.59%, 95% CI: 2.35%-8.83%) compared with the subpopulation without obesity (7.35%, 95% CI: 5.35%-9.34%). Conclusions Increased attention should be paid to reduce insurance coverage barriers for working-age adults with low income and obesity to address potential health disparities caused by lack of access to care. This is important, as access to care provides opportunities to increase prevention and treatment-oriented services to address obesity and associated health care costs.

BackgroundEven as many states adopt physical activity policies to promote physical activity and prevent childhood obesity, little is known about differences in policy implementation based on school characteristics. We studied association of school characteristics and changes in physical activity opportunities at the school level during the implementation of a statewide physical activity policy in the state of Georgia.MethodsA web-based school survey was administered to elementary schools at two time points (before and during policy execution). Matched respondents (289 classroom teachers, 234 administrators) reported the frequency and duration of recess and integrated physical activity time. We used paired t-test to assess changes in physical activity opportunities and chi-square tests to assess the association of change in physical activity opportunities with school characteristics. We then constructed a multiple linear regression model following a change score method to identify school-level factors that predict the magnitude of change in physical activity opportunities.ResultsThere was an overall significant increase in total physical activity opportunities across time; however, schools with higher poverty showed a decrease in physical activity time by 5.3 minutes per day (95% CI: -9.2, -1.3). Further, the changes in physical activity time for schools in suburban Georgia were smaller (-5.7, 95% CI: -9.5, -1.9) compared to schools located in towns.ConclusionsThe change in physical activity opportunities was not the same across schools and school characteristics predicted the magnitude of change. Additional efforts at the local level might be needed for equitable policy implementation based on schools' geographical location and poverty level of the student population.

Background Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is associated with lower breastfeeding rates, compared to similar income non-participants. Breastfeeding decisions are often made before birth hence; the prenatal period may be critical for breastfeeding support. Objective To explore whether timing of WIC enrollment has an effect on breastfeeding exclusivity at 3, 5, and 7 months. As there are racial/ethnic disparities in breastfeeding, the association of timing of enrollment and race/ethnicity with breastfeeding outcomes was also assessed. Study Design, Setting, Participants This is a secondary analysis of data collected from the WIC Infant Toddler Feeding Practices Study-2, the most recent longitudinal assessment of mother-child dyads participating in WIC nationally. Only data collected from the prenatal through 7-months post-partum were included. Measurable Outcome/Analysis Logistic regression models analyzed the association between the timing of WIC enrollment - categorized as prenatal (1st, 2nd or 3rd trimester) or post-partum and exclusive breastfeeding - defined as being fed “only breastmilk” at each time point. Covariates included race/ethnicity, maternal age, education, parity, nativity, and poverty level. Results Prenatal WIC enrollment was associated with a 1.51 (95% CI: 1.08-2.17) and 1.37 (1.01-1.89) increased likelihood of exclusive breastfeeding at 5 and 7 months, respectively, as compared to post-partum enrollment. There were no significant differences at 3 months or by trimester of pregnancy. Mothers who were Hispanic and enrolled during the 2nd trimester had a 0.55 (0.33-0.91) decreased odds of breastfeeding at 3 months, with a similar trend observed (P = 0.062) during the third trimester for breastfeeding at 7 months. Conclusion Timing of WIC enrollment was associated with mother's infant feeding choice hence, supporting the prenatal period as an opportune time for breastfeeding education. A focus on prenatal breastfeeding education for Hispanic women who enroll during the 2nd trimester or later may be warranted.

Additional file 1: Table S1. List of causes of death focused in our study and the corresponding ICD-9 & ICD-10 codes. Table S2. Test for number of joinpoints. Table S3. Estimated regression coefficients for 1 joinpoint model. Table S4. Top 10 causes of death of China and Shanghai in 2017. Figure S1. Age-specific percentage of garbage codes in 1973, 1999 and 2018 in Shanghai.

Chronic disease and opioid-related hospitalizations in the United States are increasing. We analyzed nationally representative data on patients aged 18 years or older from the 2011-2015 National Inpatient Sample to assess the association between opioid-related hospitalization and chronic diseases. We found that most patients with opioid-related hospitalization were white, aged 35-54 years, in urban hospitals, and had 2 or more comorbid conditions. Patients with 2 or more chronic conditions accounted for more than 90% of opioid-related hospitalizations in all years. The results suggest a need for targeted interventions to prevent opioid misuse in patients with multiple chronic conditions.

Background: Obesity continues to grow in prevalence in the United States and within the state of Georgia. Obesity is a risk factor for many chronic and preventable diseases. As such, obese individuals have higher demand for health care services than non-obese individuals. In addition, the health care system can play a role in preventing obesity and other conditions caused by obesity. Methods: This research follows the established positive relationship between health care use and access to health care services through insurance coverage. The paper analyzes how the Affordable Care Act (ACA) affected insurance coverage and access to health care services for obese and overweight individuals. A logistic regression was used on data from the Behavioral Risk Factor Surveillance System. Results: Results concluded that Georgia residents were less likely to have health insurance after the ACA was passed. Significant association between weight status and health care services through insurance coverage was not found. The results show that increased access to care including preventive services for obese and overweight post ACA is yet to be observed. Conclusions: Findings present a need for lawmakers to develop policy to promote insurance enrollment for Georgian residents. This is critical as the state sees an increase in overweight and obesity that are risk factor to many chronic disease conditions. Keywords: Affordable Care Act, obesity, Iisurance, healthcare

Background Data on adolescents’ physical activity and determinants are scarce in Nepal. In this study, we aim to assess the level of physical activity, its correlates and the sedentary behavior of high school students in an urban district of Nepal. Methods This is a cross-sectional study. Participants were selected using two-stage cluster sampling technique. We used Global Physical Activity Questionnaire (GPAQ) to collect information regarding physical activity and sedentary behavior. We also collected information about socio-demographic, academic, environmental and lifestyle-related factors. Data from 945 high school students from 23 randomly selected schools were analyzed. Logistic regression was used to identify correlates of low physical activity separately for male and female students. Results Based on GPAQ classification, one out of five respondents reported low physical activity. The prevalence of low physical activity was 8% for males and 31% for females. About 31% of the adolescents and 14% of young adults did not meet the WHO recommendations of physical activity. Forty-seven percent of the total physical activity was borne by recreational activities. Correlates of low physical activity included school type and mode of transport among females, family support and drinking among males, and playground/park around home among both. Conclusions The prevalence estimate of low physical activity among adolescents is high, with higher odds among females. Several different factors are associated with physical activity among males and females, therefore, interventions to promote physical activity in school may need to weigh these factors prior to/during implementation. Electronic supplementary material The online version of this article (10.1186/s12889-019-7230-2) contains supplementary material, which is available to authorized users.

The healthy immigrant effect—whereby immigrants are on average healthier than the native-born—have been well studied. However, little is known about the relationship between immigration and the health of the native-born. This study fills this important research gap by examining the association between neighborhood immigrant density and several population health measures among native-born Americans. We used data from the Los Angeles County Health Survey to analyze four individual-level health behaviors and outcomes, including regular fast food consumption, fruit and vegetable consumption, body mass index, and hypertension. We conducted multilevel logistic regressions to assess the association between neighborhood immigrant density and the four health behaviors and outcomes. The results showed that neighborhood immigrant density was negatively associated with regular fast food consumption (OR = 0.33; 95% CI, 0.18–0.59), BMI (β = −2.16, 95% CI, −3.13 to −1.19), and hypertension (OR = 0.58; 95% CI, 0.38–0.89), and positively associated with fruit/vegetable consumption (OR = 1.64; 95% CI, 1.01–2.66) among native-born Americans. In conclusion, native-born Americans who lived in a neighborhood with a high density of immigrants had healthier behaviors and better health outcomes compared to those who lived in a neighborhood with a low density of immigrants.

INTRODUCTION: Previous studies have reported a “weekend effect” on stroke mortality, whereby stroke patients admitted during weekends have a higher risk of in-hospital death than those admitted during weekdays. AIMS: We aimed to investigate whether patients with different types of stroke admitted during weekends have a higher risk of in-hospital mortality in rural and urban hospitals in the US. METHODS: We used data from the 2016 National Inpatient Sample and used logistic regression to assess in-hospital mortality for weekday and weekend admissions among stroke patients aged 18 and older by stroke type (ischemic or hemorrhagic) and rural or urban status. RESULTS: Crude stroke mortality was higher in weekend admissions (p

SedentaryBehaviorAnalysis_and_Questionnaire-LocalVersion. (DOCX 1525 kb)

Objectives: The goal of the Strong4Life School Nutrition Program is to promote healthy eating in school cafeterias in Georgia by training school nutrition managers and staff members to implement changes in the cafeteria to nudge children to make healthier choices. The objective of our study was to evaluate program effect on (1) school nutrition manager and staff member knowledge of evidence-based strategies and their self-efficacy to make positive changes, (2) the school cafeteria environment, and (3) National School Lunch Program participation. Methods: We assessed changes in participant knowledge, beliefs, and self-efficacy by administering a survey before and after training (February-July 2015); a follow-up survey (3 school months posttraining) assessed changes in the cafeteria. A total of 842 school nutrition managers and staff members were trained and completed pre- and posttraining surveys; 325 managers completed the follow-up survey. We used cafeteria records from a subsample of the first schools trained (40 intervention and 40 control) to assess National School Lunch Program participation. Results: From pretraining to posttraining, we found a significant increase in manager and staff member (n = 842) knowledge of strategies for enhancing taste perception through the use of creative menu item names (from 78% to 95%, P < .001) and understanding that food placement in the lunch line influences food selection (from 78% to 95%, P < .001), and in their self-perceived ability to influence the cafeteria environment (from 91% to 96%, P < .001). From pretraining to 3-month follow-up, managers (n = 325) reported increased use of evidence-based serving strategies: visibility (from 84% to 96% for placing healthy options in >2 locations, P < .001), convenience (from 63% to 84% for placing plain milk in front of other beverages, P < .001), sell (from 25% to 38% for branding healthy items with stickers, P < .001), price (from 17% to 27% for using bundle pricing to encourage sales, P < .001), and taste (from 77% to 85% for signage demonstrating the benefits of healthy eating, P = .01). National School Lunch Program participation did not change significantly. Conclusions: Training cafeteria managers and staff members in Smarter Lunchrooms Movement techniques may be an effective way to make changes in the school cafeteria environment to encourage healthier choices among students. Additional studies allowing time for more complex changes to be implemented are needed to assess the full effect of the program.

Background Students live outside of their family homes for the first time in college and are expected to make their own decisions regarding dietary choices. College food environment could be a major determinant of dietary intake and is of importance in relation to obesity. This research determines the impact of removing cafeteria trays on student’s food choice. Method A quasi experimental pre-post research with control treatment was conducted in university dining halls. The participants were the dining hall patrons at a large public university in Southern US, spring 2015. The dining hall trays were removed from the intervened dining hall for five consecutive days during regular university session. Outcome measures of food choice were collected by observing tray waste before and after the tray removal in the intervened dining hall with parallel observation in the control dining hall. Difference-in-difference analysis was done to find the intervention effect. Results A total of 3153 trays were observed (N = 1564 in control and N = 1589 in intervention dining). Removal of trays resulted in a significant decrease in the total number of lunch plates (1.76 vs 1.66 servings, p

Fruit and vegetable consumption in the United States is below the recommended level for two reasons: lack of access and low preference. In this work, we identify lack of preference for vegetables as a public health issue and apply theories from psychology and marketing literature to study the effect of partitioned presentation of vegetables on consumption of vegetables. Separating items into single units with clear partitions generally reduces consumption of relatively appealing foods by making the eater more aware of the amount consumed. For relatively less appealing foods (typically but not exclusively those lower in sugar/fat), a partitioned presentation format might operate to increase consumption. This expectation draws on two complementary theoretical perspectives. First, partitioning of relatively unappealing foods involve initiation rather than inhibition, and thus, fewer decision points may promote consumption. Second, because people have an intrinsic desire for completion, they may be more likely to finish a partitioned portion, even if these are made of relatively unappealing options. After conducting a pilot experiment to verify experimental procedures, we conducted two experiments (total N = 342) in which we randomly presented cauliflower (a relatively less appealing food) in either a whole presentation format (i.e., all pieces on one plate) or a partitioned presentation format (i.e., groups of cauliflower pieces arranged into subgroups with clear divisions) and measured consumption. We observed no effects of presentation format on total consumption, but we did observe an increase in minimal consumption in the partitioned format.