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Introduction: Alcohol‐attributable harms are increasing in Canada. We described trends in alcohol‐attributable hospitalisations and emergency department (ED) visits by age, sex, drinking group, attribution and health condition. Methods: Hospitalisation and ED visits for partially or wholly alcohol‐attributable health conditions by age and sex were obtained from population‐based health administrative data for individuals aged 15+ in Ontario, Canada. Population‐level alcohol exposure was estimated using per capita alcohol sales and alcohol use data. We estimated the number and rate of alcohol‐attributable hospitalisations (2008–2018) and ED visits (2008–2019) using the International Model of Alcohol Harms and Policies (InterMAHP). Results: Over the study period, the modelled rates of alcohol‐attributable health‐care encounters were higher in males, but increased faster in females. Specifically, rates of alcohol‐attributable hospitalisations and ED visits increased by 300% (19–76 per 100,000) and 37% (774–1,064 per 100,000) in females, compared to 20% (322–386 per 100,000) and 2% (2563–2626 per 100,000) in males, respectively. Alcohol‐attributable ED visit rates were highest among individuals aged 15–34, however, increased faster among individuals aged 65+ (females: 266%; males: 44%) than 15–34 years (females:+17%; males: −16%). High‐volume drinkers had the highest rates of alcohol‐attributable health‐care encounters; yet, low‐/medium‐volume drinkers contributed substantial hospitalisations (11%) and ED visits (36%), with increasing rates of ED visits in females drinking low/medium volumes. Discussion and Conclusions: Alcohol‐attributable health‐care encounters increased overall, and faster among females, adults aged 65+ and low‐/medium‐volume drinkers. Monitoring trends across subpopulations is imperative to inform equitable interventions to mitigate alcohol‐attributable harms. [ABSTRACT FROM AUTHOR]

Background: Multiple survey reports suggest that alcohol use has increased in Canada during the COVID-19 pandemic. However, less is known about how per capita alcohol sales, which predict population-level alcohol use, have changed and whether changes in alcohol sales differ from changes in sales of other products due to pandemic factors.Methods: We obtained monthly retail sales data by industry from Statistics Canada, for the six largest provinces in Canada (containing 93% of the national population), between January 2010 and November 2020, representing time before and 9 months after the start of the pandemic in Canada. We used an interrupted time series analysis to estimate pandemic impacts on the dollar value of monthly per capita (per individuals 15+ years) alcohol, essential and non-essential retail sales. We adjusted our analyses for pre-pandemic sales trends, inflation, seasonality and changing population demographics over time.Results: During the first 9 months of the pandemic, the values of per capita alcohol, essential and non-essential sales were, respectively, 13.2% higher, 3.6% higher and 13.1% lower than the average values during the same period in the prior 3 years. Interrupted time series models showed significant level change for the value of monthly per capita alcohol sales (+$4.86, 95% CIs: 2.88, 6.83), essential sales (-$59.80, 95% CIs: - 78.47, - 41.03) and non-essential sales (-$308.70, 95% CIs: - $326.60, - 290.79) during the pandemic. Alcohol sales were consistently elevated during the pandemic, and the pre- and post-pandemic slopes were comparable. In contrast, essential and non-essential retail sales declined in the early months of the pandemic before returning to regular spending levels.Conclusion: During the first 9 months of the pandemic, per capita alcohol sales were moderately elevated in Canada. In contrast, non-essential sales were lower than prior years, driven by large decreases during the initial months of the pandemic. These findings suggest that the pandemic was associated with increased population-level alcohol consumption, which may lead to increased alcohol-related harms. Ongoing research is needed to examine how factors, including pandemic-related stressors and specific alcohol sales-related policies, may have influenced changes in alcohol use and harms. [ABSTRACT FROM AUTHOR]

Measures that can provide reasonably accurate estimates of sugar-containing beverage (SCB) intake among children are needed. The primary objective of this study was to evaluate the relative validity of a short beverage screener (Nutrition and Health Questionnaire, NHQ) compared to a 24-hour recall (Automated Self-Administered 24-h (ASA24) Dietary Assessment Tool-Canada) for assessing parent proxy-reported daily SCB intake among children aged 4–14 years from the TARGet Kids! research network in Toronto, Canada. Children for whom a NHQ completed between March 2018 and June 2019 and an ASA24 completed within one year were included. A total of 471 parents who completed the NHQ beverage screener were also asked to complete the ASA24. One-hundred sixty-three completed the ASA24 and of this group, 109 were analyzed. Estimates of daily intake of 100% juices, sweetened drinks and soda, and total SCBs from the two measures were compared. The mean difference in beverage intake, Spearman correlations, and Bland-Altman plots were estimated for continuous measures. The kappa coefficient, sensitivity, and specificity were calculated for dichotomous measures of any daily intake versus none. The mean difference in total SCB intake between the NHQ and ASA24 was 0.14 cups/day (95% CI 0.01, 0.29) and the correlation was 0.43 (95% CI 0.26, 0.57). Sensitivity and specificity for any daily SCB intake were 0.63 and 0.76, respectively. Overall, parent proxy-reporting of children's total SCB intake from a beverage screener can provide reasonable estimates of SCB intake when detailed dietary assessment is not feasible. [ABSTRACT FROM AUTHOR]

Reducing health inequalities has become a major public health priority internationally. However, how best to achieve this goal is not well understood. Population health intervention research has the potential to address some of this knowledge gap. This review argues that simulation studies can produce unique evidence to build the population health intervention research evidence base on reducing social inequalities in health. To this effect, the advantages of using simulation models over other population health intervention research methods are discussed. Key questions regarding the potential challenges of developing simulation models to investigate population health intervention research on reducing social inequalities in health and the types of population health intervention research questions that can be answered using this methodology are reviewed. We use the example of social inequalities in coronary heart disease to illustrate how simulation models can elucidate the effectiveness of a number of 'what-if' counterfactual population health interventions on reducing social inequalities in coronary heart disease. Simulation models are a flexible, cost-effective, evidence-based research method with the capacity to inform public health policy-makers regarding the implementation of population health interventions to reduce social inequalities in health. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To estimate the direct and indirect pathways between education and diabetes. Methods: We examined the relative contribution of eight different pathways between education and diabetes incidence over a 9-year period in Ontario, Canada. Our data source was respondents (35–60 years of age) to the 2000–2001 Canadian Community Health Survey individually linked with physician and hospital administrative data. Our sample contained 11,899 participants with no previous diagnosis of diabetes. The direct and indirect effects of education level on incident diabetes were estimated using Aalen additive hazard models. Results: Not having completed secondary education was associated with 120 extra diabetes cases per 10,000 men per year and 43 additional diabetes cases per 10,000 women per year, compared with having Bachelors education or higher. Body mass index accounted for 13 of the 120 extra diabetes cases among men, and 24 of the 43 additional diabetes cases for women. Conclusions: Of the mediating pathways examined in this paper, body mass index was the pathway through which the largest number of diabetes cases was mediated among men and women. A substantial number of excess diabetes cases among respondents with lower education levels, in particular among men, were not mediated through any of the eight pathways examined. [Copyright &y& Elsevier]

Evidence is lacking on whether the duration and timing of low socioeconomic position (SEP) across a person's life course may be associated with incidence of type 2 diabetes mellitus (T2D). The authors’ objectives were to investigate associations between cumulative SEP and the incidence of T2D in the Framingham Offspring Study (n = 1,893; 52% women; mean baseline age = 34 years). Pooled logistic regression analyses demonstrated that age-adjusted cumulative SEP was associated with T2D in women (for low vs. high cumulative SEP, odds ratio (OR) = 1.92, 95% confidence interval (CI): 1.08, 3.42). Age-adjusted analyses for young-adulthood SEP (7.85 for ≤12 vs. >16 years of education, OR = 2.84, 95% CI: 1.03), active professional life SEP (for laborer vs. professional/executive/supervisory/technical occupations, OR = 2.40, 95% CI: 1.05, 5.47), and social-mobility frameworks (for declining life-course SEP, OR = 2.99, 95% CI: 1.39, 6.44; for stable low vs. stable high life-course SEP, OR = 1.85, 95% CI: 1.02, 3.35) all demonstrated associations between low SEP and T2D incidence in women. No association was observed between childhood SEP and T2D in women for father's education (some high school or less vs. any postsecondary education, OR = 1.26, 95% CI: 0.72, 2.22). In men, there was little evidence of associations between life-course SEP and T2D incidence. These findings suggest that cumulative SEP is inversely associated with incidence of T2D in women, and that this association may be primarily due to the women's educational levels and occupations. [ABSTRACT FROM PUBLISHER]

Background and aims: A health warning label (HWL) cautioning about the link between alcohol and cancer may be able to communicate alcohol risks to consumers and potentially counter health‐oriented nutrition advertising on ready‐to‐drink alcoholic beverages. This study aimed to examine the independent and combined effects of nutrient content claims (e.g. 0 g sugar) and a HWL on perceived product characteristics and intentions to consume, and whether these effects differed by gender and age. Design: A between‐subjects randomized experiment. Participants were randomized to view one of six experimental label conditions: nutrient content claims plus nutrition declaration (NCC + ND), ND only, NCC + ND + HWL, ND + HWL, HWL only and no NCC, ND or HWL, all on a ready‐to‐drink (RTD) vodka‐based soda container. Setting and participants: Alcohol consumers (n = 5063; 52% women) in Canada aged 18–64 recruited through a national online panel. Measurements Participants completed ratings of perceived product characteristics, perceived product health risks, and intentions to try, buy, binge and drink the product. Findings Compared with the reference condition NCC + ND (current policy scenario in Canada), the other five experimental label conditions were associated with lower ratings for perceiving the product as healthy. All experimental conditions with a HWL were associated with lower product appeal, higher risk perceptions and reduced intentions to try, buy and binge. The experimental condition with a HWL only was associated with intentions to consume fewer cans in the next 7 days (β = −0.72, 95% confidence interval [CI] = −1.37,−0.08) versus the reference. Few interactions were observed, suggesting that label effects on outcomes were similar by gender and age. Conclusions: Health warning labels on alcohol packaging appear to be associated with lower product appeal, higher perceived health risks and reduced consumption intentions, even in the presence of nutrient content claims. [ABSTRACT FROM AUTHOR]

Background and aims Design Setting, participants/cases Measurements Findings Conclusion Alcohol retail access is associated with alcohol use and related harms. This study measured whether this association differs for people with and without heavy and disordered patterns of alcohol use.The study used a repeated cross‐sectional analysis of health administrative databases.All residents of Ontario, Canada aged 10–105 years with universal health coverage (n = 10 677 604 in 2013) were included in the analysis.Quarterly rates of emergency department (ED) and outpatient visits attributable to alcohol in 464 geographic regions between 2013 and 2019 were measured. Quarterly off‐premises alcohol retail access scores were calculated (average drive to the closest seven stores) for each geographic region. Mixed‐effect linear regression models adjusted for area‐level socio‐demographic covariates were used to examine associations between deciles of alcohol retail access and health‐care visits attributable to alcohol. Stratified analyses were run for individuals with and without prior alcohol‐attributable health‐care use in the past 2 years.We included 437 707 ED visits and 505 271 outpatient visits attributable to alcohol. After adjustment, rates of ED visits were 39% higher [rate ratio (RR) = 1.39, 95% confidence interval (CI) = 1.20–1.61] and rates of outpatient visits were 49% higher (RR = 1.49, 95% CI = 1.26–1.75) in the highest versus lowest decile of alcohol access. There was a positive association between alcohol access and outpatient visits attributable to alcohol for individuals without prior health‐care attributable to alcohol (RR = 1.65, 95% CI = 1.39–1.95 for the highest to lowest decile of alcohol access) but not for individuals with prior health‐care attributable to alcohol (RR = 1.08, 95% CI = 0.90–1.30). There was a positive association between alcohol access and ED visits attributable to alcohol for individuals with and without prior health‐care for alcohol for ED visits.In Ontario, Canada, greater alcohol retail access appears to be associated with higher rates of emergency department (ED) and outpatient health‐care visits attributable to alcohol. Individuals without prior health‐care for alcohol may be more susceptible to greater alcohol retail access for outpatient but not ED visits attributable to alcohol. [ABSTRACT FROM AUTHOR]

Introduction: Individuals with low socio‐economic position (SEP) experience disproportionate alcohol‐attributable harm. Limited research has investigated whether these inequities are driven by alcohol‐attributable conditions that are acute or chronic. The study aimed to estimate the sex‐specific associations between SEP and incident wholly alcohol‐attributable emergency department (ED) visits for acute and chronic harms, respectively. Methods: A cohort study was conducted using the Canadian Community Health Survey (2003–2008) linked to the National Ambulatory Care Reporting System (2002–2017) in Alberta and Ontario. SEP was measured using educational attainment. Acute and chronic ED visits were captured in the National Ambulatory Care Reporting System follow‐up data. Hazard models were fit to estimate the association between SEP and acute and chronic wholly alcohol‐attributable ED visits. Results: The analytical sample included 88,865 respondents. In men and women, individuals with lower SEP had increased hazard of acute ED visits (women hazard ratio [HR] 1.75, 95% confidence interval [CI] 1.07–2.87; men HR 3.47, 95% CI 2.29–5.25) and chronic ED visits (women HR 2.24, 95% CI 1.04–4.80; men HR 5.02, 95% CI 2.88–8.75). Acute and chronic wholly alcohol‐attributable ED visit rates were higher in men than women. Discussion and Conclusions: The findings indicated lower SEP was associated with greater harms for both acute and chronic wholly alcohol‐attributable ED visits when compared to their higher SEP counterparts. We conclude that gradients in SEP are associated with acute and chronic harms. These results highlight a need for equitable interventions that reduce the absolute burden of inequities in both acute and chronic wholly alcohol‐attributable ED visits. [ABSTRACT FROM AUTHOR]

Introduction: There were repeated reports of increased cannabis sales, use and health impacts in Canada during the COVID‐19 pandemic. However, it was unclear whether the increases were due to pandemic effects or industry expansion. Methods: We performed interrupted time series regressions of monthly per capita legal cannabis sales from March 2019 to February 2021, first with national averages, then with provincial/territorial data after adjusting for store density. We considered two interruption alternatives: January 2020, when product variety increased; and March 2020, when pandemic restrictions began. Results: The provincial/territorial regression with the January interruption explained R2 = 69.6% of within‐jurisdiction variation: baseline monthly per capita sales growth averaged $0.21 (95% confidence interval [CI] 0.15, 0.26), sales immediately dropped in January by $1.02 (95% CI −1.67, −0.37), and monthly growth thereafter increased by $0.16 (95% CI 0.06, 0.25). With the March interruption, the regression instead explained 68.7% of variation: baseline sales growth averaged $0.14 (95% CI 0.06, 0.22), there was no immediate drop and growth thereafter increased by $0.22 per month (95% CI 0.08, 0.35). Discussion and Conclusions: Increasing cannabis sales during the pandemic was consistent with pre‐existing trends and increasing store numbers. The extra increased growth was more aligned with January's new product arrivals than with March's pandemic measures, though the latter cannot be ruled out. We found little evidence of pandemic impacts on Canada's aggregate legal cannabis sales. We therefore caution against attributing increased population‐level cannabis use or health impacts primarily to the pandemic. [ABSTRACT FROM AUTHOR]

Declines in life expectancy in developed countries have been attributed to increases in drug-related overdose, suicide, and liver cirrhosis, collectively referred to as deaths of despair. Income inequality is proposed to be partly responsible for increases in deaths of despair rates. This study investigated the associations between income inequality, deaths of despair risk in Canada, and potential mechanisms (stress, social cohesion, and access to health services). We obtained data from the Canadian Community Health Survey and the Canadian Vital Statistics Database from 2007 to 2017. A total of 504,825 Canadians were included in the analyses. We used multilevel survival analyses, as measured by the Gini coefficient, to examine the relationships between income inequality and mortality attributed to drug overdose, suicide, death of despair, and all-cause. We then used multilevel path analyses to investigate whether each mediator (stress, social cohesion , and access to mental health professionals), which were investigated using separate mediation models, influenced the relationship between income inequality and drug overdose, suicide, deaths of despair, and all-cause death. Adjusted multilevel survival analyses demonstrated significant relationships between a one-SD increase in Gini coefficient was associated with an increased hazard for drug overdose (HR adj. = 1.28; 95 CI = 1.05, 1.55), suicide (HR adj. = 1.24; 95 CI = 1.06, 1.46), deaths of despair (HR adj. = 1.26; 95 CI = 1.12, 1.40), and all-cause death (HR adj. = 1.04; 95 CI = 1.02, 1.07). Adjusted path analyses indicated that stress, social cohesion, and access to mental health professionals significantly mediated the association between income inequality and mortality outcomes. Income inequality is associated with deaths of despair and this relationship is mediated by stress, social cohesion, and access to mental health professionals. Findings should be applied to develop programs to address income inequality in Canada. • Our study explored income inequality and deaths of despair among Canadians. • Greater income inequality predicted an increased hazard of deaths of despair. • Stress, social cohesion, and service access influenced mortality outcomes. [ABSTRACT FROM AUTHOR]

Objective: To analyze workplace outbreaks by industry sector in the first wave of the pandemic, and associated household cases. Methods: Number, size, and duration of outbreaks were described by sector, and outbreak cases were compared to sporadic cases in the same time frame. Address matching identified household cases with onset ≥2 days before, ≥2 days after, or within 1 day of the workplace outbreak case. Results: There were 199 outbreaks with 1245 cases, and 68% of outbreaks and 80% of cases belonged to (1) Manufacturing, (2) Agriculture, Forestry, Fishing, Hunting, (3) Transportation and Warehousing. There were 608 household cases associated with 339 (31%) outbreak cases, increasing the burden of illness by 56%. Conclusions: Workplace outbreaks primarily occurred in three sectors. Prevention measures should target industry sectors at risk to prevent spread in and out of the workplace. [ABSTRACT FROM AUTHOR]

Background: Robust measurement of dietary intake in population studies of children is critical to better understand the diet–health nexus. It is unknown whether parent proxy-report of children's dietary intake through online 24-h recalls is feasible in large cohort studies. Objectives: The primary objective of this study was to describe the feasibility of the Automated Self-Administered 24-h Dietary Assessment Tool (ASA24) to measure parent proxy-reported child dietary intake. A secondary objective was to compare intake estimates with those from national surveillance. Methods: Parents of children aged 4–15 years participating in the TARGet Kids! research network in Toronto, Canada were invited by email to complete an online ASA24-Canada-2016 recall for their child, with a subsample prompted to complete a second recall about 2 weeks later. Descriptive statistics were reported for ASA24 completion characteristics and intake of several nutrients. Comparisons were made to the 2015 Canadian Community Health Survey (CCHS) 24-h recall data. Results: A total of 163 parents completed the first recall, and 46 completed the second, reflecting response rates of 35% and 59%, respectively. Seven (4%) first recalls and one (2%) second recall were excluded for ineligibility, missing data, or inadvertent parental self-report. The median number of foods reported on the first recall was 18.0 (interquartile range (IQR) 6.0) and median time to complete was 29.5 min (IQR 17.0). Nutrient intakes for energy, total fat, protein, carbohydrates, fiber, sodium, total sugars, and added sugars were similar across the two recalls and the CCHS. Conclusions: The ASA24 was found to be feasible for parent proxy-reporting of children's intake and to yield intake estimates comparable to those from national surveillance, but strategies are needed to increase response rate and support completion to enhance generalizability. [ABSTRACT FROM AUTHOR]

Introduction: Understanding the inequitable impacts of the ongoing COVID-19 pandemic on youth mental health are leading priorities. Existing research has linked income inequality in schools to adolescent depression, however, it is unclear if the onset of the pandemic exacerbated the effects of income inequality on adolescent mental health. The current study aimed to quantify the association between income inequality and adolescent mental health during COVID-19. Material and methods: Longitudinal data were taken from three waves (2018/19 to 2020/21) of the Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, and Sedentary behaviour (COMPASS) school-based study. Latent Growth Curve modelling was used to assess the association between Census District (CD)-level income inequality and depressive symptoms before and after the onset of COVID-19. Results: The study sample included 29,722 students across 43 Census divisions in British Columbia, Alberta, Ontario, and Quebec. The average age of the sample at baseline was 14.9 years [standard deviation (SD) = 1.5] and ranged between 12 and 19 years of age. Most of the sample self-reported as white (76.3%) and female (54.4%). Students who completed the COMPASS survey after the onset of COVID reported 0.20-unit higher depressive scores (95% CI = 0.16, 0.24) compared to pre-COVID. The adjusted analyses indicated that the association between income inequality on anxiety scores was strengthened following the onset of COVID-19 (β = 0.02, 95% CI = 0.0004, 0.03), indicating that income inequality was associated with a greater increase in anxiety scores during COVID-19. Discussion: The adjusted results indicate that the association between income inequality and adolescent anxiety persisted and was heightened at the onset of COVID-19. Future studies should use quasi-experimental methods to strengthen this finding. The current study can inform policy and program discussions regarding the effects of the COVID-19 pandemic and pandemic recovery for young Canadians and relevant social policies for improving adolescent mental health. [ABSTRACT FROM AUTHOR]

Aims: Although opioid‐related harms have reached new heights across North America, the size of the gap in opioid agonist therapy (OAT) delivery for opioid‐related health problems is unknown in most jurisdictions. This study sought to characterize the gap in OAT treatment using a cascade of care framework, and determine factors associated with engagement and retention in treatment. Design: A population‐based retrospective cohort study. Setting: Ontario, Canada. Participants: Individuals who sought medical care for opioid‐related health problems or died from an opioid‐related cause between 2005 and 2019. Measurements: Monthly treatment status for buprenorphine/naloxone or methadone OAT between 2013 and 2019 (i.e. 'off OAT', 'retained on OAT < 6 months', 'retained on OAT ≥ 6 months'). Findings Of 122 811 individuals in the cohort, 97 516 (79.4%) received OAT at least once during the study period. There was decreasing 6‐month treatment retention over time. Model results indicated that males had higher odds of being on OAT each month [odds ratio (OR) = 1.26, 95% confidence interval (CI) = 1.23–1.28] but lower odds of OAT retention (OR = 0.90, 95% CI = 0.88–0.92), while the reverse was observed for older individuals (monthly: OR = 0.76 per 10‐year increase, 95% CI = 0.76–0.77; retention: OR = 1.36 per 10‐year increase, 95% CI = 1.34–1.38) and individuals with higher neighbourhood income (e.g. highest income quintile, monthly: OR = 0.79, 95% CI = 0.77–0.82; highest income quintile, retention: OR = 1.15, 95% CI = 1.11–1.20). Individuals residing in rural areas and with a history of mental health diagnoses had poorer outcomes overall, including lower odds of being on OAT each month (rural: OR = 0.75, 95% CI = 0.73–0.78; mental health: OR = 0.89, 95% CI = 0.87–0.92) and OAT retention (rural: OR = 0.79, 95% CI = 0.77–0.82; mental health: OR = 0.81, 95% CI = 0.78–0.83), as well as higher risk of starting/stopping OAT [rural, starting OAT: hazard ratio (HR) = 1.07, 95% CI = 1.05–1.10; mental health, starting OAT: HR = 1.20, 95% CI: 1.18–1.23; rural, stopping OAT: HR = 1.24, 95% CI: = 1.22–1.26; mental health, stopping OAT: HR = 1.11, 95% CI = 1.09–1.13]. Individuals with a history of mental health diagnoses also had a higher risk of death, regardless of OAT status (off OAT death: HR = 1.49, 95% CI = 1.33–1.66; on OAT death: HR = 1.20, 95% CI = 1.09–1.31). Conclusions: Factors influencing engagement and declining retention in treatment with opioid agonist therapy in Ontario's health system include age, sex and neighbourhood income, as well as mental health diagnoses or residing in rural regions. [ABSTRACT FROM AUTHOR]

Objectives: We aimed to estimate associations between COVID-19 incidence and mortality with neighbourhood-level immigration, race, housing, and socio-economic characteristics. Methods: We conducted a population-based study of 28,808 COVID-19 cases in the provincial reportable infectious disease surveillance systems (Public Health Case and Contact Management System) which includes all known COVID-19 infections and deaths from Ontario, Canada reported between January 23, 2020 and July 28, 2020. Residents of congregate settings, Indigenous communities living on reserves or small neighbourhoods with populations <1,000 were excluded. Comparing neighbourhoods in the 90th to the 10th percentiles of socio-demographic characteristics, we estimated the associations between 18 neighbourhood-level measures of immigration, race, housing and socio-economic characteristics and COVID-19 incidence and mortality using Poisson generalized linear mixed models. Results: Neighbourhoods with the highest proportion of immigrants (relative risk (RR): 4.0, 95%CI:3.5–4.5) and visible minority residents (RR: 3.3, 95%CI:2.9–3.7) showed the strongest association with COVID-19 incidence in adjusted models. Among individual race groups, COVID-19 incidence was highest among neighbourhoods with the high proportions of Black (RR: 2.4, 95%CI:2.2–2.6), South Asian (RR: 1.9, 95%CI:1.8–2.1), Latin American (RR: 1.8, 95%CI:1.6–2.0) and Middle Eastern (RR: 1.2, 95%CI:1.1–1.3) residents. Neighbourhoods with the highest average household size (RR: 1.9, 95%CI:1.7–2.1), proportion of multigenerational families (RR: 1.8, 95%CI:1.7–2.0) and unsuitably crowded housing (RR: 2.1, 95%CI:2.0–2.3) were associated with COVID-19 incidence. Neighbourhoods with the highest proportion of residents with less than high school education (RR: 1.6, 95%CI:1.4–1.8), low income (RR: 1.4, 95%CI:1.2–1.5) and unaffordable housing (RR: 1.6, 95%CI:1.4–1.8) were associated with COVID-19 incidence. Similar inequities were observed across neighbourhood-level sociodemographic characteristics and COVID-19 mortality. Conclusions: Neighbourhood-level inequities in COVID-19 incidence and mortality were observed in Ontario, with excess burden experienced in neighbourhoods with a higher proportion of immigrants, racialized populations, large households and low socio-economic status. [ABSTRACT FROM AUTHOR]

Objective: To determine if expansion of multi-use physical activity trails in an urban centre is associated with reduced rates of cardiovascular disease (CVD). Methods: This was a natural experiment with a difference in differences analysis using administrative health records and trail-based cycling data in Winnipeg, Canada. Prior to the intervention, each year, 314,595 (IQR: 309,044 to 319,860) persons over 30 years without CVD were in the comparison group and 37,901 residents (IQR: 37,213 to 38,488) were in the intervention group. Following the intervention, each year, 303,853 (IQR: 302,843 to 304,465) persons were in the comparison group and 35,778 (IQR: 35,551 to 36,053) in the intervention group. The natural experiment was the construction of four multi-use trails, 4-7 km in length, between 2010 and 2012. Intervention and comparison areas were based on buffers of 400 m, 800 m and 1200 m from a new multi-use trail. Bicycle counts were obtained from electromagnetic counters embedded in the trail. The primary outcome was a composite of incident CVD events: CVD-related mortality, ischemic heart disease, cerebrovascular events and congestive heart failure. The secondary outcome was a composite of incident CVD risk factors: hypertension, diabetes and dyslipidemia. Results: Between 2014 and 2018, 1,681,125 cyclists were recorded on the trails, which varied ~ 2.0-fold across the four trails (2358 vs 4264 counts/week in summer months). Between 2000 and 2018, there were 82,632 CVD events and 201,058 CVD risk events. In propensity score matched Poisson regression models, the incident rate ratio (IRR) was 1.06 (95% CI: 0.90 to 1.24) for CVD events and 0.95 (95%CI: 0.88 to 1.02) for CVD risk factors for areas within 400 m of a trail, relative to comparison areas. Sensitivity analyses indicated this effect was greatest among households adjacent to the trail with highest cycling counts (IRR = 0.85; 95% CI: 0.75 to 0.96). Conclusions: The addition of multi-use trails was not associated with differences in CVD events or CVD risk factors, however the differences in CVD risk may depend on the level of trail use. Trial registration: Trial registration number: NCT04057417. [ABSTRACT FROM AUTHOR]

Background: There is inconsistent evidence on the association between physical activity and pancreatic cancer risk and few studies have investigated early life or life-course physical activity. The objective of this study was to evaluate the association between trajectories of physical activity across the life-course and pancreatic cancer risk.Methods: A population-based case-control study was conducted (2011-2013) using cases (n = 315) from the Ontario Pancreas Cancer Study and controls (n = 1254) from the Ontario Cancer Risk Factor Study. Self-reported recall of moderate and vigorous physical activity was measured at three time points: young adulthood (20s-30s), mid-adulthood (40s-50s) and older-adulthood (1 year prior to questionnaire completion). Physical activity trajectories were identified using latent class analysis. Odds ratios (OR) and 95% confidence intervals (CI) were estimated from multivariable logistic regression adjusted for covariates: age, sex, race, alcohol, smoking, vegetable, fruit and meat consumption, and family history of pancreatic cancer.Results: Six life-course physical activity trajectories were identified: inactive at all ages (41.2%), low activity at all ages (31.9%), increasingly active (3.6%), high activity in young adulthood with substantial decrease (13.0%), high activity in young adulthood with slight decrease (5.0%), and persistent high activity (5.3%). Compared to the inactive at all ages trajectory, the associations between each trajectory and pancreatic cancer after confounder adjustment were: low activity at all ages (OR: 1.11; 95% CI: 0.75, 1.66), increasingly active (OR: 1.11; 95% CI: 0.56, 2.21), high activity in young adulthood with substantial decrease in older adulthood (OR: 0.76; 95% CI: 0.47, 1.23), high activity in young adulthood with slight decrease in older adulthood (OR: 0.98; 95% CI: 0.62, 1.53), and persistently high activity (OR: 1.50; 95% CI: 0.86, 2.62). When time periods were evaluated separately, the OR for the association between high moderate activity in the 20s-30s and pancreatic cancer was 0.89 (95% CI: 0.64, 1.25) and some sex differences were observed.Conclusion: Distinct life-course physical activity trajectories were identified, but there was no evidence that any of the trajectories were associated with pancreatic cancer. Future studies with larger sample sizes are needed to understand the associations between physical activity trajectories over the life-course and pancreatic cancer risk. [ABSTRACT FROM AUTHOR]

Summary: Overweight and obesity in early life are risk factors for many adult‐onset chronic diseases. The objective of this study was to assess the validity of self‐reported recall of early life anthropometric measures. A systematic review was conducted by searching four electronic databases (PubMed, ProQuest, EMBASE, and MEDLINE). Studies were eligible if they evaluated the validity or reliability of self‐reported recall by adults of their own body mass index, height, and/or weight during earlier life periods. Meta‐analyses were conducted to pool correlation coefficients and mean differences. There were 15 studies included with a total of 17 477 participants. The mean pooled difference between self‐reported recall of BMI compared with prospective measures was 0.06 kg/m2 (95% CI, −0.62 to 0.73), and the pooled correlation coefficient was 0.72 (95% CI, 0.65‐0.79). Self‐reported weight was also strongly correlated with reference standard measures (pooled r = 0.83; 95% CI, 0.72‐0.90) with a small mean difference (0.87 kg; 95% CI, 0.19‐1.56; I2 = 91%). Despite significant heterogeneity, the findings from this review suggest self‐reported recall of early life body mass index, height, and weight may be valid measures. This evidence may inform life‐course epidemiology studies considering the use of retrospective assessment of self‐reported anthropometry. [ABSTRACT FROM AUTHOR]

Social fragmentation has been theorized and empirically associated with suicide in prior research. However, less is known about whether social fragmentation is associated with deaths attributed to alcohol use or drug use. This research examined the association between social fragmentation and risk for deaths attributable to alcohol use, drug use, and suicide (collectively known as deaths of despair) among Canadian adults. A weighted sample representing 15,324,645 Canadians within 288 census divisions between 2006 and 2019 was used. Mortality data from the Canadian Vital Statistics Database (alcoholic liver disease, drug use, and suicide) was linked with census division socioeconomic data from the 2006 Canadian census using the Canadian Census Health and Environment Cohorts. Social fragmentation at the census division was created based on the Congdon Index. Cox-proportional hazard regression with survey weights and the sandwich estimator were used to account for clustering of individuals (level-1) nested within census divisions (level-2). After adjusting for individual and census division confounders, social fragmentation was positively associated with all-cause mortality (HR = 1.04; 95% CI: 1.02, 1.07), suicide (HR = 1.09; 95%CI: 1.01, 1.18), drug overdose related mortality (HR = 1.13; 95%CI: 1.03, 1.24), and deaths of despair (HR = 1.10; 95% CI: 1.04, 1.16), and not significantly associated with alcohol related liver disease (HR = 1.06; 95% CI: 0.91, 1.23). Social fragmentation is associated with an increased hazard of deaths of despair among Canadian adults. Efforts to improve social cohesion in areas that are highly socially fragmented need to be evaluated. • Social fragmentation was associated with a greater hazard for deaths of despair. • More social fragmentation was also associated with greater all-cause mortality. • Social fragmentation was not associated with alcohol related liver disease. • Survey weighted cox-proportional hazard regression was used. [ABSTRACT FROM AUTHOR]

Background: Negative health outcomes associated with the use of both prescribed and nonprescribed opioids are increasingly prevalent. We examined long-term trends in opioid-related harms in Ontario across a set of 6 indicators and the relation between harms and neighbourhood income in 2016. Methods: We examined rates of neonatal abstinence syndrome, opioid poisoning (fatal and nonfatal) and nonpoisoning opioid-related events from 2003 to 2016 in Ontario using population-based health administrative databases. We conducted descriptive analyses for harm indicators across neighbourhood income quintiles in 2016 (2015 for death). We examined social inequalities in opioid-related harms on both relative (prevalence ratio) and absolute (potential rate reduction) scales. Results: Rates of opioid-related harms increased dramatically between 2003 and 2016. In 2016, neonatal abstinence syndrome and opioid poisoning and nonpoisoning events showed a strong social gradient, with harm rates being lowest in higher-income neighbourhoods and highest in lower-income neighbourhoods. Prevalence ratios for the lowest-income neighbourhoods compared to the highest-income neighbourhoods ranged from 2.36 (95% confidence interval [CI] 2.15–2.58) for emergency department visits for opioid poisoning to 3.70 (95% CI 2.62–5.23) for neonatal abstinence syndrome. Potential rate reductions for opioid-related harms ranged from 34.8% (95% CI 29.1–40.1) to 49.9% (95% CI 36.7–60.5), which suggests that at least one-third of all harmful events could be prevented if all neighbourhoods had the same socioeconomic profile as the highest-income neighbourhoods. Interpretation: Rates of opioid-related harms increased in Ontario between 2003 and 2016, and people in lower-income neighbourhoods experienced substantially higher rates of opioid-related harms than those in higher-income neighbourhoods. This finding can inform planning for opioid-related public health interventions with consideration of health equity. [ABSTRACT FROM AUTHOR]