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Abstract BackgroundIn-home remote foot temperature monitoring (RTM) holds promise as a method to reduce foot ulceration in high-risk patients with diabetes. Few studies have evaluated adherence to this method or evaluated the factors associated with noncompliance. ObjectiveThe aims of this study were to estimate noncompliance in patients who were enrolled in RTM nationwide across Department of Veterans Affairs (VA) and to evaluate characteristics associated with noncompliance. MethodsWe conducted an observational study including 1137 patients in the VA who were enrolled in RTM between January 2019 and June 2021, with follow-up through October 2021. Patient information was obtained from the VA’s electronic health record and RTM use was obtained from the company. Noncompliance was defined as using the mat

Objectives COVID-19 significantly impacted healthcare access and sexual behaviour, but little is known about how COVID-19 affected condom use. This study aimed to investigate whether self-reported condom use and sex in Washington State changed during pandemic restrictions compared with prepandemic.Design Cross-sectional survey data from the Behavioral Risk Factor Surveillance System.Setting Washington State.Participants 11 684 participants aged 18–65.Primary and secondary outcome measures The primary outcome was changes in the prevalence of condom use by time of interview pre-COVID-19, before the Washington State lockdown (1 January 2019 to 23 March 2020, n=7708) and during COVID-19, after the first state lockdown (24 March 2020 to 31 December 2020, n=3976). The secondary outcome was changes in the prevalence of reported sex during the same periods. We assessed whether associations differed by rurality and HIV risk behaviour.Results Condom use was similar during COVID-19 (37.3%) compared with pre-COVID-19 (37.8%) (adjusted prevalence ratio (PR): 0.98, 95% CI 0.89, 1.01). Associations did not differ by rurality or HIV risk behaviour. Compared with pre-COVID-19 (83.0%), a smaller proportion of respondents reported having sex in the last 12 months during COVID-19 (80.5%), a relative decrease of 3% (PR: 0.97, 95% CI 0.96, 0.99; p

Abstract Objective: Lower-income older adults with multiple chronic conditions (MCC) are highly vulnerable to food insecurity. However, few studies have considered how health care access is related to food insecurity among older adults with MCC. The aims of this study were to examine associations between MCC and food insecurity, and, among older adults with MCC, between health care access and food insecurity. Design: Cross-sectional study data from the 2019 Behavioral Risk Factor Surveillance System survey. Setting: Washington State, USA. Participants: Lower-income adults, aged 50 years or older (n 2118). MCC was defined as having ≥ 2 of 11 possible conditions. Health care access comprised three variables (unable to afford seeing the doctor, no health care coverage and not having a primary care provider (PCP)). Food insecurity was defined as buying food that did not last and not having money to get more. Results: The overall prevalence of food insecurity was 26·0 % and was 1·50 times greater (95 % CI 1·16, 1·95) among participants with MCC compared to those without MCC. Among those with MCC (n 1580), inability to afford seeing a doctor was associated with food insecurity (prevalence ratio (PR) 1·83; 95 % CI 1·46, 2·28), but not having health insurance (PR 1·49; 95 % CI 0·98, 2·24) and not having a PCP (PR 1·10; 95 % CI 0·77, 1·57) were not. Conclusions: Inability to afford healthcare is related to food insecurity among older adults with MCC. Future work should focus on collecting longitudinal data that can clarify the temporal relationship between MCC and food insecurity.

IntroductionCholesterol-lowering medications offer effective secondary prevention after myocardial infarction (MI). Our objective was to evaluate the association between sociodemographic factors and cholesterol-lowering medication use in high-risk adults.MethodsWe conducted an analysis using weighted data from 31,408 participants in the 2017 and 2019 Behavioral Risk Factor Surveillance Systems cross-sectional surveys, who had a self-reported history of MI and high blood cholesterol. The sociodemographic factors evaluated were sex, age, race and ethnicity, annual household income, education level, relationship status, and reported healthcare coverage. We estimated the weighted prevalence of medication use, and weighted prevalence differences (with 95% confidence intervals) across categories, adjusting for sex, age group, healthcare coverage, smoking status, hypertension, and diabetes.Results and discussionOverall, 83% of survey participants with a self-reported history of both MI and high blood cholesterol reported currently using a cholesterol-lowering medication. The prevalence of use was only 61% in those without self-reported healthcare coverage, compared to 85% of those with healthcare coverage (adjusted prevalence difference of -20%; 95% CI: -25% to -14%). Use of cholesterol-lowering medication was relatively low in younger adults and higher in older adults, leveling off after age 65 years. The proportion of Native Hawaiian or Pacific Islanders who were using a cholesterol-lowering medication was relatively low, but otherwise there was little variation by race and ethnicity. Household income, education level, and relationship status were weakly or not associated with medication use.ConclusionsKnowledge of characteristics of persons who are relatively less likely to be adherent with cholesterol-lowering medications for secondary prevention may be useful to policymakers and healthcare providers involved in the long-term treatment of MI patients. Policy makers might consider a reduced cost prescription coverage for persons without current healthcare coverage who have sustained an MI to reduce future cardiovascular morbidity and mortality.

Objectives To evaluate feasibility and acceptability of a group-based nature recreation intervention (nature hiking) and control condition (urban hiking) for military Veterans with post-traumatic stress disorder (PTSD).Design and setting A pilot randomised controlled trial conducted in the US Pacific Northwest.Participants Veterans with PTSD due to any cause.Interventions Twenty-six participants were randomised to a 12-week intervention involving either six nature hikes (n=13) or six urban hikes (n=13).Primary and secondary outcome measures Feasibility was assessed based on recruitment, retention and attendance. Questionnaires and postintervention qualitative interviews were conducted to explore intervention acceptability. Questionnaires assessing acceptability and outcomes planned for the future trial (eg, PTSD symptoms) were collected at baseline, 6 weeks, 12 weeks (immediately after the final hike) and 24 weeks follow-up.Results Of 415 people assessed for eligibility/interest, 97 were interested and passed preliminary eligibility screening, and 26 were randomised. Mean completion of all questionnaires was 91% among those in the nature hiking group and 68% in those in the urban hiking group. Over the course of the intervention, participants in the nature and urban groups attended an average of 56% and 58%, respectively, of scheduled hikes. Acceptability of both urban and nature hikes was high; over 70% reported a positive rating (ie, good/excellent) for the study communication, as well as hike locations, distance and pace. Median PTSD symptom scores (PTSD Checklist-5) improved more at 12 weeks and 24 weeks among those in the nature versus urban hiking group.Conclusions This pilot study largely confirmed the feasibility and acceptability of nature hiking as a potential treatment for Veterans with PTSD. Adaptations will be needed to improve recruitment and increase hike attendance for a future randomised controlled trial to effectively test and isolate the ways in which nature contact, physical activity and social support conferred by the group impact outcomes.Trial registration number NCT03997344.

AimsTo describe how patients respond to early signs of foot problems and the factors that result in delays in care.MethodsSemi-structured interviews were conducted with a large sample of Veterans from across the United States with diabetes mellitus who had undergone a toe amputation. Data were analyzed using inductive content analysis.ResultsWe interviewed 61 male patients. Mean age was 66 years, 41% were married, and 37% had a high school education or less. The patient-level factors related to delayed care included: 1) not knowing something was wrong, 2) misinterpreting symptoms, 3) "sudden" and "unexpected" illness progression, and 4) competing priorities getting in the way of care-seeking. The system-level factors included: 5) asking patients to watch it, 6) difficulty getting the right type of care when needed, and 7) distance to care and other transportation barriers.ConclusionA confluence of patient factors (e.g., not examining their feet regularly or thoroughly and/or not acting quickly when they noticed something was wrong) and system factors (e.g., absence of a mechanism to support patient's appraisal of symptoms, lack of access to timely and convenient-located appointments) delayed care. Identifying patient- and system-level interventions that can shorten or eliminate care delays could help reduce rates of limb loss.

Objectives: While 75-90% of people who develop lung cancer are smokers, only a small proportion of smokers develop lung cancer. Identifying factors that increase a smoker's risk of developing lung cancer may help scientists to better understand the etiology of lung cancer and more effectively target high-risk groups for screening. [ABSTRACT FROM AUTHOR]

SUMMARY: BACKGROUND Physical activity is associated with a reduced risk of several chronic diseases. Although there is considerable published research on methods to assess current or recent recreational physical activity, there are few short, self-administered questionnaires designed to assess long-term physical activity.METHODS We developed a one-page questionnaire to capture data on usual recreational physical activity during the preceding 10 years. This questionnaire was used in a cohort study of adults age 50 to 75 years residing in western Washington state. To examine the measurement characteristics of this questionnaire, we compared metabolic equivalent task (MET)-hours derived from this short questionnaire to MET-hours estimated from a detailed comparison interview in a subsample (n = 217) and to current body mass index (BMI; weight in kilograms/height in square meters) in the full sample of 57,811 persons.RESULTS The age- and sex-adjusted partial Pearson correlation coefficient for total recreational activity between the 2 instruments was 0.68. In the full cohort, BMI was inversely correlated with physical activity as assessed by the one-page questionnaire (r = -0.22).CONCLUSIONS This short questionnaire measures long-term physical activity at a level of precision appropriate to the examination of associations in studies of physical activity and disease. [ABSTRACT FROM AUTHOR]

Vitamin and mineral supplements are among the most commonly used drugs in the United States, despite limited evidence on their benefits or risks. This paper describes the design, implementation, and participant characteristics of the VITamins And Lifestyle (VITAL) Study, a cohort study of the associations of supplement use with cancer risk. A total of 77,738 men and women in western Washington State, aged 50-76 years, entered the study in 2000-2002 by completing a detailed questionnaire on supplement use, diet, and other cancer risk factors, and 70% provided DNA through self-collected buccal cell specimens. Supplement users were targeted in recruitment: 66% used multivitamins, 46% used individual vitamin C, 47% used individual vitamin E, and 46% used calcium, typically for 5-8 of the past 10 years. Analyses to identify confounding factors, the main study limitation, showed that regular nonsteroidal anti-inflammatory drug use, intake of fruits and vegetables, and recreational physical activity were strongly associated with supplement use (p < 0.001). The authors describe a follow-up system in which cancers, deaths, and changes of residence are tracked efficiently, primarily through linkage to public databases. These methods may be useful to other researchers implementing a large cohort study or designing a passive follow-up system. [ABSTRACT FROM AUTHOR]

Background Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in American Indian people. In 2022, the American Heart Association developed the Life's Essential 8 goals to promote cardiovascular health (CVH) for Americans, composed of diet, physical activity, nicotine exposure, sleep, body mass index, blood lipids, blood pressure, and blood glucose. We examined whether achievement of Life's Essential 8 goals was associated with incident CVD among SHFS (Strong Heart Family Study) participants. Methods and Results A total of 2139 SHFS participants without CVD at baseline were included in analyses. We created a composite CVH score based on achievement of Life's Essential 8 goals, excluding sleep. Scores of 0 to 49 represented low CVH, 50 to 69 represented moderate CVH, and 70 to 100 represented high CVH. Incident CVD was defined as incident myocardial infarction, coronary heart disease, congestive heart failure, or stroke. Cox proportional hazard models were used to examine the relationship of CVH and incident CVD. The incidence rate of CVD at the 20‐year follow‐up was 7.43 per 1000 person‐years. Compared with participants with low CVH, participants with moderate and high CVH had a lower risk of incident CVD; the hazard ratios and 95% CIs for incident CVD for moderate and high CVH were 0.52 (95% CI, 0.40–0.68) and 0.25 (95% CI, 0.14–0.44), respectively, after adjustment for age, sex, education, and study site. Conclusions Better CVH was associated with lower CVD risk which highlights the need for comprehensive public health interventions targeting CVH promotion to reduce CVD risk in American Indian communities.

Studies on obesity and prostate cancer risk are inconsistent, perhaps because of differential effects on aggressive and nonaggressive cancers. Participants included 34,754 men residing in Washington State (aged 50–76 years at baseline) in a prospective cohort study who were recruited between 2000 and 2002; 383 developed aggressive (regional/distant stage or Gleason sum 7–10) and 437 developed nonaggressive disease through December 2004. Compared with normal-weight men (body mass index (kg/m2) <25), obese men (≥30 kg/m2) had a reduced risk of nonaggressive disease (hazard ratio = 0.69, 95% confidence interval: 0.52, 0.93; p for trend = 0.01). Overweight men (25–29.9 kg/m2) had an increased risk of aggressive disease (hazard ratio = 1.4, 95% confidence interval: 1.1, 1.8), but there was no increased risk for obese men (p for trend = 0.69). Body mass index of >25 at age 18 years was associated with increased risk of aggressive prostate cancer; obesity at ages 30 and 45, but not 18, years was associated with reduced risk of nonaggressive prostate cancer. Height (fourth vs. first quartile) was associated with an increased risk of total prostate cancer (hazard ratio = 1.3, 95% confidence interval: 1.1, 1.6), which did not differ by aggressiveness. There were no associations of prostate cancer with age at which maximum height was reached. Results from this study demonstrate the complexity of prostate cancer epidemiology and the importance of examining risk factors by tumor characteristics. [ABSTRACT FROM AUTHOR]

Background: Maternal leisure time physical activity (LTPA) and sedentary time during pregnancy may influence programming of infant growth in a sex-specific manner. Materials and Methods: Participants (N?=?35,212) from the Danish National Birth Cohort reported moderate/vigorous LTPA (hours/week) in early (conception to mean 16 weeks of gestation) and late pregnancy (mean 31 weeks of gestation to delivery) during interviews at 16 weeks of gestation and 6 months postpartum. Participants reported screen time at work and time spent watching television/videos (hours/day) in early pregnancy. Infant weight at 12 months of age was reported by mothers. Weight-for-length was categorized using sex-specific international standards. Results: Participants reported on average 1 hour per week of early pregnancy moderate/vigorous LTPA, 0.5 hour per week of late pregnancy LTPA, and 3 hours per day of early pregnancy sedentary time. Early pregnancy LTPA category was not associated with infant weight (p for trend?=?0.62). There were suggested associations of early pregnancy sedentary time above the first quartile with greater odds of infant underweight (odds ratio?=?1.15?1.27; p for trend?=?0.27). Associations were similar in male and female infants. Conclusions: There is no clear relationship between early or late pregnancy LTPA and infant weight at 12 months in our study. Maternal early pregnancy sedentary time may be associated with infant underweight at 12 months.

Objectives: To determine the positive predictive value (PPV) of algorithms to identify patients with major (at the ankle or more proximal) lower extremity amputation (LEA) using Department of Veterans Affairs electronic medical records (EMR) and to evaluate whether PPV varies by sex, age, and race. Design: We conducted a validation study comparing EMR determined LEA status to self-reported LEA (criterion standard). Setting: Veterans who receive care at the Department of Veterans Affairs. Participants: We invited a national sample of patients (N=699) with at least 1 procedure or diagnosis code for major LEA to participate. We oversampled women, Black men, and men ≤40 years of age. Interventions: Not applicable. Main Outcome Measure: We calculated PPV estimates and false negative percentages for 7 algorithms using EMR LEA procedure and diagnosis codes relative to self-reported major LEA. Results: A total of 466 veterans self-reported their LEA status (68%). PPVs for the 7 algorithms ranged from 89% to 100%. The algorithm that required a single diagnosis or procedure code had the lowest PPV (89%). The algorithm that required at least 1 procedure code had the highest PPV (100%) but also had the highest proportion of false negatives (66%). Algorithms that required at least 1 procedure code or 2 or more diagnosis codes 1 month to 1 year apart had high PPVs (98%-99%) but varied in terms of false negative percentages. PPV estimates were higher among men than women but did not differ meaningfully by age or race, after accounting for sex. Conclusion: PPVs were higher if 1 procedure or at least 2 diagnosis codes were required; the difference between algorithms was marked by sex. Investigators should consider trade-offs between PPV and false negatives to identify patients with LEA using EMRs.

Abstract Background Sedentary behavior is associated with adverse health outcomes in the general population. Whether sedentary behavior during pregnancy is associated with newborn outcomes, such as birth size, is not established, and previous studies have been inconsistent. While previous research suggests that male and female fetuses respond differently to maternal behaviors, such as physical activity, the role of infant sex in sedentary behavior-birth size associations has not been examined. Methods Participants in the Omega study, a cohort in Washington State (1996–2008), reported leisure time sedentary behavior (non-work time spent sitting), light intensity physical activity, and moderate/vigorous leisure time physical activity duration in the year before pregnancy (N = 1373) and in early pregnancy (N = 1535, mean 15 weeks). Offspring birth size was abstracted from delivery records. Non-parametric calibration weighting was used to assign adjustment weight (matching the distribution of sociodemographic and medical characteristics of the full cohort (N = 4128)) to participants with available sedentary behavior data. Weighted linear regression models were used to estimate mean differences in offspring birthweight, head circumference, and ponderal index (birthweight/length3) associated with leisure time sedentary behavior. Regression models were run overall and stratified by offspring sex. Isotemporal substitution modeling was used to determine mean differences in birthweight associated with replacing sedentary behavior with light or moderate/vigorous physical activity. Results On average, women spent 2.3 and 2.6 h/day in leisure time sedentary behavior during pre- and early pregnancy, respectively. There were no associations of pre-pregnancy leisure time sedentary behavior with mean birthweight, head circumference, or ponderal index (adjusted β = − 12, 95% CI: -28, 4.1; β = 0.0, 95% CI: -0.04, 0.1; and β = 0.1, 95% CI: -0.2, 0.4, respectively). Early pregnancy sedentary behavior was not associated with mean birth size. Associations of sedentary behavior with mean birth size did not differ by offspring sex. Replacing sedentary time with light or moderate/vigorous physical activity was not associated with mean birthweight. Conclusions We did not observe associations of maternal sedentary behavior during pre- or early pregnancy with mean offspring birth size. Pre-pregnancy and early pregnancy sedentary behavior may have important adverse effects on maternal health, but our results do not support associations with mean offspring birth size.

Objectives. To examine associations between caregiving mental or behavioral health outcomes among emerging US adults, defined as persons aged 18 to 25 years. Methods. The study sample included emerging adult respondents to the 2015-2017 Behavioral Risk Factor Surveillance System's caregiving module. Exposures were caregiver (n = 3087), expectant caregiver (n = 2303), and noncaregiver (n = 12 216) status. Expectant caregivers were defined as persons not currently providing care but anticipating doing so within the next 2 years. Outcomes included frequent mental distress (FMD), drinking (binge or heavy), and current smoking (cigarette or e-cigarette use). We used robust Poisson regression to calculate adjusted prevalence ratios (APRs) and corresponding 95% confidence intervals (CIs). We adjusted all models for income. Results. Caregivers had a similar prevalence of FMD when compared with both expectant caregivers (APR = 1.67; 95% CI = 1.28, 2.17) and noncaregivers (APR = 1.50; 95% CI = 1.23, 1.82). Caregivers had a higher prevalence of current cigarette smoking compared with noncaregivers (APR = 1.44; 95% CI = 1.21, 1.71). Conclusions. Among emerging adults, providing care is associated with poorer mental health. Point estimates looking at FMD were higher when we compared caregivers with expectant caregivers, suggesting a difference in exchangeability between comparison groups. Public Health Implications. This study highlights the importance of including emerging adults in caregiving research.

Objectives: We examined whether military service, including deployment and combat experience, were related to smoking initiation and relapse., Methods: We included older (panel 1) and younger (panel 2) participants in the Millennium Cohort Study. Never smokers were followed for 3 to 6 years for smoking initiation, and former smokers were followed for relapse. Complementary log-log regression models estimated the relative risk (RR) of initiation and relapse by military exposure while adjusting for demographic, health, and lifestyle factors., Results: Deployment with combat experience predicted higher initiation rate (panel 1: RR = 1.44; 95% confidence interval [CI] = 1.28, 1.62; panel 2: RR = 1.26; 95% CI = 1.04, 1.54) and relapse rate (panel 1 only: RR = 1.48; 95% CI = 1.36, 1.62). Depending on the panel, previous mental health disorders, life stressors, and other military and nonmilitary characteristics independently predicted initiation and relapse., Conclusions: Deployment with combat experience and previous mental disorder may identify military service members in need of intervention to prevent smoking initiation and relapse.