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Objectives Evidence suggests that spatial accessibility to primary care is a contributing factor to appropriate health care utilization, with limited primary care access resulting in avoidable hospitalizations and emergency department visits which are burdensome on individuals and our healthcare system. Limited research, however, has examined the effects on children. Methods We evaluated associations of spatial accessibility to primary care on health care utilization among a sample of 16,709 children aged 0-3 years in Philadelphia who were primarily non-White and publicly insured. Log-Poisson models with generalized estimating equations were used to estimate incidence rate ratios (RR) and 95% confidence intervals (CI) while accounting for three levels of clustering (within individual, within primary care practice, within neighborhood). Results In age-adjusted models, the lowest level of spatial accessibility was associated with 7% fewer primary care visits (RR 0.93, 95% CI 0.91, 0.95), 15% more emergency department (ED) visits (RR 1.15, 95% CI 1.09, 1.22), and 18% more avoidable hospitalizations (RR 1.18, 95% CI 1.01, 1.37). After adjustment for individual- (race/ethnicity, sex, number of chronic conditions, insurance status) and neighborhood-level (racial composition and proportion of housing units with no vehicle), spatial accessibility was not significantly associated with rate of health care utilization. Conclusions Individual-level predisposing factors, such as age, race, and need, attenuate the association between accessibility to primary care and use of primary care, emergency department visits, and avoidable hospitalization. Given the possibility of modifying access to primary care unlike immutable individual factors, a focus on spatial accessibility to primary care may promote appropriate health care utilization.

BackgroundIn Latin America, where climate change and rapid urbanization converge, non-optimal ambient temperatures contribute to excess mortality. However, little is known about area-level characteristics that confer vulnerability to temperature-related mortality.ObjectivesExplore city-level socioeconomic and demographic characteristics associated with temperature-related mortality in Latin American cities.MethodsThe dependent variables quantify city-specific associations between temperature and mortality: heat- and cold-related excess death fractions (EDF, or percentages of total deaths attributed to cold/hot temperatures), and the relative mortality risk (RR) associated with 1 °C difference in temperature in 325 cities during 2002-2015. Random effects meta-regressions were used to investigate whether EDFs and RRs associated with heat and cold varied by city-level characteristics, including population size, population density, built-up area, age-standardized mortality rate, poverty, living conditions, educational attainment, income inequality, and residential segregation by education level.ResultsWe find limited effect modification of cold-related mortality by city-level demographic and socioeconomic characteristics and several unexpected associations for heat-related mortality. For example, cities in the highest compared to the lowest tertile of income inequality have all-age cold-related excess mortality that is, on average, 3.45 percentage points higher (95% CI: 0.33, 6.56). Higher poverty and higher segregation were also associated with higher cold EDF among those 65 and older. Large, densely populated cities, and cities with high levels of poverty and income inequality experience smaller heat EDFs compared to smaller and less densely populated cities, and cities with little poverty and income inequality.DiscussionEvidence of effect modification of cold-related mortality in Latin American cities was limited, and unexpected patterns of modification of heat-related mortality were observed. Socioeconomic deprivation may impact cold-related mortality, particularly among the elderly. The findings of higher levels of poverty and income inequality associated with lower heat-related mortality deserve further investigation given the increasing importance of urban adaptation to climate change.

Cesarean section (CS) is a surgical procedure that, when medically justified, can help reduce maternal and infant morbidity and mortality. Worldwide CS rates (CSR) have been increasing; Latin America has rates that are among the highest in the world.Describe the variability of CSR across cities in Brazil, Colombia, Guatemala, Mexico, and Peru and examine the relationship of individual-level, sub-city, and city-level socioeconomic status (SES) with CSR.We used individual level data from vital statistics over the period 2014-2016 (delivery method, mother's age and education), census data to characterize sub-city SES and city GDP per capita from other sources compiled by the SALURBAL project. We fitted multilevel negative binomial regression models to estimate associations of SES with CSR.11,549,028 live births from 1,101 sub-city units in 305 cities of five countries were included. Overall, the CSR was 52%, with a wide range across sub-cities (13-91%). Of the total variability in sub-city CSRs, 67% was within countries. In fully adjusted model higher CSR was associated with higher maternal education [(PRR (CI95%) 0.81 (0.80-0.82) for lower educational level, 1.32 (1.31-1.33) for higher level (ref. medium category)], with higher maternal age [PRR (CI95%) 1.23 (1.22-1.24) for ages 20-34 years, and 1.48 (1.47-1.49) for ages ≥ 35 years (ref. ≤19 years], higher sub-city SES [(PRR (CI95%) 1.02 (1.01-1.03) per 1SD)], and higher city GDP per capita [(PRR (CI95%): 1.03 (1.00-1.07) for GDP between 10,500-18,000, and 1.09 (1.06-1.13) for GDP 18,000 or more (ref.10,500)].We found large variability in CSR across cities highlighting the potential role of local policies on CSR levels. Variability was associated in part with maternal and area education and GDP. Further research is needed to understand the reasons for this pattern and any policy implications it may have.

Background. Highly urbanized and rapidly urbanizing countries are facing critical air pollution problems. In Latin American cities, the impact of ambient PM2·5 on child health has not been extensively explored. Objectives. To examine association between ambient PM2·5 and under-5 mortality (U5MR) infant mortality (IMR) and child mortality (CMR) in Latin American cities. Methods. We estimated U5MR, IMR, and CMR from 2010 to 2015 for 1,152 sub-city units clustered in 337 cities from Argentina, Brazil, Chile, Colombia, Costa Rica, Guatemala, and Mexico. We retrieved satellite annual PM2·5 for each sub-city unit. Using linear mixed-effects models, we estimated the percent change in U5MR, IMR, and CMR associated with a 1 μg/m3 increase in annual PM2·5, adjusted for city and municipality-level predictors (population growth, GDP, living conditions, service provision, population educational attainment, and mass transit availability). Results. Over the study period, mean annual PM2·5 was 12·7 μg/m3 (SD 6·3), U5MR and IMR were 14·2 and 12·1 deaths per 1,000 live births, respectively. CMR was 4·8 deaths per 10,000 children. A 1 μg/m3 annual increase in PM2·5 was associated with 0·4% increase in U5MR (95% CI 0.1 to 0.7) and 0·5% increase in IMR (95% CI 0.2 to 0.9) We found no significant association between PM2·5 increases and changes in CMR. Interpretation. Infants appear to be particularly vulnerable to the deleterious effect of PM2·5. Assuring a clean air environment is important to promote infant survival and health. Funding: The project is funded by Wellcome Trust Funds, Grant 205177/Z/16/Z. Declaration of Interest: We declare no competing interests. Ethical Approval: The SALURBAL study protocol has ethical approval from the Drexel University IRB with ID # 161 200 5035.

Urban transportation is an important determinant of health and environmental outcomes, and therefore essential to achieving the United Nation's Sustainable Development Goals. To better understand the health impacts of transportation initiatives, we conducted a systematic review of longitudinal health evaluations involving: a) bus rapid transit (BRT); b) bicycle lanes; c) Open Streets programs; and d) aerial trams/cable cars. We also synthesized systems-based simulation studies of the health-related consequences of walking, bicycling, aerial tram, bus and BRT use. Two reviewers screened 3302 unique titles and abstracts identified through a systematic search of MEDLINE (Ovid), Scopus, TRID and LILACS databases. We included 39 studies: 29 longitudinal evaluations and 10 simulation studies. Five studies focused on low- and middle-income contexts. Of the 29 evaluation studies, 19 focused on single component bicycle lane interventions; the rest evaluated multi-component interventions involving: bicycle lanes (n = 5), aerial trams (n = 1), and combined bicycle lane/BRT systems (n = 4). Bicycle lanes and BRT systems appeared effective at increasing bicycle and BRT mode share, active transport duration, and number of trips using these modes. Of the 10 simulation studies, there were 9 agent-based models and one system dynamics model. Five studies focused on bus/BRT expansions and incentives, three on interventions for active travel, and the rest investigated combinations of public transport and active travel policies. Synergistic effects were observed when multiple policies were implemented, with several studies showing that sizable interventions are required to significantly shift travel mode choices. Our review indicates that bicycle lanes and BRT systems represent promising initiatives for promoting population health. There is also evidence to suggest that synergistic effects might be achieved through the combined implementation of multiple transportation policies. However, more rigorous evaluation and simulation studies focusing on low- and middle-income countries, aerial trams and Open Streets programs, and a more diverse set of health and health equity outcomes is required., Graphical abstract This figure represents a word network created by extracting keywords from the paper abstracts included in our systematic review. Each keyword represents a node in the network; its size is proportional to the number of abstracts in which it appears. Keywords are connected if they are found in the same abstract. The colours represent different communities of words as identified using the Louvain method.Image 1, Highlights • Bike lanes and bus rapid transit systems promote physical activity and active travel. • Multi-component interventions can act synergistically to increase active travel. • Few longitudinal health evaluations of aerial trams and open streets programs exist. • Low-and-middle income countries are understudied in the literature.

Purpose We conducted a systematic review of literature published on January 2000–May 2017 that spatially linked electronic health record (EHR) data with environmental information for population health research. Methods We abstracted information on the environmental and health outcome variables and the methods and data sources used. Results The automated search yielded 669 articles; 128 articles are included in the full review. The number of articles increased by publication year; the majority (80%) were from the United States, and the mean sample size was approximately 160,000. Most articles used cross-sectional (44%) or longitudinal (40%) designs. Common outcomes were health care utilization (32%), cardiometabolic conditions/obesity (23%), and asthma/respiratory conditions (10%). Common environmental variables were sociodemographic measures (42%), proximity to medical facilities (15%), and built environment and land use (13%). The most common spatial identifiers were administrative units (59%), such as census tracts. Residential addresses were also commonly used to assign point locations, or to calculate distances or buffer areas. Conclusions Future research should include more detailed descriptions of methods used to geocode addresses, focus on a broader array of health outcomes, and describe linkage methods. Studies should also explore using longitudinal residential address histories to evaluate associations between time-varying environmental variables and health outcomes.

Residential segregation is the spatial manifestation of entrenched socioeconomic and racial inequities and is considered a fundamental cause of racial inequalities in health. Despite the well-documented racialized spatial inequalities that exist in urban areas throughout Brazil, few empirical investigations have examined the link between residential segregation and health and considered its implications for racial health inequalities in this setting. In the present study, we used data from the Brazilian Longitudinal Study of Adult Health (2008e2010) to examine the association between economic residential segregation and two major cardio-metabolic risk factorsdhypertension and diabetes. We also examined whether associations were stronger for historically marginalized racial groups in Brazil. Residential segregation was calculated for study-defined neighborhoods using the Getis-Ord Local Gi* statistic and was based on household income data from the 2010 IBGE demographic census. Multivariable logistic regression models were used to examine associations. In our sample, Blacks and Browns were more likely to live in economically segregated neighborhoods. After taking into account income, education, and other demographic characteristics we found that individuals living in the most economically segregated neighborhoods were 26% more likely to have hypertension and 50% more likely to have diabetes than individuals living in more affluent areas. Although Blacks and Browns living in highly segregated neighborhoods had higher prevalence of hypertension and diabetes compared to Whites, we observed no statistically significant racial differences in the associations with residential segregation. Our findings suggest that residential segregation may be an important structural determinant of cardio-metabolic risk factors in Brazil. Moreover, the systematic and disproportionate exposure of Blacks and Browns to highly segregated neighborhoods may implicate these settings as potential drivers of racial inequalities in cardio-metabolic risk factors in urban settings in Brazil.

Introduction It has been posited that policies to promote child health and prevent obesity should target neighborhood environments but evidence on the impact of neighborhoods on child weight is conflicting and longitudinal studies (which have benefits for causal inference) are scarce. Methods We used electronic health records (2007–2016) from an urban, pediatric integrated delivery system and linked children (N = 51,873, ages 6–19 years, 77% African American) to neighborhood-level data to investigate how changes in neighborhood environments relate to changes in body mass index (BMI). Measures of neighborhood environment were resources for healthy foods and physical activity (‘resources’), greenness, violent crime rate, perceived safety and social cohesion. Fixed effects models estimated associations between changes in neighborhood environment exposures and changes in BMI z-score and whether effects differed by sex, baseline age, neighborhood socioeconomic status and population density. Results Approximately 22% of the cohort was obese (BMI z-score ≥ 95th percentile). In adjusted models, increases in neighborhood greenness and perceived safety were associated with decreases in BMI z-score (mean change in BMI z-score for 1-SD increase for both: -0.012; 95% CI= (−0.018, −0.007)). Increases in neighborhood safety had a stronger effect in children ages 6–10 years than in older children. Increases in social cohesion were associated with increases in BMI z-score (mean change: 0.005 95% CI = (0.003, 0.008)) especially in boys. Increases in food and physical activity resources were not associated with changes in BMI. Conclusions This study suggests that increasing neighborhood greenness and safety are potential approaches to reduce children's BMI.

Background: Women’s Empowerment (WE) has been shown to reduce infant mortality rates (IMR) in high-income countries. However, the role of WE in affecting IMR across growing cities of the global South has not been documented. Objectives: To examine whether WE is associated with differences in IMR across Latin American cities Methods: We estimated IMR for the period 2014-2016 using vital registration and demographic methods for 286 cities with population over 100,000 in 8 countries. We calculated socioeconomic (SE) and WE indicators from national census. We combined SE indicators into factors reflecting living conditions, and service provision. WE was measured using two indicators: women’s labor force participation (WLFP) and education attainment among women. We included a scale of country’s enforcements of laws (CEL) related to women’s rights. Using Poisson multilevel regression, we estimated the percentage difference in IMR associated with one standard deviation (1SD) higher WE scores, adjusted for SE characteristics of cities. Results: Overall IMR was 11.2 deaths per 1,000 live births. A 1SD higher score for WLFP was associated with 6.1% (95%CI -11.1; -0.8) lower IMR, after accounting for SE indicators. A higher CEL was associated with a lower IMR. Education attainment among women was inversely associated with IMR only in countries with low GDP per capita. Interpretation: Strategies that promote participation of women in labor market may have a positive impact in reducing IMR in Latin American cities. Women’s educational attainment is still relevant for reducing IMR in cities from countries with lower economic development. Funding Statement: Wellcome Trust Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Not required.

Summary Background Latin America is one of the most unequal regions in the world, but evidence is lacking on the magnitude of health inequalities in urban areas of the region. Our objective was to examine inequalities in life expectancy in six large Latin American cities and its association with a measure of area-level socioeconomic status. Methods In this ecological analysis, we used data from the Salud Urbana en America Latina (SALURBAL) study on six large cities in Latin America (Buenos Aires, Argentina; Belo Horizonte, Brazil; Santiago, Chile; San Jose, Costa Rica; Mexico City, Mexico; and Panama City, Panama), comprising 266 subcity units, for the period 2011–15 (expect for Panama city, which was for 2012–16). We calculated average life expectancy at birth by sex and subcity unit with life tables using age-specific mortality rates estimated from a Bayesian model, and calculated the difference between the ninth and first decile of life expectancy at birth (P90–P10 gap) across subcity units in cities. We also analysed the association between life expectancy at birth and socioeconomic status at the subcity-unit level, using education as a proxy for socioeconomic status, and whether any geographical patterns existed in cities between subcity units. Findings We found large spatial differences in average life expectancy at birth in Latin American cities, with the largest P90–P10 gaps observed in Panama City (9·8 years for men and 11·2 years for women), Santiago (8·9 years for men and 17·7 years for women), and Mexico City (10·9 years for men and 9·4 years for women), and the narrowest in Buenos Aires (4·4 years for men and 5·8 years for women), Belo Horizonte (4·0 years for men and 6·5 years for women), and San Jose (3·9 years for men and 3·0 years for women). Higher area-level socioeconomic status was associated with higher life expectancy, especially in Santiago (change in life expectancy per P90–P10 change unit-level of educational attainment 8·0 years [95% CI 5·8–10·3] for men and 11·8 years [7·1–16·4] for women) and Panama City (8·0 years [4·4–11·6] for men and 10·0 years [4·2–15·8] for women). We saw an increase in life expectancy at birth from east to west in Panama City and from north to south in core Mexico City, and a core-periphery divide in Buenos Aires and Santiago. Whereas for San Jose the central part of the city had the lowest life expectancy and in Belo Horizonte the central part of the city had the highest life expectancy. Interpretation Large spatial differences in life expectancy in Latin American cities and their association with social factors highlight the importance of area-based approaches and policies that address social inequalities in improving health in cities of the region. Funding Wellcome Trust.

Background Exposure to particulate matter (PM2.5) is a major risk factor for morbidity and mortality. Yet few studies have examined patterns of population exposure and investigated the predictors of PM2.5 across the rapidly growing cities in lower- and middle-income countries. Objectives Characterize PM2.5 levels, describe patterns of population exposure, and investigate urban factors as predictors of PM2.5 levels. Methods We used data from the Salud Urbana en America Latina/Urban Health in Latin America (SALURBAL) study, a multi-country assessment of the determinants of urban health in Latin America, to characterize PM2.5 levels in 366 cities comprising over 100,000 residents using satellite-derived estimates. Factors related to urban form and transportation were explored. Results We found that about 172 million or 58% of the population studied lived in areas with air pollution levels above the defined WHO-AQG of 10 μg/m3 annual average. We also found that larger cities, cities with higher GDP, higher motorization rate and higher congestion tended to have higher PM2.5. In contrast cities with higher population density had lower levels of PM2.5. In addition, at the sub-city level, higher intersection density was associated with higher PM2.5 and more green space was associated with lower PM2.5. When all exposures were examined adjusted for each other, higher city per capita GDP and higher sub-city intersection density remained associated with higher PM2.5 levels, while higher city population density remained associated with lower levels. The presence of mass transit was also associated with lower PM2.5 after adjustment. The motorization rate also remained associated with PM2.5 and its inclusion attenuated the effect of population density. Discussion These results show that PM2.5 exposures remain a major health risk in Latin American cities and suggest that urban planning and transportation policies could have a major impact on ambient levels., Graphical abstract Unlabelled Image, Highlights • Cities in Latin America with higher GDP, motorization rate, and congestion have higher PM2.5. • Cities in Latin America with higher population density and green space have lower levels of PM2.5. • Intersection density and mass transit infrastructure also impact pollution levels. • Urban planning and transportation policies may have a major impact on air pollution.

Background Urban design features are often studied in relation to health and behavioural outcomes. They can also have major implications for environmental outcomes. However, the impact of these features on both health and environmental outcomes (co-benefits) is rarely examined. We investigated how urban landscape and street design profiles are related to jointly occurring health and environmental outcomes in Latin America cities. Methods We used data from the Salud Urbana en America Latina (SALURBAL) project, which has compiled and harmonised data on built environment, environmental exposures, and health outcomes for 370 cities in 11 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico, Nicaragua, Panama, and Peru. Eight city profiles were identified using finite mixture models. Four urban-landscape profiles were defined measuring patch (contiguous area of urban development) fragmentation, shape, and isolation, and four street-design profiles were defined using street connectivity, length, and directness. Multilevel regression models were used to assess associations between the city profiles and several health and environmental outcomes. Findings Our preliminary results show that compared with the urban-landscape profile labelled scattered pixels (comprising low fragmentation, compact shape, and high isolation), the proximate-stones profile (moderate fragmentation, irregular shape, and moderate isolation) had significantly higher levels of PM2·5 and nitrogen dioxide (NO2), and the proximate-inkblots profile (moderate-to-high fragmentation, complex shape, and moderate isolation) had significantly higher levels of violence-related deaths. Compared with the labyrinthine street design profile (low connectivity, moderate length, and moderate directness), the semi-hyperbolic grid (moderate connectivity, moderate length, and moderate directness) and spiderweb (high connectivity, low length, and moderate directness) profiles had significantly higher levels of PM2·5 and NO2, whereas the hyperbolic grid profile (moderate connectivity, high length, and low directness) had significantly higher levels of NO2 and lower levels of obesity. Interpretation Identifying how city profiles are related to environment and health outcomes can shed light on the urban policies that could have the greatest environment and health co-benefits. Funding The SALURBAL/Urban Health in Latin America project is funded by the Wellcome Trust (205177/Z/16/Z).

Background Highly urbanised and rapidly urbanising countries are facing critical air pollution problems. In Latin American cities, the effect of ambient PM2·5 on child health has not been extensively explored. We examined associations between ambient PM2·5 and under-5 mortality (deaths in those younger than 5 years per 1000 livebirths) infant mortality (deaths in those younger than 1 year per 1000 livebirths), and child mortality (deaths in those aged 1–4 years per 10 000 children) in Latin American cities. Methods In this longitudinal analysis, we estimated under-5 mortality, infant mortality, and child mortality for the period Jan 1, 2010, to dec 12, 2015, for 1152 subcity units clustered in 337 cities in Argentina, Brazil, Chile, Colombia, Costa Rica, Guatemala, and Mexico. We retrieved mean annual PM2·5 for each subcity unit. Using linear mixed-effects models, we estimated the percentage change in under-5 mortality, infant mortality, and child mortality associated with a 1 μg/m3 increase in annual PM2·5, adjusted for city-level and subcity-level predictors (population growth, gross domestic product, living conditions, water and sanitation provision, population education, and mass transit availability). Findings Over the study period, mean annual PM2·5 was 12·7 μg/m3 (SD 6·3), under-5 mortality was 14·2 deaths per 1000 livebirths, infant mortality was 12·1 deaths per 1000 livebirths, and child mortality was 4·8 deaths per 10 000 children. A 1 μg/m3 annual increase in PM2·5 was associated with 0·4% (95% CI 0·1 to 0·7) increase in under-5 mortality and 0·5% (95% CI 0·2 to 0·9) increase in infant mortality We found no significant association between PM2·5 increases and changes in child mortality (–0·1% [95% CI −0·8 to 0·6]). Interpretation Our findings support the need for environmental protection in the Latin American region for improving both planetary and population health. Transdisciplinary strategies at local levels, including public health practitioners and policy stakeholders involved in urban development, are key for implementing these changes. Funding The Wellcome Trust initiative Our Planet, Our Health.

Using data from Jackson Heart Study, we investigated the associations of neighborhood social and physical environments with prevalence and incidence of type 2 diabetes mellitus (T2DM) in African Americans (AA). Among non-diabetic participants at baseline (n=3670), 521 (14.2%) developed T2DM during a median follow-up of 7.3 years. Measures of neighborhood social environments, and food and physical activity resources were derived using surveys-and GIS-based methods. Prevalence ratios (PR) and Hazard ratios (HR) were estimated using generalized estimating equations and Cox proportional hazards models. Higher neighborhood social cohesion was associated with a 22% lower incidence of T2DM while higher density of unfavorable food stores was associated with a 34% higher incidence of T2DM after adjusting for individual-level risk factors (HR= 0.78 [95% CI:0.62, 0.99] and HR = 1.34 [1.12, 1.61], respectively). In addition, neighborhood problems was also associated with prevalence of T2DM (PR=1.14 [1.05, 1.24]) independent of individual-level risk factors and GIS-based measures. Our findings suggest that efforts to strengthen community ties or to attract healthy food retail outlets might be important strategies to consider for prevention of T2DM in AA.

We investigated the relationships between neighborhood socio-demographic characteristics (socioeconomic status [SES], percentage of Black residents, and percentage of Hispanic residents) and survey-based measures of the social environment (social cohesion, safety) and the physical environment (healthy food environment, walking environment) in six sites from 2000 through 2011. Neighborhood environments were patterned by area SES and racial/ethnic composition, such that higher SES and lower percentage minority neighborhoods had better physical and social environments. Increasing disparities over time were observed for some neighborhood environments. Further research should explore the role of neighborhood environments in maintaining or increasing social disparities in health.

Background There has been growing interest in understanding how neighborhoods may be related to cardiovascular risk. Neighborhood effects on sleep apnea could be one contributing mechanism. We investigated whether neighborhood walking environment and personal activity levels are related to OSA. Methods Data were analyzed from a subpopulation of the Multi-Ethnic Study of Atherosclerosis (MESA), including subjects who participated in both the MESA Sleep and Neighborhood studies (N = 1,896). Perceived neighborhood walking environment and subjects' objective activity were evaluated in multivariate, multilevel models to determine any association with sleep apnea severity as defined by using the apnea-hypopnea index. Sex, race/ethnicity, and obesity were examined as moderators. Results Residing in the lowest quartile walking environment neighborhoods (score P Conclusions Living in neighborhoods with a low walking environment score is associated with greater severity of sleep apnea, especially in male and obese individuals. In men, greater activity level is associated with less severe sleep apnea, independent of BMI, comorbidities, and socioeconomic status. Neighborhood-level interventions that increase walkability and enable increased physical activity may potentially reduce the severity of sleep apnea.

The National, Heart, Lung, and Blood Institute convened a Think Tank meeting to obtain insight and recommendations regarding the objectives and design of the next generation of research aimed at reducing health inequities in the United States. The panel recommended several specific actions, including: 1) embrace broad and inclusive research themes; 2) develop research platforms that optimize the ability to conduct informative and innovative research, and promote systems science approaches; 3) develop networks of collaborators and stakeholders, and launch transformative studies that can serve as benchmarks; 4) optimize the use of new data sources, platforms, and natural experiments; and 5) develop unique transdisciplinary training programs to build research capacity. Confronting health inequities will require engaging multiple disciplines and sectors (including communities), using systems science, and intervening through combinations of individual, family, provider, health system, and community-targeted approaches. Details of the panel's remarks and recommendations are provided in this report.

Given limited research on the impact of neighborhood environments on accelerated biological aging, we examined whether changes in neighborhood socioeconomic and social conditions were associated with change in leukocyte telomere length using 10 years of longitudinal data from the Multi-Ethnic Study of Atherosclerosis (years 2000–2011; N = 1031; mean age = 61, SD = 9.4). Leukocyte telomere length change was corrected for regression to the mean and neighborhood was defined as census tract. Neighborhood socioeconomic indicators (factor-based score of income, education, occupation, and wealth of neighborhood) and neighborhood social environment indicators (aesthetic quality, social cohesion, safety) were obtained from the U.S Census/American Community Survey and via study questionnaire, respectively. Results of linear mixed-effects models showed that independent of individual sociodemographic characteristics, each unit of improvement in neighborhood socioeconomic status was associated with slower telomere length attrition over 10-years (β = 0.002; 95% Confidence Interval (CI): 0.0001, 0.004); whereas each unit of increase in safety (β = −0.043; 95% CI: -0.069, −0.016) and overall neighborhood social environment score (β = -0.005; 95% CI: -0.009, −0.0004) were associated with more pronounced telomere attrition, after additionally adjusting for neighborhood socioeconomic status. This study provides support for considerations of the broader social and socioeconomic contexts in relation to biological aging. Future research should explore potential psychosocial mechanisms underlying these associations using longitudinal study designs with repeated observations.

Rapid urbanization in low- and middle-income countries (LMIC) is associated with increasing population living in informal settlements. Inadequate infrastructure and disenfranchisement in settlements can create environments hazardous to health. Placed-based physical environment upgrading interventions have potential to improve environmental and economic conditions linked to health outcomes. Summarizing and assessing evidence of the impact of prior interventions is critical to motivating and selecting the most effective upgrading strategies moving forward. Scientific and grey literature were systematically reviewed to identify evaluations of physical environment slum upgrading interventions in LMICs published between 2012 and 2018. Thirteen evaluations that fulfilled inclusion criteria were reviewed. Quality of evaluations was assessed using an adapted Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Findings were then pooled with those published prior to 2012. Narrative analysis was performed. Of thirteen evaluations, eight used a longitudinal study design (“primary evaluations”). All primary evaluations were based in Latin America and included two housing, two transportation, and four comprehensive intervention evaluations. Three supporting evaluations assessed housing interventions in Argentina and South Africa; two assessed a comprehensive intervention in India. Effects by intervention-type included improvements in quality of life and communicable diseases after housing interventions, possible improvements in safety after transportation and comprehensive interventions, and possible non-statistically significant effects on social capital after comprehensive interventions. Effects due to interventions may vary by regional context and intervention scope. Limited strong evidence and the diffuse nature of comprehensive interventions suggests a need for attention to measurement of intervention exposure and analytic approaches to account for confounding and selection bias in evaluation. In addition to health improvements, evaluators should consider unintended health consequences and environmental impact. Understanding and isolating the effects of place-based interventions can inform necessary policy decisions to address inadequate living conditions as rapid urban growth continues across the globe.

Background Exposure to adverse social factors has been associated with an altered inflammatory profile, a risk factor for several acute and chronic diseases. Differential gene expression may be a biological mediator in the relationship. In this study, associations between a range of social factors and expression of inflammation-related genes were investigated. Methods Social factor and gene expression data were collected from 1,264 individuals in the Multi-Ethnic Study of Atherosclerosis (MESA). Inflammation-related genes were identified from the Gene Ontology database. The associations between social factors and gene expression were first assessed using the Global Analysis of Covariance (Global ANCOVA) gene set enrichment test. When the global test was significant, linear regression and elastic net penalized regression were employed to identify the individual gene transcripts within each gene set associated with the social factor. Results Loneliness (p = 0.003), chronic burden (p = 0.002), and major or lifetime discrimination (p = 0.045) were significantly associated with global expression of the chronic inflammatory gene set. Of the 20 transcripts that comprise this gene set, elastic net selected 12 transcripts for loneliness, 8 for chronic burden, and 3 for major or lifetime discrimination. Major or lifetime discrimination was also associated with the inflammatory response (p = 0.029), regulation of the inflammatory response (p = 0.041), and immune response (p = 0.025) gene sets in global analyses, and 53, 136, and 26 transcripts were selected via elastic net for these gene sets respectively. There were no significant associations in linear regression analyses after adjustment for multiple testing. Conclusions This study highlights gene expression as a biological mechanism through which social factors may affect inflammation.

Summary Objective Prior studies have shown a bidirectional association between depression and type 2 diabetes mellitus (T2DM); however, the prospective associations of anger and anxiety with T2DM have not been established. We hypothesized that trait anger and anxiety would predict incident T2DM, independently of depressive symptoms. Research design and methods In the Multi-ethnic Study of Atherosclerosis (MESA), we prospectively examined the association of trait anger and trait anxiety (assessed via the Spielberger Trait Anger and Anxiety Scales, respectively) with incident T2DM over 11.4 years in 5598 White, Black, Hispanic, and Chinese participants (53.2% women, mean age 61.6 years) at baseline without prevalent T2DM or cardiovascular disease. We used Cox proportional hazards models to calculate the hazard ratios (HR) of incident T2DM by previously defined anger category (low, moderate, high), and anxiety quartile, as there were no previously defined categories. Results High total trait anger was associated with incident T2DM (HR 1.50; 95% CI 1.08–2.07) relative to low total trait anger. The association was attenuated following adjustment for waist circumference (HR 1.32; 95% CI 0.94–1.86). Higher anger reaction was also associated with incident T2DM (HR = 1.07; 95% CI 1.03–1.11) that remained significant after adjusting for potential confounders/explanatory factors. In contrast, trait anxiety did not predict incident T2DM. Conclusions High total trait anger and anger reaction are potential modifiable risk factors for T2DM. Further research is needed to explore the mechanisms of the anger–diabetes relationship and to develop preventive interventions.

We examined cross-sectional and longitudinal associations between neighborhood socioeconomic status, social cohesion and safety and features of the diurnal cortisol curve including: area under the curve (AUC), wake-to-bed slope, wake-up, cortisol awakening response (CAR, wake-up to 30 minutes post-awakening), early decline (30 minutes to 2 hours post-awakening) and late decline (2 hours post-awakening to bed time). In cross-sectional analyses, higher neighborhood poverty was associated with a flatter early decline and a flatter wake-to-bed slope. Higher social cohesion and safety were associated with higher wake-up cortisol, steeper early decline and steeper wake-to-bed slope. Over 5 years, wake-up cortisol increased, CAR, early decline, late decline and wake-to-bed slope became flatter and AUC became larger. Higher poverty was associated with less pronounced increases in wake-up and AUC, while higher social cohesion was associated with greater increases in wake-up and AUC. Adverse neighborhood environments were cross-sectionally associated with flatter cortisol profiles, but associations with changes in cortisol were weak and not in the expected direction.

Summary Background Prior studies have investigated the association of clinical depression and depressive symptoms with body weight (i.e. body mass index (BMI) and waist circumference), but few have examined the association between depressive symptoms and intra-abdominal fat. Of these a limited number assessed the relationship in a multi-racial/ethnic population. Methods Using data on 1017 men and women (45–84 years) from the Multi-Ethnic Study of Atherosclerosis (MESA) Body Composition, Inflammation and Cardiovascular Disease Study, we examined the cross-sectional association between elevated depressive symptoms (EDS) and CT-measured visceral fat mass at L2–L5 with multivariable linear regression models. EDS were defined as a Center for Epidemiological Studies Depression score ≥16 and/or anti-depressant use. Covariates included socio-demographics, inflammatory markers, health behaviors, comorbidities, and body mass index (BMI). Race/ethnicity (Whites [referent group], Chinese, Blacks and Hispanics) and sex were also assessed as potential modifiers. Results The association between depressive symptoms and visceral fat differed significantly by sex ( p = 0.007), but not by race/ethnicity. Among men, compared to participants without EDS, those with EDS had greater visceral adiposity adjusted for BMI and age (difference = 122.5 cm 2 , 95% CI = 34.3, 210.7, p = 0.007). Estimates were attenuated but remained significant after further adjustment by socio-demographics, inflammatory markers, health behaviors and co-morbidities (difference = 94.7 cm 2 , 95% CI = 10.5, 178.9, p = 0.028). Among women, EDS was not significantly related to visceral adiposity in the fully adjusted model. Conclusions Sex, but not race/ethnicity, was found to modify the relationship between EDS and visceral fat mass. Among men, a significant positive association was found between depressive symptoms and visceral adiposity. No significant relationship was found among women.

Background and aims DNA methylation of repetitive elements may explain the relations between dietary intake, hyperhomocysteinemia, and cardiovascular disease risk. We investigated associations of methyl micronutrient intake and plasma total homocysteine with LINE-1 and Alu methylation in a cross-sectional study of 987 adults aged 45–84 y who participated in the Multi-Ethnic Study of Atherosclerosis (MESA) Stress Study. Methods and results DNA methylation was estimated using pyrosequencing technology. A 120-item food frequency questionnaire was used to ascertain daily intake of folate, vitamin B12, vitamin B6, zinc, and methionine. Plasma total homocysteine was quantified using a fluorescence polarization immunoassay. Associations of micronutrient intake and homocysteine with LINE-1 and Alu methylation were examined using linear regression. Adjusted differences in %5-methylated cytosines (%5 mC) were examined by categories of predictors using multivariable linear regression models. Intake of methyl-donor micronutrients was not associated with DNA methylation. After adjustment for covariates, each 3 μmol/L increment of homocysteine corresponded with 0.06 (−0.01, 0.13) %5 mC higher LINE-1 methylation. Additionally, BMI was positively associated with LINE-1 methylation ( P trend = 0.03). Participants with BMI ≥ 40 kg/m 2 had 0.35 (0.03, 0.67) %5 mC higher LINE-1 than those with normal BMI. We also observed a 0.10 (0.02, 0.19) %5 mC difference in Alu methylation per 10 cm of height. These associations did not differ by sex. Conclusion Dietary intake of methyl-donor micronutrients was not associated with measures of DNA methylation in our sample. However, higher BMI was related to higher LINE-1 methylation, and height was positively associated with Alu methylation.

Summary Background Stress hormones have been hypothesized to contribute to the social patterning of cardiovascular disease but evidence of differences in hormone levels across social groups is scant. Purpose To examine the associations of socioeconomic and psychosocial factors with urinary levels of cortisol and catecholamines and determine whether these associations are modified by race/ethnicity. Methods Measures of cortisol, epinephrine, norepinephrine and dopamine were obtained on 12-h overnight urine specimens from 942 White, African American and Hispanic participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Linear regression was used to examine associations of income-wealth index, education, depression, anger, anxiety and chronic stress with the four hormones after adjustment for covariates. Results Higher income-wealth index was associated with lower levels of urinary cortisol, epinephrine, norepinephrine and dopamine, after adjustment for age, sex, race/ethnicity, medication use, body mass index, smoking, and alcohol use. Education and psychosocial factors were not associated with urinary stress hormone levels in the full sample. However, there was some evidence of effect modification by race: SES factors were more strongly inversely associated with cortisol in African Americans than in other groups and anger was inversely associated with catecholamines in African Americans but not in the other groups. Conclusions Lower SES as measured by income-wealth index in a multi-ethnic sample is associated with higher levels of urinary cortisol and catecholamines. Heterogeneity in these associations by race/ethnicity warrants further exploration.

Weight among immigrants in the United States (US) is lower than among the US-born on average, but higher among long-term immigrants than the newly arrived. Neighborhood coethnic concentration—the proportion of neighborhood residents of the same ethnic background—may influence weight among immigrants via behavioral norms and market-driven community resources. However, the relevant exposure timeframe may be far longer than is captured by existing cross-sectional and short-term studies. Using detailed historical residential address information on 1449 older Latino and Chinese long-term immigrants, we investigated associations of 10–20-year neighborhood coethnic concentration trajectories with current waist circumference and weight-related behaviors (diet, physical activity, and sedentary time). Among Chinese participants, compared to persistent low coethnic concentration, increasing coethnic concentration was associated with higher waist circumference (difference = 1.45 cm [0.51, 2.39]). In contrast, both increasing coethnic concentration and persistent high coethnic concentration were associated with a healthier diet. Among Latino participants, trajectories characterized by higher coethnic concentration were associated with higher waist circumference (e.g., difference = 2.11 cm [0.31, 3.91] for persistent high vs. persistent low) and low physical activity. Long-term patterns of neighborhood coethnic concentration may affect weight-related outcomes among immigrants in complex ways that differ by ethnicity and outcome.

This study examines associations of disaggregate land uses with self-reported walking for transportation among participants of the Multi-Ethnic Study of Atherosclerosis (MESA) in Forsyth County, NC and New York, NY. Network distance to each use (in miles), intensity (number of uses per 1/2-mile network buffer) of each use and diversity (number of different uses per 1/2-mile network buffer) of uses were calculated using Geographic Information Systems (GIS). Associations with odds of meeting recommended physical activity levels (150 min/week) were examined after controlling for individual- and census-tract-level covariates. Greater distance to and lower intensity of pedestrian-oriented uses, specifically those for social interactions, were associated with lower odds of meeting recommendations in NY. Results suggest that land uses linked to social interactions may be useful for encouraging increased transportation walking.

Quantifying the effects of specific neighborhood features on self-reported health is important to understanding the global health impact of neighborhood context. We investigated associations of neighborhood poverty, sociability and walkability with self-rated physical and mental health in the Multi-Ethnic Study of Atherosclerosis (MESA). In separate models, each neighborhood variable was associated with physical health but associations with sociability and walkability were stronger than those for poverty. Only walkability remained significant after adjusting for the other neighborhood variables. There was no evidence that self-rated mental health as assessed by the SF12 was associated with neighborhood poverty, walkability or sociability. This study provides information on how neighborhood context is associated with global health in diverse midlife and older persons.

John Henryism connotes a strong behavioral predisposition to engage in effortful, active coping with difficult social and economic stressors. This behavioral predisposition is measured by the 12 item John Henryism Scale for Active Coping (JHAC). The John Henry hypothesis predicts that the well-known inverse socioeconomic status (SES)-blood pressure association will be stronger among persons who score high rather than low on the JHAC. We tested this hypothesis in a large African American cohort using baseline data from the Jackson Heart Study. Unlike previous studies, we used multiple indicators of SES: income, education, occupation, childhood SES and cumulative SES. Because the hypothesis is most relevant for adults still in the labor force, we excluded retired participants, yielding a sample size of 3,978. Gender-specific Poisson regression models for hypertension adjusting for age, John Henryism, SES, and a John Henryism-SES interaction term, were fit to examine associations. Separate models were fit for each SES indicator. We found some evidence that John Henryism modified the association between income and hypertension in men: low income was associated with higher prevalence of hypertension in men who scored high on John Henryism (prevalence ratio (PR) for low vs. high income tertile 1.12), but with lower hypertension prevalence among men who scored low on John Henryism (PR 0.85, one sided P value for multiplicative interaction

Background Walk Score® and Transit Score® are open-source measures of the neighborhood built environment to support walking (“walkability”) and access to transportation. Purpose To investigate associations of Street Smart Walk Score and Transit Score with self-reported transport and leisure walking using data from a large multicity and diverse population-based sample of adults. Methods Data from a sample of 4552 residents of Baltimore MD, Chicago IL, Forsyth County NC, Los Angeles CA, New York NY, and St. Paul MN from the Multi-Ethnic Study of Atherosclerosis (2010–2012) were linked to Walk Score and Transit Score (collected in 2012). Logistic and linear regression models estimated ORs of not walking and mean differences in minutes walked, respectively, associated with continuous and categoric Walk Score and Transit Score. All analyses were conducted in 2012. Results After adjustment for site, key sociodemographic, and health variables, a higher Walk Score was associated with lower odds of not walking for transport and more minutes/week of transport walking. Compared to those in a “walker’s paradise,” lower categories of Walk Score were associated with a linear increase in odds of not transport walking and a decline in minutes of leisure walking. An increase in Transit Score was associated with lower odds of not transport walking or leisure walking, and additional minutes/week of leisure walking. Conclusions Walk Score and Transit Score appear to be useful as measures of walkability in analyses of neighborhood effects.

Higher serum phosphorus concentrations are associated with cardiovascular disease events and mortality. Low socioeconomic status is linked with higher serum phosphorus concentration, but the reasons are unclear. Poor individuals disproportionately consume inexpensive processed foods commonly enriched with phosphorus-based food preservatives. Accordingly, we hypothesized that excess intake of these foods accounts for a relationship between lower socioeconomic status and higher serum phosphorus concentration.Cross-sectional analysis.We examined a random cohort of 2,664 participants with available phosphorus measurements in the Multi-Ethnic Study of Atherosclerosis, a community-based sample of individuals free of clinically apparent cardiovascular disease from across the United States.Socioeconomic status, the intake of foods commonly enriched with phosphorus-based food additives (processed meats, sodas), and frequency of fast-food consumption.Fasting morning serum phosphorus concentrations.In unadjusted analyses, lower income and lower educational achievement categories were associated with modestly higher serum phosphorus concentration (by 0.02 to 0.10 mg/dL, P.05 for all). These associations were attenuated in models adjusted for demographic and clinical factors, almost entirely due to adjustment for female gender. In multivariable-adjusted analyses, there were no statistically significant associations of processed meat intake or frequency of fast-food consumption with serum phosphorus. In contrast, each serving per day higher soda intake was associated with 0.02 mg/dL lower serum phosphorus concentration (95% confidence interval, -0.04, -0.01).Greater intake of foods commonly enriched with phosphorus additives was not associated with higher serum phosphorus concentration in a community-living sample with largely preserved kidney function. These results suggest that excess intake of processed and fast foods may not impact fasting serum phosphorus concentrations among individuals without kidney disease.

The objective was to examine the cross-sectional association of diurnal salivary cortisol curve components and urinary catecholamines with diabetes status. Up to 18 salivary cortisol samples over 3 days and overnight urinary catecholamines were collected from 1002 participants in the Multi-Ethnic Study of Atherosclerosis. Diabetes was defined as a fasting blood glucose of at least 126 mg/dL or medication use. Cortisol curve measures included awakening cortisol, cortisol awakening response, early decline, late decline, and cortisol area under the curve (AUC). Urinary catecholamines included epinephrine, norepinephrine, and dopamine. Participants with diabetes had significantly lower cortisol awakening response (β = -0.19; 95% confidence interval [CI], -0.34 to -0.04) than those without diabetes in multivariable models. Whereas men with diabetes had a nonsignificant trend toward lower total AUC (β = -1.56; 95% CI, -3.93 to 0.80), women with diabetes had significantly higher total AUC (β = 2.62; 95% CI, 0.72 to 4.51) (P = .02 for interaction) compared with those without diabetes. Men but not women with diabetes had significantly lower urinary catecholamines compared with those without diabetes (P < .05). Diabetes is associated with neuroendocrine dysregulation, which may differ by sex. Further studies are needed to determine the role of the neuroendocrine system in the pathophysiology of diabetes.

Socioeconomic and psychosocial factors have been found to be associated with systemic inflammation. Although stress is often proposed as a contributor to these associations, no population studies have investigated the links between inflammation and biomarkers of stress. The current study examines associations between daily cortisol profiles and inflammatory markers interleukin-6 (IL-6), interleukin-10 (IL-10), and tumor necrosis factor (TNF-a) in a population-based sample of 869 adults with repeat measures of cortisol over multiple days. Persons with higher levels of IL-6 had a less pronounced cortisol awakening response, a less steep daily decline, and higher cortisol area under the curve for the day with associations persisting after controls for risk factors and other cytokines. Persons with higher levels of TNF-a had lower cortisol levels upon waking, and flatter daily decline, although associations with decline were attenuated when controlling for inflammatory risk factors. Higher levels of IL-10 were associated with marginally flatter daily cortisol decline (p < .10). This study is the first to identify associations of basal cortisol activity and inflammatory markers in a population-based sample. Findings are consistent with the possibility that HPA axis activity may mediate associations between psychosocial stressors and inflammatory processes. Additional prospective data are necessary to clarify the directionality of associations between cortisol and inflammatory markers.

Purpose Little research has focused on the social patterning of diabetes among African Americans. We examined the relationship between socioeconomic status (SES) and the prevalence, awareness, treatment, and control of diabetes among African Americans. Methods Education, income and occupation were examined among 4,303 participants (2,726 women and 1,577 men). Poisson regression estimated relative probabilities (RP) of diabetes outcomes by SES. Results The prevalence of diabetes was 19.6% in women and 15.9% in men. Diabetes awareness, treatment, and control were 90.0%, 86.8%, and 39.2% in women, respectively, and 88.2%, 84.4%, and 35.9% in men, respectively. In adjusted models, low-income men and women had greater probabilities of diabetes than high-income men and women (RP, 1.94; 95% confidence interval [CI], 1.28–2.92; and RP, 1.35; 95% CI, 1.04–1.74, respectively). Lack of awareness was associated with low education and low occupation in women (RP, 2.28; 95%CI 1.01–5.18; and RP, 2.62; 95% CI, 1.08–6.33, respectively) but not in men. Lack of treatment was associated with low education in women. Diabetes control was not patterned by SES. Conclusions Diabetes prevalence is patterned by SES, and awareness and treatment are patterned by SES in women but not men. Efforts to prevent diabetes in African Americans need to address the factors that place those of low SES at higher risk.

Background Low dietary quality is a key contributor to obesity and related illnesses, and lower income is generally associated with worse dietary profiles. The unequal geographic distribution of healthy food resources could be a key contributor to income disparities in dietary profiles. Purpose To explore the role that economic segregation can have in creating income differences in healthy eating and to explore policy levers that may be appropriate for countering income disparities in diet. Methods A simple agent-based model was used to identify segregation patterns that generate income disparities in diet. The capacity for household food preferences and relative pricing of healthy foods to overcome or exacerbate the differential was explored. Results Absent other factors, income differentials in diet resulted from the segregation of high-income households and healthy food stores from low-income households and unhealthy food stores. When both income groups shared a preference for healthy foods, low-income diets improved but a disparity remained. Both favorable preferences and relatively cheap healthy foods were necessary to overcome the differential generated by segregation. Conclusions The model underscores the challenges of fostering favorable behavior change when people and resources are residentially segregated and behaviors are motivated or constrained by multiple factors. Simulation modeling can be a useful tool for proposing and testing policies or interventions that will ultimately be implemented in a complex system where the consequences of multidimensional interactions are difficult to predict.

Although stress is often hypothesized to contribute to the effects of neighborhoods on health, very few studies have investigated associations of neighborhood characteristics with stress biomarkers. This study helps address the gap in the literature by examining whether neighborhood characteristics are associated with cortisol profiles. Analyses were based on data from the Multi-Ethnic Study of Atherosclerosis Stress study, which collected multiple measures of salivary cortisol over three days on a population based sample of approximately 800 adults. Multilevel models with splines were used to examine associations of cortisol levels with neighborhood poverty, violence, disorder, and social cohesion. Neighborhood violence was significantly associated with lower cortisol values at wakeup and with a slower decline in cortisol over the earlier part of the day, after sociodemographic controls. Associations were weaker and less consistent for neighborhood poverty, social cohesion, and disorder. Results revealed suggestive, though limited, evidence linking neighborhood contexts to cortisol circadian rhythms.

Rationale and Objectives Higher socioeconomic status (SES) has been associated with lower respiratory mortality and better lung function, but whether a similar gradient exists for computed tomography (CT) measures of subclinical emphysema is unknown. Materials and Methods The Multi-Ethnic Study of Atherosclerosis (MESA) recruited African-American, Chinese, Hispanic, and white participants, ages 45 to 84 years, without clinical cardiovascular disease, from six US sites between 2000 and 2002. The MESA Lung Study assessed percent emphysema, defined based on the proportion of pixels below an attenuation threshold of 910 HU from lung windows of cardiac CT scans. Generalized linear models were adjusted for demographic characteristics, height, body mass index, history of respiratory illness, occupational and residential exposures, tobacco use, and CT scanner type. Results Among 3706 participants with a mean age of 61 (±10), the median value for percent emphysema was 18 (interquartile range = 20). Compared with those who did not complete high school, participants with a graduate degree had a higher percent emphysema (difference of 4; P Conclusion Although SES indicators were positively associated with subclinical emphysema detectable on CT scan, this unexpected association may highlight potential bias because of effort dependence of both CT measures and spirometry.

We investigated cross-sectional associations of neighborhood deprivation, problems, safety, and cohesion with circulating levels of fibrinogen, interleukin-6, and C-reactive protein (n = 5370) and longitudinal associations with changes in IL-6 over a 3-4 year period (n = 946). In cross-sectional analyses, higher levels of neighborhood deprivation and problems were associated with higher levels of all three inflammatory markers, whereas higher levels of safety were associated with lower levels. Fibrinogen remained associated with all neighborhood characteristics except cohesion and IL-6 remained associated with safety after adjustment for race and SES. In longitudinal analyses, higher levels of neighborhood deprivation and problems, and lower levels of safety were associated with greater longitudinal increases in IL-6 after adjustment for age, sex, race, and SES. These findings were not substantially modified by further risk factor adjustment. Although findings regarding different inflammatory markers were mixed, the longitudinal results that are less limited by race confounding suggest that inflammatory pathways may contribute to neighborhood differences in cardiovascular disease risk.

Social support is associated with cardiovascular disease mortality, however the physiologic mechanisms underlying this relationship remains unspecified. This study evaluated the association of social support with inflammatory markers associated with cardiovascular risk: C-reactive protein (CRP), interleukin-6 (IL-6), and fibrinogen. We evaluated two competing models of the support-inflammation relationship: first, that low social support is directly associated with inflammation, and second, that high support acts to buffer the effect of stress on inflammation. Using data from the baseline interview of the Multi-Ethnic Study of Atherosclerosis (N = 6,814, 53% female, age 45–84 years) we assessed the independent and interacting associations of social support and stress with inflammation. Social support was measured by the Emotional Social Support Index. Stressors in multiple domains (work, family, finances, interpersonal) were assessed. Serum CRP, IL-6, and fibrinogen were analyzed from fasting samples using high-sensitivity assays. Multivariate linear regression, including models stratified by gender and age group (45 – 64 and 65 – 84 years), was used to assess the direct and buffering relationships between social support, stress, and inflammation. In bivariate analyses low social support was associated with higher levels of all three markers. In adjusted models, low support was associated with higher lnCRP (B: 0.15, 95% CI: 0.01, 0.30) among men but not women. High social support buffered the relationship between stress and CRP among middle-aged women only (P for interaction 0.042). Overall, social support was only modestly associated with inflammation in this relatively healthy sample, and these relationships varied by age and gender.

There is a growing interest in understanding the effects of specific neighborhood conditions on psychological wellbeing. We examined cross-sectional associations of neighborhood stressors (perceived violence and disorder, physical decay and disorder) and social support (residential stability, family structure, social cohesion, reciprocal exchange, social ties) with depressive symptoms in 3105 adults in Chicago. Subjects lived in 343 neighborhood clusters, areas of about two census tracts. Depressive symptoms were assessed with an 11-item version of the Center for Epidemiologic Studies-Depression (CES-D) scale. Neighborhood variables were measured using rater assessments, surveys, and the US census. We used two-level gender-stratified models to estimate associations of neighborhood conditions with depressive symptoms after adjusting for individual-level covariates. Most social support variables were associated with lower levels of depressive symptoms in women but not men, while stressors were moderately associated with higher levels in all subjects. Adjusting concurrently for stressors and social support did not change results. This suggests both neighborhood stressors and social support are associated with depressive symptoms.

The racial/ethnic composition of a neighborhood may be related to residents’ depressive symptoms through differential levels of neighborhood social support and/or stressors. We used the Multi-Ethnic Study of Atherosclerosis to investigate cross-sectional associations of neighborhood racial/ethnic composition with the Center for Epidemiologic Studies-Depression (CES-D) scale in adults aged 45–84. The key exposure was a census-derived measure of the percentage of residents of the same racial/ethnic background in each participant’s census tract. Two-level multilevel models were used to estimate associations of neighborhood racial/ethnic composition with CES-D scores after controlling for age, income, marital status, education and nativity. We found that living in a neighborhood with a higher percentage of residents of the same race/ethnicity was associated with increased CES-D scores in African American men (p < 0.05), and decreased CES-D scores in Hispanic men and women and Chinese women, although these differences were not statistically significant. Models were further adjusted for neighborhood-level covariates (social cohesion, safety, problems, aesthetic quality and socioeconomic factors) derived from survey responses and census data. Adjusting for other neighborhood characteristics strengthened protective associations amongst Hispanics, but did not change the significant associations in African American men. These results demonstrate heterogeneity in the associations of race/ethnic composition with mental health and the need for further exploration of which aspects of neighborhood environments may contribute to these associations.

Objectives The purpose of this study was to examine the prevalence of left ventricular hypertrophy (LVH) and left ventricular (LV) remodeling patterns within Hispanic subgroups compared with non-Hispanic whites in the MESA (Multi-Ethnic Study of Atherosclerosis). Background Hispanics are the largest and fastest-growing ethnic minority in the U.S., but there are no data on LVH and LV geometry among Hispanic subgroups. Methods Cardiac magnetic resonance imaging was performed in 4,309 men and women age 45 to 84 years without clinical cardiovascular disease. Hispanics were categorized into subgroups based on self-reported ancestry. LVH was defined as the upper 95th percentile of indexed LV mass in a reference normotensive, nondiabetic, nonobese population, and LV remodeling according to the presence/absence of LVH and abnormal/normal LV mass to LV end-diastolic volume ratio. Results Among Hispanic participants, 574 were of Mexican origin, 329 were of Caribbean origin, and 161 were of Central/South American origin. On unadjusted analysis, only Caribbean-origin Hispanics (prevalence ratio = 1.2; 95% confidence interval [CI]: 1.03 to 1.4) had greater prevalence of hypertension than non-Hispanic whites. Hispanic subgroups were more likely to have LVH than non-Hispanic whites after adjustment for hypertension and other covariates (Caribbean-origin Hispanics = odds ratio [OR]: 1.8, 95% CI: 1.1 to 3.0; Mexican-origin Hispanics = OR: 2.2, 95% CI: 1.4 to 3.3; Central/South Americans = OR: 1.5, 95% CI: 0.7 to 3.1). All Hispanic subgroups also had a higher prevalence of concentric and eccentric hypertrophy compared with non-Hispanic whites (p Conclusions Caribbean-origin Hispanics had a higher prevalence of LVH and abnormal LV remodeling compared with non-Hispanic whites. A higher prevalence of LVH and abnormal LV remodeling was also observed among Mexican-origin Hispanics, despite a lower prevalence of hypertension. Differences among Hispanic subgroups regarding LVH and LV remodeling should be taken into account when evaluating cardiovascular risk in this population.

Background: The neighborhood environment may play a role in encouraging sedentary patterns, especially for middle-aged and older adults. Purpose: The aim of this study was to examine the associations between walking and neighborhood population density, retail availability, and land-use distribution using data from a cohort of adults aged 45 to 84 years. Methods: Data from a multi-ethnic sample of 5529 adult residents of Baltimore MD, Chicago IL, Forsyth County NC, Los Angeles CA, New York NY, and St. Paul MN enrolled in the Multi-Ethnic Study of Atherosclerosis in 2000 –2002 were linked to secondary land-use and population data. Participant reports of access to destinations and stores and objective measures of the percentage of land area in parcels devoted to retail land uses, the population divided by land area in parcels, and the mixture of uses for areas within 200 m of each participant’s residence were examined. Multinomial logistic regression was used to investigate associations of self-reported and objective neighborhood characteristics with walking. All analyses were conducted in 2008 and 2009. Results: After adjustment for individual-level characteristics and neighborhood connectivity, it was found that higher density, greater land area devoted to retail uses, and self-reported proximity of destinations and ease of walking to places were each related to walking. In models including all land-use measures, population density was positively associated with walking to places and with walking for exercise for more than 90 minutes/week, both relative to no walking. Availability of retail was associated with walking to places relative to not walking, and having a more proportional mix of land uses was associated with walking for exercise for more than 90 minutes/week, while self-reported ease of access to places was related to higher levels of exercise walking, both relative to not walking. Conclusions: Residential density and the presence of retail uses are related to various walking behaviors. Efforts to increase walking may benefit from attention to the intensity and type of land development.

Purpose To investigate the association of employment status with coronary heart disease (CHD) and ischemic stroke among middle-aged women. Methods Proportional hazards regression was used to assess the association of employment status, incident CHD, and incident ischemic stroke among 7,058 women, ages 45–64 years at baseline (1987–1989), from the Atherosclerosis Risk in Communities Study. Results After adjusting for age and race-field center, women employed outside the home had a decreased risk of CHD (hazard ratio [HR], 0.70; 95% confidence interval [95% CI], 0.56–0.86) and ischemic stroke (HR, 0.62; 95% CI, 0.47–0.84) compared with homemakers. Differences in cardiovascular disease risk factors partially accounted for the association of employment status and CHD (HR, 0.79; 95% CI, 0.63–0.99) and stroke (HR, 0.79; 95% CI, 0.58–1.08). Also, modest differences were noted when the results were stratified by education, with employed women having a lower risk of CHD (HR, 0.65; 95% CI, 0.45–0.93) than homemakers among those with less than a high school education. Conclusions Women employed outside of the home had a lower risk of CHD and stroke compared with homemakers and, for CHD, this association was stronger among women with less than a high school education. These findings suggest additional research into the varied occupational experiences of women, socioeconomic status, and health is warranted.