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We examined whether residing within 2 miles of a new supermarket opening was longitudinally associated with a change in body mass index (BMI). We identified 12 new supermarkets that opened between 2009 and 2010 in 8 neighborhoods. Using the Kaiser Permanente Northern California Diabetes Registry, we identified members with type 2 diabetes residing continuously in any of these neighborhoods 12 months prior to the first supermarket opening until 10 months following the opening of the last supermarket. Exposure was defined as a reduction (yes/no) in travel distance to the nearest supermarket as a result of a new supermarket opening. First difference regression models were used to estimate the impact of reduced supermarket distance on BMI, adjusting for longitudinal changes in patient and neighborhood characteristics. Among patients in the exposed group, new supermarket openings reduced travel distance to the nearest supermarket by 0.7 miles on average. However, reduced distance to nearest supermarket was not associated with BMI changes. Overall, we found no evidence that reduced supermarket distance was associated with reduced levels of obesity for residents with type 2 diabetes.

ObjectiveTo examine the population-level association between food insecurity, HIV risk factors, and HIV serostatus among men, the group representing the majority of HIV diagnoses in the United States.DesignCross-sectional secondary data analysis using the National Health and Nutrition Examination Survey 1999-2012, a nationally representative survey of the civilian noninstitutionalized US population.MethodsLogistic regression with design weights and complex survey commands was used to estimate nationally representative associations between food insecurity and HIV serostatus (primary outcome), herpes simplex virus 2, self-reported sexually transmitted infections (STIs), and past-year illicit drug use among men, adjusting for potential confounders. Food security was measured using the 18-item Household Food Security Survey.ResultsWe analyzed data for 9150 men representing 61 million individuals in the United States. Unadjusted HIV prevalence was 1.5% among food insecure men, compared with 0.4% among food secure men (P

IntroductionFew studies have examined prenatal mood as a means to identify women at risk for negative childbirth experiences. We explore associations between prenatal mood and birth perceptions in a socioeconomically diverse, American sample.MethodsWe conducted a prospective study of 136 predominantly low-income and ethnic minority women of mixed parity. Prenatal measures of perceived stress, pregnancy-related anxiety, and depressive symptoms were used to predict maternal perceptions of birth experiences 1 month postpartum, using the childbirth experience questionnaire (CEQ; 1).ResultsAfter adjusting for sociodemographic variables and mode of delivery, higher third-trimester stress predicted worse CEQ total scores. This association was predominantly explained by two CEQ domains: own capacity (e.g., feelings of control and capability), and perceived safety. Pregnancy-related anxiety and depressive symptoms correlated with perceived stress, though neither independently predicted birth experience. An unplanned cesarean delivery was associated with a worse CEQ total score. Vaginal delivery predicted greater perceived safety. Altogether, sociodemographic covariates, mode of delivery, and prenatal mood accounted for 35 percent of the variance in birth experience (p < 0.001).DiscussionOur finding that prenatal stress explains a significant and likely clinically meaningful proportion of the variance in birth experience suggests that women perceive and recall their birth experiences through a lens that is partially determined by preexisting personal circumstances and emotional reserves. Since childbirth perceptions have implications for maternal and child health, patient satisfaction, and health care expenditures, these findings warrant consideration of prenatal stress screening to target intervention for women at risk for negative birth experiences.

Little is known about how neighborhood crime may relate to health in diabetes patients. We examined associations between individuals' perceptions of neighborhood safety or violent crime and stress, physical activity, body mass index (BMI) or hemoglobin A1c (HbA1c) in a sample (n=721) of adults (mean age:63) with diabetes. Self-reported neighborhood safety, violent crime, physical activity, and stress were collected and linked to clinical measures of BMI and HbA1c. Approximately 54% and 15% of patients reported neighborhood safety concerns and violent crimes, respectively. Any neighborhood safety concerns (β=1.14, 95% C.I. 0.04-2.24) and violent crime (β=2.04, 95% C.I. 0.34-3.73) were associated with BMI in adjusted analysis. Any violent crime was associated with class II-III obesity (BMI≥35) (OR=1.34, 95% C.I.: 1.02, 1.75). There were no significant associations between neighborhood safety concerns or violent crime with stress, physical activity, or HbA1c. Neighborhood safety is associated with BMI and obesity. Further studies, including longitudinal designs, are needed to study how people with diabetes may be influenced by a sense of poor personal safety in their neighborhoods.

Many individuals with obesity report over eating despite intentions to maintain or lose weight. Two barriers to long-term weight loss are reward-driven eating, which is characterized by a lack of control over eating, a preoccupation with food, and a lack of satiety; and psychological stress. Mindfulness training may address these barriers by promoting awareness of hunger and satiety cues, self-regulatory control, and stress reduction. We examined these two barriers as potential mediators of weight loss in the Supporting Health by Integrating Nutrition and Exercise (SHINE) randomized controlled trial, which compared the effects of a 5.5-month diet and exercise intervention with or without mindfulness training on weight loss among adults with obesity. Intention-to-treat multiple mediation models tested whether post-intervention reward-driven eating and psychological stress mediated the impact of intervention arm on weight loss at 12- and 18-months post-baseline among 194 adults with obesity (BMI: 30-45). Mindfulness (relative to control) participants had significant reductions in reward-driven eating at 6 months (post-intervention), which, in turn, predicted weight loss at 12 months. Post-intervention reward-driven eating mediated 47.1% of the total intervention arm effect on weight loss at 12 months [β = -0.06, SE(β) = 0.03, p = .030, 95% CI (-0.12, -0.01)]. This mediated effect was reduced when predicting weight loss at 18 months (p = .396), accounting for 23.0% of the total intervention effect, despite similar weight loss at 12 months. Psychological stress did not mediate the effect of intervention arm on weight loss at 12 or 18 months. In conclusion, reducing reward-driven eating, which can be achieved using a diet and exercise intervention that includes mindfulness training, may promote weight loss (clinicaltrials.gov registration: NCT00960414).

ObjectiveTo determine whether adding mindfulness-based eating and stress management practices to a diet-exercise program improves weight loss and metabolic syndrome components.MethodsIn this study 194 adults with obesity were randomized to a 5.5-month program with or without mindfulness training and identical diet-exercise guidelines. Intention-to-treat analyses with multiple imputation were used for missing data. The primary outcome was 18-month weight change.ResultsEstimated effects comparing the mindfulness to control arm favored the mindfulness arm in (a) weight loss at 12 months, -1.9 kg (95% CI: -4.5, 0.8; P = 0.17), and 18 months, -1.7 kg (95% CI: -4.7, 1.2; P = 0.24), though not statistically significant; (b) changes in fasting glucose at 12 months, -3.1 mg/dl (95% CI: -6.3, 0.1; P = 0.06), and 18 months, -4.1 mg/dl (95% CI: -7.3, -0.9; P = 0.01); and (c) changes in triglyceride/HDL ratio at 12 months, -0.57 (95% CI: -0.95, -0.18; P = 0.004), and 18 months, -0.36 (95% CI: -0.74, 0.03; P = 0.07). Estimates for other metabolic risk factors were not statistically significant, including waist circumference, blood pressure, and C-reactive protein.ConclusionsMindfulness enhancements to a diet-exercise program did not show substantial weight loss benefit but may promote long-term improvement in some aspects of metabolic health in obesity that requires further study.

We evaluated changes in mindful eating as a potential mechanism underlying the effects of a mindfulness-based intervention for weight loss on eating of sweet foods and fasting glucose levels. We randomized 194 obese individuals (M age = 47.0 ± 12.7 years; BMI = 35.5 ± 3.6; 78% women) to a 5.5-month diet-exercise program with or without mindfulness training. The mindfulness group, relative to the active control group, evidenced increases in mindful eating and maintenance of fasting glucose from baseline to 12-month assessment. Increases in mindful eating were associated with decreased eating of sweets and fasting glucose levels among mindfulness group participants, but this association was not statistically significant among active control group participants. Twelve-month increases in mindful eating partially mediated the effect of intervention arm on changes in fasting glucose levels from baseline to 12-month assessment. Increases in mindful eating may contribute to the effects of mindfulness-based weight loss interventions on eating of sweets and fasting glucose levels.

BackgroundHigh salt intake may be associated with pro-inflammatory changes in the immune response, and increased clinical and MRI activity in adults with relapsing-remitting multiple sclerosis.ObjectiveWe sought to determine if dietary salt intake is associated with pediatric-onset MS risk in a multicenter, case-control study.MethodsPediatric-onset CIS/MS cases within four years of onset and controls less than 22 years old recruited from 14 pediatric-MS centers were studied. Dietary sodium intake was assessed using the validated Block Kids Food Screener (NutritionQuest). Sodium intake, excess sodium, and sodium terciles were compared between cases and controls. Logistic regression models were adjusted for age, gender, ethnicity, body mass index, and socioeconomic status.ResultsAmong 170 cases (mean age=15.2±3.5) and 331 controls (mean age=14.0±3.7), no significant difference in unadjusted mean sodium intake was found between cases (2044mg/d) and controls (2030mg/d, p=0.99). The proportion of subjects consuming excess sodium, based on the adequate intake for age and gender, was similar between cases and controls (65% versus 69%, p=0.34). There were no increased odds of higher sodium intake among cases as compared to controls (for each 100mg/d increase in sodium, OR=1.00, 95% CI 0.98, 1.02; p=0.93, for excess sodium intake, OR=1.05, 95% CI 0.67, 1.64; p=0.84).ConclusionsOur results show no strong association between dietary salt intake and pediatric-onset MS risk, suggesting that salt intake may not play a prominent role in susceptibility to MS in children.

IntroductionLow levels of food security are associated with dyslipidemia and chronic disease in adults, particularly in women. There is a gap in knowledge about the relationship between food security among youth and dyslipidemia and chronic disease. We investigated the relationship between food security status and dyslipidemia among low-income adolescents.MethodsWe analyzed data from adolescents aged 12 to 18 years (N = 1,072) from households with incomes at or below 200% of the federal poverty level from the National Health and Nutrition Examination Survey (NHANES) 2003-2010. We used logistic regression to examine the relationship between household food security status and the odds of having abnormalities with fasting total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), serum triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C), TG/HDL-C ratio, and apolipoprotein B (Apo B). Models included age, sex, race/ethnicity, smoking status, partnered status in the household, and maternal education, with additional adjustment for adiposity.ResultsHousehold food security status was not associated with elevated TC or LDL-C. Adolescents with marginal food security were more likely than food-secure peers to have elevated TGs (odds ratio [OR] = 1.86; 95% confidence interval [CI], 1.14-3.05), TG/HDL-C ratio (OR = 1.74; 95% CI, 1.11-2.82), and Apo B (OR = 1.98; 95% CI, 1.17-3.36). Female adolescents with marginal food security had greater odds than male adolescents of having low HDL-C (OR = 2.69; 95% CI, 1.14-6.37). No elevated odds of dyslipidemia were found for adolescents with low or very low food security. Adjustment for adiposity did not attenuate estimates.ConclusionIn this nationally representative sample, low-income adolescents living in households with marginal food security had increased odds of having a pattern consistent with atherogenic dyslipidemia, which represents a cardiometabolic burden above their risk from adiposity alone.

IntroductionFood security status may moderate how people perceive barriers to fruit and vegetable consumption. This study aimed to 1) describe the association between fruit and vegetable consumption and microbarriers and mezzobarriers to consumption, and 2) test whether these associations differ by food security status.MethodsWe surveyed adults (n = 531) living in 2 economically deprived communities in Oakland, California, in 2013 and 2014. Multivariate linear regression assessed associations between microbarriers (taste, cost, busyness) and mezzobarriers (produce selection, quality, and purchase ease) and fruit and vegetable consumption, derived from a 26-item dietary screener. Interactions were tested by food security status.ResultsRespondents consumed a mean 2.4 (standard deviation, 1.5) servings of fruits and vegetables daily; 39% of the sample was food insecure. Being too busy to prepare healthy foods was associated with reduced fruit and vegetable consumption (β(busyness) = -0.40; 95% confidence interval [CI], -0.52 to -0.28) among all respondents. Food security moderated the relationship between fruit and vegetable consumption and taste, cost, and perceived ease of purchase of healthy foods. Among the food secure, disliking healthy food taste (β(taste) = -0.38; 95% CI, -0.60 to -0.15) and cost (β(cost) = -0.29; 95% CI, -0.44 to -0.15) concerns were associated with lower consumptions of fruits and vegetables. Mezzobarriers were not significantly associated with consumption in either group.ConclusionPerceived time constraints influenced fruit and vegetable consumption. Taste and cost influenced fruit and vegetable consumption among the food secure and may need to be considered when interpreting analyses that describe dietary intake and designing diet-related interventions.

ObjectiveLong-term psychological stress is associated with BMI increases in children as they transition to adulthood, whereas long-term maintenance of physical activity can slow excess weight gain. We hypothesized that in addition to these main effects, long-term physical activity mitigates the relationship between long-term stress and BMI increase.MethodThe NHLBI Growth and Health Study enrolled 2,379 10-year-old Black and White girls, following them annually for 10 measurement points. Growth curve modeling captured the dynamics of BMI, measured yearly, and stress and physical activity, measured at varying years.ResultsAt average levels of activity and stress, with all covariates remaining fixed, average BMI at baseline was 19.74 (SE = 0.38) and increased 0.64 BMI (SE = 0.01, p < .001) units every year. However, this increase in BMI significantly varied as a function of cumulative stress and physical activity. Slower BMI gain occurred in those girls who were less stressed and more active (0.62 BMI units/year, SE = .02, p < .001), whereas the most rapid and largest growth occurred in girls who were more stressed and less active (0.92 BMI units/year, SE = .02, p < .001). Racial identification did not alter these effects.ConclusionsAs hypothesized, in girls who maintained long-term activity, BMI growth was mitigated, even when reporting high long-term stress, compared with less physically active girls. This study adds to a converging literature in which physical activity, a modifiable prevention target, functions to potentially limit the damaging health effects of long-term psychological stress.

The emerging body of research suggests the unprecedented increase in housing foreclosures and unemployment between 2007 and 2009 had detrimental effects on health. Using data from electronic health records of 105,919 patients with diabetes in Northern California, this study examined how increases in foreclosure rates from 2006 to 2010 affected weight change. We anticipated that two of the pathways that explain how the spike in foreclosure rates affects weight gain-increasing stress and declining salutary health behaviors- would be acute in a population with diabetes because of metabolic sensitivity to stressors and health behaviors. Controlling for unemployment, housing prices, temporal trends, and time-invariant confounders with individual fixed effects, we found no evidence of an association between the foreclosure rate in each patient's census block of residence and body mass index. Our results suggest, although more than half of the population was exposed to at least one foreclosure within their census block, the foreclosure crisis did not independently impact weight change.

PurposeObese individuals vary in their experience of food cravings and tendency to engage in reward-driven eating, both of which can be modulated by the neural reward system rather than physiological hunger. We examined two predictions in a sample of obese women: (1) whether opioidergic blockade reduced food-craving intensity, and (2) whether opioidergic blockade reduced an association between food-craving intensity and reward-driven eating, which is a trait-like index of three factors (lack of control over eating, lack of satiation, preoccupation with food).MethodsForty-four obese, pre-menopausal women completed the Reward-Based Eating Drive (RED) scale at study start and daily food-craving intensity on 5 days on which they ingested either a pill-placebo (2 days), a 25 mg naltrexone dose (1 day), or a standard 50mg naltrexone dose (2 days).ResultsCraving intensity was similar under naltrexone and placebo doses. The association between food-craving intensity and reward-driven eating significantly differed between placebo and 50mg naltrexone doses. Reward-driven eating and craving intensity were significantly positively associated under both placebo doses. As predicted, opioidergic blockade (for both doses 25mg and 50mg naltrexone) reduced the positive association between reward-driven eating and craving intensity to non-significance.ConclusionsOpioidergic blockade did not reduce craving intensity; however, blockade reduced an association between trait-like reward-driven eating and daily food-craving intensity, and may help identify an important endophenotype within obesity.

ObjectiveGiven the critical role of behavior in preventing and treating chronic diseases, it is important to accelerate the development of behavioral treatments that can improve chronic disease prevention and outcomes. Findings from basic behavioral and social sciences research hold great promise for addressing behaviorally based clinical health problems, yet there is currently no established pathway for translating fundamental behavioral science discoveries into health-related treatments ready for Phase III efficacy testing. This article provides a systematic framework for developing behavioral treatments for preventing and treating chronic diseases.MethodThe Obesity-Related Behavioral Intervention Trials (ORBIT) model for behavioral treatment development features a flexible and progressive process, prespecified clinically significant milestones for forward movement, and return to earlier stages for refinement and optimization.ResultsThis article presents the background and rationale for the ORBIT model, a summary of key questions for each phase, a selection of study designs and methodologies well-suited to answering these questions, and prespecified milestones for forward or backward movement across phases.ConclusionsThe ORBIT model provides a progressive, clinically relevant approach to increasing the number of evidence-based behavioral treatments available to prevent and treat chronic diseases. (PsycINFO Database Record

There are currently no commonly used or easily accessible 'biomarkers' of hedonic eating. Physiologic responses to acute opioidergic blockade, indexed by cortisol changes and nausea, may represent indirect functional measures of opioid-mediated hedonic eating drive and predict weight loss following a mindfulness-based intervention for stress eating. In the current study, we tested whether cortisol and nausea responses induced by oral ingestion of an opioidergic antagonist (naltrexone) correlated with weight and self-report measures of hedonic eating and predicted changes in these measures following a mindfulness-based weight loss intervention. Obese women (N = 88; age = 46.7 ± 13.2 years; BMI = 35.8 ± 3.8) elected to complete an optional sub-study prior to a 5.5-month weight loss intervention with or without mindfulness training. On two separate days, participants ingested naltrexone and placebo pills, collected saliva samples, and reported nausea levels. Supporting previous findings, naltrexone-induced cortisol increases were associated with greater hedonic eating (greater food addiction symptoms and reward-driven eating) and less mindful eating. Among participants with larger cortisol increases (+1 SD above mean), mindfulness participants (relative to control participants) reported greater reductions in food addiction symptoms, b = -0.95, SE(b) = 0.40, 95% CI [-1.74, -0.15], p = .021. Naltrexone-induced nausea was marginally associated with reward-based eating. Among participants who endorsed naltrexone-induced nausea (n = 38), mindfulness participants (relative to control participants) reported greater reductions in food addiction symptoms, b = -1.00, 95% CI [-1.85, -0.77], p = .024, and trended toward reduced reward-based eating, binge eating, and weight, post-intervention. Single assessments of naltrexone-induced cortisol increases and nausea responses may be useful time- and cost-effective biological markers to identify obese individuals with greater opioid-mediated hedonic eating drive who may benefit from weight loss interventions with adjuvant mindfulness training that targets hedonic eating.

BackgroundIn previous research, neighborhood deprivation was positively associated with body mass index (BMI) among adults with diabetes. We assessed whether the association between neighborhood deprivation and BMI is attributable, in part, to geographic variation in the availability of healthful and unhealthful food vendors.MethodsSubjects were 16,634 participants of the Diabetes Study of Northern California, a multiethnic cohort of adults living with diabetes. Neighborhood deprivation and healthful (supermarket and produce) and unhealthful (fast food outlets and convenience stores) food vendor kernel density were calculated at each participant's residential block centroid. We estimated the total effect, controlled direct effect, natural direct effect, and natural indirect effect of neighborhood deprivation on BMI. Mediation effects were estimated using G-computation, a maximum likelihood substitution estimator of the G-formula that allows for complex data relations such as multiple mediators and sequential causal pathways.ResultsWe estimated that if neighborhood deprivation was reduced from the most deprived to the least deprived quartile, average BMI would change by -0.73 units (95% confidence interval: -1.05, -0.32); however, we did not detect evidence of mediation by food vendor density. In contrast to previous findings, a simulated reduction in neighborhood deprivation from the most deprived to the least deprived quartile was associated with dramatic declines in both healthful and unhealthful food vendor density.ConclusionsAvailability of food vendors, both healthful and unhealthful, did not appear to explain the association between neighborhood deprivation and BMI in this population of adults with diabetes.

ObjectivesWe tested whether leukocyte telomere length maintenance, which underlies healthy cellular aging, provides a link between sugar-sweetened beverage (SSB) consumption and the risk of cardiometabolic disease.MethodsWe examined cross-sectional associations between the consumption of SSBs, diet soda, and fruit juice and telomere length in a nationally representative sample of healthy adults. The study population included 5309 US adults, aged 20 to 65 years, with no history of diabetes or cardiovascular disease, from the 1999 to 2002 National Health and Nutrition Examination Surveys. Leukocyte telomere length was assayed from DNA specimens. Diet was assessed using 24-hour dietary recalls. Associations were examined using multivariate linear regression for the outcome of log-transformed telomere length.ResultsAfter adjustment for sociodemographic and health-related characteristics, sugar-sweetened soda consumption was associated with shorter telomeres (b = -0.010; 95% confidence interval [CI] = -0.020, -0.001; P = .04). Consumption of 100% fruit juice was marginally associated with longer telomeres (b = 0.016; 95% CI = -0.000, 0.033; P = .05). No significant associations were observed between consumption of diet sodas or noncarbonated SSBs and telomere length.ConclusionsRegular consumption of sugar-sweetened sodas might influence metabolic disease development through accelerated cell aging.

This article describes a comprehensive process evaluation of an efficacious store-based intervention that increased store customers' fruit and vegetable consumption. The process evaluation plan was designed at study inception and implemented at baseline, during the intervention, and at immediate postintervention. Four Latino food stores were randomly assigned either to an intervention or to a control condition. Data were collected from store managers, employees, and 139 Latino customers. Researchers used manager, employee, and customer interviews; weekly observations of the store environment; and implementation logs to assess reach, dose delivered, dose received, and fidelity. Results indicated that it is possible to reach customers in a store-based intervention. Indicators of dose delivered demonstrated that the intervention was implemented as planned, and in the case of employee training, it exceeded the plan. Dose received data indicated that customers moderately engaged with the intervention activities. Together these suggest that the intervention was delivered with good fidelity. Comprehensive process evaluation efforts can facilitate the identification and elimination of barriers to implementation. This approach can serve as a model for future store-based interventions. The study demonstrated that it is feasible to implement Latino food store-based interventions to increase access to and consumption of fruits and vegetables.

Background and objectivesThe neighborhoods in which children live, play, and eat provide an environmental context that may influence obesity risk and ameliorate or exacerbate health disparities. The current study examines whether neighborhood characteristics predict obesity in a prospective cohort of girls.MethodsParticipants were 174 girls (aged 8-10 years at baseline), a subset from the Cohort Study of Young Girls' Nutrition, Environment, and Transitions. Trained observers completed street audits within a 0.25-mile radius around each girl's residence. Four scales (food and service retail, recreation, walkability, and physical disorder) were created from 40 observed neighborhood features. BMI was calculated from clinically measured height and weight. Obesity was defined as BMI-for-age ≥ 95%. Logistic regression models using generalized estimating equations were used to examine neighborhood influences on obesity risk over 4 years of follow-up, controlling for race/ethnicity, pubertal status, and baseline BMI. Fully adjusted models also controlled for household income, parent education, and a census tract measure of neighborhood socioeconomic status.ResultsA 1-SD increase on the food and service retail scale was associated with a 2.27 (95% confidence interval, 1.42 to 3.61; P < .001) increased odds of being obese. A 1-SD increase in physical disorder was associated with a 2.41 (95% confidence interval, 1.31 to 4.44; P = .005) increased odds of being obese. Other neighborhood scales were not associated with risk for obesity.ConclusionsNeighborhood food and retail environment and physical disorder around a girl's home predict risk for obesity across the transition from late childhood to adolescence.

BackgroundPrepregnancy body mass index and excessive gestational weight gain (GWG) are associated with adverse maternal and infant outcomes. Because stress contributes to obesity and eating behaviors, stress reduction interventions during pregnancy may be a novel way to influence GWG, positively affect maternal and infant outcomes, and address the obesity epidemic intergenerationally.MethodsOur research team is developing a mindfulness-based stress reduction and nutrition intervention for low-income, overweight and obese pregnant women, with healthy GWG as the primary outcome measure. To inform development of the intervention, we conducted focus groups with our target population. Focus group transcripts were analyzed for themes related to sources and importance of stress, relationship between stress and eating, and motivation for a stress reduction pregnancy intervention.FindingsFifty-nine low-income pregnant women from the San Francisco Bay Area participated in focus groups and completed a questionnaire. The vast majority of women (80%) reported experiencing significant stress from a variety of sources and most recognized a relationship between stress and eating in their lives.ConclusionsThis at-risk population seems to be extremely interested in a stress reduction intervention to support healthy GWG during pregnancy. The women in our groups described high levels of stress and a desire for programs beyond basic dietary recommendations. These findings inform practitioners and policymakers interested in pregnancy as a "window of opportunity" for behavior change that can affect the metabolic and weight trajectory both for women and their offspring.

Why are some individuals more vulnerable to persistent weight gain and obesity than are others? Some obese individuals report factors that drive overeating, including lack of control, lack of satiation, and preoccupation with food, which may stem from reward-related neural circuitry. These are normative and common symptoms and not the sole focus of any existing measures. Many eating scales capture these common behaviors, but are confounded with aspects of dysregulated eating such as binge eating or emotional overeating. Across five studies, we developed items that capture this reward-based eating drive (RED). Study 1 developed the items in lean to obese individuals (n = 327) and examined changes in weight over eight years. In Study 2, the scale was further developed and expert raters evaluated the set of items. Study 3 tested psychometric properties of the final 9 items in 400 participants. Study 4 examined psychometric properties and race invariance (n = 80 women). Study 5 examined psychometric properties and age/gender invariance (n = 381). Results showed that RED scores correlated with BMI and predicted earlier onset of obesity, greater weight fluctuations, and greater overall weight gain over eight years. Expert ratings of RED scale items indicated that the items reflected characteristics of reward-based eating. The RED scale evidenced high internal consistency and invariance across demographic factors. The RED scale, designed to tap vulnerability to reward-based eating behavior, appears to be a useful brief tool for identifying those at higher risk of weight gain over time. Given the heterogeneity of obesity, unique brief profiling of the reward-based aspect of obesity using a self-report instrument such as the RED scale may be critical for customizing effective treatments in the general population.

ObjectiveIt is unknown whether any association between neighborhood food environment and obesity varies according to individual income and/or race/ethnicity. The objectives of this study were to test whether there was an association between food environments and obesity among adults with diabetes and whether this relationship differed according to individual income or race/ethnicity.Research design and methodsSubjects (n = 16,057) were participants in the Diabetes Study of Northern California survey. Kernel density estimation was used to create a food environment score for each individual's residence address that reflected the mix of healthful and unhealthful food vendors nearby. Logistic regression models estimated the association between the modeled food environment and obesity, controlling for confounders, and testing for interactions between food environment and race/ethnicity and income.ResultsThe authors found that more healthful food environments were associated with lower obesity in the highest income groups (incomes 301-600% and >600% of U.S. poverty line) among whites, Latinos, and Asians. The association was negative, but smaller and not statistically significant, among high-income blacks. On the contrary, a more healthful food environment was associated with higher obesity among participants in the lowest-income group (

ObjectiveTo compare associations between neighborhood deprivation and measures of BMI change among adults with type 2 diabetes.Research design and methodsUsing data from the Kaiser Permanente Diabetes Study of Northern California (DISTANCE) survey, we estimated the association between neighborhood deprivation and two measures of BMI change over 3 years: 1) a continuous measure and 2) a categorical measure of clinically substantive BMI loss or gain (≥7% of baseline BMI) versus stable BMI. The sample included 13,609 adults.ResultsOn average, there was little change in BMI (-0.12, SD 3.07); 17.0 and 16.1% had clinically substantive BMI loss or gain, respectively, at follow-up. There was a positive association between neighborhood deprivation and BMI change for adults in the most versus least-deprived quartile of neighborhood deprivation (β = 0.22, P = 0.02) in adjusted models. In addition, relative to the least-deprived quartile (Q1), adults in more-deprived quartiles of neighborhood deprivation were more likely to experience either substantive BMI loss (Q2 relative risk ratio 1.19, 95% CI 1.00-1.41; Q3 1.20, 1.02-1.42; Q4 1.30, 1.08-1.55) or gain (Q2 1.25, 1.04-1.49; Q3 1.24, 1.04-1.49; Q4 1.45, 1.20-1.75).ConclusionsGreater neighborhood deprivation was positively associated with BMI change among adults with diabetes as well as with clinically substantive BMI loss or gain. Findings stress the importance of allowing for simultaneous associations with both gain and loss in future longitudinal studies of neighborhood deprivation and weight change, which may be particularly true for studies of patients with diabetes for whom both weight loss and gain have health implications.

BackgroundOne of the largest health disparities in the USA is in obesity rates between Black and White females.PurposeThe objective of this study was to test the hypothesis that the stress-obesity link is stronger in Black females than in White females aged 10-19.MethodsMultilevel modeling captured the dynamic of acute (1 month) and chronic (10 years) stress and body mass index (BMI; weight in kilograms divided by height in meters squared) change in the National Heart, Lung, and Blood Institute Growth and Health Study, which consists of 2,379 Black and White girls across a span of socioeconomic status. The girls were assessed longitudinally from ages 10 to 19.ResultsHigher levels of stress during the 10 years predicted significantly greater increases in BMI over time compared to lower levels of stress. This relationship was significantly stronger for Black compared to White girls.ConclusionPsychological stress is a modifiable risk factor that may moderate early racial disparities in BMI.

IntroductionRecruiting participants for research studies can be challenging. Many studies fall short of their target or must prolong recruitment to reach it. We examined recruitment and retention strategies and report lessons learned in a behavioral intervention developmental trial to encourage healthy pregnancy weight gain and stress reduction in low-income overweight pregnant women.MethodsIn the San Francisco Bay area from February 2010 through March 2011, we used direct and indirect strategies to recruit English-speaking overweight and obese pregnant women who were aged 18 to 45, were in the early stages of pregnancy, and who had an annual household income less than 500% of the federal poverty guidelines. Eligible women who consented participated in focus groups or an 8-week behavioral intervention. We identified successful recruiting strategies and sites and calculated the percentage of women who were enrolled and retained.ResultsOf 127 women screened for focus group participation, 69 were eligible and enrolled. A total of 57 women participated in 9 focus groups and 3 women completed individual interviews for a completion rate of 87%. During recruitment for the intervention, we made contact with 204 women; 135 were screened, 33% were eligible, and 69.1% of eligible women enrolled. At 1 month postpartum, 82.6% of eligible women completed an assessment. Recruiting at hospital-based prenatal clinics was the highest-yielding strategy.ConclusionThe narrow window of eligibility for enrolling early stage pregnant women in a group intervention presents obstacles. In-person recruitment was the most successful strategy; establishing close relationships with providers, clinic staff, social service providers, and study participants was essential to successful recruitment and retention.

IntroductionSmall food stores are prevalent in urban neighborhoods, but the availability of nutritious food at such stores is not well known. The objective of this study was to determine whether data from 3 sources would yield a single, homogenous, healthful food store category that can be used to accurately characterize community nutrition environments for public health research.MethodsWe conducted in-store surveys in 2009 on store type and the availability of nutritious food in a sample of nonchain food stores (n = 102) in 6 predominantly urban counties in Northern California (Alameda, Contra Costa, Marin, Sacramento, San Francisco, and Santa Clara). We compared survey results with commercial database information and neighborhood sociodemographic data by using independent sample t tests and classification and regression trees.ResultsSampled small food stores yielded a heterogeneous group of stores in terms of store type and nutritious food options. Most stores were identified as convenience (54%) or specialty stores (22%); others were small grocery stores (19%) and large grocery stores (5%). Convenience and specialty stores were smaller and carried fewer nutritious and fresh food items. The availability of nutritious food and produce was better in stores in neighborhoods that had a higher percentage of white residents and a lower population density but did not differ significantly by neighborhood income.ConclusionCommercial databases alone may not adequately categorize small food stores and the availability of nutritious foods. Alternative measures are needed to more accurately inform research and policies that seek to address disparities in diet-related health conditions.

Abstract Background Neighborhood environments affect children's health outcomes. Observational methods used to assess neighborhoods can be categorized as indirect, intermediate, or direct. Direct methods, involving in-person audits of the neighborhoods conducted by trained observers, are recognized as an accurate representation of current neighborhood conditions. The authors investigated the associations of various neighborhood characteristics with young girls' diet and physical activity. Methods This study is based on a subset of participants in the Cohort Study of Young Girls' Nutrition, Environment and Transitions (CYGNET). In-person street audits were conducted within 215 girls' residential neighborhoods using a modified St. Louis Audit Tool. From the street audit data, exploratory factor analysis revealed five neighborhood scales: "mixed residential and commercial," "food and retail," "recreation," "walkability," and "physical disorder." A Neighborhood Deprivation Index was also derived from census data. The authors investigated if the five neighborhood scales and the Neighborhood Deprivation Index were associated with quartiles of total energy intake and expenditure (metabolic equivalent (MET) hours/week) at baseline, and whether any of these associations were modified by race/ethnicity. Results After adjustment for demographic characteristics, there was an inverse association between prevalence of "food and retail" destinations and total energy intake (for a one quartile increase, OR = 0.84, 95% CI 0.74, 0.96). Positive associations were also observed between the "recreation" and "walkability" scales with physical activity among Hispanic/Latina girls (for a one quartile increase in MET, OR = 1.94, 95% CI 1.31, 2.88 for recreation; OR = 1.71, 95% CI 1.11, 2.63 for walkability). Among African-American girls, there was an inverse association between "physical disorder" and physical activity (OR = 0.31, 95% CI 0.12, 0.80). Conclusions These results suggest that neighborhood food and retail availability may be inversely associated with young girls' energy intakes in contrast to other studies' findings that focused on adults. There is considerable variation in neighborhoods' influences on young girls' physical activity behaviors, particularly for young girls of different racial/ethnic backgrounds.

Abstract Background Measures to assess neighborhood environments are needed to better understand the salient features that may enhance outdoor physical activities, such as walking and bicycling for transport or leisure. The purpose of this study was to derive constructs to describe neighborhoods using both primary (neighborhood audit) and secondary (geographic information systems) data. Methods We collected detailed information on 10,770 road segments using an audit and secondary data. The road segment sample was randomly split into an exploratory (60%) and validation sample (40%) for cross-validation. Using the exploratory sample (n = 6,388), seven a priori constructs were assessed separately (functionality, safety, aesthetics, destinations, incivilities, territorality, social spaces) by urbanicity using multi-group confirmatory factor analysis (CFA). Additionally, new a posteriori constructs were derived using exploratory factor analysis (EFA). For cross-validation (n = 4,382), we tested factor loadings, thresholds, correlated errors, and correlations among a posteriori constructs between the two subsamples. Two-week test-retest reliability of the final constructs using a subsample of road segments (n = 464) was examined using Spearman correlation coefficients. Results CFA indicated the a priori constructs did not hold in this geographic area, with the exception of physical incivilities. Therefore, we used EFA to derive a four-factor solution on the exploratory sample: arterial or thoroughfare, walkable neighborhood, physical incivilities, and decoration. Using CFA on the validation sample, the internal validity for these a posteriori constructs was high (range 0.43 to 0.73) and the fit was acceptable. Spearman correlations indicated the arterial or thoroughfare factor displayed near perfect reliability in both urban and rural segments (r = 0.96). Both the physical incivilities factor and the walkable neighborhood factor had substantial to near perfect reliability in both urban and rural segments (r = 0.77 to 0.78 and r = 0.79 to 0.82, respectively). The decoration factor displayed moderate reliability in urban segments (r = 0.50; 95% CI: 0.38–0.60) and lower reliability in rural segments (r = 0.39; 95% CI: 0.25–0.52). Conclusion The results of our analyses yielded four reliably and objectively measured constructs that will be used to explore associations with physical activity in urban and rural North Carolina. These constructs should be explored in other geographic areas to confirm their usefulness elsewhere.

BackgroundHealth researchers have increasingly adopted the use of geographic information systems (GIS) for analyzing environments in which people live and how those environments affect health. One aspect of this research that is often overlooked is the quality and detail of the road data and whether or not it is appropriate for the scale of analysis. Many readily available road datasets, both public domain and commercial, contain positional errors or generalizations that may not be compatible with highly accurate geospatial locations. This study examined the accuracy, completeness, and currency of four readily available public and commercial sources for road data (North Carolina Department of Transportation, StreetMap Pro, TIGER/Line 2000, TIGER/Line 2007) relative to a custom road dataset which we developed and used for comparison.Methods and resultsA custom road network dataset was developed to examine associations between health behaviors and the environment among pregnant and postpartum women living in central North Carolina in the United States. Three analytical measures were developed to assess the comparative accuracy and utility of four publicly and commercially available road datasets and the custom dataset in relation to participants' residential locations over three time periods. The exclusion of road segments and positional errors in the four comparison road datasets resulted in between 5.9% and 64.4% of respondents lying farther than 15.24 meters from their nearest road, the distance of the threshold set by the project to facilitate spatial analysis. Agreement, using a Pearson's correlation coefficient, between the customized road dataset and the four comparison road datasets ranged from 0.01 to 0.82.ConclusionThis study demonstrates the importance of examining available road datasets and assessing their completeness, accuracy, and currency for their particular study area. This paper serves as an example for assessing the feasibility of readily available commercial or public road datasets, and outlines the steps by which an improved custom dataset for a study area can be developed.

IntroductionThe association between levels of physical activity and perceived and objectively measured proximity to physical activity resources is unclear. Clarification is important so that future programs can intervene upon the measure with the greatest association. We examined correlations between perceived and objectively measured proximity to physical activity resources and then examined associations between both measures of proximity and objectively measured physical activity.MethodsParticipants (n = 199) were underinsured women from three counties in southeastern North Carolina. Perceived proximity to physical activity resources (e.g., parks, gyms, schools) was measured using surveys. Objectively measured proximity included geographic information systems road network distance to the closest resource and existence of resources within 1- and 2-mile buffers surrounding participants' homes. To examine the association between proximity to resources and activity, the dependent variable in multiple linear regression models was the natural logarithm of accelerometer-measured moderate to vigorous physical activity in minutes per day.ResultsPearson correlation coefficients for perceptions of distance and objectively measured distance to physical activity resources ranged from 0.40 (gyms, schools) to 0.54 (parks). Perceived distance to gyms and objective number of schools within 1-mile buffers were negatively associated with activity. No statistically significant relationships were found between activity and perceived or objectively measured proximity to parks.ConclusionResults indicate the need for both individual and environmental intervention strategies to increase levels of physical activity among underinsured, midlife women. More work is needed to determine the most effective strategies.

BackgroundArea-level socioeconomic disparities have long been associated with adverse pregnancy outcomes. Crime is an important element of the neighborhood environment inadequately investigated in the reproductive and public health literature. When crime has been used in research, it has been variably defined, resulting in non-comparable associations across studies.MethodsUsing geocoded linked birth record, crime and census data in multilevel models, this paper explored the relevance of four spatial violent crime exposures: two proximal violent crime categorizations (count of violent crime within a one-half mile radius of maternal residence and distance from maternal residence to nearest violent crime) and two area-level crime categorizations (count of violent crimes within a block group and block group rate of violent crimes) for adverse birth events among women in living in the city of Raleigh NC crime report area in 1999-2001. Models were adjusted for maternal age and education and area-level deprivation.ResultsIn black and white non-Hispanic race-stratified models, crime characterized as a proximal exposure was not able to distinguish between women experiencing adverse and women experiencing normal birth outcomes. Violent crime characterized as a neighborhood attribute was positively associated with preterm birth and low birth weight among non-Hispanic white and black women. No statistically significant interaction between area-deprivation and violent crime category was observed.ConclusionCrime is variably categorized in the literature, with little rationale provided for crime type or categorization employed. This research represents the first time multiple crime categorizations have been directly compared in association with health outcomes. Finding an effect of area-level violent crime suggests crime may best be characterized as a neighborhood attribute with important implication for adverse birth outcomes.

BackgroundNeighborhood characteristics have been associated with poor maternal and child health outcomes, yet conceptualization of potential mechanisms is still needed. Census data have long served as proxies for area level socioeconomic influences. Unique information captured by neighborhood inventories, mostly conducted in northern US and Canadian urban areas, has shown important aspects of the community environment that are not captured by the socioeconomic and demographic aggregated individual statistics of census data. In this paper, we describe a neighborhood data collection effort tailored to a southern urban area.MethodsThis study used data from the Pregnancy, Nutrition and Infection (PIN) prospective cohort study to describe neighborhoods where low- and moderate-income pregnant women reside. Women who participated in the PIN study and who resided in Raleigh, NC and its surrounding suburbs were included (n = 703). Neighborhood attributes captured by the inventory included litter, housing condition, road condition, and social interactions that informed theoretical constructs of physical incivility, territoriality and social spaces. US Housing and Population Census 2000 data at the block group level were also assessed to identify the unique contribution of directly observed data. We hypothesize that neighborhood environments can influence health through psychosocial mediated pathways that lead to increased stress, or through disadvantage leading to poor neighborhood resources, or by protective attributes through increased social control.ResultsFindings suggest that directly observed neighborhood attributes distinguished between different types of areas in which low-income pregnant non-Hispanic white and non-Hispanic black women lived. Theoretically informed scales of physical incivilities, territoriality and social spaces were constructed and found to be internally consistent. Scales were weakly associated indicating that these constructs capture distinct information about these neighborhoods. Physical incivilities, territoriality and social spaces scales were poorly explained by traditional census variables used to proxy neighborhood environment.ConclusionIf neighborhoods influence health through psychosocial mediated pathways then careful detailing of neighborhood attributes that contribute to stress or deterioration, beyond traditional socioeconomic status, are needed. We believe that measuring physical incivility, territoriality and social spaces as expressions of underlying issues of maintenance and social communication make important contributes to this field.

Objective Analyze the association between household food security status and diet quality during pregnancy. Methods Cross-sectional analysis of pregnant women from the National Health and Nutrition Examination Survey from 1999 to 2008. Of the 1158 pregnant women with complete household food security information, we analyzed 688 women who had complete dietary information and household incomes [less than or equal to]300 % of the Federal Poverty Level (FPL). Diet quality was measured by the Alternate Healthy Eating Index modified for Pregnancy (AHEI-P) from 1 to 2 24 h dietary recalls. Multivariate linear and logistic regression models were implemented to assess the association between household food security status and AHEI-P, adjusting for age, nativity, marital status, race/ethnicity, education, and household income. Results Among women with household incomes [less than or equal to]300 % of the FPL, 19 % were food insecure and 4 % were marginally food secure. The mean AHEI-P score was 41.9 (95 % CI 40.4, 43.3). Household food insecurity was not associated with overall diet quality. However, living in a food insecure household compared to a food secure household was associated with a 2.3 (1.3, 4.1) greater odds of having a calcium component score greater than the median intake of calcium scores among food secure women in the sample. Conclusions for Practice In a nationally representative sample of pregnant women, 80 % lived in a fully food secure household. Improving household food security during pregnancy is a public health opportunity to improve health outcomes; however household food security status may not be associated with overall diet quality., Author(s): Ryan Gamba[sup.1] , Cindy W. Leung[sup.2] , Sylvia Guendelman[sup.3] , Maureen Lahiff[sup.4] , Barbara A. Laraia[sup.5] Author Affiliations: (1) Division of Epidemiology, UC Berkeley School of Public Health, 101 [...]