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This chapter provides an overview of alternative ways to conceptualize the links between places and health with special attention to urban places. It reviews some common conceptual models of the drivers of urban health and introduces the idea of systems thinking for urban health. It reviews the connections between urban health and two key multisectoral approaches to health: health in all policies and planetary health. The chapter concludes by summarizing different types of research questions and studies of urban health and key features of urban policies and interventions that may have health impacts.

This chapter reviews ways the concepts and tools of systems approaches can help understand how city environments affect health and identify the most effective policies. The authors discuss basic conceptual elements of systems thinking, review core systems modeling methods, and provide examples of their applications in urban health. They conclude with a discussion of the challenges involved in using these approaches.

Objective To determine the association between neighborhood socioeconomic status (NSES) and cardio-metabolic risk and whether this relationship differs by race/ethnicity. Methods Participants in the Multi-Ethnic Study of Atherosclerosis (n = 5750), ages 45–84 years, from 6 US counties, including 5 examinations from 2000 to 2012. We calculated a modified allostatic load (AL) index, indicating cardio-metabolic risk. NSES score included census-derived measures at census tract of residence. Mixed effects growth curve models were used to assess linear and non-linear associations between NSES and AL at baseline and over time. Results Higher NSES was associated with lower AL across race/ethnic groups; considering NSES quintiles, significant associations were found only for the highest NSES quintiles (difference of -0.86 and -1.15 for white and Hispanic participants) vs. the lowest. We found no significant association between NSES and change in AL over time. Discussion Our findings suggest that the relationship between NSES and AL reflects the health benefits of living in the most advantaged neighborhoods. Public health implications Understanding the impact of higher NSES on health effects may help identify interventions to effectively target high risk neighborhoods., Highlights • These findings confirm the association between high NSES and low AL; pattern is similar across race/ethnic groups. • The relationship between NSES and AL reflects the health benefits of living in the most advantaged neighborhoods. • Identifying neighborhood factors that impact health is crucial to effectively target high risk neighborhoods.

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.

Background: Current knowledge regarding the relationship between segregation and body weight is derived mainly from cross-sectional data. Longitudinal studies are needed to provide stronger causal inference. Methods: We use longitudinal data from the Multi-Ethnic Study of Atherosclerosis and apply an econometric fixed-effect strategy, which accounts for all time-invariant confounders, and compare results to conventional cross-sectional analyses. We examine the relationship between neighborhood-level racial/ethnic segregation, neighborhood poverty, and body mass index (BMI) separately for blacks, Hispanics, and whites. Segregation*gender interactions are included in all models. Neighborhood segregation was operationalized by the local Gi* statistic, which assesses the extent to which a neighborhood’s racial/ethnic composition is under (Gi* statistic 0) represented, given the composition in the broader (e.g., county) area. For black, Hispanic, and white stratified models, the Gi* statistic reflects the level of black, Hispanic, and white segregation, respectively. The Gi* statistic was scaled such that a unit change represents a 1.96 difference in the score. Results: Cross-sectional models indicated higher segregation to be negatively associated with BMI for white females and positively associated for Hispanic females. No association was found for black females or males in general. In contrast, fixed-effect models adjusting for neighborhood poverty, higher segregation was positively associated with BMI for black females (coeff= 0.25 kg/m2; 95% CI=[0.03, 0.46]; P-value=0.03) but negatively associated for Hispanic females (coeff= −0.17 kg/m2 ; 95% CI=[−0.33, −0.01]; P-value=0.04) and Hispanic males (coeff= −0.20; 95% CI=[−0.39, −0.01]; P-value=0.04.). Further controls for socioeconomic factors fully explained the associations for Hispanics but not for black females. Conclusions: Fixed-effect results suggest that segregation’s impacts might not be universally harmful, with possible null or beneficial impacts, depending on race/ethnicity. The persistent associations after accounting for neighborhood poverty indicate that the segregation-BMI link may operate through different pathways other than neighborhood poverty.

Understanding health disparity causes is an important first step toward developing policies or interventions to eliminate disparities, but their nature makes identifying and addressing their causes challenging. Potential causal factors are often correlated, making it difficult to distinguish their effects. These factors may exist at different organizational levels (e.g., individual, family, neighborhood), each of which needs to be appropriately conceptualized and measured. The processes that generate health disparities may include complex relationships with feedback loops and dynamic properties that traditional statistical models represent poorly. Because of this complexity, identifying disparities’ causes and remedies requires integrating findings from multiple methodologies. We highlight analytic methods and designs, multilevel approaches, complex systems modeling techniques, and qualitative methods that should be more broadly employed and adapted to advance health disparities research and identify approaches to mitigate them.

BACKGROUND: Road-traffic injuries are a key cause of death and disability in low-income and middle-income countries, but the effect of city characteristics on road-traffic mortality is unknown in these countries. The aim of this study was to determine associations between city-level built environment factors and road-traffic mortality in large Latin American cities. METHODS: We selected cities from Argentina, Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico, Panama, and Peru; cities included in the analysis had a population of at least 100 000 people. We extracted data for road-traffic deaths that occurred between 2010 and 2016 from country vital registries. Deaths were grouped by 5-year age groups and sex. Road-traffic deaths were identified using ICD-10 codes, with adjustments for ill-defined codes and incomplete registration. City-level measures included population, urban development, street design, public transportation, and social environment. Associations were estimated using multilevel negative binomial models with robust variances. FINDINGS: 366 cities were included in the analysis. There were 328 408 road-traffic deaths in nearly 3·5 billion person-years across all countries, with an average crude rate of 17·1 deaths per 100 000 person-years. Nearly half of the people who died were younger than 35 years. In multivariable models, road-traffic mortality was higher in cities where urban development was more isolated (rate ratio [RR] 1·05 per 1 SD increase, 95% CI 1·02-1·09), but lower in cities with higher population density (0·94, 0·90-0·98), higher gross domestic product per capita (0·96, 0·94-0·98), and higher intersection density (0·92, 0·89-0·95). Cities with mass transit had lower road mortality rates than did those without (0·92, 0·86-0·99). INTERPRETATION: Urban development policies that reduce isolated and disconnected urban development and that promote walkable street networks and public transport could be important strategies to reduce road-traffic deaths in Latin America and elsewhere. FUNDING: Wellcome Trust.

Background: African Americans have a higher risk for hypertension compared to other racial or ethnic groups in the United States. One possible explanation for this health disparity is perceived discrimination. Few studies have prospectively examined the association between discrimination and the incidence of hypertension. Methods: We examined the associations of everyday, lifetime, and stress from lifetime discrimination with incident hypertension and whether these associations differed by sex, discrimination attribution (i.e. the main reason for the discrimination event), and coping responses to discrimination among African Americans enrolled in the Jackson Heart Study. Discrimination was self-reported by 1845 African Americans aged 21 to 85 years without hypertension at baseline (2000-2004). Participants completed two follow-up study visits from 2005-2008 and 2009-2013. We used interval-censored Cox regression to estimate associations of discrimination with incident hypertension (antihypertensive medication use; and/or systolic blood pressure ≥ 140 mm Hg and diastolic blood pressure ≥ 90 mm Hg at follow-up visits 2 or 3) after adjustment for confounding variables. Results: Overall, 52% (954 of 1845) of participants developed hypertension over the follow-up period. After adjustment for age, sex, education and hypertension risk factors (body mass index, alcohol use, smoking, diet and physical activity), medium versus low levels of lifetime discrimination (hazard ratio-HR: 1.45, 95% confidence interval-CI: 1.15-1.82) and high versus low levels of lifetime discrimination (HR: 1.35, CI: 1.08-1.68) were associated with a higher incidence of hypertension. High versus low stress from lifetime discrimination was associated with hypertension risk after adjustment for demographics (HR: 1.20, CI: 1.02-1.41), but the association was attenuated after adjustment for hypertension risk factors (HR: 1.14, CI: 0.97-1.35). Lifetime discrimination and stress from discrimination were associated with an increased hypertension risk among females, but not males. No interactions with age, attribution or coping were present for any type of discrimination. Conclusions: Findings from this study support an association between lifetime discrimination and incident hypertension in African Americans.

Introduction: The prevalence of type-2 diabetes is increasing globally with the sharpest increases occurring in low and middle-income countries. Residential segregation results in increased exposure to adverse neighborhood environments that may inhibit the successful management of diabetes. Moreover, due to historical and contemporary forms of structural racism, marginalized racial groups are more likely to live in these environments. Using a spatial measure of neighborhood-level economic residential segregation (hereafter, segregation) we examined the association between segregation and uncontrolled diabetes in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Methods: The sample included 828 Black, Brown/Mixed-Race, and White participants ages 35-74 with diagnosed diabetes and complete, geocoded information from the baseline examination of ELSA-Brasil (2008-2010). Residential segregation was based on data from the 2010 IBGE demographic census and calculated for study-defined neighborhoods using the local G i * statistic— a spatially weighted z-score that represents how much a neighborhood’s income composition deviates from the larger metropolitan area. Uncontrolled diabetes was based on 2017 ADA criteria and defined as HbA1c ≥ 7%. Multivariable logistic regression models were used to test cross-sectional associations between segregation and uncontrolled diabetes. Results: Black and Brown participants were more likely than Whites to live in highly segregated neighborhoods. The prevalence of uncontrolled diabetes increased across low, medium, and high levels of segregation (23.1% vs. 37.8% vs. 47.7%, respectively). In multivariable models adjusting for age, gender, race, education, income, and study site, segregation was positively associated with uncontrolled diabetes (OR: 1.20, 95% CI: 1.07-1.56). The association was attenuated but remained statistically significant in models adjusting for neighborhood characteristics, behavioral risk factors and time since diabetes diagnosis. (OR: 1.16; 95% CI: 1.05-1.28). In models that included segregation as a categorical variable, individuals living in highly segregated neighborhoods had a 2-fold higher risk of uncontrolled diabetes compared to individuals living in less segregated neighborhoods (High Segregation, OR: 2.20, 95% CI: 1.35-3.58; Medium Segregation, OR: 1.65, 95% CI: 1.08-2.51). Conclusions: Residential segregation may lead to disparate diabetes-related morbidity among urban-dwelling adults in Brazil. Moreover, the disproportionate clustering of Blacks and Browns within segregated neighborhoods implicates segregation as a potential driver of racial inequalities in these outcomes. Policies and/or structural interventions designed to improve neighborhood conditions may be viable strategies to improve the management of diabetes in this setting.

Background: Cable cars provide urban mobility benefits for vulnerable populations. However, no evaluation has assessed cable cars' impact from a health perspective. TransMiCable in Bogotá, Colombia, provides a unique opportunity to (1) assess the effects of its implementation on the environmental and social determinants of health (microenvironment pollution, transport accessibility, physical environment, employment, social capital, and leisure time), physical activity, and health outcomes (health-related quality of life, respiratory diseases, and homicides); and (2) use citizen science methods to identify, prioritize, and communicate the most salient negative and positive features impacting health and quality of life in TransMiCable's area, as well as facilitate a consensus and advocacy-building change process among community members, policymakers, and academic researchers. Methods: TrUST (In Spanish: Transformaciones Urbanas y Salud: el caso de TransMiCable en Bogotá) is a quasi-experimental study using a mixed-methods approach. The intervention group includes adults from Ciudad Bolívar, the area of influence of TransMiCable. The control group includes adults from San Cristóbal, an area of future expansion for TransMiCable. A conceptual framework was developed through group-model building. Outcomes related to environmental and social determinants of health as well as health outcomes are assessed using questionnaires (health outcomes, physical activity, and perceptions), secondary data (crime and respiratory outcomes) use of portable devices (air pollution exposure and accelerometry), mobility tracking apps (for transport trajectories), and direct observation (parks). The Stanford Healthy Neighborhood Discovery Tool is being used to capture residents' perceptions of their physical and social environments as part of the citizen science component of the investigation. Discussion: TrUST is innovative in its use of a mixed-methods, and interdisciplinary research approach, and in its systematic engagement of citizens and policymakers throughout the design and evaluation process. This study will help to understand better how to maximize health benefits and minimize unintended negative consequences of TransMiCable.

Leukocyte telomere length (LTL) is a biomarker of cellular aging. African Americans report more stress than other groups; however, the association of psychosocial stressors with biological aging among African Americans remains unclear. The current study evaluated the association of psychosocial factors (negative affect and stressors) with LTL in a large sample of African American men and women (n = 2,516) from the Jackson Heart Study. Using multivariable linear regression, we examined the sex-specific associations of psychosocial factors (cynical distrust, anger in and out, depressive symptoms, negative affect summary scores, global stress, weekly stress, major life events, and stress summary scores) with LTL. Model 1 adjusted for demographics and education. Model 2 adjusted for model 1, smoking, alcohol intake, physical activity, diabetes, hypertension, and high-sensitivity C-reactive protein. Among women, high (vs. low) cynical distrust was associated with shorter mean LTL in model 1 (b = -0.12; p = 0.039). Additionally, high (vs. low) anger out and expressed negative affect summary scores were associated with shorter LTL among women after full adjustment (b = -0.13; p = 0.011; b = -0.12, p = 0.031, respectively). High levels of cynical distrust, anger out, and negative affect summary scores may be risk factors for shorter LTL, particularly among African-American women.

BackgroundLow socioeconomic status (SES) is associated with cardiovascular disease (CVD) risk, but its association with different markers of SES may be heterogeneous by sex and race/ethnicity.MethodsWe have examined the relationships of four SES markers (education, family income, occupation and neighborhood SES) to ideal cardiovascular health (ICH), an index formed by seven variables. A total of 6792 cohort participants from six regions in the USA: Baltimore City and Baltimore County, MD; Chicago, IL; Forsyth County, NC; Los Angeles County, CA; New York, NY; and St. Paul, MN of the Multi-Ethnic Study of Atherosclerosis (MESA) (52.8% women) were recruited at baseline (2000–2) and included in the present analysis.ResultsICH was classified as poor, intermediate or ideal. Level of education was significantly and inversely associated with ICH in non-Hispanic White men and women, in Chinese-American and Hispanic American men and African-American women. Family income was inversely and significantly associated with poor ICH in African-American men only.ConclusionsWe conclude that the strength of the associations between some SES markers and ICH differ between sexes and race/ethnic groups.

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.

Although dense neighborhood built environments support increased physical activity and lower obesity, these features may also disturb sleep. Therefore, we sought to understand the association between the built environment and objectively measured sleep. From 2010 to 2013, we analyzed data from examination 5 of the Multi-Ethnic Study of Atherosclerosis, a diverse population from 6 US cities. We fit multilevel models that assessed the association between the built environment (Street Smart Walk Score, social engagement destinations, street intersections, and population density) and sleep duration or efficiency from 1-week wrist actigraphy in 1,889 individuals. After adjustment for covariates, a 1-standard-deviation increase in Street Smart Walk Score was associated with 23% higher odds of short sleep duration (≤6 hours; odds ratio = 1.2, 95% confidence interval: 1.0, 1.4), as well as shorter average sleep duration (mean difference = -8.1 minutes, 95% confidence interval: -12.1, -4.2). Results were consistent across other built environment measures. Associations were attenuated after adjustment for survey-based measure of neighborhood noise. Dense neighborhood development may have multiple health consequence. In promoting denser neighborhoods to increase walkability, it is important to also implement strategies that reduce the adverse impacts of this development on sleep, such as noise reductions efforts.

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.

Differences in coping within the African American population are not well understood, yet these differences may be critical to reducing stress, improving health, and reducing racial health disparities. Using a descriptive, exploratory analysis of the Jackson Heart Study (N = 5301), we examine correlations between coping responses and associations between coping and demographic, socioeconomic, psychosocial, and neighborhood factors. Overall, coping responses were not strongly correlated and patterns of associations between covariates and coping responses were largely inconsistent. The results suggest that coping varies substantially within this African American population and is driven mainly by psychosocial factors such as spirituality and interpersonal support. Understanding these complex relationships may inform strategies by which to intervene in the stress process to mitigate the effects of stress on health and to identify vulnerable subgroups of African Americans that might need targeted interventions to reduce exposure to stressors and improve coping capacities.

Risk factors can drive socioeconomic inequalities in cardiovascular disease (CVD) through differential exposure and differential vulnerability. In this paper, we show how econometric decomposition directly enables simultaneous, policy-oriented assessment of these 2 mechanisms. We specifically estimate contributions of neighborhood environment and proximal risk factors to socioeconomic inequality in CVD incidence via these mechanisms. We followed 5,608 participants in the Multi-Ethnic Study of Atherosclerosis (2000-2012) to their first CVD event (median length of follow-up, 12.2 years). We used a summary measure of baseline socioeconomic position (SEP). Covariates included baseline demographics, neighborhood characteristics, and psychosocial, behavioral, and biomedical risk factors. Using Poisson models, we decomposed the difference (inequality) in incidence rates between low- and high-SEP groups into contributions of 1) differences in covariate means (differential exposure) and 2) differences in CVD risk associated with covariates (differential vulnerability). Notwithstanding large uncertainty in neighborhood estimates, our analysis suggested that differential exposure to poorer neighborhood socioeconomic conditions, adverse social environment, diabetes, and hypertension accounted for most of the inequality. Psychosocial and behavioral contributions were negligible. Further, neighborhood SEP, female sex, and white race were more strongly associated with CVD among low-SEP (vs. high-SEP) participants. These differentials in vulnerability also accounted for nontrivial portions of the inequality and could have important implications for intervention.

Self-rated health (SRH) is considered a strong indicator of well-being and clinical health status and has been linked to inflammatory markers. The objective of this work was to examine how self-rated physical health (SRPH) and mental health (SRMH) influence the immune system through the regulation of a stress-related gene expression profile known as the ‘conserved transcriptional response to adversity’ (CTRA), which involves the up-regulation of pro-inflammatory genes and down-regulation of genes involved in type I interferon (IFN) response and antibody synthesis. CTRA expression data were derived from genome-wide transcriptional data on purified monocytes in 1264 adult participants from the multi-ethnic study of atherosclerosis. SRPH and SRMH were assessed through the SF-12 questionnaire. Multiple linear regression models were used to determine the association between the composite score of the CTRA subsets and SRPH and SRMH. Higher scores of SRPH and SRMH were associated with an increased expression of the overall CTRA profile. The individual gene subsets analysis did not reveal an increased expression of pro-inflammatory genes in persons with lower scores of SRH. However, we observed that higher scores of SRPH positively modulate the immune response through the up-regulation of both type I interferon response and antibody synthesis-related genes, while better scores of SRMH were associated with a down-regulation of genes involved in antibody synthesis. The significant association between SRH and a gene expression profile related to type I IFN response and antibody synthesis suggests that SRH may be linked to the immunocompetence status. Impact statement In this work, we evaluated for the first time how self-rated mental (SRMH) and physical health (SRPH) influence the immune response at the molecular level in a large multi-ethnic cohort. We observed that both SRMH and SRPH are related to immunocompetence status. These findings indicated that the link between how we perceive our health and poorer health outcomes could be explained by alterations in the immune response by shifting the expression of genes related to the type I IFN response and antibody synthesis.

Using data from the Multi-Ethnic Study of Atherosclerosis (MESA), we evaluated associations of neighborhood crime and safety with changes in adiposity (body mass index (BMI) and waist circumference). MESA is a longitudinal study of cardiovascular disease among adults aged 45-84 years at baseline in 2000-2002, from 6 US sites, with follow-up for MESA participants until 2012. Data for this study were limited to Chicago, Illinois, participants in the MESA Neighborhood Ancillary Study, for whom police-recorded crime data were available, and who had complete baseline data (n = 673). We estimated associations of individual-level safety, aggregated neighborhood-level safety, and police-recorded crime with baseline levels and trajectories of BMI and waist circumference over time using linear mixed modeling with random effects. We also estimated how changes in these factors related to changes in BMI and waist circumference using econometric fixed-effects models. At baseline, greater individual-level safety was associated with more adiposity. Increasing individual- and neighborhood-level safety over time were associated with decreasing BMI over the 10-year period, with a more pronounced effect observed in women for individual-level safety and men for neighborhood-level safety. Police-recorded crime was not associated with adiposity. Neighborhood-level safety likely influences adiposity change and subsequent cardiovascular risk in multiethnic populations.

A critical component of longitudinal study design involves determining the sampling schedule. Criteria for optimal design often focus on accurate estimation of the mean profile, although capturing the between-subject variance of the longitudinal process is also important since variance patterns may be associated with covariates of interest or predict future outcomes. Existing design approaches have limited applicability when one wishes to optimize sampling schedules to capture between-individual variability. We propose an approach to derive optimal sampling schedules based on functional principal component analysis (FPCA), which separately characterizes the mean and the variability of longitudinal profiles and leads to a parsimonious representation of the temporal pattern of the variability. Simulation studies show that the new design approach performs equally well compared to an existing approach based on parametric mixed model (PMM) when a PMM is adequate for the data, and outperforms the PMM-based approach otherwise. We use the methods to design studies aiming to characterize daily salivary cortisol profiles and identify the optimal days within the menstrual cycle when urinary progesterone should be measured.

Research linking characteristics of the neighborhood environment to health has relied on traditional regression methods where prespecified distances from participant's locations or areas are used to operationalize neighborhood-level measures. Because the relevant spatial scale of neighborhood environment measures may differ across places or individuals, using prespecified distances could result in biased association estimates or efficiency losses. We use novel hierarchical distributed lag models and data from the Multi-Ethnic Study of Atherosclerosis (MESA) to (1) examine whether and how the association between the availability of favorable food stores and body mass index (BMI) depends on continuous distance from participant locations (instead of traditional buffers), thus allowing us to indirectly infer the spatial scale at which this association operates; (2) examine if the spatial scale and magnitude of the association differs across six MESA sites, and (3) across individuals. As expected, we found that the association between higher availability of favorable food stores within closer distances from participant's residential location was stronger than at farther distances, and that the magnitude of the adjusted association declined quickly from zero to two miles. Furthermore, between-individual heterogeneity in the scale and magnitude of the association was present; the extent of this heterogeneity was different across the MESA sites. Individual heterogeneity was partially explained by sex. This study illustrated novel methods to examine how neighborhood environmental factors may be differentially associated with health at different scales, providing nuance to previous research that ignored the heterogeneity found across individuals and contexts.

The concept of a so-called urban advantage in health ignores the possibility of heterogeneity in health outcomes across cities. Using a harmonized dataset from the SALURBAL project, we describe variability and predictors of life expectancy and proportionate mortality in 363 cities across nine Latin American countries. Life expectancy differed substantially across cities within the same country. Cause-specific mortality also varied across cities, with some causes of death (unintentional and violent injuries and deaths) showing large variation within countries, whereas other causes of death (communicable, maternal, neonatal and nutritional, cancer, cardiovascular disease and other noncommunicable diseases) varied substantially between countries. In multivariable mixed models, higher levels of education, water access and sanitation and less overcrowding were associated with longer life expectancy, a relatively lower proportion of communicable, maternal, neonatal and nutritional deaths and a higher proportion of deaths from cancer, cardiovascular disease and other noncommunicable diseases. These results highlight considerable heterogeneity in life expectancy and causes of death across cities of Latin America, revealing modifiable factors that could be amenable to urban policies aimed toward improving urban health in Latin America and more generally in other urban environments.

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.

The growing recognition of often substantial neighborhood variation in health within cities has motivated greater demand for reliable data on small-scale variations in health outcomes. The goal of this article is to explore temporal changes in geographic disparities in obesity prevalence in the City of Philadelphia by race and sex over the period 2000-2015. Our data consist of self-reported survey responses of non-Hispanic whites, non-Hispanic blacks, and Hispanics from the Southeastern Pennsylvania Household Health Survey. To analyze these data-and to obtain more reliable estimates of the prevalence of obesity-we apply a Bayesian model that simultaneously accounts for spatial-, temporal-, and between-race/ethnicity dependence structures. This approach yields estimates of the obesity prevalence by age, race/ethnicity, sex, and poverty status for each census tract at all time-points in our study period. While the data suggest that the prevalence of obesity has increased at the city-level for men and women of all three race/ethnicities, the magnitude and geographic distribution of these increases differ substantially by race/ethnicity and sex. The method can be flexibly used to describe and visualize spatial heterogeneities in levels, trends, and in disparities. This is useful for targeting, surveillance, and etiologic research.

Background: Cortisol, a stress hormone released by the activation of the hypothalamic-pituitary-adrenal (HPA) axis, is critical to the body's adaptive response to physiological and psychological stress. Cortisol has also been implicated in the health effects of air pollution through the activation of the sympathetic nervous system. This study evaluates the cross-sectional and longitudinal association between several air pollutants and salivary cortisol. Methods: We used data from the Multi-Ethnic Study of Atherosclerosis (MESA), a cohort of 45–85 years old participants from six US cities. Salivary cortisol was evaluated at two time points between 2004 and 2006 and then again from 2010 to 2012. Cortisol samples were taken several times per day on two or three consecutive days. Particulate matter

Previous studies have demonstrated an inverse association between chronic psychosocial stress and leukocyte telomere length (LTL), a potential marker of cellular aging. However, due to paucity of longitudinal data, responses of LTL and the LTL aging trajectory to changes in chronic stress exposure remain less well understood. Using data from the Stress I and II ancillary studies of the Multi-Ethnic Study of Atherosclerosis, we estimated the 10-year longitudinal (n = 1,158) associations of within-person changes in chronic stress with changes in LTL, as well as the pooled, cross-sectional associations of chronic stress and LTL (total n = 2,231). We measured chronic stress from both individual and neighborhood-environment sources. At the individual level, we calculated a summary score of each participant’s rating of their ongoing (>6 months) material/social problems as moderately/very stressful on the Chronic Burden Scale. Neighborhood-level stress was measured using a summary score of reverse-coded MESA Neighborhood safety, aesthetic quality, and social cohesion scales. Quantiles of these scores were empirically categorized as high, moderate, or low stress. We then summed these individual- and neighborhood-level categorical variables for a total stress measure. Longitudinal within-person associations were estimated with fixed-effects models, which control for all time-invariant confounding, with additional control for time-varying demographics, lagged behaviors and chronic conditions, and specimen storage duration, as well as correction for regression to the mean. Change from low to high total chronic stress was associated with telomere shortening by 0.054 units [95% confidence interval: −0.095, −0.013] over 10 years. This was consistent with, though stronger in magnitude than, cross-sectional estimates. Change in individual-level stress was the primary driver of this effect. We also found suggestive evidence that 1) individuals with persistently high stress experienced the least shortening of telomeres, and 2) changes in individual-level stress were associated with stronger telomere shortening among women, whereas changes in neighborhood stress were associated with stronger shortening among men. Our findings provide longitudinal support to existing evidence, and point to interesting dynamics in telomere attrition across stress levels and genders.

Racial disparities in cardiovascular health (CVH) continue to remain a public health concern in the United States. We use unique population-based data from the Multi-Ethnic Study of Atherosclerosis cohort to explore the black-white differences in optimal CVH. Utilizing geographically weighted regression methods, we assess the spatial heterogeneity in black-white differences in optimal CVH and the impact of both individual- and neighborhood-level risk factors. We found evidence of significant spatial heterogeneity in black-white differences that varied within and between the five sites. Initial models showed decreased odds of optimal CVH for blacks that ranged from 60% to 70% reduced odds - with noticeable variation of these decreased odds within each site. Adjusting for risk factors resulted in reductions in the black-white differences in optimal CVH. Further understanding of the reasons for spatial heterogeneities in black-white differences in nationally representative cohorts may provide important clues regarding the drivers of these differences.

Background Pediatric primary care visits are a foundational element in the health maintenance of children. Differential access may be a driver of racial inequities in health. We hypothesized that pediatric primary care accessibility would be lowest in neighborhoods with higher proportion of non-Hispanic Black residents. Methods Annual ratios (2008–2016) of providers to pediatric population were calculated by census tract in Philadelphia, Pennsylvania. Marginal logistic regression was used to estimate the independent association between neighborhood racial composition and access to pediatric primary care controlling for confounders. Results In general, low access to care was associated with greater neighborhood disadvantage (e.g., SES, % poverty, % public insurance). After controlling for neighborhood indicators of disadvantage, risk of being in the lowest quintile of access significantly increased as the percent of non-Hispanic Black residents increased. Conclusion A new measure of pediatric primary care accessibility demonstrates a persistent disparity in primary care access for predominantly non-Hispanic Black neighborhoods.

Autonomic nervous system effects have been hypothesized as a mechanism of air pollutant health effects, though scant prior epidemiologic research has examined the association between air pollutants and catecholamines.To examine the association of long-term air pollutants with three urinary catecholamines: dopamine (DA), epinephrine (EPI), and norepinephrine (NE). As a secondary aim, we also examined the association between short-term (or acute) exposure to fine particulate matter [particulate matter with aerodynamic diameter [Formula: see text] ([Formula: see text])] and those catecholamines.We used data from the Multi-Ethnic Study of Atherosclerosis (MESA) and two of its ancillary studies, the MESA Air Pollution Study and the MESA Stress Study, to provide exposure and outcome data. DA, EPI, and NE from urine samples were collected from 2004 to 2006 from 1,002 participants in the New York, New York, and Los Angeles, California, study sites. Spatiotemporal models incorporated cohort-specific monitoring and estimated annual average pollutant concentrations ([Formula: see text], [Formula: see text], [Formula: see text] and black carbon) at participants' homes the year prior to urine collection. Secondarily, short-term [Formula: see text] was evaluated (day of, day prior, and 2- to 5-d lags prior to urine collection). Several covariates were considered confounders (age, race, sex, site, socioeconomic status, cardiovascular disease risk factors, psychosocial stressors, and medication use) in linear regression models.A [Formula: see text] higher annual [Formula: see text] concentration was associated with 6.3% higher mean EPI level [95% confidence interval (CI): 0.3%, 12.6%]. A 2-[Formula: see text] higher annual ambient [Formula: see text] concentration was associated with 9.1% higher mean EPI (95% CI: 3.2%, 15.3%) and 4.4% higher DA level (95% CI: 1%, 7.9%). [Formula: see text], black carbon, and short-term [Formula: see text] exposures were not significantly associated with any of the catecholamines.We found an association between EPI and long-term concentrations of [Formula: see text] and [Formula: see text] and an association between DA and long-term ambient [Formula: see text]. These novel findings provide modest support for the hypothesis that air pollutant exposures are related to sympathetic nervous system activation. https://doi.org/10.1289/EHP3286.

Study ObjectivesSleep disturbances and sleep apnea are associated with increased vulnerability to age-related disease, altering molecular pathways affecting biological aging. Telomere length captures one component of biological aging. We evaluated whether objectively assessed sleep and sleep apnea relate to leukocyte telomere length (LTL) in the Multi-Ethnic Study of Atherosclerosis (MESA).MethodsMen and women aged 44–84 years (n = 672) from the MESA Stress and MESA Sleep studies underwent polysomnography and 7 day actigraphy (at Exam 5) and assessment of LTL (at baseline [Exam 1] and about 10 years later [Exam 5]).ResultsGeneral linear models adjusting for age, sex, race/ethnicity, BMI, physical activity, and smoking found that severe obstructive sleep apnea (OSA; apnea–hypopnea index > 30) was cross-sectionally associated with shorter LTL (p = 0.007). Modest associations of shorter LTL with less rapid eye movement sleep, more stage 1 sleep, wake after sleep onset >30 min, and long sleep duration were found, but these effects were diminished after adjusting for lifestyle and OSA. Exploratory analyses found that higher arousal index at Exam 5 was associated with greater LTL decline over the prior 10 years (p = 0.004).ConclusionsOSA was associated with shorter LTL. Individuals with high-arousal frequency had greater leukocyte telomere attrition over the prior decade. These findings suggest that sleep apnea and sleep fragmentation are associated with accelerated biological aging.

ObjectiveAfrican Americans, especially those in the Southeastern USA, have different dietary behaviours from the general US population, and have the highest prevalence, incidence and mortality of diet-related disease outcomes, such as cardiovascular disease. However, there are scant data regarding factors such as socioeconomic position (SEP) across the life course that influence dietary behaviours in this high-risk population. Our aim was to examine the impact of life course and neighbourhood SEPs on dietary intake among African Americans.Participants and settingData for this cross-sectional analysis came from the community-based Jackson Heart Study (JHS). We analysed a total of 3948 JHS participants (mean age: 55.4±12.5; 63.9% women), who had complete dietary intake and covariate information.MethodsWe examined the associations of childhood SEP (CSEP), adulthood SEP (ASEP) and neighbourhood SEP (NSEP) with 10 selected dietary intake measures, using multilevel log-gamma generalised linear regression models.Outcome measuresDietary intake measures include daily saturated fat, sodium, protein, fibre, fruits and vegetables, whole grains, sugar-sweetened beverage, nuts, fish and processed meat.ResultsIn age, sex and total energy intake adjusted models, most dietary intakes were associated with these three SEP measures. After additional adjustment for other SEP measures, most of the significant associations with CSEP and NSEP were attenuated, except for the associations of fibre with CSEP (relative rate [RR] [95% CI] 1.05 [1.00–1.10]) and whole grains with NSEP (RR [95% CI] 1.28 [1.02–1.61]). The associations (shown as RR [95% CI]) between ASEP and sugar-sweetened beverage: 0.70 (0.59–0.83), processed meat: 0.75 (0.63–0.90), sodium: 0.99 (0.94–1.00), fibre: 1.10 (1.03–1.16), protein: 1.05 (1.01–1.09), fruits and vegetables: 1.21 (1.11–1.32), nuts: 2.13 (1.59–2.87), and fish: 1.57 (1.27–1.95) generally persisted after additional adjustment for both CSEP and NSEP. However, the association between ASEP and whole grains was attenuated.ConclusionsHigh ASEP may have a more beneficial influence on dietary practices in African Americans than CSEP or NSEP.

Introduction: Obesity and obesity-related diseases are increasing globally with the sharpest increases occurring in low and middle-income countries. Economic residential segregation results in increased exposure to adverse neighborhood environments; however, the impact of segregation on markers of obesity have been mostly investigated in US-based samples. Using a novel spatial measure of neighborhood-level economic residential segregation (hereafter, segregation) we examined the association between segregation, obesity and visceral adiposity in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Methods: The sample included 6,104 women and 4,789 men ages 35-74 with complete geocoded information from the baseline examination of ELSA-Brasil (2008-2010). Segregation was based on data from the 2010 IBGE demographic census and calculated for study-defined neighborhoods using the local Gi* statistic— a spatially weighted z-score that represents how much a neighborhood’s income composition deviates from the larger metropolitan area. Body mass index (BMI) was calculated by dividing the participants’ measured weight in kilograms by their measured height in meters squared. Participants were considered “obese” if they had a BMI greater than 30 kg/m 2 . Visceral adiposity was assessed using measured waist circumference (in cm) as a proxy. Based on statistically significant interactions between gender and segregation, gender-stratified multivariable logistic and linear regression models were used to test associations between segregation and obesity status and visceral adiposity, respectively. Results: Approximately 14% of the sample resided in segregated neighborhoods. Blacks and Browns were more likely to reside in segregated neighborhoods than Whites (Blacks: 25.9%; Browns: 20.2%; Whites: 8.2%). The prevalence of obesity in the sample was 24% among women and 20% among men and was highest among Black women living in the most economically segregated neighborhood environments (35%). After adjusting for age, sex, race, education, income, and study site, segregation was positively associated with obesity among women (OR: 1.29, 95% CI: 1.07-1.56). Associations for men were not statistically significant (OR: 1.07; 95% CI: 0.85-1.34). Similar patterns were found for visceral adiposity among women (High Segregation, β=1.94 ± 0.51, p=0.0002; Medium Segregation, β=0.90 ± 0.39, p=0.0192) with no statistically significant findings among men. Conclusion: Women residing in economically segregated neighborhoods in Brazil appear to be at an increased risk of obesity and have higher levels of visceral adiposity. Black women may be at highest risk in these settings. Policies and/or structural interventions designed to improve neighborhood conditions may be viable strategies to mitigate the burden of obesity in this setting.

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.

Physical fitness in children has many beneficial effects, including the maintenance of a healthy weight. The built environment may influence youths' physical fitness by encouraging physical activity. This paper assessed whether higher density of parks, playgrounds, and sports facilities around a school is related to improvements in fitness in middle school boys and girls. Fitness scores and other student covariates collected as part of NYC FITNESSGRAM between the 2006-2007 and 2010-2011 school years were linked with school neighborhood data on characteristics of the built environment for NYC public school students in grades 6-8. Data were analyzed in 2015. Medium, but not high, density of recreational resources in the area surrounding a school was associated with greater annual improvements in fitness for both boys and girls. This association appeared to be driven mainly by the presence of parks. Findings for sports facilities and playgrounds were inconsistent. Overall, few associations were observed between recreational resources near a school and changes in student fitness. Future studies of school influences on student fitness should consider the influence of school resources and the home neighborhood.

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.

Home foreclosures can precipitate declines in health among the individuals who lost their homes. Whether home foreclosures can "spillover" to affect the health of other neighborhood residents is largely unknown. Using longitudinal data from the Multi-Ethnic Study of Atherosclerosis that were linked to foreclosure data from 2005 to 2012, we assessed whether greater exposure to neighborhood foreclosures was associated with temporal changes in 3 objectively measured cardiometabolic risk factors: body mass index, systolic blood pressure, and fasting glucose level. We used fixed-effects models to estimate mean changes in cardiometabolic risk factors associated with changes in neighborhood foreclosures over time. In models in which we controlled for time-varying income, working status, medication use, neighborhood poverty, neighborhood unemployment, and interactions of age, sex, race, and state foreclosure laws with time, a standard-deviation increase in neighborhood foreclosures (1.9 foreclosures per quarter mile) was associated with increases in fasting glucose (mean = 0.22 mg/dL, 95% confidence interval: -0.05, 0.50) and decreases in blood pressure (mean = -0.27 mm Hg, 95% confidence interval: -0.49, -0.04). Changes in neighborhood foreclosure rates were not associated with changes in body mass index. Overall, greater exposure to neighborhood foreclosures had mixed associations with cardiometabolic risk factors over time. Given the millions of mortgages still in default, further research clarifying the potential health effects of neighborhood foreclosures is needed.

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.

This report presents findings of an ad hoc working group assembled by the National Heart, Lung, and Blood Institute (NHLBI) to assess research needs to improve prevention, treatment, and control of hypertension among African Americans. Non-Hispanic Blacks (African American and Black will be used for US and international studies, respectively) tend to have an earlier onset, higher prevalence, and disproportionately high risk of complications for hypertension compared with non-Hispanic Whites and Mexican Americans.1 Surveys identify substantial variation in mean blood pressure (BP) among populations of African origin.2 In high-income countries, including the United States, mean BP and prevalence of hypertension are higher in adults self-described,3–6 observer reported,7,8 or otherwise identified9,10 as being black or having darker skin color.11 However, the relationship between African origin and BP is absent or only minimally apparent in reports from middle-income countries.12–14 Research to clarify reasons for this variability may contribute to understanding of hypertension-related racial disparities in the United States. In US National Health and Nutrition Examination Survey (NHANES) reports, crude and age-adjusted prevalence of hypertension (systolic BP [SBP] ≥140 mm Hg, diastolic BP ≥90 mm Hg, or taking antihypertensive medication) in adults has remained fairly constant at ≈30% since 1999 to 2000.3,4 The corresponding prevalence estimate for African Americans is ≈40% and has also remained reasonably stable. In African Americans, hypertension awareness and treatment rates are higher but control rates lower compared with non-Hispanic Whites (85.7% versus 82.7% for awareness, 77.4% versus 76.7% for treatment, and 49.5% versus 53.9% for control in NHANES 2011–2012).4 The lower prevalence of BP control is present despite use of more BP-lowering medications, including thiazide diuretics.15 This contrasts with clinical trial experience, where differences in BP control rates by race/ethnicity …