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Introduction: Women engaging in sex work (WESW) have 21 times the risk of HIV acquisition compared with the general population. However, accessing HIV pre-exposure prophylaxis (PrEP) remains challenging, and PrEP initiation and persistence are low due to stigma and related psychosocial factors. The WiSSPr (Women in Sex work, Stigma and PrEP) study aims to (1) estimate the effect of multiple stigmas on PrEP initiation and persistence and (2) qualitatively explore the enablers and barriers to PrEP use for WESW in Lusaka, Zambia., Methods and Analysis: WiSSPr is a prospective observational cohort study grounded in community-based participatory research principles with a community advisory board (CAB) of key population (KP) civil society organi sations (KP-CSOs) and the Ministry of Health (MoH). We will administer a one-time psychosocial survey vetted by the CAB and follow 300 WESW in the electronic medical record for three months to measure PrEP initiation (#/% ever taking PrEP) and persistence (immediate discontinuation and a medication possession ratio). We will conduct in-depth interviews with a purposive sample of 18 women, including 12 WESW and 6 peer navigators who support routine HIV screening and PrEP delivery, in two community hubs serving KPs since October 2021. We seek to value KP communities as equal contributors to the knowledge production process by actively engaging KP-CSOs throughout the research process. Expected outcomes include quantitative measures of PrEP initiation and persistence among WESW, and qualitative insights into the enablers and barriers to PrEP use informed by participants' lived experiences., Ethics and Dissemination: WiSSPr was approved by the Institutional Review Boards of the University of Zambia (#3650-2023) and University of North Carolina (#22-3147). Participants must give written informed consent. Findings will be disseminated to the CAB, who will determine how to relay them to the community and stakeholders., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

After a tumultuous 3 years of pandemic-, political-, and race-related unrest in the United States, the public is demanding accountability to communities of color (defined here as American Indian/Alaska Native, Asian, Black, Native Hawaiian/Pacific Islander, and Hispanic people) to rectify historic and contemporary injustices that perpetuate health inequities and threaten public health. Structural racism pervades all major societal systems and exposes people to detrimental social determinants of health. Disrupting structural racism within public health systems is essential to advancing health equity and requires organized partnerships between health departments and community leaders. As those who are most affected by structural racism, communities of color are the experts in knowing its impacts. This case study describes the King County Pandemic and Racism Community Advisory Group (PARCAG) and its use of an innovative accountability tool. The tool facilitated institutional transparency and accountability in the adoption of community recommendations. PARCAG was influential in shaping Public Health-Seattle & King County's COVID-19 and antiracism work, with 66 of 75 (88%) recommendations adopted partially or fully. For example, a fully adopted recommendation in May 2020 was to report King County COVID-19 case data by race and ethnicity, and a partially adopted recommendation was to translate COVID-19 information into additional languages. PARCAG members were recruited from a 2019 advisory board on Census 2020 and were adept at shifting to advising on COVID-19 and equitable practices and policies. Organizations that have made declarations that racism is a public health crisis should center the experiences, expertise, and leadership of communities of color in accountable ways when developing and implementing strategies to disrupt and repair the effects of structural racism and efforts to promote and protect public health., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Education for public health is at a critical inflection point, and either transforms for success or fails to remain relevant. In 2020, the Association for Schools and Programs of Public Health launched an initiative, Framing the Future 2030: Education for Public Health (FTF 2030) to develop a resilient educational system for public health that promotes scientific inquiry, connects research, education, and practice, eliminates inequities, incorporates anti-racism principles, creates and sustains diverse and inclusive teaching and learning communities, and optimizes systems and resources to prepare graduates who are clearly recognizable for their population health perspectives, knowledge, skills, attitudes, and practices. Three expert panels: (1) Inclusive excellence through an anti-racism lens; (2) Transformative approaches to teaching and learning; and (3) Expanding the reach, visibility, and impact of the field of academic public health are engaged in ongoing deliberations to generate recommendations to implement the necessary change. The article describes the panels' work completed thus far, a "Creating an Inclusive Workspace" guide, and work planned, including questions for self-evaluation, deliberation, and reflection toward actions that support academe in developing a resilient education system for public health, whether beginning or advancing through a process of change. The FTF 2030 steering committee asserts its strong commitment to structural and substantial change that strengthens academic public health as an essential component of a complex socio-political system. Lastly, all are called to join the effort as collaboration is essential to co-develop an educational system for public health that ensures health equity for all people, everywhere., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Sullivan, Weist, Barrington, Fairchild, Hwang, Kiviniemi, Mohammed, Wyant, Alexander and Magaña.)

The current study examined the associations between perceptions of the social and physical neighborhood environments and cognitive function in older adults. This cross-sectional study analyzed 821 adults aged ≥65 years from the Adult Changes in Thought study. Perceived neighborhood attributes were measured by the Physical Activity Neighborhood Environment Scale. Cognitive function was assessed using the Cognitive Ability Screening Instrument. The associations were tested using multivariate linear regression. One point greater perceived access to public transit was associated with 0.56 points greater cognitive function score (95% confidence interval [CI] [0.25, 0.88]), and an additional one point of perceived sidewalk coverage was related to 0.22 points higher cognitive function score (95% CI [0.00, 0.45]) after controlling for sociodemographic factors. The perception of neighborhood attributes alongside physical infrastructure may play an important role in supporting older adults' cognitive function. [ Journal of Gerontological Nursing, 49 (8), 35-41.].

The aim of this study was to examine the role of walking in explaining associations between perceived and objective measures of walkability and cognitive function among older adults. The study employed a cross-sectional design analyzing existing data. Data were obtained from the Adult Changes in Thought Activity Monitor study. Cognitive function and perceived walkability were measured by a survey. Objective walkability was measured using geographic information systems (GIS). Walking was measured using an accelerometer. We tested the mediating relationship based on 1,000 bootstrapped samples. Perceived walkability was associated with a 0.04 point higher cognitive function score through walking (p = 0.006). The mediating relationship accounted for 34% of the total relationship between perceived walkability and cognitive function. Walking did not have a significant indirect relationship on the association between objective walkability and cognitive function. Perceived walkability may be more relevant to walking behavior than objective walkability among older adults. Greater levels of perceived walkability may encourage older adults to undertake more walking, and more walking may in turn improve cognitive function in older adults., Competing Interests: Declaration of competing interest No potential conflict of interest reported by the authors., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction: Racism is a root cause of ill health for communities of color, and hate incidents are one manifestation of racism. Marginalized racial and ethnic groups, including but not limited to Asian Americans, have been the target of highly publicized violence, hate, and discrimination which has been amplified during the COVID-19 pandemic., Objectives: This paper investigates (1) the prevalence of hate incidents across racial and ethnic groups, and (2) the relationship between race and ethnicity and hate incidents during the first year of the COVID-19 pandemic. We also seek to (3) situate study findings within theories of racism., Methods: This study utilizes national data from the Understanding America Study (UAS) COVID-19 Longitudinal Survey from June 10, 2020 to March 30, 2021 ( n = 8,436). Hate incidents in six categories were examined: being treated with less courtesy, receiving poorer service, others acting as if they were not smart, others acting as if they were afraid of them, being threatened or harassed, and experiencing any of the previous categories of hate incidents. Main analyses were conducted via population averaged logistic panel regression., Results: The majority of members of all six marginalized racial and ethnic groups reported at least one hate incident during the first year of the COVID-19 pandemic. In addition, all marginalized racial or ethnic groups had statistically significant higher odds of experiencing at least two categories of hate incidents compared to white individuals. Asian, AI/AN, Black, and Multiracial groups had significantly higher odds of experiencing each category of hate incident. All marginalized racial and ethnic groups had significantly higher odds of receiving poorer service and others acting as if they were afraid of them., Conclusion: All marginalized racial and ethnic groups experienced significant levels of hate incidents within the first year of the COVID-19 pandemic. The public health community must continue to research, monitor, treat, and prevent hate incidents as a public health issue while recognizing the social and historical contexts of structural and interpersonal racism in the US., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Fan, Hara-Hubbard, Barrington and Baquero.)

Background: Over the last several decades in the United States, socioeconomic life-expectancy inequities have increased 1-2 years. Declining labor-union density has fueled growing income inequities across classes and exacerbated racial income inequities. Using Panel Study of Income Dynamics (PSID) data, we examined the longitudinal union-mortality relationship and estimated whether declining union density has also exacerbated mortality inequities., Methods: Our sample included respondents ages 25-66 to the 1979-2015 PSID with mortality follow-up through age 68 and year 2017. To address healthy-worker bias, we used the parametric g-formula. First, we estimated how a scenario setting all (versus none) of respondents' employed-person-years to union-member employed-person-years would have affected mortality incidence. Next, we examined gender, racial, and educational effect modification. Finally, we estimated how racial and educational mortality inequities would have changed if union-membership prevalence had remained at 1979 (vs. 2015) levels throughout follow-up., Results: In the full sample (respondents = 23,022, observations = 146,681), the union scenario was associated with lower mortality incidence than the nonunion scenario (RR = 0.90, 95% CI = 0.80, 0.99; RD per 1,000 = -19, 95% CI = -37, -1). This protective association generally held across subgroups, although it was stronger among the more-educated. However, we found little evidence mortality inequities would have lessened if union membership had remained at 1979 levels., Conclusions: To our knowledge, this was the first individual-level US-based study with repeated union-membership measurements to analyze the union-mortality relationship. We estimated a protective union-mortality association, but found little evidence declining union density has exacerbated mortality inequities; importantly, we did not incorporate contextual-level effects. See video abstract at, http://links.lww.com/EDE/B839., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Existing evidence indicates household income as a predictor of health-related quality of life (HRQoL) following a colorectal cancer diagnosis. This association likely varies with neighborhood socioeconomic status (nSES), but evidence is limited., Methods: We included data from 1,355 colorectal cancer survivors participating in the population-based Puget Sound Colorectal Cancer Cohort (PSCCC). Survivors reported current annual household income; we measured HRQoL via the Functional Assessment of Cancer Therapy - Colorectal (FACT-C) tool. Using neighborhood data summarized within a 1-km radial buffer of Census block group centroids, we constructed a multidimensional nSES index measure. We employed survivors' geocoded residential addresses to append nSES score for Census block group of residence. With linear generalized estimating equations clustered on survivor location, we evaluated associations of household income with differences in FACT-C mean score, overall and stratified by nSES. We used separate models to explore relationships for wellbeing subscales., Results: We found lower household income to be associated with clinically meaningful differences in overall FACT-C scores [<$30K: -13.6; 95% confidence interval (CI): -16.8 to -10.4] and subscale wellbeing after a recent colorectal cancer diagnosis. Relationships were slightly greater in magnitude for survivors living in lower SES neighborhoods., Conclusions: Our findings suggest that recently diagnosed lower income colorectal cancer survivors are likely to report lower HRQoL, and modestly more so in lower SES neighborhoods., Impact: The findings from this work will aid future investigators' ability to further consider the contexts in which the income of survivors can be leveraged as a means of improving HRQoL., (©2021 American Association for Cancer Research.)

Union members enjoy better wages and benefits and greater power than nonmembers, which can improve health. However, the longitudinal union-health relationship remains uncertain, partially because of healthy-worker bias, which cannot be addressed without high-quality data and methods that account for exposure-confounder feedback and structural nonpositivity. Applying one such method, the parametric g-formula, to US-based Panel Study of Income Dynamics data, we analyzed the longitudinal relationships between union membership, poor/fair self-rated health (SRH), and moderate mental illness (Kessler 6-item score of ≥5). The SRH analyses included 16,719 respondents followed from 1985-2017, while the mental-illness analyses included 5,813 respondents followed from 2001-2017. Using the parametric g-formula, we contrasted cumulative incidence of the outcomes under 2 scenarios, one in which we set all employed-person-years to union-member employed-person-years (union scenario), and one in which we set no employed-person-years to union-member employed-person-years (nonunion scenario). We also examined whether the contrast varied by sex, sex and race, and sex and education. Overall, the union scenario was not associated with reduced incidence of poor/fair SRH (relative risk = 1.01, 95% confidence interval (CI): 0.95, 1.09; risk difference = 0.01, 95% CI: -0.03, 0.04) or moderate mental illness (relative risk = 1.02, 95% CI: 0.92, 1.12; risk difference = 0.01, 95% CI: -0.04, 0.06) relative to the nonunion scenario. These associations largely did not vary by subgroup., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Metabolic syndrome (MetS) is associated with increased mortality independent of BMI, resulting in discordant metabolic phenotypes, such as metabolically healthy obese and metabolically unhealthy normal-weight individuals. Studies investigating dietary intake in MetS have reported mixed results, due in part to the limitations of self-reported measures., Objectives: To investigate the role of biomarker-calibrated estimates of energy and protein in MetS and metabolic phenotypes., Methods: Postmenopausal participants from the Women's Health Initiative (WHI) study who were free of MetS at baseline, had available data from FFQs at baseline, and had components of MetS at Year 3 (n = 3963) were included. Dietary energy and protein intakes were estimated using biomarker calibration methods. MetS was defined as 3 or more of the following: elevated serum triglycerides (≥150 mg/dL), low HDL cholesterol (<50 mg/dL), hypertension [systolic blood pressure (BP) ≥130 or diastolic BP ≥85 mmHg], elevated serum glucose (>100 mg/dL), and abdominal adiposity (waist circumference > 89 cm). Models were adjusted for age, WHI study component, race/ethnicity, education, income, smoking, recreational physical activity, disease history, and parity., Results: For every 10% increment in total calibrated energy intake, women were at a 1.37-fold elevated risk of MetS (95% CI, 1.15-1.63); a 10% increment in calibrated total protein intake was associated with a 1.21-fold elevated risk of MetS (95% CI, 1.00-1.47). Specifically, animal protein intake was associated with MetS (OR, 1.08; 95% CI, 1.02-1.14), whereas vegetable protein intake was not (OR, 0.99; 95% CI, 0.95-1.03). No differences were seen when examining metabolic phenotypes., Conclusions: We found that higher calibrated total energy, total protein, and total animal protein intakes were strongly associated with MetS. If replicated in clinical trials, these results will have implications for the promotion of energy and animal protein restrictions for the reduction of MetS risks., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background: It is biologically plausible that genotoxic estrogens, namely estrogen DNA adducts (EDA), have a role in breast cancer development. Support comes from three prior studies that reported elevated concentrations of EDA relative to estrogen metabolites and conjugates (EDA:EMC) in women with breast cancer relative to control women., Methods: In postmenopausal women in the Women's Health Initiative (WHI), EDA:EMC in 191 controls was compared with findings in 194 prediagnosis urine samples from breast cancer cases. EDA:EMC determinations were by mass spectrometry as previously described, and logistic regression was employed to estimate ORs., Results: EDA:EMC did not differ in breast cancer cases compared with controls overall [0.93 (95% confidence interval, 0.71-1.23)], with a mean (SD) of 2.3 (0.8) and 2.4 (1.1) in cases and controls, respectively. Similarly, the ratio did not differ when examined by estrogen receptor or recency of biospecimen collection prior to breast cancer., Conclusions: Despite the demonstrated genotoxic properties of certain catechol estrogens resulting in EDAs, this analysis did not provide evidence for an increased breast cancer risk in relation to an elevated EDA:EMC., Impact: This analysis, conducted prospectively within postmenopausal women in the WHI study, suggests that a strong association between EDA:EMC and breast cancer could be ruled out, as this study was powered to detect an OR of 2.2 or greater., (©2020 American Association for Cancer Research.)

Background: Recent clinical trials have evaluated angiotensin-converting enzyme (ACE) inhibitors (ACEis), angiotensin receptor blockers (ARBs), and beta blockers (BBs) in relation to cardiotoxicity in patients with cancer, typically defined by ejection fraction declines. However, these trials have not examined long-term, hard clinical endpoints. Within a prospective study, we examined the risk of heart failure (HF) and coronary heart disease (CHD) events in relation to use of commonly used antihypertensive medications, including ACEis/ARBs, BBs, calcium channel blockers (CCB), and diuretics, comparing women with and without cancer., Materials and Methods: In a cohort of 56,997 Women's Health Initiative study participants free of cardiovascular disease who received antihypertensive treatment, we used multivariable-adjusted Cox regression models to calculate the hazard ratios (HRs) of developing CHD, HF, and a composite outcome of cardiac events (combining CHD and HF) in relation to use of ACEis/ARBs, CCBs, or diuretics versus BBs, separately in women with and without cancer., Results: Whereas there was no difference in risk of cardiac events comparing ACEi/ARB with BB use among cancer-free women (HR = 0.99 [0.88-1.12]), among cancer survivors ACEi/ARB users were at a 2.24-fold risk of total cardiac events (1.18-4.24); p-interaction = .06). When investigated in relation to CHD only, an increased risk was similarly observed in ACEi/ARB versus BB use for cancer survivors (HR = 1.87 [0.88-3.95]) but not in cancer-free women (HR = 0.91 [0.79-1.06]; p-interaction = .04). A similar pattern was also seen in relation to HF but did not reach statistical significance (p-interaction = .23)., Conclusion: These results from this observational study suggest differing risks of cardiac events in relation to antihypertensive medications depending on history of cancer. Although these results require replication before becoming actionable in a clinical setting, they suggest the need for more rigorous examination of the effect of antihypertensive choice on long-term cardiac outcomes in cancer survivors., Implications for Practice: Although additional research is needed to replicate these findings, these data from a large, nationally representative sample of postmenopausal women indicate that beta blockers are favorable to angiotensin-converting enzyme inhibitors in reducing the risk of cardiac events among cancer survivors. This differs from the patterns observed in a noncancer cohort, which largely mirrors what is found in the randomized clinical trials in the general population., (© AlphaMed Press 2020.)

Background: Physical activity is frequently proposed as an intervention to reduce fatigue and sleep disturbance in cancer survivors; however, the long-term effects of physical activity are often not reported, and older adults are typically excluded from these intervention studies., Objectives: This article aimed to examine if postdiagnosis physical activity is associated with lower long-term fatigue and sleep disturbance in older adult breast cancer survivors., Methods: Data were analyzed of a prospective cohort of 440 breast cancer survivors aged 65 years or older from the Women's Health Initiative study. Multiple linear and logistic regression models were used to examine associations of physical activity with fatigue and sleep disturbance., Findings: Higher postdiagnosis physical activity was associated with lower long-term fatigue but was not associated with lower sleep disturbance after adjusting for demographics, cancer characteristics, and baseline measures.

Purpose: Delays in adjuvant breast cancer (BC) therapy have been shown to worsen outcomes. However, thus far studies have only evaluated delays to initial treatment, or a particular modality, such as chemotherapy, leaving uncertainty about the role of delay to subsequent therapy and the effects of cumulative delay, on outcomes. We investigated the associations of delays across treatment modalities with survival., Methods: We included 3368 women with incident stage I-III BC in the Women's Health Initiative (WHI) enrolled in fee-for-service Medicare who underwent definitive surgery. This prospective analysis characterized treatment delays by linking WHI study records to Medicare claims. Delays were defined as > 8 weeks to surgery, chemotherapy, and radiation from diagnosis or prior treatment. We used Cox proportional hazards models to estimate BC-specific mortality (BCSM) and all-cause mortality (ACM) in relation to treatment delays., Results: We found 21.8% of women experienced delay to at least one therapy modality. In adjusted analysis, delay to chemotherapy was associated with a higher risk of BCSM (HR = 1.71; 95% CI 1.07-2.75) and ACM (HR = 1.39; 95% CI 1.02-1.90); delay in radiation increased BCSM risk (HR = 1.49; 95% CI 1.00-2.21) but not ACM risk (HR = 1.19; 95% CI 0.99-1.42). Delays across multiple treatment modalities increased BCSM risk threefold (95% CI 1.51-6.12) and ACM risk 2.3-fold (95% CI 1.50-3.50)., Conclusions: A delay to a single treatment modality and delay to a greater extent an accumulation of delays were associated with higher BCSM and ACM after BC. Timely care throughout the continuum of breast cancer treatment is important for optimal outcomes.

Background: Recently, United States life expectancy has stagnated or declined for the poor and working class and risen for the middle and upper classes. Declining labor-union density-the percent of workers who are unionized-has precipitated burgeoning income inequity. We examined whether it has also exacerbated racial and educational mortality inequities., Methods: From CDC, we obtained state-level all-cause and overdose/suicide mortality overall and by gender, gender-race, and gender-education from 1986-2016. State-level union density and demographic and economic confounders came from the Current Population Survey. State-level policy confounders included the minimum wage, the generosity of Aid to Families with Dependent Children or Temporary Assistance for Needy Families, and the generosity of unemployment insurance. To model the exposure-outcome relationship, we used marginal structural modeling. Using state-level inverse-probability-of-treatment-weighted Poisson models with state and year fixed effects, we estimated 3-year moving average union density's effects on the following year's mortality rates. Then, we tested for gender, gender-race, and gender-education effect-modification. Finally, we estimated how racial and educational all-cause mortality inequities would change if union density increased to 1985 or 1988 levels, respectively., Results: Overall, a 10% increase in union density was associated with a 17% relative decrease in overdose/suicide mortality (95% confidence interval [CI]: 0.70, 0.98), or 5.7 lives saved per 100 000 person-years (95% CI: -10.7, -0.7). Union density's absolute (lives-saved) effects on overdose/suicide mortality were stronger for men than women, but its relative effects were similar across genders. Union density had little effect on all-cause mortality overall or across subgroups, and modeling suggested union-density increases would not affect mortality inequities., Conclusions: Declining union density (as operationalized in this study) may not explain all-cause mortality inequities, although increases in union density may reduce overdose/suicide mortality., (© 2019 Wiley Periodicals, Inc.)

Few data are available on patient navigators (PNs) across diverse roles and organizational settings that could inform optimization of patient navigation models for cancer prevention. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and the Colorectal Cancer and Control Program (CRCCP) are two federally-funded screening programs that support clinical- and community-based PNs who serve low-income and un- or underinsured populations across the United States. An online survey assessing PN characteristics, delivered activities, and patient barriers to screening was completed by 437 of 1002 identified PNs (44%). Responding PNs were racially and ethnically diverse, had varied professional backgrounds and practice-settings, worked with diverse populations, and were located within rural and urban/suburban locations across the U.S. More PNs reported working to promote screening for breast/cervical cancers (BCC, 94%) compared to colorectal cancer (CRC, 39%). BCC and CRC PNs reported similar frequencies of individual- (e.g., knowledge, motivation, fear) and community-level patient barriers (e.g., beliefs about healthcare and screening). Despite reporting significant patient structural barriers (e.g., transportation, work and clinic hours), most BCC and CRC PNs delivered individual-level navigation activities (e.g., education, appointment reminders). PN training to identify and champion timely and patient-centered adjustments to organizational policies, practices, and norms of the NBCCEDP, CRCCP, and partner organizations may be beneficial. More research is needed to determine whether multilevel interventions that support this approach could reduce structural barriers and increase screening and diagnostic follow-up among the marginalized communities served by these two important cancer-screening programs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Student populations in the United States are increasingly diverse, prompting the need to make learning environments in schools of nursing more inclusive. Training for faculty is needed to support this work; however, evidence regarding best practices to make classrooms more inclusive is lacking., Method: A 3-day Diversity, Equity, and Inclusion (DEI) Institute was developed and conducted to create inclusive learning environments; facilitate crucial conversations on racism and other -isms, especially in the context of nursing and health equity; and practice these skills and develop or transform at least one actual class activity., Results: DEI Institute satisfaction and impact were overwhelmingly positive, and statistically significant increases in DEI-related teaching self-efficacy were observed post-Institute (p values ranging from .0004 to < .0001)., Conclusion: The DEI Institute is one example of a successful approach that can create inclusive learning environments and address issues related to health equity. [J Nurs Educ. 2019;58(11):633-640.]., (Copyright 2019, SLACK Incorporated.)

Reported relationships between frequency, type, and timing of eating occasions and obesity-risk among adults are mixed while associations with obesogenic eating behaviors remain unexplored. The Physical Activity and Changes in Eating (PACE) study was a group-randomized controlled trial to prevent weight gain among 34 small worksites in Seattle from 2005-2009. Baseline surveys assessed body mass index (BMI), obesogenic eating behaviors (e.g., fast food and distracted-eating), and eating occasions (i.e., snacks and meals) among 2265 employees. BMI and waist circumference were measured on a subset ( n = 567). Time-periods for analyses included: morning (12:00 a.m. to 10:59 a.m.), mid-day (11:00 a.m. to 4:29 p.m.), and evening (4:30 p.m. to 11:59 p.m.). Multilevel linear models estimated associations between snack timing, obesity, and related behaviors while adjusting for meal timing, gender, and worksite random effects. Greater morning snacking was associated with increased fruit and vegetable consumption, while greater evening snacking was associated with higher BMI, higher obesogenic dietary index (intake of fast food, French fries, and soft drinks), and higher percent time eating while distracted. Associations with mid-day snacking were mixed. Patterns of association were consistent across repeated and objective measures. Findings suggest that evening snacking is more detrimental to healthy weight compared to snacking at other times of day. Reducing evening snacks may be an important and simple message for population-level obesity prevention efforts.

Introduction: The purpose of this study was to assess effects of three different educational intervention arms on knowledge of and intention to receive Pap testing and HPV co-testing., Methods: Three active educational intervention arms were developed: a fotonovela, a radionovela, and a digital story. A pilot randomized controlled trial of 160 Latinas was conducted to assess the effectiveness of the intervention arms in increasing knowledge of cervical cancer and HPV and intention to be screened for cervical cancer compared to an attention control group (flu vaccination)., Results: Women in all three treatment arms significantly increased knowledge about cervical cancer compared to control arm (p = 0.02). Knowledge about cervical cancer screening also increased in the active arms compared to control (p = 0.0003). Knowledge of HPV risk also increased relative to the control (p = 0.0001). There were no significant differences between the intervention arms in increased knowledge of cervical cancer or cervical cancer screening (p = 0.57 and 0.16, respectively)., Discussion: This study supported the use of small media interventions in narrative education form as effective in increasing knowledge and intention to be screened for cervical cancer. The three culturally relevant interventions, built on qualitative data, were all successful in increasing knowledge.

Background: Obesity rates differ between Hispanic and White (non-Hispanic) women in the United States, with higher rates among Hispanic women. Socioeconomic processes contribute to this disparity both at the individual and the environmental level. Understanding these complex relationships requires multilevel analyses within cohorts of women that have a shared environment. In population-based samples of Hispanic and White (non-Hispanic) women from the same neighborhoods, we evaluated within each ethnic group a) The association of individual-level socioeconomic status (SES) with body mass index (BMI); and b) The additional contribution of neighborhood-level measures of SES., Methods: Using population-based multi-stage sampling methods, we oversampled low SES and Hispanic block groups. During household screening, we identified women aged 30 to 50 years. Among White women, we specifically oversampled women with low educational levels. 515 Hispanic and 503 White women completed baseline. Height and weight were measured. Baseline surveys, in Spanish and English, included four measures of SES. Three measures of area-level SES were examined. Analysis of log e BMI on each SES measure used linear mixed models, incorporating design effects., Results: Among White women, low education, social status, and neighborhood SES were associated with higher BMI (p < 0.001, p < 0.0001, and p < 0.05, respectively), independent of other SES measures. Although the highest grouped category of education, income and subjective social status within the Hispanic cohort had the lowest mean estimated BMI, the point estimates across categories were not monotonic, and had wide confidence intervals. As a result, in contrast to the findings among White women, no statistically significant associations were found between BMI and measures of SES among Hispanic women., Discussion: Neighborhood and individual measures of SES operate differently in Hispanic compared with White women. We had assumed the measures we included to be most salient and operate similarly for both groups of women. Rather the salient factors for Hispanic women have yet to be identified. Improved understanding may ultimately inform the design of culturally-relevant multilevel obesity prevention strategies., Competing Interests: Conflict of Interest None.

The objective of this effort is to gather data to tailor interventions appropriately. Greater understanding of the correlates of socioeconomic status and obesogenic dietary behaviors was the focus of this manuscript. Using multistage sampling, women with varied education levels completed a baseline assessment in a longitudinal study of women aged 30 to 50 years. This study was conducted in low-SES areas of South King County, Washington State. This study included 530 Caucasian and 510 Hispanic women. Fruit and vegetable consumption was positively associated and soft drink consumption inversely associated with the level of education in Caucasian women. In contrast, percentage calories from fat was positively associated with the level of education in Hispanic women. In Hispanic women, level of education interacted significantly with food security in relation to percentage calories from fat, and with eating norms in relation to soft drink consumption. Neighborhood presence of ethnic food stores was associated with outcomes for Hispanic women, but for Caucasians, presence of fast food restaurants was important. Education was consistently associated with two of the three obesogenic dietary behaviors studied among Caucasian women. Education played a moderating role in the associations of food security and eating norms, independent of area level food availability, in two of three obesogenic dietary behaviors studied. However, these patterns differed for Hispanic women, indicating the need for more research into important variables to support change in Hispanic women. Women of differing ethnic groups did not respond similarly to environmental conditions and policy-relevant surroundings. These data have meaning for considering urban policy that impacts obesity levels in the population.

Background: Obesity is a chronic inflammatory condition strongly associated with the risk of numerous cancers. We examined the association between circulating high-sensitivity C-reactive protein (hsCRP), a biomarker of inflammation and strong correlate of obesity, and the risk of three understudied obesity-related cancers in postmenopausal women: ovarian cancer, kidney cancer, and multiple myeloma., Methods: Participants were 24,205 postmenopausal women who had measurements of baseline serum hsCRP (mg/L) in the Women's Health Initiative (WHI) CVD Biomarkers Cohort, a collection of four sub-studies within the WHI. Incident cancers were identified over 17.9 years of follow-up (n = 153 ovarian, n = 110 kidney, n = 137 multiple myeloma). hsCRP was categorized into study-specific quartiles. Adjusted Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for associations of baseline hsCRP with the risk of these cancers., Results: There was no clear association between baseline hsCRP concentration and the risk of ovarian cancer (quartile 4 vs. 1: HR 0.87, 95% CI 0.56-1.37), kidney cancer (HR 0.95, 95% CI 0.56-1.61), or multiple myeloma (HR 0.82, 95% CI 0.52-1.29). HRs for 1 mg/L increases in hsCRP also approximated the null value for each cancer., Conclusions: The results of this study suggest that elevated CRP is not a major risk factor for these obesity-related cancers (ovarian or kidney cancers, or multiple myeloma) among postmenopausal women. Given the importance of elucidating the mechanisms underlying the association of obesity with cancer risk, further analysis with expanded biomarkers and in larger or pooled prospective cohorts is warranted.

Social environmental factors are theoretically identified as influential drivers of health behaviors - tobacco smoking, alcohol consumption, and physical activity - related to chronic disease disparities. Empirical studies investigating relationships involving social environmental factors have found that either greater interpersonal racial-ethnic discrimination or perceived neighborhood disorder were associated with adverse health behaviors, with potentially larger effects among women. We simultaneously tested whether measures of perceived racial-ethnic discrimination and perceived neighborhood disorder were associated with physical activity, alcohol consumption and tobacco smoking; lifestyle risk factors of major chronic disease among women. Data were from the 2013 California Behavioral Risk Factor Surveillance System. In addition to demographic and socioeconomic factors, women self-reported experiences with racial-ethnic discrimination and perception of neighborhood disorder (i.e., crime safety, traffic safety, and aesthetics/physical disorder). Survey-, and inverse probability of censoring-weighted regression models of each chronic disease risk factor were used to investigate associations involving racial-ethnic discrimination and neighborhood disorder, controlling for potential confounders. Perceiving racial-ethnic discrimination and greater neighborhood disorder were associated with a greater tobacco smoking prevalence. Experiences of racial-ethnic discrimination were associated with greater alcohol consumption among African American and Latino women, but not White women. Similarly, African American women reporting experiences with racial-ethnic discrimination report engaging in physical activity about half as much time as women reporting no racial-ethnic discrimination. Increases in perceived neighborhood disorder were associated with increases in alcohol consumption. All associations with social environmental factors were adjusted for potential confounders and each other. Neighborhood disorder and racial-ethnic discrimination may be important, independent contributors to chronic disease risk through relationships with tobacco smoking, alcohol consumption, and physical activity.

To evaluate the success of dietary interventions, we need measures that are more easily assessed and that closely align with intervention messaging. An index of obesogenic dietary behaviors (e.g., consumption of fast food and soft drinks, low fruit and vegetable consumption, and task eating (eating while engaging in other activities)) may serve this purpose and could be derived via data-driven methods typically used to describe nutrient intake. We used behavioral and physical measurement (i.e., body mass index, waist circumference) data from a subset of 2 independent cross-sectional samples of employees enrolled in the Promoting Activity and Changes in Eating (PACE) Study (Seattle, Washington) who were selected at baseline (2005-2007) (n = 561) and during follow-up (2007-2009) (n = 155). Index derivation methods, including principal components regression, partial least squares regression, and reduced rank regression, were compared. The best-fitting index for predicting physical measurements included consumption of fast food, French fries, and soft drinks. In linear mixed models, each 1-quartile increase in index score was associated with a 5% higher baseline body mass index (ratio of geometric means = 1.053, 95% confidence interval: 1.031, 1.075) and an approximately 4% higher baseline waist circumference (ratio = 1.036, 95% confidence interval: 1.019, 1.054) after adjustment for covariates. Results were similar at follow-up before and after adjustment for baseline measures. This index may be useful in evaluating public health or clinic-based dietary interventions to reduce obesity, especially given the ubiquity of these behaviors in the general population.

Limited evidence suggests that hyperinsulinemia may contribute to the risk of breast, endometrial, and, possibly, ovarian cancer. The aim of this study was to assess the association of serum glucose and insulin with risk of these cancers in postmenopausal women, while taking into account potential confounding and modifying factors. We studied 21 103 women with fasting baseline insulin and glucose measurements in a subsample of the Women's Health Initiative. The subsample was composed of four studies within Women's Health Initiative with different selection and sampling strategies. Over a mean of 14.7 years of follow-up, 1185 breast cancer cases, 156 endometrial cancer cases, and 130 ovarian cancer cases were diagnosed. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) by quartile of glucose or insulin. Serum insulin was positively associated with breast cancer risk (multivariable-adjusted HR for highest vs. lowest quartile 1.41, 95% CI: 1.16-1.72, Ptrend<0.0003), and glucose and insulin were associated with roughly a doubling of endometrial cancer risk (for glucose: HR: 2.00, 95% CI: 1.203.35, Ptrend=0.01; for insulin: HR: 2.39, 95% CI: 1.32-4.33, Ptrend=0.008). These associations remained unchanged or were slightly attenuated after mutual adjustment, adjustment for serum lipids, and assessment of possible reverse causation. Glucose and insulin showed no association with ovarian cancer. Our findings provide support for a role of insulin-related pathways in the etiology of cancers of the breast and endometrium. However, because of the unrepresentative nature of the sample, our results need confirmation in other populations.

Background: Depression is an important contributor to the global burden of disease. Besides several known individual-level factors that contribute to depression, there is a growing recognition that neighbourhood environment can also profoundly affect mental health. This study assessed associations between three neighbourhood constructs-socioeconomic deprivation, residential instability and income inequality-and depression among adult twin pairs. The twin design is used to examine the association between neighbourhood constructs and depression, controlling for selection factors (ie, genetic and shared environmental factors) that have confounded purported associations., Methods: We used multilevel random-intercept Poisson regression among 3738 same-sex twin pairs from a community-based twin registry to examine the association between neighbourhood constructs and depression. The within-pair association controls for confounding by genetic and environmental factors shared between twins within a pair, and is the main parameter of interest. Models were adjusted for individual-level income, education and marital status, and further by neighbourhood-level population density., Results: When twins were analysed as individuals (phenotypic model), all neighbourhood constructs were significantly associated with depression. However, only neighbourhood socioeconomic deprivation showed a significant within-pair association with depression. A 10-unit within-pair difference in neighbourhood socioeconomic deprivation was associated with 6% greater depressive symptoms (1.06, 95% CI 1.01 to 1.11); the association did not substantially change in adjusted models., Conclusion: This study provides new evidence linking neighbourhood socioeconomic deprivation with greater depression. Future studies should employ longitudinal designs to better test social causation versus social selection., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: Bioavailable insulin-like growth factor-I (IGF-I) interacts with obesity and exogenous estrogen (E) in a racial disparity in obesity-related cancer risk, yet their interconnected pathways are not fully characterized. We investigated whether circulating bioavailable IGF-I acted as a mediator of the racial disparity in obesity-related cancers such as breast and colorectal (CR) cancers and how obesity and E use regulate this relationship., Methods: A total of 2,425 white and 164 African American (AA) postmenopausal women from the Women's Health Initiative Observational Study were followed from October 1, 1993 through August 29, 2014. To assess bioactive IGF-I as a mediator of race-cancer relationship, we used the Baron-Kenny method and quantitative estimation of the mediation effect., Results: Compared with white women, AA women had higher IGF-I levels; their higher risk of CR cancer, after accounting for IGF-I, was no longer significant. IGF-I was associated with breast and CR cancers even after controlling for race. Among viscerally obese (waist/hip ratio >0.85) and overall nonobese women (body mass index <30), IGF-I was a strong mediator, reducing the racial disparity in both cancers by 30% and 60%, respectively. In E-only users and nonusers, IGF-I explained the racial disparity in CR cancer only modestly., Conclusions: Bioavailable IGF-I is potentially important in racial disparities in obesity-related breast and CR cancer risk between postmenopausal AA and white women. Body fat distribution and E use may be part of the interconnected hormonal pathways related to racial difference in IGF-I levels and obesity-related cancer risk.

Objective: To evaluate associations of fast-food items (FFI) and sugar-sweetened drinks (SSD) with mortality outcomes including deaths due to any cause, CVD and total cancers among a large sample of adults., Design: Using a prospective design, risk of death was compared across baseline dietary exposures. Intakes of FFI and SSD were quantified using a semi-quantitative FFQ (baseline data collected 2000-2002). Deaths (n 4187) were obtained via the Washington State death file through 2008, excluding deaths in the first year of follow-up. Causes of death were categorized as due to CVD (I00-I99) or cancer (C00-D48). Cox models were used to estimated hazard ratios (HR) and 95 % CI., Setting: The Vitamins and Lifestyle (VITAL) study among adults living in Western Washington State., Subjects: Men and women (n 69 582) between 50 and 76 years of age at baseline., Results: Intakes of FFI and SSD were higher among individuals who were younger, female, African-American, American Indian or Alaska Native, Asian-American or Pacific Islander, of lower educational attainment, and of lower income (P<0·0001 for all). Higher risk of total mortality was associated with greater intake of FFI (HR=1·16; 95 % CI 1·04, 1·29; P=0·004; comparing highest v. lowest quartile) and SSD (HR=1·19; 95 % CI 1·08, 1·30; P<0·0001; comparing highest v. lowest quartile). Higher intake of FFI was associated with greater cancer-specific mortality while an association with CVD-specific mortality was suggested. Associations between intake of SSD and cause-specific mortality were less clear., Conclusions: Intake of FFI and SSD has a detrimental effect on future mortality risk. These findings may be salient to socially patterned disparities in mortality.

Introduction: Neighborhood environments may play a role in the rising prevalence of obesity among older adults. However, research on built environmental correlates of obesity in this age group is limited. The current study aimed to explore associations of Walk Score, a validated measure of neighborhood walkability, with BMI and waist circumference in a large, diverse sample of older women., Methods: This study linked cross-sectional data on 6,526 older postmenopausal women from the Women's Health Initiative Long Life Study (2012-2013) to Walk Scores for each participant's address (collected in 2012). Linear and logistic regression models were used to estimate associations of BMI and waist circumference with continuous and categorical Walk Score measures. Secondary analyses examined whether these relationships could be explained by walking expenditure or total physical activity. All analyses were conducted in 2015., Results: Higher Walk Score was not associated with BMI or overall obesity after adjustment for sociodemographic, medical, and lifestyle factors. However, participants in highly walkable areas had significantly lower odds of abdominal obesity (waist circumference >88 cm) as compared with those in less walkable locations. Observed associations between walkability and adiposity were partly explained by walking expenditure., Conclusions: Findings suggest that neighborhood walkability is linked to abdominal adiposity, as measured by waist circumference, among older women and provide support for future longitudinal research on associations between Walk Score and adiposity in this population., (Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Importance: African American men have the highest rates of prostate cancer incidence and mortality in the United States. Understanding underlying reasons for this disparity could identify preventive interventions important to African American men., Objective: To determine whether the association of obesity with prostate cancer risk differs between African American and non-Hispanic white men and whether obesity modifies the excess risk associated with African American race., Design, Setting, and Participants: Prospective study of 3398 African American and 22,673 non-Hispanic white men who participated in the Selenium and Vitamin E Cancer Prevention Trial (2001-2011) with present analyses completed in 2014., Main Outcomes and Measures: Total, low-grade (Gleason score <7), and high-grade (Gleason score ≥7) prostate cancer incidence., Results: With a median (interquartile range) follow-up of 5.6 (1.8) years, there were 270, 148, and 88 cases of total, low-, and high-grade prostate cancers among African American men and a corresponding 1453, 898, and 441 cases in non-Hispanic white men, respectively. Although not associated with risk among non-Hispanic white men, BMI was positively associated with an increase in risk among African American men (BMI, <25 vs ≥35: hazard ratio [HR], 1.49 [95% CI, 0.95, 2.34]; P for trend = .03). Consequently, the risk associated with African American race increased from 28% (HR, 1.28 [95% CI, 0.91-1.80]) among men with BMI less than 25 to 103% (HR, 2.03 [95% CI, 1.38-2.98]) among African American men with BMI at least 35 (P for trend = .03). Body mass index was inversely associated with low-grade prostate cancer risk within non-Hispanic white men (BMI, <25 vs ≥35: HR, 0.80 [95% CI, 0.58-1.09]; P for trend = .02) but positively associated with risk within African American men (BMI, <25 vs ≥35: HR, 2.22 [95% CI, 1.17-4.21]; P for trend = .05). Body mass index was positively associated with risk of high-grade prostate cancer in both non-Hispanic white men (BMI, <25 vs ≥35: HR, 1.33 [95% CI, 0.90-1.97]; P for trend = .01) and African American men, although the increase may be larger within African American men, albeit the racial interaction was not statistically significant (BMI, <25 vs ≥35: HR, 1.81 [95% CI, 0.79-4.11]; P for trend = .02)., Conclusions and Relevance: Obesity is more strongly associated with increased prostate cancer risk among African American than non-Hispanic white men and reducing obesity among African American men could reduce the racial disparity in cancer incidence. Additional research is needed to elucidate the mechanisms underlying the differential effects of obesity in African American and non-Hispanic white men.

Obesity has been characterized as a disease. Strategies to change the incidence and prevalence of this disease include a focus on changing physical and social environments, over and above individual-level strategies, using a multilevel or systems approach. We focus our attention on evidence published between 2008 and 2013 on the effectiveness of interventions in nutrition environments, i.e., environmental interventions designed to influence the intake of healthful foods and amount of energy consumed. An overarching socioecological framework that has guided much of this research was used to characterize different types of environmental strategies. Intervention examples in each area of the framework are provided with a discussion of key findings and related conceptual and methodological issues. The emphasis in this review is on adults, but clearly this literature is only one part of the picture. Much research has been focused on child-specific interventions, including environmental interventions. Some evidence suggests effectiveness of policy-based or other types of interventions that aim to regulate or restructure environments to promote healthy dietary choices, and these strategies would apply to both children and adults. Opportunities to evaluate these policy changes in adults' social and physical environments are rare. Much of the existing research has been with children. As conceptual and methodological issues continue to be identified and resolved, we hope that future research in this domain will identify environmental strategies that can be included in intervention toolboxes to build healthy nutrition environments for both adults and children.

Background: Understanding mechanisms linking neighborhood context to health behaviors may provide targets for increasing lifestyle intervention effectiveness. Although associations between home neighborhood and obesogenic behaviors have been studied, less is known about the role of worksite neighborhood., Purpose: To evaluate associations between worksite neighborhood context at baseline (2006) and change in obesogenic behaviors of adult employees at follow-up (2007-2009) in a worksite randomized trial to prevent weight gain., Methods: Worksite property values were used as an indicator of worksite neighborhood SES (NSES). Worksite neighborhood built environment attributes associated with walkability were evaluated as explanatory factors in relationships among worksite NSES, diet, and physical activity behaviors of employees. Behavioral data were collected at baseline (2005-2007) and follow-up (2007-2009). Multilevel linear and logistic models were constructed adjusting for covariates and accounting for clustering within worksites. Product-of-coefficients methods were used to assess mediation. Analyses were performed after study completion (2011-2012)., Results: Higher worksite NSES was associated with more walking (OR=1.16, 95% CI=1.03, 1.30, p=0.01). Higher density of residential units surrounding worksites was associated with more walking and eating five or more daily servings of fruits and vegetables, independent of worksite NSES. Residential density partially explained relationships among worksite NSES, fruit and vegetable consumption, and walking., Conclusions: Worksite neighborhood context may influence employees' obesogenic behaviors. Furthermore, residential density around worksites could be an indicator of access to dietary and physical activity-related infrastructure in urban areas. This may be important given the popularity of worksites as venues for obesity prevention efforts., (Published by Elsevier Inc.)

Stress has been associated with eating patterns in human studies with differences due to the type and duration of stressor, type of food, and individual susceptibility factors. Laboratory and smaller epidemiological studies have reported stress-associated preferences for foods high in sugar and fat; associations have been found more consistently among women and people who are obese. Larger studies are needed to sufficiently test these relationships. The aim of this study was to evaluate associations between self-reported amount of stress and dietary nutrient intakes (percentage energy from fat, carbohydrates, added sugar) and dietary behaviors (number of eating occasions and servings of fruits and vegetables, high-fat snacks, fast-food items, and sweetened drinks) by sex, obesity status, and stress vulnerability. Linear regression was used to estimate associations of perceived stress with eating patterns among 65,235 older adults while adjusting for demographic factors, body mass index, physical activity, alcohol intake, number of comorbidities, and other relevant covariates. Higher perceived stress was associated with greater intake of energy from fat, high-fat snacks, and fast-food items as well as lower intake of energy from carbohydrates (all P for trend ≤0.002). Among those with high perceived stress vulnerability, perceived stress was associated with fewer eating occasions (P for interaction <0.0001). Although associations were small, significant relationships were found for perceived stress arising from everyday experiences among an older, mostly white population. These findings have public health implications and suggest that stress may be important to consider in programs promoting healthy eating., (Copyright © 2014 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Associations between measures of neighborhood socioeconomic deprivation and health have been identified, yet work is needed to uncover explanatory mechanisms. One hypothesized pathway is through stress, yet the few studies that have evaluated associations between characteristics of deprived neighborhoods and biomarkers of stress are mixed. This study evaluated whether objectively measured neighborhood socioeconomic deprivation and individual perceived neighborhood characteristics (i.e. social control and fear of crime) impacted cortisol responses to an induced stressor among older healthy adults. Data from Heart Scan, a sub-study of the Whitehall II cohort, were used to generate multilevel piecewise growth-curve models of cortisol trajectories after a laboratory stressor accounting for neighborhood and demographic characteristics. Neighborhood socioeconomic deprivation was significantly associated with individual perceptions of social control and fear of crime in the neighborhood while an association with blunted cortisol reactivity was only evidence among women. Social control was significantly associated with greater cortisol reactivity and mediation between neighborhood socioeconomic deprivation and cortisol reactivity was suggested among women. These findings support a gender-dependent role of neighborhood in stress process models of health., (Published by Elsevier Ltd.)

Introduction: Stress in numerous contexts may affect the risk for obesity through biobehavioral processes. Acute stress has been associated with diet and physical activity in some studies; the relationship between everyday stress and such behavior is not clear. The objective of this study was to examine associations between perceived stress, dietary behavior, physical activity, eating awareness, self-efficacy, and body mass index (BMI) among healthy working adults. Secondary objectives were to explore whether eating awareness modified the relationship between perceived stress and dietary behavior and perceived stress and BMI., Methods: Promoting Activity and Changes in Eating (PACE) was a group-randomized worksite intervention to prevent weight gain in the Seattle metropolitan area from 2005 through 2007. A subset of 621 participants at 33 worksites provided complete information on perceived stress at baseline. Linear mixed models evaluated cross-sectional associations., Results: The mean (standard deviation [SD]) Perceived Stress Scale-10 score among all participants was 12.7 (6.4), and the mean (SD) BMI was 29.2 kg/m2 (6.3 kg/m2). Higher levels of perceived stress were associated with lower levels of eating awareness, physical activity, and walking. Among participants who had low levels of eating awareness, higher levels of perceived stress were associated with fewer servings of fruit and vegetables and greater consumption of fast food meals., Conclusion: Dietary and physical activity behaviors of workers may be associated with average levels of perceived stress. Longitudinal studies are needed, however, to support inclusion of stress management or mindfulness techniques in workplace obesity prevention efforts.