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Objective: To examine the association between language use – predominantly English, English and Spanish equally, and predominantly Spanish – and food insecurity among Hispanic adults residing in the United States, 1999-2018. Design: Pooled cross-sectional study design. Setting: United States. Participants: 15,073 Hispanic adults. Results: Compared to Hispanic adults who predominantly spoke English and after adjusting for age, sex, family income-to-poverty ratio, education level, and employment status, Hispanic adults who spoke English and Spanish equally (OR=1.28, 95%CI=1.05-1.56) or predominantly Spanish (OR=1.25, 95%CI=1.04-1.49) had higher odds of food insecurity. After stratifying by country of birth, language use was associated with higher odds of food insecurity only for Hispanic adults born outside of the United States, but not for Hispanic adults born in the United States. Hispanic adults born outside of the United States who spoke English and Spanish equally (OR=1.27, 95%CI=1.04-1.55) or spoke predominantly Spanish (OR=1.24, 95%CI=1.04-1.48) had higher odds of food insecurity when compared to those who predominantly spoke English. Conclusion: Foreign-born Hispanic adults who speak predominantly Spanish, or English and Spanish equally, have higher odds of food insecurity. Food and nutrition assistance programs that serve Hispanic immigrants should make sure to provide linguistically- and culturally appropriate services to this population.

Purpose To explore factors associated with community garden use. Approach Environmental assessment of community gardens and semi-structured interviews. Setting New Orleans, Louisiana. Participants 10 community gardens (environmental assessment), 20 community members (including garden users and non-users) and garden administrators (qualitative interviews). Method Gardens were assessed based on (1) accessibility, (2) information, (3) design, (4) cleanliness, (5) walkability, (6) parking, and (7) noise. Semi-structured interviews took place over Zoom; transcribed interviews were analyzed using thematic analysis. Results Gardens assessed in the environmental assessment ranked high in design and cleanliness but low on accessibility and information availability. Salient themes from the qualitative interviews include skill-building, access to fresh foods, and increased social engagement as enablers of community garden participation, with availability of information and time as both potential enablers of, or barriers to, participation. Community members perceived that gardens could increase fresh food access, while administrators believed that it is not possible for community gardens to produce enough food to create community-wide impact, highlighting instead the importance of the social aspects of the garden as beneficial for health. Conclusion Community gardens should improve garden physical accessibility and information availability to incentivize use. Community gardens are valued as means for skill-building and social engagement. Future research should prioritize investigating the association between the social aspects of participating in community gardens and health outcomes.

BACKGROUND: Food insecurity (FI) is an important social determinant of health that is associated with many forms of violence. We hypothesized that FI would be associated with gun violence. METHODS: Firearm injury data was collected from 2016–2020 (n=3115) at a single institution that serves as the only Level I trauma center in a major southern US city. The data was linked with Map the Meal Gap data, a publicly available dataset which estimates rates of county-level FI based on state-level FI and social determinants, including unemployment, poverty, disability, and other factors. Regression analysis was utilized to examine the relationship between FI with rates of overall gun trauma and odds of gun-related violence. FI by county of patient residence was categorized by rates less than the national average of 11.5% (Low), between the national and state average (16.5%) (Moderate), and greater than the state average (High). Out of state residents were excluded from the analyses. RESULTS: Of the 3115 patients with firearm injuries identified, 138 (4.4%) resided in counties with low FI rates, 1048 (33.6%) in moderate FI, and 1929 (62.0%) in counties with high FI. Patients in regions of high FI were more likely to be a level 1 trauma activation, a victim of assault, and have Medicaid or be self-pay. There was no significant difference in mortality by levels of FI. FI was significantly associated with firearm injury, with each percent increase in FI being related to approximately 56 additional gun-related injuries per 100,000 people (95% confidence interval (CI): 54 – 59) and increased odds of the injury classified as assault (odds ratio: 1.13, 95% CI 1.07–1.19). CONCLUSION: Violence prevention initiatives targeting food insecure communities may help alleviate the US gun violence epidemic. Further, trauma center screening for household FI and in-hospital interventions addressing FI may help reduce gun violence recidivism. LEVEL OF EVIDENCE: IV STUDY TYPE: Epidemiologic

This study examines the associations between water insecurity, self-reported physical health, and objective measures of biological health among 225 Awajún adults (107 women; 118 men) living in the Peruvian Amazon, a "water-abundant" region.A survey, which included multiple measures of self-reported physical health, and objective measures of biological health such as blood pressure and nutritional and immune biomarkers.Greater water insecurity was associated with multiple measures of self-reported physical health, including higher incidence of reported diarrhea, nausea, back pain, headaches, chest pain, fatigue, dizziness, overall poor perceived health, and "being sick." These symptoms align with the physical strain associated with water acquisition and with drinking contaminated water. A significant association between higher water insecurity and lower systolic blood pressure emerged, which may be linked to dehydration. None of the other biomarkers, including those for nutrition, infection, and stress were significantly associated with water insecurity scores.These analyses add to the growing body of research examining the associations between water insecurity and health. Biocultural anthropologists are well-positioned to continue probing these connections. Future research will investigate relationships between measures of water insecurity and biomarkers for gastrointestinal infection and inflammation in water-scarce and water-abundant contexts.

Background Type of infant feeding has been linked to later nutritional outcomes, including dietary diversity and obesity in childhood. Little is known about how introduction to complementary feeding and diet quality in early childhood vary by infant feeding type and sex. Objective Our objective was to investigate whether early childhood dietary patterns vary by infant feeding type and sex. Methods Data from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Infants and Toddler Feeding Practices Study 2 (ITFPS-2) was used, including children with complete information on the WIC infant food package received at ages 1, 7, and 11 mo (N = 2839). Based on this information, children were grouped as fully breastfed, mostly breastfed, mostly formula fed, and fully formula fed. Outcomes include introduction of complementary foods; caloric intake aged between 1 and 36 mo; and Healthy Eating Index (HEI)-2015 between 13 and 36 mo. Mixed models were used adjusting for child's, mother's, and family's sociodemographic characteristics. Results Across all infant feeding groups, the mean age of introduction to any solids was before the age of 6 mo; fully breastfed children were introduced to complementary foods closer to the recommended age (mean 5.1-5.2 mo) compared with other feeding groups (mean 4.6-4.8 mo). Fully formula fed infants consumed significantly more energy than fully breastfed infants at ages 1 mo (boys = 55 kcal/d, girls = 47 kcal/d), 12 mo (boys = 68 kcal/d, girls = 59 kcal/d), 24 mo (boys = 81 kcal/d, girls = 71 kcal/d), and 36 mo (boys = 95 kcal/d, girls = 83 kcal/d). No meaningful differences were observed for HEI-2015 between infant feeding groups or child sex, with average scores of HEI-2015 for all children being 61-63 out of 100. Conclusion Early childhood dietary patterns were slightly better among children who were fully breastfed as infants, compared with children in other infant feeding groups. The diets of all WIC-participating children could be improved.

Disparities in obesity highlight the need for an examination of determinants that may be uniquely experienced by race and sex. An understudied factor is household composition with the potential for variation in its obesogenic impacts. This study examines the association between household composition and body mass index (BMI) among Black, Hispanic, and White adults and determines whether income moderates these associations. Using cross-sectional data from the 2011–2018 National Health and Nutrition Examination Survey, the number of children and adults aged ≥ 60 years in the household were reported among non-Hispanic Black and White adults as well as Hispanic adults aged 20–59 years old. Multivariable linear regressions were used to assess the associations between household composition and BMI with income as a potential moderator. Having multiple school-aged children was associated with higher BMI (β = 1.34, standard error (s.e.) = 0.50) among Hispanic men, while having older adults in the household was associated with lower BMI among Black women (β = − 3.21, s.e. = 1.42). Income moderated the associations between household composition and BMI among Black women and men. There were no associations between household composition and BMI in White women or men. Future studies should further explicate the mechanisms of household composition that uniquely impact obesity outcomes among Black women and men by income. Efforts to address higher BMI among those with more young children in the household should target Hispanic men.

Objective:To determine whether a previously reported association between the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) food package change and reduced child obesity risk among WIC-participating children in Los Angeles County holds across levels of family income and neighbourhood poverty.Design:Analysis of prospectively collected WIC administrative data. The outcome was obesity at age 4 years (BMI-for-age ≥ 95th percentile). Poisson regression was applied to a matched sample (n 79 502) to determine if the association between the WIC food package change and child obesity was modified by family income (100 % but Setting:Los Angeles County, California.Participants:Children who participated in WIC in Los Angeles County between 2003 and 2016; children were grouped as receiving the old WIC food package (2003–2009) or the new WIC food package (2010–2016).Results:Receiving the new WIC food package (i.e., post-2009) was associated with 7–18 % lower obesity risk across all family income categories. Neither family income nor neighbourhood poverty significantly modified the association between the WIC food package and child obesity. However, certain sub-groups seemed to benefit more from the food package change than others. In particular, boys from families with income above poverty but residing in the poorest neighbourhoods experienced the greatest reductions in obesity risk (relative risk = 0·77; 95 % CI 0·66, 0·88).Conclusions:The WIC food package revisions were associated with reduced childhood obesity risk among all WIC-participating families in Los Angeles County, across levels of income eligibility and neighbourhood poverty.

Racial inequities in food insecurity have been documented for the past 2 decades in the U.S., with the prevalence of food insecurity among Black households being 2-3 times higher than that among White households across time. The purpose of this study was to determine the association between socioeconomic indicators of structural racism at the state level and food insecurity among White and Black households in the U.S.This study is a secondary analysis of pooled, cross-sectional data from the Current Population Survey and the American Community Survey, 2015-2019 (N=158,551 Black and White households). Data analysis occurred in 2021-2022. The outcome was household food insecurity, and the exposure was structural racism indicators, operationalized as state-level racial inequities in income, earnings, education, unemployment, and home ownership. Individual-, household-, and state-level sociodemographic covariates were included.Among Black households, state-level racial inequities in income, unemployment, and home ownership were associated with 34% (OR=1.34; 95% CI=1.05, 1.70), 14% (OR=1.14; 95% CI=1.02, 1.28), and 11% (OR=1.11; 95% CI=1.05, 1.16) higher odds of food insecurity, respectively. For White households, state-level racial inequities in income, education, unemployment, and home ownership were associated with 21% (OR=0.79; 95% CI=0.63, 0.98), 27% (OR=0.73; 95% CI=0.66, 0.85), 10% (OR=0.90; 95% CI=0.82, 0.98), and 8% (OR=0.92; 95% CI=0.89, 0.95) lower odds of food insecurity, respectively.Structural racism may be a key driver of food insecurity among Black households and may be protective against food insecurity among White households. Implementing policies addressing state-level racial inequity in socioeconomic indicators could be effective at reducing racial inequities in food insecurity.

The objective of this study was to investigate the association between household food insecurity and food intake among children who participated in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), including a sub-sample who also participated in the Supplemental Nutrition Assistance Program (SNAP). Data came from the 2014 and 2017 Los Angeles County WIC Surveys, involving a random sample of WIC participating families in Los Angeles, California. Outcome variables were average daily consumption of fruit, 100% fruit juice, vegetables, milk, other juice, other sweetened drinks, and sweet foods, and frequency of fast-food consumption, as reported by the child's caregiver. Our predictor was household food insecurity, obtained from the 6-item Household Food Security Survey Module. Poisson regression (fruit, 100% fruit juice, vegetables, and milk), Negative Binomial regression (other juice, other sweetened drinks, and sweet foods) and multinomial logistic regression (frequency of fast food) models were run, adjusting for child's age and sex; maternal age, ethnicity and language, education, and employment; and type of WIC participation (WIC only vs. WIC + SNAP). In fully adjusted models, household food insecurity was associated with higher consumption of 100% fruit juice (RR = 1.08, 95%CI = 1.03-1.11), milk (RR = 1.04, 95%CI = 1.01-1.07), other juice (RR = 1.16, 95%CI = 1.08-1.26), other sweetened drinks (RR = 1.28, 95%CI = 1.12-1.46), and sweet foods (RR = 1.09, 95%CI = 1.04-1.14). No significant associations were found between household food insecurity and fruit and vegetable consumption. Nutrition education provided by WIC should continue to emphasize the importance of consuming fresh foods, while limiting foods high in sugar for this young population. Efforts should be made to identify food insecure families at the point of service delivery for enhanced nutrition education and social services referrals.

Background:The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition assistance to half of infants born in the United States. The nationally representative WIC Infants and Toddler Feeding Practices Study-2 (ITFPS-2) reported a caloric deficit at 7 months among infants receiving WIC mixed feeding packages, suggesting these infants may be at risk for growth deceleration/faltering.Methods:Longitudinal administrative data collected prospectively from WIC participants in Southern California between 2010 and 2019 were used (n= 16,255). Infant lengths and weights were used to calculate weight-for-length (WLZ), weight-for-age (WAZ) and length-for-age (LAZ) z-scores at different time points. Growth deceleration/faltering was determined at 9, 12, 18, and 24 months by the change in z-score from the last measurement taken ≤ 6 months of age. Infant feeding was categorized by the food package (breastfeeding, mixed feeding, and formula feeding) infants received from WIC at 7 months. Poisson regression models were used to evaluate the association between WIC infant package at 7 months and deceleration/faltering at 9, 12, 18, and 24 months.Results:The proportion of infants displaying decelerated/faltering growth was low for all infant food package groups. Receiving the WIC mixed feeding package at 7 months of age was not associated with WLZ, WAZ, and LAZ deceleration/faltering growth.Conclusions:Growth deceleration/faltering rates were very low among WIC participating children in Southern California, highlighting the critical role of nutrition assistance in supporting adequate growth in early childhood.

Background The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) changed the food packages provided to its participants in 2009, to better align them with the Dietary Guidelines for Americans. Previous research found that the 2009 WIC food package change was associated with reduced obesity risk, particularly among breastfed infants but also among those who were never breastfed. The objective of this study was to determine if the new child food package introduced in 2009, including more produce and whole grains for 1–4-year old children, was associated with healthier growth trajectories and reduced obesity risk at age 4 years among children who were exclusively formula fed during infancy. Methods Administrative data on WIC-participating children in Los Angeles County, 2003–2016, were used (N = 74,871), including repeated measures of weight and length (or height); child’s age, gender, and race/ethnicity; maternal education and language; and family poverty. Gender-stratified spline mixed models were used to examine weight-for-height z-score (WHZ) growth trajectories from 0 to 4 years and Poisson regression models were used to assess obesity (BMI-for-age > 95th percentile) at age 4. The main independent variable was duration of receipt (dose) of the new child package, categorized as 0, > 0 to Results WHZ growth trajectories were similar for children across new child package dose groups. Boys and girls who were fully formula fed during infancy but received the new child food package for 4 years had a 7% (RR = 0.93; 95%CI = 0.89–0.98) and a 6% (RR = 0.94; 95%CI = 0.89–0.99) lower obesity risk, respectively, compared to children who received the new child food package for 0 years. There were no differences in obesity risk for children receiving child package vs. 0 years. Conclusions Providing healthy foods during childhood to children who were exclusively formula fed as infants was associated with modest improvements in obesity outcomes. While breastfeeding promotion should still be prioritized among WIC participants, providing healthy foods during childhood may provide health benefits to formula fed children, who comprise a sizeable proportion of children served by WIC.

Background From 2014–2019, Latin America and the Caribbean had the fastest growth of moderate-to-severe food insecurity than any other region, rising from 22.9% to 31.7%. While the prevalence of food insecurity is higher among women than men in every continent, Latin America has the largest food insecurity gender gap. Factors contributing to this gender inequity include underrepresentation of women in formal employment, heightened burden of dependent care on women, and unequal compensation of labor for women vs. men. The objective of this study was to investigate the association between the gender of the head of the household, employment status of household members, and food insecurity in households with children in a low-income district of Lima, Peru. Methods This cross-sectional study was carried out in Villa El Salvador, the fifth largest district in Metropolitan Lima, Peru, where over 20% of the population lives in poverty. Data were collected on a stratified random sample (n = 329) using a household questionnaire, including a validated food security tool (HFIAS). We ran multivariate logistic regression models predicting household food insecurity, with independent variables including gender of household head, education of household head, employment of household head, household-level employment status, age, and weekly food expenses per person. Results In fully adjusted models, woman-headed households had almost thrice the odds of being food insecure compared to man-headed households. Education also had a significant effect size: a household whose household head did not complete high school was 3.4 times more likely to be food insecure than if they had some post-secondary education. Woman-headed households had a significantly higher proportion of members not formally employed, compared to man-headed households, but employment status was not associated with food insecurity. Conclusions Gender of the household head was a major contributing factor to household food insecurity in Villa el Salvador. Gender dynamics affecting opportunities for employment, education, and non-remunerated work should inform national food security policies and interventions with the goal to not only lower food insecurity, but also reduce gender inequities in food insecurity and other nutritional outcomes.

OBJECTIVES: The purpose of this study is to assess the perceived role of food assistance programs (FAPs) in the development and prevention of overweight/obesity (OW/OB) in two low-income districts of Lima, Peru and analyze how these perceptions have changed across time. METHODS: In 2009, we conducted focus groups with FAP beneficiaries and in-depth interviews with FAP administrators (N = 34) from three common FAPs in two low-income districts of Lima, Peru. These data captured participants’ perceptions of OW/OB and their recommendations to address them. We conducted grounded theory analysis on this dataset to identify dominant themes and structure a second round of data collection. In January-February 2021, we are conducting in-depth interviews with FAP beneficiaries and administrators from the same programs and districts (current N = 16, expected N = 36). We will conduct grounded theory analysis on the second dataset and cross-analyze the two datasets to measure differences and similarities. RESULTS: In 2009, nearly all FAP beneficiaries and half of FAP administrators identified OW/OB as a public health problem in their community. They expressed need for more nutrition education, potentially through FAPs. Most FAP administrators and some beneficiaries also recommended offering healthier food in one particular FAP (Community Kitchens). Preliminary results from 2021 reveal that nearly all FAP beneficiaries and administrators perceived OW/OB to be a problem in their community. Educational resources about OW/OB were limited and participants continued to recommend increased outreach, potentially through FAPs. Most beneficiaries of Community Kitchens cited the need for healthier food options. CONCLUSIONS: From 2009 to 2021, more FAP beneficiaries and administrators perceived OW/OB to be a problem in their communities; however, resources to address this problem remained limited. Our findings suggest the need for increased nutrition education through FAPs and adjustments to foods available in specific FAPs. FUNDING SOURCES: Tulane University.

Disparities in obesity highlight the need for an examination of determinants that may be uniquely experienced by race and sex. An understudied factor is household composition with the potential for variation in its obesogenic impacts. This study examines the association between household composition and body mass index (BMI) among Black, Hispanic, and White adults and determines whether income moderates these associations.Using cross-sectional data from the 2011-2018 National Health and Nutrition Examination Survey, the number of children and adults aged ≥ 60 years in the household were reported among non-Hispanic Black and White adults as well as Hispanic adults aged 20-59 years old. Multivariable linear regressions were used to assess the associations between household composition and BMI with income as a potential moderator.Having multiple school-aged children was associated with higher BMI (β = 1.34, standard error (s.e.) = 0.50) among Hispanic men, while having older adults in the household was associated with lower BMI among Black women (β = - 3.21, s.e. = 1.42). Income moderated the associations between household composition and BMI among Black women and men. There were no associations between household composition and BMI in White women or men.Future studies should further explicate the mechanisms of household composition that uniquely impact obesity outcomes among Black women and men by income. Efforts to address higher BMI among those with more young children in the household should target Hispanic men.

BACKGROUND The decrease in stunting in Peru is seen as a "success story" in the fight against malnutrition; however, the parallel increase in obesity has often been ignored. OBJECTIVE To investigate trends in the double burden of malnutrition (i.e., the coexistence of stunting and overweight/obesity) in Peru compared with trends in household food expenditures by family socioeconomic status and urban/rural residency. METHODS Using Peruvian nationally representative surveys, we analyzed stunting (children aged 0-5 y) and overweight/obesity (women aged 18-49 y) trends between 1992 and 2017, as well as trends in household energy consumption from healthy and unhealthy foods between 2001 and 2017 by education, income, participation in the Juntos cash-transfer program, and urban/rural residency. Joinpoint software was used for all trends analyses. RESULTS Overall, stunting decreased and obesity increased among all social groups between 1992 and 2017. Inequities in stunting by income and urban/rural residency widened over time. From 1992 to 2017, urban stunting prevalence decreased at an average annual percent change (AAPC) of -4.5% (SE = 0.27%, P

OBJECTIVES: To examine the association between food insecurity – the inability to acquire adequate nutritious foods due to economic constraints – and perceptions of food accessibility, quality, and variety in one's neighborhood in a low socioeconomic district of Lima, Peru. METHODS: A household survey was conducted among randomly selected households with at least one child

OBJECTIVES: The objective of this study was to examine trends in pre-pregnancy obesity among WIC-participating mothers between 2000–2016 across twenty U.S. states. METHODS: Data on self-reported maternal pre-pregnancy body mass index (BMI, kg/m2) were obtained from publicly available records and trends were analyzed for states with data for all selected years (2000–2016; n = 20). Pre-pregnancy obesity was defined as BMI ≥30 kg/m2. Trends were adjusted for race, ethnicity, and median education. RESULTS: Overall, all states experienced a significant increase in the prevalence of pre-pregnancy obesity from 2000 until 2016. Noteworthy trends were found in several states: 1) Alabama consistently had the highest prevalence of pre-pregnancy obesity, ranging from 31.8% in 2000 to 42.8% in 2016. 2) Wisconsin had the most significant increase of the 20 states, increasing from 22.4% in 2000 to 42.3% in 2016 (annual % change [APC] = 6%). 3) Michigan had a significant increase in prevalence between 2000 and 2006, from 27.9% in 2000 to 32.5% in 2006 (APC = 2.5%), but then plateaued at 33% from 2006–2016. 4) Vermont had a significant increase from 2000–2012 (29% to 36.5%), but then experienced a decline from 2012 to 2016 (36.5% to 33.4%). CONCLUSIONS: These findings suggest that obesity interventions should be targeted at women before they start their reproductive lives. Identifying ways to support a healthy gestational weight gain within WIC may ameliorate the negative consequences associated with pre-pregnancy obesity on both women and children, especially since most women join WIC when they are already pregnant, if not later. FUNDING SOURCES: This research was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the grant: Maternal and Child Health Nutrition Training Program. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.

Aim: The aim of this study was to investigate whether women’s adult overweight and obesity risk was associated with their childhood family structure, measured as their mothers’ marital status history, during the women’s first 18 years of life. Methods: Using linked register data, we analyzed 30,584 primiparous women born in Sweden in 1975 who were between 19–35 years of age when their height and pre-pregnancy weight was recorded. The outcomes were women’s overweight/obesity (body mass index (BMI) ≥ 25 kg/m2) and obesity (BMI ≥ 30 kg/m2) and the predictor was mothers’ marital status history, which was summarized using sequence analysis. We carried out nested logistic regression models adjusting for women’s age and maternal sociodemographic characteristics. Results: Mothers’ marital status history was summarized into six clusters: stable marriage, stable cohabitation, married then divorcing, cohabiting then separating, varied transitions, and not with father. In fully adjusted models and compared with women whose mothers belonged to the stable marriage cluster: (1) women whose mothers belonged to the other marital status clusters had higher odds of overweight/obesity (odds ratio (OR) ranging 1.15–1.19; p < 0.05); and (2) women whose mothers belonged to the stable cohabitation (OR = 1.31; 95% confidence interval (CI) = 1.14–1.52), cohabiting then separating (OR = 1.23; 95% CI = 1.01–1.49), varied transitions (OR = 1.24; 95% CI = 1.11–1.39), and not with father (OR = 1.24; 95% CI = 1.00–1.54) clusters had higher odds of obesity. Conclusions: Women whose mothers were not in stable marriage relationships had higher odds of being overweight or obese in adulthood. The finding that even women raised in the context of stable cohabitation had higher odds of being overweight or obese is intriguing as these relationships are socially accepted in Sweden.

Aims: To investigate if early life characteristics and social mobility during childhood are associated with incident thrombotic stroke (TS), haemorrhagic stroke (HS) and other stroke (OS). Methods: Our study population consists of all live births at Uppsala University Hospital in 1915–1929 (Uppsala Birth Cohort; n = 14,192), of whom 5532 males and 5061 females were singleton births and lived in Sweden in 1964. We followed them from 1 January 1964 until first diagnosis of stroke (in the National Patient Register or Causes of Death Register), emigration, death, or until 31 December 2008. Data were analysed using Cox regression, stratifying by gender. Results: Gestational age was negatively associated with TS and OS in women only. Women had increased risk of TS if they were born early preterm (

ObjectiveTo investigate the association between the neighbourhood social environment, including social cohesion, perceived neighbourhood safety, perceived neighbourhood violence, and obesity in Brazil.DesignCross-sectional study.Setting6 state capitals in Brazil (Salvador, Vitoria, Belo Horizonte, Porto Alegre, Sao Paulo and Rio de Janeiro)ParticipantsCurrent or former employees of five federal universities and one research centre in each of the six Brazilian state capitals who were participants of the baseline wave (2008–2010) of the Brazilian Longitudinal Study of Adult Health (n=11 456; 56% women; 56% White, 28% Brown, and 16% Black).Primary outcome measureObesity, based on measured weight and height, and defined as having a body mass index ≥30 kg/m2.ResultsNo associations were found between the neighbourhood social environment and obesity among men. In multilevel logistic regression models adjusted for age, education, skin colour, state of residence, and individual-level social cohesion and perceived violence scores, respectively, women living in the least socially cohesive neighbourhoods and in those perceived as most violent had higher odds of obesity compared with their counterparts (OR=1.25, 95% CI=1.02–1.53; OR=1.28, 95% CI=1.04–1.56, respectively). When stratified by neighbourhood socioeconomic status (SES)—defined based on number of people per household, proportion of children 0–4 years, median income and per cent of white residents at the neighbourhood level—results for social cohesion and for violence remained only for women residing in high SES and low SES neighbourhoods, respectively.ConclusionsIn this civil-servant sample in six large cities in Brazil, the neighbourhood social environment was associated with obesity among women, but not men. Neighbourhood-level interventions to increase social cohesion and reduce violence may help in the prevention of obesity among women in Brazil.

Exposure to violence and obesity continues to be growing epidemics, particularly among children. Our objective was to increase our understanding of the association between neighborhood violence exposure and children's weight and how biologic stress may mediate this relation. A matched, community-recruited cross-sectional study of 90 children, ages 5–16 years, from 52 neighborhoods took place in the greater New Orleans, LA area between 2012 and 2013. Children were matched on their propensity for living in a high violence neighborhood and previous exposure to Hurricane Katrina. Primary neighborhood exposure included violent crime, operationalized as crime rates within specific radii of children's home. Rates of exposure within 500, 1000 and 2000 meter radii from the child's home were calculated. Primary outcomes were body mass index (BMI) and waist circumference, and the primary mediator was telomere length (TL), a marker of cellular aging. Significant variation in obesity and TL was observed at the neighborhood level and violent crime was significantly associated with weight status, with an increase of 1.24 units in BMI for each additional violent crime in the child's neighborhood and a significant mediated or indirect effect of TL in the crime-BMI relation (0.32, 95% bootstrapped CI = 0.05, 0.81; 32% total mediated effect). Findings strengthen existing evidence linking neighborhood violence to childhood health and identify biologic stress, indexed by TL, as one mechanistic pathway by which neighborhood violence may influence childhood obesity. Neighborhood violence may be an important target for interventions focused on reducing obesity and other stress related health outcomes in children. Keywords: Neighborhood, Violence, Obesity, Children, Telomere, Stress

Background In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages were updated. WIC-participating children in Los Angeles County receiving the new food package, compared with the old, had lower obesity risk at age 4. Objective To determine if the association between the new WIC food package and obesity varies by type of infant WIC food package received. Design Longitudinal study using administrative data on children participating in WIC in Los Angeles County continuously from birth until age 4. Children were compared across periods: Before (period 1: born 2003-2004), straddling (period 2: born 2005-2008), and after (period 3: born 2009-2011) the food package change. Children were further grouped as Fully Breastfed, Mostly Breastfed, Mostly Formula Fed, and Fully Formula Fed based on the type of food packages received during the first year of life. Participants/setting WIC-participating children in Los Angeles County between 2003 and 2016 (N=116,991). Main outcome measures Weight-for-height z-score growth trajectories from 0 to 4 years and obesity (body mass index-for-age≥95th percentile) at age 4. Statistical analyses performed Children were matched across periods on infant feeding group; age, sex, race or ethnicity, and initial weight status; maternal education and language; and family poverty. Sex-stratified piecewise linear spline mixed models and Poisson regression models were fit to the data. Results No differences across periods were observed for children in the Fully Breastfed group. Boys in the Mostly Breastfed (relative risk [RR]=1.27, 95% CI=1.17 to 1.38), Mostly Formula Fed (RR=1.07, 95% CI=1.02 to 1.13), and Fully Formula Fed (RR=1.13, 95% CI=1.06 to 1.20) groups in period 1 had higher obesity risk than their counterparts in period 3; girls in the Mostly Breastfed group in period 1 had a higher obesity risk than those in period 3 (RR=1.17, 95% CI=1.07 to 1.28). Conclusions The association between the WIC food package change and obesity varied by type of infant food package received, with the strongest associations observed for those who were mostly breastfed.

Background: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a federal nutrition assistance program which provides supplemental food and nutrition services to children 0-5 years and their mothers, living in low-income households. In October of 2009, WIC food packages were changed to be better aligned to the Dietary Guidelines of Americans. Objective: The objective of this study was to evaluate whether observed differences in children’s BMI z-scores (BMIz) at age 4 years between WIC participants enrolled before and after the 2009 policy change could be attributable to changes in the type of infant feeding package they were exposed to. Methods: Our sample is based on children enrolled in WIC in Los Angeles County, CA between 2003 and 2016, from birth to age 5, with infant package issuance data for 11 or more of the first 13 months of life. Infant package exposure was quantified by the number of months receiving the fully breastfeeding infant package (a proxy for exclusive breastfeeding). A mediation analysis was performed in which BMIz at age 4 was the outcome, WIC package (new vs. old) was the exposure, and the number of months receiving the fully breastfeeding infant package was the mediator. Mediation was assessed by a product of coefficients method, and confidence limits for the mediated effect were based on the non-normal distribution of the mediated effect, using the PRODCLIN program in SAS. Models were gender-stratified and adjusted for child race/ethnicity, maternal education and language preference, household poverty status, initial weight status, and whether the child had a sibling in the sample. Results: The sample consisted of 140,204 children. Boys and girls exposed to the new WIC package received the fully breastfeeding infant package for 1.40 and 1.45 months longer than boys and girls exposed to the old WIC package. Among boys, the new WIC package was associated with a 0.12 standard deviation lower BMIz at age 4 (SE 0.01, p fully breastfeeding infant package partially mediated the association between exposure to the new WIC food package (vs. old) and BMIz at age 4, explaining 22.1% of the total effect (95% CI 19.1-25.1) for boys and 34.4% of the total effect (95% CI 29.9-38.9) for girls. Conclusions: Longer exposure to the fully breastfeeding infant package seemed to explain part of the association between BMIz at age 4 and receiving the new (vs. old) WIC food package. The percent of the total effect mediated by months of fully breastfeeding exposure was greater in girls than in boys. Future revisions to the WIC packages that continue to support women to fully breastfeed are likely to have significant effects on childhood obesity.

OBJECTIVE To assess whether the effect of the 2009 women, infants, and children (WIC) food package change on obesity outcomes varies by initial weight status and gender. METHODS Using 2003 to 2016 data from Los Angeles County, we compared growth trajectories and obesity at age 4 years among children exposed to WIC after the food package change (n = 53 075) vs children exposed before (n = 53 075). Analyses were stratified by gender and initial weight status: low weight-for-height z-score (WHZ ≤ 25th percentile), average WHZ (25th

The goal of this study was to evaluate how self-rated health (SRH) and objective measures of health (biomarkers) are associated, and if this association varies by gender, age, and socioeconomic position (measured by household income). Data come from the UK Household Longitudinal Study nurse visit (2010–2012), including a representative sample of adults in Great Britain (N = 15 687 maximum sample). SRH was assessed by the question “In general, would you say your health is excellent, very good, good, fair, or poor?” and dichotomized into good or poor. Indices were created for four biomarker categories based on the aspects of health they are likely to reflect, including visible weigh-related, fitness, fatigue, and disease risk biomarkers. Logistic regression models were run with SRH as the outcome and each biomarker index as a predictor, adjusting by gender, age, and income. Further, interaction terms between each biomarker index and gender, age, and income (independently) were added to test for effect modification. All biomarker indices were associated with SRH in expected directions, with the fitness index most strongly predicting SRH. Gender, age, or income modified the associations between SRH and all biomarker indices to different extents. The association between the visible weight-related biomarker index (including body mass/fat variables) and SRH was stronger for women than men and for those in higher income groups than lower income groups. Income also modified the association between SRH and the fitness biomarker index, whereas age modified the association between SRH and the fatigue biomarker index. When using SRH to investigate health inequalities, researchers and policy makers should be clear that different social groups may systematically consider different dimensions of health when reporting their SRH., Highlights • The association between self-rated global health and underlying objective health as measured by biomarkers varies by type of biomarker, age, sex and socioeconomic status. • Biomarkers that measure different aspects of fitness most strongly predicting self-rated health. • The association between the visible biomarkers (including body mass/fat variables) and self-rated health was stronger for women than men and for those in higher income groups than lower income groups. • Income also modified the association between self-rated health and biomarkers of disease, with a stronger association for higher income groups. • When rating own health individuals from different social groups may systematically consider different dimensions of health.

Neighborhood safety has been linked to physical activity and obesity among adolescents, but few studies have used objective measures of crime or examined associations by gender. The goal of this study was to investigate if exposure to objectively measured neighborhood crime was associated with physical activity and overweight/obesity among adolescents, and if this association varied by gender.Georeferenced data from the National Health and Nutrition Examination Survey (NHANES) 1999-2006 were linked to census tract-level data on crime reports from the Federal Bureau of Investigation, focusing on a sample of adolescents 12-20 years of age (n = 15,261). Our outcome variables were engaging in moderate-to-vigorous physical activity in the previous week and overweight/obesity status, defined as ≥85th percentile in the CDC's age- and sex-specific BMI-for-age growth charts (based on measured weight and height). Our exposure variable was neighborhood-level violent crime risk, categorized as low vs. high. Gender-stratified three-level multilevel logistic regression models were fitted adjusting for individual, family, and neighborhood-level demographic and socioeconomic variables and adolescents' diet quality.In fully adjusted models, girls exposed to high crime neighborhoods had 26% lower odds of engaging in moderate-to-vigorous physical activity during the previous week [odds ratio (OR) = 0.74, confidence interval (95% CI) = 0.59-0.92] and 27% higher odds of being overweight/obese (OR = 1.27, 95% CI = 1.02-1.58), compared with adolescent girls exposed to low crime neighborhoods. No significant associations were found between exposure to neighborhood crime and physical activity and overweight/obesity among boys.Prevention efforts focused on encouraging adolescents to be physically active need to account for gender-specific barriers to exercise outdoors.

Background In 2009, for the first time since the program's inception in 1974, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) changed their food packages, providing food options better aligned with the 2005 Dietary Guidelines for Americans. Objective The aim of this study was to evaluate whether the 2009 WIC food package change was associated with changes in growth trajectories from age 0 to 4 y or obesity at age 4 among children who participated in WIC in Los Angeles County between 2003 and 2016. Methods Children were grouped into 1 of 4 exposure groups: full-dose, new food package group (participating in WIC from birth to age 4, post 2009, N = 70,120), full-dose, old food package group (participating from birth to age 4, pre 2009, N = 85,871), late-dose, new food package group (participating from age 2 to 4 y, post 2009, N = 8386), and late-dose, old food package group (participating from age 2 to 4 y, pre 2009, N = 18,241). Children were matched across groups on gender, race/ethnicity, maternal education and language, family income, and initial weight status, and matched analyses were performed. Longitudinal growth trajectories were modeled using piecewise linear spline mixed models, and differences in obesity at age 4 were compared using Poisson regression models. Results Children receiving a full dose of the new food package had healthier growth trajectories and a lower obesity risk at age 4 than children receiving a full dose of the old food package (RR [95% CI]: 0.88 [0.86, 0.91] for boys, 0.90 [0.87, 0.93] for girls). Boys, but not girls, in the late-dose, new food package group had a lower obesity risk at age 4 compared with boys in the late-dose, old food package group (RR = 0.89, 95% CI = 0.81, 0.98). Conclusions The WIC food package change appears to be associated with improved childhood obesity outcomes. These findings are important in informing policymakers considering further improvements to the WIC food packages.

Aims: To investigate regional differences and time trends in women’s overweight and obesity in Sweden. Methods: Using data from the Swedish Medical Birth Register (women aged ⩾18 years, first pregnancy only) and the Total Population Register accessed through the Umeå SIMSAM Lab, age-standardized prevalence of pre-pregnancy overweight/obesity (BMI ⩾ 25 kg/m2) and obesity (BMI ⩾ 30 kg/m2) were estimated by county for the years 1992, 2000, and 2010. Maps were created using ArcMap v10.2.2 to display regional variations over time and logistic regression analyses were used to assess if the observed trends were significant. Results: The prevalence of pre-pregnancy overweight/obesity and obesity increased significantly in all Swedish counties between 1992, and 2010. In 2010, Södermanland and Gotland exhibited the highest age-standardized overweight/obesity (39.7%) and obesity (15.1%) prevalence, respectively. The sharpest increases between 1992 and 2010 were observed in Västerbotten for overweight/obesity (75% increase) and in Gotland for obesity (233% increase). Across the years, Stockholm had the lowest prevalence of overweight/obesity (26.3% in 2010) and obesity (7.3% in 2010) and one of the least steep increases in prevalence of both between 1992 and 2010. Conclusions: Substantial regional differences in pre-pregnancy overweight and obesity prevalence are apparent in Sweden. Further research should elucidate the mechanisms causing these differences.

Table S1. Qualitative summary of significant mediation effects in stratified samples by age, gender, smoking status, urbanity, and region. Results from complete case and stratified analyses of the data as sensitivity tests for main findings. (DOCX 20Â kb)

ObjectiveTo investigate if the association between maternal pre-pregnancy BMI and offspring’s body composition in late adolescence and young adulthood varies by offspring birth order and sex.DesignFamily cohort study, with data from registers, questionnaires and physical examinations. The main outcome under study was offspring body composition (percentage fat mass (%FM), percentage lean mass (%LM)) measured by dual-energy X-ray absorptiometry.SettingUppsala, Sweden.SubjectsTwo hundred and twenty-six siblings (first-born v. second-born; average age 19 and 21 years) and their mothers.ResultsIn multivariable linear regression models, maternal pre-pregnancy BMI was positively associated with daughter’s %FM, with stronger estimates for first-born (β=0·97, 95 % CI 0·14, 1·80) v. second-born daughters (β=0·64, 95 % CI 0·08, 1·20). Mother’s BMI before her first pregnancy was associated with her second-born daughter’s body composition (β=1·05, 95 % CI 0·31, 1·79 (%FM)) Similar results albeit in the opposite direction were observed for %LM. No significant associations were found between pre-pregnancy BMI and %FM (β=0·59, 95 % CI−0·27, 1·44 first-born; β=−0·13, 95 % CI−0·77, 0·52 second-born) or %LM (β=−0·54, 95 % CI−1·37, 0·28 first-born; β=0·11, 95 % CI−0·52, 0·74 second-born) for sons.ConclusionsA higher pre-pregnancy BMI was associated with higher offspring %FM and lower offspring %LM in late adolescence and young adulthood, with stronger associations for first-born daughters. Preventing obesity at the start of women’s reproductive life might reduce the risk of obesity in her offspring, particularly for daughters.

OBJETIVO Investigar associação entre participação no programa de assistência alimentar e sobrepeso/obesidade, segundo nível de pobreza. MÉTODOS Estudo transversal com dados sobre 46.217 mulheres não gestantes e não lactantes, de Lima, Peru, obtidos de pesquisas, com representatividade nacional, nos anos de 2003, 2004, 2006 e 2008-2010. A variável dependente foi o sobrepeso/obesidade e a independente foi a participação no programa de assistência alimentar. Utilizou-se regressão de Poisson; os modelos foram estratificados por nível socioeconômico familiar para todo o país, por área de residência (Lima versus o resto do país; urbano versus residência rural) e anos de estudo (2003-2006 versus 2008-2010). Os modelos foram ajustados por idade, nível acadêmico, urbanização e ano de estudo. RESULTADOS Participar do programa de assistência alimentar associou-se com risco aumentado de sobrepeso/obesidade para as mulheres que viviam em domicílios sem indicadores de pobreza (PR = 1,29; IC95% 1,06;1,57). Quando estratificados por área de residência, foram observadas associações similares para as mulheres que vivem em Lima e em áreas urbanas; não foram encontradas associações entre a participação no programa de assistência alimentar e sobrepeso/obesidade entre as mulheres que vivem fora de Lima ou em áreas rurais, independentemente de sua condição de pobreza. CONCLUSÕES Participar do programa de assistência alimentar associou-se com sobrepeso/obesidade para mulheres não pobres. Estudos adicionais serão necessários em países que enfrentam ambas as faces da má nutrição. pia.chaparro@chess.su.se OBJECTIVE The objective of this study was to investigate the association between food assistance program participation and overweight/obesity according to poverty level. METHODS A cross-sectional analysis of data from 46,217 non-pregnant and non-lactating women in Lima, Peru was conducted; these data were obtained from nationally representative surveys from the years 2003, 2004, 2006, and 2008-2010. The dependent variable was overweight/obesity, and the independent variable was food assistance program participation. Poisson regression was used to stratify the data by family socioeconomic level, area of residence (Lima versus the rest of the country; urban versus rural), and survey year (2003-2006 versus 2008-2010). The models were adjusted for age, education level, urbanization, and survey year. RESULTS Food assistance program participation was associated with an increased risk of overweight/obesity in women living in homes without poverty indicators [prevalence ratio (PR) = 1.29; 95% confidence interval (CI) 1.06;1.57]. When stratified by area of residence, similar associations were observed for women living in Lima and urban areas; no associations were found between food assistance program participation and overweight/obesity among women living outside of Lima or in rural areas, regardless of the poverty status. CONCLUSIONS Food assistance program participation was associated with overweight/obesity in non-poor women. Additional studies are required in countries facing both aspects of malnutrition. Revisión por pares

Background Few studies have examined the association between the food environment and adiposity in early childhood, a critical time for obesity prevention. The objective of this study was to examine the longitudinal association between neighbourhood food environment and adiposity among low-income preschool-aged children in a major metropolitan region in the USA. Methods The study sample was 32 172 low-income preschool-aged children in Los Angeles County who had repeated weight and height measurements collected between ages 2 and 5 years through a federal nutrition assistance programme. We conducted multilevel longitudinal analyses to examine how spatial densities of healthy and unhealthy retail food outlets in the children's neighbourhoods were related to adiposity, as measured by weight-for-height z-score (WHZ), while controlling for neighbourhood-level income and education, family income, maternal education, and child's gender and race/ethnicity. Results Density of healthy food outlets was associated with mean WHZ at age 3 in a non-linear fashion, with mean WHZ being lowest for those exposed to approximately 0.7 healthy food outlets per square mile and higher for lesser and greater densities. Density of unhealthy food outlets was not associated with child WHZ. Conclusions We found a non-linear relationship between WHZ and density of healthy food outlets. Research aiming to understand the sociobehavioural mechanisms by which the retail food environment influences early childhood obesity development is complex and must consider contextual settings. © 2014 by the BMJ Publishing Group Ltd.

Food insecurity among lower income adults is associated with adverse health outcomes including sleep disorders. Using data from the National Health and Nutrition Examination Survey (NHANES), 2005-2008, we explored the association between participation in the Supplemental Nutrition Assistance Program (SNAP), a safety net program addressing food insecurity, and sleep outcomes among older adults. Total sleep duration (

Objectives. We assessed the effect of the new Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package, implemented in October 2009, on breastfeeding outcomes among a predominately Latina sample of WIC participants in Los Angeles County, California. Methods. We used data from 5020 WIC participants who were interviewed in a series of repeated cross-sectional surveys conducted in 2005, 2008, and 2011. Participants were randomly selected from Los Angeles County residents who received WIC services during those years. Results. Consistent with the WIC population in Los Angeles, participants were mostly Latina and had low levels of income and education; more than half were foreign-born. We found small but significant increases from pre- to postimplementation of the new WIC food package in prevalence of prenatal intention to breastfeed and breastfeeding initiation, but no changes in any breastfeeding at 3 and 6 months. The prevalence of exclusive breastfeeding at 3 and 6 months roughly doubled, an increase that remained large and significant after adjustment for other factors. Conclusions. The new food package can improve breastfeeding outcomes in a population at high risk for negative breastfeeding outcomes.

While neighborhood environments are increasingly recognized as important contributors to obesity risk, less has been reported on the socio-cultural aspects of neighborhoods that influence obesity development. This is especially true among immigrants, who may lack the necessary language skills to navigate their new living environments. In this study, we tested the hypothesis that young children of immigrants would be at lower obesity risk if they lived in neighborhoods where neighbors share the same language and culture. Using 2000 Census data and 2003–2009 data from the Special Supplemental Nutrition Program for Women, Infants and Children in Los Angeles County, we examined the relation between BMI z-scores in low-income children aged 2–5 years (N = 250,029) and the concentration of neighborhood residents who spoke the same language as the children's mothers. Using multi-level modeling and adjusting for child's gender and race/ethnicity, household education, neighborhood socioeconomic status, and year the child was examined, we found that percent of neighborhood residents who spoke the same language as the child's mother was negatively associated with BMI z-scores. This relation varied by child's race/ethnicity and mother's preferred language. The relation was linear and negative among children of English-speaking Hispanic mothers and Chinese-speaking mothers. However, for Hispanic children of Spanish-speaking mothers the relation was curvilinear, initially exhibiting a positive relation which reversed at higher neighborhood concentrations of Spanish-speaking residents. Our findings suggest that living in neighborhoods where residents share the same language may influence obesity-related behaviors (namely diet and physical activity) possibly through mechanisms involving social networks, support, and norms.

Background Participation in the Supplemental Nutrition Assistance Program (SNAP) has been linked to an increased risk of obesity, but not much is known about the mechanisms behind this association. The objective of this study was to determine if the neighborhood density of unhealthy food outlets modifies the association between obesity and participation in SNAP. Methods Data comes from the first wave of the Los Angeles Family and Neighborhood Survey; included are a subsample of adults (18+ years) who were SNAP participants or eligible non-participants (N = 1,176). We carried out multilevel analyses with obesity (BMI ≥ 30 Kg/m2), SNAP participation, and the neighborhood density of unhealthy food outlets as dependent, independent and modifying variables, respectively, controlling for age, gender, race/ethnicity, marital status, working status, mental health, and neighborhood poverty. Results SNAP participants had double the odds of obesity compared to eligible non-participants (OR = 2.02; 95%CI = 1.44-2.83). However, the neighborhood density of unhealthy food outlets did not modify this association. Conclusions SNAP participation was associated with higher odds of obesity in our primarily Hispanic sample in Los Angeles County, with no effect modification found for the unhealthy portion of the food environment. More research is needed with additional food environment measures to confirm our null findings. Additional research is needed to elucidate the mechanisms linking SNAP participation and obesity as they remain unclear.

Data from 66 446 low-income adults who participated in the California Health Interview Survey are used to describe trends in food insecurity between 2001 and 2009. Food security was assessed using the short form of the Household Food Security Survey Module. There was a statistically significant increase in food insecurity between 2001 and 2009, from 28.6% to 40.5%. During the same time period, the prevalence of very low food security nearly doubled, from 8.3% to 15%. The increase in food insecurity remained significant even after controlling for differences in income, employment status, participation in food assistance programs, and other sociodemographic factors.