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Influence of the food environment on obesity risk in a large cohort of US veterans by community type

Rummo, Pasquale E; Kanchi, Rania; Adhikari, Samrachana; Titus, Andrea R; Lee, David C; McAlexander, Tara; Thorpe, Lorna E; Elbel, Brian
OBJECTIVE:The aim of this study was to examine relationships between the food environment and obesity by community type. METHODS:Using electronic health record data from the US Veterans Administration Diabetes Risk (VADR) cohort, we examined associations between the percentage of supermarkets and fast-food restaurants with obesity prevalence from 2008 to 2018. We constructed multivariable logistic regression models with random effects and interaction terms for year and food environment variables. We stratified models by community type. RESULTS:Mean age at baseline was 59.8 (SD = 16.1) years; 93.3% identified as men; and 2,102,542 (41.8%) were classified as having obesity. The association between the percentage of fast-food restaurants and obesity was positive in high-density urban areas (odds ratio [OR] = 1.033; 95% CI: 1.028-1.037), with no interaction by time (p = 0.83). The interaction with year was significant in other community types (p < 0.001), with increasing odds of obesity in each follow-up year. The associations between the percentage of supermarkets and obesity were null in high-density and low-density urban areas and positive in suburban (OR = 1.033; 95% CI: 1.027-1.039) and rural (OR = 1.007; 95% CI: 1.002-1.012) areas, with no interactions by time. CONCLUSIONS:Many healthy eating policies have been passed in urban areas; our results suggest such policies might also mitigate obesity risk in nonurban areas.
PMID: 38298108
ISSN: 1930-739x
CID: 5627212

Gentrification and childhood obesity: Evidence from New York City public school students in public housing

Zhou, Eric G; Schwartz, Amy Ellen; Elbel, Brian
OBJECTIVE:The study objective was to determine the effect of gentrification on the weight outcomes of New York City public school students living in public housing. METHODS:In a prospective cohort of 19,022 New York City public school students in public housing followed during 2009-2017, weight outcomes of students living in public housing buildings in gentrified neighborhoods were compared to those living in consistently low-socioeconomic-status neighborhoods; assignment was quasi-random in each borough. RESULTS:Among the 42,182 student-year observations, gentrification did not increase weight outcomes significantly, for BMI z scores (0.037; 95% CI: -0.012 to 0.086), obesity (0.6 percentage points [pp]; 95% CI: -0.9 to 2.1), or overweight (1.3 pp; 95% CI: -0.7 to 3.2). However, heterogeneous effects by borough were found, where the gentrification in Manhattan increased students' BMI z scores by 0.19 (95% CI: 0.09-0.29), obesity by 3.4 pp (95% CI: 0.03-6.5), and overweight by 9.2 pp (95% CI: 6.3-12.1). No heterogeneity by race and ethnicity, gender, or age was found. CONCLUSIONS:With strong internal validity, this study shows that neighborhood gentrification differentially influenced children's health through obesity, based on borough of residence. Such findings could inform policies or interventions focused on subpopulations and geographies.
PMID: 37984557
ISSN: 1930-739x
CID: 5608322

"I don't want an App to do the work for me": A Qualitative Study on the Perception of Online Grocery Shopping from Small Food Retailers

Trude, Angela C B; Bunzl, Natasha B; Rehman, Zoya N; Elbel, Brian; Lau, Serena; Talal, Lillian A; Weitzman, Beth C
BACKGROUND:Small food retailers often stock energy-dense convenience foods and are ubiquitous in low-income urban settings. With the rise in e-commerce, little is known about the acceptability of online grocery shopping from small food retailers. OBJECTIVE:To explore perceptions of the role of small food retailers (bodegas) in food access and the acceptability of online grocery shopping from bodegas among customers and owners in a diverse NYC urban neighborhood with low-income. DESIGN/METHODS:In-depth interviews were conducted with bodega owners and adult customers between May-July 2022. PARTICIPANTS/SETTING/METHODS:Bodega owners who had either implemented a locally designed online grocery system (n=4) or not (n=2). Customers (n=25) were recruited through purposive sampling and eligible if they purchased at bodegas ( > once/month), had low-income (household income ≤ 130% of the federal poverty level or Supplemental Nutrition Assistance Program (SNAP) participants), and owned smartphones. ANALYSES PERFORMED/UNASSIGNED:All interviews were transcribed and analyzed in MAXQDA using grounded theory. RESULTS:To owners and customers, bodegas were seen as good neighbors providing culturally appropriate foods and an informal financial safety net. Their perceptions concerning food cost and availability of healthy foods in bodegas diverged. Although most perceived online grocery from bodegas as a positive community resource, they also believed it was not suited to their own community due to the bodega's proximity to customers' homes and the low digital literacy of some community members. Customers reported social norms of pride in not using online grocery shopping. Owners and customers believed the service would more likely be used if government benefits like SNAP allowed payment for online orders. Both suggested improved outreach to increase program awareness and uptake. CONCLUSIONS:Online grocery shopping from small food retailers may be acceptable in urban communities with low-income and was perceived as a community resource. However, important barriers need to be addressed such as social norms related to pride in not using online grocery services, digital literacy, program awareness, and allowing SNAP payment for online orders from bodegas.
PMID: 38103594
ISSN: 2212-2672
CID: 5612522

Effects of inclusion of food purchase restrictions and incentives in a food benefit program on diet quality and food purchasing: Results from a randomized trial

Harnack, Lisa J; Oakes, J Michael; Elbel, Brian; Rydell, Sarah A; Lasswell, Tessa A; Mitchell, Nathan R; Valluri, Sruthi; French, Simone A
BACKGROUND:There is interest in reshaping the Supplemental Nutrition Assistance Program (SNAP) to better support family nutrition. OBJECTIVE:The Grocery Assistance Program Study (GAPS) for Families evaluated the effects of prohibiting the purchase of certain sugary foods using program funds on the nutritional quality of foods purchased and consumed by program participants. DESIGN/METHODS:A randomized experimental trial was carried out with participants randomized to one of three food benefit conditions. Baseline and follow-up measures collected included interviewer administered 24-hour dietary recalls, food purchase receipts, food security, height, and weight. PARTICIPANT/SETTING/UNASSIGNED:Adult-child dyads in households eligible for SNAP but currently not enrolled were recruited from the Minneapolis/St Paul MN metropolitan area from May of 2018 through May of 2019. A total of 293 adult-child dyads received the intervention as allocated. Of these dyads, 233 adults completed follow-up measures and met criteria for inclusion in the analytic sample, resulting in an attrition rate of 20.5%. For children, a total of 224 completed follow-up measures and met criteria for inclusion in the analytic sample, resulting in an attrition rate of 23.5%. INTERVENTION/METHODS:Participants were randomized to one of three conditions: restriction (not allowed to buy sugar sweetened beverages [SSB], sweet baked goods or candy with program funds); restriction paired with incentive (30% incentive for fruits and vegetables [FV] purchased with funds); and control (funds provided with no restrictions or incentives). Funds were provided on a four-week cycle for 20 weeks via a study provided debit card. MAIN OUTCOME MEASURES/METHODS:The primary outcome was the Healthy Eating Index (HEI)-2015 total score. Additional outcomes included selected HEI-2015 component scores; energy intake; food security; body weight; and purchasing of SSB, sweet baked goods, candies, fruits, and vegetables. STATISTICAL ANALYSIS/METHODS:Linear regression analyses were conducted with change in the outcome regressed on treatment condition for the primary outcome analyses. RESULTS:There were no differences observed between conditions in change in the nutrition and food security measures examined. Purchases of SSB and sweet baked goods and candies significantly differed by experimental condition. Purchase of restricted foods was lower at follow-up in the restriction and restriction paired with incentive conditions compared to the control condition. For example, spending on SSB at follow-up was significantly lower in the restriction ($2.66/week) and restriction paired with incentive ($2.06/week) conditions in comparison to control condition ($4.44/week) (p<.0003 and p<.0001 respectively). CONCLUSIONS:This study failed to find evidence in support of prohibiting the purchase of sugary foods with food program funds as a strategy to improve program participant nutrition, even when paired with a FV incentive. Research carried out in the context of the SNAP program is needed for a more robust evidence base.
PMID: 38052304
ISSN: 2212-2672
CID: 5595512

Menu Labeling and Calories Purchased in Restaurants in a US National Fast Food Chain

Rummo, Pasquale E; Mijanovich, Tod; Wu, Erilia; Heng, Lloyd; Hafeez, Emil; Bragg, Marie A; Jones, Simon A; Weitzman, Beth C; Elbel, Brian
IMPORTANCE/UNASSIGNED:Menu labeling has been implemented in restaurants in some US jurisdictions as early as 2008, but the extent to which menu labeling is associated with calories purchased is unclear. OBJECTIVE/UNASSIGNED:To estimate the association of menu labeling with calories and nutrients purchased and assess geographic variation in results. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:A cohort study was conducted with a quasi-experimental design using actual transaction data from Taco Bell restaurants from calendar years 2007 to 2014 US restaurants with menu labeling matched to comparison restaurants using synthetic control methods. Data were analyzed from May to October 2023. EXPOSURE/UNASSIGNED:Menu labeling policies in 6 US jurisdictions. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was calories per transaction. Secondary outcomes included total and saturated fat, carbohydrates, protein, sugar, fiber, and sodium. RESULTS/UNASSIGNED:The final sample included 2329 restaurants, with menu labeling in 474 (31 468 restaurant-month observations). Most restaurants (94.3%) were located in California. Difference-in-differences model results indicated that customers purchased 24.7 (95% CI, 23.6-25.7) fewer calories per transaction from restaurants in the menu labeling group in the 3- to 24-month follow-up period vs the comparison group, including 21.9 (95% CI, 20.9-22.9) fewer calories in the 3- to 12-month follow-up period and 25.0 (95% CI, 24.0-26.1) fewer calories in the 13- to 24-month follow-up period. Changes in the nutrient content of transactions were consistent with calorie estimates. Findings in California were similar to overall estimates in magnitude and direction; yet, among restaurants outside of California, no association was observed in the 3- to 24-month period. The outcome of menu labeling also differed by item category and time of day, with a larger decrease in the number of tacos vs other items purchased and a larger decrease in calories purchased during breakfast vs other times of the day in the 3- to 24-month period. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this quasi-experimental cohort study, fewer calories were purchased in restaurants with calorie labels compared with those with no labels, suggesting that consumers are sensitive to calorie information on menu boards, although associations differed by location.
PMID: 38100109
ISSN: 2574-3805
CID: 5588992

Association between racial residential segregation and walkability in 745 U.S. cities

Spoer, Ben R; Conderino, Sarah E; Lampe, Taylor M; Ofrane, Rebecca H; De Leon, Elaine; Thorpe, Lorna E; Chang, Virginia W; Elbel, Brian
Despite higher chronic disease prevalence, minoritized populations live in highly walkable neighborhoods in US cities more frequently than non-minoritized populations. We investigated whether city-level racial residential segregation (RRS) was associated with city-level walkability, stratified by population density, possibly explaining this counterintuitive association. RRS for Black-White and Latino-White segregation in large US cities was calculated using the Index of Dissimilarity (ID), and walkability was measured using WalkScore. Median walkability increased across increasing quartiles of population density, as expected. Higher ID was associated with higher walkability; associations varied in strength across strata of population density. RRS undergirds the observed association between walkability and minoritized populations, especially in higher population density cities.
PMID: 37774640
ISSN: 1873-2054
CID: 5602802

Demographic, social and geographic factors associated with glycaemic control among US Veterans with new onset type 2 diabetes: a retrospective cohort study

Lee, David C; Orstad, Stephanie L; Kanchi, Rania; Adhikari, Samrachana; Rummo, Pasquale E; Titus, Andrea R; Aleman, Jose O; Elbel, Brian; Thorpe, Lorna E; Schwartz, Mark D
OBJECTIVES:This study evaluated whether a range of demographic, social and geographic factors had an influence on glycaemic control longitudinally after an initial diagnosis of diabetes. DESIGN, SETTING AND PARTICIPANTS:We used the US Veterans Administration Diabetes Risk national cohort to track glycaemic control among patients 20-79-year old with a new diagnosis of type 2 diabetes. PRIMARY OUTCOME AND METHODS:We modelled associations between glycaemic control at follow-up clinical assessments and geographic factors including neighbourhood race/ethnicity, socioeconomic, land use and food environment measures. We also adjusted for individual demographics, comorbidities, haemoglobin A1c (HbA1c) at diagnosis and duration of follow-up. These factors were analysed within strata of community type: high-density urban, low-density urban, suburban/small town and rural areas. RESULTS:We analysed 246 079 Veterans who developed a new type 2 diabetes diagnosis in 2008-2018 and had at least 2 years of follow-up data available. Across all community types, we found that lower baseline HbA1c and female sex were strongly associated with a higher likelihood of within-range HbA1c at follow-up. Surprisingly, patients who were older or had more documented comorbidities were more likely to have within-range follow-up HbA1c results. While there was variation by community type, none of the geographic measures analysed consistently demonstrated significant associations with glycaemic control across all community types.
PMCID:10582880
PMID: 37832984
ISSN: 2044-6055
CID: 5604382

Effect of Financial Incentives and Default Options on Food Choices of Adults With Low Income in Online Retail Settings: A Randomized Clinical Trial

Rummo, Pasquale E; Roberto, Christina A; Thorpe, Lorna E; Troxel, Andrea B; Elbel, Brian
IMPORTANCE:Despite recent growth in online redemption of Supplemental Nutrition Assistance Program (SNAP) benefits, no previous work has tested the impact of economic and behavioral economic strategies on food purchasing behaviors in an online grocery retail setting among adults with low income. OBJECTIVE:To examine the extent to which financial incentives and default shopping cart options influence fruit and vegetable purchases. DESIGN, SETTING, AND PARTICIPANTS:This randomized clinical trial used an experimental online grocery store for adults who currently or have ever received SNAP benefits. From October 7 to December 2, 2021, participants were instructed to shop for a week's worth of groceries for their household, with a budget tailored to household size; no payment was taken. INTERVENTIONS:Random assignment to 1 of 4 conditions: no intervention, 50% discount on eligible fruits and vegetables, prefilled shopping carts with tailored fruit and vegetable items (ie, default options), or a combination of the discount and default options. MAIN OUTCOMES AND MEASURES:The primary outcome was the percentage of nondiscounted dollars spent on eligible fruit and vegetables per basket. RESULTS:Of 2744 participants, mean (SD) age was 46.7 (16.0) years, and 1447 (52.7%) identified as women. A total of 1842 participants (67.1%) reported currently receiving SNAP benefits and 1492 (54.4%) reported shopping online for groceries in the previous 12 months. Participants spent a mean (SD) 20.5% (23.5%) of total dollars on eligible fruits and vegetables. Compared with no intervention, those in the discount condition spent 4.7% (98.3% CI, 1.7%-7.7%) of more total dollars on eligible fruits and vegetables; those in the default condition, 7.8% (98.3% CI, 4.8%-10.7%) more; and those in the combination condition, 13.0% (98.3% CI, 10.0%-16.0%) more (P < .001 for all). There was no difference between the discount and the default conditions (P = .06), but the effect in the combination condition was significantly larger than both discount and default conditions (P < .001). Default shopping cart items were purchased by 679 participants (93.4%) in the default condition and 655 (95.5%) in the combination condition, whereas 297 (45.8%) in the control and 361 (52.9%) in the discount conditions purchased those items (P < .001). No variation was observed by age, sex, or race and ethnicity, and results were similar when those who reported never shopping online for groceries were excluded. CONCLUSIONS AND RELEVANCE:In this randomized clinical trial, financial incentives for fruits and vegetables and default options, especially in combination, led to meaningful increases in online fruit and vegetable purchases among adults with low income. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT04766034.
PMID: 36897592
ISSN: 2574-3805
CID: 5448662

Disparities in routine healthcare utilization disruptions during COVID-19 pandemic among veterans with type 2 diabetes

Adhikari, Samrachana; Titus, Andrea R; Baum, Aaron; Lopez, Priscilla; Kanchi, Rania; Orstad, Stephanie L; Elbel, Brian; Lee, David C; Thorpe, Lorna E; Schwartz, Mark D
BACKGROUND:While emerging studies suggest that the COVID-19 pandemic caused disruptions in routine healthcare utilization, the full impact of the pandemic on healthcare utilization among diverse group of patients with type 2 diabetes is unclear. The purpose of this study is to examine trends in healthcare utilization, including in-person and telehealth visits, among U.S. veterans with type 2 diabetes before, during and after the onset of the COVID-19 pandemic, by demographics, pre-pandemic glycemic control, and geographic region. METHODS:We longitudinally examined healthcare utilization in a large national cohort of veterans with new diabetes diagnoses between January 1, 2008 and December 31, 2018. The analytic sample was 733,006 veterans with recently-diagnosed diabetes, at least 1 encounter with veterans administration between March 2018-2020, and followed through March 2021. Monthly rates of glycohemoglobin (HbA1c) measurements, in-person and telehealth outpatient visits, and prescription fills for diabetes and hypertension medications were compared before and after March 2020 using interrupted time-series design. Log-linear regression model was used for statistical analysis. Secular trends were modeled with penalized cubic splines. RESULTS:In the initial 3 months after the pandemic onset, we observed large reductions in monthly rates of HbA1c measurements, from 130 (95%CI,110-140) to 50 (95%CI,30-80) per 1000 veterans, and in-person outpatient visits, from 1830 (95%CI,1640-2040) to 810 (95%CI,710-930) per 1000 veterans. However, monthly rates of telehealth visits doubled between March 2020-2021 from 330 (95%CI,310-350) to 770 (95%CI,720-820) per 1000 veterans. This pattern of increases in telehealth utilization varied by community type, with lowest increase in rural areas, and by race/ethnicity, with highest increase among non-hispanic Black veterans. Combined in-person and telehealth outpatient visits rebounded to pre-pandemic levels after 3 months. Despite notable changes in HbA1c measurements and visits during that initial window, we observed no changes in prescription fills rates. CONCLUSIONS:Healthcare utilization among veterans with diabetes was substantially disrupted at the onset of the pandemic, but rebounded after 3 months. There was disparity in uptake of telehealth visits by geography and race/ethnicity.
PMCID:9842402
PMID: 36647113
ISSN: 1472-6963
CID: 5410652

A matched analysis of the association between federally-mandated smoke-free housing policies and health outcomes among Medicaid-enrolled children in subsidized housing, 2015-2019, New York City

Titus, Andrea R; Mijanovich, Tod N; Terlizzi, Kelly; Ellen, Ingrid G; Anastasiou, Elle; Shelley, Donna; Wyka, Katarzyna; Elbel, Brian; Thorpe, Lorna E
Smoke-free housing policies are intended to reduce the deleterious health effects of secondhand smoke (SHS) exposure, but there is limited evidence regarding their health impacts. We examined associations between implementation of a federal smoke-free housing rule by the New York City Housing Authority (NYCHA) and pediatric Medicaid claims for asthma, lower respiratory infections (LRIs), and upper respiratory infections (URIs) in the early post-policy period. We used geocoded address data to match children living in tax lots with NYCHA buildings (exposed to policy) to children living in lots with other subsidized housing (unexposed to policy). We constructed longitudinal difference-in-differences models to assess relative changes in monthly rates of claims between November 1, 2015 and December 31, 2019 (policy introduction was July 30, 2018). We also examined effect modification by baseline age group (0-2, 3-6, 7-15). In NYC, introduction of a smoke-free policy was not associated with lower rates of Medicaid claims for any outcomes in the early post-policy period. Exposure to the smoke-free policy was associated with slightly higher than expected rates of outpatient URI claims (IRR=1.05, 95% CI=1.01, 1.08), a result most pronounced among children ages 3-6. Ongoing monitoring is essential to understanding long-term health impacts of smoke-free housing policies.
PMID: 35551590
ISSN: 1476-6256
CID: 5214782