Faculty Bibliography

BACKGROUND:Accumulating evidence links ultra-processed foods to poor diet quality and chronic diseases. Understanding dietary trends is essential to inform priorities and policies to improve diet quality and prevent diet-related chronic diseases. Data are lacking, however, for trends in ultra-processed food intake. OBJECTIVES/OBJECTIVE:We examined US secular trends in food consumption according to processing level from 2001 to 2018. METHODS:We analyzed dietary data collected by 24-h recalls from adult participants (aged >19 y; N  = 40,937) in 9 cross-sectional waves of the NHANES (2001-2002 to 2017-2018). We calculated participants' intake of minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods as the relative contribution to daily energy intake (%kcal) using the NOVA framework. Trends analyses were performed using linear regression, testing for linear trends by modeling the 9 surveys as an ordinal independent variable. Models were adjusted for age, sex, race/ethnicity, education level, and income. Consumption trends were reported for the full sample and stratified by sex, age groups, race/ethnicity, education level, and income level. RESULTS:Adjusting for changes in population characteristics, the consumption of ultra-processed foods increased among all US adults from 2001-2002 to 2017-2018 (from 53.5 to 57.0 %kcal; P-trend < 0.001). The trend was consistent among all sociodemographic subgroups, except Hispanics, in stratified analyses. In contrast, the consumption of minimally processed foods decreased significantly over the study period (from 32.7 to 27.4 %kcal; P-trend < 0.001) and across all sociodemographic strata. The consumption of processed culinary ingredients increased from 3.9 to 5.4 %kcal (P-trend < 0.001), whereas the intake of processed foods remained stable at ∼10 %kcal throughout the study period (P-trend = 0.052). CONCLUSIONS:The current findings highlight the high consumption of ultra-processed foods in all parts of the US population and demonstrate that intake has continuously increased in the majority of the population in the past 2 decades.

INTRODUCTION/OBJECTIVES/UNASSIGNED:Patient activation describes the knowledge, skills, and confidence that allow patients to actively engage in managing their health. Prior studies have found a strong relationship between patient activation and clinical outcomes, costs of care, and patient experience. Patients who are obese or overweight may be less engaged than normal weight patients due to lower confidence or stigma associated with their weight. The objective of this study is to examine whether weight status is associated with patient activation and its sub-domains (confidence, communication, information-seeking behavior). METHODS/UNASSIGNED:This repeated cross-sectional study of the 2011 to 2013 Medicare Current Beneficiary Survey (MCBS) included a nationally representative sample of 13,721 Medicare beneficiaries. Weight categories (normal, overweight, obese) were based on body mass index. Patient activation (high, medium, low) was based on responses to the MCBS Patient Activation Supplement. RESULTS/UNASSIGNED:We found no differences in overall patient activation by weight categories. However, compared to those with normal weight, people with obesity had a higher relative risk (RRR 1.24; CI 1.09-1.42) of "low" rather than "high" confidence. Respondents with obesity had a lower relative risk (RRR 0.82; CI 0.73-0.92) of "low" rather than "high" ratings of communication with their doctor. DISCUSSION AND CONCLUSIONS/UNASSIGNED:Though patients with obesity may be less confident in their ability to manage their health, they are more likely to view their communication with physicians as conducive to self-care management. Given the high receptivity among patients with obesity toward physician communication, physicians may be uniquely situated to guide and support patients in gaining the confidence they need to reach weight loss goals.

Non-adherence to COVID-19 guidelines may be attributable to low levels of worry. This study assessed whether endorsing COVID-19-stigmatizing restrictions, COVID-19 knowledge, and preferred news source were associated with being 'very worried' versus 'not at all' or 'somewhat' worried about contracting COVID-19. Survey data were collected in July-August 2020 from N = 547 New York State (NYS) and N = 504 national Amazon MTurk workers. Respondents who endorsed COVID-19 stigmatizing restrictions (NYS OR 1.96; 95% CI 1.31, 2.92; national OR 1.80; 95% CI 1.06, 3.08) and consumed commercial news (NYS OR 1.89; 95% CI 1.21, 2.96; national OR 1.93; 95% CI 1.24, 3.00) were more likely to be very worried. National respondents who consumed The New York Times (OR 1.52; 95% CI 1.00, 2.29) were more likely to be very worried, while those with little knowledge (OR 0.24; 95% CI 0.13, 0.43) were less likely to be very worried. NYS (OR 2.66; 95% CI 1.77, 4.00) and national (OR 3.17; 95% CI 1.95, 5.16) respondents with probable depression were also more likely to be very worried. These characteristics can help identify those requiring intervention to maximize perceived threat to COVID-19 and encourage uptake of protective behaviors while protecting psychological wellbeing.

BACKGROUND:Little is known about disparities in pain treatment associated with weight status despite prior research on weight-based discrepancies in other realms of healthcare and stigma among clinicians. OBJECTIVE:To investigate the association between weight status and the receipt of prescription analgesics in a nationally representative sample of adults with back pain, adjusting for the burden of pain. DESIGN/METHODS:Cross-sectional analyses using the Medical Expenditure Panel Survey (2010-2017). PARTICIPANTS/METHODS:Five thousand seven hundred ninety-one civilian adults age ≥ 18 with back pain. MAIN MEASURES/METHODS:We examine the odds of receiving prescription analgesics for back pain by weight status using logistic regression. We study the odds of receiving (1) any pain prescription, (2) three pain prescription categories (opioid only, non-opioid only, the combination of both), and (3) opioids conditional on having a pain prescription. KEY RESULTS/RESULTS:The odds of receiving pain prescriptions increase monotonically across weight categories, when going from normal weight to obesity II/III, despite adjustments for the burden of pain. Relative to normal weight, higher odds of receiving any pain prescription is associated with obesity I (OR = 1.30 [95% CI = 1.04-1.63]) and obesity II/III (OR = 1.72 [95% CI = 1.36-2.18]). Obesity II/III is also associated with higher odds of receiving opioids only (OR = 1.53 [95% CI = 1.16-2.02]), non-opioids only (OR = 1.77 [95% CI = 1.21-2.60]), and a combination of both (OR = 2.48 [95% CI = 1.44-4.29]). Obesity I is associated with increased receipt of non-opioids only (OR = 1.55 [95% CI = 1.07-2.23]). Conditional on having a pain prescription, the odds of receiving opioids are comparable across weight categories. CONCLUSIONS:This study suggests that, relative to those with normal weight, adults with obesity are more likely to receive prescription analgesics for back pain, despite adjustments of the burden of pain. Hence, the possibility of weight-based undertreatment is not supported. These findings are reassuring because individuals with obesity generally experience a higher prevalence of back pain. The possibility of over-treatment associated with obesity, however, may warrant further investigation.

Brazil was a low and middle-income country (LMIC) in the late-1980s when it implemented a robust national tobacco-control program (NTCP) amidst rapid gains in national incomes and gender equality. We assessed changes in smoking prevalence between 1989 and 2013 by education level and related these changes to trends in educational inequalities in smoking. Data were from four nationally representative cross-sectional surveys (1989, n = 25,298; 2003 n = 3845; 2008 n = 28,938; 2013 n = 47,440, ages 25-69 years). We estimated absolute (slope index of inequality, SII) and relative (relative index of inequality, RII) educational inequalities in smoking prevalence, separately for males and females. Additional analyses stratified by birth-cohort to assess generational differences. Smoking declined significantly between 1989 and 2013 in all education groups but declines in females were steeper in higher-educated groups. Consequently, both absolute and relative educational inequalities in female smoking widened threefold between 1989 and 2013 (RII: 1.31 to 3.60, SII: 5.3 to 15.0), but absolute inequalities widened mainly until 2003 (SII: 15.8). Conversely, in males, declines were steeper in higher-educated groups only relative terms. Thus, relative educational inequalities in male smoking widened between 1989 and 2013 (RII: 1.58 to 3.19) but mainly until 2008 (3.22), whereas absolute inequalities were unchanged over the 24-year period (1989: 21.1 vs. 2013: 23.2). Younger-cohorts (born ≥1965) had wider relative inequalities vs. older-cohorts at comparable ages, particularly in the youngest female-cohorts (born 1978-1988). Our results suggest that younger lower-SES groups, especially females, may be particularly vulnerable to differentially higher smoking uptake in LMICs that implement population tobacco-control efforts amidst rapid societal gains.

Policy Points Although it is well established that educational attainment improves health and longevity, the economic value of this benefit is unknown. We estimate that the economic value of education for longer, healthier lives is comparable to or greater than the value of education for lifetime earnings. Policies that increase rates of completion of high school and college degrees could result in longer, healthier lives and substantial economic value for the population. We provide a template for assigning an economic value to the health benefits associated with education or other social determinants, allowing policymakers to prioritize those interventions that yield the greatest value for the population.

Importance/UNASSIGNED:Health profiles and patterns of involvement in the criminal justice system among people with various levels of opioid use are poorly defined. Data are needed to inform a public health approach to the opioid epidemic. Objective/UNASSIGNED:To examine the association between various levels of opioid use in the past year and physical and mental health, co-occurring substance use, and involvement in the criminal justice system. Design, Setting, and Participants/UNASSIGNED:This retrospective, cross-sectional analysis used the 2015-2016 National Survey on Drug Use and Health to assess the independent association of intensity of opioid use with health, co-occurring substance use, and involvement in the criminal justice system among US adults aged 18 to 64 years using multivariable logistic regression. Exposures/UNASSIGNED:No opioid use vs prescription opioid use, misuse, or use disorder or heroin use. Main Outcomes and Measures/UNASSIGNED:Self-reported physical and mental health, disability, co-occurring substance use, and past year and lifetime involvement in the criminal justice system. Results/UNASSIGNED:The sample consisted of 78 976 respondents (42 495 women and 36 481 men), representative of 196 280 447 US adults. In the weighted sample, 124 026 842 adults reported no opioid use in the past year (63.2%; 95% CI, 62.6%-63.7%), 61 462 897 reported prescription opioid use in the past year (31.3%; 95% CI, 30.8%-31.8%), 8 439 889 reported prescription opioid misuse in the past year (4.3%; 95% CI, 4.1%-4.5%), 1 475 433 reported prescription opioid use disorder in the past year (0.8%; 95% CI, 0.7%-0.8%), and 875 386 reported heroin use in the past year (0.4%; 95% CI, 0.4%-0.5%). Individuals who reported any level of opioid use were significantly more likely than individuals who reported no opioid use to be white, have a low income, and report a chronic condition, disability, severe mental illness, or co-occurring drug use. History of involvement in the criminal justice system increased as intensity of opioid use increased (no use, 15.9% [19 562 158 of 123 319 911]; 95% CI, 15.4%-16.4%; prescription opioid use, 22.4% [13 712 162 of 61 204 541]; 95% CI, 21.7%-23.1%; prescription opioid misuse, 33.2% [2 793 391 of 8 410 638]; 95% CI, 30.9%-35.6%; prescription opioid use disorder, 51.7% [762 189 of 1 473 552]; 95% CI, 45.4%-58.0%; and heroin use, 76.8% [668 453 of 870 250]; 95% CI, 70.6%-82.1%). In adjusted models, any level of opioid use was associated with involvement in the criminal justice system in the past year compared with no opioid use. Conclusions and Relevance/UNASSIGNED:Individuals who use opioids have complicated health profiles and high levels of involvement in the criminal justice system. Combating the opioid epidemic will require public health interventions that involve criminal justice systems, as well as policies that reduce involvement in the criminal justice system among individuals with substance use disorders.

Ultra-processed foods provide 58 % of energy intake and 89 % of added sugars in the American diet. Nevertheless, the association between ultra-processed foods and excess weight has not been investigated in a US sample. The present investigation therefore aims to examine the association between ultra-processed foods and excess weight in a nationally representative sample of US adults. We performed a cross-sectional analysis of anthropometric and dietary data from 15 977 adults (20-64 years) participating in the National Health and Nutrition Examination Survey 2005-2014. Dietary data were collected by 24-h recall. Height, weight and waist circumference (WC) were measured. Foods were classified as ultra-processed/non-ultra-processed according to the NOVA classification. Multivariable linear and logistic regression was used to evaluate the association between ultra-processed food consumption (% energy) and BMI, WC and odds of BMI≥25 kg/m2, BMI≥30 kg/m2 and abdominal obesity (men: WC≥102 cm, women: WC≥88 cm). Prevalence of BMI≥25 kg/m2, BMI≥30 kg/m2 and abdominal obesity was 69·2, 36·1 and 53·0 %, respectively. Consuming ≥74·2 v. ≤36·5 % of total energy from ultra-processed foods was associated with 1·61 units higher BMI (95 % CI 1·11, 2·10), 4·07 cm greater WC (95 % CI 2·94, 5·19) and 48, 53 and 62 % higher odds of BMI≥25 kg/m2, BMI≥30 kg/m2 and abdominal obesity, respectively (OR 1·48; 95 % CI 1·25, 1·76; OR 1·53; 95 % CI 1·29, 1·81; OR 1·62; 95 % CI 1·39, 1·89, respectively; P for trend<0·001 for all). A significant interaction between being female and ultra-processed food consumption was found for BMI (F 4,79=4·89, P=0·002), WC (F 4,79=3·71, P=0·008) and BMI≥25 kg/m2 (F 4,79=5·35, P<0·001). As the first study in a US population, our findings support that higher consumption of ultra-processed food is associated with excess weight, and that the association is more pronounced among women.

BACKGROUND:While the Affordable Care Act's (ACA) Medicaid expansion has increased insurance coverage, its effects on health outcomes have been mixed. This may be because previous research did not disaggregate mental and physical health or target populations most likely to benefit. OBJECTIVE:To examine the association between Medicaid expansion and changes in mental health, physical health, and access to care among low-income childless adults with and without chronic conditions. DESIGN/METHODS:We used a difference-in-differences analytical framework to assess differential changes in self-reported health outcomes and access to care. We stratified our analyses by chronic condition status. PARTICIPANTS/METHODS:Childless adults, aged 18-64, with incomes below 138% of the federal poverty level in expansion (n = 69,620) and non-expansion states (n = 57,628). INTERVENTION/METHODS:Active Medicaid expansion in state of residence. MAIN MEASURES/METHODS:Self-reported general health; total days in past month with poor health, poor mental health, poor physical health, or health-related activity restrictions; disability; depression; insurance coverage; cost-related barriers; annual check-up; and personal doctor. KEY RESULTS/RESULTS:Medicaid expansion was associated with reductions in poor health days (-1.2 days [95% CI, -1.6,-0.7]) and days limited by poor health (-0.94 days [95% CI, -1.4,-0.43]), but only among adults with chronic conditions. Trends in general health measures appear to be driven by fewer poor mental health days (-1.1 days [95% CI, -1.6,-0.6]). Expansion was also associated with a reduction in depression diagnoses (-3.4 percentage points [95% CI, -6.1,-0.01]) among adults with chronic conditions. Expansion was associated with improvements in access to care for all adults. CONCLUSIONS:Medicaid expansion was associated with substantial improvements in mental health and access to care among low-income adults with chronic conditions. These positive trends are likely to be reversed if Medicaid expansion is repealed.

BACKGROUND:Obesity has been associated with improved short-term mortality following common acute illness, but its relationship with longer-term mortality is unknown. METHODS:Observational study of U.S. Health and Retirement Study (HRS) participants with federal health insurance (fee-for-service Medicare) coverage, hospitalized with congestive heart failure (N = 4287), pneumonia (N = 4182), or acute myocardial infarction (N = 2001), 1996-2012. Using cox proportional hazards models, we examined the association between overweight or obese BMI (BMI ≥ 25.0 kg/m2) and mortality to 5 years after hospital admission, adjusted for potential confounders measured at the same time as BMI, including age, race, sex, education, partnership status, income, wealth, and smoking status. Body mass index (BMI) was calculated from self-reported height and weight collected at the HRS survey prior to hospitalization (a median 1.1 year prior to hospitalization). The referent group was patients with a normal BMI (18.5 to < 25.0 kg/m2). RESULTS:Patients were a median of 79 years old (IQR 71-85 years). The majority of patients were overweight or obese: 60.3% hospitalized for heart failure, 51.5% for pneumonia, and 61.6% for acute myocardial infarction. Overweight or obese BMI was associated with lower mortality at 1 year after hospitalization for congestive heart failure, pneumonia, and acute myocardial infarction-with adjusted hazard ratios of 0.68 (95% CI 0.59-0.79), 0.74 (95% CI: 0.64-0.84), and 0.65 (95%CI: 0.53-0.80), respectively. Among participants who lived to one year, however, subsequent survival was similar between patients with normal versus overweight/obese BMI. CONCLUSIONS:In older Americans, overweight or obese BMI was associated with improved survival following hospitalization for congestive heart failure, pneumonia, and acute myocardial infarction. This association, however, is limited to the shorter-term. Conditional on surviving to one year, we did not observe a survival advantage associated with excess weight.