Faculty Bibliography

PURPOSE/OBJECTIVE:To examine the association between cumulative exposure to neighborhood walkability (NW) and diabetes risk. METHODS:A total of 11,037 women free of diabetes at enrollment were included. We constructed a 4-item NW index at baseline, and a 2-item average annual NW across years of follow-up that captured both changes in neighborhood features and residential moves. We used multivariable Cox PH regression models with robust variance to estimate the hazard ratios (HRs) of diabetes by NW scores. RESULTS:Compared with women living in areas with lowest NW (Q1), those living in areas with highest NW (Q4) had 33 % (26 %-39 %) reduced risk of incident diabetes, using baseline NW, and 25 % (95 % CI 11 %-36 %), using average annual NW. Analysis using time-varying exposure showed that diabetes risks decreased by 13 % (10 %-16 %) per -standard deviation increase in NW. The associations remained similar when using inverse probability of attrition weights and/or competing risk models to account for the effect of censoring due to death or non-response. The associations of average annual NW with incident diabetes were stronger in postmenopausal women as compared to premenopausal women. CONCLUSION/CONCLUSIONS:Long-term residence in more walkable neighborhoods may be protective against diabetes in women, especially postmenopausal women.

INTRODUCTION/BACKGROUND:Recent federal regulatory changes governing the delivery of methadone treatment for opioid use disorder at Opioid Treatment Programs (OTPs) support continued practice changes towards greater and flexible methadone take-home medication. Existing payment models for OTPs were closely tied with onsite medication administration and thus misaligned with the need to conduct more and flexible take-homes. This study aims to understand OTP organizations' experience with the newly created OTP bundled payment model in New York State as an alternative to the pre-existing per-service payment model during 2020-2023 to inform financing strategies to support and sustain practice changes. METHODS:The study conducted semi-structured interviews with financial leaders and staff from OTP organizations in New York State. Snowball sampling supplemented purposeful sampling of OTP organizations based on their billing practices by. Qualitative data from 12 interviews (with 11 OTP organizations and 1 trade organization) were analyzed with an integrated (inductive and deductive) approach to derive themes. RESULTS:Study informants recognized that the bundled payment model served to protect revenue in a time when OTPs had to pivot quickly to increase take-home medication to patients. Informants described a wide spectrum of practices to operationalize billing in the alternative payment systems, revealing confusion with the billing rules and significant logistical and technical challenges. Informants expressed concerns regarding the substantial difference between the full bundled rate, paid in weeks with one or more qualifying services, and the medication-only rate, reporting that extended (2 weeks or more) take-homes might not be sustainable under the two-tiered model with the low medication-only rate and advocating for a single bundled rate. Informants believed that increased take-home medication and federal regulatory changes had profound implications for the delivery of counseling services, the counselor workforce, and financial viability for OTPs. CONCLUSIONS:Our study of OTP organization experience in New York State provided data on OTP organization perspectives regarding the potential revenue-protecting effects of bundled payments and generated insights to inform future research and policy experimentation to support flexible take-home medication. Future implementation studies are needed to better understand the roles of financing strategies at large in supporting clinical practice changes in substance use disorder treatment.

INTRODUCTION/BACKGROUND:The general population is chronically exposed to organophosphate pesticides through various routes including ingestion, hand-to-mouth contact, inhalation, and dermal contact. Exposure to organophosphate pesticides during pregnancy impairs fetal development, but the potential long-term effects of gestational organophosphate pesticide exposure are less well understood. METHODS:We investigated associations between gestational organophosphate pesticide exposure and cardiovascular outcomes in 643 children in the Generation R Study, a prospective pregnancy cohort based in Rotterdam, The Netherlands. Urinary organophosphate pesticide metabolites (dimethyl [∑DMAP], diethyl [∑DEAP], and total dialkyl phosphate [∑DAP] metabolites) were quantified in three urine samples collected from pregnant participants, and their children were followed until age 10 years at which time cardiac magnetic resonance imaging, ultrasonography, blood pressure, and serum biomarkers assessed cardiovascular health. Linear regression models estimated associations (β and 95 % confidence interval [CI]) between a one-interquartile range (IQR) increase in averaged gestational exposure biomarker concentrations and z-scored pediatric cardiovascular outcomes. We investigated effect modification of associations by PON1 genotype. RESULTS:Carotid intima-media thickness z-score was lower (β: -0.14 [95 % CI: -0.25, -0.02]) and HDL cholesterol z-score was higher (β: 0.14 [95 % CI: 0.02, 0.25]) for increases in ∑DEAP concentrations. Carotid intima-media distensibility z-score was lower (β: -0.08 [95 % CI: -0.19, 0.03]) for increases in ∑DMAP concentrations, and systolic blood pressure z-score was higher (β: 0.10 [95 % CI: -0.01, 0.21]) for increases in ∑DMAP and ∑DAP. Among those with PON1-161CC and PON1-L55MTT genotypes, higher organophosphate pesticide concentrations conferred an excess risk of adverse vascular and glycemic outcomes, respectively. CONCLUSIONS:We observed heterogenous associations between gestational organophosphate pesticide exposure and pediatric cardiovascular health: an anti-atherogenic profile was observed for increases in ∑DEAP concentrations, and impairments in multiple aspects of cardiovascular health was observed for increases in ∑DMAP concentrations. PON1-161 and PON1-L55M single nucleotide polymorphisms modified associations for vascular and glycemic outcomes, respectively.

OBJECTIVE:To examine the association between social capital and household food insecurity among US families with newborns. STUDY DESIGN/METHODS:This cross-sectional analysis used enrollment data from 881 newborn-caregiver dyads at six geographically-diverse US academic sites enrolled in the Greenlight Plus Trial, a comparative effectiveness trial to prevent childhood obesity. Ordinal proportional-odds models were used to characterize the associations of two self-reported measures of social capital: 1) caregiver social support and 2) neighborhood social cohesion, with household food insecurity after controlling for sociodemographic characteristics. RESULTS:Among 881 newborn-caregiver dyads (49% Hispanic, 23% non-Hispanic white, 17% non-Hispanic Black; 49% with annual household income <$50,000), food security was high for 75%, marginal for 9%, low for 11% and very low for 4%. In covariate-adjusted analyses, caregivers with a low social support score of 18 had five times the odds (aOR=5.03 95%CI=3.28-7.74) of greater food insecurity compared with caregivers with a high social support score of 30. Caregivers with a low neighborhood social cohesion score of 10 had nearly three times the odds (aOR=2.87 95%CI 1.61-5.11) of greater food insecurity compared with caregivers with a high neighborhood social cohesion score of 20. These associations remained robust when both social capital measures were included in one model. CONCLUSIONS:Caregiver social support and neighborhood social cohesion each appear to be inversely associated with food insecurity among US families with newborns. Longitudinal research is needed to determine the directionality of these relationships and whether improving social capital for families with young children reduces household food insecurity.

Exposure to unhealthy food and beverage marketing is a major contributor to excessive weight gain among young people and it may disproportionately affect Black and Latinx communities. Appropriate and comprehensive regulations on food and beverage companies are essential, particularly as companies expand their reach and leverage the latest technologies to create marketing experiences using immersive virtual reality (VR). Although immersive VR technology is in its infancy, the potential effects of immersive VR food and beverage marketing on consumption, coupled with the history of racially targeted marketing by food and beverage corporations toward Black and Latinx communities, and the heightened burden of diet-related illnesses in Black and Latinx communities underscore a critical need to investigate immersive VR marketing targeting young people of color. This viewpoint will provide a brief description of VR food and beverage marketing as the newest food and beverage marketing frontier, highlight key concerns and knowledge gaps, and underscore future directions in research.

INTRODUCTION/BACKGROUND:Organophosphate esters (OPEs) are increasing in use as flame retardants and plasticizers and concerns have been raised given their endocrine-disrupting activities and possible obesogenic consequences. However, longitudinal studies on gestational OPE exposure and childhood obesity are scarce. This study examined whether OPE levels in maternal urine during pregnancy were associated with the risk of childhood obesity. METHODS:OPEs were analyzed in pregnancy urine samples of 5,087 individuals from 14 studies contributing to the Environmental influences on Child Health Outcomes (ECHO) Cohort. BDCPP, DBUP/DIBP, and DPHP, detected in > 80 % of the samples, were modeled continuously and by tertiles; whereas BCPP, BBOEP, and BCETP, detected in 50-80 % of samples, were modeled categorically (not-detected, low, and high). Childhood obesity was defined by BMI z-score ≥ 95th percentile according to WHO (<2 years) and the CDC (≥2 years) metrics. Adjusted modified Poisson regression models assessed childhood obesity risk and the mixture effect was assessed using Bayesian kernel machine regression (BKMR). RESULTS:BMI measurements were available for 3,827 children in infancy (0.5-1.9 years), 3,921 children in early childhood (2.0-4.9 years), and 2,541 children in mid-childhood (5.0-10.0 years). Obesity was present in 16-21 % of children across age groups. In mid-childhood DBUP/DIBP second and third versus first tertiles were associated with increased obesity risk (RR 1.14; 95 % CI: 1.02, 1.28; and RR 1.11; 95 % CI: 0.97, 1.27; respectively); whereas BDCPP second and third versus first tertiles reflected an inverse association with obesity risk (RR 0.85; 95 % CI: 0.80, 0.91 and RR 0.91; 95 % CI: 0.77, 1.07; respectively). No association with obesity risk was observed for DPHP, BCPP, BBOEP, and BCETP. Directions observed were consistent with those seen in BKMR models. CONCLUSIONS:This study identified mixed associations between gestational OPE exposure and childhood obesity. Further investigation across a comprehensive range of OPE exposures is warranted.

The number and complexity of obesity treatments has increased rapidly in recent years. This is driven by the approval of new anti-obesity medications (AOMs) that produce larger degrees of weight loss than previously approved AOMs. Unfortunately, access to these highly effective therapies and to integrated team-based obesity care is limited by intra-/interpersonal patient, institutional/practitioner, community, and policy factors. We contextualized these complexities and the impact of patients' social drivers of health (SDOH) by adapting the social ecological model for obesity. Without multi-level intervention, these barriers to care will deepen the existing inequities in obesity prevalence and treatment outcomes among historically underserved communities. As General Internal Medicine (GIM) physicians, we can help our patients navigate the complexities of evidence-based obesity treatments. As care team leaders, GIM physicians are well-positioned to (1) improve education for trainees and practitioners, (2) address healthcare-associated weight stigma, (3) advocate for equity in treatment accessibility, and (4) coordinate interdisciplinary teams around non-traditional models of care focused on upstream (e.g., policy changes, insurance coverage, health system culture change, medical education requirements) and downstream (e.g., evidence-based weight management didactics for trainees, using non-stigmatizing language with patients, developing interdisciplinary weight management clinics) strategies to promote optimal obesity care for all patients.

Electronic health record (EHR)-embedded tools are known to improve prescribing of guideline-directed medical therapy (GDMT) for patients with heart failure. However, physicians may perceive EHR tools to be unhelpful, and may be therefore hesitant to implement these in their practice. We surveyed cardiologists about two effective EHR-tools to improve heart failure care, and they perceived the EHR tools to be easy to use, helpful, and improve the overall management of their patients with heart failure.

IMPORTANCE/UNASSIGNED:Plasma biomarkers show promise for identifying Alzheimer disease (AD) neuropathology and neurodegeneration, but additional examination among diverse populations and throughout the life course is needed. OBJECTIVE/UNASSIGNED:To assess temporal plasma biomarker changes and their association with all-cause dementia, overall and among subgroups of community-dwelling adults. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:In 1525 participants from the US-based Atherosclerosis Risk in Communities (ARIC) study, plasma biomarkers were measured using stored specimens collected in midlife (1993-1995, mean age 58.3 years) and late life (2011-2013, mean age 76.0 years; followed up to 2016-2019, mean age 80.7 years). Midlife risk factors (hypertension, diabetes, lipids, coronary heart disease, cigarette use, and physical activity) were assessed for their associations with change in plasma biomarkers over time. The associations of biomarkers with incident all-cause dementia were evaluated in a subpopulation (n = 1339) who were dementia-free in 2011-2013 and had biomarker measurements in 1993-1995 and 2011-2013. EXPOSURE/UNASSIGNED:Plasma biomarkers of amyloid-β 42 to amyloid-β 40 (Aβ42:Aβ40) ratio, phosphorylated tau at threonine 181 (p-tau181), neurofilament light (NfL), and glial fibrillary acidic protein (GFAP) were measured using the Quanterix Simoa platform. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Incident all-cause dementia was ascertained from January 1, 2012, through December 31, 2019, from neuropsychological assessments, semiannual participant or informant contact, and medical record surveillance. RESULTS/UNASSIGNED:Among 1525 participants (mean age, 58.3 [SD, 5.1] years), 914 participants (59.9%) were women, and 394 participants (25.8%) were Black. A total of 252 participants (16.5%) developed dementia. Decreasing Aβ42:Aβ40 ratio and increasing p-tau181, NfL, and GFAP were observed from midlife to late life, with more rapid biomarker changes among participants carrying the apolipoprotein E epsilon 4 (APOEε4) allele. Midlife hypertension was associated with a 0.15-SD faster NfL increase and a 0.08-SD faster GFAP increase per decade; estimates for midlife diabetes were a 0.11-SD faster for NfL and 0.15-SD faster for GFAP. Only AD-specific biomarkers in midlife demonstrated long-term associations with late-life dementia (hazard ratio per SD lower Aβ42:Aβ40 ratio, 1.11; 95% CI, 1.02-1.21; per SD higher p-tau181, 1.15; 95% CI, 1.06-1.25). All plasma biomarkers in late life had statistically significant associations with late-life dementia, with NfL demonstrating the largest association (1.92; 95% CI, 1.72-2.14). CONCLUSIONS AND RELEVANCE/UNASSIGNED:Plasma biomarkers of AD neuropathology, neuronal injury, and astrogliosis increase with age and are associated with known dementia risk factors. AD-specific biomarkers' association with dementia starts in midlife whereas late-life measures of AD, neuronal injury, and astrogliosis biomarkers are all associated with dementia.