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1.  Disentangling neighborhood contextual associations with child body mass index, diet, and physical activity: The role of built, socioeconomic, and social environments 
Obesity prevalence among US children and adolescents has tripled in the past three decades. Consequently, dramatic increases in chronic disease incidence are expected, particularly among populations already experiencing health disparities. Recent evidence identifies characteristics of “obesogenic” neighborhood environments that affect weight and weight-related behaviors. This study aimed to examine associations between built, socioeconomic, and social characteristics of a child’s residential environment on body mass index (BMI), diet, and physical activity. We focused on pre-adolescent children living in New Haven, Connecticut to better understand neighborhood environments’ contribution to persistent health disparities. Participants were 1048 fifth and sixth grade students who completed school-based health surveys and physical measures in fall 2009. Student data were linked to US Census, parks, retailer, and crime data. Analyses were conducted using multilevel modeling. Property crimes and living further from a grocery store were associated with higher BMI. Students living within a 5-min walk of a fast food outlet had higher BMI, and those living in a tract with higher density of fast food outlets reported less frequent healthy eating and more frequent unhealthy eating. Students’ reported perceptions of access to parks, playgrounds, and gyms were associated with more frequent healthy eating and exercise. Students living in more affluent neighborhoods reported more frequent healthy eating, less unhealthy eating, and less screen time. Neighborhood social ties were positively associated with frequency of exercise. In conclusion, distinct domains of neighborhood environment characteristics were independently related to children’s BMI and health behaviors. Findings link healthy behaviors with built, social, and socioeconomic environment assets (access to parks, social ties, affluence), and unhealthy behaviors with built environment inhibitors (access to fast food outlets), suggesting neighborhood environments are an important level at which to intervene to prevent childhood obesity and its adverse consequences.
doi:10.1016/j.socscimed.2013.04.003
PMCID: PMC4058500  PMID: 23642646
New Haven, Connecticut, USA; Health behaviors; Neighborhood; Built environment; Socioeconomic status; Social environment; Health disparities
2.  Neighborhood Effects on Youth Substance Use in a Southwestern City 
This study examines neighborhood influences on alcohol, cigarette and marijuana use among a predominantly Latino middle school sample. Drawing on theories of immigrant adaptation and segmented assimilation, we test whether neighborhood immigrant, ethnic, and socioeconomic composition, violent crime, residential instability, and family structure have differential effects on substance use among youth from different ethnic and acculturation backgrounds. Data are drawn from self-reports from 3,721 7th grade students attending 35 Phoenix, Arizona middle schools. Analysis was restricted to the two largest ethnic groups, Latino students of Mexican heritage and non-Hispanic Whites. After adjusting for individual-level characteristics and school- level random effects, only one neighborhood effect was found for the sample overall, an undesirable impact of neighborhood residential instability on recent cigarette use. Sub-group analyses by individual ethnicity and acculturation showed more patterned neighborhood effects. Living in neighborhoods with high proportions of recent immigrants was protective against alcohol, cigarette, and marijuana use for Latino students at different acculturation levels, while living in predominantly Mexican heritage neighborhoods (mostly non-immigrants) was a risk factor for alcohol and marijuana use for less acculturated Latinos. There were scattered effects of neighborhood poverty and crime, which predicted more cigarette and alcohol use, respectively, but only among more acculturated Latinos. Inconsistent effects confined to bilingual and more acculturated Latinos were found for the neighborhood's proportion of single mother families and its residential instability. No neighborhood effects emerged for non-Hispanic White students. Results suggested that disadvantaged neighborhoods increase substance use among some ethnic minority youth, but immigrant enclaves appear to provide countervailing protections.
doi:10.1525/sop.2007.50.2.273
PMCID: PMC3040571  PMID: 21339890
neighborhood effects; substance use; adolescents; Mexican Americans; acculturation
3.  Residential Racial Composition and Black-White Obesity Risks: Differential Effects of Neighborhood Social and Built Environment 
This study investigates the association between neighborhood racial composition and adult obesity risks by race and gender, and explores whether neighborhood social and built environment mediates the observed protective or detrimental effects of racial composition on obesity risks. Cross-sectional data from the 2006 and 2008 Southeastern Pennsylvania Household Health Survey are merged with census-tract profiles from 2005–2009 American Community Survey and Geographic Information System-based built-environment data. The analytical sample includes 12,730 whites and 4,290 blacks residing in 953 census tracts. Results from multilevel analysis suggest that black concentration is associated with higher obesity risks only for white women, and this association is mediated by lower neighborhood social cohesion and socioeconomic status (SES) in black-concentrated neighborhoods. After controlling for neighborhood SES, black concentration and street connectivity are associated with lower obesity risks for white men. No association between black concentration and obesity is found for blacks. The findings point to the intersections of race and gender in neighborhood effects on obesity risks, and highlight the importance of various aspects of neighborhood social and built environment and their complex roles in obesity prevention by socio-demographic groups.
doi:10.3390/ijerph110100626
PMCID: PMC3924464  PMID: 24452257
obesity; neighborhood; racial segregation; social cohesion; built environment
4.  Neighborhoods and Obesity in Older Adults: The Baltimore Memory Study 
Background
Obesity has reached epidemic proportions. Although its causes are not well understood, its increasing prevalence is not likely to be due to genetic factors or underlying biology. This has led to interest in the role of environmental factors, although few studies have focused on the role of the social environment. This study investigated whether neighborhood psychosocial hazards independent of individual risk factors were associated with increased odds of obesity.
Methods
Baseline data were analyzed in 2005 from a cohort study of 1140 randomly selected community-dwelling men and women aged 50–70 years from 65 contiguous neighborhoods in Baltimore MD. Body mass index (BMI in kg/m2) was calculated from measured height and weight at baseline (2001–2002). People with BMI ≥30 were considered obese. Multilevel logistic regression was used to examine associations between a 12-item scale of neighborhood psychosocial hazards and the odds of obesity.
Results
Thirty-eight percent of the cohort were obese. Residents of neighborhoods in the highest quartile of the Multidimensional Neighborhood Hazards scale were nearly twice as likely to be obese compared to residents in the least-hazardous neighborhoods (53% vs 27%). After adjustment for age, gender, race/ethnicity, education, household wealth, alcohol consumption, tobacco use, self-reported physical activity, and dietary intake, living in more hazardous neighborhoods was associated with a graded increase in the odds of obesity. This association was partially mediated by physical activity.
Conclusions
Even after controlling for a large set of demographic, behavioral, and socioeconomic individual-level risk factors, living in a neighborhood with greater psychosocial hazards was independently associated with obesity.
doi:10.1016/j.amepre.2006.07.028
PMCID: PMC1851911  PMID: 17169707
5.  Racial and Ethnic Residential Segregation, the Neighborhood Socioeconomic Environment, and Obesity Among Blacks and Mexican Americans 
American Journal of Epidemiology  2013;177(4):299-309.
We used cross-sectional data on 2,660 black and 2,611 Mexican-American adult participants in the National Health and Nutrition Examination Survey (1999–2006) to investigate the association between metropolitan-level racial/ethnic residential segregation and obesity and to determine whether it was mediated by the neighborhood socioeconomic environment. Residential segregation was measured using the black and Hispanic isolation indices. Neighborhood poverty and negative income incongruity were assessed as mediators. Multilevel Poisson regression with robust variance estimates was used to estimate prevalence ratios. There was no relationship between segregation and obesity among men. Among black women, in age-, nativity-, and metropolitan demographic-adjusted models, high segregation was associated with a 1.29 (95% confidence interval (CI): 1.00, 1.65) times higher obesity prevalence than was low segregation; medium segregation was associated with a 1.35 (95% CI: 1.07, 1.70) times higher obesity prevalence. Mexican-American women living in high versus low segregation areas had a significantly lower obesity prevalence (prevalence ratio, 0.54; 95% CI: 0.33, 0.90), but there was no difference between those living in medium versus low segregation areas. These associations were not mediated by neighborhood poverty or negative income incongruity. These findings suggest variability in the interrelationships between residential segregation and obesity for black and Mexican-American women.
doi:10.1093/aje/kws372
PMCID: PMC3566709  PMID: 23337312
health disparities; obesity; residential segregation; social environment
6.  Do Neighborhood Economic Characteristics, Racial Composition, and Residential Stability Predict Perceptions of Stress Associated with the Physical and Social Environment? Findings from a Multilevel Analysis in Detroit 
As the body of evidence linking disparities in the health of urban residents to disparate social, economic and environmental contexts grows, efforts to delineate the pathways through which broader social and economic inequalities influence health have burgeoned. One hypothesized pathway connects economic and racial and ethnic inequalities to differentials in stress associated with social and physical environments, with subsequent implications for health. Drawing on data from Detroit, Michigan, we examined contributions of neighborhood-level characteristics (e.g., poverty rate, racial and ethnic composition, residential stability) and individual-level characteristics (e.g., age, gender) to perceived social and physical environmental stress. We found that neighborhood percent African American was positively associated with perceptions of both social and physical environmental stress; neighborhood percent poverty and percent Latino were positively associated with perceived physical environmental stress; and neighborhood residential stability was negatively associated with perceived social environmental stress. At the individual level, whites perceived higher levels of both social and physical environmental stress compared to African American residents of the same block groups, after accounting for other variables included in the models. Our findings suggest the importance of understanding and addressing contributions of neighborhood structural characteristics to perceptions of neighborhood stress. The consistency of the finding that neighborhood racial composition and individual-level race influence perceptions of both social and physical environments suggests the continuing importance of understanding the role played by structural conditions and by personal and collective histories that vary systematically by race and ethnicity within the United States.
doi:10.1007/s11524-008-9288-5
PMCID: PMC2527427  PMID: 18481182
Perceived social environmental stress; Perceived physical environmental stress; Residential stability; Urban health
7.  Running to the Store? The Relationship between Neighborhood Environments and the Risk of Obesity 
Social science & medicine (1982)  2009;69(10):1493-1500.
We expand the search for modifiable features of neighborhood environments that alter obesity risk in two ways. First, we examine residents’ access to neighborhood retail food options in combination with neighborhood features that facilitate physical activity. Second, we evaluate neighborhood features for both low income and non-low income neighborhoods (bottom quartile of median neighborhood income vs. the top three quartiles).
Our analyses use data from the Utah Population Database merged with U.S. Census data and Dun & Bradstreet business data for Salt Lake County, Utah. Linear regressions for BMI and logistic regressions for the likelihood of being obese are estimated using various measures of the individual’s neighborhood food options and walkability features.
As expected, walkability indicators of older neighborhoods and neighborhoods where a higher fraction of the population walks to work is related to a lower BMI/obesity risk, although the strength of the effects varies by neighborhood income. Surprisingly, the walkability indicator of neighborhoods with higher intersection density was linked to higher BMI/obesity risk. The expected inverse relationship between the walkability indicator of population density and BMI/obesity risk is found only in low income neighborhoods.
We find a strong association between neighborhood retail food options and BMI/obesity risk with the magnitude of the effects again varying by neighborhood income. For individuals living in non-low income neighborhoods, having one or more convenience stores, full-service restaurants, or fast food restaurants is associated with reduced BMI/obesity risk, compared to having no neighborhood food outlets. The presence of at least one healthy grocery option in low income neighborhoods is also associated with a reduction in BMI/obesity risk relative to no food outlets. Finally, multiple food options within a neighborhood reduce BMI/obesity risk, relative to no food options, for individuals living in either low-income or non-low neighborhoods.
doi:10.1016/j.socscimed.2009.08.032
PMCID: PMC2791711  PMID: 19766372
USA; obesity; body mass index (BMI); neighborhood walkability; food environment; retail food outlets
8.  Relationships Between Neighborhoods, Physical Activity, and Obesity: A Multilevel Analysis of a Large Canadian City 
Obesity (Silver Spring, Md.)  2012;20(10):2093-2100.
In Canada, there is limited research examining the associations between objectively measured neighborhood environments and physical activity (PA) and obesity. The purpose of this study was to determine the relationships between variables from built and social environments and PA and overweight/obesity across 86 Ottawa, Canada neighborhoods. Individual-level data including self-reported leisure-time PA (LTPA), height, and weight were examined in a sample of 4,727 adults from four combined cycles (years 2001/03/05/07) of the Canadian Community Health Survey (CCHS). Data on neighborhood characteristics were obtained from the Ottawa Neighbourhood Study (ONS); a large study of neighborhoods and health in Ottawa, Canada. Binomial multivariate multilevel models were used to examine the relationships between environmental and individual variables with LTPA and overweight/obesity using survey weights in men and women separately. Within the sample, ~75% of the adults were inactive (<3.0 kcal/kg/day) while half were overweight/obese. Results of the multilevel models suggested that for females greater park area was associated with increased odds of LTPA and overweight/obesity. Greater neighborhood density of convenience stores and fast food outlets were associated with increased odds of females being overweight/obese. Higher crime rates were associated with greater odds of LTPA in males, and lower odds of male and female overweight/obesity. Season was significantly associated with PA in men and women; the odds of LTPA in winter months were half that of summer months. Findings revealed that park area, crime rates, and neighborhood food outlets may have different roles with LTPA and overweight/obesity in men and women and future prospective studies are needed.
doi:10.1038/oby.2011.392
PMCID: PMC3458203  PMID: 22262164
9.  Individual and neighborhood differences in diet among low-income foreign and U.S.-born women 
Background
Research on the “Immigrant,” or “Latino health paradox” has demonstrated that Latinos exhibit better health than U.S.-born whites, for multiple health outcomes, despite adjusting for socioeconomic status. However, little empirical research has focused on women and even less has focused on how the neighborhood residential environment is associated with these health differences, particularly in the area of diet.
Methods
We analyzed baseline data from 641 low-income women, nested within 184 census tracts, enrolled in a nutrition intervention trial for postpartum women. Individual-level variables, including race/ethnicity, nativity and duration of time in the United States, language acculturation, emotional and instrumental support, and socioeconomic position, were merged with tract-level variables from U.S. Census data (2000) based on residential address. We assessed daily fruit and vegetable servings through a semi-quantitative food frequency questionnaire. Using MLWin 2.0 software, we employed a 2-level linear regression model to ascertain associations of neighborhood immigrant, racial, and socioeconomic composition with individual diet, adjusting for individual-level socio-demographic characteristics.
Results
In our fully adjusted model, we observed a statistically significant increase of 1/3 of fruit and vegetable daily servings for each 10 percentage point increase in the tract foreign born population. Each 10 percentage point increase in the tract Black population was associated with a significant 1/5 serving decrease in individual daily fruit and vegetable intake.
Conclusions
Among this population of U.S. and foreign-born women, neighborhood composition was associated with individual diet, above and beyond individual level characteristics, illuminating neighborhood context, immigrant health and diet.
doi:10.1016/j.whi.2007.11.001
PMCID: PMC2760067  PMID: 18222706
10.  Social context explains race disparities in obesity among women 
Background
National data do not account for race differences in health risks resulting from racial segregation or the correlation between race and socioeconomic status. Therefore, these data may inaccurately attribute differences in obesity to race rather than differing social context. The goal of this study was to investigate whether race disparities in obesity among women persist in a community of black people and white people living in the same social context with similar income.
Methods
Race disparities in obesity were examined among black women and white women living in the same social context with similar income, using the data from the Exploring Health Disparities in Integrated Communities-SWB (EHDIC-SWB) study, and these estimates were compared to national data (National Health Interview Survey) to determine if race disparities in obesity were attenuated among women in EHDIC-SWB. Obesity was based on participants’ self-reported height and weight. Logistic regression was used to examine the association between race and obesity.
Results
In the national sample, black women exhibited greater odds of being obese (OR 1.99, 95% CI 1.71 to 2.32) than white women after controlling for covariates. In the EHDIC-SWB sample, black women had similar odds of being obese (OR 1.25, 95% CI 0.90 to 1.75) as compared to white women, after adjusting for covariates.
Conclusions
There are no race disparities in obesity among poor, urban women sharing the same social context. Developing policies that focus on modifying social aspects of the environment may reduce disparities in obesity among low-income women living in urban communities.
doi:10.1136/jech.2009.096297
PMCID: PMC3099623  PMID: 20445215
11.  The Determinants of Neighborhood Satisfaction: Racial Proxy Revisited 
Demography  2011;48(3):1203-1229.
Understanding the factors that drive individuals' residential preferences is a critical issue in the study of racial segregation. An important debate within this field is whether individuals – especially whites – prefer to live in predominantly white neighborhoods because they wish to avoid the social problems that may be more likely to occur in predominantly black neighborhoods (i.e., the racial proxy hypothesis) or because of racial factors that go beyond these social class-related characteristics. Through a multilevel analysis of data from the 2004–2005 Chicago Area Study and several administrative sources, we assess the extent to which the racial proxy hypothesis describes neighborhood satisfaction among whites, African Americans, and Latinos living across a broad range of neighborhood contexts. The racial proxy perspective applies weakly to whites' satisfaction: whites report less satisfaction in neighborhoods with more minority residents, and only some of their dissatisfaction can be attributed to local social characteristics. The racial proxy hypothesis applies more strongly to blacks' and Latinos' satisfaction. In some cases, especially for Latinos, higher levels of satisfaction in integrated neighborhoods can largely be attributed to the fact that these places have better socioeconomic conditions and fewer social problems than predominantly minority communities. At the same time, effects of racial/ethnic composition persist in unique and somewhat divergent ways for blacks and Latinos, supporting the assertion that racial composition matters, above and beyond its relation to social class. Taken together, these findings suggest that individuals balance both socioeconomic and race-related concerns in their residential preferences.
doi:10.1007/s13524-011-0047-y
PMCID: PMC3694587  PMID: 21706255
12.  Neighborhood socioeconomic status and fruit and vegetable intake among Whites, Blacks, and Mexican-Americans in the United States 
Background
Socioeconomic and racial/ethnic disparities in health status across the United States are large and persistent. Obesity rates are rising faster in Black and Hispanic populations than in Whites and foreshadow even greater disparities in chronic diseases such as diabetes and cardiovascular disease in years to come. Factors that influence dietary intake of fruits and vegetables in these populations are only partly understood.
Objective
We examined associations between fruit and vegetable intake and neighborhood socioeconomic status (NSES), analyzed whether NSES explains racial differences in intake, and explored the extent to which NSES has differential effects by race/ethnicity of United States (U.S.) adults.
Design
Using geocoded residential addresses from the Third National Health and Nutrition Examination Survey (NHANES III), we merged individual-level data with county and census-tract level U.S. Census data. We estimated three-level hierarchical models predicting fruit and vegetable intake with individual characteristics and an index of neighborhood SES as explanatory variables.
Results
Neighborhood SES was positively associated with fruit and vegetable intake: a one standard deviation increase in the neighborhood SES index was associated with consumption of nearly 2 additional servings of fruit and vegetables per week. Neighborhood SES explained some of the Black-White disparity in fruit and vegetable intake and was differentially associated with fruit and vegetable intake among Whites, Blacks, and Mexican-Americans.
Conclusions
The positive association of neighborhood SES with fruit and vegetable intake is one important pathway through which the social environment of neighborhoods affects population health and nutrition for Whites, Blacks and Hispanics in the United States.
PMCID: PMC3829689  PMID: 18541581
Neighborhood Socioeconomic Status; Race/Ethnicity; Fruit and Vegetable Consumption
13.  Perceived neighborhood environmental attributes associated with adults’ transport-related walking and cycling: Findings from the USA, Australia and Belgium 
Background
Active transportation has the potential to contribute considerably to overall physical activity levels in adults and is likely to be influenced by neighborhood-related built environment characteristics. Previous studies that examined the associations between built environment attributes and active transportation, focused mainly on transport-related walking and were conducted within single countries, limiting environmental variability. We investigated the direction and shape of relationships of perceived neighborhood attributes with transport-related cycling and walking in three countries; and examined whether these associations differed by country and gender.
Methods
Data from the USA (Baltimore and Seattle), Australia (Adelaide) and Belgium (Ghent) were pooled. In total, 6,014 adults (20–65 years, 55.7% women) were recruited in high-/low-walkable and high-/low-income neighborhoods. All participants completed the Neighborhood Environmental Walkability Scale and the International Physical Activity Questionnaire. Generalized additive mixed models were used to estimate the strength and shape of the associations.
Results
Proximity to destinations, good walking and cycling facilities, perceiving difficulties in parking near local shopping areas, and perceived aesthetics were included in a ‘cyclability’ index. This index was linearly positively related to transport-related cycling and no gender- or country-differences were observed. The ‘walkability’ index consisted of perceived residential density, land use mix access, proximity of destinations and aesthetics. A non-linear positive relationship with transport-related walking was found. This association was stronger in women than in men, and country-specific associations were identified: the strongest association was observed in Seattle, the weakest in Adelaide. In Ghent, the association weakened at higher levels of walkability.
Conclusions
For cycling, consistent correlates were found in the three countries, but associations were less straightforward for transport-related walking. Moreover, the identified neighborhood environmental correlates were different for walking compared to cycling. In order to further clarify the shape of these associations and reach more specific international guidelines for developing walkable and bikeable neighborhoods, future studies should include even more countries to maximize environmental variability.
doi:10.1186/1479-5868-9-70
PMCID: PMC3489620  PMID: 22691723
Physical activity; Ecological model; NEWS; Walkability
14.  Children’s physical activity and parents’ perception of the neighborhood environment: neighborhood impact on kids study 
Background
Physical activity is important to children’s physical health and well-being. Many factors contribute to children’s physical activity, and the built environment has garnered considerable interest recently, as many young children spend much of their time in and around their immediate neighborhood. Few studies have identified correlates of children’s activity in specific locations. This study examined associations between parent report of their home neighborhood environment and children’s overall and location-specific physical activity.
Methods
Parents and children ages 6 to 11 (n=724), living in neighborhoods identified through objective built environment factors as high or low in physical activity environments, were recruited from Seattle and San Diego metropolitan areas, 2007–2009. Parents completed a survey about their child’s activity and perceptions of home neighborhood environmental attributes. Children wore an accelerometer for 7 days. Multivariate regression models explored perceived environment correlates of parent-reported child’s recreational physical activity in their neighborhood, in parks, and in general, as well as accelerometry-based moderate-to-vigorous activity (MVPA) minutes.
Results
Parent-reported proximity to play areas correlated positively with both accelerometery MVPA and parent-reported total child physical activity. Lower street connectivity and higher neighborhood aesthetics correlated with higher reported child activity in the neighborhood, while reported safety from crime and walk and cycle facilities correlated positively with reported child activity in public recreation spaces.
Conclusions
Different aspects of parent’s perceptions of the neighborhood environment appear to correlate with different aspects of children’s activity. However, prioritizing closer proximity to safe play areas may best improve children’s physical activity and, in turn, reduce their risk of obesity and associated chronic diseases.
doi:10.1186/1479-5868-10-39
PMCID: PMC3615958  PMID: 23531282
Built environment; Perceptions; Recreation; Play
15.  The Built Environment and Risk of Obesity in the United States: Racial-Ethnic Disparities 
Health & place  2012;18(6):1314-1322.
Using data from the 2003–2008 waves of the continuous National Health Nutrition Examination Survey merged with the 2000 census and GIS-based data, this study conducted genderspecific analyses to explore whether neighborhood built environment attributes are significant correlates of obesity risk and mediators of obesity disparities by race-ethnicity. Results indicate that the built environment is a significant correlate of obesity risk but is not much of a mediator of obesity disparities by race-ethnicity. Neighborhood walkability, density, and distance to parks are significant covariates of obesity risks net of individual and neighborhood controls. Gender differences are found for some of these associations.
doi:10.1016/j.healthplace.2012.09.002
PMCID: PMC3501580  PMID: 23099113
Obesity; racial-ethnic disparities; neighborhood SES; built environment; continuous NHANES
16.  Understanding Social Disparities in Hypertension Prevalence, Awareness, Treatment, and Control: The Role of Neighborhood Context 
Social science & medicine (1982)  2007;65(9):1853-1866.
The spatial segregation of the U.S. population by socioeconomic position and especially race-ethnicity suggests that the social contexts or “neighborhoods” in which people live may substantially contribute to social disparities in hypertension. The Chicago Community Adult Health Study did face-to-face interviews, including direct measurement of blood pressure, with a representative probability sample of adults in Chicago. These data were used to estimate socioeconomic and racial-ethnic disparities in the prevalence, awareness, treatment, and control of hypertension, and to analyze how these disparities are related to the areas in which people live. Hypertension was significantly negatively associated with neighborhood affluence/gentrification, and adjustments for context eliminated the highly significant disparity between blacks/African-Americans and whites, and reduced the significant educational disparity by 10–15% to borderline statistical significance. Awareness of hypertension was significantly higher in more disadvantaged neighborhoods and in places with higher concentrations of blacks (and lower concentrations of Hispanics and immigrants). Adjustment for context completely eliminated blacks’ greater awareness, but slightly accentuated the lesser awareness of Hispanics and the greater levels of awareness among the less educated. There was no consistent evidence of either social disparities in or contextual associations with treatment of hypertension, given awareness. Among those on medication, blacks were only 40–50% as likely as whites to have their hypertension controlled, but context played little or no role in either the level of or disparities in control of hypertension. In sum, residential contexts potentially play a large role in accounting for racial-ethnic, and to a lesser degree, socioeconomic disparities in hypertension prevalence and, in a different way, awareness, but not in treatment or control of diagnosed hypertension.
doi:10.1016/j.socscimed.2007.05.038
PMCID: PMC2705439  PMID: 17640788
Neighborhoods; social disparities; multi-level modeling; health inequalities; hypertension; blood pressure
17.  Neighborhood walkability and cardiometabolic risk factors in australian adults: an observational study 
BMC Public Health  2013;13:755.
Background
Studies repeatedly highlight associations between the built environment and physical activity, particularly walking. Fewer studies have examined associations with cardiometabolic risk factors, with associations with obesity inconsistent and scarce evidence examining associations with other cardiometabolic risk factors. We aim to investigate the association between neighborhood walkability and the prevalence of obesity, hypertension, hypercholesterolaemia, and type-2 diabetes mellitus.
Methods
Cross-sectional study of 5,970 adults in Western Australia. Walkability was measured objectively for a 1,600 m and 800 m neighborhood buffer. Logistic regression was used to assess associations overall and by sex, adjusting for socio-demographic factors. Mediation by physical activity and sedentary behavior was investigated.
Results
Individuals living in high compared with less walkable areas were less likely to be obese (1,600 m OR: 0.84, 95% CI: 0.7 to 1; 800 m OR: 0.75, 95% CI: 0.62 to 0.9) and had lower odds of type-2 diabetes mellitus at the 800 m buffer (800 m OR: 0.69, 95% CI: 0.51 to 0.93). There was little evidence for an association between walkability and hypertension or hypercholesterolaemia. The only significant evidence of any difference in the associations in men and women was a stronger association with type-2 diabetes mellitus at the 800 m buffer in men. Associations with obesity and diabetes attenuated when additionally adjusting for physical activity and sedentary behavior but the overall association with obesity remained significant at the 800 m buffer (800 m OR: 0.78, 95% CI: 0.64 to 0.96).
Conclusions
A protective association between neighborhood walkability and obesity was observed. Neighborhood walkability may also be protective of type-2 diabetes mellitus, particularly in men. No association with hypertension or hypercholesterolaemia was found. This warrants further investigation. Findings contribute towards the accumulating evidence that city planning and policy related strategies aimed at creating supportive environments could play an important role in the prevention of chronic diseases.
doi:10.1186/1471-2458-13-755
PMCID: PMC3844350  PMID: 23947939
Built environment; Walkability; Cardiometabolic risk factors
18.  Do measures matter? Comparing surface-density-derived and census-tract-derived measures of racial residential segregation 
Background
Racial residential segregation is hypothesized to affect population health by systematically patterning health-relevant exposures and opportunities according to individuals' race or income. Growing interest into the association between residential segregation and health disparities demands more rigorous appraisal of commonly used measures of segregation. Most current studies rely on census tracts as approximations of the local residential environment when calculating segregation indices of either neighborhoods or metropolitan areas. Because census tracts are arbitrary in size and shape, reliance on this geographic scale limits understanding of place-health associations. More flexible, explicitly spatial derivations of traditional segregation indices have been proposed but have not been compared with tract-derived measures in the context of health disparities studies common to social epidemiology, health demography, or medical geography. We compared segregation measured with tract-derived as well as GIS surface-density-derived indices. Measures were compared by region and population size, and segregation measures were linked to birth record to estimate the difference in association between segregation and very preterm birth. Separate analyses focus on metropolitan segregation and on neighborhood segregation.
Results
Across 231 metropolitan areas, tract-derived and surface-density-derived segregation measures are highly correlated. However overall correlation obscures important differences by region and metropolitan size. In general the discrepancy between measure types is greatest for small metropolitan areas, declining with increasing population size. Discrepancies in measures are greatest in the South, and smallest in Western metropolitan areas. Choice of segregation index changed the magnitude of the measured association between segregation and very preterm birth. For example among black women, the risk ratio for very preterm birth in metropolitan areas changed from 2.12 to 1.68 for the effect of high versus low segregation when using surface-density-derived versus tract-derived segregation indices. Variation in effect size was smaller but still present in analyses of neighborhood racial composition and very preterm birth in Atlanta neighborhoods.
Conclusion
Census tract-derived measures of segregation are highly correlated with recently introduced spatial segregation measures, but the residual differences among measures are not uniform for all areas. Use of surface-density-derived measures provides researchers with tools to further explore the spatial relationships between segregation and health disparities.
doi:10.1186/1476-072X-9-29
PMCID: PMC2898812  PMID: 20540797
19.  Prevalence of Major Cardiovascular Risk Factors and Cardiovascular Diseases Among Hispanic/Latino Individuals of Diverse Backgrounds in the United States 
Context
Major cardiovascular diseases (CVDs) are leading causes of mortality among US Hispanic and Latino individuals. Comprehensive data are limited regarding the prevalence of CVD risk factors in this population and relations of these traits to socioeconomic status (SES) and acculturation.
Objectives
To describe prevalence of major CVD risk factors and CVD (coronary heart disease [CHD] and stroke) among US Hispanic/Latino individuals of different backgrounds, examine relationships of SES and acculturation with CVD risk profiles and CVD, and assess cross-sectional associations of CVD risk factors with CVD.
Design, Setting, and Participants
Multicenter, prospective, population-based Hispanic Community Health Study/Study of Latinos including individuals of Cuban (n =2201), Dominican (n = 1400), Mexican (n=6232), Puerto Rican (n=2590), Central American (n=1634), and South American backgrounds (n = 1022) aged 18 to 74 years. Analyses involved 15 079 participants with complete data enrolled between March 2008 and June 2011.
Main Outcome Measures
Adverse CVD risk factors defined using national guidelines for hypercholesterolemia, hypertension, obesity, diabetes, and smoking. Prevalence of CHD and stroke were ascertained from self-reported data.
Results
Age-standardized prevalence of CVD risk factors varied by Hispanic/Latino background; obesity and current smoking rates were highest among Puerto Rican participants (for men, 40.9% and 34.7%; for women, 51.4% and 31.7%, respectively); hypercholesterolemia prevalence was highest among Central American men (54.9%) and Puerto Rican women (41.0%). Large proportions of participants (80% of men, 71% of women) had at least 1 risk factor. Age- and sex-adjusted prevalence of 3 or more risk factors was highest in Puerto Rican participants (25.0%) and significantly higher (P<.001) among participants with less education (16.1%), those who were US-born (18.5%), those who had lived in the United States 10 years or longer (15.7%), and those who preferred English (17.9%). Overall, self-reported CHD and stroke prevalence were low (4.2% and 2.0% in men; 2.4% and 1.2% in women, respectively). In multivariate-adjusted models, hypertension and smoking were directly associated with CHD in both sexes as were hypercholesterolemia and obesity in women and diabetes in men (odds ratios [ORs], 1.5–2.2). For stroke, associations were positive with hypertension in both sexes, diabetes in men, and smoking in women (ORs, 1.7–2.6).
Conclusion
Among US Hispanic/Latino adults of diverse backgrounds, a sizeable proportion of men and women had adverse major risk factors; prevalence of adverse CVD risk profiles was higher among participants with Puerto Rican background, lower SES, and higher levels of acculturation.
doi:10.1001/jama.2012.14517
PMCID: PMC3777250  PMID: 23117778
20.  Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups 
The American journal of psychiatry  2008;165(3):359-369.
Objective
Although widely reported among Latinos, contradictory evidence exists regarding the generalizability of the immigrant paradox; that foreign nativity is protective against psychiatric disorders. We examine whether this paradox applies to all Latino groups by contrasting estimates of lifetime psychiatric disorders among Latino immigrants, Latino U.S-born, and non-Latino whites.
Method
Data from the National Latino and Asian American Study and the National Comorbidity Survey Replication represent some of the largest nationally-representative samples with psychiatric information.
Results
In aggregate, Latinos are at lower risk of most psychiatric disorders compared to non-Latinos whites and, consistent with the immigrant paradox, U.S.-born Latinos report higher rates for most psychiatric disorders than Latino immigrants. However, rates vary when data are stratified by nativity and disorder and adjusted by demographic and socioeconomic differences across groups. Among Mexicans, the immigrant paradox consistently holds across mood, anxiety and substance disorders while it is only evident among Cubans and Other Latinos for substance disorders. No differences were found in lifetime prevalence rates between migrant and U.S.-born Puerto Ricans.
Conclusions
Caution should be exercised in generalizing the immigrant paradox to all Latinos and for all psychiatric disorders. Aggregating Latinos into a single group masks great variability in lifetime risk for psychiatric disorders, with some subgroups, like Puerto Ricans, suffering from psychiatric disorders at rates comparable to non-Latino whites. Our findings thus suggest that the protective context in which immigrants lived in their country of origin possibly inoculated them against risk for substance disorders, particularly if they immigrated as adults.
doi:10.1176/appi.ajp.2007.07040704
PMCID: PMC2712949  PMID: 18245178
21.  Generational status and duration of residence predict diabetes prevalence among Latinos: the California Men's Health Study 
BMC Public Health  2009;9:392.
Background
Diabetes disproportionately affects Latinos. However, examining Latinos as one group obscures important intra-group differences. This study examined how generational status, duration of US residence, and language preference are associated with diabetes prevalence and to what extent these explain the higher prevalence among Latinos.
Methods
We determined nativity, duration of US residence, language preference, and diabetes prevalence among 11 817 Latino, 6109 black, and 52 184 white participants in the California Men's Health Study. We combined generational status and residence duration into a single migration status variable with levels: ≥ third generation; second generation; and immigrant living in the US for > 25, 16-25, 11-15, or ≤ 10 years. Language preference was defined as language in which the participant took the survey. Logistic regression models were specified to assess the associations of dependent variables with prevalent diabetes.
Results
Diabetes prevalence was 22%, 23%, and 11% among Latinos, blacks, and whites, respectively. In age-adjusted models, we observed a gradient of risk of diabetes by migration status among Latinos. Further adjustment for socioeconomic status, obesity and health behaviors only partially attenuated this gradient. Language preference was a weak predictor of prevalent diabetes in some models and not significant in others. In multivariate models, we found that odds of diabetes were higher among US-born Latinos than US-born blacks.
Conclusion
Generational status and residence duration were associated with diabetes prevalence among middle-aged Latino men in California. As the Latino population grows, the burden of diabetes-associated disease is likely to increase and demands public health attention.
doi:10.1186/1471-2458-9-392
PMCID: PMC2770491  PMID: 19840393
22.  Racial differences in the built environment—body mass index relationship? A geospatial analysis of adolescents in urban neighborhoods 
Background
Built environment features of neighborhoods may be related to obesity among adolescents and potentially related to obesity-related health disparities. The purpose of this study was to investigate spatial relationships between various built environment features and body mass index (BMI) z-score among adolescents, and to investigate if race/ethnicity modifies these relationships. A secondary objective was to evaluate the sensitivity of findings to the spatial scale of analysis (i.e. 400- and 800-meter street network buffers).
Methods
Data come from the 2008 Boston Youth Survey, a school-based sample of public high school students in Boston, MA. Analyses include data collected from students who had georeferenced residential information and complete and valid data to compute BMI z-score (n = 1,034). We built a spatial database using GIS with various features related to access to walking destinations and to community design. Spatial autocorrelation in key study variables was calculated with the Global Moran’s I statistic. We fit conventional ordinary least squares (OLS) regression and spatial simultaneous autoregressive error models that control for the spatial autocorrelation in the data as appropriate. Models were conducted using the total sample of adolescents as well as including an interaction term for race/ethnicity, adjusting for several potential individual- and neighborhood-level confounders and clustering of students within schools.
Results
We found significant positive spatial autocorrelation in the built environment features examined (Global Moran’s I most ≥ 0.60; all p = 0.001) but not in BMI z-score (Global Moran’s I = 0.07, p = 0.28). Because we found significant spatial autocorrelation in our OLS regression residuals, we fit spatial autoregressive models. Most built environment features were not associated with BMI z-score. Density of bus stops was associated with a higher BMI z-score among Whites (Coefficient: 0.029, p < 0.05). The interaction term for Asians in the association between retail destinations and BMI z-score was statistically significant and indicated an inverse association. Sidewalk completeness was significantly associated with a higher BMI z-score for the total sample (Coefficient: 0.010, p < 0.05). These significant associations were found for the 800-meter buffer.
Conclusion
Some relationships between the built environment and adolescent BMI z-score were in the unexpected direction. Our findings overall suggest that the built environment does not explain a large proportion of the variation in adolescent BMI z-score or racial disparities in adolescent obesity. However, there are some differences by race/ethnicity that require further research among adolescents.
doi:10.1186/1476-072X-11-11
PMCID: PMC3488969  PMID: 22537116
Spatial epidemiology; Neighborhood effects; Built environment; BMI; Adolescents; Race effects
23.  Individual and environmental factors associated for overweight in urban population of Brazil 
BMC Public Health  2013;13:988.
Background
Obesity is a significant global public health problem and the main cause of many chronic diseases in both developed and developing countries. The increase in obesity in different populations worldwide cannot be explained solely by metabolic and genetic factors; environmental and social factors also have a strong association with obesity. Thus, it is believed that the current obesity epidemic is the result of a complex combination of genetic factors and an obesogenic environment .The purpose of this study was to evaluate individual variables and variables within the built and social environment for their potential association with overweight and obesity in an urban Brazilian population.
Methods
Cross-sectional study was carried out in a sample of 3404 adults living in the urban area of the city. Information from the surveillance system for chronic diseases of Brazilian Ministry of Health was used and individual data was collected by telephone interviews. The database was geocoded using the Brazilian System of Postal Codes for participant residences. An updated, existing list based on the current addresses of supermarkets and hypermarkets in the city was used as an indicator variable of the availability and access to food. Georeferenced information on parks, public squares, places for practicing physical activity and the population density were also used to create data on the built environment. To characterize the social environment, we used the health vulnerability index (HVI) and georeferenced data for homicide locations.
Results
The prevalence was 44% for overweight, poisson regression was used to create the final model. The environment variables that independently associated with overweight were the highest population density, very high health vulnerability index and the homicide rate adjusted for individuals variables. The results of the current study illustrate and confirm some important associations between individual and environmental variables and overweight in a representative sample of adults in the Brazilian urban context.
Conclusions
The social environment variables relating to the socioeconomic deprivation of the neighborhood and the built environment variables relating to higher walkability were significantly associated with overweight and obesity in Belo Horizonte.
doi:10.1186/1471-2458-13-988
PMCID: PMC3854448  PMID: 24143958
24.  Neighborhood Context and Social Disparities in Cumulative Biological Risk Factors 
Psychosomatic medicine  2011;73(7):572-579.
Objective
This study examines the role of neighborhood context in the accumulation of biological risk factors and racial/ethnic and socioeconomic disparities.
Method
Data come from face-to-face interviews and blood collection on a probability sample of adults (n=549) in the 2002 Chicago Community Adult Health Study. Following the approach of prior studies, we constructed an index of cumulative biological risk (CBR) by counting how many of eight biomarkers exceeded clinically defined criteria for “high risk”: systolic and diastolic blood pressure, resting heart rate, hemoglobin A1c, C-reactive protein, waist size, and total and HDL cholesterol. Data are presented as incidence rate ratios (IRR) based on generalized linear models with a Poisson link function and population-average estimates with robust standard errors.
Results
Non-Hispanic blacks (n=200), Hispanics (n=149), and people with low (n=134) and moderate (n=275) education had significantly higher numbers of biological risks than their respective reference groups (IRR=1.48, 1.59, 1.62, and 1.48, respectively, with p-values <0.01). Black-white (p<0.001) and Hispanic-white (p<0.003) disparities in CBR remained significant after adjusting for individual-level socioeconomic position and behavioral factors, while individual-level controls substantially diminished the low/high (p<0.069) and moderate/high (p<0.042) educational differences. Estimating “within-neighborhood” disparities to adjust for neighborhood context fully explained the black-white gap in CBR (p<0.542) and reduced the Hispanic-white gap to borderline significance (p<0.053). Neighborhood affluence predicted lower levels of CBR (IRR=0.82, p<0.027), but neighborhood disadvantage was not significantly associated with CBR (IRR=1.00, p<0.948).
Conclusions
Neighborhood environments appear to play a pivotal role in the accumulation of biological risk and disparities therein.
doi:10.1097/PSY.0b013e318227b062
PMCID: PMC3216672  PMID: 21862824
social environment; health disparities; cumulative biological risk; allostatic load; risk factor
25.  The Neighborhood Energy Balance Equation: Does Neighborhood Food Retail Environment + Physical Activity Environment = Obesity? The CARDIA Study 
PLoS ONE  2013;8(12):e85141.
Background
Recent obesity prevention initiatives focus on healthy neighborhood design, but most research examines neighborhood food retail and physical activity (PA) environments in isolation. We estimated joint, interactive, and cumulative impacts of neighborhood food retail and PA environment characteristics on body mass index (BMI) throughout early adulthood.
Methods and Findings
We used cohort data from the Coronary Artery Risk Development in Young Adults (CARDIA) Study [n=4,092; Year 7 (24-42 years, 1992-1993) followed over 5 exams through Year 25 (2010-2011); 12,921 person-exam observations], with linked time-varying geographic information system-derived neighborhood environment measures. Using regression with fixed effects for individuals, we modeled time-lagged BMI as a function of food and PA resource density (counts per population) and neighborhood development intensity (a composite density score). We controlled for neighborhood poverty, individual-level sociodemographics, and BMI in the prior exam; and included significant interactions between neighborhood measures and by sex. Using model coefficients, we simulated BMI reductions in response to single and combined neighborhood improvements. Simulated increase in supermarket density (from 25th to 75th percentile) predicted inter-exam reduction in BMI of 0.09 kg/m2 [estimate (95% CI): -0.09 (-0.16, -0.02)]. Increasing commercial PA facility density predicted BMI reductions up to 0.22 kg/m2 in men, with variation across other neighborhood features [estimate (95% CI) range: -0.14 (-0.29, 0.01) to -0.22 (-0.37, -0.08)]. Simultaneous increases in supermarket and commercial PA facility density predicted inter-exam BMI reductions up to 0.31 kg/m2 in men [estimate (95% CI) range: -0.23 (-0.39, -0.06) to -0.31 (-0.47, -0.15)] but not women. Reduced fast food restaurant and convenience store density and increased public PA facility density and neighborhood development intensity did not predict reductions in BMI.
Conclusions
Findings suggest that improvements in neighborhood food retail or PA environments may accumulate to reduce BMI, but some neighborhood changes may be less beneficial to women.
doi:10.1371/journal.pone.0085141
PMCID: PMC3874030  PMID: 24386458

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