A systematic review of neighbourhood economic context on child obesity and obesity-related behaviours.

Childhood obesity is of great importance given a third of children in the USA are overweight or obese. Previous research has examined neighbourhood economic context in relation to children's obesity and obesity-rated behaviours. However, different definitions and measures of neighbourhood context make it difficult to compare findings and make definitive conclusions. This review is to synthesize studies assessing the associations between neighbourhood economic context and children's obesity or obesity-related behaviours. The review included 39 studies investigating the relationship between residential neighbourhood economic context and children's obesity, dietary habits or physical activity after controlling for family-level economic status. Studies reported mixed results in the relationship between neighbourhood economic indicators and child obesity outcomes. Of reviewed studies, 60% showed an inverse association between higher neighbourhood economic status and obesity, and 33% and 14% showed positive associations between higher neighbourhood economic status and healthy dietary habits or physical activity. Several studies suggested gender, age, race/ethnicity, individual-level economic status, rurality and social connectedness as moderators in the neighbourhood-obesity association. Findings suggest that, in order to move towards causal inferences and inform interventions, future research should examine neighbourhood impacts longitudinally and test theory-driven mediators and moderators to clarify the mechanisms by which neighbourhoods influence child obesity.

Dynamic poverty experiences and development of overweight in a prospective cohort of US children aged 4-14 years.

OBJECTIVE: To examine the associations between poverty dynamics and the long-term risk of developing overweight or obesity. DESIGN AND METHODS: Our data are a representative sample of US children from the National Longitudinal Survey of Youth 1979 Child and Young Adult Survey (1986-2008). We used survival analysis to compare risk of developing overweight or obesity among 5,613 children aged 4-14 years from never poor households, transient poor households (those that became poor only once), recurrent poor households (those that became poor more than once), and persistent poor households (those that became poor and remained poor for at least 4 consecutive years) and examined interactions by race/ethnicity, gender, and age. RESULTS: Compared with children from never poor households, children from transient poor households (HR 0.79, 95% CI: 0.68-0.92), recurrent poor households (HR: 0.73, 95% CI: 0.62-0.87), and persistently poor households (HR: 0.62, 95% CI: 0.51-0.74) had significantly reduced risks of becoming overweight or obese. These associations did not vary by race/ethnicity, gender, or age. CONCLUSIONS: Our findings suggest that poverty experiences are associated with reduced risk of becoming overweight or obese among children of 4-14 years.

Levels of analysis for the study of environmental health disparities.

Reducing racial/ethnic and socioeconomic environmental health disparities requires a comprehensive multilevel conceptual and quantitative approach that recognizes the various levels through which environmental health disparities are produced and perpetuated. We propose a conceptual framework that incorporates the micro level, contained within the local level, which in turn is contained within the macro level. We discuss the utility of multilevel techniques to examine environmental level (both physical and social) and individual-level factors to appropriately quantify and improve our understanding of environmental health disparities. We discuss the reasoning and the methodological approach behind multilevel modeling, including differentiating between individual and contextual influences on individual outcomes. Next we address the questions and principles that guide the choice of levels or geographic units in multilevel studies. Finally, we address the ways in which different data sources can be combined to produce suitable data for multilevel analyses. We provide some examples of how such data sources can be linked to create multilevel data structures, and offer suggestions to facilitate the integration of multilevel techniques in environmental health disparities research and monitoring.

Influence of individual and neighbourhood socioeconomic status on mortality among black, Mexican-American, and white women and men in the United States.

STUDY OBJECTIVE: s: This study examines the influence of individual and neighbourhood socioeconomic status (SES) on mortality among black, Mexican-American, and white women and men in the US. The authors had three study objectives. Firstly, they examined mortality rates by both individual level SES (measured by income, education, and occupational/employment status) and neighbourhood level SES (index of neighbourhood income/wealth, educational attainment, occupational status, and employment status). Secondly, they examined whether neighbourhood SES was associated with mortality after controlling for individual SES. Thirdly, they calculated the population attributable risk to estimate the reduction in mortality rates if all women and men lived in the highest SES neighbourhoods. DESIGN: National Health Interview Survey (1987-1994), linked with 1990 census tract (neighbourhood proxy) and mortality data through 1997. SETTING/PARTICIPANTS: Nationally representative sample of 59 935 black, 19 201 Mexican-American, and 344 432 white men and women (six gender and racial/ethnic groups), aged 25-64 at interview. MAIN RESULTS: Mortality rates for all six gender and racial/ethnic groups were two to four times higher for those with the lowest incomes (lowest quartile) who lived in the lowest SES neighbourhoods (lowest tertile) compared with those with the highest incomes who lived in the highest SES neighbourhoods. For the six groups, the age adjusted mortality risk associated with living in the lowest SES neighbourhoods ranged from 1.43 to 1.61. The mortality risk decreased but remained significant (p values <.05) after adjusting for each of the three individual measures of SES, with the exception of Mexican-American women. Furthermore, the mortality risk associated with living in the lowest SES neighbourhoods remained significant after simultaneously adjusting for all three individual measures of SES for white men (p<0.001) and white women (p<0.05). Deaths would hypothetically be reduced by about 20% for each subgroup if everyone had the same death rates as those living in the highest SES neighbourhoods (highest tertile). CONCLUSIONS: Living in a low SES neighbourhood confers additional mortality risk beyond individual SES.

Neighborhood context and cardiovascular disease risk factors: the contribution of material deprivation.

This paper investigates whether neighborhood material deprivation is associated with cardiovascular disease (CVD) risk factors (physical inactivity, diabetes, smoking, body mass index, blood pressure, cholesterol) independent of individual socioeconomic status (SES) in Black, Mexican-American, and White women and men aged 25-64 using data from the Third National Health and Nutrition Examination Survey (1988-1994, N = 9,961). The data were linked to 1990 Census tract characteristics (unemployment, car ownership, rented housing, crowded housing), which were used to construct a neighborhood-level material deprivation index. Results are stratified by gender and race/ethnicity. Multiple logistic and linear regression models were specified using SUDAAN to account for the clustered design. In general, residence in a deprived neighborhood increased the probability of having an adverse CVD risk profile, independent of an individual's SES. For example, after adjusting for SES, Black women living in deprived neighborhoods were at increased risk of being diabetic, being a smoker, and having a higher body mass index and blood pressure compared to Black women living in less deprived neighborhoods (P values <.05). Stronger associations were found between neighborhood deprivation and CVD risk factors in Blacks than in Mexican Americans despite living in similarly deprived neighborhoods. Neighborhood deprivation may influence CVD risk factors through a variety of mechanisms including the availability of healthy environments, municipal services, and political/cultural characteristics. Policies and interventions that address the socioeconomic context in which people live might reduce inequalities in CVD risk factors.

Measuring socioeconomic status/position in studies of racial/ethnic disparities: maternal and infant health.

OBJECTIVE: Theoretical and empiric considerations raise concerns about how socioeconomic status/position (abbreviated here as SES) is often measured in health research. The authors aimed to guide the use of two common socioeconomic indicators, education and income, in studies of racial/ethnic disparities in low birthweight, delayed prenatal care, unintended pregnancy, and breastfeeding intention. METHODS: Data from a statewide postpartum survey in California (N = 10,055) were linked to birth certificates. Overall and by race/ethnicity, the authors examined: (a) correlations among several measures of education and income; (b) associations between each SES measure and health indicator; and (c) racial/ethnic disparities in the health indicators "adjusting" for different SES measures. RESULTS: Education-income correlations were moderate and varied by race/ethnicity. Racial/ethnic associations with the health indicators varied by SES measure, how SES was specified, and by health indicator. CONCLUSIONS: Conclusions about the role of race/ethnicity could vary with how SES is measured. Education is not an acceptable proxy for income in studies of ethnically diverse populations of childbearing women. SES measures generally should be outcome- and population-specific, and chosen on explicit conceptual grounds; researchers should test multiple theoretically appropriate measures and consider how conclusions might vary with how SES is measured. Researchers should recognize the difficulty of measuring SES and interpret findings accordingly.

Socioeconomic status and injury mortality: individual and neighbourhood determinants.

STUDY OBJECTIVE: This study examined both individual and neighbourhood correlates of injury mortality to better understand the contribution of socioeconomic status to cause specific injury mortality. Of particular interest was whether neighbourhood effects remained after adjusting for individual demographic characteristics and socioeconomic status. DESIGN: Census tract data (measuring small area socioeconomic status, racial concentration, residential stability, urbanisation, and family structure) was merged with the National Health Interview Survey (NHIS) and a file that links the respondents to subsequent follow up of vital status and cause of death data. Cox proportional hazards models were specified to determine individual and neighbourhood effects on homicide, suicide, motor vehicle deaths, and other external causes. Variances are adjusted for the clustered sample design of the NHIS. SETTING: United States, 1987-1994, with follow up to the end of 1995. PARTICIPANTS: From a sample of 472 364 persons ages 18-64, there were 1195 injury related deaths over the follow up period. MAIN RESULTS: Individual level effects were generally robust to the inclusion of neighbourhood level variables in the models. Neighbourhood characteristics had independent effects on the outcome even after adjustment for individual variability. For example, there was approximately a twofold increased risk of homicide associated with living in a neighborhood characterised by low socioeconomic status, after adjusting for individual demographic and socioeconomic characteristics. CONCLUSIONS: Social inequalities in injury mortality exist for both persons and places. Policies or interventions aimed at preventing or controlling injuries should take into account not only the socioeconomic characteristics of people but also of the places in which they live.

Socioeconomic status and the occurrence of fatal and nonfatal injury in the United States.

OBJECTIVES: This study examined the contribution of socioeconomic status (SES) to the risk of injury mortality and morbidity among working-age adults. METHODS: The sample consisted of respondents to the National Health Interview Survey (1987-1994), and separate analyses were conducted for injury deaths to respondents by linking to the National Death Index. Proportional hazards regression models were used to analyze mortality. Logistic regression models were used to analyze morbidity. RESULTS: The effects of SES varied substantially by cause of injury mortality and indicator of SES. In the multivariate models, blue-collar workers were at significantly increased odds of nonfatal injury. Education was unrelated to total injury morbidity, although associations were observed after stratification of the outcome by severity and place of occurrence. Black persons were at increased risk for homicide, and Black and Hispanic persons were at decreased risk for suicide and nonfatal injuries, after adjustment for SES. CONCLUSIONS: SES is an important determinant of injury, although the effect depends on the indicator of SES and the cause and severity of injury.

Social context and geographic patterns of homicide among US black and white males.

OBJECTIVES: The recently published Atlas of United States Mortality depicted striking regional differences in homicide rates for Black and White males in the United States. This study examined these rates to gain an understanding of the contribution of social context to geographic variability in homicide. METHODS: Homicide rates were calculated by health service area for the years 1988 to 1992. The contributions of age, geographic location, urbanization, and sociostructural characteristics were evaluated by means of a weighted linear mixed effects model. RESULTS: Regional differences in urbanization explained much of the geographic variation in homicide rates, but sociostructural factors also had a significant impact. The results suggest that these effects operate similarly for White and Black males, although differences were found in the magnitudes of the effects for the 2 groups. CONCLUSIONS: Results point to a strong association between homicide and urbanization and socioeconomic conditions in all regions of the country for both Black and White males. These findings shed light on the potential correlates of high homicide rates in the United States in the near future.

Pathways by which SES and ethnicity influence cardiovascular disease risk factors.

Little is known about pathways by which socioeconomic status (SES) translates into individual differences in cardiovascular disease (CVD) risk factors. Because the socioeconomic structure is not the same for all ethnic subgroups, the pathways that lead to the development of CVD risk factors may vary by both SES and ethnicity. We used data from a large national survey to examine the independent associations of two indicators of SES (education and income) and ethnicity with six primary CVD risk factors. We then used data on smoking that reflected a temporal sequence to examine the extent to which SES and ethnicity influenced smoking at three different time points, from smoking onset, to a serious quit attempt, to successful quitting. These analyses provide an understanding of the relationships between SES, ethnicity, and CVD risk factors and suggest that if the timing, focus, and content of intervention programs take pathways into account they will result in more successful outcomes.

The structure of informal care: are there differences by race?

This study investigated whether there are race differences in the structure of informal caregiving networks. Data on 3,793 functionally impaired persons age 65 and over from the 1989 National Long-Term Care Survey were analyzed. The size of the total caregiver network and the unpaid network did not differ by race, but the likelihood of there being a non-immediate family member among unpaid caregivers was higher among disabled older blacks. These findings raise questions about whether race differences in nursing home utilization and paid long-term care services, documented in other studies, can be explained by differences in caregiving arrangements.

Distribution of O-acetylated sialomucin in the normal and diseased gastrointestinal tract shown by a new monoclonal antibody.

AIMS: To produce and characterise a monoclonal antibody specific for O-acetylated sialomucin and to assess its use in immunohistochemistry on a panel of normal and diseased intestinal tissue samples. METHODS: Mouse monoclonal antibodies were developed following immunisation with highly purified human colonic mucin. One of these (MMM-17) showed strong binding to mucin throughout the normal colon with relative lack of binding to colon cancer tissue. The binding epitope of MMM-17 was then characterised by screening for agglutination activity against a panel of human and animal erythrocytes and by assessment of its binding to a range of normal and chemically treated slot blotted mucins. Further immunohistochemical studies were then performed on formalin fixed, normal, and diseased human intestinal samples. RESULTS: Binding of MMM-17 to slot blotted human colonic mucin was reduced by 38 (SD 14%) (n = 4) by alkali treatment of the mucin, sequential alkali and sialidase treatment completely abolished binding. Sialidase treatment alone, however, caused only an 11 (11%) reduction in binding. MMM-17 failed to agglutinate any human, rabbit, rat or mouse erythrocytes. These findings were compatible with specificity of MMM-17 for sialomucins O-acetylated at the C-7 or C-8 positions on the sialic acid. Strong staining by MMM-17 was found in all goblet cells throughout all 40 normal colonic and rectal samples studied, but staining was absent in seven of 13 colorectal carcinomas. Normal duodenum (n = 16) and normal ileum (n = 3) all showed occasional positive goblet cells. The normal gastric antral mucosa was generally negative B MMM-17, but in all of 15 cases of gastritis with intestinal metaplasia the metaplastic glands were strongly positive for MMM-17. CONCLUSION: Monoclonal antibody MMM-17 has specificity for O-acetylated sialomucins and its binding depends both on the position of O-acetylation and on the adjacent oligosaccharide structure. Preliminary studies using the antibody on archival tissue samples support the previous reports of reduced O-acetylation in colon cancer demonstrated by indirect histochemistry and show the neo-formation of O-acetylated sialomucin in intestinal metaplasia in the stomach.