Jeffrey R. Kling

Neighborhoods, Obesity, and Diabetes — A Randomized Social Experiment

BACKGROUNDnThe question of whether neighborhood environment contributes directly to the development of obesity and diabetes remains unresolved. The study reported on here uses data from a social experiment to assess the association of randomly assigned variation in neighborhood conditions with obesity and diabetes.nnnMETHODSnFrom 1994 through 1998, the Department of Housing and Urban Development (HUD) randomly assigned 4498 women with children living in public housing in high-poverty urban census tracts (in which ≥40% of residents had incomes below the federal poverty threshold) to one of three groups: 1788 were assigned to receive housing vouchers, which were redeemable only if they moved to a low-poverty census tract (where <10% of residents were poor), and counseling on moving; 1312 were assigned to receive unrestricted, traditional vouchers, with no special counseling on moving; and 1398 were assigned to a control group that was offered neither of these opportunities. From 2008 through 2010, as part of a long-term follow-up survey, we measured data indicating health outcomes, including height, weight, and level of glycated hemoglobin (HbA(1c)).nnnRESULTSnAs part of our long-term survey, we obtained data on body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) for 84.2% of participants and data on glycated hemoglobin level for 71.3% of participants. Response rates were similar across randomized groups. The prevalences of a BMI of 35 or more, a BMI of 40 or more, and a glycated hemoglobin level of 6.5% or more were lower in the group receiving the low-poverty vouchers than in the control group, with an absolute difference of 4.61 percentage points (95% confidence interval [CI], -8.54 to -0.69), 3.38 percentage points (95% CI, -6.39 to -0.36), and 4.31 percentage points (95% CI, -7.82 to -0.80), respectively. The differences between the group receiving traditional vouchers and the control group were not significant.nnnCONCLUSIONSnThe opportunity to move from a neighborhood with a high level of poverty to one with a lower level of poverty was associated with modest but potentially important reductions in the prevalence of extreme obesity and diabetes. The mechanisms underlying these associations remain unclear but warrant further investigation, given their potential to guide the design of community-level interventions intended to improve health. (Funded by HUD and others.).

Neighborhood Effects on the Long-Term Well-Being of Low-Income Adults

Location, Location, Location It seems obvious that a persons residential neighborhood will influence their sense of well-being, but it has been difficult to nail down cause and effect. Ludwig et al. (p. 1505; see the Perspective by Sampson) describe the analysis, 10 to 15 years onward, of a large-scale social experiment carried out in five U.S. cities in the mid 1990s. Several thousand residents of poor neighborhoods were given housing vouchers that could only be used if they moved into much less poor neighborhoods. In comparison to a similar group of individuals who did not move, those who did experienced substantial improvement in their subjective well-being. Moving from a poor to a less poor residential environment makes people feel good for a long time. Nearly 9 million Americans live in extreme-poverty neighborhoods, places that also tend to be racially segregated and dangerous. Yet, the effects on the well-being of residents of moving out of such communities into less distressed areas remain uncertain. Using data from Moving to Opportunity, a unique randomized housing mobility experiment, we found that moving from a high-poverty to lower-poverty neighborhood leads to long-term (10- to 15-year) improvements in adult physical and mental health and subjective well-being, despite not affecting economic self-sufficiency. A 1–standard deviation decline in neighborhood poverty (13 percentage points) increases subjective well-being by an amount equal to the gap in subjective well-being between people whose annual incomes differ by

Associations of Housing Mobility Interventions for Children in High-Poverty Neighborhoods With Subsequent Mental Disorders During Adolescence

13,000—a large amount given that the average control group income is

Framing Lifetime Income

20,000. Subjective well-being is more strongly affected by changes in neighborhood economic disadvantage than racial segregation, which is important because racial segregation has been declining since 1970, but income segregation has been increasing.

Notice of Retraction and Replacement: Kessler RC, et al. Associations of Housing Mobility Interventions for Children in High-Poverty Neighborhoods With Subsequent Mental Disorders During Adolescence. JAMA. 2014;311(9):937-947.

IMPORTANCEnYouth in high-poverty neighborhoods have high rates of emotional problems. Understanding neighborhood influences on mental health is crucial for designing neighborhood-level interventions.nnnOBJECTIVEnTo perform an exploratory analysis of associations between housing mobility interventions for children in high-poverty neighborhoods and subsequent mental disorders during adolescence.nnnDESIGN, SETTING, AND PARTICIPANTSnThe Moving to Opportunity Demonstration from 1994 to 1998 randomized 4604 volunteer public housing families with 3689 children in high-poverty neighborhoods into 1 of 2 housing mobility intervention groups (a low-poverty voucher group vs a traditional voucher group) or a control group. The low-poverty voucher group (n=1430) received vouchers to move to low-poverty neighborhoods with enhanced mobility counseling. The traditional voucher group (n=1081) received geographically unrestricted vouchers. Controls (n=1178) received no intervention. Follow-up evaluation was performed 10 to 15 years later (June 2008-April 2010) with participants aged 13 to 19 years (0-8 years at randomization). Response rates were 86.9% to 92.9%.nnnMAIN OUTCOMES AND MEASURESnPresence of mental disorders from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) within the past 12 months, including major depressive disorder, panic disorder, posttraumatic stress disorder (PTSD), oppositional-defiant disorder, intermittent explosive disorder, and conduct disorder, as assessed post hoc with a validated diagnostic interview.nnnRESULTSnOf the 3689 adolescents randomized, 2872 were interviewed (1407 boys and 1465 girls). Compared with the control group, boys in the low-poverty voucher group had significantly increased rates of major depression (7.1% vs 3.5%; odds ratio (OR), 2.2 [95% CI, 1.2-3.9]), PTSD (6.2% vs 1.9%; OR, 3.4 [95% CI, 1.6-7.4]), and conduct disorder (6.4% vs 2.1%; OR, 3.1 [95% CI, 1.7-5.8]). Boys in the traditional voucher group had increased rates of PTSD compared with the control group (4.9% vs 1.9%, OR, 2.7 [95% CI, 1.2-5.8]). However, compared with the control group, girls in the traditional voucher group had decreased rates of major depression (6.5% vs 10.9%; OR, 0.6 [95% CI, 0.3-0.9]) and conduct disorder (0.3% vs 2.9%; OR, 0.1 [95% CI, 0.0-0.4]).nnnCONCLUSIONS AND RELEVANCEnInterventions to encourage moving out of high-poverty neighborhoods were associated with increased rates of depression, PTSD, and conduct disorder among boys and reduced rates of depression and conduct disorder among girls. Better understanding of interactions among individual, family, and neighborhood risk factors is needed to guide future public housing policy changes.

Mechanism Experiments and Policy Evaluations

We provide evidence that individuals optimize imperfectly when making annuity decisions, and that this result is not driven by loss aversion. Annuities are more attractive when presented in a consumption frame rather than in an investment frame. Highlighting the purchase price in the consumption frame does not alter this result. The level of habitual spending has little interaction with preferences for annuities in the consumption frame. In an investment frame, consumers prefer annuities with principal guarantees; this result is similar for guarantee amounts below, at, and above the purchase price. We discuss implications for the retirement services industry and its regulators.

Long-Term Neighborhood Effects on Low-Income Families: Evidence from Moving to Opportunity

Letters COMMENT & RESPONSE Notice of Retraction and Replacement: Kessler RC, et al. Associations of Housing Mobility Interventions for Children in High-Poverty Neighborhoods With Subsequent Mental Disorders During Adolescence. JAMA. 2014;311(9):937-947. To the Editor In the Original Investigation entitled “Associa- tions of Housing Mobility Interventions for Children in High- Poverty Neighborhoods With Subsequent Mental Disorders During Adolescence” published in the March 5, 2014, issue of JAMA, 1 we inadvertently reported incorrect confidence inter- vals and a P value in 2 tables. This study explored the associa- tions between 2 types of vouchers given to volunteer public housing families to encourage them to move out of high- poverty neighborhoods (when children were age 0-8 years) and no intervention and subsequent mental disorders in 2872 ado- lescents (at age 13-19 years). The errors were due to failure to update results from an earlier set of models. These errors were discovered in the course of rechecking the code in conjunction with a secondary analy- sis. We have corrected these errors and confirmed that there are no other errors after reviewing our original analysis and findings. The corrections for these errors have changed 1 of the major findings of the study: the previously reported statisti- cally significant reduction in major depressive disorder in girls was not statistically significant. Thus, we have requested that the original article be retracted and replaced. In Table 4, incorrect 95% CIs were reported for major de- pressive disorder for each of the groups; the absolute risks (ARs) and absolute risk reductions (ARRs) have not changed. For the AR in the low-poverty voucher group (n = 1424), the correct data are AR 6.8%, 95% CI 4.9%-8.7% (not 6.8%, 95% CI −12.0% to 25.6%); and the correct data for the ARR are 0.3%, 95% CI −1.8% to 2.3% (not 0.3%, 95% CI, −27.0% to 27.6%). For the AR in the traditional voucher group (n = 1074), the correct data are AR 6.1%, 95% CI 4.5% to 7.7% (not 6.1%, 95% CI −20.1% to 32.4%) and for the ARR, the correct data are 1.0%, 95% CI −1.0% to 3.0% (not 1.0%, 95% CI −30.7% to 32.7%). For the AR in the control group (n = 1173), the correct data are AR 7.1%, 95% CI 5.8% to 8.4% (not 7.1%, 95% CI −21.8% to 35.9%). An incor- rect CI was also reported in Table 5 for the AR of conduct dis- order among girls in the traditional voucher group (n = 533). The correct data are AR 0.3%, 95% CI −0.1% to 0.7% (not 0.3%, 95% CI 0.0% to 0.7%). An incorrect P value was also reported in Table 5 for the effect of the traditional voucher interven- tion on major depressive disorder among girls. The correct P value is .06 (not .04). None of the other findings in Tables 4 or 5 were affected by the errors. The corrections for these errors indicate that the previ- ously reported statistically significant reduction in major de- pressive disorder in girls was not statistically significant, and this result has been removed from the conclusion of the ar- ticle. The article now concludes: “Interventions to encourage moving out of high-poverty neighborhoods were associated with increased rates of depression, PTSD, and conduct disor- der among boys and a reduced rate of conduct disorder among girls. Better understanding of interactions among individual, family, and neighborhood risk factors is needed to guide fu- ture public housing policy changes.” We regret these errors as well as the confusion caused to JAMA, readers, and potentially to public housing policy plan- ners. The abstract, text, and Tables 4 and 5 of the original ar- ticle have been corrected and replaced online. 1 An additional online supplement has been added that includes a version of the original article with the errors highlighted and a version of the replacement article with the corrections highlighted. Ronald C. Kessler, PhD Greg J. Duncan, PhD Lisa A. Gennetian, PhD Lawrence F. Katz, PhD Jeffrey R. Kling, PhD Nancy A. Sampson, BA Lisa Sanbonmatsu, PhD Alan M. Zaslavsky, PhD Jens Ludwig, PhD Author Affiliations: Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (Kessler, Sampson, Zaslavsky); School of Education, University of California-Irvine (Duncan); National Bureau of Economic Research, Cambridge, Massachusetts (Gennetian, Katz, Kling, Sanbonmatsu, Ludwig); Department of Economics, Harvard University, Cambridge, Massachusetts (Katz); Congressional Budget Office, Washington, DC (Kling); Harris School of Public Policy, University of Chicago, Chicago, Illinois (Ludwig). Corresponding Author: Ronald C. Kessler, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (kessler @hcp.med.harvard.edu). Published Online: June 17, 2016. doi:10.1001/jama.2016.6187 Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Kessler reported that he has been a consultant for AstraZeneca, Analysis Group, Bristol-Myers Squibb, Cerner-Galt Associates, Eli Lilly, GlaxoSmithKline, HealthCore, Health Dialog, Hoffman-LaRoche, Integrated Benefits Institute, J & J Wellness & Prevention, John Snow, Kaiser Permanente, Lake Nona Institute, Matria, Mensante, Merck, Ortho-McNeil Janssen Scientific Affairs, Pfizer, Primary Care Network, Research Triangle Institute, sanofi-aventis, Shire US, SRA International, Takeda Global Research & Development, Transcept Pharmaceuticals, and Wyeth-Ayerst; has served on advisory boards for Appliance Computing II, Eli Lilly, Mindsite, Ortho-McNeil Janssen Scientific Affairs, Johnson & Johnson, Plus One Health Management, and Wyeth-Ayerst; has had research support for his epidemiological studies from Analysis Group Inc, Bristol-Myers Squibb, Eli Lilly & Company, EPI-Q, GlaxoSmithKline, Johnson & Johnson Pharmaceuticals, Ortho-McNeil Janssen Scientific Affairs, Pfizer, sanofi-aventis, Shire US, and Walgreens; and owns 25% share in DataStat. Dr Gennetian reported that he has served on advisory boards for Family Self Sufficiency TWG, Administration for Children and Families, and National Opinion Research Center, University of Chicago. Dr Katz reported that he has served on advisory boards for Manpower Demonstration Research Corporation and the Russell Sage Foundation. Dr Ludwig reported that he serves on advisory jama.com (Reprinted) JAMA July 12, 2016 Volume 316, Number 2 Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/ by a University of California - Irvine User on 12/30/2016