Rachel Widome

Food Security and Metabolic Syndrome in U.S. Adults and Adolescents: Findings From the National Health and Nutrition Examination Survey, 1999–2006

PURPOSE We sought to examine the association of food security and metabolic syndrome in a representative sample of U.S. adults and adolescents. We hypothesized that compared with those in food-secure households, adolescents and adults living in food-insecure households would have increased odds of (MetS). METHODS Data from the National Health and Nutrition Examination Surveys from 1999 to 2006 were combined and analyzed cross-sectionally. Logistic regression was used to compute odds ratios and 95% confidence intervals (95% CI) in the association of household food security (fully food secure, marginal, low, and very low food security) and MetS. RESULTS Compared with those who were food secure, adults in households with marginal food security had 1.80-fold increased odds of MetS (95% CI, 1.30-2.49), and those with very low food security had a 1.65-fold increased odds of MetS (95% CI 1.12-2.42). There was no association with low food security. The association of marginal household food security and MetS was not significant in adolescents. In adults and adolescents, very low was food security not associated with increased odds of MetS compared with those who were food secure. CONCLUSIONS Members of households with marginal and very low food security are at increased risk of MetS. A mechanism may be that foods that are inexpensive and easily accessible tend to be energy dense and nutrient poor.

Adolescent Smoking Trajectories: Results from a Population-Based Cohort Study

PURPOSE To identify distinct smoking trajectories during adolescence and assess how smoking-related factors relate to trajectory membership. METHODS The sample includes 3637 youth from across the state of Minnesota. Measures include tobacco use, smoking behaviors of parents and friends, youth smoking-related attitudes and beliefs, and home smoking policies. A cohort-sequential design was used to identify smoking trajectories, including five cohorts of youth (ages 12-16) followed for 3 years. RESULTS Six distinct trajectories of tobacco use were found: nonsmokers (54%), triers (17%), occasional users (10%), early established (7%), late established (8%), and decliners (4%). Several factors were associated with increased likelihood of being in a smoking trajectory group (vs. the nonsmoking group): parental smoking, friend smoking, greater perceptions of the number of adults and teenagers who smoke, and higher functional meaning of tobacco use. In contrast, higher perceived difficulty smoking in public places, negative perceptions of the tobacco industry, and home smoking policies were associated with less likelihood of being in one of the smoking trajectories (vs. the nonsmoking trajectory). CONCLUSIONS Adolescents exhibit diverse patterns of smoking during adolescence and tobacco-related influences were strong predictors of trajectory membership.

Meaningful Differences: Comparison of Adult Women Who First Traded Sex as a Juvenile Versus as an Adult

The authors analyzed experiences, characteristics, and risks of adult women who trade sex in Minneapolis, MN (n = 117), and found significant differences between women who first traded sex as a juvenile compared with those who first traded sex as an adult. Adult starters were 3.44 times more likely to use drugs prior to their first sex trade. They were also more likely to have children. Juvenile starters were more likely to trade sex prior to their first instance of drug use and they had worse outcomes in most other domains that were measured. The study findings showed that they can be useful in shaping prevention of prostitution and methods to be used for its intervention.

The relationship of neighborhood demographic characteristics to point-of-sale tobacco advertising and marketing

Objectives. Exposure to tobacco marketing has been associated with an increased likelihood that youth start smoking and may interfere with tobacco cessation. We aimed to describe the prevalence, placement, and features of tobacco advertising at the point of sale by race, ethnicity, and other neighborhood demographics, as well as by store type. Design. A cross-sectional assessment of the advertising environment in establishments that held tobacco licenses in our study region (a metropolitan area in the Midwest USA) was conducted in 2007. Stores were geocoded and linked with block group demographic data taken from the Year 2000 US census. We calculated associations between our hypothesized predictors, race, ethnicity, and other neighborhood demographics, and two types of outcomes (1) amount and (2) characteristics of the advertising. Results. Tobacco advertising at the point of sale was most common in gas stations/convenience stores, liquor stores, and tobacco stores. A 10% difference in a block groups African-American/Black population was associated with 9% (95% confidence interval [CI]=3%, 16%) more ads as well as a greater likelihood that ads would be close to the ground (prevalence ratio [PR]=1.15 [95% CI=1.04, 1.28]). Block groups with greater African-American/Black, Asian, people on public assistance or below 150% of the poverty threshold, or people under the age of 18 years had more ads for menthol brands. Block groups with greater proportions of Whites were more likely to have ads that used health words, such as ‘light’ or ‘natural’ (PR for 10% difference in White population=1.41 [95% CI=1.17–1.70]). Chain stores were more likely to have greater amounts of advertising, ads close to the ground, ads for price deals, or ads that use words that imply health. Conclusion. Tobacco advertising targets communities with various racial and ethnic profiles in different ways. Now that US Food and Drug Administration has the authority to regulate the marketing and sale of tobacco products, there is new opportunity to reduce the harmful impact of tobacco advertising.

Post-traumatic stress disorder and health risk behaviors among Afghanistan and Iraq War veterans attending college

OBJECTIVE To determine if post-traumatic stress disorder (PTSD) is associated with health risk behaviors among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans attending college. METHOD Using 2008 Boynton College Student Health Survey data, we tested associations between self-reported PTSD diagnosis and self-reported risk behaviors (n=406). RESULTS We found PTSD diagnosis to be significantly associated with reporting involvement in a physical fight in the past year (ARR = 3.1; 95% CI: 2.2, 4.4) and marginally associated with highrisk drinking (ARR = 1.3; 95% CI: 1.1, 1.6). However, no association was seen between PTSD and the tobacco use and other safety behaviors that we examined. CONCLUSION PTSD is likely a factor that contributes to the relationship between military service and certain health risk behaviors.

Relapse among cigarette smokers: The CARDIA longitudinal study - 1985–2011:

RATIONALE There is little information about long-term relapse patterns for cigarette smokers. OBJECTIVE To describe long-term prevalence of relapse and related smoking patterns by sex, race, age, and education level among a community-based cohort of young adults followed for 25 years. METHODS We examined 25 years of data from Coronary Artery Risk Development in Young Adults (CARDIA), an ongoing study of a community-based cohort of 5115 men and women aged 18 to 30 years at baseline with periodic re-examinations. At each examination smoking, quitting, and relapse were queried. We examined prevalence of smoking relapse among 3603 participants who attended at least 6 of the 8 examinations. RESULTS About 53% of 3603 participants never reported smoking on a regular basis. Among the remaining 1682 ever smokers, 52.8% of those who reported current smoking at baseline were still smoking by the end of the study, compared to 10.7% of those who initiated smoking by year 5. Among those classified as former smokers at baseline, 39% relapsed at least once; of these, 69.5% had quit again by the end of the study. Maximum education level attained, age at study baseline, and race were associated with failure to quit smoking by the end of the study and relapse among those who did quit. Maximum education level attained and age at study baseline were also associated with ability to successfully quit after a relapse. CONCLUSIONS Smoking relapse after quitting is common, especially in those with lower education level. Education was the strongest predictor of all three outcomes. Improvements in access to treatment and treatment options, especially for underserved populations, are needed to prevent relapse when smokers quit.

Science, Prudence, and Politics: The Case of Smoke-Free Indoor Spaces

PURPOSE We examine the process of how epidemiologic evidence regarding the harms of secondhand smoke (SHS) exposure has been translated into policy and distill lessons that could be applied to other public health areas. METHODS We detail the history of the growth of evidence and the development of prudent policies in this area and the parallel, organized efforts led by the tobacco industry to oppose them. We also describe how opposition to these policies helped shape the emerging research agenda. RESULTS Seven lessons emerged from our study. (i) Even after a policy goal has been achieved, the need for epidemiological evidence and inquiry remains. (ii) Dissemination and implementation research is necessary. (iii) The best and most necessary research questions do not always come from epidemiologists. (iv) There is a need for epidemiologists to work with other researchers across disciplines. (v) Epidemiologists must anticipate the opposition. (vi) Focused, well-organized advocacy is needed to translate even the strongest epidemiological evidence into policy change. (vii) Epidemiologists should be trained to engage and interact with public health advocates, practitioners, and policy makers. CONCLUSIONS Although this case study shows that policy can be driven by science, it also demonstrates that clear scientific evidence does not automatically lead to optimal policy.

Training primary care clinicians in motivational interviewing: A comparison of two models

OBJECTIVES To evaluate implementing two training models for motivational interviewing (MI) to address tobacco use with primary care clinicians. METHODS Clinicians were randomized to moderate or high intensity. Both training modalities included a single ½ day workshop facilitated by MI expert trainers. The high intensity (HI) training provided six booster sessions including telephone interactions with simulated patients and peer coaching by MI champions over 3 months. To assess performance of clinicians to deliver MI, an objective structured clinical evaluation (OSCE) was conducted before and 12 weeks after the workshop training. RESULTS Thirty-four clinicians were enrolled; 18 were randomly assigned to HI. Compared to the moderate intensity group, the HI group scored significantly higher during the OSCE for three of six global Motivational Interviewing Treatment Integrity scale scores. There was also significant improvement for three of the four measures of MI counseling knowledge, skills and confidence. CONCLUSIONS Using champions and telephone interactions with simulated patients as enhancement strategies for MI training programs is feasible in the primary care setting and results in greater gains in MI proficiency. PRACTICE IMPLICATIONS Results confirm and expand evidence for use of booster sessions to improve the proficiency of MI training programs for primary care clinicians.

Young People and Violence

Violence is one of the leading causes of adolescent morbidity and mortality around the world. Young people are disproportionately represented among both the perpetrators and victims of violence. There are multiple factors within the contexts in which young people live, their families, schools, peer groups, neighborhoods, and sociopolitical environments, that predispose to and buffer against violence. Likewise, there are multiple preventive strategies that effectively address these factors and reduce violence involvement and injury. Youth violence can be prevented by applying science-based public health approaches to defining the problem, determining root causes, correlates, and modifiable risk and resilience factors, and designing, implementing, evaluating, disseminating, and sustaining effective interventions.

The Effect of Cognitive Load and Patient Race on Physicians' Decisions to Prescribe Opioids for Chronic Low Back Pain: A Randomized Trial

OBJECTIVE To test the hypothesis that racial biases in opioid prescribing would be more likely under high levels of cognitive load, defined as the amount of mental activity imposed on working memory, which may come from environmental factors such as stressful conditions, chaotic workplace, staffing insufficiency, and competing demands, ones own psychological or physiological state, as well as from demands inherent in the task at hand. DESIGN Two (patient race: White vs Black) by two (cognitive load: low vs high) between-subjects factorial design. SETTING AND PARTICIPANTS Ninety-eight primary care physicians from the Veterans Affairs Healthcare System. METHODS Web-based experimental study. Physicians were randomly assigned to read vignettes about either a Black or White patient, under low vs high cognitive load, and to indicate their likelihood of prescribing opioids. High cognitive load was induced by having physicians perform a concurrent task under time pressure. RESULTS There was a three-way interaction between patient race, cognitive load, and physician gender on prescribing decisions (P = 0.034). Hypotheses were partially confirmed. Male physicians were less likely to prescribe opioids for Black than White patients under high cognitive load (12.5% vs 30.0%) and were more likely to prescribe opioids for Black than White patients under low cognitive load (30.8% vs 10.5%). By contrast, female physicians were more likely to prescribe opioids for Black than White patients in both conditions, with greater racial differences under high (39.1% vs 15.8%) vs low cognitive load (28.6% vs 21.7%). CONCLUSIONS Physician gender affected the way in which patient race and cognitive load influenced decisions to prescribe opioids for chronic pain. Future research is needed to further explore the potential effects of physician gender on racial biases in pain treatment, and the effects of physician cognitive load on pain treatment.