Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

Geographic Residency Status and Census Tract Socioeconomic Status as Determinants of Colorectal Cancer Outcomes

Objectives. We examined the impact of geographic residency status and census tract (CT)-level socioeconomic status (SES) on colorectal cancer (CRC) outcomes.Methods. This was a retrospective cohort study of patients diagnosed with CRC in Georgia for the years 2000 through 2007. Study outcomes were late-stage disease at diagnosis, receipt of treatment, and survival.Results. For colon cancer, residents of lower-middle-SES and low-SES census tracts had decreased odds of receiving surgery. Rural, lower-middle-SES, and low-SES residents had decreased odds of receiving chemotherapy. For patients with rectal cancer, suburban residents had increased odds of receiving radiotherapy, but low SES resulted in decreased odds of surgery. For survival, rural residents experienced a partially adjusted 14% (hazard ratio [HR] = 1.14; 95% confidence interval [CI] = 1.07, 1.22) increased risk of death following diagnosis of CRC that was somewhat explained by treatment differences and completely explained by CT-level SES. Lower-middle- and low-SES participants had an adjusted increased risk of death following diagnosis for CRC (lower-middle: HR = 1.16; 95% CI = 1.10, 1.22; low: HR = 1.24; 95% CI = 1.16, 1.32).Conclusions. Future efforts should focus on developing interventions and policies that target rural residents and lower SES areas to eliminate disparities in CRC-related outcomes.For men and women in the United States, colorectal cancer (CRC) ranks third in incidence and mortality among cancers, with an estimated 142 820 new cases and 50 830 deaths in 2013.1 Reflecting the US population distribution according to geography2 and evidence of similar incidence rates3,4 for rural residents, approximately 20% of incident CRC cases are expected to occur in rural populations. Although CRC incidence is equivalent for rural and urban residents, CRC mortality is higher in rural populations,5 and the causes of rural versus urban disparities in CRC mortality are not well understood. Compared with their suburban and urban counterparts, rural citizens are more likely to be older, live in poverty, have less education, lack health insurance, and have no regular health care provider.6–9 These facets of rural living pose challenges to accessing health promotional messages and high-quality primary care, not to mention treatment of cancer.10,11Those of lower socioeconomic status (SES) have worse health-related outcomes than their more affluent counterparts, and SES often has a gradient effect on health.12 A challenge in studying the association between rurality and health is being able to disentangle the confounding effect of SES associated with geographic residency.13 As we previously demonstrated for a sample of urban and rural residents of Georgia with CRC, rural residence was associated with an increased risk of death following diagnosis.14 A limitation of that study was an inability to account for SES differences between urban and rural populations. If adjustment for SES explains the poorer survival that is associated with rural residence, this explanation provides an opportunity to investigate mediators of the SES effect as potential avenues for intervention.15 Identification of these mediating factors will facilitate the development of focused interventions with the goal of eliminating rural CRC-related disparities.16,17Building on our previous work,14 we evaluated the independent and combined effects of rurality and area-level SES on CRC outcomes. In our previous study, (1) we were unable to evaluate the independent and potential confounding effect of SES on rurality,2 (2) our study population was a sample of the Georgia CRC population, and (3) residents were classified as urban or rural at the county level, which may have resulted in misclassification. In the present study, the exposures of interest were geographic residency status (rural, suburban, or urban) and area-level SES, both at the census tract (CT) level. In addition, the study population represents the entire state of Georgia rather than a sample. The primary study outcome was overall survival. Secondarily, we wanted to evaluate the effect of SES and geography adjusted for SES on the odds of late-stage disease at diagnosis and receipt of first-course treatment.The findings of this study are meant to bring importance to a highly relevant area of public health research: disparities related to rural versus urban cancer outcomes, and specifically to rural CRC outcomes. As a result, interventions may be designed and policies developed to address the difficulties of accessing and providing high-quality cancer care in rural areas of the United States.11 It is through the combination of applying what is learned from epidemiological findings to community-level interventions and policymaking that the elimination of health disparities will occur.18     

Let’s Get Physical: Sexual Orientation Disparities in Physical Activity,Sports Involvement,and Obesity Among a Population-Based Sample of Adolescents

Objectives. We examined sexual orientation disparities in physical activity, sports involvement, and obesity among a population-based adolescent sample.Methods. We analyzed data from the 2012 Dane County Youth Assessment for 13 933 students in grades 9 through 12 in 22 Wisconsin high schools. We conducted logistic regressions to examine sexual orientation disparities in physical activity, sports involvement, and body mass index among male and female adolescents.Results. When we accounted for several covariates, compared with heterosexual females, sexual minority females were less likely to participate in team sports (adjusted odds ratio [AOR] = 0.44; 95% confidence interval [CI] = 0.37, 0.53) and more likely to be overweight (AOR = 1.28; 95% CI = 1.02, 1.62) or obese (AOR = 1.88; 95% CI = 1.43, 2.48). Sexual minority males were less likely than heterosexual males to be physically active (AOR = 0.62; 95% CI = 0.46, 0.83) or to participate in team sports (AOR = 0.26; 95% CI = 0.20, 0.32), but the 2 groups did not differ in their risk of obesity.Conclusions. Sexual orientation health disparities in physical activity and obesity are evident during adolescence. Culturally affirming research, interventions, and policies are needed for sexual minority youths.Obesity is an increasing and serious health problem among adolescents.1,2 This is of major concern because obesity has many health and social consequences and it affects adolescents’ overall well-being.3,4 Obesity among adolescents also has a high likelihood of continuing into adulthood.5 Recent population-based and longitudinal research has demonstrated that there are disparities in obesity between sexual minority and heterosexual adolescents.6–8 Research has also documented sexual orientation disparities in physical activity and sports involvement in adolescence.9,10 Despite this increased attention, the overall empirical base remains limited, and findings also suggest some gender nuances that need further exploration. More population-based research is needed to investigate these disparities, consistent with federal health priorities.7,11There are sexual orientation–based disparities in physical activity and sports involvement among adolescents; however, there are mixed findings for females. One study reported that sexual minority females are less likely than heterosexual females to participate in moderate to vigorous physical activity and team sports,9 whereas another study found no such differences in physical activity.10 Findings are more consistent for sexual minority male adolescents, who are less likely than heterosexual males to engage in moderate to vigorous physical activity, to engage in recommended levels of physical activity, and to participate in team sports.9,10 More research is needed because of the paucity of studies and mixed results. This is especially important given that adolescents’ physical activity has been shown to relieve stress and protect against many mental and physical health conditions, including obesity,12,13 for which sexual minority adolescents are at greater risk.Research on sexual orientation disparities in obesity suggests that there are some gender nuances. Many studies have found that sexual minority female adolescents have higher risk of obesity than heterosexual females (e.g., higher body mass index [BMI], defined as weight in kilograms divided by the square of height in meters).6,8,10,14 These sexual orientation disparities in obesity among adolescent females parallel those among sexual minority adult women.15,16Findings of elevated obesity risk among sexual minority male adolescents are mixed. Some studies show that sexual minority males, specifically bisexual males, have higher odds of obesity than heterosexuals,14 whereas other studies have documented no differences.10 By contrast, some studies have found that heterosexual males have increases in BMI during adolescence compared with sexual minority males.6,8 These mixed findings for sexual minority males might be attributed to physical maturation and developmental changes in adolescence that some of the cross-sectional studies could not examine.10,14 Specifically, one study found that sexual minority males had higher obesity risk than heterosexual males in early adolescence, but their risk of obesity became lower than for heterosexual males later in adolescence.6 The authors postulated that, compared with heterosexual males, sexual minority males reach puberty maturation earlier in adolescence but make less substantial weight gains later in adolescence.6Sexual orientation health disparities have been explained through the minority stress model: sexual minority youths experience unique stressors and stigma related to their sexual identity (e.g., homophobic bullying), which lead to poorer health.17 Sexual minority adolescents might therefore be less likely to be physically active or involved in team sports because of potential minority stressors that they often experience at school, especially bias and heightened discrimination experienced in the context of sports or in their communities.18–20 More recently, the negative effects of minority stress and stigma on physical health disparities have been documented,21,22 including their effects on obesity for sexual minority women.23 However, the minority stress model is not sufficient in explaining how sexual minority adolescent females, but not males, are at greater risk for obesity compared with their heterosexual peers.Another potential explanation of these obesity disparities is related to cultural norms and sexual minority females’ experiences of internalizing ideals for femininity and appearance8 and sexual minority males’ ideals for muscularity and body image.24 For instance, compared with heterosexual women, sexual minority women are more likely to be satisfied with their bodies and attracted to women with greater body mass,25,26 whereas sexual minority men are less likely to be satisfied with their bodies compared with heterosexual men and are more likely to be attracted to muscular men.25,27 Therefore, these 2 groups might engage (or not engage) in differing body weight management and dieting behaviors compared with their heterosexual peers; concomitantly, these behaviors might render differing risks for obesity.Sexual minority adolescents’ lack of physical activity and sports involvement might be influenced by traditional gender norms associated with athleticism and sports, which has implications for their athletic self-esteem and involvement. For adolescent males, team sports are a means to define masculinity28; however, adolescent males often engage in homophobic banter to prove their masculinity and heterosexuality and to enforce traditional gender norms.29,30 Sexual prejudice is pervasive in athletic settings,19,20 making sports contexts unwelcoming and unsafe for many sexual minority males. Traditional feminine gender norms and homophobia also affect sexual minority females’ involvement in sports.31 However, sexual minority adolescent females have unique gendered experiences in relation to sports. Because women’s athleticism can be a stereotype for being a lesbian,32 sexual minority females might avoid sports involvement. Expecting or experiencing exclusion in sports settings might also affect sexual minority adolescents’ athletic self-esteem, consequently preventing them from engaging in future sports or physical activity.9 In fact, athletic self-esteem has been found to contribute to sexual orientation disparities in sports involvement and physical activity.9Emerging evidence of sexual orientation disparities in physical activity, sports involvement, and obesity among adolescents, in addition to potential gender nuances in these disparities, points to the need for more population-based research in this area. We therefore examined sexual orientation disparities among a large adolescent population-based sample and tested for gender differences. While accounting for variables commonly associated with physical activity and obesity among adolescents,4,33 we hypothesized that sexual minority adolescents would be less likely to report physical activity and sports involvement than would their heterosexual peers. We also hypothesized that sexual minority females would be at higher risk for being overweight and obese than their heterosexual peers. Because of mixed findings in existing sexual orientation disparities research among adolescent males, we hypothesized that sexual minority males would be at equal risk for being overweight and obese than their heterosexual male peers.     

Socioeconomic Status and Bullying: A Meta-Analysis

We examined whether socioeconomic status (SES) could be used to identify which schools or children are at greatest risk of bullying, which can adversely affect children’s health and life.We conducted a review of published literature on school bullying and SES. We identified 28 studies that reported an association between roles in school bullying (victim, bully, and bully-victim) and measures of SES. Random effects models showed SES was weakly related to bullying roles. Adjusting for publication bias, victims (odds ratio [OR] = 1.40; 95% confidence interval [CI] = 1.24, 1.58) and bully-victims (OR = 1.54; 95% CI = 1.36, 1.74) were more likely to come from low socioeconomic households. Bullies (OR = 0.98; 95% CI = 0.97, 0.99) and victims (OR = 0.95; 95% CI = 0.94, 0.97) were slightly less likely to come from high socioeconomic backgrounds.SES provides little guidance for targeted intervention, and all schools and children, not just those with more socioeconomic deprivation, should be targeted to reduce the adverse effects of bullying.Bullying is defined as repeated, harmful behavior, characterized by an imbalance of power between the victim and perpetrator(s).1 There is compelling evidence that school bullying affects children’s health and well being, with the effects lasting long into adulthood.2,3 Victims of school bullying are at greater risk of physical and mental health problems,4,5 including depression,6,7 anxiety,8,9 psychotic or borderline personality symptoms,10,11 and are more likely to self-harm and attempt suicide.12,13 A small proportion of victims are classified as bully-victims, children who are victimized by their peers, but who also bully other children. Bully-victims are at even greater risk for maladjustment,5 exhibiting attention and behavioral difficulties,4,14 displaying poor social skills,15,16 and reporting increased levels of depression and anxiety through adolescence and into adulthood.2 By contrast, the negative outcomes of bullying perpetration are less clear. Bullies have been found more likely to engage in delinquent or antisocial behavior17,18; however, once other family and childhood risk factors are taken into account, they do not appear to be at any greater risk for poorer health, criminal, or social outcomes in adulthood.3Up to one third of children are involved in bullying, as bully, victim, or bully-victim,19,20 and when considered alongside the damaging effects on physical and mental health, bullying can be seen as a major public health concern.21 Identifying risk factors for bullying aids potential efforts in targeting resources, which can prevent youths from becoming involved in bullying, but also limits the impact it has on their health and well being. Traditional risk factors, such as age and gender, show a clear association22,23; however, there are a range of other potential determinants whose relationship to bullying remain unclear. One such determinant is socioeconomic status (SES), which shows some links to bullying, but at present, research findings are inconsistent regarding roles (i.e., bully, victim, or bully-victim).SES is an aggregate concept comprising resource-based (i.e., material and social resources) and prestige-based (individual’s rank or status) indicators of socioeconomic position, which can be measured across societal levels (individual, household, and neighborhood) and at different periods in time.24 It can be assessed through individual measures, such as education, income, or occupation,25,26 but also through composite measures that combine or assign weights to different socioeconomic aspects to provide an overall index of socioeconomic level. There is no standard measure of SES; indicators are used to measure specific aspects of socioeconomic stratification.26 Accordingly, different measures of SES may show varying effects, which can result from differing causal pathways, or through interactions with other social characteristics, such as gender or race.27 The multifaceted nature of SES has resulted in a lack of consistency in how researchers measure its relationship to bullying, and although several studies provide individual assessments of this relationship, as yet there is no clear consensus over whether roles in bullying are associated with individual socioeconomic measures, or in general, with SES.Currently, the literature suggests some link between low SES and victims or bully-victims at school.28,29 Specifically, being a victim has been reported to be associated with poor parental education,30,31 low parental occupation,32 economic disadvantage,33,34 and poverty.35 In addition, several studies found that bully-victims are also more likely to come from low socioeconomic backgrounds,29,30 including low maternal education28 and maternal unemployment.36 However, others found little or no association between SES and victims or bully-victims.37–39 The type of bullying may matter in relation to SES. Victims of physical and relational bullying have been found to more often come from low affluence families, whereas victims of cyber bullying have not.40Compared with victimization, few studies have explored the link between SES and bullying others. Some studies found bullying others to be associated with low SES, including economic disadvantage,34 poverty,35 and low parental education.30 Additionally, where composite measures have been used, children from low socioeconomic backgrounds have been found to bully others slightly more often.29,41 By contrast, others found no association between bullying perpetration and measures of SES.38,39,42There is a small but growing body of literature that examines the relationship between bullying and SES, and although findings tend to suggest that victims, bully-victims, and bullies are more likely to come from low socioeconomic backgrounds, the results are far from conclusive. First, studies differ in their approach to measuring SES; some use composite measures, combining multiple indicators such as parental education, wealth, and occupation, whereas others concentrate on a single socioeconomic indicator, most often parental education, affluence, or occupation. How bullying relates to SES may differ according to which socioeconomic indicator is used; therefore, in interpreting results, one must consider not only how bullying relates to SES in general, but also which socioeconomic indicator was used, and how this may have influenced the result. Furthermore, although several studies indicate an association between bullying and low SES, the reported effect sizes vary greatly across studies, with some reporting weak and others moderate to strong associations. So far, the associations between bullying and SES have not been quantified across a range of studies in a systematic way. To address this gap in the literature, we conducted a systematic review and meta-analysis that aimed to determine more precisely the exact nature and strength of the relationship between SES and bullying. We systematically investigated the association between the role taken in school bullying (victim, bully, or bully-victim) and measures of SES.     

Mediation by Peer Violence Victimization of Sexual Orientation Disparities in Cancer-Related Tobacco,Alcohol, and Sexual Risk Behaviors: Pooled Youth Risk Behavior Surveys

Objectives. We examined the role of adolescent peer violence victimization (PVV) in sexual orientation disparities in cancer-related tobacco, alcohol, and sexual risk behaviors.Methods. We pooled data from the 2005 and 2007 Youth Risk Behavior Surveys. We classified youths with any same-sex sexual attraction, partners, or identity as sexual minority and the remainder as heterosexual. We had 4 indicators of tobacco and alcohol use and 4 of sexual risk and 2 PVV factors: victimization at school and carrying weapons. We stratified associations by gender and race/ethnicity.Results. PVV was related to disparities in cancer-related risk behaviors of substance use and sexual risk, with odds ratios (ORs) of 1.3 (95% confidence interval [CI] = 1.03, 1.6) to 11.3 (95% CI = 6.2, 20.8), and to being a sexual minority, with ORs of 1.4 (95% CI = 1.1, 1.9) to 5.6 (95% CI = 3.5, 8.9). PVV mediated sexual orientation disparities in substance use and sexual risk behaviors. Findings were pronounced for adolescent girls and Asian/Pacific Islanders.Conclusions. Interventions are needed to reduce PVV in schools as a way to reduce sexual orientation disparities in cancer risk across the life span.The Institute of Medicine recently reviewed the research literature on health disparities between lesbian, gay, bisexual, and transgender individuals and heterosexuals across the life span.1 It identified the significant role of stigma in the health of lesbian, gay, bisexual, and transgender individuals and areas in need of research, including disparities in cancer between sexual minorities (lesbian, gay, and bisexual persons) and heterosexuals. Behaviors that increase cancer risk (e.g., tobacco and alcohol use, unprotected sexual intercourse) may be initiated during adolescence. For sexual minorities, peer violence victimization (PVV) may partly explain disparities in cancer-related risk behaviors because such disparities between sexual minorities and heterosexuals have been attributed to the differential burden of stigma experienced by sexual minorities.1Certain behaviors place one at risk for cancer, and sexual orientation disparities exist in those cancer-related risk behaviors. Tobacco and alcohol use are risk factors for various types of cancers, such as lung, esophageal, oropharyngeal, and colon.2–8 More sexual minority adults and youths than their heterosexual peers report tobacco and alcohol use.9–18Several sexual risk behaviors (number of partners, early age of first intercourse, concurrent sexual partners, lack of condom use, and substance use during intercourse) are known to increase vulnerability to infection with, for example, human papillomavirus (HPV)19–29 and hepatitis B.30,31 Women who have sex with women have elevated rates of such sexual risk behaviors relative to women who only have sex with men.32–34 Women who only have sex with women are less likely to be screened for sexually transmitted infections,33,35,36 despite the risk of HPV transmission during female-to-female sexual intercourse.37 HPV in men is important because it is linked to anal, oral, and penile cancers.24,38 The risk of cancer-related sexual behaviors may be elevated among sexual minority men, because of the links between anal intercourse, HPV, and anal cancer,39 especially among men who are HIV positive.40 Hepatitis B has been linked to liver cancer41 and increased risk of anal HPV among men.31     

Community Poverty and Trends in Racial/Ethnic Survival Disparities Among People Diagnosed With AIDS in Florida, 1993–2004

Objectives. We described the racial/ethnic disparities in survival among people diagnosed with AIDS in Florida from 1993 to 2004, as the availability of highly active antiretroviral therapy (HAART) became widespread. We determined whether these disparities decreased after controlling for measures of community-level socioeconomic status.Methods. We compared survival from all causes between non-Hispanic Blacks and non-Hispanic Whites vis-a-vis survival curves and Cox proportional hazards models controlling for demographic, clinical, and area-level poverty factors.Results. Racial/ethnic disparities in survival peaked for those diagnosed during the early implementation of HAART (1996–1998) with a Black-to-White hazard ratio (HR) of 1.72 (95% confidence interval [CI] = 1.62, 1.83) for males and 1.40 (95% CI = 1.24, 1.59) for females. These HRs declined significantly to 1.48 (95% CI = 1.35, 1.64) for males and nonsignificantly to 1.25 (95% CI = 1.05, 1.48) for females in the 2002 to 2004 diagnosis cohort. Disparities decreased significantly for males but not females when controlling for baseline demographic factors and CD4 count and percentage, and became nonsignificant in the 2002 to 2004 cohort after controlling for area poverty.Conclusions. Area poverty appears to play a role in racial/ethnic disparities even after controlling for demographic factors and CD4 count and percentage.The HIV/AIDS epidemic has disproportionately affected the non-Hispanic Black population in the United States. In 2008, an estimated 545 000 non-Hispanic Blacks were living with HIV/AIDS.1 The estimated prevalence of HIV infection for 2008 among non-Hispanic Blacks was 18.2 per 1000 population, more than 7 times higher than the estimated rate for non-Hispanic Whites (non-Hispanic Whites; 2.4 per 1000).1 Non-Hispanic Blacks as a group not only have a higher prevalence of HIV/AIDS, but once infected also have a lower survival rate. The 3-year survival rate in the United States for people diagnosed with AIDS between 2001 and 2005 was 80% among non-Hispanic Blacks compared with 84% for non-Hispanic Whites, 83% for Hispanics, and 88% for Asians,2 further contributing to the disparities in the HIV mortality rate of 16.8 per 100 000 among non-Hispanic Blacks compared with 1.6 per 100 000 among non-Hispanic Whites during 2007.3 Race/ethnicity is a fundamentally social as opposed to a biological construct,4,5 and survival disparities between non-Hispanic Blacks and non-Hispanic Whites have not generally been seen in settings with universal health care access such as in the Veterans Administration health care system,6 the military health care system,7 or a health maintenance organization.8 Therefore, potentially modifiable social explanations for the observed racial/ethnic disparities in survival should be examined.A most remarkable advance in medical treatment in the past century was the development of highly active antiretroviral therapy (HAART). It led to a significant improvement in survival from HIV/AIDS, 9–12 but racial/ethnic disparities in HIV/AIDS survival remain2, 13–16 and in New York City appeared to widen.17 Despite these well-recognized health disparities, there is a critical gap in the knowledge about why the disparity exists. Two population-based studies, both in San Francisco, California (a city that has provided free HIV care for those who cannot afford it), found that Black race was no longer associated with survival between 1996 and 2001 after controlling for neighborhood socioeconomic status (SES), and that this SES effect seemed to be related to HAART use.18,19 However, in a study using HIV surveillance data from 33 states, racial/ethnic disparities in 5-year survival after HIV diagnosis between 1996 and 2003 persisted after adjusting for county-level SES and other factors.20 The objective of this study was to describe the racial/ethnic disparities in AIDS survival in Florida among people diagnosed with AIDS between 1993 and 2004 (a period spanning the time before and during the widespread availability of HAART) and to determine if these disparities decrease after controlling for community-level SES.     

Socioeconomic Disparities in Telephone-Based Treatment of Tobacco Dependence

Objectives. We examined socioeconomic disparities in tobacco dependence treatment outcomes from a free, proactive telephone counseling quitline.Methods. We delivered cognitive–behavioral treatment and nicotine patches to 6626 smokers and examined socioeconomic differences in demographic, clinical, environmental, and treatment use factors. We used logistic regressions and generalized estimating equations (GEE) to model abstinence and account for socioeconomic differences in the models.Results. The odds of achieving long-term abstinence differed by socioeconomic status (SES). In the GEE model, the odds of abstinence for the highest SES participants were 1.75 times those of the lowest SES participants. Logistic regression models revealed no treatment outcome disparity at the end of treatment, but significant disparities 3 and 6 months after treatment.Conclusions. Although quitlines often increase access to treatment for some lower SES smokers, significant socioeconomic disparities in treatment outcomes raise questions about whether current approaches are contributing to tobacco-related socioeconomic health disparities. Strategies to improve treatment outcomes for lower SES smokers might include novel methods to address multiple factors associated with socioeconomic disparities.In the United States, the prevalence of daily smoking among lower socioeconomic status (SES) groups is 3 to 4 times higher than that of higher SES groups and a leading contributor to socioeconomic health disparities.1–5 Comprehensive tobacco control programs can reduce these disparities by providing all smokers with effective treatment for tobacco dependence; however, significant socioeconomic disparities in treatment outcomes are observed in many treatment settings, raising concerns about contributing to or at least maintaining existing disparities with these approaches.6–14 Treatment delivered through telephone quitlines has become widely available in the United States and the United Kingdom.15 Proactive quitlines attract a large proportion of lower SES smokers16–18 and smokers with different demographic and clinical characteristics than in-person, community-based treatments.16,19,20 Because of their ubiquitous nature and because they appear to be especially accessible and attractive to lower SES smokers,16,17,18 quitlines have the potential to attenuate tobacco-related disparities; however, if quitlines also demonstrate socioeconomic disparities in treatment outcomes, then this would strengthen concerns about current approaches contributing to or maintaining these disparities.SES ideally incorporates the social and economic factors that influence what position individuals or groups hold in a societal structure.21,22 In health research, SES is a broad construct describing relative access to basic resources required to achieve or maintain good health.23,24 Consistent with leading conceptual models of health disparities,23–26 SES is empirically related to smoking cessation through complex reciprocal relations among clinical, environmental, and treatment utilization factors including stress, coping resources, psychological factors, exposure to other smokers, and use of treatment resources.6,27–32Cognitive–behavioral treatment (CBT) provided through proactive quitlines is a practical innovation that attracts a promising number of lower SES smokers.15–17,33 Although not targeted to or tailored for lower SES groups, CBT, when delivered appropriately, addresses individuals’ treatment-related clinical characteristics (e.g., stress, coping, dependence level, motivation, self-efficacy, environmental challenges). Nonetheless, significant disparities have been found in CBT treatment outcomes in many tobacco treatment settings.6–14 Quitlines treat smokers with different characteristics than in-person treatment,16,19,20 however, and thus might not demonstrate the same disparities as in-person CBT treatment.6–13We investigated socioeconomic disparities in tobacco dependence treatment outcomes using data from a proactive quitline in Arkansas in operation from 2005 to 2008. We used statistical modeling of abstinence at the end of treatment (EOT) and 3 and 6 months after treatment to examine the independent contribution of SES to treatment outcomes controlling for other factors. Consistent with findings from community-based treatment, we hypothesized that after accounting for demographic, clinical, environmental, and treatment utilization factors, the lowest SES participants would be least likely to achieve long-term abstinence.     

Community Socioeconomic Disadvantage and the Survival of Infants With Congenital Heart Defects

Objectives. We examined the association between survival of infants with severe congenital heart defects (CHDs) and community-level indicators of socioeconomic status.Methods. We identified infants born to residents of Arizona, New Jersey, New York, and Texas between 1999 and 2007 with selected CHDs from 4 population-based, statewide birth defect surveillance programs. We linked data to the 2000 US Census to obtain 11 census tract–level socioeconomic indicators. We estimated survival probabilities and hazard ratios adjusted for individual characteristics.Results. We observed differences in infant survival for 8 community socioeconomic indicators (P < .05). The greatest mortality risk was associated with residing in communities in the most disadvantaged deciles for poverty (adjusted hazard ratio [AHR] = 1.49; 95% confidence interval [CI]  = 1.11, 1.99), education (AHR = 1.51; 95% CI = 1.16, 1.96), and operator or laborer occupations (AHR = 1.54; 95% CI = 1.16, 1.96). Survival decreased with increasing numbers of indicators that were in the most disadvantaged decile. Community-level mortality risk persisted when we adjusted for individual-level characteristics.Conclusions. The increased mortality risk among infants with CHDs living in socioeconomically deprived communities might indicate barriers to quality and timely care at which public health interventions might be targeted.Advances in medical and surgical care for individuals born with congenital heart defects (CHDs) has improved survival in recent years, yet despite this progress, mortality due to CHDs remains a significant public health issue.1,2 CHDs are the most common type of birth defect and are the leading cause of death among those born with birth defects.3,4 CHDs necessitate medical and often surgical intervention early in life, and timely detection and quality care can improve health outcomes.5,6 Medical factors such as low birth weight, preterm birth, severity of the condition, and the presence of comorbidities are well-established risk factors for mortality, particularly during the neonatal period.7 Nonmedical factors (particularly race/ethnicity) also play an important role in the survival of infants with birth defects and potentially contribute significantly to unexplained survival differences.8 Several factors that influence access to and use of care have been examined among cohorts of infants born with CHDs, but these have been limited to race/ethnicity,2,9–16 medical insurance,9,16–20 and distance to specialty care.10,17,21,22 Assessment of the potential impact of socioeconomic status (SES) on survival has been challenging, largely because SES has been defined and measured in many ways and is often unavailable in large, population-based data sets. SES has been investigated as a risk factor for the occurrence of different types of birth defects,23–28 but few published population-based studies have included SES as a risk factor for CHD-related mortality.Community-level factors related to socioeconomic conditions have been associated with decreased access to pediatric subspecialty care and early mortality of infants with low birth weight,29,30 and they might provide evidence of contextual factors that could potentially influence the survival of infants with CHDs, who require timely medical intervention.31–33 In this population-based study, we estimated the association of census tract–level indicators of SES with the survival of infants born with CHDs and examined the potential impact of communities on observed racial/ethnic disparities in infant survival.     

Racial/Ethnic Disparities in Hypertension Prevalence: Reconsidering the Role of Chronic Stress

Objectives. We investigated the association between anticipatory stress, also known as racism-related vigilance, and hypertension prevalence in Black, Hispanic, and White adults.Methods. We used data from the Chicago Community Adult Health Study, a population-representative sample of adults (n = 3105) surveyed in 2001 to 2003, to regress hypertension prevalence on the interaction between race/ethnicity and vigilance in logit models.Results. Blacks reported the highest vigilance levels. For Blacks, each unit increase in vigilance (range = 0–12) was associated with a 4% increase in the odds of hypertension (odds ratio [OR] = 1.04; 95% confidence interval [CI] = 1.00, 1.09). Hispanics showed a similar but nonsignificant association (OR = 1.05; 95% CI = 0.99, 1.12), and Whites showed no association (OR = 0.95; 95% CI = 0.87, 1.03).Conclusions. Vigilance may represent an important and unique source of chronic stress that contributes to the well-documented higher prevalence of hypertension among Blacks than Whites; it is a possible contributor to hypertension among Hispanics but not Whites.Racial and ethnic disparities in hypertension are some of the most widely studied and consequential sources of social disparities in health in the United States.1–3 For example, recent prevalence estimates show that roughly 40% of Black adults but only 30% of White adults have hypertension.4 In addition, the incidence of hypertension occurs at younger ages for Blacks than Whites.1 These disparities are reflected in the larger burden of hypertension-related health and economic costs carried by non-White than White Americans. For example, mortality rates attributable to hypertension are roughly 15 deaths per 100 000 people for White men and women; the mortality rate for Black women is 40 per 100 000 and more than 50 per 100 000 for Black men.5 Among all health conditions, hypertension accounts for the greatest portion of disparities in years of lost life.6 Economically speaking, if Black Americans had the hypertension prevalence of White Americans, about $400 million would be saved in out-of-pocket health care expenses, about $2 billion would be saved in private insurance costs, and $375 million would be saved from Medicare and Medicaid—per year.7Despite the tremendous amount of research devoted to clarifying the factors that generate these disparities, most studies find that they persist after adjustment for a wide range of socioeconomic, behavioral, and biomedical risk factors.8 In fact, although disparities exist for several of these risk factors (e.g., socioeconomic status), numerous studies have shown no disparities in many others (e.g., smoking, obesity for men, lipid profile).2 Despite substantial investment in interventions to eliminate hypertension disparities, evidence suggests that these disparities have actually grown over the past few decades,9 suggesting that numerous unknown factors drive disparities in hypertension.3     

Socioeconomic Status,Food Security,and Dental Caries in US Children: Mediation Analyses of Data From the National Health and Nutrition Examination Survey, 2007–2008

Objectives. We examined associations of household socioeconomic status (SES) and food security with children’s oral health outcomes.Methods. We analyzed 2007 and 2008 US National Health and Nutrition Examination Survey data for children aged 5 to 17 years (n = 2206) to examine the relationship between food security and untreated dental caries and to assess whether food security mediates the SES–caries relationship.Results. About 20.1% of children had untreated caries. Most households had full food security (62%); 13% had marginal, 17% had low, and 8% had very low food security. Higher SES was associated with significantly lower caries prevalence (prevalence ratio [PR] = 0.77; 95% confidence interval = 0.63, 0.94; P = .01). Children from households with low or very low food security had significantly higher caries prevalence (PR = 2.00 and PR = 1.70, respectively) than did children living in fully food-secure households. Caries prevalence did not differ among children from fully and marginally food-secure households (P = .17). Food insecurity did not appear to mediate the SES–caries relationship.Conclusions. Interventions and policies to ensure food security may help address the US pediatric caries epidemic.Tooth decay (dental caries) is the most prevalent disease worldwide and the most common pediatric disease in the United States.1,2 From 1999 to 2004, the prevalence of untreated tooth decay was 24.5% for children aged 6 to 11 years and 19.6% for adolescents aged 12 to 19 years.3 Untreated tooth decay can lead to difficulties eating and sleeping, pain, the need for invasive restorative treatment, emergency department visits and inpatient hospitalizations, poor quality of life, systemic health problems, and, in rare cases, death.4–7 To date, most public health efforts aimed at addressing the pediatric caries epidemic have focused on tooth-level interventions (e.g., topical fluorides, dental sealants). Although disparities in oral health are considered a measure of social injustice,8 comparatively less research has been conducted on the social determinants of pediatric oral health.9Low socioeconomic status (SES), one of the strongest determinants of caries in children,10–12 is associated with food insecurity,10–17 defined as inadequate access to food resulting in food shortages, disrupted eating patterns, and hunger.18 Food insecurity, in turn, is associated with oral health–related behaviors, including increased fermentable carbohydrate intake,19,20 a risk factor for dental caries.21,22 The American Dietetic Association recognizes the link between nutrition and oral health,23 and numerous studies have drawn associations between dietary factors and disparities in dental caries.24 Collectively, these studies suggest that food insecurity is related to caries and is a potential mechanism linking SES and caries, but these relationships have not yet been evaluated empirically. We used nationally representative data from the United States to test 3 hypotheses: (1) food insecurity is positively associated with untreated dental caries, (2) food insecurity mediates the SES–caries relationship, and (3) food insecurity mediates the SES–caries relationship differentially for children from higher- versus lower-SES households.     

The Effect of a “Maintain,Don’t Gain” Approach to Weight Management on Depression Among Black Women: Results From a Randomized Controlled Trial

Objectives. We evaluated the effect of a weight gain prevention intervention (Shape Program) on depression among socioeconomically disadvantaged overweight and obese Black women.Methods. Between 2009 and 2012, we conducted a randomized trial comparing a 12-month electronic health–based weight gain prevention intervention to usual primary care at 5 central North Carolina community health centers. We assessed depression with the Patient Health Questionnaire (PHQ-8). We analyzed change in depression score from baseline to 12- and 18-month follow-up across groups with mixed models. We used generalized estimating equation models to analyze group differences in the proportion above the clinical threshold for depression (PHQ-8 score ≥ 10).Results. At baseline, 20% of participants reported depression. Twelve-month change in depression scores was larger for intervention participants (mean difference = −1.85; 95% confidence interval = −3.08, −0.61; P = .004). There was a significant reduction in the proportion of intervention participants with depression at 12 months with no change in the usual-care group (11% vs 19%; P = .035). All effects persisted after we controlled for weight change and medication use. We saw similar findings at 18 months.Conclusions. The Shape Program, which includes no mention of mood, improved depression among socioeconomically disadvantaged Black women.Depression is one of the most common and disabling, yet treatable, mental health conditions in the United States.1,2 Women are twice as likely as men to be affected,3 and more than 1 in 7 (14.9%) Black women will experience major depression in their lifetime.4 Observational evidence suggests that, although the prevalence of major depression is lower among Blacks than Whites, its severity is greater for Blacks.5 This is likely a result of racial disparities in access to depression treatment.6 Indeed, compared with their White counterparts, Black adults with depression are less likely to receive treatment for depression (39.7% vs 54.0%).6 Of those who do seek treatment, Blacks are less likely than Whites to receive care that corresponds to clinical practice guidelines.6,7 These racial disparities are magnified by socioeconomic disadvantage.8 Depression is 3 times more common for those with incomes below the federal poverty level, compared with those with higher incomes.9 As a consequence, the challenge remains how to effectively treat socioeconomically disadvantaged Black women with depression.Obesity is also disproportionately prevalent among Black women relative to other racial/ethnic groups.10 The high burden of obesity among Black women not only indicates a higher prevalence of obesity-related chronic diseases (e.g., diabetes, heart disease),11 but it may also have an impact on psychosocial outcomes such as depression.12 As such, interventions focusing on behavioral weight control may present a useful opportunity to address both obesity and depression.Behavioral weight loss interventions typically include frequent contact with a weight loss counselor; self-monitoring of diet, exercise, and weight; and lessons that cover various topics such as problem solving, relapse prevention, and stress management. Indeed, across numerous studies, behavioral weight loss interventions have been shown to promote reductions in depression.13,14 Such findings are generally believed to be related to weight loss15 and mediated by improvements in body satisfaction; that is, for many, weight loss might enhance body satisfaction and, thus, improve depression outcomes.16,17 However, this finding has most frequently been demonstrated in predominantly socioeconomically advantaged White women, who tend to exhibit strong relations between body size and mood.16,18 In contrast, Black women have greater social acceptance of overweight, less body weight dissatisfaction, and higher body weight ideals compared with White women.19–22 Thus, it is unclear whether Black women would experience a similar reduction in depression as a result of obesity treatment.Although weight loss is indicated for those with obesity, promoting clinically meaningful weight change among Black women has been a major challenge.23 Across various studies, Black women achieve less weight loss relative to White women.24–26 The reason for this racial disparity in weight loss outcomes is unclear, but may be influenced in part by differences in sociocultural norms related to weight, diet, and physical activity.27 As a result, interventions that focus on preventing weight gain may be a useful alternative treatment approach among overweight and obese Black women.27We recently conducted a study titled the Shape Program, a 12-month randomized controlled trial with follow-up at 18 months, evaluating an electronic health weight gain prevention intervention among Black women compared with usual care in the primary care setting.27 The Shape intervention was found to be effective in staving off weight gain at 12 and 18 months.28 It is unclear whether a weight gain prevention approach, as was tested in Shape, would be helpful for treating depression among Black women. As such, we sought to examine the potential spillover benefits produced by this “maintain, don’t gain” approach on depression, compared with usual care.     

Gender-Stratified Models to Examine the Relationship Between Financial Hardship and Self-Reported Oral Health for Older US Men and Women

Objectives. We evaluated the relationship between financial hardship and self-reported oral health for older men and women.Methods. We focused on adults in the 2008 Health and Retirement Study (n = 1359). The predictor variables were 4 financial hardship indicators. We used Poisson regression models to estimate the prevalence ratio of poor self-reported oral health.Results. In the non–gender-stratified model, number of financial hardships was not significantly associated with self-reported oral health. Food insecurity was associated with a 12% greater prevalence of poor self-reported oral health (95% confidence interval [CI] = 1.04, 1.21). In the gender-stratified models, women with 3 or more financial hardships had a 24% greater prevalence of poor self-reported oral health than women with zero (95% CI = 1.09, 1.40). Number of hardships was not associated with self-reported oral health for men. For men, skipping medications was associated with 50% lower prevalence of poor self-reported oral health (95% CI = 0.32, 0.76).Conclusions. Number of financial hardships was differentially associated with self-reported oral health for older men and women. Most financial hardship indicators affected both genders similarly. Future interventions to improve vulnerable older adults’ oral health should account for gender-based heterogeneity in financial hardship experiences.The Institute of Medicine’s 1998 publication Gender Differences in Susceptibility of Environmental Factors called attention to how socioeconomic factors differentially affect health outcomes for men and women.1 Gender-based health disparities are pronounced among older adults.2,3 In 2010, 25% of the US population was aged 55 years or older, a 15% increase from 2000.4 Advances in chronic disease management have improved adult life expectancy,5–12 making older adults the fastest growing subgroup in the United States. The close relationship between oral and systemic health13–15 has motivated interest in addressing oral health disparities in older adults, particularly among those who are financially vulnerable.16Poverty and low socioeconomic status (SES) are associated with tooth decay, gum diseases, and oral cancers—all of which are indicators of poor oral health.17–28 Older men and women are at differential risk for dental diseases and conditions.29,30 For instance, older men are more likely to have untreated tooth decay,31,32 gum disease,33 and oropharyngeal cancer34 whereas older women are more likely to have missing teeth and to be edentulous.29 Dental care use by women partially explains this heterogeneity in disease risk35 although the mechanisms underlying gender-based differences have not been elucidated. Differential risk for dental disease may translate to differences in self-reported oral health. Based on 1999–2004 US National Health and Nutrition Examination Survey data, a larger proportion of men aged 65 years and older reported fair or poor oral health compared with women (40.1% and 36.9%, respectively).29 Although 2 studies suggest that self-reported oral health measures are weakly associated with dental disease status as assessed by a dentist,36,37 most studies have concluded that self-reported oral health is a valid and reliable measure of clinical oral health.38–41There is a growing body of literature on gender, socioeconomic inequality, and health disparities.42–45 Most studies have focused on traditional measures of SES such as education, income, or occupation.46–48 However, these measures do not adequately capture the multiple pathways by which socioeconomic and financial circumstances influence health.49–53 For example, focusing on income alone may not fully capture an individual’s ability to garner resources to meet financial obligations.54 Alternative SES measures such as financial hardship have been shown to have an impact on health over and above traditional measures of SES.55,56 Furthermore, recent studies suggest that alternative SES measures, which account for economic resources, assets, and household material conditions, are moderated by gender on outcomes such as self-rated health, psychological distress, musculoskeletal disorders, and mortality.55–58 This interaction is particularly relevant for older adults, many of whom are retired or are preparing to exit the workforce.59Currently, there is little understanding of how gender and financial hardship interact on oral health outcome measures. In addition, the studies relevant to adult oral health have 2 limitations: (1) the inclusion of both younger and older adults in the same models, which assumes that the relationship between socioeconomic indicators and oral health is homogeneous across the adult life span20,22,27,47; and (2) the lack of gender-stratified models,28 which treats gender as a confounder rather than as an effect modifier.The aim of the present study was to test the hypothesis that the association between financial hardship and self-reported oral health is different for women and men. This research continues the line of work aimed at identifying ways to improve the oral health of vulnerable older adults, and has important implications in the development of interventions and policies that address gender-based disparities in adult oral health.60,61     

Socioeconomic Disparities in Sleep Duration Among Veterans of the US Wars in Iraq and Afghanistan

We characterized socioeconomic disparities in short sleep duration, which is linked to multiple adverse health outcomes, in a population-based sample of veterans of the US wars in Iraq and Afghanistan who had interacted with the Minneapolis VA Health Care System. Lower reported household assets, lower food security, greater reported discrimination, and lower subjective social status were significantly (P < .05) related to less sleep, even after adjusting for demographics, health behaviors, and posttraumatic stress disorder diagnosis. Assisting veterans to navigate social and socioeconomic stressors could promote healthful sleep and overall health.Inadequate sleep is common, with just more than 1 in 4 adults in the United States reporting that they average 6 or less hours of sleep per night.1 Short sleep duration (commonly defined as < 6–8 hr per day) has been linked to serious health problems, including injury,2–4 cardiovascular disease and associated risk factors,5–14 poor mental health,15–19 and all-cause mortality.20–27 Disparities exist in which Blacks28–32 and those who are of lower socioeconomic status (SES)33 are at increased risk for sleep deficiency. Military members and veterans, especially those who have been deployed, appear to be at greater risk for short sleep duration.34–37 This risk may relate to aspects of the deployment cycle such as irregular schedule and shift work, stress, mental health issues such as posttraumatic stress disorder (PTSD), and injury. Of further concern is that short sleep duration and its risk factors may be part of a mutually reinforcing cycle. Indeed, research has indicated that predeployment short sleep duration may contribute to the development of PTSD.38,39In this study, we sought to characterize socioeconomic disparities in short sleep duration among veterans who served in the US wars in Iraq or Afghanistan and to test whether, independent of other known risk factors, socioeconomic obstacles, such as having low income or experiencing discrimination, are linked to short sleep duration.     

Sexual Minority Women and Depressive Symptoms Throughout Adulthood

Objectives. We examined the associations between depressive symptoms and sexual identity and behavior among women with or at risk for HIV.Methods. We analyzed longitudinal data from 1811 participants in the Women’s Interagency HIV Study (WIHS) from 1994 to 2013 in Brooklyn and the Bronx, New York; Chicago, Illinois; Washington, DC; and Los Angeles and San Francisco, California, by comparing depressive symptoms by baseline sexual identity and ongoing sexual behavior. We controlled for age, socioeconomic status, violence history, and substance use.Results. In separate analyses, bisexual women and women who reported having sex with both men and women during follow-up had higher unadjusted odds of depressive symptoms compared with heterosexuals and women who reported only having male sexual partners (adjusted odd ratio [AOR] = 1.36; 95% confidence interval [CI]  = 1.10, 1.69 and AOR = 1.21; 95% CI = 1.06, 1.37, respectively). Age was a significant effect modifier in multivariable analysis; sexual minority women had increased odds of depressive symptoms in early adulthood, but they did not have these odds at midlife. Odds of depressive symptoms were lower among some sexual minority women at older ages.Conclusions. Patterns of depressive symptoms over the life course of sexual minority women with or at risk for HIV might differ from heterosexual women and from patterns observed in the general aging population.Depression is a major health concern for women. According to the Centers for Disease Control and Prevention (CDC), 10% of US women reported any depression and 5% reported major depression in the previous 2 weeks.1 Depression has been reported in 19% to 62%2–4 of HIV-infected women and is associated with reduced cognitive function,5 decreased adherence to highly active antiretroviral therapy (HAART),6 higher rates of unprotected sex among substance users,7 and increased mortality.2,6Women with or at risk for HIV are often exposed to factors such as poverty,8 substance use, and violence,9–11 which can independently and jointly contribute to depression. A recent study found that any combination of intimate partner violence (IPV), substance use, and HIV infection increased the odds of depression.12 Lower socioeconomic status (SES) in women12 and HIV infection4,5 were also independently associated with depression. However, studies showed no association among HIV stage, HAART use,4,8 CD4 count,8,13 or viral load and depression.4,8,13There is a strong association between sexual minority status (i.e., women who identify as lesbian or bisexual or have female sex partners) and poor mental health. In a US survey, lifetime major depression was reported by 42% of lesbians, 52% of bisexuals, and 27% of heterosexual women (P < .01); in the same study, major depression was reported by 15% of women who have sex with women (WSW), 51% of women who have sex with men and women (WSMW), and 27% of women who have sex with men (WSM; P < .01).14 In this study, we examined 2 aspects of sexual orientation15–17: sexual identity and sexual behavior. Although sexual attraction is also considered part of an individual’s sexual orientation, data on attraction was not collected in the original study.Despite the strong association between sexual minority status and depression, it is unknown whether sexual minority status acts as an independent predictor or effect modifier of depressive symptoms among women affected by HIV, substance use, and violence. Our original hypothesis was that lesbian, bisexual, and WSMW (but not WSW) would have higher odds of depression, with race/ethnicity acting as a potential effect modifier.     

Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

Initiation of Human Papillomavirus Vaccination Among Predominantly Minority Female and Male Adolescents at Inner-City Community Health Centers

Objectives. We examined the prevalence and correlates of human papillomavirus (HPV) vaccine initiation among adolescents in low-income, urban areas.Methods. The study consisted of electronic health record data on HPV vaccination for 3180 adolescents (aged 10–20 years) at a multisite community health center in 2011.Results. Only 27% initiated the HPV vaccine. The adjusted odds ratio (AOR) of HPV vaccination was lower among older adolescents (AOR = 0.552; 95% confidence interval [CI] = 0.424, 0.718) and those seen by nonpediatric health care providers (HCPs; AOR = 0.311; 95% CI = 0.222, 0.435), and higher among non-English speakers (AOR = 1.409; 95% CI = 1.134, 1.751) and those seen at 2 site locations (AOR = 1.890; 95% CI = 1.547, 2.311). Insurance status was significant only among female and Hispanic adolescents. Language was not a predictor among Hispanic adolescents. Across all analyses, the interaction of age and HCP specialty was associated with HPV vaccination. Dramatically lower HPV vaccination rates were found among older adolescents seen by nonpediatric HCPs (3%–5%) than among other adolescents (23%–45%).Conclusions. Improving HPV vaccination initiation in low-income urban areas is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.Human papillomavirus (HPV) infection is a known risk factor for the development of several cancers. Between 2004 and 2008, there was a national average of 33 369 HPV-associated cancers annually, including cervical, vulvar, vaginal, penile, anal, and oropharyngeal cancers.1 The Centers for Disease Control and Prevention estimates 26 000 new HPV-associated cancers each year, 18 000 for women and 8000 for men,1 which could be prevented through the HPV vaccine.According to the US Cancer Statistics Working Group,2 there are pervasive disparities in national morbidity and mortality rates of HPV-related cancers for Black and Hispanic individuals. Cervical cancer is more common among Black and Hispanic women and results in disproportionately higher mortality for Black women. In 2009, the national age-adjusted cervical cancer incidence rates (per 100 000) for Hispanic and Black women (10.9 and 10.0, respectively) were higher than the rate for White women (7.6).2 The national age-adjusted cervical cancer mortality rate (per 100 000) for Black women (4.2) is considerably higher than the rates for White and Hispanic women (2.1 and 2.9, respectively).2 Also, Black women have higher morbidity and mortality rates of vaginal cancer. Morbidity and mortality rates of penile cancers are significantly higher among Black and Hispanic men. Black men have higher morbidity and mortality rates of anal cancer.2 In addition to race/ethnicity, incidence rates of penile, cervical, and vaginal cancers increase with higher poverty rates.3 Factors that contribute to cancer disparities among Black, Hispanic, and low-income populations include higher exposure to risk factors such as smoking, physical inactivity, and HPV infection as well as lack of access to early detection and treatment services.4New Jersey had the 10th highest morbidity rate for cervical cancer nationally for 2006 through 2010.5 According to the New Jersey State Cancer Registry, cervical cancer morbidity from 2005 to 2009 was significantly higher in the Greater Newark area (relative risk = 1.86; the study target area) than other areas in the state, as well as among women who are Black, Hispanic, foreign-born, non–English-speaking, uninsured, with lower income and education, unmarried, unemployed, and living in a rented residence.6 According to a community health needs assessment for the City of Newark in 2013,7 52.4% of the residents are Black, 33.8% are Hispanic, and 30% are foreign-born, compared with 13%, 18%, and 20%, respectively, in the state. Also, 28.4% of the residents are below the federal poverty level compared with 9.4% statewide, and 28% are uninsured compared with 8.4% statewide. A significant proportion of the residents has less than a high-school education (30%) and a low level of English proficiency (25%).7Transmission of HPV can be reduced through limiting the number of sexual partners, delaying the initiation of sexual activity, practicing safe sex, and getting vaccinated.8 Two vaccines have been approved by the Food and Drug Administration for protection against HPV: the quadrivalent vaccine (Gardasil, Merck, Kenilworth, NJ) for female and male individuals aged 9 to 26 years,9 and the bivalent vaccine (Cervarix, GlaxoSmithKline, Middlesex, England) for female individuals aged 10 to 25 years.10 The HPV vaccine requires a series of 3 injections within 6 months. Markowitz et al.11 examined the rates of HPV infection among female individuals before and after the vaccine was introduced in 2006, by using data from the National Health and Nutrition Examination Surveys for 2003 through 2010. They found that for female adolescents aged 14 to 19 years, there was a 55.7% reduction in vaccine-type HPV infection rate (HPV types 6, 11, 16, and 18) and a 50% reduction in high-risk vaccine-type HPV infection rate (HPV types 16 and 18). There was also an 88% decrease among the sexually active women in their rate of vaccine-type HPV infection when they compared those who were vaccinated to those who were not vaccinated.11 Niccolai et al.12 also found significant decline in the rates of high-grade cervical lesions from 2008 to 2011 among women aged 21 to 24 years in Connecticut. Unfortunately, this trend was attenuated in urban areas as well as areas with higher concentrations of Black, Hispanic, and low-income populations.12According to the National Immunization Survey—Teen (NIS-Teen),13 HPV vaccine initiation rates for female adolescents were 44.3% in 2009, 48.7% in 2010, 53.0% in 2011, and 53.8% in 2012. This reflects minimal improvement in 2011, no improvement in 2012, and reaching a plateau for female vaccination at a level dramatically lower than the goal of 80% completion rate for girls aged 13 to 15 years set by Healthy People 2020. In site-based studies, HPV vaccine initiation among female adolescents ranged between 9.4% and 62.9%.14–21 Also, initiation for female adolescents was lower for Spanish speakers,22 those who were uninsured,23–25 those with shorter duration of enrollment in health insurance,26 in nonpediatric settings,21,24 among those who have not had a preventive visit in the past 12 months,21,24,27–30 and with mothers’ lack of knowledge about HPV infection or vaccine.18,27,28,31,32 Some studies reported lower initiation among younger female adolescents,15,18,21,24,29,30 whereas others reported the opposite.21,26 Several studies have shown the importance of health care providers’ (HCPs’) recommendations for HPV vaccine initiation among female adolescents.16,28,30,31,33According to NIS-Teen,13 HPV vaccine initiation rates for male adolescents were 1.4% in 2010, 8.3% in 2011, and 20.8% in 2012. This reflects low but steady improvement in HPV vaccination rates among male adolescents. In site-based studies, HPV vaccine initiation among male adolescents ranged between 1.1% and 30%.14,34–37 Literature is lacking on factors associated with HPV vaccine initiation among male adolescents. One study reported lower levels of knowledge among Black and Hispanic parents about the use of HPV vaccine for male adolescents.35 A few studies indicated the importance of HCPs’ recommendation for HPV vaccine initiation among male adolescents.14,35,36,38Pervasive disparities exist in HPV vaccination among Black, Hispanic, and low-income groups, and more specifically in the study target area. Even though the NIS-Teen data for 2011 and 2012 show slightly higher HPV vaccination among Black and low-income groups,39,40 several studies have demonstrated a significant and continuing trend of lower HPV vaccination among Black and Hispanic adolescents,14,15,17,24,26,41,42 as well as in low-income and urban areas.22,33,41,43 Vaccination disparities in urban areas (compared with suburban or rural areas) may be attributed to residential segregation, differential distribution of health clinics and health professionals, and unequal access to a broad range of services.44–46 As urban areas, particularly the Greater Newark area, have high proportions of immigrants who may be hesitant to seek health care services because of cultural or language barriers or concerns about immigration status,7 a study of adolescents’ adherence to public health recommendations in underserved, inner-city areas is warranted and important.Literature is lacking information on correlates of HPV vaccination among Black and Hispanic adolescents in low-income urban areas, who represent populations with the greatest disparities in cervical cancer and other HPV-related cancers compared with White and higher-income groups. Therefore, the purpose of this study was to examine the correlates of HPV vaccine initiation in a sample of predominantly Black and Hispanic adolescents at inner-city community health centers. The study addresses gaps in knowledge about the correlates of HPV vaccination among both male and female adolescents as well as a low-income predominantly minority population with pervasive disparities in cervical cancer morbidity and mortality.1–3,5,6     

Socioeconomic Status,Race, and Mortality: A Prospective Cohort Study

Objectives. We evaluated the independent and joint effects of race, individual socioeconomic status (SES), and neighborhood SES on mortality risk.Methods. We conducted a prospective analysis involving 52 965 non-Hispanic Black and 23 592 non-Hispanic White adults taking part in the Southern Community Cohort Study. Cox proportional hazards modeling was used to determine associations of race and SES with all-cause and cause-specific mortality.Results. In our cohort, wherein Blacks and Whites had similar individual SES, Blacks were less likely than Whites to die during the follow-up period (hazard ratio [HR] = 0.78; 95% confidence interval [CI] = 0.73, 0.84). Low household income was a strong predictor of all-cause mortality among both Blacks and Whites (HR = 1.76; 95% CI = 1.45, 2.12). Being in the lowest (vs highest) category with respect to both individual and neighborhood SES was associated with a nearly 3-fold increase in all-cause mortality risk (HR = 2.76; 95% CI = 1.99, 3.84). There was no significant mortality-related interaction between individual SES and neighborhood SES among either Blacks or Whites.Conclusions. SES is a strong predictor of premature mortality, and the independent associations of individual SES and neighborhood SES with mortality risk are similar for Blacks and Whites.From birth through approximately age 85 years, there is a mortality rate disparity between Blacks and Whites in the United States that peaks in early adulthood and slowly narrows thereafter.1–4 Most of the excess deaths among Blacks occur in middle-aged adults, given the confluence of rising mortality rates and the disparity at those ages. During much of the 20th century, this disparity was unyielding,4–6 but recent data point to some narrowing of the gap beginning in the 1990s.7–9 Still, in 2011 the highest age-standardized death rate in the United States was that among non-Hispanic Blacks (877.4 per 100 000 standard population), followed by non-Hispanic Whites (738.1 per 100 000 standard population).10 Also, average life expectancies at birth in 2011 were 4.5 years shorter for Black than White men and 3.1 years shorter for Black than White women.10Although national mortality data are routinely reported by race/ethnicity, their interpretation must consider the determinants of race-specific mortality rates, including behavioral, social, economic, and political factors that determine the resources available to maintain health and prolong life.3 Whether socioeconomic status (SES) completely accounts for mortality differences between Blacks and Whites is not clear. Previous studies have reported that SES alone cannot fully account for the disparity, although in settings where Blacks and Whites are drawn from considerably different SES strata, confounding by SES may be difficult to overcome.11–14 By contrast, in settings where race-specific SES differences are minimal (including the current study), it has been suggested that important health indicators are quite similar by race.15–17 Individual-level SES aside, neighborhood-level SES has also been reported to influence mortality rates,18 but fewer investigations have assessed the joint contribution of individual and neighborhood SES,19–22 and analyses assessing the interplay of these 2 SES domains with race are rare.19,21We thus took the opportunity, within a large prospective study of non-Hispanic Black and White adults (residing in a large area of the United States, enrolled mainly in low-income settings but also non-low-income settings, and representing a range of SES levels), to evaluate the independent and joint contributions of race, individual SES, and neighborhood SES to overall and cause-specific mortality risk.     

A Novel Look at Racial Health Disparities: The Interaction Between Social Disadvantage and Environmental Health

Objectives. We explored the notion that social disadvantage increases vulnerability to the health effects of environmental hazards. Specifically, we examined (1) whether race modifies the association between blood lead and blood pressure and (2) whether socioeconomic status (SES) plays a role in this modifying effect.Methods. Using the National Health and Nutrition Examination Survey (2001–2008) and linear regression, we estimated the association between blood lead and blood pressure. Using interactions among race, SES, and lead, we estimated this association by levels of social disadvantage.Results. Black men and women showed a 2.8 (P < .001) and 4.0 (P < .001) millimeters mercury increase in SBP, respectively, for each doubling of blood lead. White adults showed no association. This lead–SBP association exhibited by Blacks was primarily isolated to Blacks of low SES. For example, poor but not nonpoor Black men showed a 4.8 millimeters mercury (P < .001) increase in SBP for each doubling of blood lead.Conclusions. Our results suggest that social disadvantage exacerbates the deleterious health effects of lead. Our work provides evidence that social and environmental factors must be addressed together to eliminate health disparities.Black–White disparities in hypertension have been well-documented for decades.1–3 A 2010 American Heart Association report put nationwide prevalence estimates at roughly 33% for White adults but 43% for Black adults.4 Economically, if Black Americans had the hypertension rates of White Americans, about $400 million would have been saved in out-of-pocket health care expenses, about $2 billion would have been saved in private insurance costs, and $375 million would have been saved from Medicare and Medicaid—per year.5 More seriously, disparities are also seen in outcomes related to hypertension. For example, mortality rates because of hypertension are roughly 15 deaths per 100 000 people for White men and women; but 40 and more than 50 per 100 000 for Black men and women, respectively.4 Disparities in hypertension account for the greatest disparities in years of lost life compared with any other health condition.6A growing body of literature in different disciplines indicates that both social and environmental factors are important in the production and maintenance of hypertension disparities.7–10 There are racial disparities in numerous social factors, such as socioeconomic status (SES), that have a robust association with hypertension.2 For example, 2009 estimates put 26% of Blacks living in poverty compared with only 12% of Whites.11 Importantly, however, controlling for poverty does not attenuate the racial disparities in hypertension, indicating that there are complex mechanisms at work.12 There are also racial disparities in numerous environmental hazards, some of which are associated with hypertension. For example, lead is causally associated with a modest increase in blood pressure and risk of hypertension in a dose-dependent manner13–16 through several biological mechanisms, including increases in oxidative stress and alterations in control of the cardiovascular system.17 Furthermore, racial disparities in lead have been reported for decades.18,19In the environmental health literature, researchers have described the notion of differential vulnerability to the deleterious health effects of environmental hazards.20,21 Some have shown that psychosocial stress and social stressors potentiate the association between lead and blood pressure. For example, in 1 study, men who report high levels of perceived stress show an association between bone lead and blood pressure, whereas men who do not report high levels of stress do not reveal this association.22 Similarly, those adults who have higher allostatic load scores, a measure of stress-related wear and tear on the body, show a stronger association between blood lead and the odds of hypertension compared with adults with lower allostatic load scores.23,24It may be that this differential vulnerability, resulting from differential exposure to social factors, contributes to racial disparities in hypertension.25 In other words, it may be that the greater social stressors and psychosocial stress experienced by Black compared with White Americans may exacerbate the health effects of environmental hazards, including lead. In fact, researchers have reported that there is a modifying effect of race on the association between blood lead and blood pressure. Specifically, Black adults exhibit a roughly 1 millimeter mercury increase in systolic blood pressure for every 3 micrograms increase in blood lead.26 Yet, no such association is seen for Whites.19,26,27 It may be that, compared with White adults, Black adults show a stronger association between lead and blood pressure because they experience greater social stressors, such as higher levels of poverty.In the present study, we have updated and expanded on previous work by examining the notion that social disadvantage, as marked by race and SES, modifies the association between blood lead and blood pressure. Specifically, we first updated the literature on the modifying effect of race on the association between blood lead and blood pressure. The most recent work in this area is based on data from 1988 to 1991. Blood lead levels have continued to decline for both Blacks and Whites.19 Because there is a dose-dependent association between lead and blood pressure, it is not known whether blood lead and blood pressure are associated for Black adults using current data (2001 to 2008). Second, we examined the role of SES, specifically education and poverty, in the stronger association between blood lead and blood pressure seen in Black compared with White adults.     

Impact of an Exercise Intervention on Physical Activity During Pregnancy: The Behaviors Affecting Baby and You Study

Objectives. We examined the impact of a prenatal exercise intervention on physical activity in 260 women at risk for gestational diabetes mellitus.Methods. We randomized participants in the Behaviors Affecting Baby and You (BABY) Study, which took place from 2007 to 2012, to either a 12-week individually tailored, motivationally matched exercise intervention (n = 132) or to a comparison health and wellness intervention (n = 128). We assessed physical activity with the Pregnancy Physical Activity Questionnaire. We used linear mixed models to evaluate the impact of the interventions on change in physical activity according to intensity and type, total walking, and sedentary behavior.Results. Compared with the health and wellness arm, the exercise arm had significantly greater increases in sports or exercise activity (0.3 vs 5.3 metabolic equivalent of task [MET] hours/week; P < .001), and smaller declines in total activity (–42.7 vs –2.1 MET hours/week; P = .02) and activities of moderate to vigorous intensity (–30.6 vs −10.6 MET hours/week; P = .05), and was more likely to achieve recommended guidelines for physical activity (odds ratio = 2.12; 95% confidence interval = 1.45, 3.10).Conclusions. These findings extend the previous literature by demonstrating the benefits of a clinically feasible exercise intervention in an ethnically and socio-economically diverse population. Given the increased risk of adverse maternal health outcomes in ethnic minority groups, these findings may have important implications for reducing health disparities.The American College of Obstetricians and Gynecologists (ACOG) recommends that all women who are free from medical or obstetric complications engage in 30 minutes or more of moderate intensity physical activity on most days of the week.1 Physical activity during pregnancy is associated with reduced risk for excess gestational weight gain,2–4 and a reduced risk of gestational diabetes mellitus (GDM)5 and preeclampsia.6 Despite the benefits of physical activity, pregnant women are less likely to meet physical activity recommendations than nonpregnant women of childbearing age.7,8 Furthermore, physical activity levels decline throughout pregnancy, even in women who were active before pregnancy.9,10 Physical activity levels are even lower in Hispanic women; Hispanic women are 40% less likely to meet recommended levels of physical activity than are non-Hispanic White women.11 These numbers are concerning because of the excess risk of adverse maternal outcomes, such as GDM, in Hispanic women.12 Thus, it is important to develop culturally adapted interventions that can engage pregnant women in more active lifestyles.The impact of exercise interventions during pregnancy has been conflicting. Several interventions have been successful at attenuating the decrease in physical activity levels over the course of pregnancy13–15; however, most studies have observed no impact.16–20 In addition, the majority of the successful interventions to date have been conducted in predominantly White non-Hispanic study populations or have used intensive interventions that may not be feasible in clinical practice.21Individually tailored, motivationally matched interventions have been shown to be cost-effective approaches to increasing physical activity in nonpregnant women in community settings.22,23 These interventions are also readily translatable to clinical practice. However, whether these programs are effective at increasing physical activity during pregnancy is unknown. Therefore, we assessed the effectiveness of an individually tailored, motivationally matched exercise intervention on physical activity levels in an ethnically diverse sample of pregnant women at high risk for GDM.     

Disparities in Weight and Weight Behaviors by Sexual Orientation in College Students

Objectives. We assessed disparities in weight and weight-related behaviors among college students by sexual orientation and gender.Methods. We performed cross-sectional analyses of pooled annual data (2007–2011; n = 33 907) from students participating in a Minnesota state-based survey of 40 two- and four-year colleges and universities. Sexual orientation included heterosexual, gay or lesbian, bisexual, unsure, and discordant heterosexual (heterosexuals engaging in same-sex sexual experiences). Dependent variables included weight status (derived from self-reported weight and height), diet (fruits, vegetables, soda, fast food, restaurant meals, breakfast), physical activity, screen time, unhealthy weight control, and body satisfaction.Results. Bisexual and lesbian women were more likely to be obese than heterosexual and discordant heterosexual women. Bisexual women were at high risk for unhealthy weight, diet, physical activity, and weight control behaviors. Gay and bisexual men exhibited poor activity patterns, though gay men consumed significantly less regular soda (and significantly more diet soda) than heterosexual men.Conclusions. We observed disparities in weight-, diet-, and physical activity–related factors across sexual orientation among college youths. Additional research is needed to better understand these disparities and the most appropriate intervention strategies to address them.In 2011, the Institute of Medicine highlighted the significant lack of research on the health of lesbian, gay, and bisexual (LGB) groups.1 Research has indicated that LGB adults experience worse health outcomes than their heterosexual peers.2–11 These disparities may be attributable to an array of factors, including stigmatization, stress, and limited access to and use of health services.1,12,13 Specific areas of potential disparities among LGB groups lacking substantial research evidence include obesity, diet, physical activity patterns, unhealthy weight control behaviors, and body image. With two thirds of US adults now overweight or obese,14 obesity prevention is a national health priority. Findings from studies examining adult weight disparities by sexual orientation have consistently indicated that lesbian women are more likely to be overweight than heterosexual women.2,11,15–19 Several recent population-based studies have suggested that gay men may be less likely to be overweight than heterosexual men,2,18,20 and additional studies have highlighted concerns regarding body image and unhealthy weight control behaviors among gay men.21–24 Disparities in other behaviors, such as dietary intake and physical activity patterns, have not been studied extensively using population-based samples and, when studied, have yielded inconsistent findings.11,25,26Furthermore, much of the work in this area to date has not focused on the college years. Because nearly half of US high school graduates up to age 24 years are enrolled in postsecondary education,27 colleges and universities offer unique environments for addressing health disparities among young people, including those of LGB students. For many, the college years represent a time during which health disparities emerge28,29 and adverse changes occur in weight, dietary quality, physical activity, and other behaviors.30–38 For LGB people, this age is commonly when sexual identity is declared and assimilation into the LGB community occurs.39 Important postsecondary institutions that could act as platforms for intervention delivery include not only traditional 4-year universities but also 2-year community and technical colleges, which serve millions of students, particularly those from lower income and minority backgrounds.40,41The objective of this study was to characterize gender-specific weight-related disparities among college students by sexual orientation. We analyzed state survey data of nearly 34 000 students attending a wide array of 2- and 4-year colleges and universities in 2007 to 2011, including a subsample of more than 2000 LGB-identified and LGB-questioning participants. This research was intended to fill several gaps in the literature. For example, although a recent wave of studies11,19,22–25 were published after the release of the Institute of Medicine report,1 most of these studies used data from 1999 to 2007 and thus were not able to characterize disparities during the past 5 to 8 years (when important societal shifts in weight-related factors42,43 and social shifts regarding LGB issues occurred). Moreover, a majority of these studies focused not on the college years but rather on adulthood overall (e.g., 18–74 years) or on adolescence (e.g., 9th–12th grade). Finally, only a small number of studies have examined population-level LGB disparities in dietary intake or physical activity,11,20,25,26 which are critical factors to address in weight-related intervention strategies. Among the few population-based studies that have addressed diet and activity, unidimensional indicators have been used to assess fruit and vegetable consumption or moderate to vigorous intensity physical activity, but these studies have generally lacked characterization of other important dietary factors (e.g., frequency of soda, fast food, away-from-home eating, or breakfast consumption) or activities (e.g., strengthening activities, screen time).