Elevated Risk of Posttraumatic Stress in Sexual Minority Youths: Mediation by Childhood Abuse and Gender Nonconformity

Objectives. We examined whether lifetime risk of posttraumatic stress disorder (PTSD) was elevated in sexual minority versus heterosexual youths, whether childhood abuse accounted for disparities in PTSD, and whether childhood gender nonconformity explained sexual-orientation disparities in abuse and subsequent PTSD.Methods. We used data from a population-based study (n = 9369, mean age = 22.7 years) to estimate risk ratios for PTSD. We calculated the percentage of PTSD disparities by sexual orientation accounted for by childhood abuse and gender nonconformity, and the percentage of abuse disparities by sexual orientation accounted for by gender nonconformity.Results. Sexual minorities had between 1.6 and 3.9 times greater risk of probable PTSD than heterosexuals. Child abuse victimization disparities accounted for one third to one half of PTSD disparities by sexual orientation. Higher prevalence of gender nonconformity before age 11 years partly accounted for higher prevalence of abuse exposure before age 11 years and PTSD by early adulthood in sexual minorities (range = 5.2%–33.2%).Conclusions. Clinicians, teachers, and others who work with youths should consider abuse prevention and treatment measures for gender-nonconforming children and sexual minority youths.Posttraumatic stress disorder (PTSD) has severe sequelae that can particularly affect youths by disrupting the achievement of adulthood milestones. PTSD negatively affects career prospects through elevated risk of substance abuse1 and unemployment,2 reduces educational attainment by increasing the risk of school dropout,2 and affects family formation by increasing the risk of relationship instability and adolescent pregnancy.2 Studies have also indicated that the course of PTSD is chronic in one third of cases2; identifying risk factors in children and early adulthood is therefore particularly important for public health because PTSD in adolescence or early adulthood may affect health and well-being throughout adulthood. Research indicates that lesbian, gay, and bisexual youths have higher prevalence of mental health problems than heterosexuals, including anxiety, depression, and suicidality3–6; to our knowledge, however, no studies of youths have examined the association between sexual orientation and probable PTSD in samples including both sexual minorities and heterosexuals.Childhood abuse greatly increases risk of developing PTSD.7–9 Child abuse can directly trigger PTSD,10 increase the risk of exposure to subsequent stressful events,8 and increase the conditional risk of developing PTSD following exposure to subsequent stressful events.11,12 Sexual minorities—lesbians, gay men, bisexuals, and “mostly heterosexuals”—experience higher rates of childhood abuse than do heterosexuals.13–18 Thus, disparities in childhood abuse may be a cause of higher prevalence of PTSD among sexual minority youths compared with heterosexuals.Additionally, gender-nonconforming appearance and behavior in childhood is more common among persons who will later have a minority sexual orientation.19–21 Differences in gender nonconformity may contribute to sexual-orientation disparities in maltreatment in early and middle childhood, before sexual identity has developed, as childhood gender nonconformity has been associated with parental rejection, harassment, and physical and verbal victimization related to sexual orientation.22–26We examine whether there are disparities in lifetime probable PTSD in youths by sexual orientation and whether greater exposure to child abuse may account for differences in PTSD. Additionally, we examine whether gender nonconformity accounts for higher prevalence of abuse before age 11 years and possible increased risk of PTSD among sexual minorities compared with heterosexuals. Because gender nonconformity has been associated with psychosocial stressors other than childhood abuse—namely, harassment and bullying—nonconformity may increase the risk of PTSD above and beyond its possible effects on childhood abuse. Given the high population prevalence of PTSD, its chronicity, and its associated impairment,2 identifying factors that put children and youths at risk for PTSD is vital.Although several studies have separately noted elevated prevalence of both child maltreatment and adulthood PTSD in sexual minorities,17,22 to date, only 1 study in adults has shown that higher rates of childhood abuse may partially account for higher prevalence of PTSD in sexual minorities.15 Very few studies have examined whether childhood gender nonconformity might explain elevated exposure to child abuse before adolescence24,27 or probable PTSD among sexual minorities. We examine possible sexual-orientation disparities in childhood abuse and PTSD separately by gender because studies have found gender differences in PTSD and childhood abuse.28,29 We further examine possible gender-by-sexual-orientation interactions in risk of PTSD and abuse.     

Racial Differences in Breast Cancer Stage at Diagnosis in the Mammography Era

Objectives. We assessed racial differences in breast cancer mortality by stage at diagnosis, since mammography became available.Methods. We calculated adjusted odds of distant (versus local or regional) tumors for 143 249 White and 13 571 Black women aged 50 to 69 years, diagnosed with breast cancer between 1982 and 2007 and living in a Surveillance, Epidemiology, and End Results region. We compared linear trends in stage at diagnosis before and after 1998.Results. Distant-stage cancer was diagnosed in 5.8% of White and 10.2% of Black participants. The Black–White disparity in distant tumors narrowed until 1998 (1998 adjusted difference = 0.65%), before increasing. Between 1982 and 1997, the proportion of distant tumors decreased for Blacks (adjusted odds ratio [AOR]/y = 0.973; 95% confidence interval [CI] = 0.960, 0.987) and Whites (AOR/y = 0.978; 95% CI = 0.973, 0.983), with no racial differences (P = .47). From 1998 to 2007, the odds of distant versus local or regional tumors increased for Blacks (AOR/y = 1.036; 95% CI = 1.013, 1.060) and Whites (AOR/y = 1.011; 95% CI = 1.002, 1.021); the rate of increase was greater for Blacks than Whites (P = .04).Conclusions. In the mammography era, racial disparities remain in stage at diagnosis.Despite a lower incidence of invasive breast cancer, Black women in the United States are more likely than are White women to die of the disease.1,2 Since 1992, although breast cancer deaths have declined in both White and Black women, the overall disparity in mortality has increased.3 Stage at diagnosis is the strongest predictor of survival in breast cancer,4–6 and Black women are more often diagnosed with advanced-stage disease than are White women.7–10Mammography is an important tool in the early detection of breast cancer.11–13 First introduced in the United States in the early 1980s,14 mammography was initially most prevalent among White women. Racial disparities in mammography rates narrowed by the mid-1990s,12,15 and Black women had rates equivalent to or greater than those of White women between 1996 and 2000.10,15,16 From 2000 to 2005, mammography use declined nationally in women aged 50 to 64 years (78.6% to 71.8%), with a slightly larger decrement for White (−4.0%) than Black (−3.3%) women.13The survival benefit of any screening program, including mammography, is related to its ability to detect tumors at earlier stages. Meta-analyses continue to find mortality benefit for mammography, although uncertainty remains regarding both the appropriate target population and the optimal screening interval.11,17,18 Consistent with the expected effect of screening, an observational cohort analysis found that improvements in screening rates for both Black and White women during the 1990s contributed to diagnosis at an earlier stage in both groups.10Nevertheless, despite generally equivalent rates of mammography for the past 15 years, the racial disparity in breast cancer mortality between Black and White women persists. Although previous meta-analyses suggested a mortality benefit for mammography, randomized controlled data regarding the efficacy of screening programs in minority populations are limited.18,19 Because stage at diagnosis is an important predictor of survival in breast cancer, we assessed temporal changes in the distribution of stage at diagnosis between 1982 and 2007, in both Black and White women, adjusting for covariates known to affect stage at diagnosis.     

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     

Connecting Race and Place: A County-Level Analysis of White,Black, and Hispanic HIV Prevalence,Poverty, and Level of Urbanization

Objectives. We evaluated the role of poverty in racial/ethnic disparities in HIV prevalence across levels of urbanization.Methods. Using national HIV surveillance data from the year 2009, we constructed negative binomial models, stratified by urbanization, with an outcome of race-specific, county-level HIV prevalence rates and covariates of race/ethnicity, poverty, and other publicly available data. We estimated model-based Black–White and Hispanic–White prevalence rate ratios (PRRs) across levels of urbanization and poverty.Results. We observed racial/ethnic disparities for all strata of urbanization across 1111 included counties. Poverty was associated with HIV prevalence only in major metropolitan counties. At the same level of urbanization, Black–White and Hispanic–White PRRs were not statistically different from 1.0 at high poverty rates (Black–White PRR = 1.0, 95% confidence interval [CI] = 0.4, 2.9; Hispanic–White PRR = 0.4, 95% CI = 0.1, 1.6). In nonurban counties, racial/ethnic disparities remained after we controlled for poverty.Conclusions. The association between HIV prevalence and poverty varies by level of urbanization. HIV prevention interventions should be tailored to this understanding. Reducing racial/ethnic disparities will require multifactorial interventions linking social factors with sexual networks and individual risks.Within the United States, disparities in diagnosed HIV prevalence among the 3 major racial/ethnic groups (White, Black, and Hispanic) are striking. At the end of 2009, 43% of people living with an HIV diagnosis were Black, 35% White, and 19% Hispanic.1 Concurrently, Blacks constituted only 12% of the population, non-Hispanic Whites 65%, and Hispanics 16%.2 In the 46 states with confidential name-based HIV reporting since at least January 2007, the estimated diagnosed HIV prevalence rate at the end of 2009 was 952 per 100 000 people among Blacks (near the threshold for a generalized epidemic),1 320 per 100 000 among Hispanics, and 144 per 100 000 among Whites; compared with Whites, therefore, Blacks and Hispanics were respectively 6.6 times and 2.2 times more likely to be living with an HIV diagnosis.A number of mechanisms, primarily structural and social factors, have been proposed to explain these stark racial/ethnic disparities in HIV prevalence.3,4 Structural factors, such as oppression and mistrust in government, may hinder receptivity to prevention outreach and increase HIV prevalence.3 Social constructs (e.g., homophobia and HIV stigma) may discourage open discussion of risk behaviors and limit HIV testing and treatment. Additionally, limited access to health care resources has been identified as a key driver of racial/ethnic health disparities.5 Finally, Black men are more likely than White men to be both incarcerated and infected with HIV while incarcerated.6,7 All of these factors are, in turn, associated with poverty.8 However, specific relationships among these multiple factors and racial/ethnic HIV prevalence disparities, and variation of these relationships across levels of urbanization, are not well understood.Previous analyses of national surveillance and survey data in the United States have focused on associations between HIV prevalence rates, poverty, and race exclusively in urban areas, finding no disparities in poverty-adjusted HIV prevalence rates among heterosexuals in urban settings.9,10 Furthermore, among heterosexuals living in US urban areas with high AIDS prevalence, HIV prevalence rates among those living at or below the poverty line were 2.2 times as high as rates among those living above the poverty line.10 A more recent analysis of US surveillance data confirmed the complex associations between demographics, social determinants of health, and AIDS diagnosis rates.8However, variation in these factors across the urban–rural continuum may limit generalizability of these findings to nonurban settings, where similar research is lacking. In 2009, the proportions of Black and Hispanic Americans living in poverty were roughly twice that of White Americans.11 For all races/ethnicities, the proportion living in poverty is greater in rural areas than in urban areas.12 Additionally, rural areas, with lower HIV prevalence, are more likely to be medically underserved, with reduced access to HIV care and treatment.13In the context of these complex sociodemographic associations, previously observed associations in the United States between poverty and racial/ethnic disparities in HIV may differ outside of urban areas. Therefore, using publicly available county-level data, we first describe the association between poverty and HIV prevalence by race/ethnicity across levels of urbanization. We subsequently examine racial/ethnic disparities in HIV prevalence across levels of urbanization, after controlling for poverty. We hypothesized that, in all strata of urbanization, poverty-adjusted Black–White and Hispanic–White HIV prevalence rate ratios (PRRs) would statistically differ from 1.0.     

Racial/Ethnic and Socioeconomic Differences in Short-Term Breast Cancer Survival Among Women in an Integrated Health System

Objectives. We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment.Methods. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010.Results. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer–specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival.Conclusions. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients.Breast cancer is the most common cancer among women in the United States, and it is the second leading cause of cancer death.1 Despite significant improvements in breast cancer survival from 1992 to 2009,1,2 racial/ethnic and socioeconomic survival disparities have persisted.3,4 African American women have consistently been found to have worse survival after breast cancer,3,5–11 Hispanic women have worse or similar survival,3,9,11,12 and Asian women as an aggregated group have better or similar survival3,9,11,12 than do non-Hispanic White women. Underlying factors thought to contribute to these racial/ethnic disparities include differences in stage at diagnosis,8,12,13 distributions of breast cancer subtypes,14–16 comorbidities,12,13,17 access to and utilization of quality care,13,18 and treatment.12,13Numerous studies also have found poorer survival after breast cancer diagnosis among women residing in neighborhoods of lower socioeconomic status (SES).6,9,19,20 Research has shown that inadequate use of cancer screening services, and consequent late stage diagnosis and decreased survival, contribute to the SES disparities.21,22 Similar to racial/ethnic disparities, SES disparities have been attributed to inadequate treatment and follow-up care and comorbidities.18 Previous population-based studies have continued to observe racial/ethnic survival disparities after adjusting for neighborhood SES, but these studies have not considered the combined influence of neighborhood SES and race/ethnicity.3,9,11,12,23 These disparities may remain because information on individual-level SES, health insurance coverage, comorbidities, quality of care, and detailed treatment regimens have typically not been available.3,8,9,11,13 Even among studies using national Surveillance Epidemiology and End Results–Medicare linked data, in which more detailed information on treatment and comorbidities are available among some patients aged 65 years and older, survival disparities have remained.12,23,24 However, not all data on medical conditions and health care services are captured in Medicare claims, including data on Medicare beneficiaries enrolled in HMOs (health maintenance organizations).25,26Using electronic medical records data from Kaiser Permanente Northern California (KPNC) linked to data from the population-based California Cancer Registry (CCR), we recently reported that chemotherapy use followed practice guidelines but varied by race/ethnicity and neighborhood SES in this integrated health system.27 Therefore, to overcome the limitations of previous studies and address simultaneously the multiple social28 and clinical factors affecting survival after breast cancer diagnosis, we used the linked KPNC–CCR database to determine whether racial/ethnic and socioeconomic differences in short-term overall and breast cancer–specific survival persist in women in a membership-based health system. Our study is the first, to our knowledge, to consider the combined influence of neighborhood SES and race/ethnicity and numerous prognostic factors, including breast cancer subtypes and comorbidities, thought to underlie these long-standing survival disparities among women with uniform access to health care and treatment.     

Eating Disorder Symptoms and Obesity at the Intersections of Gender,Ethnicity, and Sexual Orientation in US High School Students

Objectives. We examined purging for weight control, diet pill use, and obesity across sexual orientation identity and ethnicity groups.Methods. Anonymous survey data were analyzed from 24 591 high school students of diverse ethnicities in the federal Youth Risk Behavioral Surveillance System Survey in 2005 and 2007. Self-reported data were gathered on gender, ethnicity, sexual orientation identity, height, weight, and purging and diet pill use in the past 30 days. We used multivariable logistic regression to estimate odds of purging, diet pill use, and obesity associated with sexual orientation identity in gender-stratified models and examined for the presence of interactions between ethnicity and sexual orientation.Results. Lesbian, gay, and bisexual (LGB) identity was associated with substantially elevated odds of purging and diet pill use in both girls and boys (odds ratios [OR] range =  1.9–6.8). Bisexual girls and boys were also at elevated odds of obesity compared to same-gender heterosexuals (OR = 2.3 and 2.1, respectively).Conclusions. Interventions to reduce eating disorders and obesity that are appropriate for LGB youths of diverse ethnicities are urgently needed.The prevalence of childhood obesity has markedly increased in the past few decades, more than tripling in the last 30 years.1 Obesity in adolescence is especially concerning because of the high risk of immediate- and long-term problems associated with the condition. Obese adolescents are at an elevated risk for high cholesterol, hypertension, prediabetes, bone and joint problems, and sleep apnea.2−5 They are 20 times more likely to become obese adults,6 increasing the odds of long-term health consequences secondary to obesity, such as type 2 diabetes, heart disease, stroke, cancer, and osteoarthritis.7 Eating disorders and disordered weight-control behaviors, such as purging and diet pill use, represent the third most common chronic childhood illnesses, after obesity and asthma,8 and are associated with a range of serious comorbidities, including disorders of the cardiovascular, gastrointestinal, and endocrine systems.9 In addition, children and adolescents who are obese have been found to be at increased risk of eating disorder symptoms.10−12These health problems affect individuals during crucial physiological and psychological developmental periods and disproportionately affect marginalized subgroups of youths. Numerous studies have highlighted disparities based on ethnicity,13−17 sexual orientation,18−22 and gender.23−26 However, little is known about how these disparities intersect and the ways in which individuals who are members of multiple minority subgroups may be affected.Minority stress theory posits that members of marginalized social populations are subject to health consequences as a result of experiences of stigma and discrimination associated with possessing a minority identity.27 These stressors may have direct health consequences through chronic perturbations of biological systems or may cause psychological distress, influencing health behaviors (substance use, weight-control behaviors, sexual risk behaviors, etc.) and health care utilization. Multiple minority stress theory focuses on the intersection of ethnicity, gender, and sexual orientation and proposes that lesbian, gay, and bisexual (LGB) people of color are exposed to multiple stressors that may create an additive health disadvantage.28,29 Several population-based studies have supported the additive hypothesis, demonstrating increased prevalence of health risks among LGB people of color compared with their White LGB counterparts, including disparities in mental health disorders,30,31 chronic health conditions,32 adolescent suicide,33 and obesity.34The additive hypothesis of minority stress theory, however, has been scrutinized because it has not been consistently borne out. For example, other studies35,36 found that ethnicity did not modify sexual orientation–related health disparities, and 1 study29 found that being a member of a ethnic minority group had some protective effect on mental health among LGB individuals, specifically for adolescent girls.We found a limited number of studies that addressed health disparities affecting LGB people of color and an even smaller number of studies that addressed adolescents and young adults.29,33,35−37 In addition, no studies, to our knowledge, specifically examined the issue of disordered weight-control behaviors. We were aware of only 1 study that examined the prevalence of obesity among sexual minorities as associated with ethnicity; this study found that Asian Pacific Islanders had lower body mass index (BMI) and African Americans had higher BMI in a sample of lesbian and bisexual women compared with White women.34 The aim of the present study examined how gender and ethnicity were associated with sexual orientation identity disparities in obesity and disordered weight-control behaviors in youths using data from the Youth Risk Behavior Surveillance System (YRBSS), a biennial survey conducted by the Centers for Disease Control and Prevention (CDC) in US high schools. This study was unique in its focus on disordered weight-control behaviors and obesity, 2 important adolescent health issues in LGB ethnic minority youths, who are an understudied population.     

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.     

Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors

Objectives. We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.Methods. We identified men aged 18 years and older from the 2006–2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).Results. In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).Conclusions. Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.Gender and racial/ethnic disparities in health care utilization are prevalent. Men are less likely than are women to use health care services, including physician office visits and preventive care visits.1,2 Minorities are also less likely to use health care services than are non-Hispanic Whites.3–6 Contributors to these disparities include low socioeconomic status7–10 and lack of health insurance.7,8,11,12 Even after controlling for socioeconomic status and health insurance coverage, racial/ethnic disparities in health care utilization persist.4 These disparities are associated with poorer health and higher mortality rates among minorities and have important implications for survival and well-being for men with serious and chronic health conditions such as cancer.5Although numerous studies have documented racial/ethnic disparities in cancer screening, diagnosis, treatment, and mortality,10,13–18 little is known about how racial/ethnic disparities in health care among posttreatment cancer survivors influence follow-up care. Such care includes monitoring and managing late and long-term effects and follow-up tests to monitor for recurrence and detect second cancers. Management of noncancer comorbidities (e.g., diabetes) and preventive health care19 (e.g., vaccinations) are also recommended for cancer survivors.20–22 Follow-up care may include visits to both primary care and specialist providers.13,23–25 It is strongly recommended that cancer survivors receive lifelong follow-up care because of increased risk of recurrence, morbidity, and mortality.19Prior studies have used administrative data to explore this issue,13,24,26,27 but few of these studies have focused on male cancer survivors and none included younger survivors who are not covered by Medicare. Additionally, it is not known how patterns of health care receipt might differ among men with and without a history of cancer.We assessed racial/ethnic disparities in health care receipt among adult male cancer survivors and men without cancer using the National Health Interview Survey (NHIS).28 We first wanted to compare cancer survivors to a noncancer group to shed light on whether the disparities are specific to cancer or reflect underlying disparities. We explored (1) racial/ethnic disparities in health care receipt among cancer survivors compared with men with no cancer history, (2) racial/ethnic disparities in cancer survivors, and (3) the extent to which predisposing, enabling, and need factors explain racial/ethnic disparities in health care receipt among male cancer survivors.     

Race,Place, and Obesity: The Complex Relationships Among Community Racial/Ethnic Composition,Individual Race/Ethnicity,and Obesity in the United States

Objectives. We explored the association between community racial/ethnic composition and obesity risk.Methods. In this cross-sectional study, we used nationally representative data from the Medical Expenditure Panel Survey linked to geographic data from the US Decennial Census and Census Business Pattern data.Results. Living in communities with a high Hispanic concentration (≥ 25%) was associated with a 0.55 and 0.42 increase in body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) and 21% and 23% higher odds for obesity for Hispanics and non-Hispanic Whites, respectively. Living in a community with a high non-Hispanic Asian concentration (≥ 25%) was associated with a 0.68 decrease in BMI and 28% lower odds for obesity for non-Hispanic Whites. We controlled for individual- and community-level social, economic, and demographic variables.Conclusions. Community racial/ethnic composition is an important correlate of obesity risk, but the relationship differs greatly by individual race/ethnicity. To better understand the obesity epidemic and related racial/ethnic disparities, more must be learned about community-level risk factors, especially how built environment and social norms operate within communities and across racial/ethnic groups.The prevalence of obesity has risen significantly over the past few decades and is now considered one of the most pressing public health problems in the United States.1–5 Currently, more than one third of adults older than 20 years are obese, defined as having a body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) of 30 or more.2 Obesity and sedentary lifestyle are risk factors for a variety of chronic conditions and are leading causes of premature mortality and years of life lost.6–9 Various estimates put the number of deaths attributable to obesity in the United States between 112 000 and 300 000, second only to cigarette smoking.10–12 Members of the current US generation may have a shorter life expectancy than their parents if the obesity epidemic continues.13–16 There are large financial costs associated with obesity, too.17 For example, a recent study found that the annual medical burden of obesity and overweight is nearly 10% of total medical spending, or $147 billion in 2008.18The US obesity epidemic has disproportionately affected certain racial and ethnic minority groups.2,5,19 For example, approximately 50% of African American women are obese compared with only 33% of White women.2 Individual factors such as income and education explain some of the observed racial/ethnic differences in obesity, but wide differences persist even after a large number of individual characteristics are held constant.20 Recent research suggests that community-level characteristics such as the availability and accessibility of sidewalks, parks, and recreational facilities21–26 and food selection and cost27–30 are related to obesity independent of individual characteristics. Thus, one line of research documents wide racial/ethnic disparities in the risk of obesity at the individual level, whereas another identifies several community characteristics that are associated with both the risk of obesity and related racial/ethnic disparities. There is a gap between these 2 lines of research; little is known about how the racial and ethnic composition of residential communities is associated with individual-level obesity risk and how this association might differ by individual-level race/ethnicity. Investigating community-level racial/ethnic composition as a risk factor for obesity, above and beyond individuals’ own characteristics, will help improve understanding of racial/ethnic disparities in health, and guide future interventions to eliminate health disparities, which is a national priority.31Although little empirical evidence exists on the possible relationship between community racial/ethnic composition and obesity, there is reason to hypothesize that a relationship might exist. Social norms regarding body weight may differ significantly across ethnic groups. For example, perceived ideal body size for non-Hispanic Black women is larger than for non-Hispanic White women, and non-Hispanic White women report dissatisfaction with their bodies at significantly lower weights than do non-Hispanic Black women.32 Furthermore, non-Hispanic Black men report a preference for larger body sizes in female partners than do non-Hispanic White men.33 Given that obesity rates and norms regarding body weight differ across racial and ethnic groups and, at the same time, the United States is highly segregated along racial and ethnic lines, it is plausible that norms regarding body weight could develop at the community level. This, in turn, may give rise to an association between community-level racial/ethnic composition and the risk of obesity independent of the characteristics of individuals.This study addresses 2 main questions. First, is the racial/ethnic composition of communities associated with obesity beyond what would be expected given the characteristics of the individuals? Second, if an association exists, does it differ on the basis of an individual’s own racial/ethnic identity? Our findings will enhance understanding of disparities in the US obesity epidemic, and the mechanisms by which certain racial/ethnic minorities are disproportionately affected.     

Explaining Racial Disparities in Infant Health in Brazil

Objectives. We sought to quantify how socioeconomic, health care, demographic, and geographic effects explain racial disparities in low birth weight (LBW) and preterm birth (PTB) rates in Brazil.Methods. We employed a sample of 8949 infants born between 1995 and 2009 in 15 cities and 7 provinces in Brazil. We focused on disparities in LBW (< 2500 g) and PTB (< 37 gestational weeks) prevalence between infants of African ancestry alone or African mixed with other ancestries, and European ancestry alone. We used a decomposition model to quantify the contributions of conceptually relevant factors to these disparities.Results. The model explained 45% to 94% of LBW and 64% to 94% of PTB disparities between the African ancestry groups and European ancestry. Differences in prenatal care use and geographic location were the most important contributors, followed by socioeconomic differences. The model explained the majority of the disparities for mixed African ancestry and part of the disparity for African ancestry alone.Conclusions. Public policies to improve children’s health should target prenatal care and geographic location differences to reduce health disparities between infants of African and European ancestries in Brazil.Large health disparities exist between Black and White infants in Brazil.1−4 Infant mortality is more than twice as common among Black as White infants in Southern Brazil (30.4 vs 13.9 per 1000).5 Poor birth outcomes including low birth weight (LBW) and preterm birth (PTB) are also more common among Black infants. Racial disparities are also reported in prenatal and postnatal care, with White mothers having more and higher-quality prenatal visits and greater use of postnatal care.6,7Documenting the prevalence and magnitude of racial disparities in infant’s and children’s health is important. However, of more importance is explaining these disparities and identifying the pathways through which they arise to identify contributors that can be targeted by policy interventions. Such effort has lifelong implications because of the importance of children’s health for adult health and human capital attainment.8−12 Because children’s health may have multiplicative effects on health over life, early health disparities may extend into large health and human capital disparities later in life.13,14Studies in the United States have shed light on several pathways that lead to racial disparities in infant’s and children’s health.15−21 Individual-level factors including socioeconomic status (SES),22 maternal age, prenatal care use,22−24 and stressful life events before delivery,17 as well as differences in health care access and quality25−27 and social inequalities because of residential segregation and poverty,15,28,29 are thought to be important contributors to racial disparities in infants’ health in the United States.To our knowledge, there are no studies that simultaneously quantify the contributions of a large number of conceptually relevant factors to racial disparities in infants’ health in Brazil. In this study, we examined the extent to which socioeconomic, health care, demographic, and geographic effects explain disparities in LBW (< 2500 grams) and PTB (< 37 gestational weeks) rates by African ancestry in Brazil. Unlike any previous study for Brazil, we evaluated the contributions of the explanatory factors to the disparities by different degrees of African ancestry. We focused on disparities by African ancestry because they are the most prevalent and affect a large percentage of the Brazilian population.1−5Our study is the first to simultaneously quantify the contributions of several factors both as a group and each on its own (with control for the others) to explaining racial disparities in infant health in Brazil. Such a study is needed not only because Brazil is the largest country in South America but also because there are many historical, demographic, economic, social, cultural, and health care system differences between Brazil and other racially admixed countries such as the United States. These differences limit the generalizability of studies of racial infant health disparities in the United States to the Brazilian population as these differences may modify the underlying factors and the extent of their contributions to the disparities.There is a sharp contrast in perception of race between Brazil and the United States.30 Race for individuals of African and European ancestry in Brazil has been historically and socially defined on a “continuum” of skin color including Black, Brown (mixed between Black and White), or White, instead of the Black or White color line as in the United States. This is in part because of the large racial admixing in Brazil.31 The difference in perceptions of racial identity between Brazil and the United States implies potential differences in cultural and socioeconomic factors related to race and how these may affect health and contribute to racial disparities. Brazil also differs significantly in its economic growth and extent of economic disparities by race from the United States.32 Finally, there are major differences in access to and quality of health care between Brazil and the United States.33,34 For all of these reasons, a study that explains the racial disparities in LBW and PTB in Brazil is needed to draw inferences that can help to inform policymaking and interventions to reduce these disparities in that country.     

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     

Trust,Medication Adherence,and Hypertension Control in Southern African American Men

We examined the relationship between trust in the medical system, medication adherence, and hypertension control in Southern African American men. The sample included 235 African American men aged 18 years and older with hypertension. African American men with higher general trust in the medical system were more likely to report better medication adherence (odds ratio [OR] = 1.06), and those with higher self-efficacy were more likely to report better medication adherence and hypertension control (OR = 1.08 and OR = 1.06, respectively).Trust remains an important issue with African Americans (AAs), particularly in the South where its history of mistreatment and racial discrimination at times were highly prevalent.1 Racial and ethnic minorities are more prone than are Whites to distrust the health care establishment, and historically, minority men have had less access to culturally competent providers.2–4 Southern AAs are more likely than are Whites to report perceived racial barriers to care,5 and AA men are more likely than are AA women to report perceived discrimination.6–10 Perceived discrimination and mistreatment are associated with poorer medical adherence and delays in seeking health care.11–14 In addition, higher levels of trust in the health care system are associated with better adherence to recommended care, greater patient satisfaction, and better outcomes.15–18 This has significant implications considering that AA men develop hypertension (HTN) at an earlier age, have higher rates of advanced (stage 3) HTN, are more likely to experience HTN complications, and are less likely to achieve HTN-control compared with White men.19–21 The rates of HTN are even higher in the South for AA men, accounting, in part, for higher stroke (80% higher) and cardiovascular mortality (50% higher) in this subpopulation compared with other groups in other regions.21–23The goal of this brief study was to assess the relationship between trust in the medical, medication adherence,24 and HTN control25 among Southern AA men. Other covariates were perceived discrimination, perceived racism, self-efficacy, and participation in medical decision-making. This study is based on the Race and Health Outcomes Model developed by Williams et al.26     

Density and Proximity of Fast Food Restaurants and Body Mass Index Among African Americans

Objectives. The purpose of this study was to address current gaps in the literature by examining the associations of fast food restaurant (FFR) density around the home and FFR proximity to the home, respectively, with body mass index (BMI) among a large sample of African American adults from Houston, Texas.Methods. We used generalized linear models with generalized estimating equations to examine associations of FFR density at 0.5-, 1-, 2-, and 5-mile road network buffers around the home with BMI and associations of the closest FFR to the home with BMI. All models were adjusted for a range of individual-level covariates and neighborhood socioeconomic status. We additionally investigated the moderating effects of household income on these relations. Data were collected from December 2008 to July 2009.Results. FFR density was not associated with BMI in the main analyses. However, FFR density at 0.5, 1, and 2 miles was positively associated with BMI among participants with lower incomes (P ≤ .025). Closer FFR proximity was associated with higher BMI among all participants (P < .001), with stronger associations emerging among those of lower income (P < .013) relative to higher income (P < .014).Conclusions. Additional research with more diverse African American samples is needed, but results supported the potential for the fast food environment to affect BMI among African Americans, particularly among those of lower economic means.Obesity and its associated health conditions are a growing problem in the United States, with obesity prevalence having more than doubled since the 1960s.1 The health care cost of Americans’ growing waistlines is substantial and expected to top $860 billion by 2030.2 Racial/ethnic disparities in obesity are of particular concern for the nation’s health, with African Americans experiencing the highest prevalence of obesity relative to other racial/ethnic groups.1 The National Health and Nutrition Examination Survey from 2009 to 2010 indicated that 38.8% of African American men and 58.5% of African American women were obese compared with 36.2% of non-Hispanic White men and 32.2% of non-Hispanic White women.3 Racial/ethnic disparities have also been cited for body mass index (BMI), with the gap in BMI growth widening between African Americans and Whites in recent decades.4To better understand the factors associated with these trends, researchers and policymakers are paying increased attention to the retail food environment. The growing availability of low-cost, calorie-dense consumables from fast food restaurants (FFRs) is one of the factors implicated in the nation’s rising BMI.5–7 The availability of FFRs may be particularly relevant to the growing racial/ethnic disparities in BMI because several studies support a higher density of FFRs among predominately African American neighborhoods relative to predominately White neighborhoods.8–11 Moreover, at least 1 study reports stronger relations between fast food availability and fast food consumption among non-White versus White populations.12 Thus, African Americans may be more likely to consume fast food if it is available, and it may be more available to them because FFRs tend to be clustered in African American neighborhoods. Not surprisingly, greater fast food consumption is associated with higher BMI.13–15Several studies examined associations between the availability of fast food and BMI. Fast food availability was most commonly conceptualized as the density of FFRs near a person’s home, work, or school environment. Findings about the associations of FFR density with BMI and overweight or obesity status, however, were mixed,5,11 with some studies supporting positive associations,16–19 and others citing null results.14,20 Less commonly, studies conceptualized fast food availability as the proximity of the closest FFR to a person’s home. Studies taking this approach yielded mixed results regarding relations between FFR proximity and fast food consumption,21,22 as well as between FFR proximity and BMI or obesity status.11,23 Unfortunately, most of these studies focused predominately on White populations, and many had methodological limitations (e.g., self-reported BMI) that could have contributed to mixed results.5,11 We found only a single study that focused on an all-African American sample, which yielded null results regarding associations between FFR density and BMI.24 Although this study had several strengths, including a sample of more than 4500 African Americans and investigator-measured BMI, limitations included only 1 conceptualization of FFR availability (FFR density), and the use of Euclidean distances (“as the crow flies”) in density buffer calculation, which may be less realistic than buffers based on road networks (i.e., the only places along which FFRs can be found).5 In addition, we found no previous studies that examined whether associations between FFR availability and BMI were moderated by household income. Because reasons cited for frequent fast food consumption include both accessibility and affordability,6 it might be that relations of FFRs and BMI are stronger among those of lower economic means for whom fast food might be more affordable than other dining options. Therefore, additional research is needed to better understand the relations of fast food availability and BMI among African Americans.The purpose of this study was to address current gaps in the literature by examining the associations of FFR density around the home and FFR proximity to the home, respectively, with BMI among a large sample of African American adults from Houston, Texas. We additionally investigated the moderating effects of household income on these relations.     

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.     

The Role of Socioeconomic Factors in Black–White Disparities in Preterm Birth

Objectives. We investigated the role of socioeconomic factors in Black–White disparities in preterm birth (PTB).Methods. We used the population-based California Maternal and Infant Health Assessment survey and birth certificate data on 10 400 US-born Black and White California residents who gave birth during 2003 to 2010 to examine rates and relative likelihoods of PTB among Black versus White women, with adjustment for multiple socioeconomic factors and covariables.Results. Greater socioeconomic advantage was generally associated with lower PTB rates among White but not Black women. There were no significant Black–White disparities within the most socioeconomically disadvantaged subgroups; Black–White disparities were seen only within more advantaged subgroups.Conclusions. Socioeconomic factors play an important but complex role in PTB disparities. The absence of Black–White disparities in PTB within certain socioeconomic subgroups, alongside substantial disparities within others, suggests that social factors moderate the disparity. Further research should explore social factors suggested by the literature—including life course socioeconomic experiences and racism-related stress, and the biological pathways through which they operate—as potential contributors to PTB among Black and White women with different levels of social advantage.Higher rates of preterm birth (PTB) among Blacks than Whites have been documented in the United States since at least the early 20th century.1–3 This racial disparity is of great concern because PTB strongly predicts infant mortality4,5 and adverse health and neurodevelopmental outcomes in childhood,4,6,7 and has been linked with chronic disease, disability, and premature mortality in adulthood.8–10The underlying reasons for the racial disparity in PTB are not well understood.4 A range of socioeconomic factors—including income, wealth, and education at the individual, household, and area levels—vary across racial/ethnic groups11–16 and are biologically plausible underlying causes of PTB.4,17–20 Socioeconomic effects on health, including PTB, could operate independently of and in concert with the effects of stressful experiences related more directly to racial discrimination.4,16,21,22 Many studies have observed different PTB risks associated with socioeconomic or socioeconomically linked characteristics of the geographic areas where women reside,4,11,23–32 including area-level measures of poverty, unemployment,26 segregation,24,28 and crime rates.25 Various individual-, household-, and neighborhood-level socioeconomic factors could plausibly affect PTB through diverse causal pathways, including those involving poor nutrition or prepregnancy health status, adverse health-related behaviors, lack of medical care, social isolation, stress, and hazardous physical exposures in the home, neighborhood, workplace, or in transit.4 Biological pathways leading from stressful experiences to PTB through neuroendocrine processes have been described.33–36A systematic review17 of studies examining relationships between adverse birth outcomes and socioeconomic factors found that 93 of 106 studies reported a significant association, overall or within a subgroup, between a socioeconomic measure and a birth outcome; effects varied, however, across racial/ethnic groups and socioeconomic measures. Several birth outcome studies have examined interactions between variables reflecting racial/ethnic group and socioeconomic factors, with inconsistent results. Some studies have found minimal or no Black–White differences in PTB among highly disadvantaged women.37–39 Others have observed a significant racial disparity among socioeconomically disadvantaged women, but an even greater disparity among more socioeconomically advantaged women.24,40,41 Some other studies, however, have not reported differences in the racial disparity in PTB across socioeconomic subgroups.4 Although the biological mechanisms for low birth weight are thought to be distinct from those for PTB,4 several studies42–49 have observed relatively smaller—but not necessarily small—racial disparities in low birth weight or infant mortality within socioeconomically disadvantaged versus more advantaged subgroups.In some studies, the Black–White disparity in PTB has persisted after adjustment for socioeconomic and other known or suspected risk factors,31,50–52 leading some researchers to conclude that the Black–White disparity in PTB reflects underlying genetic differences.53–56 Others have challenged this, noting that the disparity may reflect significant unmeasured socioeconomic factors and other social experiences including those related to racial discrimination throughout life, not only during pregnancy.18,21,57–62 With few exceptions,30,31,39,63,64 however, most studies of the Black–White disparity in PTB have had limited socioeconomic information, and few have examined systematically how the disparity may vary at different socioeconomic levels.The goal of this study was to investigate the role of socioeconomic factors in the Black–White disparity in PTB by using a unique population-based data source on California births with more extensive information than generally available in previous PTB research, including multiple socioeconomic measures at the individual, household, and area levels and a wide range of covariables reflecting potential confounders suggested by the literature. The aim was to assess the combined contribution of multiple socioeconomic factors—representing different dimensions of social advantage and disadvantage—to the racial disparity in PTB, and to examine whether and how these socioeconomic factors might moderate the relationship between racial group and PTB.     

Longitudinal Associations Between Poverty and Obesity From Birth Through Adolescence

Objectives. We examined the relationship between timing of poverty and risk of first-incidence obesity from ages 3 to 15.5 years.Methods. We used the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (1991–2007) to study 1150 children with repeated measures of income, weight, and height from birth to 15.5 years in 10 US cities. Our dependent variable was the first incidence of obesity (body mass index ≥ 95th percentile). We measured poverty (income-to-needs ratio < 2) prior to age 2 years and a lagged, time-varying measure of poverty between ages 2 and 12 years. We estimated discrete-time hazard models of the relative risk of first transition to obesity.Results. Poverty prior to age 2 years was associated with risk of obesity by age 15.5 years in fully adjusted models. These associations did not vary by gender.Conclusions. Our findings suggest that there are enduring associations between early life poverty and adolescent obesity. This stage in the life course may serve as a critical period for both poverty and obesity prevention.There are significant socioeconomic disparities in rates of childhood and adolescent obesity, defined as a body mass index (BMI) at or above the 95th percentile, adjusted for age and gender.1–3 Children of low socioeconomic status (SES) are 1.6 times more likely to be obese than high-SES children4 and have steeper rates of increase in obesity.5,6 Despite evidence that the prevalence of obesity has recently stabilized among children overall, it continues to increase among low-SES children.2,5 The positive relationship between low SES and obesity is especially worrisome because of relatively high rates of childhood poverty that have only increased in the recent economic downturn.7 One in 5 US children (16.4 million) now live in families with incomes below the federal poverty level.8To better understand the relationship between poverty and obesity, longitudinal studies of childhood poverty and its associations with obesity throughout childhood are needed. To develop effective policies preventing the incidence of child obesity, studies must also determine critical periods in childhood during which poverty may exert greater influence on the incidence of obesity.9,10 Most studies demonstrating a link between SES and obesity, however, have used a cross-sectional study design.1,5,6,11–16 Fewer studies address the issue of timing of childhood poverty (or other SES measures) and obesity incidence (or changes in BMI) later in life.17–20 Moreover, these few studies omit key information on weight history17,19 and SES prior to middle childhood (younger than 7 years)18,19 or are based on non-US populations,21 which precludes the study of early life associations between poverty and obesity, and limits generalizability to the United States.We used a comprehensive, community-based data set of US children followed from birth to about 15 years of age and for whom multiple measures of children’s SES, height, and weight were collected. Our objective was to examine critical periods in the relationship between poverty and the risk of the first incidence of obesity across the early life course.     

The Influence of Implicit Bias on Treatment Recommendations for 4 Common Pediatric Conditions: Pain,Urinary Tract Infection,Attention Deficit Hyperactivity Disorder,and Asthma

Objectives. We examined the association between pediatricians’ attitudes about race and treatment recommendations by patients’ race.Methods. We conducted an online survey of academic pediatricians (n = 86). We used 3 Implicit Association Tests to measure implicit attitudes and stereotypes about race. Dependent variables were recommendations for pain management, urinary tract infections, attention deficit hyperactivity disorder, and asthma, measured by case vignettes. We used correlational analysis to assess associations among measures and hierarchical multiple regression to measure the interactive effect of the attitude measures and patients’ race on treatment recommendations.Results. Pediatricians’ implicit (unconscious) attitudes and stereotypes were associated with treatment recommendations. The association between unconscious bias and patient’s race was statistically significant for prescribing a narcotic medication for pain following surgery. As pediatricians’ implicit pro-White bias increased, prescribing narcotic medication decreased for African American patients but not for the White patients. Self-reported attitudes about race were associated with some treatment recommendations.Conclusions. Pediatricians’ implicit attitudes about race affect pain management. There is a need to better understand the influence of physicians’ unconscious beliefs about race on pain and other areas of care.Management of asthma, attention deficit hyperactivity disorder (ADHD), urinary tract infection (UTI), and pain are common conditions routinely treated by pediatricians. The childhood prevalence of asthma, the most common chronic pediatric illness, is 10% (n = 7 million), with 8% of White children, 8% of Hispanic children, and 17% of non-Hispanic Black children currently diagnosed with asthma.1 African American children experience the highest rates of asthma hospitalization and asthma mortality relative to other racial and ethnic groups, and this disparity is widening.2 ADHD is diagnosed in 4.1% of all children, with the greatest prevalence among White children (5.1%). However, among male children, prevalence of ADHD by race is 3% for Hispanics, 4.3% for Whites, and 5.65% for African Americans.3 A meta-analysis to determine prevalence of UTI in children found that UTIs accounted for 5% to 14% of all pediatric emergency room visits annually and for 7% of infants presenting with fevers.4Racial and ethnic disparities are found in asthma care, medication use for ADHD, children’s timely and appropriate receipt of medication, pain management, and quality of primary care.2,5–8 For asthma, the rate of emergency department visits is 3 times higher for minority children than for nonminority children and use of daily anti-inflammatory medication is lower.9 African American and Hispanic children are more likely to have a potentially avoidable asthma hospitalization.9 African American and Hispanic children with asthma in the Military Health System are less likely to see a specialist than White children with asthma,9 even though specialist care for asthma is more likely than primary care to follow recommended guidelines.10 Minority children have lower likelihood of receiving a diagnosis of ADHD and of receiving any medication for ADHD.11 For the current research, we adopted the following National Institutes of Health definition of “race” (derived from a more detailed definition by the National Research Council):

a continuously evolving social construct used to categorize individuals into groups that have typically been based on the physical characteristics (e.g. skin color, hair texture or other distinctive characteristics, etc.) of an individual or their ancestors.12

We used the following Institute of Medicine definition of “ethnicity”: “a concept referring to a shared culture and way of life.”5^(p523)Pain management is an area in which racial and ethnic disparities are well documented and persist.8,13 In a national study of hospital emergency departments that measured pain medication–prescribing patterns over a 13-year period (1993–2005), White patients were more likely to receive an opioid analgesic than African American, Hispanic, or Asian patients.8 Differential treatment, which was found among adults and children for all types of pain, was greater as severity of pain increased, and the disparities did not decrease over time.8 Compared with research on adult pain, there is less research on racial and ethnic disparities in pain management for children, although pain is generally undertreated in children.14 One study in a pediatric hospital setting showed that Latino children received 30% less opioid analgesics than did White children for early postoperative pain.7It is not uncommon for minority patients or parents to report discrimination in health care.15–20 Parents of minority children report lower scores on interpersonal relationship with primary care providers, lower scores for provider communication, and less participatory decision-making.2 Patient perceptions and experiences of discrimination in health care can cause delay in timely treatment, an interruption in continuity of care, and mistrust and avoidance of the health care system.20,21 A study of physician behavior in real-world clinical interactions with adults found that, compared with White patients, physicians spend less time with African American patients, are more verbally dominant, and show a less positive affect.22The Institute of Medicine report Unequal Treatment (2003) found that “bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare.”5⁽¹²⁾ Social psychologists and the Institute of Medicine speculate that providers’ explicit and implicit attitudes and beliefs may subtly and unintentionally contribute to disparities.5,23,24 Explicit attitudes are ones we know we have and can report to others.25 Implicit refers to attitudes that are outside of awareness, are not available to report, and are thus considered “unconscious.”25 Implicit attitudes and stereotypes can exist even among individuals who endorse egalitarian beliefs.26–29 Explicit and implicit attitudes and stereotypes are often only weakly related.29–32 In the more affective dimensions of social interactions such as nonverbal behavior, implicit attitudes and stereotypes about race are more closely related to the behavior of prejudice and discrimination than is self-report.33,34 The existence of implicit bias in an individual does not always result in discrimination, but because implicit attitudes and beliefs are unrecognized and unintentional, these biases may subtly affect behavior.We are extending our previous work that reported on the strength of pediatricians’ implicit and explicit attitudes and beliefs about race and their association with the difference between optimal care and “adequate” or good enough care.35 In this study, we examined pediatricians’ implicit and explicit attitudes and beliefs about race and their association with each treatment recommendation for 4 conditions that are routinely seen in pediatric practice: asthma, ADHD, UTI, and pain. We expected that physicians’ self-reported attitudes and beliefs about race would be related to treatment recommendations. We hypothesized that we would find an association between strength of physicians’ implicit pro-White attitudes and stereotypes about race and treatment recommendations by patients’ race.     

Preconception Stress,Birth Weight,and Birth Weight Disparities Among US Women

Objectives. We examined the impact of preconception acute and chronic stressors on offspring birth weight and racial/ethnic birth weight disparities.Methods. We included birth weights for singleton live first (n = 3512) and second (n = 1901) births to White, Mexican-origin Latina, other-origin Latina, and Black women reported at wave IV of the National Longitudinal Study of Adolescent Health (2007–2008; ages 24–32 years). We generated factor scores for preconception acute and chronic stressors from wave I (1994–1995; ages 11–19 years) or wave III (2001–2002; ages 18–26 years) for the same cohort of women.Results. Linear regression models indicated that chronic stressors, but not acute stressors, were inversely associated with birth weight for both first and second births (b = −192; 95% confidence interval = −270, −113; and b = −180; 95% confidence interval = −315, −45, respectively), and partially explained the disparities in birth weight between the minority racial/ethnic groups and Whites.Conclusions. Preconception chronic stressors contribute to restricted birth weight and to racial/ethnic birth weight disparities.Birth weight, a marker of infant health, predicts infant survival and subsequent health status. Low birth weight, defined as weight less than 2500 grams, is associated with increased risk of developing both short-term and long-term health problems.1 The prevalence of restricted birth weight has been increasing since the 1980s in the United States,2 and marked differences in birth weight persist by race/ethnicity.3,4 Limitations of prenatal care and other pregnancy interventions to address the increase over time and disparities in prevalence of adverse birth outcomes1,5 have led to a focus on preconception health, defined broadly as health before a pregnancy (although often used in public health practice to denote health during the reproductive years) and including interconception health, or health between pregnancies.6,7 Drawing on a life course framework,8–10 the concept of preconception health suggests that infants are affected not only by maternal exposures in the 9-month prenatal period, but also by maternal development before the pregnancy.One preconception exposure of interest is stress. Pearlin’s stress process model posits that social characteristics including those surrounding race/ethnicity in the United States lead to stress exposures that affect health,11–13 and has been used to understand elevated risk of adverse health outcomes among minority groups.14,15 It is worth noting that elevated stress is not inherent to persons of minority race/ethnicity, because race/ethnicity is a social construct and not a biological one. Rather, stress results from historical and societal constraints leading to differential life chances across groups.16In studies of its health consequences, stress was defined most frequently as exposure to an inventory of life events within a specified period of time.17 These acute stressors, such as a death in the family or exposure to a crime, are relatively brief in duration but may have continued ramifications.17,18 Consistent with a life course perspective, more recent studies examined chronic stressors as a risk factor for health outcomes.18,19 These stressful life conditions, including individual and neighborhood socioeconomic disadvantage, recur or accumulate throughout a respondent’s life. However, measurement of chronic stressors is less standardized across studies than that of acute stressors; validated scales of acute events19 but not chronic conditions have been developed.Physiologic mechanisms have been hypothesized to link maternal stress to maternal and infant health.20–22 For example, cumulative stress exposure may result in accelerated aging, or “weathering,” wearing down the body’s adaptive systems.21,22 Weathering in particular was proposed as a source of racial/ethnic disparities in perinatal health, such that the higher stress experienced by African American women causes their reproductive functioning to deteriorate more rapidly than that of White women.22 Other possible pathways through which stress can lead to birth outcome disparities include infection,23 nutrition,19 and pregnancy complications.24The majority of studies assessing the effects on birth outcomes of stress and related factors have relied on prenatal measurement with mixed results.19,25,26 A smaller number of studies have examined effects of acute stressors or specific chronic stressors in the reproductive period.27–30 Although several of these analyses suggested associations, this work included limitations such as small sample sizes,27 European cohorts not generalizable to the United States,29 or retrospectively reported preconception measures.30 Furthermore, none included both acute and chronic stressors or compared racial/ethnic differences for groups besides non-Hispanic Black and non-Hispanic White.To address these gaps in the literature, the objective of this study was to examine the impact of maternal preconception acute stressors (or stressful life events) and preconception chronic stressors (or stressful life conditions) on offspring birth weight and racial/ethnic birth weight disparities. Our hypotheses were as follows: (1) acute and chronic stressors will be inversely associated with birth weight, (2) the distributions of birth weight and stress will vary by maternal race/ethnicity, and (3) stress will partially explain racial/ethnic differences in birth weight where such differences exist. Our conceptual model is shown in Figure 1.Open in a separate windowFIGURE 1—Conceptual model depicting hypothesized relationships among maternal race/ethnicity, preconception stress, and offspring birth weight: National Longitudinal Study of Adolescent Health, United States, 1994–2008.     

Impact of County Disadvantage on Behavior Problems Among US Children With Cognitive Delay

Objectives. We investigated relationships among cognitive delay, community factors, and behavior problems over 2 years in early childhood with a national sample of US families.Methods. Data were from 3 waves of the Early Childhood Longitudinal Study, Birth Cohort (2001–2005; n = 7650). We defined cognitive delay as the lowest 10% of mental scores from the Bayley Short Form–Research Edition, administered at 9 and 24 months. At 24 months, we classified children as typically developing or as having resolved, newly developed, or persistent cognitive delays. Behavior was measured at age 4 years with the Preschool and Kindergarten Behavior Scales (range = 0–36). Community factors included perceived neighborhood safety and an index of county disadvantage.Results. Behavior scores at age 4 years (mean = 12.4; SD = 4.9) were higher among children with resolved (Β = 0.70; SE = 0.20), newly developed (Β = 1.92; SE = 0.25), and persistent (Β = 2.96; SE = 0.41) cognitive delays than for typically developing children. The interaction between county disadvantage and cognitive delay status was statistically significant (P < .01), suggesting that county disadvantage was particularly detrimental for children with persistent delays.Conclusions. The community context may provide an opportunity for public health interventions to improve the behavioral health of children with cognitive delays.Children with cognitive delays develop behavior problems at much higher rates than do their typically developing peers.1–5 Such problems have been shown to emerge at very young ages6 and to persist through school age into adulthood,7,8 contributing to a wide range of negative consequences for children’s health and well-being.9,10 Despite these marked disparities, there has been very little research to date to inform the mechanisms underlying the development of behavior problems among children with cognitive delays, especially in early childhood.1,11 In a recent review, Einfeld et al.1 noted that few studies reporting on the prevalence of mental health or behavior problems among children with cognitive delays have examined associated risk factors beyond age, gender, and severity of the child’s limitation. Further inquiry into factors associated with behavior problems among children with cognitive delays is needed to illuminate the etiology of such problems and inform future intervention studies.From a social–ecological perspective,12,13 the contextual environment in which children with cognitive delays grow and develop may contribute to their risk for behavior problems. A number of studies have shown significant associations between community and neighborhood socioeconomic factors and young and early school-aged children’s mental health, internalizing and externalizing behavior problems,14 and criminal, delinquent, and violent behaviors.15–17 It is possible that young children with cognitive delays who are prone to health and developmental difficulties are especially sensitive to their community’s social and economic characteristics. However, to our knowledge, the relationship between community factors and behavior problems has not yet been examined among children with cognitive delays.Therefore, the purpose of this study was to investigate the relationships among cognitive delay, community factors, and behavior problems in early childhood by using a national sample of US children. We focused on very early childhood as it is a critical period for the development of behavior problems among children with cognitive delays.6 We expected to observe significant disparities in behavior problems between 4-year-old children with and without cognitive delays. Furthermore, we hypothesized that children with cognitive delays living in adverse community environments would be particularly vulnerable to developing behavior problems. To our knowledge, this is the first study to investigate the role of community factors on behavior problems among young children with cognitive delays.     

Early Life Conditions,Adverse Life Events,and Chewing Ability at Middle and Later Adulthood

Objectives. We sought to determine the extent to which early life conditions and adverse life events impact chewing ability in middle and later adulthood.Methods. Secondary analyses were conducted based on data from waves 2 and 3 of the Survey of Health, Ageing, and Retirement in Europe (SHARE), collected in the years 2006 to 2009 and encompassing information on current chewing ability and the life history of persons aged 50 years or older from 13 European countries. Logistic regression models were estimated with sequential inclusion of explanatory variables representing living conditions in childhood and adverse life events.Results. After controlling for current determinants of chewing ability at age 50 years or older, certain childhood and later life course socioeconomic, behavioral, and cognitive factors became evident as correlates of chewing ability at age 50 years or older. Specifically, childhood financial hardship was identified as an early life predictor of chewing ability at age 50 years or older (odds ratio = 1.58; 95% confidence interval = 1.22, 2.06).Conclusions. Findings suggest a potential enduring impact of early life conditions and adverse life events on oral health in middle and later adulthood and are relevant for public health decision-makers who design strategies for optimal oral health.Oral diseases remain a major public health issue globally.1 Not only do they affect nearly 4 billion people worldwide,2 but they are also one of the most expensive diseases to treat.1 Oral health is also recognized as an important component of general health and well-being.3–8 Chronic diseases are increasingly studied within a life course framework that considers health impairments as a consequence of risk exposure in critical periods of life or accumulated exposure over time. Multiple events can occur throughout early- and later-life stages and pathways may link childhood conditions with health impairments in later life through intermediary adverse events. Models incorporating the entire life course have primarily been used to assess chronic conditions such as coronary heart disease and diabetes9–11 but their application to oral health remains limited.Like other chronic diseases, oral diseases result from exposure to various risk factors throughout life.12 Evidence from birth-cohort studies on life course determinants of oral health suggests that socioeconomic background,13–16 dental-attendance patterns in early life years,17,18 and parental oral health19,20 play an important role in terms of tooth decay, periodontal health, tooth loss, and self-rated oral health at early adulthood. Moreover, it has been shown that caries experience in early life predicts caries occurrence later in life.21 Despite robust methodological value and relevant findings, a limitation of birth-cohort studies containing oral health information is that they are age restricted. As these were not initiated before the early 1970s,22,23 there has not yet been sufficient time to follow up individuals into middle and later adulthood. Consequently, they are not suitable to address research questions in terms of life course influences on oral health at older adulthood. This area of research could be served by longitudinal studies of older adults that contain current oral health-related outcomes and have also collected information on the major life course events and experiences of their participants.A significant consequence of oral diseases is deteriorating chewing ability. This represents serious functional impairment, interrelates with numerous oral health problems which determine oral health-related quality of life, and impacts on general health through influencing nutritional choices; chewing ability is thus often considered a meaningful marker of oral health, particularly in middle and late life years.24–29 The study’s objective was to determine the extent to which childhood conditions and adverse life events impact on the chewing ability in middle and late adulthood populations from 13 European countries.